Deciding whether to involve social services can be straightforward, or can be very difficult. If it has become obvious that a child with weight faltering is living in a family with other major social problems, such as domestic violence or drug or alcohol abuse, a referral to social services should be made, as in any case where there is evidence suggesting abuse or neglect. The much more diffi-cult situation is where there are suspicions that the weight faltering may be a result of neglect or emotional factors, but there are no other concerns about the care of the child. In this case a referral would usually only be considered if there was very severe weight faltering which persisted despite appropriate advice and support. It is important to ensure that families have been appropriately advised and have truly heard this advice (Wright and Talbot 1996). Sometimes it may need to be repeated by different people or with different degrees of authority before the message finally gets through.
A global picture should be built up and the consideration of possible referral returned to as new information is obtained. The health visitor is usually the most well aware of family circumstances, but may need the prompt of dis-cussion with a multidisciplinary team or from one of the other specialists involved, to arrive at a decision to refer. Most of the factors to be taken into account are themselves part of a spectrum and Table 10.1 summarizes the sorts of issues that should be considered and how they might influence the decision.
How might social services help?
Children can usually be referred as children ‘in need’ unless there are active concerns about concurrent abuse. A planning meeting or informal case discus-sion should usually be convened to discuss the range and extent of the family’s problems and what would be the best therapeutic options. Possible initial options would include:
· social work assessment
· social work aide input
· family centre input
· specialist nursery placements
· sponsored child-minding.
Table10.1RiskAssessmentgrid:indicatorsforreferraltosocialservices Category1Category2Category3Category4 GrowthpatternWorsening,severe,weight falteringandunderweightLackofimprovementin growthpatternorrelapse afterinitialimprovement
Partialimprovementonlyor partialrelapseSteadycatch-uporrisen <2centilespacesbelo expectedweight Child’sfeedingbehaviour (atawitnessedmeal)Familyknowntowithold foodChildobservedtobe hungryChildobservetoeatpoorlyChildobservedtoeat Development (assumingmedicalfactors excluded)
Worseningdevelopmental delaySomedevelopmentaldelay ConcernsaboutabuseorneglectNewevidenceofphysicalor sexualabuseConcernsaboutglobal neglectofchildorsiblingsSomeconcernaboutgeneral careorpaternalcompetence GrowthofsiblingsSiblingscurrently under-nourisedSiblingfalteredinthepastOthersiblingsnotaffected FamilysituationMajorsocialorfinancial problemsMultiplesocialorfinancial problemsApparentlyisolatedissues FamilymotivationFamilyseekingsocial servicesinputFamilywillingforsocial serviceinput AnyiteminCategory1shouldusuallytriggerreferral,asshouldtwoormoreinCategory2orfourormoreinCategory3. AnyiteminCategory4wouldnormallylessenthelevelofoverallconcern,butwouldnotover-rideothermajorconcerns.
Box 10.1 Case example: Anne Marie
Anne-Marie had prolonged involvement with health and social services because of early concerns about neglect. Concerted multi-disciplinary work began with the family when she was 12 months old. She was regis-tered at the age of 33 months on the ground of neglect, with her two siblings who also had faltering growth. The family then received inten-sive daily support, but it became apparent that nearly all food and care was now being offered by social services, nursery staff and extended family members. There were also signs of emotional and physical abuse.
When the care package was wound back, family conditions deteriorated rapidly. Finally, after the parents had failed to engage with formal assess-ment of their parenting, all three siblings were removed into care when Anne-Marie was 4½ years old.
2 4 6 8 10 12 14 16 18 20 22
0 6 12 18 24 30 36 42 48 54 60
Age in months
Weight(Kg)
Registered on grounds of neglect
Intensive care package Full time nursery place + meals
Support Reduced Foster
care
Weight faltering identified Multi-disciplinary input
Figure 10.4 Anne-Marie’s weight gain pattern over time plotted on a standard UK growth chart
Box 10.2 Case example: Paul
Paul showed early severe weight faltering which was investigated at an early stage and revealed no organic cause. Although there were concerns about possible physical abuse and the mother was known to be depressed, she proved difficult to engage in any way.
After showing rapid catch-up weight gain during a hospital admis-sion aged 19 months, but no further improvement, social services’
involvement was sought. They were initially reluctant to play a role but at the age of 27 months a social worker was allocated, a nursery placement was found and his mother accepted counselling.
Figure 10.5 Paul’s weight gain pattern over time plotted on a standard UK growth chart
2 4 6 8 10 12 14 16 18 20
0 6 12 18 24 30 36 42 48
Age in months
Weight(Kg)
Steady catch-up after social worker allocated and services taken up Rapid weight gain in
hospital
Static weight at home
Rapid early fall in centile without recovery
Monitoring progress
Clear goals should be set for the family in terms both of engagement with services and of the expectation of sustained weight catch-up. Dramatic improvement can be seen while still at home and alternative care is not usually needed. While parental co-operation is important neither this alone, nor their reports of their child’s diet, can be used as a robust measure of progress unless they are reflected in actual changes in growth.
Progress should therefore be assessed using a series of weights plotted on centile charts. Any single weight may not be representative so it is important not to let the last weight measured influence decisions in isolation. Children with continuing failure to thrive usually do gain weight over time, but at too slow a rate, with the result that their weight tracks along the low centile they have fallen to. Catch-up weight gain is occurring when a child gains weight more rapidly, with most plotted weights being at a higher centile position than the last. This means that over time the child’s weight moves from their low centile to one more appropriate to their genetic potential.
Catch-up weight gain can begin rapidly after dietary change has occurred, but it is usually two to three months before this can be clearly recognized on a growth chart. Recovery can be said to have occurred when a child’s weight and height have caught up to within two centile spaces of their expected centile, taking into account early weight and height gain and parental heights. Where there has been a long fall in weight this will take between one and three years, and may never be complete. However, if there is continued catch-up over 6–12 months, with one to two centile spaces (or their equivalent) crossed upwards, social services input could probably then be safely withdrawn, with monitor-ing only by health.
Interpretation of progress can be difficult where there is a conflict between the parents’ account and the child’s objective progress. It is important to remember that all foods eaten must be used by the body in some way except in rare medical conditions that will have been excluded before referral. Therefore, whatever parents report, if there has been no catch-up there has not been an overall increase in intake.
Alternatively, if very extensive support is provided for the family and child, any recovery seen may result solely from external input, rather than family change. If this is thought to be the case, there should be a period of continued monitoring after withdrawal of intensive support before the case is closed.