. Vulnerable Child Syndrome

Vulnerable Child Syndrome

Yi Hui Liu

In 1964, Green and Solnit¹ described a group of 25 children ages 17 months to 14 years old with a history of a condition perceived, and often-times physician-endorsed, as life-threatening (eg, prematurity, seizures, congenital cardiac disease, pneumonia, diabetes mellitus, head trauma). Despite recovery, these children were then inappropriately considered by their parents to be at heightened ongoing risk for premature death. Although the majority of the precipitating illnesses occurred within the first 2 years of life, the parent–child relationship was persistently altered, generating in later years maladaptive behaviors such as separation difficulties, infantilization, bodily overconcerns, and school underachievement. Vulnerable child syndrome (VCS) is currently viewed as an extreme manifestation of persistent and unfounded parental expectations of medical vulnerability after a real or perceived health threat to a child. The high parental perception of child vulnerability (PPCV) significantly increases use of acute medical care, attention to behavioral and developmental problems, and parental distress.

EPIDEMIOLOGY, SPECIFIC POPULATIONS AT RISK, AND ASSOCIATED DISORDERS

The prevalence of vulnerable child syndrome is unknown and is difficult to measure. However, studies^2,3 have documented that approximately 10% of children seeking care in pediatric ambulatory settings may be inappropriately perceived by their parents as vulnerable.

Predisposing factors to high parental perception of child vulnerability may include parent factors (eg, history of infertility or miscarriage, postpartum depression, unresolved grief from the death of a close family member, hereditary disorder in the family, maternal psychological factors, limited social support), child factors (eg, prematurity,^4,5 a congenital anomaly, difficult temperament, chronic illness), and threat of fetal or maternal death during pregnancy or delivery.^1,6

In 1986, Green described variants of vulnerable child syndrome that included (1) the “illness-prone child” who has no underlying disorder to account for the numerous illnesses and injuries that result in medical attention⁷; (2) a parent who watches a child vigilantly for the earliest signs of a specific medical or behavioral disorder that affects relatives; and (3) a parent misconstruing a normal variation on a physical examination, a false-positive screening test result, or an apparently “abnormal” test result as indicating a serious problem with the child.^6,8-10 Parents of children with chronic medical conditions who have an incomplete understanding of their child’s disease may overestimate the child’s true vulnerability. All these variants have in common the frequent use of health care services.

ETIOLOGY

High parental perception of child vulnerability (PPCV) often develops after an event at birth, persists through the preschool years,^12,13 and then resolves a few years later.¹⁴ The earlier the event, the less severe that event needs to be to produce a high parental perception of child vulnerability (PPCV) and the more likely that high PPCV occurs.¹⁵ Treatments such as phototherapy for jaundice,¹⁶ formula changes for feeding problems,¹³ or hospitalization¹⁷ may reinforce the PPCV. Even a health screening procedure may elicit inappropriate concern when false positives or minor abnormalities are found.² Mothers who are more anxious, who are less satisfied with their lives, and who have fewer social supports are more likely to view their children as vulnerable.^4,5 In preterm infants, poor maternal adaptation to parenting and feeding prior to hospital discharge may predispose to high PPCV.¹⁸

A parent may fear recurrence of the initiating problem or may believe this child is in danger but not his or her siblings (eg, unpredictable course, rapid decline in health status).² These fears and guilt are associated with expectations of disappointment in the child’s development (eg, toilet training, separation, school performance).¹ Age-appropriate separation and individuation from the parent is inhibited. Acting overindul-gent or overprotective, the mother hesitates to allow her child autonomy. The child may sense the parent’s worries and fears and may respond to inappropriate limit-setting with behaviors that reinforce those anxieties.^1,5,7,15 While these children stay attached and dependent on their mothers, they may display defiance, risk-taking, and hyperactivity, or they may develop functional somatic symptoms (eg, headaches, stomachaches) or avoid activities.^4,15,19

CLINICAL FEATURES

Exaggerated separation problems are common due to an altered parent-child relationship.^1,6 A parent who fears a child falling ill when they are not together may rarely let others care for her child or may awaken the child frequently at night to check on breathing or other signs of life.²⁰ For the older child, separation challenges and an inability to concentrate on learning may produce school refusal and absence, somatic symptoms on school days, and poor school performance. Furthermore, because the parent is unable to allow her child autonomy and independence, she may become overindulgent or overprotective; she is unable to allow her child autonomy and may unnecessarily restrict the child’s activities. Discipline may be limited when a parent feels guilty or mistakenly worries about emotional or physical harm from responding to a tantrum. Dependent or defiant children may become aggressive with their parents by biting or hitting.

Some parents may be unable to judge the seriousness of their child’s symptoms and seek medical attention at the first signs of illness, prompting overuse of and dissatisfaction with acute medical services.^2,3,21 In these instances, other factors should be considered, such as a family crisis (eg, marital discord, illness, death, loss), a lack of social support for the parent, secondary gain for the parent (eg, increased attention from family and friends), or fabrication of symptoms (eg, factitious syndrome by proxy; see Chapter 94).⁶

Among parents with children 2 to 5 years of age, high parental perception of child vulnerability persists after 2 years in 15% to 31% of cases.¹² VCS does not appear to persist into school age when there are no current health problems.¹⁴

DIAGNOSIS

When any of the clinical signs or symptoms suggest vulnerable child syndrome (VCS) (see Table 98-1), the parental perception of child vulnerability (PPCV) should be assessed. Parents are frequently unaware of the connection between a prior health threat to their child and their own response to it. Clinicians can inquire with specific questions about past health events (eg, pregnancy, delivery, illness, injury, hospitalization, surgery, medical tests and procedures). Attention should be given to the parent’s emotions and recollections of the precipitating event, interactions with health care providers, responses to the event, and interpretation of its significance. Understanding the parent’s current understanding of the child’s health and ongoing medical problems, potential reinforcers of continued legitimate parental fears, as well as aspects of the social history that may contribute is useful. A significant residual emotional response to a past threat supports the diagnosis of VCS. The Child Vulnerability Scale³ and its modifications—the Vulnerable Child Scale⁴ and the Vulnerable Baby Scale²²—can be used clinically to screen for PPCV.

Table 98-1. Clinical Features of the Vulnerable Child Syndrome

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