This Policy Guide provides staff with both an overview of how CSWs are to assess Failure to Thrive and the follow up actions when there is suspicion that a child is failing to thrive.

This policy guide was updated from the 09/22/10 version, as part of the Policy Redesign, in accordance with the DCFS Strategic Plan.

Failure to Thrive

Failure to thrive is a medical condition involving a spectrum of disorders. It describes a child who is not developing at the age appropriate rate, physically, emotionally, and/or cognitively.  This may include:

• A lack of physical growth, measured weight, height, and head circumference
• Malnutrition
• Retardation of social and motor development

Failure to thrive can result in irreversible damage and, in its extreme state, can be fatal. There must be a medical examination and assessment, preferably by a doctor or clinic that specializes in pediatrics to diagnose Failure to Thrive. Infants and babies, age two and younger, are most likely to receive a diagnosis of Failure to Thrive. Older children (age three to twelve) may also be diagnosed. (It may then be called psycho-social Failure to Thrive or dwarfism.)

There are three classifications of Failure to Thrive. These categories are not absolute as there may be a substantial overlap in children with Organic Failure to Thrive who may also experience psycho-social difficulties.

• Organic Failure to Thrive – Implies that there may be a medical reason for the symptoms (e.g. gastrointestinal system problems)
• Non-organic Failure to Thrive – Implies that there are no medical findings to support an organic cause for any symptoms (e.g. a baby is not receiving enough food due to economic factors, psychosocial problems, or parental neglect)
• Mixed Failure to Thrive – Organic and non-organic factors are contributing to the child’s diagnosis of Failure to Thrive

The CSW may receive a referral from medical sources after the child has been medically diagnosed as Failure to Thrive. However, in some cases, the CSW may be the initial individual to suspect/assess for failure to thrive during a face-to-face contact. In such cases, the CSW must always involve the Public Health Nurse in the assessment process as soon as Failure to Thrive is suspected.

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Considering the Presence of Failure to Thrive in a Child

CSW Responsibilities

1. Consider Organic Failure to Thrive when there may be a medical reason for any symptoms causing concern.
   • Medical reasons for concern may include any biological conditions such as cystic fibrosis, congenital heart disease, central nervous system abnormalities, gastrointestinal system problems, cleft palate/lip, immunologic diseases, HIV, or chronic infections.
2. Consider Non-organic Failure to Thrive when there are no medical findings to support an organic cause for any symptoms causing concerns. Consider the following symptoms:
   • Abnormal physical features such as little fat on the extremities, lack of muscle in the buttocks, poor muscle tone, bloated stomach, small or short stature, or lack of skin coloring or a head that appears proportionally large to the size of the body.
     • When assessing the child, it is essential that he/she be disrobed, as blankets or clothing may frequently hide the fact that the child is either small (low-weight) or has a severe diaper rash.
   • Excessive diarrhea or severe diaper rash.
   • Abnormal eye movements, including poor or no eye contact, glassy eyes, being watchful, wary or wide-eyed with a lack of focus or gaze avoidance.
   • Arches back when picked up, rigidity, clenched hands, or a scissoring effect. (outstretched legs/feet)
   • Voracious appetite or is anorexic.
   • Self-soothing behavior such as rocking, swaying, or self-stimulation play.
   • Irritability, especially when handled; apathy, or listlessness.
   • Lack of spontaneous movement, verbalizations or laughter.
   • Excessive sleep.
   • Preference for objects over people.
   • Delays in language or other types of development.
   • Bizarre eating habits. (stealing, gorging, hiding)
   • Changes in the child’s growth pattern. (e.g., a child whose size was within normal limits at birth fails to maintain the expected growth pattern)
3. Consider Mixed Failure to Thrive when there is a combination of both organic and non-organic symptoms causing concern. Consider the following signs of Mixed Failure to Thrive in a child:
   • Prenatal exposure to drugs/alcohol or maternal infections.
   • Illness, poor nutrition or poor prenatal care received by the child’s mother.
   • Premature or low birth weight.
   • Inconsistent growth pattern.
   • Problems sucking, swallowing, or feeding.
4. Document the home visit. Include specific and detailed observations of the child’s environment, appearance and behavior in order to enhance the referral for a thorough medical assessment, if appropriate. 

Assessing Parental or Environmental Factors that Contribute to Failure to Thrive

CSW Responsibilities

1. Interview the child’s parent/caregiver and observe the caregiver-child interaction.  Consider:
   • Maternal depression.
   • Any expressions of anger or resentment towards, or rejection of, the child.
   • Social isolation by caregiver or family.
   • Conflict or stress related to substance abuse, domestic violence or illness. (physical or mental)
   • A significant loss in caregiver’s life that has not been worked through.
   • Limited parenting skills displayed by the parent/caregiver. (e.g., unaware of cues from infant for food, unrealistic expectations, misinformed regarding nutritional requirements, improper mixing of formula, possible presence of developmental delays)
   • Parent/Caregiver verbalizes or displays an inability or unwillingness to provide proper feeding, nutrition, bonding, or nurturing.
   • Emotional rejection and lack of infant stimulation can also be a primary causative factor for Failure to Thrive even when sufficient food is available.
2. Observe the home and note whether there are any signs of a child-friendly environment (e.g., crib, or special sleeping/play area, toys, etc.), or if there is any evidence in the home that a child lives there.
   • Consider the role extreme poverty may play in any lack of resources.
3. Visit the family at mealtime and consider the following:
   • Type and amount of food available
   • Whether food is properly prepared and age-appropriate
   • Available and working kitchen appliances
   • How much, where, and when the child eats
4. Physically interact with the infant or child by holding him/her or by attempting to engage an older child in play. Note the child’s reactions.
5. Document the home visit. Include specific and detailed observations of the child’s environment, appearance, and behavior in order to enhance the referral for a thorough medical assessment, if appropriate.

Suspicion of Failure to Thrive

CSW Responsibilities

During the investigation, if there is suspicion that a child exhibits symptoms of Failure to Thrive:

1. If it is an emergency situation and/or the child is not breathing or responding, call 911.
2. Collect information from the parent/caregiver on the child’s medical services that are already utilized/offered.
3. If the child has not been seen to a doctor recently, request that parent/caregiver seek medical attention immediately.
4. Obtain a signed release of information form from the parent(s) in order to access the child’s medical records.
5. Consult with the Public Health Nurse (PHN) in order to:
   1. Request a joint CSW/PHN visit by completing DCFS 5646-1, Public Health Nurse Consultation Request.
      • A joint visit with the PHN is required prior to closing a referral involving Failure to Thrive or other serious medical problem(s).
   2. Request assistance in obtaining the child’s feeding history from the caregiver as well as the child’s thorough medical history, including birth history, growth charts, medical problems, physical exams, etc.
   3. Understand child’s pertinent developmental milestones, including graphing of a child’s height, weight, and head circumference over time
   4. Locate resources for medical assessments and follow-ups, including SCAN teams (e.g. Medical HUB)
6. If needed, conduct a joint visit with the PHN to further assess the child and parent/caregiver.
7. Document the home visit. Include specific and detailed observations of the child’s environment, appearance and behavior to enhance the referral for a thorough medical assessment, if appropriate.
   • The PHN will document each joint visit/consultation in the Contact Notebook and all pertinent medical information in the child’s Health Notebook.
8. Follow the recommendations made by the PHN.
9. Document follow-up activities in the Contact Notebook
   • When a child with Failure to Thrive is detained, consult with the PHN regarding a suitable placement (e.g. F-Rate home).
10. Contact the Medical Case Management Section (MCMS) for placement consultation and for a possible transfer to MCMS.

Forms

LA Kids

DCFS 5646-1, Public Health Nurse Consultation Request

ABCDM 228, Applicant’s Authorization for Release of Information

Referenced Policy Guides

0070-516.10, Assessing a Child’s Development & Referring to a Regional Center

0070-521.11, Assessment of Medical Neglect

0070-531.10, Visual Inspection of Children

0070-548.10, Disposition of Allegations and Closure of Emergency Response Referrals

0070-548.24, Structural Decision Making (SDM)

0070-548.25, Completing the Structured Decision Making (SDM) Safety Plan

0070-560.05, Joint Response Referral

0400-503.10 , Contact Requirements and Exceptions

0600-500.00, Medical Hubs

1000-504.10, Case Transfer Criteria and Procedures

0900-522.11, Specialized Care Increment (SCI) – F-Rate

Statutes

California Department of Social Services (CDSS) Manual of Policies and Procedures (MPP) Division 31-320.111 – Lists objectives of social worker’s contact with the child.