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Nonorganic failure to thrive: A theoretical approach
Nonorganic Failure to Thrive: A Theoretical Approach Deborah K. Steward, MSN, RN, and BonnieJ. Garvin, PhD, RN Nonorganic failure to thrive (NOFTT) is a significant health problem of infancy. Although NOFTT is thought to be a result of multiple factors, exactly what these factors are is unclear. Explaining the development of NOFTT has been hindered by a lack of a theoretical approach. The purpose of this article is to provide a review of the literature and the discussion of a theoretical framework to guide future research in the area of NOFTT.
Copyright 9 1997 by W.B. Saunders Company
'ONORGANIC FAILURE TO THRIVE (NOFTT) is a significant health problem of infancy. Although the exact incidence is unknown, NOFTT accounts for 10% of all children seen in an outpatient setting and 1% to 5% of all admissions to pediatric hospitals (Broughton, 1989; Casey, 1987; Frank, Silva, & Needlman, 1993). At least 80% of cases occur prior to 18 months of age (Bithoney, Dubowitz, & Egan, 1992) during the critical time of rapid weight gain. Nonorganic failure to thrive is a syndrome in which an infant's weight gain deviates from an established pattern of growth and becomes dramatically less than norms for age and sex (Frank & Zeisel, 1988). When NOFTT is identified there is no obvious disease process to account for the growth failure. All infants with NOFTT present with varying degrees of malnutrition (Ramsay, Gisel, & Boutry, 1993). NOFTT can be detrimental to both long-term physical growth and neurodevelopment. Despite intervention, children with histories of NOFTT as infants exhibit continued growth failure (Kristiansson & Fallstrom, 1987; Skuse, Reilly, & Wolke, 1994), developmental delay (Field, 1984), behavioral problems (Brinich, Drotar, & Brinich, 1989; Drotar & Sturm, 1992), and cognitive deficits (Drotar & Sturm, 1988; Singer, 1986). Although NOFTT is a significant problem, the
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From The Ohio State University, College of Nursing, Department of Adult Health & Illness, Columbus, OH. Address reprint requests to Bonnie J. Garvin, PhD, RN, The Ohio State University, College of Nursing, Department of Adult Health & Illness, 1585 Neil Avenue, Columbus, Ohio 432101289. Copyright 9 1997 by W.B. Saunders Company 0882-5963/97/1204-000453.00/0
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development of NOFTT has not been thoroughly explained. The causes of NOFTT are thought to be a result of multiple factors (Boddy & Skuse, 1994; Casey, 1987). What those factors are and how they interact to result in NOFTT is not well understood. One plausible explanation for the dearth of knowledge concerning the development of NOFTT may be related to the lack of theory to guide the inquiry. Theory specific to explaining the multiple causes of NOFTT is limited (Hutcheson, Black, & Starr, 1993). The lack of theoretical advancement in NOFTT has left many unanswered questions concerning causation. A theoretical framework is needed to organize knowledge development (Boddy & Skuse, 1994). Explaining the multiple causes of NOFTT would necessitate identifying and clarifying those variables that contribute to the development of NOFTT. The purpose of this article is to present an integrative review of what is known about NOFTT and to describe a theoretical framework that would provide the direction necessary for asking relevant questions related to the development of NOFTT (Fawcett, 1995). This literature review and proposed framework to explain the development of NOFTT could be used to guide future research.
MATERNAL FACTORS Historically, the primary emphasis for determining the cause of NOFTT was directed toward examining maternal characteristics. Researchers interested in explaining how NOFTT developed concentrated on the maternal contribution to the occurrence of NOFTT. Early researchers focused on characteristics of mothers of NOFTT infants considered to be related to inadequate mothering Journalof PediatricNursing,Vol 12, No 6 (December),1997
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ability. These included various forms of psychopathology such as anxiety and depression, preoccupation with life stresses, feelings of parental incompetence, and an inability to interact appropriately with the environment (Barbero & Shafieen, 1967; Elmer, 1960; Evans, Reinhart, & Succop, 1972; Fischoff, Whitten, & Pettit, 1971; Shaheen, Alexander, Truskowsky, & Barbero, 1968; Togut, Allen, & Lelchuck, 1969). While there are some commonalities among these findings, the failure to include control groups limits the generalizability and significance of these findings (Boddy & Skuse, 1994; Pollitt, Eichler, &Chan, 1975). Current researchers using control groups have demonstrated that when compared with mothers of healthy infants, mothers of NOFTT infants have no more life stresses (Altemeier, O'Connor, Sherrod, & Vietze, 1985; Bithoney, Van Sciver, Foster, Corso, & Tentindo, 1995; Lobo, Barnard, & Coombs, 1992) or psychopathology (Polan et al., 1991; Singer, Song, Hill, & Jaffe, 1990) and no differences in perceived social support (Altemeier et al., 1985; Bithoney & Newberger, 1987; Hutcheson et al., 1993). Some differences have been noted when mothers of NOFTF infants were compared with mothers of healthy infants. Mothers of NOF-q~ infants were less likely to have finished high school (Haynes, Cutler, Gray, & Kempe, 1984; Hutcheson et al., 1993; Kotelchuck & Newberger, 1983; Singer et al., 1990). NOFTF mothers differed on perceptions of their own childhood and the relationship with their partners. Nonorganic failure to thrive mothers described their childhood's as more negative. These mothers were more likely to experience an increased incidence of abuse and neglect (Altemeier et al., 1985; Haynes et al., 1984), inadequate nurturing (Altemeier et al., 1985; Haynes et al., 1984), and more childhood stresses (Kotelchuck & Newberger, 1983; Range, Brown, & King, 1983). Relationships with their partners were also perceived as negative. Numerous problems with the partner included lack of involvement, abuse, increased conflict, and incarceration (Altemeier et al., 1985; Benoit, Zeanah, & Barton, 1989; Crittenden, 1987; Lobo et al., 1992). Although there are some differences between NOFI'T mothers and comparison mothers, these differences and the focus on maternal factors have not been distinct enough to explain the development of NOF/T. This narrow emphasis has excluded the examination of other potentially significant factors and their contribution to NOFTI" (Drotar, 1991).
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INFANT FACTORS Researchers now recognize that infants may contribute to their own growth failure because of the behaviors they exhibit. Growing evidence suggests that NOFTF infants are perceived as behaviorally difficult by their mothers (Bithoney & Newberger, 1987; Bithoney et al., 1995; Wolke, Skuse, & Mathisen, 1990). Early researchers also described NOFTF infants as behaviorally difficult exhibiting apathy, unusual watchfulness, diminished vocalizations, lack of cuddliness, and poor feeding (Glaser, Heagarty, Bullard, & Pivchik, 1968; Leonard, Rhymes, & Solnit, 1966). Currently, the few researchers who have studied NOFTI" infants have identified similar behaviors unique to NOFTF infants, such as low behavioral reactivity, including lethargy, passivity, and decreased motor activity, hypervigilance, and poor feeding ability (Bithoney et al., 1992; Frank & Zeisel, 1988; Powell, 1988). NOFTF infants have also been described as irritable, resistant to touch, exhibiting distress when approached, and indifferent to separation (Powell & Low, 1983; Rosen, Loeb, & Jura, 1980). While the unique behaviors exhibited by NOFTF infants could be significant to the development of NOFTT, the specific contribution of these behaviors remains unknown (Bithoney et al., 1995).
INFANT-MOTHER INTERACTION In considering causation, it is highly improbable that maternal and infant factors are individually responsible for the development of NOFTT (Bithoney et al., 1992; Skuse, 1985). Nonorganic failure to thrive may result from a problematic infant-mother interaction, whereby the infant and mother both make an important contribution to the interactional process (Benoit et al., 1989; Bithoney et al., 1992; Drotar, 1991; Skuse, 1985). Investigators propose that very early in the infant-mother relationship, the reciprocal interaction between the infant and mother becomes maladaptive resulting in an interference with nutritional intake and the subsequent development of NOFTT (Bithoney & Newberger, 1987; Casey, 1987; Polan et al., 1991; Sullivan, 1991). Individual characteristics of the infant and mother influence the reciprocal interaction in such a way that a continual cycle of negative behavioral responses are perpetuated (Crittenden, 1987; Haynes et al., 1984), thus N O F I T may occur because of a poor fit between the infant and mother (Wittenberg, 1990). Although it is now recognized that the infantmother interaction is paramount to the development of NOFFF, researchers continue to focus on
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maternal behaviors. "Interactive" characteristics of the mothers of NOFTT infants have been implicated as causative factors in the infant's NOFTT (Benoit et al., 1989). Maternal behaviors with NOFTT infants have been well described across a variety of feeding and play interactions. When compared with the interactional behaviors of mothers of healthy infants, mothers of NOFTT infants demonstrated fewer vocalizations (Berkowitz & Senter, 1987; Bradley, Casey, & Wortham, 1984), less social responsiveness (Bradley et al., 1984; Drotar, Eckerle, Satola, Pallotta, & Wyatt, 1990; Lobo et ak, q992), insensitivity to infant cues (Crittenden, 1987; Fosson & Wilson, 1987; Ramsay et al., 1993), more negative emotional behavior (Fosson & Wilson, 1987; Hanks, Hobbs, Seymour, & Stratton, 1988), poor affective expression (A1fasi, 1982; Drotar et al., 1990; Ramsay et al., 1993), and emotional unavailability (Benoit et al., 1989; Drotar et al., 1990; Singer et al., 1990). The described maternal interactive behaviors provide partial support for the hypothesized maladaptive interaction associated with NOFTT. While evidence may support the maternal contribution to the interactive process of NOFTT, the infant's behavioral style and its potential contribution to this maladapted interaction and subsequent development of NOFTT has not been as clearly explained. Observations of NOFTT infants during interactions with others have focused on motor, vocal, and facial characteristics. Compared with healthy infants, NOFTT infants have been found to demonstrate limited motor responses, such as infantile posturing, decreased motor activity, and belowage locomotive skills (Bithoney & Newberger, 1987; Powell & Low, 1983; Powell, Low, & Speers, 1987). Vocal responsiveness is also diminished in NOFTT infants. When observed interacting with others, NOFTT infants have diminished vocalizations when stimulated, diminished spontaneous vocalizations, more fussing and whining, and more crying when approached (Powell & Low, 1983; Powell et al., 1987; Rosen et al., 1980; Wolke et al., 1990). NOFTT infants were described as having an emotionless face (Powell et al., 1987) with gaze aversion and minimal smiling, and when emotions were displayed, the facial expressions were most often of a negative affect (Abramson, 1991; Polan et al., 1991; Wolke et al., 1990). These similar motor, vocal, and facial characteristics also have been found to distinguish NOFTT infants from infants whose FTT is secondary to organic disease (Powell et al., 1987; Rosen et al., 1980) thereby eliminating poor weight gain as the only
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explanation for the behavioral style of NOFTT infants. While these behaviors are characteristic of the NOFTT infant, the impact of these behaviors on the infant-mother interaction has not been thoroughly examined. The hypothesized problematic infant-mother interaction is also influenced by the environmental context in which it occurs. The infant and mother interact individually with the environment and these environmental influences are reflected in the reciprocal relationship between the infant and mother. Home environments of NOFTT infants, including the feeding environment, have been described as less than optimal for fostering growth. These home environments were characterized as disorganized with mothers who were nonresponsive and unaccepting (Bradley et al., 1984), impoverished and overcrowded (Dubowitz, Zuckerman, Bithoney, & Newberger, 1989), with limited external resources (Drotar & Sturm, 1989), and having problematic family relationships with less cohesion and less expressiveness (Drotar & Eckerle, 1989). Examination of the feeding environment of the NOFTT infant has demonstrated a number of variables that have created tension during feeding. Infant feedings have been found to occur in a tense and chaotic atmosphere with high levels of distracting noise and movement and parental indifference (Heptinstall et al., 1987; Mathisen, Skuse, Wolke, & Reilly, 1989). While the described characteristics of the mother, the infant, and the environment would certainly support the hypothesis that a maladaptive infantmother interaction results in NOFTT, the dilemma is that all of these findings are based on research after NOFFT has occurred. In explaining the development of NOFTT, cause and effect are difficult to determine from these findings (Casey, 1987). An important question to consider is whether these maternal and infant characteristics existed prior to the development of NOFTT and contributed to the problematic infant-mother interaction or whether these characteristics are the result of NOFTT and then resulted in a problematic infant-mother interaction. The observed interactional difficulties between the infant and mother could be either causative or consequential of NOFTT (Hutcheson et al., 1993). Although a problematic infant-mother interaction is hypothesized to be a causative factor in the development of NOFTT, especially in early infancy (Chatoor & Egan, 1983; Drotar, 1985), this interaction remains one of the least understood aspects of NOFFT (Benoit et al., 1989). Equal consideration of the interactive contribution of both the infant and
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the mother in the development of N O F T r would result in a more comprehensive understanding of this phenomenon (Skuse, 1985).
TRANSACTIONAL MODEL OF NONORGANIC FAILURETO THRIVE In the NOFFT literature, discussion has focused on the need for development of a theoretical model that emphasizes a transactional approach to explaining the role of the infant-mother interaction in the etiology of NOFTT (Bithoney et al., 1992; Bradley & Casey, 1985; Casey, 1987). In understanding NOb-TF, a transactional model is relevant because the infant is viewed as an active participant in its own growth outcome and a balanced view is taken of the infant's and mother's contribution to the infant's growth outcome (Sameroff & Chandler, 1975). Because the infant-mother interaction is a responsive process, a transactional approach recognizes the multiple interactions and mutual adaptations that occur over time between the infant and mother (Boddy & Skuse, 1994; Casey, 1983). A synthesis of these discussions builds on the early work of Bradley and Casey (1985), who first discussed the transactional model of nonorganic failure to thrive. The transactional model of N O F I T has been expanded to further define the conceptual framework. This framework can be used to predict how the behavioral characteristics that the infant and the mother bring to the infant-mother interaction influence this interaction in such a manner that an interference with nutritional intake and the subsequent development of NOFTT occurs. The transactional model of NOF'VF (Fig. 1) specifies that central to the development of NOF-TI" is a breakdown in the infant-mother interaction that is directly related to the ongoing transactions that occur between the infant and mother (Bithoney et al., 1992; Bradley & Casey, 1985). Transactions are defined as the continual and progressive interplay that occurs between the infant and mother (Sameroff & Chandler, 1975). Neither the infant nor the
ENVIRONMENT ~ % ~ ~-~Alterati~ Nutritionin~-~~ ~-~~ --4~ NOFTT TIME I,
Figure !. TransactionalModel of Nonorganic Failure to Thrive. Infant characteristics; M = Maternal characteristics. A = Negative changes in infant-molher interaction. 9 = Diminishing Infant-molher interaction.
I =
mother singularly determines the infant's growth outcome; rather it is the synergistic nature of the transactions between the infant and the mother and the environmental context in which these transactions occur that determines the infant's growth outcome (Bradley & Casey, 1985; Bithoney et al., 1992). The nature of these transactions are influenced by the characteristics of both the infant and the mother, such that these characteristics transact over time resulting in changes in the infant and mother that perpetuate a cycle of maladaptation in the infant-mother interaction (Casey, 1987; Frank & Zeisel, 1988; Goldson, Milla, & Bentovim, 1985). The breakdown in the infant-mother interaction is not simply related to the inability of either the infant or mother to respond appropriately, but rather it is related to a continuous malfunction in the transactions across time that prevent mutual adaptation in the interaction (Sameroff & Chandler, 1975). As this maladapted interaction continues in a problematic trajectory, the context for undernutrition is created, ultimately culminating in the development of N O F I T (Frank & Zeisel, 1988). For example, the infant who is apathetic and passive and does not give clear cues is ineffective in communicating with the mother. The mother, in turn, misinterprets the infant's cues and needs, resulting in a perpetuation of a problematic infantmother interaction. The transactional model of NOFTT provides a conceptual framework for predicting growth outcome in infants through recognition of equal consideration of both the infant and the mother and the influence of the environment on the bidirectional nature of the infant-mother interaction. Because the causes of NOFTI" are thought to be due to multiple factors, the transactional model of NOFTT allows consideration of multiple infant and maternal characteristics as well as characteristics of the home environment that interact to impact the infant's nutritional intake (Bradley et al., 1984). However, because the role of infant, matemal, and environmental factors in the etiology of NOFTT essentially remains speculative, methodologically sound research guided by theory is essential (Boddy & Skuse, 1994). Because current research findings indicate that N O F I T infants and mothers are a heterogeneous population (Drotar, 1992), the transactional model of NOFTT provides the framework to ask the many questions necessary to account for the multiple interactions between the characteristics of the infant, mother, and environment that may explain the cause of N O P T r (Bradley et al., 1984). This model further directs these questions to focus
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on understanding the transactional changes that must occur between the infant and mother to result in NOFTT. As a conceptual framework, the transactional model of NOFTT is an abstract representation of the phenomena that can guide more specific theorizing at a midrange level. This framework can be an overarching framework that would encompass other midrange theories such as Barnard's (1991) theory of parent-child interaction, cognitive theories of decision-making (Fishbein, 1994), and self-efficacy (Bandura, 1995). This model offers useful assumptions about how the behavior develops over time and how a number of factors in the infant's environment interact to create the present health state of the infant.
CONCLUSION It is of limited value after NOFTT has occurred to continue to describe characteristics of the NOFTT infant or mother in isolation if no attempt is made to understand how the behaviors of the infant and mother resulted in NOFTT (Boddy & Skuse, 1994). Prospective evaluation of the infant-mother interac-
tion prior to the development of NOFTT would provide the most conclusive evidence for the relationship between the infant-mother interaction and NOFTT. Research with a prospective design would facilitate identifying those variables that alter the infant-mother interaction and contribute to the development of NOFTT (Berkowitz & Senter, 1987; Casey, 1987; Polan et al., 1991; Wolke et al., 1990) and would provide further clarification of those variables that contribute to NOFTT and which variables are a result of NOFTT (Casey, 1987). While there are many unanswered questions surrounding NOFTT, the most significant questions should focus on understanding how NOFTT develops. The transactional model of NOFTT can be a useful theoretical framework to guide that understanding.
Acknowledgments The authors would like to thank Dr. Debra Moser and Dr. Nancy Ryan-Wenger for their editorial assistance with this manuscript.
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Copyright 9 1997 by W.B. Saunders Company
'ONORGANIC FAILURE TO THRIVE (NOFTT) is a significant health problem of infancy. Although the exact incidence is unknown, NOFTT accounts for 10% of all children seen in an outpatient setting and 1% to 5% of all admissions to pediatric hospitals (Broughton, 1989; Casey, 1987; Frank, Silva, & Needlman, 1993). At least 80% of cases occur prior to 18 months of age (Bithoney, Dubowitz, & Egan, 1992) during the critical time of rapid weight gain. Nonorganic failure to thrive is a syndrome in which an infant's weight gain deviates from an established pattern of growth and becomes dramatically less than norms for age and sex (Frank & Zeisel, 1988). When NOFTT is identified there is no obvious disease process to account for the growth failure. All infants with NOFTT present with varying degrees of malnutrition (Ramsay, Gisel, & Boutry, 1993). NOFTT can be detrimental to both long-term physical growth and neurodevelopment. Despite intervention, children with histories of NOFTT as infants exhibit continued growth failure (Kristiansson & Fallstrom, 1987; Skuse, Reilly, & Wolke, 1994), developmental delay (Field, 1984), behavioral problems (Brinich, Drotar, & Brinich, 1989; Drotar & Sturm, 1992), and cognitive deficits (Drotar & Sturm, 1988; Singer, 1986). Although NOFTT is a significant problem, the
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From The Ohio State University, College of Nursing, Department of Adult Health & Illness, Columbus, OH. Address reprint requests to Bonnie J. Garvin, PhD, RN, The Ohio State University, College of Nursing, Department of Adult Health & Illness, 1585 Neil Avenue, Columbus, Ohio 432101289. Copyright 9 1997 by W.B. Saunders Company 0882-5963/97/1204-000453.00/0
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development of NOFTT has not been thoroughly explained. The causes of NOFTT are thought to be a result of multiple factors (Boddy & Skuse, 1994; Casey, 1987). What those factors are and how they interact to result in NOFTT is not well understood. One plausible explanation for the dearth of knowledge concerning the development of NOFTT may be related to the lack of theory to guide the inquiry. Theory specific to explaining the multiple causes of NOFTT is limited (Hutcheson, Black, & Starr, 1993). The lack of theoretical advancement in NOFTT has left many unanswered questions concerning causation. A theoretical framework is needed to organize knowledge development (Boddy & Skuse, 1994). Explaining the multiple causes of NOFTT would necessitate identifying and clarifying those variables that contribute to the development of NOFTT. The purpose of this article is to present an integrative review of what is known about NOFTT and to describe a theoretical framework that would provide the direction necessary for asking relevant questions related to the development of NOFTT (Fawcett, 1995). This literature review and proposed framework to explain the development of NOFTT could be used to guide future research.
MATERNAL FACTORS Historically, the primary emphasis for determining the cause of NOFTT was directed toward examining maternal characteristics. Researchers interested in explaining how NOFTT developed concentrated on the maternal contribution to the occurrence of NOFTT. Early researchers focused on characteristics of mothers of NOFTT infants considered to be related to inadequate mothering Journalof PediatricNursing,Vol 12, No 6 (December),1997
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ability. These included various forms of psychopathology such as anxiety and depression, preoccupation with life stresses, feelings of parental incompetence, and an inability to interact appropriately with the environment (Barbero & Shafieen, 1967; Elmer, 1960; Evans, Reinhart, & Succop, 1972; Fischoff, Whitten, & Pettit, 1971; Shaheen, Alexander, Truskowsky, & Barbero, 1968; Togut, Allen, & Lelchuck, 1969). While there are some commonalities among these findings, the failure to include control groups limits the generalizability and significance of these findings (Boddy & Skuse, 1994; Pollitt, Eichler, &Chan, 1975). Current researchers using control groups have demonstrated that when compared with mothers of healthy infants, mothers of NOFTT infants have no more life stresses (Altemeier, O'Connor, Sherrod, & Vietze, 1985; Bithoney, Van Sciver, Foster, Corso, & Tentindo, 1995; Lobo, Barnard, & Coombs, 1992) or psychopathology (Polan et al., 1991; Singer, Song, Hill, & Jaffe, 1990) and no differences in perceived social support (Altemeier et al., 1985; Bithoney & Newberger, 1987; Hutcheson et al., 1993). Some differences have been noted when mothers of NOFTF infants were compared with mothers of healthy infants. Mothers of NOF-q~ infants were less likely to have finished high school (Haynes, Cutler, Gray, & Kempe, 1984; Hutcheson et al., 1993; Kotelchuck & Newberger, 1983; Singer et al., 1990). NOFTF mothers differed on perceptions of their own childhood and the relationship with their partners. Nonorganic failure to thrive mothers described their childhood's as more negative. These mothers were more likely to experience an increased incidence of abuse and neglect (Altemeier et al., 1985; Haynes et al., 1984), inadequate nurturing (Altemeier et al., 1985; Haynes et al., 1984), and more childhood stresses (Kotelchuck & Newberger, 1983; Range, Brown, & King, 1983). Relationships with their partners were also perceived as negative. Numerous problems with the partner included lack of involvement, abuse, increased conflict, and incarceration (Altemeier et al., 1985; Benoit, Zeanah, & Barton, 1989; Crittenden, 1987; Lobo et al., 1992). Although there are some differences between NOFI'T mothers and comparison mothers, these differences and the focus on maternal factors have not been distinct enough to explain the development of NOF/T. This narrow emphasis has excluded the examination of other potentially significant factors and their contribution to NOFTI" (Drotar, 1991).
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INFANT FACTORS Researchers now recognize that infants may contribute to their own growth failure because of the behaviors they exhibit. Growing evidence suggests that NOFTF infants are perceived as behaviorally difficult by their mothers (Bithoney & Newberger, 1987; Bithoney et al., 1995; Wolke, Skuse, & Mathisen, 1990). Early researchers also described NOFTF infants as behaviorally difficult exhibiting apathy, unusual watchfulness, diminished vocalizations, lack of cuddliness, and poor feeding (Glaser, Heagarty, Bullard, & Pivchik, 1968; Leonard, Rhymes, & Solnit, 1966). Currently, the few researchers who have studied NOFTI" infants have identified similar behaviors unique to NOFTF infants, such as low behavioral reactivity, including lethargy, passivity, and decreased motor activity, hypervigilance, and poor feeding ability (Bithoney et al., 1992; Frank & Zeisel, 1988; Powell, 1988). NOFTF infants have also been described as irritable, resistant to touch, exhibiting distress when approached, and indifferent to separation (Powell & Low, 1983; Rosen, Loeb, & Jura, 1980). While the unique behaviors exhibited by NOFTF infants could be significant to the development of NOFTT, the specific contribution of these behaviors remains unknown (Bithoney et al., 1995).
INFANT-MOTHER INTERACTION In considering causation, it is highly improbable that maternal and infant factors are individually responsible for the development of NOFTT (Bithoney et al., 1992; Skuse, 1985). Nonorganic failure to thrive may result from a problematic infant-mother interaction, whereby the infant and mother both make an important contribution to the interactional process (Benoit et al., 1989; Bithoney et al., 1992; Drotar, 1991; Skuse, 1985). Investigators propose that very early in the infant-mother relationship, the reciprocal interaction between the infant and mother becomes maladaptive resulting in an interference with nutritional intake and the subsequent development of NOFTT (Bithoney & Newberger, 1987; Casey, 1987; Polan et al., 1991; Sullivan, 1991). Individual characteristics of the infant and mother influence the reciprocal interaction in such a way that a continual cycle of negative behavioral responses are perpetuated (Crittenden, 1987; Haynes et al., 1984), thus N O F I T may occur because of a poor fit between the infant and mother (Wittenberg, 1990). Although it is now recognized that the infantmother interaction is paramount to the development of NOFFF, researchers continue to focus on
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maternal behaviors. "Interactive" characteristics of the mothers of NOFTT infants have been implicated as causative factors in the infant's NOFTT (Benoit et al., 1989). Maternal behaviors with NOFTT infants have been well described across a variety of feeding and play interactions. When compared with the interactional behaviors of mothers of healthy infants, mothers of NOFTT infants demonstrated fewer vocalizations (Berkowitz & Senter, 1987; Bradley, Casey, & Wortham, 1984), less social responsiveness (Bradley et al., 1984; Drotar, Eckerle, Satola, Pallotta, & Wyatt, 1990; Lobo et ak, q992), insensitivity to infant cues (Crittenden, 1987; Fosson & Wilson, 1987; Ramsay et al., 1993), more negative emotional behavior (Fosson & Wilson, 1987; Hanks, Hobbs, Seymour, & Stratton, 1988), poor affective expression (A1fasi, 1982; Drotar et al., 1990; Ramsay et al., 1993), and emotional unavailability (Benoit et al., 1989; Drotar et al., 1990; Singer et al., 1990). The described maternal interactive behaviors provide partial support for the hypothesized maladaptive interaction associated with NOFTT. While evidence may support the maternal contribution to the interactive process of NOFTT, the infant's behavioral style and its potential contribution to this maladapted interaction and subsequent development of NOFTT has not been as clearly explained. Observations of NOFTT infants during interactions with others have focused on motor, vocal, and facial characteristics. Compared with healthy infants, NOFTT infants have been found to demonstrate limited motor responses, such as infantile posturing, decreased motor activity, and belowage locomotive skills (Bithoney & Newberger, 1987; Powell & Low, 1983; Powell, Low, & Speers, 1987). Vocal responsiveness is also diminished in NOFTT infants. When observed interacting with others, NOFTT infants have diminished vocalizations when stimulated, diminished spontaneous vocalizations, more fussing and whining, and more crying when approached (Powell & Low, 1983; Powell et al., 1987; Rosen et al., 1980; Wolke et al., 1990). NOFTT infants were described as having an emotionless face (Powell et al., 1987) with gaze aversion and minimal smiling, and when emotions were displayed, the facial expressions were most often of a negative affect (Abramson, 1991; Polan et al., 1991; Wolke et al., 1990). These similar motor, vocal, and facial characteristics also have been found to distinguish NOFTT infants from infants whose FTT is secondary to organic disease (Powell et al., 1987; Rosen et al., 1980) thereby eliminating poor weight gain as the only
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explanation for the behavioral style of NOFTT infants. While these behaviors are characteristic of the NOFTT infant, the impact of these behaviors on the infant-mother interaction has not been thoroughly examined. The hypothesized problematic infant-mother interaction is also influenced by the environmental context in which it occurs. The infant and mother interact individually with the environment and these environmental influences are reflected in the reciprocal relationship between the infant and mother. Home environments of NOFTT infants, including the feeding environment, have been described as less than optimal for fostering growth. These home environments were characterized as disorganized with mothers who were nonresponsive and unaccepting (Bradley et al., 1984), impoverished and overcrowded (Dubowitz, Zuckerman, Bithoney, & Newberger, 1989), with limited external resources (Drotar & Sturm, 1989), and having problematic family relationships with less cohesion and less expressiveness (Drotar & Eckerle, 1989). Examination of the feeding environment of the NOFTT infant has demonstrated a number of variables that have created tension during feeding. Infant feedings have been found to occur in a tense and chaotic atmosphere with high levels of distracting noise and movement and parental indifference (Heptinstall et al., 1987; Mathisen, Skuse, Wolke, & Reilly, 1989). While the described characteristics of the mother, the infant, and the environment would certainly support the hypothesis that a maladaptive infantmother interaction results in NOFTT, the dilemma is that all of these findings are based on research after NOFFT has occurred. In explaining the development of NOFTT, cause and effect are difficult to determine from these findings (Casey, 1987). An important question to consider is whether these maternal and infant characteristics existed prior to the development of NOFTT and contributed to the problematic infant-mother interaction or whether these characteristics are the result of NOFTT and then resulted in a problematic infant-mother interaction. The observed interactional difficulties between the infant and mother could be either causative or consequential of NOFTT (Hutcheson et al., 1993). Although a problematic infant-mother interaction is hypothesized to be a causative factor in the development of NOFTT, especially in early infancy (Chatoor & Egan, 1983; Drotar, 1985), this interaction remains one of the least understood aspects of NOFFT (Benoit et al., 1989). Equal consideration of the interactive contribution of both the infant and
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the mother in the development of N O F T r would result in a more comprehensive understanding of this phenomenon (Skuse, 1985).
TRANSACTIONAL MODEL OF NONORGANIC FAILURETO THRIVE In the NOFFT literature, discussion has focused on the need for development of a theoretical model that emphasizes a transactional approach to explaining the role of the infant-mother interaction in the etiology of NOFTT (Bithoney et al., 1992; Bradley & Casey, 1985; Casey, 1987). In understanding NOb-TF, a transactional model is relevant because the infant is viewed as an active participant in its own growth outcome and a balanced view is taken of the infant's and mother's contribution to the infant's growth outcome (Sameroff & Chandler, 1975). Because the infant-mother interaction is a responsive process, a transactional approach recognizes the multiple interactions and mutual adaptations that occur over time between the infant and mother (Boddy & Skuse, 1994; Casey, 1983). A synthesis of these discussions builds on the early work of Bradley and Casey (1985), who first discussed the transactional model of nonorganic failure to thrive. The transactional model of N O F I T has been expanded to further define the conceptual framework. This framework can be used to predict how the behavioral characteristics that the infant and the mother bring to the infant-mother interaction influence this interaction in such a manner that an interference with nutritional intake and the subsequent development of NOFTT occurs. The transactional model of NOF'VF (Fig. 1) specifies that central to the development of NOF-TI" is a breakdown in the infant-mother interaction that is directly related to the ongoing transactions that occur between the infant and mother (Bithoney et al., 1992; Bradley & Casey, 1985). Transactions are defined as the continual and progressive interplay that occurs between the infant and mother (Sameroff & Chandler, 1975). Neither the infant nor the
ENVIRONMENT ~ % ~ ~-~Alterati~ Nutritionin~-~~ ~-~~ --4~ NOFTT TIME I,
Figure !. TransactionalModel of Nonorganic Failure to Thrive. Infant characteristics; M = Maternal characteristics. A = Negative changes in infant-molher interaction. 9 = Diminishing Infant-molher interaction.
I =
mother singularly determines the infant's growth outcome; rather it is the synergistic nature of the transactions between the infant and the mother and the environmental context in which these transactions occur that determines the infant's growth outcome (Bradley & Casey, 1985; Bithoney et al., 1992). The nature of these transactions are influenced by the characteristics of both the infant and the mother, such that these characteristics transact over time resulting in changes in the infant and mother that perpetuate a cycle of maladaptation in the infant-mother interaction (Casey, 1987; Frank & Zeisel, 1988; Goldson, Milla, & Bentovim, 1985). The breakdown in the infant-mother interaction is not simply related to the inability of either the infant or mother to respond appropriately, but rather it is related to a continuous malfunction in the transactions across time that prevent mutual adaptation in the interaction (Sameroff & Chandler, 1975). As this maladapted interaction continues in a problematic trajectory, the context for undernutrition is created, ultimately culminating in the development of N O F I T (Frank & Zeisel, 1988). For example, the infant who is apathetic and passive and does not give clear cues is ineffective in communicating with the mother. The mother, in turn, misinterprets the infant's cues and needs, resulting in a perpetuation of a problematic infantmother interaction. The transactional model of NOFTT provides a conceptual framework for predicting growth outcome in infants through recognition of equal consideration of both the infant and the mother and the influence of the environment on the bidirectional nature of the infant-mother interaction. Because the causes of NOFTI" are thought to be due to multiple factors, the transactional model of NOFTT allows consideration of multiple infant and maternal characteristics as well as characteristics of the home environment that interact to impact the infant's nutritional intake (Bradley et al., 1984). However, because the role of infant, matemal, and environmental factors in the etiology of NOFTT essentially remains speculative, methodologically sound research guided by theory is essential (Boddy & Skuse, 1994). Because current research findings indicate that N O F I T infants and mothers are a heterogeneous population (Drotar, 1992), the transactional model of NOFTT provides the framework to ask the many questions necessary to account for the multiple interactions between the characteristics of the infant, mother, and environment that may explain the cause of N O P T r (Bradley et al., 1984). This model further directs these questions to focus
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on understanding the transactional changes that must occur between the infant and mother to result in NOFTT. As a conceptual framework, the transactional model of NOFTT is an abstract representation of the phenomena that can guide more specific theorizing at a midrange level. This framework can be an overarching framework that would encompass other midrange theories such as Barnard's (1991) theory of parent-child interaction, cognitive theories of decision-making (Fishbein, 1994), and self-efficacy (Bandura, 1995). This model offers useful assumptions about how the behavior develops over time and how a number of factors in the infant's environment interact to create the present health state of the infant.
CONCLUSION It is of limited value after NOFTT has occurred to continue to describe characteristics of the NOFTT infant or mother in isolation if no attempt is made to understand how the behaviors of the infant and mother resulted in NOFTT (Boddy & Skuse, 1994). Prospective evaluation of the infant-mother interac-
tion prior to the development of NOFTT would provide the most conclusive evidence for the relationship between the infant-mother interaction and NOFTT. Research with a prospective design would facilitate identifying those variables that alter the infant-mother interaction and contribute to the development of NOFTT (Berkowitz & Senter, 1987; Casey, 1987; Polan et al., 1991; Wolke et al., 1990) and would provide further clarification of those variables that contribute to NOFTT and which variables are a result of NOFTT (Casey, 1987). While there are many unanswered questions surrounding NOFTT, the most significant questions should focus on understanding how NOFTT develops. The transactional model of NOFTT can be a useful theoretical framework to guide that understanding.
Acknowledgments The authors would like to thank Dr. Debra Moser and Dr. Nancy Ryan-Wenger for their editorial assistance with this manuscript.
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