The Vulnerable Child Syndrome

Reactions to the Threatened Loss of a Child: A Vulnerable Child Syndrome. Green M, Solnit AJ. Pediatrics. 1964;34:58–66Vulnerable Child Syndrome and Its Variants. Green M. Pediatr Rev. 1986;8:75–80The Vulnerable Child: New Evidence, New Approaches. Boyce WT. Adv Pediatr. 1992;39:1–33The Morbidity of Cardiac Nondisease in Schoolchildren. Bergman AB, Stamm SJ. N Engl J Med. 1967;276:1008–1013Jaundice, Terminating Breast-Feeding, and the Vulnerable Child. Kemper K, Forsyth B, McCarthy P. Pediatrics. 1989;84:773–778Vulnerable Children: Parents’ Perspectives and the Use of Medical Care. Levy JC. Pediatrics. 1980;65:956–963Is My Child Normal Yet? Correlates of Vulnerability. Perrin EC, West PD, Culley BS. Pediatrics. 1989;83:355–363Expanded Newborn Screening for Biochemical Disorders: The Effect of a False-Positive Result. Gurian EA, Kinnamon DD, Henry JJ, Waisbren SE. Pediatrics. 2006;117:1915–1921Consultation with the Specialist: The Vulnerable Child Syndrome. Pearson SR, Boyce WT. Pediatr Rev. 2004;25:345–349In a landmark study in 1964, Green and Solnit described the vulnerable child syndrome (VCS) as a set of clinical features in which unfounded parental anxiety about the health of a child resulted in disturbances of the parent-child interaction. The parents’ perception of their child as being vulnerable led to maladaptive behaviors. The parents overprotected the child, were unable to set age-appropriate limits, and displayed excessive concerns in medical settings about their child's health. The children responded with exaggerated separation anxiety, out-of-control behavior, school underachievement, and distorted perceptions of their own health. Parental perception of a child as being medically vulnerable was not always related to a severe illness, but more likely reflected how an individual family responded to an illness in their child. Thus, the syndrome could be seen with a minor illness or even a “nondisease” if parents misunderstood medical information.The clinical hallmarks of VCS are excessive parental concerns and a high frequency of health-care use. Pediatricians can play a central role in the primary and secondary prevention of VCS through early recognition and treatment. VCS is diagnosed when a physician notices a child who uses health care excessively and is perceived by a parent to be vulnerable, and the clinician uncovers an antecedent event that instigated parental anxiety and symptoms in the child. The Child Vulnerability Scale and the Vulnerable Child Scale are psychometric measures helpful for research purposes and for use in screening during clinical encounters.Particular risk factors for VCS include a child who has a history of serious illness or injury; who is “symbolic” for the parent of a significant person who died prematurely or unexpectedly; whose life or whose mother's life was at risk during pregnancy or delivery; who a physician said might die; and whose mother has a history of threatened abortion, multiple spontaneous abortions or stillbirths, or fertility issues. 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 rating of her own health.Parents typically are overprotective, show separation anxiety, are unable to set age-appropriate limits, have excessive concerns about their child's health, and overuse medical services, including emergency departments. Affected children may have sleep disorders, school problems ranging from avoidance and absence to underachievement, discipline problems, and hypochondria. In addition, the children can be abusive to their parents.With an exaggerated view of their child's predisposition to disease, parents make disproportionate use of health-care services. Children who have been high users of health-care services have higher-than-expected rates of psychological distress and mental health problems as adults and continue a pattern of frequent health-care use.Early fears about a child's health can have lasting adverse effects on how parents perceive their child's vulnerability, and those fears can be iatrogenic. Bergman and Stamm showed that 40% of parents who were told that their child had an innocent heart murmur continued to restrict the child's activity into early adolescence. Kemper and colleagues demonstrated that an intervention as seemingly simple as the treatment of physiologic neonatal jaundice can have lasting effects on parents’ perceptions of their child. Mothers of infants who underwent phototherapy were more likely than control mothers to regard illnesses sustained over the first postnatal months as serious and were more likely to make more frequent health-care visits. They also were more likely to stop breastfeeding and were less likely to leave their babies with another person.In a large population of children receiving primary care in Boston, Levy found that about 25% were perceived as being vulnerable by their parents, but there was no clinical basis for the perceived vulnerability for almost 50% of such children. The children were seen more frequently by physicians and had more visits to the emergency department, and their parents expressed more dissatisfaction with the care received. Parents’ unwarranted concerns often were derived from something a physician said or did, such as a minor abnormality discovered in routine screening that was explained incompletely to the parent or understood incorrectly by the parent. In other situations, parental anxiety arose from some connection the parents made to a past illness of the child or that of other family members.Using a Vulnerable Child Scale, Perrin and associates showed that preterm infants, even when healthy, were almost ten times more likely to be viewed as being vulnerable as term infants by their mothers. Maternal perceptions also were associated significantly with education and marital satisfaction; more educated women and those less supported within their marriages reported greater vulnerability in their children. Also, mothers who viewed their children as being vulnerable reported more problems in their children in terms of discipline, peer relationships, and self-control.More recently, expanded newborn screening for biochemical genetic disorders, with its consequent increased false-positive results, has introduced another source of parental stress: creating expectations of illness in an otherwise healthy child. Children who have false-positive results are more likely than children whose results are normal to experience hospitalization and to have parents who are more overprotective and more focused on the child's physical symptoms.Evidence shows that many seemingly innocuous medical events and procedures can engender lasting parental anxiety about the health and well-being of a child. The threatened loss of a child, especially when the anticipated loss occurs early in life, can alter a parent's view of a child and change the character of parent-child interactions for years to come. Treating a child as a vulnerable, more fragile member of the family also can change the child's own behavior, affecting awareness of bodily symptoms, perception of health and illness, and self-esteem.The best management of VCS is prevention, which begins with the physician's awareness of the settings in which VCS is likely to arise. The key is uncovering the source of the parents’ anxiety and re-educating them about their child's health. The assessment should begin with a history and physical examination, especially noting and remarking on normal physical findings for the benefit of the parent and child. The parents’ underlying anxiety about the child's health should be addressed, suggesting the connection between past threats and present concerns, because parents often are unaware that their current concerns stem from unresolved anxiety about a past incident.Close, regular communication between physician and parent should be exact and clear. At routine scheduled appointments, the physician can teach the parents appropriate interpretation of signs and symptoms and reinforce the child's healthy status. The parents should learn to set firm disciplinary limits, diminish overprotectiveness, and deal with issues of separation and behavior. If the 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, a referral should be made for appropriate therapy. Pediatricians can avert VCS by foresight and communication, recognizing families who overuse primary care services, being aware of settings in which VCS can develop, and intervening preemptively.Comment: The power of language is enormous, and our words can have an impact beyond what we intend. As much as we try to explain neonatal jaundice as being “physiologic” and heart murmurs as being “innocent,” what parents take home often is a message far different from what we understood ourselves to say. Learning to appreciate this reality is critical to the care we give. Children whose families view them as being vulnerable are at risk for growing up to see themselves in the same way.