Consultation with the Specialist

This is the authors' abstract. We don't add key points for this paper.

After completing this article, readers should be able to: A 3-year-old boy is brought to the pediatrician’s office by his mother for stomachaches and poor appetite, which she says have been a problem for as long as she can remember. She also is concerned that he seems to tire easily and get sick more often than other children. At birth, he was kept in the hospital for 1 week for a sepsis evaluation, which was negative, but has had no subsequent hospitalizations or major medical problems. However, he has been seen on average once a month in the clinic or emergency department for minor injuries and illnesses.The “vulnerable child” can be defined as a child who has an unusual or exaggerated susceptibility to disease or disorder. Complex and heterogeneous groups of children are considered vulnerable, including those who are medically, psychologically, socially, or economically at risk as well as those who are biologically susceptible to physical and mental health problems.Parents who take their children to the pediatrician sometimes perceive an individual child as being highly vulnerable to illness and injury. In a study of 750 parents interviewed in the waiting rooms of five pediatric practices in the Boston area, Levy found that 27% reported fears of their child being uniquely vulnerable. Review of the medical records indicated no clinical basis for parental concern in 40% of these cases (Levy, 1980). Unwarranted medical concerns often stemmed from fear of the recurrence of an earlier, already resolved medical problem.Why do some parents perceive their children as being vulnerable? Are these children truly more vulnerable than others? What is the role of the pediatrician in helping parents who are concerned that their child is vulnerable?Green and Solnit initially identified the importance of parental perception of vulnerability in 1964. Their observation that “parental reactions to an acute, life-threatening illness in a child may have long-term psychologically deleterious effects on both parents and children” now is a well-recognized clinical entity: the vulnerable child syndrome (VCS). The VCS refers to a physically healthy child who is viewed by his or her parents as being at greater risk for behavioral, developmental, or medical problems, usually following a serious childhood illness.Studies generally support the clinical impression that VCS arises after a perceived life-threatening event, often at birth, and that symptoms frequently persist through preschool, resolving a few years later. However, VCS also can develop after a later incident (again real or fictitious), with subsequent parental misperception of the child’s susceptibility and ongoing, unwarranted anxiety about the child’s vulnerability. The antecedents, presentation, and prognosis of VCS are understood best when it is viewed as a family disorder in which the parents have multiple concerns about a child whose life has been threatened—authentically or symbolically—in the past.Although VCS can develop in any family, Green and Solnit hypothesized that the families at greatest risk often have “predisposing experiences which predate the [child’s] serious illness.” A mother’s perception of her child’s vulnerability can be exacerbated by environmental stress, family stress, lack of social support, low socioeconomic status, and poor maternal rating of her own health, but VCS tends to occur in families in which there are one or more of the following groups of risk factors: 1) serious illness or injury in the child; 2) problems with fertility, pregnancy, or birth; or 3) parental psychological issues.Risk factors stemming from problems in the child include: preterm delivery, an illness or accident from which the child was not expected to recover (“near miss”), presence of a congenital anomaly, acquisition of a handicap, heart disease or jaundice in the newborn period, or crying or feeding problems in the first 5 years after birth.Risk factors related to fertility, pregnancy, or delivery include: a history of infertility or recurrent stillbirths; no expectation of additional children; acquired infertility due to sterilization, hysterectomy, or concurrent disease; concern over a familial hereditary disorder; expression of a physician’s concern that the fetus might die during gestation; or risk to the mother’s life during pregnancy or delivery.Risk factors related to parental psychological issues include: a mother’s experience of postpartum depression; ambivalence or negative feelings toward the child; feelings toward the child that the parent deems unacceptable and that are manifested as a need to find something wrong with the child; an unresolved grief reaction in which the child symbolizes a significant person who has died; or displacement of fear, anger, depression, or other strong emotion on to the child.Excessive parental concerns and a high frequency of health care use are the clinical hallmarks of VCS. Parental symptoms include separation difficulties, overindulgence, overprotectiveness, inability to set age-appropriate limits, and tolerance of physical abusiveness toward the parent by the child. Child symptoms include sleep problems, hyperactivity, underachievement, and learning difficulties. One explanation for the psychodynamics of VCS begins with parental difficulty in separating from the child; the child senses unwarranted parental anxiety and subconsciously develops symptoms or risk behaviors that reinforce parental fears.In practice, VCS is diagnosed when a physician notices parental misperception of the child’s vulnerability (often brought to attention by excess use of health services) and uncovers an antecedent event that instigated parental anxiety, child symptoms, and characteristic family dynamics. There also are clinically reliable psychometric measures, the Child Vulnerability Scale and the Vulnerable Child Scale (Table T1), that are helpful both for research purposes and to give primary care clinicians a fuller understanding of the complexity of VCS and a means of screening for it during clinical encounters.An additional diagnostic possibility is a subset of children, well known to practicing pediatricians but less well described in the medical literature, who sustain a disproportionate share of illness and injuries, although no obvious underlying disorder is present. Such an “illness-prone child” (IPC) truly is more vulnerable to mental and physical health problems than other children, is among the 20% of children responsible for more than 50% of all outpatient visits, and sustains a disproportionate burden of illness and injury despite having no known underlying disease. In such instances, clinicians often worry that they may be missing a major diagnosis.Four possible explanations have been proposed for the IPC. First, major social risk factors, such as low socioeconomic status, could predispose a child to greater risk of illness and injury. A second possible explanation is that “illness begets illness” by reducing resistance to pathogens. A third possibility is that greater exposure to environmental threats, such as microbiologic pathogens, chemical toxins, or psychosocial stressors, lowers disease resistance and, thus, accounts for increased rates of illness and injury. Finally, some illness-prone children may have a constitutional, genetically based vulnerability to physical and psychological stressors. There is a growing body of psychobiologic research to support the hypothesis that individuals vary in response to environmental and emotional stressors and that those who are more susceptible to stress are more likely to incur higher rates of mental and physical illness and injury. Although the diagnosis and management of the IPC is a topic for another review, it is important to consider true predispositions to recurrent illness when identifying and managing VCS.Early fears or misperceptions about a child’s health can have lasting adverse effects on parental interpretation of a child’s vulnerability. Bergman and Stamm showed that 40% of parents who were told that their child had an innocent heart murmur continued to restrict that child’s athletic activity into early adolescence. Forsythe and associates demonstrated that children who were hospitalized between 6 months and 3 years of age were perceived as being more vulnerable by their parents 6 months later than were children who never were hospitalized. Perrin and colleagues found that past events were more important than current health status in parental ratings of children’s vulnerability.Management of VCS relies on physicians uncovering the events that initially created the parental anxiety and re-educating parents about their child’s health. The assessment should begin with a meticulous history and physical examination, especially noting and remarking on normal physical findings for the benefit of the parent and the child. Next, the underlying parental anxiety about the child’s health should be addressed, and the connection between past threats and present concerns be suggested. Discussing the significance of the past illness is essential because parents often are unaware that their current concerns stem from unresolved anxiety about a past incident.Close, regular communication between physician and family should be initiated. Communication should be exact and clear. It is important not to exaggerate or understate the significance of past events or the current condition. At routinely scheduled appointments, the physician can teach the parents appropriate interpretation of symptoms and signs; reinforce the child’s healthy status; and encourage the parent to set firm disciplinary limits, discontinue or diminish overprotectiveness, and deal with separation issues. Physicians also can address sleeping problems and behavioral issues.If the child still is at increased risk for specific health problems, those should be stated clearly, and if there are opportunities for prevention, the family should be educated appropriately. If necessary, the clinician should define the time period during which the child needs to follow any special precautions. The family should be told directly that after a given amount of time, the child no longer will be at increased risk. The physician can manage VCS best by being realistic about the child’s complaints, helping the parents recognize the connection of past experience to current complaints, and encouraging the parents to let go of the past “near loss.”Parents who see their child as being vulnerable often do not respond to usual reassurance and may consume excessive amounts of the physician’s time. These visits can be frustrating for both family and physician. Given the reality of time constraints on clinical practice, clear communication is especially important to elicit the concerns of patients and their parents. It could be helpful to have parents fill out questionnaires in the waiting room to increase the likelihood that their concerns are addressed during the visit. In addition, including a few yes/no questions, such as “Has your child experienced a life-threatening illness in the past?” could help identify families at risk for VCS. If parents are unable to understand the connection between past events and current concerns and the physician is unable to interrupt the cycle of parental anxiety and child symptoms, referral to a family therapist or child behavioral specialist is recommended.VCS can be averted by physician foresight and communication. Prevention begins with the physician being aware of the settings in which the VCS can develop. Following serious illness or a perceived “near miss,” the physician should offer prospective counseling about ongoing risks and necessary precautions. It is helpful to describe VCS explicitly to families at risk, explaining to the parents that often a “natural” reaction to a child’s illness is to overprotect or treat the child in a special manner, but that ultimately viewing the child as vulnerable is disadvantageous to both the child and the family. The clinician should advise the family to return rapidly to normal life and suggest social work or support services that might assist their transition.Careful and frequently scheduled follow-up is essential (although it is best not to have the child miss school and to emphasize that these follow-up visits are routine). Re-examination and reassurance by specialists also can help prevent the onset of VCS. Making accurate statements about the diagnosis and prognosis and listening to the parents’ concerns and questions can help the physician gauge parental understanding of their child’s situation. In all clinical encounters, it is important to avoid hyperbole and retrospective comments about the gravity of a past illness (ie, statements such as “It is good that you took your baby to the emergency department when you did” or “We started the antibiotics just in time”). Although the intention is to affirm the parental action on behalf of the child, the effect often is to alarm the parent. Similarly, it is important to think about the psychological implications of all medical interventions, referrals, and screening tests. By staying alert to the families that overuse primary care, the physician may note which families seem to be developing VCS and intervene preemptively.