Published online July 2, 2007
PEDIATRICS Vol. 120 No. 1 July 2007, pp. 59-69 (doi:10.1542/peds.2006-1657)
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ARTICLE

Early Intervention and Recovery Among Children With Failure to Thrive: Follow-up at Age 8

Maureen M. Black, PhDa, Howard Dubowitz, MS, MDa, Ambika Krishnakumar, PhDb and Raymond H. Starr, Jr, PhDc

a Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
b Department of Child and Family Studies, Syracuse University, Syracuse, New York
c Department of Psychology, University of Maryland Baltimore County, Baltimore, Maryland


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVES. We sought to examine the impact of a randomized, controlled trial of home visiting among infants with failure to thrive on growth, academic/cognitive performance, and home/classroom behavior at age 8.

METHODS. Infants with failure to thrive (N = 130) or adequate growth (N = 119) were recruited from pediatric primary care clinics serving low-income, urban communities. Eligibility criteria included age <25 months, gestational age >36 weeks, birth weight >2500 g, and no significant medical conditions. Evaluation included anthropometries, Bayley scales, maternal anthropometries, demographics, negative affect, IQ, and the Home Observation for Measurement of the Environment scale. Infants with failure to thrive were treated in an interdisciplinary growth and nutrition clinic and randomized into clinical-intervention-plus-home-intervention or clinical-care-only groups. The home-visiting curriculum promoted maternal sensitivity, parent-infant relationships, and child development. Follow-up visits were conducted by evaluators who were unaware of the children's growth or intervention history. At age 8, the evaluation included anthropometries, the Wechsler Intelligence Scale for Children III, and the Wide Range Achievement Test, Revised. Mothers completed the Child Behavior Checklist and teachers completed the Teacher Report Form.

ANALYSIS. Multivariate analyses of variance were used to examine differences in growth, cognitive/academic performance, and home/school behavior, adjusted by maternal education, public assistance, and, when appropriate, infant Bayley score, maternal BMI, height, negative affect, IQ, and Home Observation for Measurement of the Environment scores.

RESULTS. Retention was 74% to 78%. Children in the adequate-growth group were significantly taller, heavier, and had better arithmetic scores than the clinical-intervention-only group, with the clinical-intervention-plus-home-intervention group intermediate. There were no group differences in IQ, reading, or mother-reported behavior problems. Children in the clinical-intervention-plus-home-intervention group had fewer teacher-reported internalizing problems and better work habits than the clinical-intervention-only group.

CONCLUSIONS. Early failure to thrive increased children's vulnerability to short stature, poor arithmetic performance, and poor work habits. Home visiting attenuated some of the negative effects of early failure to thrive, possibly by promoting maternal sensitivity and helping children build strong work habits that enabled them to benefit from school. Findings provide evidence for early intervention programs for vulnerable infants.

Key Words: failure to thrive • early intervention • home visiting • longitudinal follow-up

Abbreviations: FTT—failure to thrive • AG—adequate growth • FTT-HI—clinical intervention plus home intervention • FTT-CO—clinical intervention only • MDI—Mental Development Index • PDI—Psychomotor Development Index • HOME—Home Observation for Measurement of the Environment • AFDC—Aid to Families With Dependent Children

During the first years of life when energy needs are high, growth serves as an objective measure of children's well-being. Failure to thrive (FTT) occurs when infants' rate of weight gain is below expectations based on age- and gender-specific growth charts.1 Until recently, many investigators relied on hospitalized or referred samples of children with FTT3 and found that FTT was associated with long-term deficits in height, weight, cognitive and academic performance, and behavior.2,4–11 However, hospitalized and referred patients are likely to represent the most extreme and complex cases of FTT. Most children with FTT are treated as outpatients, consistent with recommendations from the American Academy of Pediatrics' Committee on Nutrition1,12–14 and managed in specialized, interdisciplinary clinics.4

Investigators relying on population- and community-based samples have found that by school age, most children with a history of FTT have experienced growth recovery.15–17 Although many continue to be shorter than age-matched peers, they rarely experience growth deficits indicative of severe malnutrition.15,16 When cognitive and academic performance have been considered, by school age, children with FTT recruited from primary care or community sites achieved IQ scores that were ~4.2 points lower than children with a history of adequate growth (AG).8,17–19 These findings suggest that early FTT may have a small, though potentially important, impact on children's cognitive performance.

Although a recent meta-analysis of 60 home-visiting programs introduced early in life showed encouraging findings on children's cognitive and social-emotional development,20 the 6 home visitation trials conducted among children with FTT have reported inconsistent effects on children's growth and development. Haynes and colleagues21 studied 50 hospitalized children with FTT and 26 comparison children and found no effect of short-term home visitation on growth, development, or parent-child interaction patterns. Drotar and Sturm7 used a randomization procedure to assign children into 1 of 3 home intervention programs and found no difference in growth or cognitive performance at 3 years of age. Casey and colleagues22 reported that among 914 preterm children with low birth weight, the incidence of FTT did not differ on the basis of participation in an early intervention program. However, among the children with FTT, there were beneficial effects of the intervention on cognition and behavior at age 3. Wright and colleagues13 studied 229 children with FTT identified through community screening and showed that children assigned to the intervention group who received home health visitors were heavier and taller at 3 years old than children assigned to the control group.13 Raynor and colleagues23 enrolled 83 children with FTT and provided home visiting to 42 of them. After 12 months, both groups experienced a significant increase in weight, with no differential effects of home visiting. We conducted a weekly home-based intervention among 130 infants and toddlers with FTT recruited from primary care.12 After 1 year, there were no differences in height or weight, but infants in the intervention group had better cognitive performance and caregivers who were more responsive and child focused than infants in the control group.12 Two years after the home intervention ended, when the children were 4 years old, children in the intervention group had better cognitive scores and were more socially interactive than children in the control group, but only if their mothers did not report negative affect.24

To examine whether early intervention altered the children's developmental course, we followed children with FTT12,24 through their school-age years, along with a cohort of adequately growing children from the same low-income communities. The primary objective of the follow-up was to examine the long-term impact of home-based intervention on children's growth, academic and cognitive performance, and home and school behavior at age 8.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
Infants were recruited from 1989–1992 from pediatric primary care clinics that serve low-income, urban communities. Eligibility criteria included age <25 months, gestational age >36 weeks, birth weight ≥2500 g, and no congenital problems, disabilities, or chronic illnesses.12

Children in the FTT group had to meet 1 of 2 criteria using age- and gender-specific National Center for Health Statistic growth charts25: sustained weight for age <5th percentile or weight for length <10th percentile. Children in the AG group had to meet 2 criteria: sustained weight for age and weight for length >10th percentile. The groups were matched by gender, race, and socioeconomic status, defined by marital status and dependence on public assistance.26 All infants were examined by a pediatrician, who also reviewed their medical charts to ensure they met criteria for group classification and there were no known syndromes or obvious major organ system dysfunctions, such as congenital heart disease, to account for the growth failure of the infants in the FTT group.

Procedure
Research assistants invited caregivers to participate in a longitudinal research project, using consent procedures approved by the institutional review board of the University of Maryland. More than 90% of eligible caregivers agreed and participated in an initial evaluation that included measures of growth, standardized developmental assessments, and a 60-minute interview of questionnaires on demographics, children's behavior, and maternal and family functioning. Developmental assessments were administered by psychology graduate students, supervised by a pediatric psychologist. A home visit was scheduled within 2 weeks of the initial evaluation.

Children with FTT were treated in an interdisciplinary clinic.27 Based on a randomization procedure, stratified by race, gender, and infant age and designed by a statistician to ensure equivalence across groups, children with FTT were randomized to receive either the clinical intervention plus home intervention (FTT-HI) or the clinical intervention only (FTT-CO)12 (Fig 1). The AG children received standard pediatric primary care.


Figure 1
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  		FIGURE 1 Description of sample recruitment and retention.

 
The children and caregivers returned for evaluations at 4, 6, and 8 years of age. Evaluators were unaware of their growth or intervention status. Caregivers provided the name of the children's school and requests were sent for information on classroom behavior. Families and teachers were compensated for participating. We report here on the 8-year evaluation.

Intervention
Details regarding the home intervention have been published previously12 and will be summarized. The intervention was based on ecological theory28,29 and included a therapeutic alliance between the interventionist and the caregiver; support to the caregiver's personal, family, and environmental needs; opportunities to model and promote responsive parent-infant interaction; and problem-solving strategies regarding personal, parenting, and children's issues. The Hawaii Early Learning Program30 was used as a curriculum guide.

The intervention was delivered by 3, part-time lay home visitors employed by a community-based agency specializing in early intervention. The home visitors received an 8-session training program and were supervised by a community health nurse. The home visitors had portable mats and toys to demonstrate developmentally appropriate activities and to facilitate parent-child interaction. They did not focus on nutrition or feeding behavior and they did not weigh the children. One-hour visits were scheduled weekly for 1 year; the number of visits varied from 0 to 47 (mean: 19.2; SD: 11.5; median: 25; interquartile range: 18–30).

Baseline Measures
Infant Growth
Children were weighed and measured by a nurse using scales calibrated regularly. Length was converted into age- and gender-specific SD units (z scores) of length for age, adjusted for midparental stature.31 Weight was converted into age- and gender-specific SD units (z scores) for weight for age and weight for length.

Infant Mental and Motor Development
Mental and motor development were assessed by the Bayley Scale of Infant Development. Raw scores for the mental and motor scales were converted to age-normed Mental Development Index (MDI) and Psychomotor Development Index (PDI) scores with a population mean of 100 and an SD of 15.

Maternal negative affect was measured with the Brief Symptom Inventory,32 a symptom scale in which respondents report on the frequency of symptoms over the preceding 7 days using a 4-point scale, ranging from not at all (1) to extremely (4). Low scores are optimal. Scores from the depression, anxiety, and hostility subscales were combined into a measure of negative affect,33 with an internal consistency, calculated by Cronbach's {alpha} of .92.

Maternal IQ was measured with the comprehension and vocabulary subscales from the Wechsler Adult Intelligence Scale.34 The subscales correlated highly with the full-scale IQ.

The home environment was measured by using the Home Observation for Measurement of the Environment (HOME), an observation scale that has been widely used in child development research and has a strong relationship with subsequent intellectual development and achievement.35,36 It consists of 45 items organized into 6 scales (emotional and verbal responsivity, avoidance of restriction and punishment, organization of the physical and temporal environment, provision of appropriate play materials, maternal involvement with the child, and opportunities for variety in daily stimulation). Observers were trained until they reached >90% agreement on 10 observations. Reliability was maintained at >90% agreement.

Age 8 Measures
At age 8, family demographics and maternal negative affect were repeated.

Growth
Children were weighed and measured by a trained nurse on scales calibrated regularly. Height and weight were converted into age- and gender-specific SD units (z scores) of height for age and weight for age. BMI was calculated by using the formula: weight (kg)/length (m2) and converted to age- and gender-specific z scores on the basis of the 2000 Centers for Disease Control and Prevention tables37 (ww.cdc.gov/growthcharts).

Cognitive Performance
The vocabulary and block-design subtests of the Wechsler Intelligence Scale for Children-III were administered.34 A composite score was transformed into a standardized score with a mean of 100 and an SD of 15.

Academic Performance
The Arithmetic and Reading Subtests of the Wide Range Achievement Test-Revised were administered.38

Home Behavior
Mothers completed the Child Behavior Checklist,39 which consists of 118 behavior-problem items rated on a 3-point scale ranging from 0 (not true) to 3 (very true). T scores were obtained for externalizing (eg, delinquency and aggression) and internalizing problem behaviors (eg, depression, anxiety/withdrawal). High scores represent more problems.

School Behavior
Teachers completed the Teacher Report Form,39 consisting of 118 behavior-problem items rated on a 3-point scale ranging from 0 (not true) to 3 (very true). T scores were obtained for externalizing and internalizing problem behaviors, with high scores representing more problems. The Teacher Report Form includes 4 positive classroom work habits (works hard, behaves appropriately, learns, and happy), based on 7-point Likert scales comparing the target child to typical students, ranging from much less (1) to much more (7). Cronbach's {alpha} value for our sample was .87. Teachers were unaware of the children's growth or intervention history.

Sample Demographics
The baseline demographic characteristics of the 189 families who completed the 8-year evaluation indicated that most families received public assistance (Aid To Families With Dependent Children [AFDC] or Medical Assistance: 76.2%) (Table 1). Approximately half of the mothers had not completed high school (54%), and most were unemployed (87%) and single (89%). At baseline, the children with a history of FTT were slightly younger than AG children. With the exception of maternal education, the families of children with and without a history of FTT were similar on most demographic characteristics. There were no group differences in maternal IQ, maternal negative affect, maternal anthropometry, or the home environment among the children in the FTT-HI, FTT-CO, and AG groups.


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  		TABLE 1 Mean (SD) Maternal and Child Characteristics

 
The children with FTT were shorter and thinner than children in the AG group, as expected. There were no differences in anthropometry between the 2 FTT groups. Children in the FTT groups had significantly lower scores on psychomotor development than those in the AG group; there were no group differences on mental development.

Analysis Plan
In keeping with the guidelines for a randomized trial, the analysis was based on assignment of the FTT group into intervention or control, regardless of the amount of intervention received. To examine the effects of early growth failure on children's growth, cognitive/academic performance, and home and school behavior at age 8, we used multivariate analysis of variance.40 The analyses examined the effects of group (FTT-HI, FTT-CO, and AG), followed by pairwise comparisons. In the initial analyses, we did not adjust for confounders because our goal was to examine the children's functioning at age 8, regardless of their early history. In subsequent analyses, we adjusted for confounders.

To identify potential confounders, we examined the relation between baseline indicators of poverty (public assistance and household size), maternal anthropometry (weight and height), and maternal functioning (maternal education, IQ, marital status, negative affect, and the HOME inventory) with children's growth and functioning at age 8 (Table 2). Receipt of public assistance (AFDC or Medical Assistance) was associated with lower reading scores and worse school behavior. Maternal height and BMI were positively associated with children's corresponding measures at age 8. Maternal education was positively associated with BMI, height, IQ, reading and arithmetic scores, and classroom behavior, and negatively associated with externalizing behavior at home. Maternal IQ was positively associated with IQ and reading. HOME scores were positively associated with IQ, reading, arithmetic, and learning in school. Maternal negative affect was positively associated with internalizing and externalizing behavior at home.


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  		TABLE 2 Correlations Between Baseline Public Assistance, Maternal Height, Weight, and Functioning With Growth, Cognitive/Academic Performance, and Home and School Behavior at Age 8

 
We examined associations between children's baseline anthropometry and performance on the Bayley Scales with their growth and functioning at age 8. Baseline weight for height was positively associated with BMI (r = 0.33; P < .001) and baseline length for age was associated with height for age (r = 0.63; P < .001). Baseline Bayley MDI and PDI were correlated (r = 0.53; P < .001), and both were associated with reading and arithmetic at age 8 (r = 0.24–0.33; P < .001). In addition, Bayley MDI was associated with IQ (r = 0.27; P < .001).

To ensure that findings were not confounded by household resources, we controlled for receipt of public assistance and maternal education in all analyses. When analyzing age 8 BMI and height for age, we also controlled for maternal BMI and height for age. In the analyses for cognitive/academic performance, we controlled for maternal IQ and HOME. In the analysis for home behavior, we controlled for maternal negative affect. We used estimated marginal means to examine group differences (FTT-HI, FTT-CO, and AG).

To examine how contemporaneous environmental measures were related to child growth and functioning, we examined relations between age 8 measures of public assistance, maternal education, marital status, and negative affect and children's growth and functioning. There were no significant associations between public assistance and marital status with age 8 growth or functioning. Maternal education was significantly positively associated with all the growth and cognitive/academic measures (r = 0.18–0.26; P < .05) and significantly negatively associated with externalizing (r = –0.17; P = .02), but not internalizing behavior at home. Maternal negative affect was significantly negatively associated with arithmetic (r = –0.14; P = –.04) and positively associated with internalizing and externalizing behavior at home (r = 0.35–0.45; P < .001). The analyses were repeated, controlling for maternal education and negative affect at age 8.

For unadjusted analyses, we set {alpha} at .05. Given the longitudinal nature of the study and the risk of committing a type II error (failing to detect a difference when a difference exists), we extended {alpha} to .10 for analyses adjusted by covariates.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Retention
At age 8, there were complete data for 96 (74%) of 130 FTT (47 of 64 HI and 49 of 66 CO) (Fig 1) and 93 (78%) of 119 AG families. With an {alpha} value of .05, this sample size provided power of 0.80 to detect a difference of 0.6 SDs (~8 points) in measures of IQ and academic performance among children in the 3 groups. Demographic comparisons between those who participated at age 8 and those who did not indicated no group differences in rates of retention and no differences on any background variables, including anthropometric status, gender, race, mental and motor development, maternal variables (height, weight, education, IQ, negative affect, marital status), HOME, household size, or intervention status.

Growth At Age 8
In unadjusted analyses, children in the AG group were taller and heavier than children in the 2 FTT groups (Table 1). There were no significant differences in height for age z score between the 2 FTT groups, but there was a significant linear trend (F = 11.84; P = .001), with the children in the FTT-HI group occupying an intermediate position between children in the FTT-CO and AG groups. Rates of stunting (height for age less than –2 z scores) were higher for children in the FTT-CO (8.0%) and FTT-HI groups (6.4%) than in the AG group (0%) ({chi}2 = 7.16; P < .05). When analyses were adjusted for maternal education, receipt of public assistance, and maternal anthropometry, paired comparisons revealed significant differences between all 3 groups, with the FTT-CO children having the lowest scores, FTT-HI intermediate, and AG the highest (Table 3).


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  		TABLE 3 Mean (SD) Scores on Child Growth, Cognitive/Academic Performance, and Home and School Behavior at Age 8

 
When BMI was considered, children in the AG group were heavier than children in the FTT-HI and FTT-CO groups. Although there were no significant differences between the 2 FTT groups, there was a significant linear trend (F = 8.96; P = .003), with children in the FTT-HI group maintaining an intermediate position between children in the FTT-CO and AG groups. Rates of wasting (weight for age less than –2 z scores) were higher for children in the FTT-CO group (6%) than for children in the FTT-HI (0%) and the AG groups (0%) ({chi}2 = 8.53; P < .05). When analyses were adjusted for maternal education, public assistance, and anthropometry, the children in the FTT-CO group were significantly thinner than those in the AG group (P = .003; Table 3) and marginally thinner than those in the FTT-HI group (P = .065). The FTT-HI group did not differ from the AG group.

Cognitive/Academic Performance at Age 8
There were no group differences in IQ (Table 3) in either unadjusted or adjusted analyses. Children in all groups obtained IQ scores that were ~1 SD below those in the standardization sample. Rates of mental retardation (IQ score <70) did not differ across groups: FTT-CO (16%), FTT-HI (12.8%), and AG (12.9%).

In reading, there were no group differences in either unadjusted or adjusted analyses. In arithmetic, children in the AG group obtained significantly higher scores than children in the FTT-CO group in unadjusted analyses (P < .05). Although children in the FTT-HI group obtained intermediate scores, the linear trend was not significant. When analyses for arithmetic were adjusted for public assistance, maternal education and IQ, and HOME scores, there were significant differences between children in the AG and FTT-CO groups (P = .03), favoring the AG group. The children in the FTT-HI group attained intermediate scores.

Home Behavior
There were no differences in unadjusted or adjusted analyses of internalizing or externalizing behaviors as reported by caregivers (Table 3). In comparison with published standards, 16.3% of children in the entire sample had internalizing behavior and 27.4% had externalizing behavior above the clinical cut point. There were no differences across the groups.

School Behavior
In unadjusted analyses, teachers reported more internalizing behavior problems for children in the FTT-CO group compared with children in the FTT-HI group (P < .05) or the AG group (P < .05). There were no differences in internalizing behaviors between the children in the FTT-HI and AG groups, and no differences in externalizing behaviors among the 3 groups. When positive behaviors were considered, children in the FTT-HI group had significantly higher scores on the works-hard and learning subscales than children in the FTT-CO group (P < .05).

In adjusted analyses, children in the FTT-CO group had significantly higher scores in internalizing behaviors (P = .008) and marginally lower scores in learning (P = .07) than children in the AG group. Children in the FTT-HI group had marginally lower scores in internalizing behaviors (P = .06), significantly higher scores in works hard (P = .05), and marginally higher scores in happy and learning (P < .10) than children in the FTT-CO group. There were no differences in school behaviors between the FTT-HI and AG groups (Table 3).

Contemporary Measures at Age 8
Rates of single parenthood (76.8%) and dependence on public assistance (88.9%) continued to be high (Table 1). With the exception of maternal education, there were no group differences in demographics, family characteristics, or maternal negative affect at age 8.

The analyses were repeated by using age 8 measures of maternal education, public assistance, and maternal negative affect as covariates, rather than baseline measures. The only difference from findings using baseline covariates is that the difference in arithmetic between children in the FTT-CO and AG groups reached significance (P = .03), favoring children in the AG group.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Longitudinal Follow-up of FTT
These longitudinal analyses make important contributions to the controversies surrounding the long-term consequences of FTT on children's growth, cognitive and academic performance, and home and school behavior, and demonstrate the lasting effects of an early home intervention among children with FTT. Our sample avoided referral bias by recruiting children from primary care and yielded almost no baseline differences in family demographics, maternal negative affect, or the home environment, based on the children's early growth history. Thus, group differences in growth, arithmetic performance, and classroom work habits that occurred at age 8 may be attributed to early growth failure and home intervention.

Growth
By 8 years of age, children with a history of AG were an average of 5.5 cm taller than children with FTT who received an intervention and 6 cm taller than children with FTT who did not. Differences in height remained significant, after controlling for public assistance, maternal height, and maternal education, suggesting that early malnutrition experienced by the children with FTT was severe enough to hinder their linear growth, at least through the school age years. The deficient linear growth among children with a history of FTT is consistent with findings from other follow-up studies.16,41 Early stunting is a marker for chronic undernutrition and has been associated with poor school-age academic performance.42–44

Children with a history of AG were an average of 4 kg heavier than children with FTT who received an intervention and 6 kg heavier than children with FTT who did not, resulting in BMI differences favoring children in the AG group. Previous analyses demonstrated a pattern of recovery whereby the children in both FTT groups experienced catch-up weight gain between recruitment and age 6.27 The findings are similar to growth patterns from developing countries, where linear growth faltering begins early in life and continues through at least preschool years and weight for length faltering occurs in the first 15 months of life, followed by recovery.45 The importance of considering genetic endowment when studying children's growth is illustrated by the significant associations between mothers' weight and height with their child's weight and height at age 8.

Cognition
The lack of significant differences in cognition between children with and without a history of FTT is consistent with recent literature from the United Kingdom, in which children with FTT were recruited from health centers or communities, rather than from hospitals or referral sources.8,16–18,41 In 2 studies, children's cognitive performance was higher than the scores achieved in the current sample.16,41 For example, in the Boddy study,41 scores on the McCarthy General Cognitive Index were well within the expected range regardless of early growth history (mean: ~101.7; SD: ~17.8). The differences in cognitive performance between our data and the United Kingdom data may be partially explained by the socioeconomic status of the samples. The United Kingdom samples were population-based and represented a wider range of socioeconomic status than the current sample, which was recruited from primary care clinics serving a very low-income urban community. The United Kingdom samples also differed from the current sample in race (white versus black), maternal age (older versus younger), maternal IQ (higher versus lower) and household composition (2-parent versus single parent). Thus, children in the current sample may have been living in more impoverished households than those in the United Kingdom studies.

The present finding of low cognitive scores among children (~1 SD below the normative sample), regardless of their growth history, is consistent with findings from other samples of low-income children. Evidence from the National Institute of Child Health and Human Development Early Child Care Research Network has shown that children in chronically impoverished families have lower cognitive performance and more behavior problems than children who are not exposed to poverty, partially explained by a lack of stimulating behaviors and home experiences among low-income families.26

A major finding from the current study is evidence that the early caregiving environment plays a critical role in children's cognitive and academic performance at age 8, regardless of early growth history. On average, the children in our study had cognitive skills slightly below the reference range when they were recruited during infancy. Infant performance on the Bayley was associated with measures of IQ and academic performance at age 8. By age 8, the children's cognitive and academic performance had declined significantly, possibly because of limited intellectual opportunities in the caregiving environment. Not only did mothers in our sample have IQ scores that were >1 SD below the norm, but maternal IQ and the quality of the HOME, measured when the children were ~15 months of age, were significantly associated with 3 independent assessments of children's functioning at age 8: a standardized measure of IQ, a standardized test of arithmetic, and teacher assessments of learning skills. These findings suggest that limitations in the early caregiving environment may have hindered children's cognitive and academic performance regardless of their growth history.

Home Intervention
The protective effects of early intervention are demonstrated by the children's age 8 growth, academic performance, and school behavior. The home intervention was designed to enhance mother-child relationships and maternal sensitivity by teaching mothers to respond to their child's bids for interaction. At the conclusion of the intervention, mothers in the intervention group were more child focused and responsive than mothers in the control group.12 One possible explanation for the beneficial effects of the home intervention on academic performance and schoolwork habits at age 8 is that mothers continued to provide responsive and stimulating home environments for their children. Our findings are consistent with other long-term studies that have reported beneficial effects of early home visiting on children's intellectual performance, vocabulary, arithmetic performance, and behavior.30,46

The significant linear trend in both height and BMI, with children in the FTT-HI group occupying an intermediate position between the children in the FTT-CO and AG groups, suggests that the home intervention may have provided some protection against the relatively poor growth of the children in the FTT-CO group. The mechanism linking home intervention and growth is not clear because the intervention provided neither supplementation nor counseling regarding nutrition or feeding. One possibility is that the sensitivity demonstrated by mothers in the home intervention group12 may have enabled them to provide a more responsive and interactive feeding environment than mothers in the clinic only group.

When academic skills were considered, children in the AG group outperformed children in the FTT-CO group by an average of ~6.7 points in arithmetic and 4.2 points in reading. The difference in arithmetic was significant, but the difference in reading was not. These findings are alarming because they demonstrate the vulnerability of children with early growth failure that occurs in the midst of urban poverty. The intermediate position of children in the FTT-HI group provides additional evidence that home intervention reduced the negative effects on arithmetic experienced by children with FTT who did not receive home intervention.

The teachers who rated the children's behavior viewed the children in the FTT-HI group as demonstrating better work habits and fewer behavior problems than children in the FTT-CO group. The teachers were unaware of the children's growth or intervention history. One possible explanation for this finding is that the intervention group children were exposed to a stimulating home environment that addressed their emotional needs and helped them learn to regulate their behavior and take advantage of learning opportunities at school. These findings are consistent with long-term benefits of early intervention reported from the Abecedarian Project in North Carolina,47 a home-visiting project among stunted preschool children in Jamaica,48 the Infant Health and Development Project among low birth weight and premature infants,49 and a nurse home-visiting program in New York.30

Methodologic Considerations
Although this follow-up study avoided many of the sampling and methodologic problems present in follow-up studies of children with FTT that rely on referred or hospitalized children,17 there are several methodologic considerations. First, the sample is limited to children recruited from pediatric primary care clinics serving a low-income, largely minority community and, therefore, findings are limited to low-income, urban, minority children.

Second, as with most studies, we have suggestive, but not conclusive, evidence regarding the mechanisms linking caregiver behavior and children's growth, cognitive/academic performance, and behavior. We presume that parenting characterized by responsiveness and stimulating opportunities enabled children to take advantage of developmentally stimulating and educational opportunities.

Clinical Implications
The findings from this investigation generate several recommendations. First, FTT continues to serve as an early warning sign of children's vulnerability. Although many children with FTT experience growth and cognitive recovery by school age, they continue to be at risk for poor growth, low academic achievement, and poor academic work habits that are likely to undermine future performance. Community studies indicate that up to 50% of children with FTT are not identified,50,51 suggesting that the prevalence of FTT is higher than reported estimates. When FTT co-occurs with other threats to children's well-being, such as neglect, the negative effects on children's behavior, cognitive, and academic function are compounded.52,53 Growth screening strategies to identify children with FTT and interdisciplinary interventions have been effective in promoting children's growth and development4,27 and should be continued. Second, there are few longitudinal studies of children with a history of FTT and most are compromised by serious methodologic problems, including referral bias.17 Following children with a history of FTT through elementary school and into adolescence would enable investigators to examine how children handle the increasingly sophisticated academic and social challenges that occur during later childhood and adolescence.

Third, the negative consequences of poverty were apparent across multiple indicators of the children's development, regardless of their growth and intervention status. In communities where there are social safeguards through public assistance programs, such as WIC (Supplemental Nutrition Program for Women, Infants, and Children) and the Food Stamp program, the likelihood of severe FTT is reduced.54 Strategies are needed to protect children from the negative consequences of poverty through economic resources and opportunities for their families to provide responsive and stimulating caregiving environments.

Finally, early home intervention mitigated many of the negative effects of FTT. It is likely that the stimulating caregiving environment resulting from early intervention was effective in helping children build strong work habits that enabled them to take advantage of academic opportunities. As Nobel laureate and economist James J. Heckman concluded in a recent review, "early interventions targeted toward disadvantaged young children have much higher returns than later interventions."55(p1902) Efforts to provide early intervention to vulnerable children and their families should be continued, along with long-term follow-up evaluations to assess and ameliorate additional developmental risks.


   ACKNOWLEDGMENTS
 
This research was supported by grants MCJ-240568 and MCJ-240621 from the Maternal and Child Health Research Program, US Department of Health and Human Services, and grants to the Consortium for Longitudinal Studies on Child Abuse and Neglect (LONGSCAN) from the Children's Bureau, Office on Child Abuse and Neglect, Administration for Children, Youth, and Families.


   FOOTNOTES
 
Accepted Mar 1, 2007.

Address correspondence to Maureen Black, PhD, Department of Pediatrics, University of Maryland School of Medicine, 737 W Lombard St, Room 161, Baltimore, MD 21201. E-mail: mblack{at}peds.umaryland.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


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