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This is to certify that the

thesis entitled

PSYCHOSGEIAL ASSESSMENTI AND MANACEMEN'I‘ OF
NONORGANIC FAILURE TO THRIVE:
CCNSENSUS RECII’MENDATIONS VERSUS ACTUAL PRACTICE

IN A WfilTY—‘BASEQHOSBITAL SEITING
presented by

NICHOLAS SALVATORE IALONGO

 

has been accepted towards fulfillment
of the requirements for

M.A. degree in PSYCHOLOGY

DR. FITZGERALD

Major professor

Date 8-10-84

0-7639 MSU is an Affirmative Action/Equal Opportunity Institution

 

 

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PSYCHOSOCIAL ASSESSMENT ANDI Attainment“ or

1

NONORGANIC FAILURE TO THRIVE:
CONSENSUS RECOMMENDATIONS VERSUS ACTUAL PRACTICE

IN A COMMUNITY-BASED HOSPTIAL SETTING
BY

Nicholas Salvatore lalongo

A THESIS

Submitted to
Michigan State University
in partial fufillment of the requirements

for the degree of
MASTER OF ARTS
Department of Psychology

l98h

ABSTRACT
PSYCHOSOCIAL ASSESSMENT AND MANAGEMENT OF
NONORGANIC FAILURE To THRIVE:
CONSENSUS RECOMMENDATIONS VERSUS ACTUAL PRACTICE
IN A COMMUNITY BASED HOSPITAL SETTING
By

Nicholas Salvatore lalongo

The purpose of the present study was to determine whether the
clinical practices of a community-based hospital reflected the consensus
in the literature regarding the need to consider psychosocial as well as
biomedical factors in the diagnosis and management of nonorganic failure
to thrive (NOFT). To that end, the charts of I] of the 18 infants admitted
to the hospital over a one year period for unexplained growth failure were
reviewed to assess compliance with the psychosocial components of the Kerr
and Kennel (l980) NOFT diagnostic protocol. Also assessed was the match
between the psychosocial services provided and the corresponding needs of
the l5 infants and families for which the diagnosis of NOFT was confirmed.
Psychosocial need was determined by an evaluation consistent with Kerr
and Kennel's (l980) NOFT diagnostic protocol. In addition to finding a
general failure to comply with the psychosocial components of the Kerr
and Kennel model, a relatively poor match was found between psychosocial
need and the relevant services provided. Results were consistent with a
previous report suggesting that hospital practices may not reflect the
consensus in the literature regarding the diagnosis and management of

NOFT.

ACKNOWLEDGEMENTS

I wish to thank all my committee members for their assistance and
the inordinate amount of patience and flexibility they displayed in
serving on my committee. Special thanks to Dr. Fitzgerald for
his invaluable editorial assistance. Much thanks to Jolie Brams who
made this project possible. Finally, thanks to Jane for her help

with the typing of the thesis and her continual moral support.

TABLE OF CONTENTS

Page
LIST OF TABLES. . . . . . . . . . . . . . . . . . . . . . . iv
LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . v
Chapter
I. INTRODUCTION. . ...... . . . . . . . . . . . . . l
ll. LITERATURE REVIEW . . . . . . . . . . . . . . . . . . 3
III. METHOD. . . . . . . . ...... . . . . . . . . . . l2
Subjects. . . . ..... . . . . . . . . . . . . . . 12
Setting . . . . . ...... . . . . . . . . . . . . l3
Measures. . . . . . . . . . . . . . . . . . . . . . . 13
Procedures. . . . . . . . . . . . . . . . . . . . . . 18
IV. RESULTS . . . . . . . . . . . . . . . . . . . . . . . 20
V. DISCUSSION. . . . . . . . . . . . . . . . . . . . . . 28
Limitations . . . . . . . . . . . . . . . . . . . . . 39

LIST OF REFERENCES . . . . . . . . . . . . . . . . . . . A2

APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . 50

TABLE

LIST OF TABLES

Hospital compliance with the proceedures
specified in the Kerr 8 Kennel (l980)
protOCOI O O O O O O O O O O O O O O O O 0 O O O 0 O O 2]

Results of psychosocial assessments in the
15 confirmed cases of NOFT . . . . . . . . . . . . . . 23

Psychosocial needs of the IS confirmed cases
of NOFT and the psychosocial services provided . . . . 25

FIGURE

l

A multilevel,

LIST OF FIGURES

interactional model of NOFT .

O

INTRODUCTION ‘

Nonorganic failure to thrive (NOFT) is a relatively common but serious
disturbance in infant physical development that has multiple psychosocial
concomitants, sequelae and determinants. Consistent with the biopsycho-
social nature of this serious pediatric problem. there is a clear consen-
sus in the literature regarding the necessity of a comprehensive biopsy-
chosocial approach to its diagnosis and management. Yet the results of a
recent study (Drotar. Malone, Negray, 8 Dennestaedt, l98l) raise serious
doubts as to whether this consensus is reflected in actual practice. In
their retrospective chart review of 30 infants hospitalized for NOFT over
a two year period at a university based teaching hospital. Drotar et al.
found an almost exclusively biomedical approach to assessment and inter-
vention. Specifically. for nearly two-thirds of the cases reviewed,
diagnosis and management consisted soley of the ruling out of organic
cause and the provision of nutritional therapy. Drotar et al. (l98l)
note the importance of further studies to establish the generalizability
of their results to community based hospitals, where the majority of
NOFT infants are seen. The data presented here address the issue of the
of the generalizability of the Drotar et al. findings to community-based
settings. The specific questions addressed are: (I) Do community-based
hospital practices adequately reflect the consensus in the literature re-
garding the necessity of considering psychosocial as well as biomedical

factors in the diagnosis of NOFT? (2) How effective is the match between

the psychosocial needs of NOFT infants and their families and the ser-

vices provided in a community-based hospital setting?

LITERATURE REVIEW

Failure to thrive (FTT) is a serious disturbance in infant
physical growth, which presents in eighty per cent of cases before
the age of l8 months, and accounts for an estimated one per cent of
all pediatric hospitalizations (Berwick, I980; Kotelchuck 5 Newberger,
I978). Although there are discrepancies in the diagnostic criteria
for FTT. the term is typically used to describe infants whose
weight is persistently below the third percentile for age on stand-
ardized growth charts or less than 85 per cent of ideal weight for
age (Barbero 8 Shaheen. I967; Berwick, l980). FTT may also present
as acute weight loss or a failure to gain weight with the loss of
two or more major percentiles on the growth curve (Bithoney 8 Rath-
bun, I983). In as many as 30 per cent of the cases an organic basis
for the infant's growth failure is found (Homer 8 Ludwig, I981;
Sills, l978)--with cogenital heart disease. central nervous system
defects and malabsorption problems the most common organic causes.
However, in the majority of FTT cases an organic etiology will be
ruled out after extensive laboratory investigations (Homer 8 Ludwig,
I981; Sills, I978). The diagnostic term used to refer to this
latter group of infants Is nonorganic failure to thrive (NOFT).

NOFT infants are frequently characterized by one or more of the
following: food refusal, an atrophied sucking response. spitting up,
vomitting, diarrhea, and irritability--especially during feeding.
There appear to be a number of age related characterics as well.
Among the reported characteristics of NOFT infants less than four

months of age are unusual watchfulness. a lack of cuddliness, little

3

I;

smiling, and few vocalizations, whereas a lack of appropriate stranger
anxiety. few vocalizations (with delay in prespeech complex sound
utterances), deficiency in motor skill development and extreme passiv-
ity have been identified in infants between four and ten months of age
(Fischoff, Whitten 8 Pettit, l97l). It is extremely important to
to note that some NOFT infants may not display any of the behavioral
disturbances described above, while others may only display some.
The severity of the disorder and the particular deficits present
will vary for different children and circumstances.

Host NOFT cases show onset during early infancy, and the babies
are usually hospitalized between six and l2 months of age-~the primary
reasons for hospitalization usually being the failure to identify the
the cause of and to effectively treat the infant's growth failure on
an outpatient basis. More extensive laboratory investigations can be
be performed in the hospital. Furthermore, the infant's nutritional
deficits can be treated more aggressively--with superalimentation, an
important treatment option only available with hospitalization.

Although in as many as ten percent of hospital-admitted NOFT children.
the infant will show evidence of fractures and contusions (Bullard.
Glaser, Heagarty 5 Pivchik, I967), the evidence is not convincing that
NOFT is a by-product of battering. Retrospective studies of NOFT chil-
den strongly suggest a history of adverse perinatal conditions (Shaheen,
Alexander, Truskowsby 8 Barbero, 1968). but in most cases prior
indications of gross neurological and physical abnormalities are absent

or unremarkable (Bullard et al., I967).

5

Long-term follow-up studies suggest a number of psychological and
physical sequelae, including: standardized intelligence-score deficits,
poor school performances and a high indidence of socioemotional disorders,
and chronic physical illness (Glaser, Heagarty, Bullard 8 Pivchik, I968;
Elmer, Gregg G Ellison, I969; Pollitt 8 Eicher. I976; Hufton 8 Dates,
I977). Recently, however, Mitchell, Gorell 8 Greenberg (I980) presented
evidence that runs counter to these findings. The current research
on the effects of early adversity on later development (see Rutter,
l98l, l980; Kagan, Kearsley, E Zelazo, I978; and Clarke and Clarke,
l976) suggests that the reason for this discrepancy may be that
Hitchell et al.'s sample differed from those in the above studies in
terms of the severity and duration of the insult, the age at which
it occurred, and whether subsequent improvements were made in the
caregiving environment at a sufficiently early_age. None of the above
studies. however. provide the necessary data on their samples to
verify this hypothesis.

Research and theory on the etiology of NOFT have proceded at a num-
ber of levels. A point of sustained contention at the most basic level
has been whether NOFT is the result of inadequate caloric intake
(Krieger, I973; Whitten. Pettit, 8 Fischoff, I969) or a neuroendo-
crine disorder, secondary to emotional deprivation (Gardner, I972;
Powell, Brasel, & Blizzard. l967). Pollitt and Leibel (I980)
recently took the position, however. that these alternative expla-
nations are not mutually exclusive. Their stance is consistent with
the theoretical work of Lester (l979) and Rossetti-Ferreira (l978),
wherein the physical and psychological deficits associated with

early malnutrition are seen to be the result of a synergistic

6

interplay between nutritional and stimulatory factors. Specifically,
Lester (l979) and Rossetti-Ferriera argue that nutritional deficits
gradually produce a state of energy deprivation in the infant. Conse-
quently, the infant grows progressively less responsive to the caregiving
environment and, in turn, fails to elicit the stimulation and nurturance
necessary for adequate physical and psychological development development.
Accelerating this process in synergistic fashion is the fact that with
with decreased levels of infant activity, energy demands are lowered and,
as a result, infant appetite is suppressed.

Martorell (I980) argues that an additional factor, infection, needs
to be added to this synergistic equation. He presents evidence
that chronic malnutrition adversely affects the immune system, conse-
quently leaving the infant highly susceptible to infection. In turn,
infection simultaneously suppresses infant appetite and activity level.
Diarrhea, which is a frequent side effect of infection in malnourished
infants, further intensifies the nutritional deficits. The addition of
infection to the synergistic equation fits in nicely with Homer 8 Ludwig's
(l981) notion of the existence of a subgroup of failure to thrive infants
with a mixed organic/ndnorganic etiology (Homer 8 Ludwig, l98l).

The explanation of the occurence of these nutritional and stim-
ulatory deficits has been the subject of research and theory at
a second level of analysis. Here, too, a unifactor model of causation
has been superceded by an interactional one. This transition is con-
sistent with evolving developmental theory and the empirical evidence
supporting a multifactor. interactional theory of child development
(see Sameroff 8 Chandler. I975). Indeed, the view that these nutritional

and stimulatory deficits are solely the result of parent psychopathology

7
(Fischoff, Nhitten, 8 Pettit, l97l; Kerr, Bogues, 5 Kerr, I968; Glaser,
Heagarty, 8 Pivchik, I966; Elmer, I960) is no longer considered to
have merit. The current view holds that these deficits are the result
of a complex interplay of factors operating at the levels of the
individual parent and child. the family, the community. and the
culture (Vietze, Sherrod, Falsey, O'Connor, 8 Altemeier, I980;
Belsky, I980: Parke 8 Lewis, l98l). In this view. interactions
are seen as occurring across, as well as within levels. Furthermore,
it is not necessary that deficits be present in all of these areas
for NOFT to occur; as the equation may differ in each family in terms
of the number, type and severity of the deficits present. Figure l,
(adapted from Parke 5 Lewis, l98l) provides a schematic overview of
this model.

This current view of the etiology of NOFT is reflected in the
treatment literature where a clear consensus exists as to the
necessity of a multifactor. biopsychosocial approach to diagnosis and
management (Bithoney 5 Rathburn.l983; Berwick, Levy, 8 Kleienerman,
l982; Moore, l982; Berwick, l980; Cupoli, Hallock, 8 Barness, I980;
Frailberg, I980; Kleinberg, l980; Drotar, Malone, 8 Negray, I979;
Roberts 5 Homer, I979; Sills, I978; Garfunkel, I977; Paulsen,l976).
Commonly agreed upon areas for psychosocial assessment and inter-
vention--consistent with the model described in Figure I--include
infant cognitive and socioemotional development, infant temperament
and feeding behavior, the parent-child interaction, parenting skills.
parent psychopathology, family functioning. family and life stresses.

and the availability and utilization of family and community support

 

 

CULTURAL LEVEL

 

Relevant Variables

ATTITUDES TONARD THE ALLOCATION or PusLIC AND PRIVATE FUNDS FOR THE .
—::VELDPRENT or IORHAL SUPPORT SYSTEHS (SEE IELOIII) FOR CHILDREN AND 6—'

HILIES -
ATTITUDES TONARO CHILDREN‘S RIGHTS

l W l

Relevant Variables

INPORHAL SUPPORT SYSTEHS:
NEIGHBORHOOD-FAHILY RELATIONSHIPS. INFORHAL CHILD CARE GROUPS.
ETC.. SOCIAL CLUOS. CHURCH ORGANIZATIONS (EDUCATION AND ASSISTANCE
IN CHILDREARING AND STRESS RELIEF)

PORHAL SUPPORT SYSTEHS: '
--HEALTH-CARE FACILITIES. COUNSELING AND LEGAL SERVICES. NELEARE <P---w
ASSISTANCE. EHPLOVHENT. RECREATIONAL. CHILD-CARE FACILITIES.
EDUCATIONAL OPPORTUNITES. ETC. (EDUCATION FOR CHILD REARING.
INTERVENTION THROUGH SOCIAL SERVICES)

ADUSE/NECLECT SPECIFIC PROGRAMS:
HOT LINES. CRISES CENTERS. HOHEHANER SERVICES. ETC.

ERHILY

Relevant Variables

tAHILV INTERACTION PATTERNS (HARITAL/FAHILY DISCORD). FAHILY
STRESSES (INSUFFICIENT INCOME. LOSS or JOB. UNSAFE AND OVERCRONDED
“’UVINC CONDITIONS. LOSS OR INCAPACITATION or SIGNIFICANT FAHILY
FARILV HEADER. JOD RELOCATION. ETC.). UTILIZATION or EORHAL AND
INFORHAL SUPPORT SYSTEHS

 

 

I INDIVIDUAL PARENT AND CHILD
Relevant variables

PARENT:
PHYSICAL/RENTAL HEALTH FUNCTIONINC. EDUCATION. SIGNIFICANT
.ACHIEVEHENTS AND SETIACKS. STRESSFUL EVENTS. PARENTING SKILLS.
PHILOSOPHY ON CHILD CAREGIVING AND DISCIPLINE. HISTORY or ONN
NURTURANCE AS A CHILD ___J

 

 

 

Ni

INFANT:
CHARACTERISTICSIPASSIVE OR IRRITAILE INFANT). SPECIFIC HEALTH
PROBLEMS DR HAHDICAPPS THAT RAKE CAREGIVINC DIFFICULT. DEVELOPHENTAL
LEVEL. HEALTH HISTORY AND HEALTH CARE PROVIDED

 

Flgure l. A multilevel. InteraCtIenal model of NDFT

9
systems. Biomedical aspects of diagnosis and care include the ruling
out of an organic basis for the infant's growth failure. the provision
of nutritional therapy. and the treatment of any accompanying infec-
tions or other physical illnesses. It is generally recognized
in the literature that the potentially wide range of biomedical
and psychosocial needs in NOFT cases often necessitates a multi-
disciplinary approach to diagnosis and treatment. And in accord
with the Joint Commission on Accreditation of Hospitals (I982. in
Nickel. I982). it is the responsibility of the primary care physician
(PCP) to carry out a preliminary assessment of infant and family needs,
and to order the necessary consults with or referrals to the appro-
priate health and social service providers for further assessment and/or
treatment.

Despite this clear consensus regarding the diagnosis and treatment
of NOFT. Drotar. Malone. Negray. 5 Dennestaedt (l98l). in a retrospec-
tive chart review of 30 infants hospitalized for NOFT over a two-year
period at a university based teaching hospital, found an almost exclu-
sively biomedical approach to assessment and intervention. Specifically.
for nearly two-thirds of the cases reviewed, diagnosis and management
consisted soley of the ruling out of organic cause and the provision of
Ithritional therapy. Drotar et al. argue that their findings are attri-
butibde. in large part. to the well documented inadequacies in physician
psychosocial trainin'g (Fischler, I983; Friedman. Philips, 5 Parrish.
I983; Poole, I983; Jewett, Greenberg, Champion. Cluck. Leikin, Altieri.
syl.ipnic. I982; Jones. Badger, Parlour, 8 Coggins. I982; Poole. Morrison,
Adolf. 8 Reed. I982; Cassata 5 Kirkman-Liff. I98l; National Institute of

Medicine. I980; American Academy of Pediatrics. l978) and practice

l0

(Cassata 8 Kirkman-Liff. I981; Hesbacher, Rickels, Morris. Newman. 8
Rosenfeld. I980; Jacobsen. Goldberg. Burns. Hoeper, Hankin. 5 Hewitt.
I980; Noren,-Frazier. Altman. 8 DeLozier. I980; Rieger. l980; Goldberg,
Reiger, Mclnerny. Pless. 8 Roghman. I979; Goldberg. Babigan. Locke. 5
Rosen. I978; Drotar 8 Halone. l982; Lewis. l978) and the almost exclu-
sively biomedical model upon which physician training and practice is
based (Schwartz. I983; Engel. I980. I977). An obvious and important im-
plication of Drotar et al's arguement is that their findings may be gen-I
erlizable to other hospital setting. including community-based settings
in which the majority of NOFT infants are seen. Drotar et al. note the
importance. however. of further empirical studies to establish the
generalizability of their results to community-based hOSpitals. The data
presented here address this important issue. The specific questions
addressed are: (I) Do community-based hospital practices adequately re-
flect the consensus in the literature regarding the necessity of consid-
ering psychosocial as well as biomedical factors in the diagnosis of
NOFT? (2) How effective is the match between the psychosocial needs of
NOFT infants and their families and the services provided in
a community based hospital setting?

Kerr and Kennel's (l980) protocol for the diagnosis of NOFT
serves as the standard for evaluating hospital psychosocial assessment
practices and as a guide for collecting data on infant and family
psychosocial functioning relevant to treatment. The Kerr and Kennel
protocol is the only one of its kind to be published in the last
five years and is the product of a comprehensive review of the

current treatment Iiterature--representing the consensus in that

ll
literature as to the appropriate areas for NOFT assessment and interven-
tion. The protocol specifies the biomedical and psychosocial procedures
to be performed and the data to be collected in investigations of unex-
plained infant growth failure. In the current study. the charts of in-
fants hospitalized for an investigation of growth failure were reviewed to
determine whether the psychosocial procedures specified in the Kerr and
Kennel protocol were performed by hospital staff and the appropriate data
collected. Furthermore, in order to address the question of the match
between psychosocial need and the relevant services provided. psychosocial
assessments consistent with the Kerr and Kennel protocol were carried out
for all infants and families in which the diagnosis of NOFT was confirmed.
Data on the psychosocial services provided were then extracted from infant
charts.

In contrast to the retrospective methodology employed by Drotar et
al.. charts were reviewed concurrent with an infant's hosptial stay or
immediately thereafter. The advantage in employing a concurrent method-
ology is that confirmation by physicians and parents of the accuracy and
completeness of medical charts is much more readily obtained and less sub-

ject to the effects of memory loss.

METHOD

Subissls

Conceptually. the present study was divided into two phases--with
the criteria for subject selection varying by phase. In the first
phase--wherein compliance with the Kerr and Kennell (I980) diag-
nostic model was assessed--the selection criteria were as follows:
(I) An admitting diagnosis of failure to thrive without apparent
cause. as confirmed by the attending physician; (2) A rate of growth
since birth of weight relative to height at or below the tenth per-
centile on National Center for Health Statistics growth charts; and
(3) An age between one and 2A months. Eighteen infants meeting this
criteria were admitted to the unit over the year long course of the
study. Seventeen of the l8 infants and their mothers participated
in the study. One mother refused to take part. Although the number
of subjects was small. the fact that these l7 infants represented
all but one of the admissions for FTT over an extensive period of
time strongly suggests that a representative sample of hospital
practices was obtained.

Selection criteria for the second phase of the study included
those outlined for the first phase and the additional criterion that
organic causality was ruled out by the attending physician. This
additional criterion was consistent with the question posed in the
second phase of the study: Where the diagnosis of NOFT is confirmed.
how effective is the match between the psychosocial needs of these
infants and their families and the services provided? Fifteen of
the I7 infants included in the first phase met this additional

12

13

criterion. and as such. were included in the second phaSe of the study.
These l5 infants ranged in age from one to 23 months, with only two

of them beyond l2 months of age. Six of the infants were white. Eight
were black. One was mulatto. Only two of the mothers reported not
having finished high school--with one completing the tenth grade and:the
other the llth before leaving school. One mother reported having a year
of business college. Fourteen of the IS families were on some sort of
public assistance. either welfare or unemployment. Six of the mothers

were single parents. whereas nine reported having a live-in mate.

Setting
The regional pediatric care unit of a community based, teaching hos-
pital was the setting for the present study. AlthOugh located in a mid-
western city of l50.000. the unit serves a mixed urban/surburban/rural
population of 500.000, which includes a large indigent population.
Usaiunss
Listed below are the psychosocial proceedures specified in the Kerr
and Kennel protocol and the data to be collected.
A. Observations of parent-infant interaction
I. Inadequate affectional bonds
2. Conflict and tension during feeding
B. Psychosocial history
I. Personality characteristics of parents
A. Depression
8. Preoccupation with own needs
C. Hostile

D. Overburdened and unable to cope

IA
2. History of the early nurtUring of the
parents
A. Perceptions of family conflict
3. Separation from their parents
3. Family adaptation to stress
A. Financial crises--unemployment
8. Marriage conflicts
C. Conflicts with the extended family
D. Substance abuse in the family
A. Resources available to parents
A. Spouse
8. Friends. neighborhoods. organizations
C. Health care facilities. health workers

C. Developmental testing

Described below are the measures used to assess the areas of infant

and family functioning specified in the Kerr and Kennel protocol.

Observation; of Egggg;-|nfagt Intgcagtign

Barnard and Eyres'(l978) nursing child assessment feeding scale
(NCAFS) was used to assess infant and maternal interactional skills
during a feeding. For each feeding observation. 2l seven-point scales
(II maternal and l0 infant scales) are scored. with the midpoint rep-
resenting usual or expected behavior. The scales describe the ways the
mother sets up the environment for feeding. the attentiveness of dis-
tractability of the mother and infant. the modes of stimulation and
response used. the mood. tension. and irritability of the mother and

baby. and the give and take of control of the interaction.

.15

The 2I scales are reduced to a single feeding score for the mother
and one for the infant at each data point by first "folding” each
scale so that optimum behavior is scored highest. and any deviation
from the optimal is scored lower. and then summing these scores
across all scales for each participant. The mother's feeding score
describes her sensivitity and adaptability to the infant; the in-
fant's feeding score describes its adaptability and responsiveness.

The scale was standardized on a sample of I93 "...basically healthy
working class and middle class mothers and their infants" (Bee.
Barnard. Eyres. Gray. Hammond. Speitz. Snyder, 8 Clark. I982).
Cronbach's alpha for the total mother score in the Bee et al. study

was .86 when the infant was four months old and .80 when the infant was
twelve months of age; for the infant scores. alpha was .70 and .67 at
the same two ages.

Training in the use of the NCAFS consisted of having the observers
jointly score a series of videotaped feeding interactions. Disagree-
ments were discussed until a consensus was reached. which was consis-
tent with the NCAFS training manual. To be judged competent in the use
of the scale. each of the raters needed to achieve 80 per cent agreement
within one point with the other trainees across the 2l items making up
the scale over three consecutive observations. These observations were
scored independently and percent agreement was calculated prior to any
discussion of disagreements. The formula used was the number of agree-

ments divided by the number of agreements plus the number of disagreements.

l6

E l . I H' |

Altemeier et al.'s Maternal History Interview (MHI) was converted
to a multiple choice format for use in the present study. The conversion
obviated the need for extensive interviewer training and eliminated the
the interviewer as a potential source of error. Although it's likely
a greater amount of information may have been obtained with the use of
the interview format. the limited resources available to the author in
in terms of time. funding, and personnel made the conversion to the multi-
ple choice format a necessity. The answers used in this adaptation of the
MHI were the responses of the Altemeier et al.'s standardization sample of
I,A00 prospective mothers. attending a prenatal clinic for low income
families in Nashville. Tennessee. Neither the questions nor the system
for scoring the scale were changed. The scale assesses nine areas found
in the literature to be associated with the occurrence of NOFT as well
as abuse and neglect. These eight areas are: mother's perception of
her nurture as a child; personality factors of self-image. isolation.
and tolerance to stress; social support available from others; pos-
itive and negative feelings about her pregnancy; knowledge of parent
skills and philosophy about discipline; alcohol. drug and health prob-
lems found in the family; marital conflict and/or conflict with the
extended family; life stresses. Altemeier et al. assigned a score to
each response based upon arbitrary estimates of the degree of impair-
Inent or dysfunction reflected in the answer. Item scores are added
vvithin categories to yield eight subscale raw scores. These raw scores
are then converted to standard scores. A score above the 95th percen-

tile on any two of the eight subscales. above the 99th percentile

17
on one of the eight. or if the mean of all eight percentiles is above
75. indicates the presence of significant impairment or dysfunction.
Using this system. Altemeier et al. accurately classified 79 percent
of the cases where NOFT. abuse. or neglect occurred. Altemeier et al.
state that per cent agreement between interviewers during the piloting
of the scale was at or above 90 percent. No other data are available on
the psychometric properties of the MHI. [Note as the MHI was converted
to a questionnarie format by the author. it will be referred to henceforth

as the Maternal History Questionnaire (MHQ).]

Deselenmental_lsstinn

The Bayley Scales of Infant Development (Bayley. I969) were used
to assess infant mental and motor development. A pediatric psychologist
trained the research assistants in their use. To be judged competent to
administer the scales. a trainee needed to correctly administer and score
95 per cent of the items over three consecutive testings. The pediatric
psychologist was present during all testings. judging the correctness

of the administration and scoring of the items.

ELOCGOULG.

The charts of new admittees to the unit were scanned on a daily ba-
sis to identify potential subjects for the study. Upon discovering an
admittee who met the study criteria. the attending physician was
contacted to confirm the admitting diagnosis and to obtain consent to
tappmoach the infant's parents regarding participation in the study.

When the admitting diagnosis was confirmed and physician consent

l8
obtained. the infant's mother was contacted and provided a written
and verbal explanation of the study. Mothers wishing to participate were
then asked to sign the informed consent forms. Following a successful
recruitment effort. arrangements were made to carry out an assessment
of infant and family psychosocial needs. based on the Kerr 6 Kennel pro-
tocol. Times were scheduled with the mother for the completion of the
MHQ. an observation of the mother-infant interaction during feeding and
the administration of the Bayley scales.

In all but one case. the above procedures were carried out during
the infant's hospital stay. Regarding the one exception, the infant
was released from the hospital before the above procedures could be
carried out. The assessment was then performed in the infant's home
approximately h8 hours after his release from the hospital.

The observation of the parent-child interaction during feeding was
arranged to coincide with a regularly scheduled feeding. Mothers were
simply told to ignore the observer present and to feed their infant as
normally would. The obServer sat facing the mother. approximately six
feet away. The parent-child observation was scored by the observer
immediately after its completion.

At. or shortly after the subject's discharge from the hospital.
infants' charts were reviewed to determine the psychosocial services
provided and compliance with the psychosocial specifications of the Kerr 5
Kennel protocol. Following this. the attending physician was contacted to
confirm the diagnosis at discharge and the accuracy and completeness of
chart notes regarding the diagnostic procedures employed and the treatment
provided and/or treatment recommendations made. Subjects' mothers' were

also contacted to verify the treatment provided and/or the treatment

19
recommendations made. In addition. mothers were asked if hospital
personnel performed testing and observations similar to those performed

by the research team.

RESULTS

Relative to the initial phase of the study and the assessment of com-
pliance with the psychosocial specifications of the Kerr and Kennel diag-
nostic protocol. no evidence was found in the l7 charts reviewed that de-
velopmental teSting or mother-infant observations were performed. (Chart
notes. however. did indicate that in nine of the I7 cases observations were
made of the quality of infant interactions with hospital personnel during
routine caregiving and the provision of medical care.) Finally. only five
of the charts reviewed contained evidence that a psychosocial history was
taken. In each case. the history was taken by a member of the hosptial's
pediatric social work Staff. upon order of the attending physician. The
worker who took the history was contacted in all five cases to determine
whether the areas specified in the Kerr and Kennel model were covered
The results of these queries suggested the following areas were assessed:
family adaptation to stress and the social support available. However,
since a formal protocol was not used in taking these histories. this
finding must be interpreted cautiously. The results of this first phase
of the study are summarized in Table l. The accuracy of chart notes were
confirmed in each case by the attending physician as well as by the II
mothers able to be reached.

Regarding the psychosocial assessments of the IS confirmed cases of
NOFT. data relevant to all three areas of the assessment--psychosocial
history. developmental level, mother and infant interactional skills--
were obtained in only 8 of the IS cases. However. data relevant to at

20

21

Table I. Hospital Compliance with Procedures Specified
in Kerr S Kennel's (I980) Protocol

SUBJECT * MOTHER/CHILD PSYCHOSOCIAL DEVELOPMENTAL
NAME OBSERVATION HISTORY TESTING
Lisa No Yes No
Susan No Yes No
Fred No No No
Jimmy No Yes No
Art No No No
Billy No No No
Carla No Yes No
Mary No No No
Kurt No No No
Jerry No No No
Oscar No No No
Tommy No Yes No
Paul No No No
Jane No No No
Ellen No No No
Jill No No No
Becky No No No

* Fictious names are used

22
least one of these areas was collected for all l5 infants. As to the
the specifics of the missing data, four mothers failed to complete the
MHQ. One infant was discharged from the hospital before developmental
' testing could be performed--with the family moving out state almost
immediately thereafter. And. finally. only nine mother-infant observa-
tions were completed: one infant was too old to be observed with the
NCAFS. two mothers refused, two were banned from the hospital by court
order. and one failed to show up at the scheduled time even after repeated
attempts at rescheduling. The infants in these last five cases were
were observed. however, while being fed by a member of the hospital
staff. Thus data on the interactional skills of IA of the IS infants
were obtained.

With respect to the available data. which is summarized in Table 2.
the presence of significant impairment in at least one of the areas
assessed was found in I3 of the IS cases. Although there were no cases
in which deficits in all three areas were discovered. there were three
cases in which impairment in two of the areas assessed was found. It
is important to note that had there been complete data available for all
l5 cases the incidence of multiple impairments may have been higher. As
to the areas of impairment in the three cases where multiple deficits
were present. all three infants scored two standard deviations or
more below the mean on the motor and mental scales of the Bayley
and on the infant interactional scale of the NCAFS. Data on maternal
psychosocial history and interactional skills were not available

in any of these cases.

FEEDING INTERACTION** MATERNAL HISTORY

SUBJE
NAME

Lisa

Susan

Fred

Jimmy

Art

Billy

Carla

Mary

Kurt

Jerry

Oscar

23

Confirmed Cases of NOFT

Table 2.
CT BAYLEY SCORES

MENTAL MOTOR MOTHER
12* 13* .GA
65ers 56*** NAAAAA
Ion Ilo NA**A*
18* 8* -.77

8A 76 -l.56
l06 I36 NAAAAA
I03 I06 -.2A

9i IOA -l.59
sosaa 5oAAA NAAARA
NA**** NA**** -I.62
eoaas azaaa "Asses
I02 85 -l.79

80 66 1.87
67AAR sheet NA****

INFANT

-I.09

-.A3

'1-73

-.89

-I.68

-.A7

-I.O6

-2.8A**t

'l.7l

“-93
-2.93***

-I.8h

l.90

Results of Psychosocial Assessments in the IS

QUESTIONNAIRE

Family Conflict***
Life Stresses***
Substance Abuse***

NA****

Family Conflict***
Life Stresses***
Substance Abuse***

Family Conflict***
Life Stresses***

Family Conflict***
Life Stresses***

Family Conflict***
Life Stresses***

Family Conflict***
Life Stresses***
Parenting Skills***

Family Conflict***
Life Stresses***

Family Conflict***
Life Stresses***

Family Conflict**t
Life Stressesttt

* Raw Score: Unable to obtain standard score due to child's age
** Standard score with a mean of I and a standard deviation of 0
*** Standard scores indicating significant impairment

**** Scores not available

2A

In nine of the ten cases where impairment in a single area was found.
the sole indicator of that impairment was a score above the 95 percen-
tile on at least two of the subscales of the MHQ. While in the one re-
maining case. the single indicator was a score two or more standard de-
viations below the mean on the mental and motor scales of the Bayley.
There were six cases in which the 95th percentile was exceeded on only
two subscales of the MHQ and three cases where it was exceeded on three
subscales. A score above the 95th percentile on the family conflict
and life stresses subscales was reached in all nine cases; on the
substance abuse and health problems in the family subscale in two; and
on the parenting skills/attitudes subscale in one case.

As to the match between the psychosocial needs of these I3 infants and
their families and the services provided. only three received psychosocial
services of any kind (see Table 3). It is important to note however that
two families were receiving psychosocial services prior to hospitaliza-
tion-- a social worker in one case and a visiting nurse in the other
(According to the agencies providing the service. in addition to infant
medical care. the responsibilities of the visiting nurse include emotional
support for the parents and advice on child caregiving). As such five
(rather than three) of the l3 cases received psychosocial services fol-
lowing hospitalization. The accuracy of chart notes regarding treatment
services provided was confirmed in each case by the attending physician
as well as by the eight mothers available for confirmation.

As to the treatment services provided in the three other cases cited
above. in two cases the infants were placed in foster care. while
their mothers received psychotherapy through a community mental health

center and attended parenting classes conducted by the hospital. In

SUBJECT
NAME

Lisa

Susan

Fred

Jimmy

Art

Billy

Carla

Mary

Kurt

Jerry

Oscar

Tommy

25

Table 3. Psychosocial Needs of the IS Confirmed Cases of NOFT
and the Psychosocial Services Provided

 

BAYLEY SCORES

MENTAL

12*

65aea

IDA

I8*

8A

I06

IO}

9]

soesa

NAAARA

I02

soaas

I02

80

67eae

MOTOR MOTHER
13* .6h
56aaa NAAAAA
IIO NAAAAA

8* --77

76 -l.56
I36 Haaaaa
I06 -.2h
ION -l.59
50st: NAAAAA
HAtttt -I.62
127 -.75
azaaa NAAAAA
85 '1-79

66 I.87
buses NAAAAA

INFANT

-l.09

'3-73

-.A7

-I.O6
-2.8A*ta

-I.7I
"-93

-2.93AAA

-I.8A
I.90

-2.03

QUESTIONNAIRE

Family Conflict***
Life Stresses***
Substance Abuse***

NAtttR

Family Confiict***
Life Stresses**t
Substance Abuse***

Family Conflictttt
Life Stresses**t

Family Conflict***
Life Stressesttt

Family Conflict***
Life Stressesttt

Family Conflicttts
Life Stresses**t

Parenting Skilisfitt

Family Conflictttt
Life Stressesttt

Family Conflictitt
Life Stressesttt

Family Conflictttfi
Life Stressesttt

FEEDING INTERACTIDN** MATERNAL HISTORY PSYCHOSOCIAL

TREATMENT

None

Foster care
Psychotherapy
Parenting Classes
Receiving Social
Hork Services
Prior to Hospi-
talization

Visiting
Nurse

None

None

Visiting Nurse
Parenting Classes

None

Visiting Nurse
Prior to Hospi-
talization

None

None

Foster Care
Psychotherapy
Parenting Classes

None

None

None

 

A Raw Score: Unable to obtain standard score due to child's age

** Standard score with a mean of I and a standard deviation of O
*tt Standard scores indicating significant impairment
*ttt Scores not available

26

the one other case. the mother also attended the parenting classes
conducted by the hospital. In addition. the services of a visiting
public health nurse were provided.

The question of the match between service and need remains rela-
vent in these five cases. In three of the five cases. infant perfor-
mance on the mental and motor scales of the Bayley and on the NCAFS
was two or more standard deviations below the means of the respective
standardization samples for these instruments--signifying severe deficits.
The consensus in the literature is that when such deficits are found a
program of developmental stimulation should be instituted. along with an
assessment of the quality of the social and cognitive stimulation in the
home and attempt at upgrading those aspects of the home environment found
to be deficient ( e.g.. Bithoney 8 Rathbun. I983; Drotar. Malone C Negray.
I979). However. in none of these cases were such services provided. This
despite the fact that the research team informed the attending physician
in each case of the developmental deficits present. In the two remaining
cases where services were provided. scores on the MHQ indicated severe
family conflict and life stresses. In one case. the services of a social
worker were provided. while in the other a visiting nurse. Based on the
MHQ data. social work intervention was appropriate in both cases.

In as much as the provision of psychosocial services is dependent
on the availability of such services. an inventory of the relevant
mental health and social service resources available within the hospital
and in the community was made. The information presented below
was obtained through personal cornnunication with staff members from
the following agencies: the hospital's pediatric and social work depart-

ments. the children's health center affiliated with the hospital. and

27

the county departments of mental health and social services. In
addition to the social work department and parenting classes alluded
to above. the hospital houses a pediatric psychiatry unit. which
provides outpatient as well as inpatient care. The children's
health clinic affiliated with the hospital and a community mental
mental health center offer marital and family counseling. as well as
individual child and adult psychotherapy. The former agency also
operates a developmental assessment clinic consistent with the
Early and Periodic Screening, Diagnosis. and Treatment model (Amer-
ican Orthopsychiatric Association. l978): Where developmental def-
icits are found. remediative services in the areas of cognitive.
language. and motor development are available in the cOmmunity. A
number of substance abuse programs are in operation in the community.
In addition. the services of a visiting nurse are available through a
non-profit private agency. as well as the department of public health.
Finally. both public and private agencies offer help in meeting needs
for food, clothing. medical expenses. and housing.

To summarize. compliance with the psychosocial specifications of the
Kerr and Kennel diagnostic protocal was limited to psychosocial histories
being performed in five of the I7 cases reviewed. Developmental testing
and mother/child observations were not carried out in any case. As
to the match between psychosocial need and the services provided. only
five of the I3 infants and families found to have significant psychosocial
needs were provided services relevant to those needs. In four of
these five cases. the services provided failed to completely match the

level and/or type of need present.

DISCUSSION

The results of the present study suggest that the clear consensus
in the literature regarding the necessity of considering psychosocial
factors in the diagnosis and management of NOFT was not reflected in
the practices of this community-based hospital. In addition to finding
a general failure to comply with the psychosocial components of the
Kerr and Kennel diagnostic model. a relatively poor match was found
between psychosocial need and the relevant services provided.

The fact that primary care physicians (PCP) are in a strategic
position to see that the psychosocial needs of their patients are met is
clearly recognized by the National Institute of Medicine (I980). The
American Academy of Pediatrics (I978). and the American Academy of
Family Practitioners (I979). Indeed. these organizations agree that
PCP's should regularly screen for psychosocial impairment. inter-
vene in cases bf mild disorder. and consult and/or refer where there
are indications of severe disturbances. Obviously. this did not
occur here. Adding to the disquieting nature of this finding is that
the psychosocial services necessary to meet the needs of these
infants and families were readily obtainable within the hospital
and the community. Indeed, members of the pediatric psychiatry
and social work staffs were available to consult with attending phy-
sicians at all times. Furthermore. a number of screening measures
of infant (Rosenbaum. Chuu-lim. Wilhite, 8 Mankad, I982) and family
functioning (Smilkstein. Ashworth. 6 Montana. I982) are currently
available to assist the PCP in making the decision to order a

behavioral consult or referral. These instruments can be easily

28

29

incorporated into a standard medical history as they take little time
to administer and require little or no training to use. If the PCP
is pressed for time. a member of the nursing staff could easily
administer the measures.

It may be argued that the provision of psychosocial services to all
NOFT infants and families is not justified by the data on the long-
term effects of NOFT. Indeed. long-term follow-up studies indicate that
a substantial proportion of NOFT infants will go on to develop normally
without psychosocial intervention. Ideally. health care providers could
predict from an assessment at hospitalization which specific infants
will have later psychosocial impairments. Psychosocial services would
then be provided only to this subgroup of at risk NOFT infants. Unfor-
tunately. however. predictions of this nature are virtually impos-
sible to make. as the predictive power of any single psychosocial assess-
ment wanes considerably over time (Parke. I981; Daniel. Newberger. Reed.
6 Kotelchuck. l978; Parmelee. Sigman. Kopp. 6 Haber. I976). Consequently.
the most reasonable course of action to follow in providing psychosocial
services to NOFT infants would be to: First. screen for psychosocial
impairment/need in all cases; second. where the results are negative
continue to screen in the context of followup or well baby visits to
the PCP; when the results are positive. proceed with a comprehensive
assessment; third, treat in line with the results of the assessment;
fourth. regularly justify the continued proVision of care based on
current infant and family functioning. When functioning is adequate.
terminate services but screen periodically for renewed dysfunction.

Where is the money to come from for the multiple assessments proposed
above. given that a significant proportion of NOFT families are indigent?

The answer to this important question is the Early Periodic Screening.

30
Diagnosis. and Treatment program. the nation's largest preventive child
health screening program designed to detect and treat early childhood
medical and developmental conditions in indigent children. This
program is presently mandated by the federal government to provide
preventive health screening services and diagnosis and treatment of
of problems found in screening to all children between the ages of 0
to 2l years who are eligible for the Medicaid program.

With regard to the generalizability issue. the results of the present
study lend clear support to the notion of the generalizability of the
Drotar et al. (l98l) findings to community-based hospitals. However.
as the study of a single setting is the equivalent of a single subject
design. repeated replications at other hospitals will be necessary to
assure generalizabilty. An important question at this juncture is
whether there is sufficient justification beyond the data presented
here for these necessary replications. The research summarized below
on physician psychosocial training and practices has an important
bearing on the answer to this question:

(I) Studies of ambulatory (Cassata 6 Kirkman-Liff. l98l;
Hesbacher et al.. I980; Jacobsen et al.. I980; Noren et
et al., I980; Reiger, I980; Goldberg et al.. I979: Gold-
berg et al. I978) and hospital (Drotar C Malone. I982;
Lewis. l978) care settings indicate the rate of PCP
ordered psychosocial consults and/or referrals is signi-
ficantly lower than would be expected. given the preva-
Ience of impairment in these settings warranting such
action. In fact. Rieger (I980) estimates that a PCP is
likely to make a psychosocial referral for only one in

ten to twenty patients in need of such a referral.

3l
(2) In I978, the American Academy of Pediatrics (AAP)
Task Force on Pediatric Education concluded that physi-
cian training in the psychosocial aspects of health
care was inadequate. Indeed. the task force found that
more than half of newly practicing pediatricians rated
their residencies as providing insufficient experience
with psychosocial and behavioral problems. In l980 the
National Institute of Medicine (NIH) reached the same
conclusion as the AAP task force. More recent reports
suggest that inadequacies in physician psychosocial
training continue to exist (Fischler, I983; Friedman.
Philips. 8 Parrish. l983; Poole. l983; Jewett. Green-
berg. Champion, Cluck. Leikin. Altieri.& Lipnic. l982;
Jones. Badger, Parlour. 6 Coggins. I982; Poole. Morr-
ision. Adolf. 6 Reed. I982; Cassata 6 Kirkmann-Liff.
l98l).

The above documentation of widespread inadequacies in physician psy-
chosocial training and practices lends plausibility to the notion that
the results of Drotar et al. are generalizable to community based settings.
As such. relative to the question posed above. there does appear to be
sufficient justification for the multiple replications necessary to confirm
this notion.

Documenting the generalizability of the present study's findings is
undoubtly important as well as justified. However. Maccoby. Kahn, S
Everret (l983) contend that if public policy affecting child welfare is to
be changed. the researcher must not only document the existence of a prob-

lem but provide cost-effective and cost-feasible remedies as well.

32
Accordingly. in the ensuing discussion the clear possibilty that the pres-
ent study's findings are generalizable is entertained and solutions to
this potential problem are proposed. Consistent with the above discussion
on generalizabilty. the documented inadequacies in physician psychosocial
training are viewed as responsible. in large part, for the deficiencies
in NOFT psychosocial care observed in the present Study and Drotar et al.
(I98l). Consequently. the ensuing discussion begins with the question of
why do inadequacies exist in physician training in the psychosocial aspects
of health care?

The answer to the question why are physicians inadequately trained in
in the psychosocial aspects of health care is undoubtly a complex one.
However. one factor that seems to be of paramount importance is the fail-
ure of agencies such as the American Academy of Pediatrics and the Amer—
ican Academy of Family Practitioners to modify their training program
accredidation requirements to reflect the conSensus in the literature
regarding the ways to upgrade physician psychosocial training (Jones et
al.. I982; Poole et al.. l982). This consensus is reflected in the recom-
mendations of a recent National Institute of Medicine (I980) report regar-
ding this important issue of improving physician psychosocial training:

(I) Revising the content of standard medical school
curriculum in terms of both orientation and instruction

in specific (psychosociaL) skills; (2) Offering more

more appropriate clinical training experiences to

prepare medical students and residents for the practice

of integrated health/mental health care; (3) Providing
appropriate and effective role models throughout the educa-
tional and training process; and‘(h) Upgrading continuing

education for practicing physicians (NIM. I980. p. I93)

33

Importantly. a number of training curricula have been developed whiCh
reflect the NIH recommendations (Fischler, l983; Poole. 1983; Fink. 1980.
1977; Freeman 5 Sack. I979; NIMH. 1977: Fink 6 Strosnider. l976)--with
perhaps the most comprehensive of these in the area of pediatric
psychosocial care (Fischler, I983; Poole. 1983). Particularly
impressive about the latter is that not only do they specify what
to teach but the most effective ways of teaching it. as well.

Regarding the failure to modify existing accreditation guidelines
and to disseminate these training curricula. it is likely that
the cost to training programs is an important factor. Yet the
continued efforts of the National Institute of Mental Health
(NIMH. 1983) to determine the nature and prevalence of psychosocial
impairment in medical settings. as well as the factors influencing
its detection and management. suggest a strongcommittment on the
part of the federal government to increasing the quality of
psychosocial care provided in medical settings. This. in turn.
bodes well for government funding to support efforts to provide
more comprehensive physician psychosocial training. Furthermore.
the rising number. indeed. the mere existence of family practice
residencies. attests to the power of intensive lobbying efforts
by allied health professionals at the federal level (Geyman. 1981).
Perhaps a similar effort at this time could result in legisla-
tion that would provide the funding necessary to achieve quality
training for physicians in the behavioral sciences. The professional
mix of its members--physicians. nurses. social workers. psychologists--
makes the Society for Research in Child Development (SRCD) an excellent

vehicle for such a collaborative effort. That the Society might look

3h
favorably on such a role is clearly indicated in the Congressional
Fellowship Program it has run since 1977. and with its recent decision to
increase the size and scope of its Washington liason office.

Private foundations may be a second source of funding for improve-
ments in physician psychosocial training. An excellent example of this
is the W.T. Grant Foundation's funding of the development of a beha-
vioral pediatrics component in II of the nation's leading pediatric
residency programs (Friedman et al.. 1983 ). However. as Brim
and Oustan (1983) note. perhaps the most efficient strategy would
involve collaborative funding efforts on the part of the private and
public sectors. of which there are a number of successful examples.

As it is a time of dwindling public and private resources. it
is extremely important to develop strategies for reducing the
cost of improved physician psychosocial training. One potential
method for reducing costs is the sharing of faculty. Most universities
which contain a medical school also house programs in the behavioral
sciences. As such. appropriate behavioral science faculty could serve
in the medical school on some part-time basis. with the two depart-
ments sharing faculty costs. This would preclude the need for the
medical school to make the costly move of hiring additional full-time
faculty to meet training requirements. The utilization of community
Inental health personnel in a similar way is a possibility as well.
Additional strategies to cut down faculty costs include the use of
teleconferences. television. and audio and videotapes to present
lecture material. Indeed. given the current state of the art in tele-

comunications. a uniform curriculum in the behavioral sciences for the

35

nation's medical students-- taught by the experts in the field--is
economically as well as technically feasible.
Importantly. however. while necessary. adequate training in the

behavioral sciences may not be sufficient to insure the provision
of quality psychosocial care in medical settings. Studies have
shown that physician detection of psychosocial impairment as well
as orders for psychosocial consults and/or referrals increase
dramatically where mental health and medical care services are
integrated professionally. administratively. and structurally (Burns.
1980). In addition. it is more likely for a patient to follow through
on a physician ordered referral where medical and mental health services
are integrated (Jacobsen. Regier. 8 Burns. 1978). In apparent recog-
nition of the benefits of integrated health care services. the depart-
ment of Health. Education. and Welfare had supported a number of acti-
vities to encourage linkages between health services and alcohol.
drug abuse. and mental health services to promote a comprehensive
health system. Notable among these is an agreement between the Alcohol.
Drug Abuse and Mental Health administrations to spend 1.5 million dol-
lars in Community Health Center (CHC) funds to provide on-site mental
health personnel. and encourage linkages of community health centers
with a nearby mental health center. According to the administrating
agencies. these arrangements should allow for:

(1) Mental health personnel to provide direct care and

treatment in the health care setting to patients with

emotional disorders whose problems exceed the skills

of non-psychiatric health care practioners;

36
(2) Consultation directed toward altering behavioral
patterns that increase the risk of physical illness;
(3) Collaborative treatment with non-psychiatric health
care practioners for those patients with combined physical
and mental illnesses;
(A) Training non-psychiatric physicians and other health
care personnel to enhance their skills in the treatment
of patients with relatively mild emotional disorders
(report to the President from the President's Commission
on Mental Health, 1978. p. 20).

Preliminary data from this model program suggest these objectives
are being realized (Burns. 1980; Orso. 1979). Of particular impor-
tance is the finding that unlike non-integrated settings. physician
detection of psychosocial impairment and orders for consults and
referrals adequately reflect existing prevalence data. Also emerging
from this model program are data necessary for the successful dissemi-
nation and implementation of such linkages(Burns. 1980; Orso. I979).

AS the above discussion would indicate. the failure in the present
study to find effective linkages between pediatrics and the mental
health/social service resources available within and outside the
hospital cannot be attributed to a lack of innovation in this area.
Indeed. beyond what was presented here, Drotar (1982) and others
(Lewis. 1978; Anders. 1977) have described a number of models for
effective liasions between medical and mental health/social service
providers in hospital settings. Once again the salient issue is the

dissemination and implementation of existing innovation. From the

37

above discussion it seems the CMH would be the ideal agency for dis-
seminating effective models for hospital liasions between medical and
mental health/social services. Circumscribing its efforts to public
hospitals. the CMH could determine the existence of such Iiasons;
establish them where none exist; and evaluate and give input

regarding improvements where they do exist. As few hospitals

will likely have the resources to completely meet the mental health
and social service needs of their patients. creating liasions with
community agencies will be of vital importance. The CMH could serve
as "clearing house" for information on such community agencies. as
well as facilitate the development of linkages bewteen these agencies
and the hosptial. In those instances where there are no existing men-
tal health resources within the hosptial. the CMH could play a similar
role to that described in Burns (1980). providing on-site personnel for
treatment. consultative and teaching purposes.

The cost of the linkages discussed here and above will undoubtly
vary with the characteristics of the setting and the linkage. Creating
a linkage similar to that described in Burns (1980) should be relatively
inexpensive in a setting where medical and mental health/social services
already exist. However. such an endeavor would be considerably more
expensive in a setting without coexisting medical and psychosocial ser-
vices. Nevertheless. in both cases the benefits clearly outweigh the
the cost; as these linkages can provide a rapid--albeit partialt-solution
to an immediate and significant problem. The addition of adequate
training for medical students. interns. and residents in the psychosocial
aspects of health care would complete the solution. However. the benefits

of the latter would not be shortcoming. as it would take at least ten

38

years before the students receiving this improved training would make up
a significant proportion of practicing physicians. Thus the attractive-
ness of the linkage model.

Clearly. this discussion has gone well beyond the issue of whether
community based hospital practices adequately reflect the consensus in
in the literature regarding the appropriate approach to the diagnosis and
and management of NOFT. To summarize. evidence was presented which
strongly suggests that the results of the present study are merely
reflective of overall shortcomings in the provision of psychosocial
care in medical settings. Cited as major contributors to these
pervasive deficiencies were inadequate physician psychosocial
training and the near absence of linkages between medical and mental
health/social service providers. It was argued that the continued
existence of the training and linkage problems was not due to a lack
of innovative solutions. but because of a failure to disseminate
and implement these solutions. Cost was hypothesized to be a major
stumbling block to dissemination and implementation of these solutions.
Cost-effective ways of upgrading the quality of physician psychosocial
training were discussed.

An important note--immediately following the termination of the
present study, an hoc committee of hospital personnel-~consisting
of physicians, nurses. and social workers--concluded the psychosocial
care provided NOFT infants in their hospital was inadeqate. The committee
made a number of recommendations for improvements. including the adoption
of a formal protocol. similar to Kerr 6 Kennel (1980). for diagnosing and
treating NOFT cases and the requirement that pediatric residents demon-
strate proficiency in screening for abnormalities in psychosocial develop-

ment and functioning.

Limitations of the present study and implications for future research

The present study suffers from a number of limitations. What
follows is a discussion of these limitations and suggestions for
future studies of this kind.

Perhaps the most serious limitation of the present study is that
the attending physicians were aware prior to data collection of our
intention to perform psychosocial evaluations. Thus. physicians
may have been expecting to receive psychosocial assessment data from
the researchers and therefore did not obtain such information inde-
pendently. On the other hand. there are several reasons to suspect
that physicians in fact had no such expectations with respect to
psychosocial data from the current study. First. an ad hoc committee
composed of members of the hospital's medical and social work staffs
had recently concluded--independent of the present investigation--
that the pediatric staff was insufficiently trained to provide adequate
psychosocial care to NOFT infants and their families. Second. the
attending physicians were told that the assessment data were being
collected solely for research purposes and that the research team
should not be viewed as a clinical entity. in that none of the staff
were trained mental health professionals and their clinical experience
with the assessment instruments was limited. Third. if physicians were
expecting to receive psychosocial assessment data from the research staff
one suspects that they would have requested the information when it was
not forthcoming. No such requests were made. In retrospect. a better
approach may have been to review the charts of FTT infants seen at the
hospital during the year preceding the current study and then compare

the number of psychosocial evaluations during this time with the number

39

A0

performed or ordered over the course of the current study. This
comparison would have provided an opportunity to determine the
presence of artifacts in the current findings.

A second limitation of the present Study was that although a
a number of the explanations were offered for the results obtained.
the data necessary to test these hypotheses were not collected. For
instance. the "training" hypothesis could have been evaluated in the
present study by comparing the training histories of the physicians
who ordered psychosocial workups with those who didn't. Future
investigations might explore the effects of the training factor as
as well as the effects of other variables hypothesized to influence
physician psychosocial practices. Among these variables are the
role perceptions of physicans who maintain a biological orientation
in contrast to biopsychosocial orientation. physicians' personality
characteristics (e.g.. Burns 8 Cromer. 1978). and their sensitivity
to the negative social consequences of labelling a parent inadequate
or an infant as developmentally retarded (e.g.. Goldberg. 1979). As
pointed out previously. patient and contextual factors may also
affect physician psychosocial practices. The severity of an infant's
growth failure and the presence or absence of other signs physical
abuse or neglect are examples of patient variables that may have
that may have affected physician psychosocial practices in the current
study. The staff-to-patient ratio is an example of a contextual
variable that also may have exerted an important influence.

Consistent with the above discussion future studies should provide
more comprehensive descriptions of physician. contextual and patient

variables hypothesized to influence the provision of psychosocial care

AI
in medical settings. Such data would help to evaluate the extent to
which one can generalize the results of one study to other hospital
settings. Ultimately. studies of this kind should include multiple
settings across communities and regions. Such a study is currently
being designed by a research group composed of individuals from

a number of the nation's leading medical institutions (Drotar. personal

communication).

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APPENDIX

Consent Lotter (NOFT Subjects)

Dear Parent or Guardian:

He would like your help in getting a better idea of how effective
Hurley Medical Center's treatment program has been for your infant.
There are three things which we need your help with.

First. we'd like to observe you feeding your infant. We'd like
to make this observation as sea: as possible. Our reason for
doing this observation is to better understand just what about
your infant is causing his/her feeding problems. To make sure
we don't lose any important information. we would like to record
the observation on videotape. Of course. we will make this
observation in the hospital.

The second thing we'd like for you to do is to fill out some
questionnaires. These questionnaires will provide us with inform-
ation.which we feel is important for developing the best treatment
program for your baby and other children like him/her. The
questionnaires will cover the following areas: your feelings about
your child and yourself. the ways in which you discipline your
child. whether you feel you receive enough support from famil

and friends. how you get along with your spouse or boyfriend
girlfriend. and whether you're facing any special problems at the
present time. We realize this information is very personnel. and
as such. we'd like to assure you that all information collected

by us concerning you and your baby will be kept strictly confi-
dential. Furthermore. if you find any of the questions contained
in these questionnaries to be offensive or too personal. feel free
not to answer them. But please try to answer all the questions
you can.

The third way you can help us is by letting us come to your home
to observe and test your child about a month.after he/she is
released from the hospital. This home visit will consist of

1) our weighing your infant. 2) the administration of a test of
infant development (this test generall involves watching an
infant play with a variety of toys). 3 observing you and your
infant going about your daily routine. A) an observation of you
feeding your infant (again. we would like to record this observa-
tion on videotape). and 5) having you complete the same question—
naires you filled out while your child was in the hospital.

The Visit should take no more than three hours of your time.

2.221%; e Emmy. mwill pggiven p coupon good _f_o_x_-
enemas newsman.

Rest assured. we will also share any important findings with.you.

Eagzigipgsipp‘ivaoluntapy. Neither you nor your infant has to
participate in this program. In.addition. you may decide to remove

her from the research at any time. However. we hope that you
will talk to us about your concerns first. Gail either Jolie
Brams or Nick Ialongo at 766-OA60.

Consent Letter (NOFT Subjects). cont.

lost important. whatever you decide. it will not affect the care
or your infant. Your infant will receive the some medical care
whether ha/ahe is involved in the research or not.

If you want your infant to participate in this important research.
please fill out the attached form.

We truly appreciate your time in reading this.

Sincerely.

Nick Ialongo

Graduate Student
Clinical-Child Psychology
Michigan State University

Jolie Brams. Ph. D.
Child Clinical Psychologist

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