Vulnerable Children
Carol C. Weitzman
I. Description of the problem. The term vulnerable child is used to refer to children who have an increased, atypical, or exaggerated susceptibility to disease or disorder due to medical, socioeconomic, psychological, biological, genetic, and environmental risk factors. The term vulnerable child syndrome (VCS) was coined by Green and Solnit (1964) to describe children who have often experienced a real or imagined life-threatening incident or illness and are now viewed by their parents as being at greater risk for behavioral, developmental, or medical problems. Although these children appear to have recovered from their initial illness, their parents continue to view them as especially prone to illnesses and death. Perceiving both an essentially healthy child and a chronically ill child as exceedingly vulnerable has been shown to adversely influence many aspects of children’s health, development, and adaptation. The VCS represents a transactional relationship between child and parent factors.
The VCS represents the extreme end of a spectrum. The severity of any individual contributing factor will influence how fully the syndrome is expressed and how fixed the beliefs of the family system will be. The term VCS should be reserved only for cases meeting the criteria in Table 107-1.
A. Epidemiology. The percentage of parents who perceive their child as vulnerable is unknown, as is the extent to which the VCS underpins child problems. The literature on outcomes related to perceptions of child vulnerability is limited but suggests that children’s development may be adversely influenced in a number of ways.
In a community-wide study of 1095 children aged 4-8 years, 10% of children were categorized as “perceived vulnerable.” In that study, 21% of all the mothers reported that they had had prior fears that their child might die.
Studies have shown that 64% of infants born prematurely continued to be viewed as vulnerable by their parents when they were preschoolers.
In a cohort of 116 premature infants, those children whose parents had high perceptions of child vulnerability were more likely to have lower adaptive development at 1-year adjusted age.
In a cohort of 69 children with chronic rheumatologic and pulmonary diseases, those children whose parents had increased perceptions of child vulnerability had greater social anxiety.
A number of studies have demonstrated an increased sense of vulnerability among mothers who are unmarried, of younger age, and of lower socioeconomic status. The influence of maternal education has been less clear on the development of VCS across different studies.
The persistence of parental perception of child vulnerability remains unclear. In some studies, it has been shown to decrease over time as the child’s health improves and parents are able to reshape their views of their child’s health and resilience. Other studies have shown that early perceptions continue to predict later perceptions.
Children with chronic and serious illnesses, such as diabetes, cancer, and asthma, whose parents perceive them as vulnerable have been shown to have poorer behavioral and social adjustment, and greater uncertainty about their illness, than children whose parents do not hold these beliefs.
B. Etiology. Child, parent, and sociodemographic factors can all contribute to a parent perceiving his or her child as vulnerable. Parent risk factors may relate to problems with fertility, pregnancy, or birth, as well as parental psychopathology or mental health (Table 107-2). In general, the earlier that an event occurs in a child’s life, the more likely it is to enhance the parent’s perception of the child as vulnerable. The transformation of parental fears into childhood problems is a complex process that is transactional in nature. Perceptions of vulnerability reflect parents’ cognitions, attitudes, and beliefs related to their child’s health and well-being. These perceptions may lead to a pattern of parents’ behaviors including overprotection, reluctance to allow the child to have typical separation and individuation experiences, and a need to maintain control. The child, in
turn, sensing parents’ concerns and their need or desire to keep the child close may begin to behave in ways that reinforce these beliefs, such as acting frailer and having more illness complaints. Conversely, children may act out in ways to defy these perceptions.
Table 107-1. Diagnostic criteria for the vulnerable child syndrome
A real or imagined event in the child’s life that the parent considered to be life-threatening.
The parent’s continuing unrealistic or disproportionate belief that the child is especially susceptible to illness or death (often associated with a high frequency of healthcare use).
The presence of symptoms in the child that appear disproportionate to the apparent level of illness or impairment.
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