Parents’ Perceptions of Services for Young Children with Faltering Growth
Abstract
This article reports on a qualitative study exploring the experiences of parents of young children with faltering growth and feeding difficulties. They were interviewed as part of an evaluation of two projects using a behavioural model to resolve persistent feeding problems. The 22 respondents provided valuable insights into their experiences of parenting such children and of the various services they had received. One important finding was the extent to which they found input by some professionals unhelpful. It concludes by suggesting how workers in this field might better support parents, using the principles of partnership combined with behavioural techniques. © 2006 The Author(s). Journal compilation © 2006 National Children's Bureau
Introduction
Failure to thrive (FTT) is normally defined in terms of inadequate weight gain, identified by means of a growth chart or thrive index (Wright, 2000). In the past it was dichotomised into organic or non-organic FTT, with assumptions that all children with faltering growth either had an undiagnosed organic condition or were not thriving because of neglect, particularly maternal deprivation. Since the 1980s evidence of the multi-factorial aetiology of faltering growth (as FTT is now often known) and of the inadequacies of diagnoses and interventions based on this dichotomised view has mounted. It is now known that few children with faltering growth and no other symptoms will be found to have a previously undiagnosed organic condition (Wright, 2000; Wright and Talbot, 1996). In only a small proportion of families of children with faltering growth are found abuse and neglect factors (Wright, 2005; Wright and Birks, 2000). FTT results from inadequate nutrition, frequently due to feeding problems (Batchelor and Kerslake, 1990; Motion and others, 2001; Ramsay, 1995; Ramsay and others, 1993; Underdown and Birks, 1999; Wilensky and others, 1996). These feeding difficulties may, in turn, be due to a range of factors related to the child, the parents, the wider family and the social environment (Batchelor, 1999; Robinson and others, 2001).
In the late 1980s a voluntary child care organisation commissioned a review of the FTT research literature by Batchelor and Kerslake (1990) and then established two projects using their proposed model (Hampton, 1996). Staffed by health and social care professionals, both projects worked with children aged six to 36 months with persistent feeding difficulties and at risk of growth failure. The present qualitative study was commissioned by the projects’ funder and primarily focused on parents’ views of the projects’ effectiveness and the extent to which the theoretical underpinnings of the model informed day-to-day practice.
Locating these projects within their policy context, they were launched at a time of rapid change in children's health and social care. Evidence of the impact of the 1989 Children Act was accumulating (Department of Health, 2001) and whilst partnership with parents was a reality for some, the need for more responsive children's services was apparent. Policy developments such as the ‘Supporting Families’ consultation paper (Home Office, 1998) and the launch of the Sure Start Programme (Department for Education and Employment, 1999) were taking place alongside a major overhaul of public services (Department of Health, 1998) aimed at improving the quality of services, including greater responsiveness to the needs of service users. Finally the discourse of evidence-based practice was progressively being adopted by those in primary health and social care, with a growing expectation that any new intervention would be based on sound evidence of its effectiveness and efficiency.
Theoretical underpinnings of the projects
The theoretical underpinnings of the projects were social learning theory, building on the work of Iwaniec and others (1985). Primarily the projects used home visiting programmes, with workers helping parents to use behaviour therapy to reinforce their children's desired behaviour and to use planned ignoring of behaviours to be extinguished. Their work with parents was similarly informed by social learning theory. For example, workers might model desired responses to a child's behaviour at mealtimes.
Evidence regarding the potential effectiveness of such programmes grows (e.g. Barrett, 2003; Macdonald, 2001). Programmes using professional home visitors are associated with improvements in home environments and are effective in ameliorating child behavioural problems (Kendrick and others, 2000), although the process of the work is known to be key. Early models of partnership were critiqued for assuming service users would change their behaviour if simply told or shown how to do things differently by a professional (Easen and others, 1992). It is now recognised that a fundamental prerequisite for partnership is that practitioners operate from a value base that respects the expertise of service users. This was encapsulated in Pugh and De'Ath's (1989) early model of partnership, described as a working relationship ‘characterised by a shared sense of purpose, mutual respect and the willingness to negotiate’ (Easen and others, 1992, p. 285). Partnership work is fundamental to empowering, anti-oppressive practice, the hallmark of which is minimum intervention into service users’ lives, with negotiated goals and time-limits, written agreements and regular reviews and evaluations (Dalrymple and Burke, 1995; Stevenson and Parsloe, 1993).
The practice model
Project workers aimed to apply these principles of partnership combined with behavioural techniques to their day-to-day practice. As described by Hampton (1996), workers initially visited families to listen to parents’ concerns and attempted solutions and to observe mealtime interactions, supplemented by video recording and food diaries. Workers often shared initial assessments with project colleagues before producing summaries of observations and provisional work plans which they took back to families for discussion. Written agreements detailing goals, steps to be taken to achieve them, the number and frequency of visits and the responsibilities of parents and workers were then negotiated. The action stage was intense but relatively short, with workers helping parents to change mealtime interactions using such strategies as modelling and coaching. Finally, progress was reviewed against the original goals and decisions were made about termination or further work. Once the work ended (and again six months later) both projects sought feedback from families (and referrers).
Aims and methodology
The overall aim of the evaluation was systematically to collect and analyse data regarding the process, content, structure and outcomes of the project work as reported by parents of children with feeding difficulties. Parents’ experiences of such services, or of the stresses of raising a child whose growth falters, are rarely heard by researchers or by academics (but see Miguel and Burton, 1990; Underdown, 2000). Did social learning theory and behavioural work, embedded within the principles of anti-oppressive practice, partnership and empowerment underpin project practice? What were parents’ views of this process and of the outcomes?
As one objective was to test whether specified theories were applied and were successful in terms of outcomes (Clarke, 1999), the researchers sought users’ actual experiences of the projects. Semi-structured interview schedules were developed in consultation with project staff and piloted, prior to interviews being, conducted with a small sample of parents drawn from the two projects. Research approval was obtained from the National Health Service Trust Local Ethics Committees and potential participants were contacted by letter.
Of the two projects, one (located in the south-west) had worked with over 200 families in its present form. Of these, the 45 families with whom work had been finished for 12 months or more were approached. Seven mothers agreed to interviews, plus both parents of an eighth child. The north-east project had worked with over 80 families since its inception (including 17 minority ethnic families). Most were approached and 12 mothers and one lone father participated, including one minority ethnic family. Thus a total of 22 parents (20 mothers and two fathers) of 21 referred children were interviewed.
The interview schedules were structured chronologically, with parents initially being asked about their child's birth and early growth prior to problems being identified. They were then asked about previous attempted solutions (including other services used), the circumstances that led them to referral, their expectations of the projects, their experiences of the work and the outcomes. Attention was also paid to their views about the way the work was conducted and about the strengths and weaknesses of the model. The interviews were conducted in families’ homes and tape-recorded (with their permission). The tapes were transcribed and then analysed alongside the researchers’ interview notes. A time line of the process of work from pre-referral to post-project evaluation was constructed. Transcripts were then re-read to identify material relating to the way the work was conducted and the parents’ views about this, including how it might have been done better. Analysis was undertaken manually by the two researchers (including the author).
Findings: what parents told us
Only 20 per cent of families approached took up our invitation to participate in this evaluation. It is reasonable to assume that those unhappy with the content or process of the work are less likely to have been interviewed, plus perhaps those for whom the time when their child was not eating was so painful that they did not want the memories resurrected, regardless of the outcome of the work. This has implication for the findings but does not negate the positive views of many of the respondents as presented here. Rather it highlights the need for further research, for example with those who withdrew from work early.
From the parents’ descriptions we learned that most of the 21 referred children were the result of full-term pregnancies and normal births, although nine had special needs or medical problems and five of these had been premature (see Table 1). Eight of the 21 had undergone medical tests for poor weight, two had been hospitalised and three tube-fed. Their ages at the start of work had ranged from six months to just over three years. One-third had siblings and most (18) lived with both parents. At referral to the projects, all had feeding problems and weight loss or poor weight gain.
| Child: sex, age at referral, health status at birth | Prior services (and attempted solutions, e.g. tests, hospital, tube-fed) | Problems at time of referral to project |
|---|---|---|
| A Girl 18 months | HV/GP/paediatrician (tests) | Feeding, weight loss, reflux |
| B Girl 36 months. Medical problems | HV | Feeding, weight loss |
| C Girl 15 months. Prem/medical problems | HV/GP/neonatal nurse/speech therapist/paed (tests/tube-fed) | Feeding, weight loss, vomits |
| D Girl 11 months | GP/dietician/Paediatrician (tests/hospital) | Feeding, weight loss |
| E Boy 12 months. Special needs | HV/GP/speech therapist (tests) | Feeding, weight loss, reflux |
| F Boy 12 months | HV | Feeding, weight loss |
| G Girl 24 months? Prem | HV/GP/paediatrician (tests) | Feeding, weight loss |
| H Girl 24 months. Prem | HV/GP/paediatrician/dietician (tests, hospital, tube/pump-fed) | Feeding, weight loss |
| I Boy 36 months | HV | Vomits, slow weight gain |
| J Boy 30 months SCBU/ medical problems | Community nurse (tube-fed since birth) | Reflux, feeding |
| K Boy 18 months | HV | Weight loss |
| L Girl eight months | HV | Weight loss, feeding, choking |
| M Girl 24 months. Prem/medical problems | Children's hosp/tube-fed at birth | Feeding |
| N Boy 39 months. Caesar/special needs | HV | Feeding |
| O Girl 33 months. Prem | HV. Tube-fed at birth | Feeding/weight gain slow, chokes |
| P Girl 18 months. Medical problems | HV/Paediatrician | Vomiting, weight loss |
| Q Boy 12 months | HV/Paediatrician (tests) | Feeding/weight loss/retched |
| R Girl six months. Prem/medical problems | HV/Paediatrician/dietician | No weight gain, feeding |
| S Boy 24 months | HV/GP/dietician | Feeding |
| T Girl 24 months | HV/GP/paediatrician/dietician (tests) | Feeding, weight loss |
| U Girl nine months. Prem/special needs | HV | Feeding, weight loss |
- Children I to U are those from the north-east project.
Parents’ reports of prior services
A wide range of health professionals had previously been approached by these 21 families in their quest to resolve their children's feeding difficulties (see Table 1). Eighteen had consulted their health visitor and eight of these their general practitioner. Eleven children had been referred to other health professionals, such as paediatricians (nine), dieticians (five) or speech and language therapists (two). Eight of these 11 had then undergone medical tests and two had subsequently been admitted to hospital for investigation. Parents’ experiences of these health interventions varied. A few reported receiving excellent (albeit short-lived) support whilst some had very negative experiences. For example, one mother described the health visitor attempting to force-feed her child. Several said they felt ‘shunted’ from one professional to another in their quest to find out why their child was not eating. One parent described how, once an organic cause had been ruled out, she was simply told to go home and get food into the child, with no further guidance. Such experiences undermined parents’ confidence and exacerbated power differentials between workers and service users.
Parents’ experiences of the projects
Parents were then asked about the project work, from referral to ending, focusing on how they felt about each stage. Comments about their referral included, ‘I felt we'd been saved’ and ‘we were all for it; anything that could help him eat was a bonus’. These positive views were tinged, for some, with worries that they would be seen as over-anxious. Parents spoke of being scared as they blamed themselves for their children's feeding problems. Many expressed their hope that staff would believe what they had been trying to tell other professionals for some time — that they could not get their child to eat enough, despite their best efforts.
In describing the initial assessment visits, parents reported that the project workers listened to their concerns and observed the feeding. As one mother said, she was ‘very relieved to be listened to and believed’. Although nervous about being videotaped, most said they since recognised its value. Of the 21 families, 19 then progressed beyond this initial assessment phase so we asked about their experiences of negotiating working agreements. Several expressed relief at being offered help so agreed to the plan of work suggested by their practitioner whilst others actively negotiated it. For example, one mother commented, ‘I was happy for [project worker] to take control. The working agreement was concrete and it gave me boundaries’, whilst another thought the proposed number of mealtime visits was too high so discussed this with her practitioner and reached a compromise. A third mother said, ‘We worked out between us when to have visits … we agreed it between us’. One reported that the project worker suggested changes to mealtimes but this was not what this mother wanted, as she did not want to turn them into ‘a battle’. She explained, ‘The worker then asked me, ‘‘Would you like to talk about nutrition?’’ and I said yes, so I saw a paediatric dietician’. The parents’ responses did not suggest they felt pressured to accept workers’ suggestions. They described decisions being taken together, conveying a sense that they had been listened to and then participated in negotiations with the worker regarding the focus of work, the frequency of visits and the changes they wished to achieve.
Describing the action stage, parents reported mealtime visits ranging from one to four a week over approximately two months, although some negotiated less frequent visits over longer time scales. Most were happy with the number of visits and had not experienced them as intrusive. One mother drew comparisons between prior professional help and the project, saying:
At first the health visitor said she will eat eventually, she won't starve. She didn't give me any instructions — as if I was a worrying mother. Whereas with [project staff] they had a plan and said ‘This is what you should do’. They also said, ‘If at any time you've had enough of us and want to drop out, that's fine’.
This parent conveyed a sense that she remained in control of the work, knowing she could call a halt if she wished.
The focus of change was usually mealtime arrangements, such as ensuring family members ate together at a table (without toys or television), with children being praised when they ate and ignored when behaviour was unacceptable. The parents reported being primed to resist encouraging children to eat more when they stopped, removing uneaten food after an agreed period. Several mothers commented on how difficult this was. As one said, ‘It was hard not to encourage her to eat a bit more’ and another said ‘It was hell having to ignore [daughter] and take away her meal’. The fact that so many parents interviewed reported doing this, despite their anxieties, suggests a shared sense of purpose and commitment to the goal of improved feeding. Such interventions were congruent with the projects’ stated theoretical base of behavioural interventions, but could only be effective within working relationships based on principles of partnership.
As parents implemented strategies that reduced the time they spent on feeding, some reported more quality time with all family members. As one respondent said, ‘It has stopped me from dreading mealtimes’, another explained, ‘Now I can have a break between meals … we can do things like go swimming’ and the third stated, ‘We can all go out now and do whatever we want’.
The parents also appreciated practical help, such as the loan of high chairs, or suggestions regarding cutlery. One child feared eating as her desperate parent had attempted force-feeding. The worker suggested giving the child a bowl of water and spoon to play with and soon she was happily putting it in her mouth — the first step to improving her feeding. Minor adjustments to children's present diet to maximise calories (e.g. adding cream) often resulted in weight increases, giving parents experiences of success.
When asked about outcomes (see Table 2), only one family reported no change by the end of the first working agreement, whereas four parents said they achieved change within one week. For example, one reported that by the end of the first day their child progressed to sitting quietly at the table and not screaming. A further 16 parents reported gradual changes, including two mothers who said they had stopped worrying or become more relaxed.
| Child: Sex, age at referral, health status at birth | Initial changes by end of project work | Parents’ view of current situation |
|---|---|---|
| A Girl 18 months | Child sitting at table not screaming by end of 1st day | ‘Enormous difference … she really enjoys her food’ |
| B Girl 36 months. Medical problems | Child stopped screaming at mealtimes/sat quietly at table | ‘Eating fantastically now & enjoys her food’ |
| C Girl 15 months. Prem/medical problems | In one week mother spending less time feeding/child not vomiting | ‘She enjoys eating when well’ |
| D Girl 11 months | None | ‘She's happy and content, slim but not underweight’ |
| E Boy 12 months. Special needs | Child feeding self by end of first day | ‘… a big improvement but he still doesn't eat normally’ |
| F Boy 12 months | Gradually improved | ‘His weight is fine and he'll eat well for weeks and then have a spell of just picking’ |
| G Girl 24 months. ?Prem | Gradually improved | ‘improved but still a slow and fussy eater’ |
| H Girl 24 mos. Prem | Weight gain in under three weeks | ‘She eats fine but I wonder if she ever enjoys food’ |
| I Boy 36 months | Gained weight and sustained it | ‘His eating improved and he sat at the table’ (but recently slipped back) |
| J Boy 30 months SCBU/medical problems | Slight improvement | ‘He improved slightly’ |
| K Boy 18 months | Started to put weight on | ‘We have more structured mealtimes … he started eating’ |
| L Girl eight months | Mother stopped worrying | ‘I stopped worrying once I knew it wasn't a physical problem’ |
| M Girl 24 months. Prem/medical problems | Child no longer scared of food | ‘She used to be scared of food, now she'll put anything in her mouth’ |
| N Boy 39 months. Caesar/special needs | ‘Not dramatic’— same diet but mother more relaxed | ‘I'm more relaxed’ |
| O Girl 33 months. Prem | Took six weeks and worse before better | ‘Now she is quite a good eater’ |
| P Girl 18 months. Medical problems | Mother cooking differently and child eats finger foods | ‘She eats finger foods’ (but recently slipped back) |
| Q Boy 12 months | Initially hard till child started eating | ‘Gradually he started putting weight on’ |
| R Girl six months. Prem/medical problems | Meals are different — more relaxed | ‘She eats well in spurts … I'm more relaxed’ |
| S Boy 24 months | Gradually started to eat more | ‘For a few weeks he was OK’ |
| T Girl 24 months | Improved straightaway | ‘Her eating hasn't changed dramatically but it's much better’ |
| U Girl nine months. Prem/special needs | Up and down | ‘Still up and down … but I've learned to cope with it’ |
We then asked parents whether the progress made had been sustained. As shown in Table 2, across the 21 families interviewed, 16 reported lasting improvements, saying such things as ‘Now she is quite a good eater’ or ‘She really enjoys her food’. Four mothers observed they now had a different attitude to their child's eating. They recognised they had become less stressed and as a result their children often ate more. Comments such as ‘I stopped worrying once I knew it wasn't a physical problem’ and ‘He still has the same diet but I'm more relaxed’ were made. Just one reported no sustained change, although several who reported an overall improvement in their child's feeding said it was still erratic, describing it as ‘up and down’ or ‘he'll eat well for weeks and then have a spell of just picking’. This is congruent with evidence that children with faltering growth may have poor appetite regulation (Motion and others, 2001). Three parents acknowledged that changes that had been achieved had since slipped back, but two of them recognised this was because they were not keeping to the strategies learned, such as the planned ignoring of unacceptable behaviour. These findings support the point made by several parents that, although the timing of the ending of work was appropriate, they would have liked ongoing links with other parents of children with faltering growth.
Finally, the parents were asked about the strengths and weaknesses of the projects. A common theme was positive comments about the work being conducted in the family home, involving all family members whenever possible. Another theme was the respect and consideration accorded them by workers. The parents reported they were listened to, not blamed, had their concerns understood and were treated as a person. As a result, they could voice fears they had for their child, such as that they might die. This contrasted with many of their accounts of other services they had used.
Discussion
This evaluation research was conducted using a quasi-experimental design. As it was not possible to interview a comparison group, any causal inferences drawn must be tentative (Clarke, 1999). In addition, the sample obtained was small. Even allowing for the possibility that families had moved and so had never received our request, the response rate was below 20 per cent. Parents unhappy about the way the work was conducted, including those with whom a working partnership had never been successfully forged, may be most reluctant to respond, hence skewing the findings. Although the sample encompassed a range of family types in terms of structure (including lone-parent, two-parent and three-generation households) this was not the case for ethnicity. As only one minority ethnic family was in the final sample we have limited information on the extent to which the projects met the needs of such families.
Parenting a child with feeding problems
Parents vividly described their battles when trying to feed their children. Several said their children had problems with lumpy foods. One said her child only liked dry foods (e.g. bread sticks) and liquids, but not wet food such as purees. Several children had very limited diets (e.g. only one brand of criSPS). One child reportedly ate only spaghetti hoops for weeks and then went off them, leaving the parents distraught. Parents also revealed how desperate they were for help. Many discussed their feelings of failure, reinforced by friends, family and sometimes professionals who could not comprehend that their child refused to eat. Feeding often became a nightmare, with mealtimes running together, leaving little space for regular family life. Holidays, outings and even shopping trips were limited. Several mothers spoke of having being imprisoned in their homes with a deep sense of isolation. They also conveyed the impact of the feeding problems on parent–child relationships. For most parents, especially mothers, successful feeding of their child was intimately bound up with their sense of themselves as competent and caring. The feelings of failure engendered when, despite their best efforts, their child did not eat undermined their belief in their capacity to be good parents, even for those who were not first-time parents.
Parents’ experiences of project assessment
The parents described full assessments by project workers, reporting they listened carefully and took the time to observe family interactions in their home. Attending to the families’ attempted solutions was an effective way that the workers built their understanding of parents’ views of the problem, including their beliefs about the cause. As one mother explained, her project worker had simply said ‘Let me see you feed her’. In contrast, parents who had previously been referred to specialist health services rarely had opportunities to explain their concerns and attempted solutions. In the setting of busy outpatient clinics, assessment of non-medical factors had been very limited. As a result some parents reported being given inappropriate advice, confirming for them the professionals’ lack of understanding of their problems. As one mother said, ‘When I come out of the specialist I say to my mother ‘‘He makes me feel it's my fault’’… it's the way they word things’.
Social learning theory and behaviour therapy in practice
The model of intervention used by the projects, based primarily on coaching parents in using behavioural techniques with their children, was effective for the majority of families that we interviewed. The work undertaken, whilst based on behavioural principles, encompassed interventions ranging from practical advice on maximising calories to intensive work with individual parents. For some families, one or two visits concluding with practical suggestions were sufficient for them to achieve a change. For others, improving their child's feeding took longer. Whilst mindful of the limitations of the sample, for the parents we interviewed it appeared that the intensity, length and focus of intervention took account of their goals for change, the severity of feeding problems and its multi-factorial aetiology.
Having achieved changes in their child's feeding, several parents reported a positive effect on other areas of parenting and enhanced self-esteem as their skills increased. Apparently workers had helped some parents think and feel differently about their child's feeding, so enabling them to respond differently to other aspects of their behaviour. This suggests that elements of cognitive behavioural therapy (which includes changing thoughts and feelings about behaviour) were sometimes used, in addition to the behavioural work presented as underpinning the model (Hampton, 1996).
Parenting programmes, home visiting and parent support
The projects conducting home-based work used a practice model already established as effective in terms of developmental outcomes for mothers and children (Macdonald, 2001). With one exception, respondents reported that the projects had helped them achieve changes in their children's feeding. It was also evident that the workers were skilled in engaging these families and building working relationships. They did this by hearing parents’ accounts, not jumping to provide solutions yet offering immediate practical tips. Some parents thereby quickly achieved small improvements, so boosting their sense of control over the situation and hence their self-esteem. This also contributed to the working relationship, helping to build trust between parents and workers. Such an approach is congruent with other research findings regarding what parents find supportive when accessing services to address parenting problems. Parents appreciate receiving services that are practical whilst also wanting to feel in control and to have their expertise acknowledged (Quinton, 2004).
Partnership and empowerment in practice
It was apparent that much of the success of the model of intervention used by the projects rested on the partnership formed between the practitioners and these families. This partnership process was set in train from the point of referral, when parents received a prompt response, even if they were put on a waiting list for a first appointment. At assessment, the project workers evidently operated from a value base that respected the parents’ expertise in relation to their own child, whilst the home-based work meant each family was on its own territory when negotiating working agreements. This created a firm foundation for a relationship experienced by parents as empowering and anti-oppressive. Subsequent work was flexible in terms of pace, with decisions over when to start and how to space appointments and the goals being negotiated. As a result the partnerships between the workers and parents were sustained and these parents were able to implement even the most demanding strategies to achieve change, such as removing food after a reasonable time. This may not have been the case for those families who chose not to participate in this evaluation.
Although this was not identified explicitly by the respondents as an important element of the work, several commented on the ways they felt in control of the process, including being able to cease work with the project at any point should they wish. If parents have participated in the work as true partners and clear goals for change have been established jointly at the outset then ending is unproblematic once these are achieved. This is what the parents we interviewed reported, although several expressed their sense of loss after such a close working relationship with a highly supportive practitioner.
The past and present policy context
The findings from this study suggest there are several ways in which both these projects were ahead of their time, in terms of the policy context when they were launched in the 1990s. They were targeted at the needs of young children and their families and based on principles of partnership and user participation, as later proposed in the Supporting Families consultation paper (Home Office, 1998). They were also designed on the basis of best evidence from research.
The projects’ model of practice also fits well within current policies relating to services for young children and their families. It is congruent with many elements of the Change for Children initiatives in Every Child Matters (Department for Education and Skills, 2003), such as the need for services providers to listen and respond to the various needs of children and their families. Similarly it accords with expectations set out in the Children's National Service Framework (Department of Health, 2004), focusing as it does on intervening early and promptly, providing services that are responsive to the needs of children and families using them.
Conclusions: implications for research and practice
The findings from this small-scale evaluation contribute further to the evidence base regarding the effectiveness of home-based parenting programmes that draw on behavioural therapy. They also provide evidence of the importance of such interventions being conducted in the context of a working relationship that is mutually respectful and based on trust and participatory (Department of Health, 2001; Pugh and De'Ath, 1989).
Whilst many working in health and social care will not have the resources to provide home-based assessment and intervention to families of children with faltering growth, all of us can learn from what these parents told us. Future research needs to explore the potential of such a model with problems other than feeding, and in situations where parents and professionals hold differing views on the nature or extent of difficulties, particularly where parents are mandated to accept intervention (Department of Health, 1995). However, for the families that participated in this evaluation, their needs were met through the provision of a tailored programme of behavioural work by voluntary-sector practitioners who, applying the principles of partnership work, took time to listen, watch and learn, drew on the expertise of their multi-professional team in formulating interventions and then supported parents closely whilst they achieved the changes necessary to reach their goal. Clearly services based on these principles are welcomed by parents of children with faltering growth, have the potential to enable many of them to resolve their children's feeding problems successfully and may be applicable in a range of other situations when parents are struggling to meet the needs of their young children.
Acknowledgements
The Children's Society sponsored the evaluation study on which this article is based. Thanks go to research officer Lyn James (previously Webster) for undertaking some of the interviews and analysis and to Di Hampton for commenting on early drafts of this paper.
References
Contributor's details
Jane Batchelor qualified as a social worker in the 1970s and worked with children and families in community teams and residential settings before taking up her first post at the University of Bath in 1988. She has been conducting research in the field of failure to thrive for nearly 20 years.
