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Documentos de Profesional
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Its Variants
Morris
Green,
Child
Syndrome
MD*
In 1 964, Solnit
and Green1
described
a vulnerable
child syndrome
characterized,
among
other
clinical
manifestations,
by difficulty
with separation,
over protectiveness,
bodily
overconcerns,
and
school
underachievement.
This
constellation
of
symptoms
has been repeatedly
observed
by us and by others
in the
following
groups
and
of
children
(Table
1).1_3
* Perry
W. Lesh Professor
and Chairman,
Department
of Pediatrics,
Indiana
University
School of Medicine,
Indianapolis,
IN 46223.
EDUCATIONAL
MANIFESTATIONS
The
complex
condition
encompassed by the term vulnerable
child
syndrome
cannot
be characterized
simply, because
of the many factors
that influence
its manifestations
and
the variability
of its symptomatology.
The following
clinical
features
are
commonly
but not invariably
present
in the fully expressed
syndrome
(Table 2). Variants
of the syndrome
will
be discussed
later.
1 . Pathologic
separation
difficulties
occur in which the mother
and child
rarely or never separate.
When separation
is unavoidable,
eg, during
hospitalization
of the mother,
the
child may reluctantly
be entrusted
to
a close relative,
such as the grandmother,
but other
baby-sitters
are
rarely used. Although
seemingly
unrecognized
by the parent,
the child
regularly
senses
and is made fearful
by the mothers
expectation
of his
vulnerability.
This concern
is communicated
in many subtle ways but
mainly through
the mothers
moods
and in her way of limiting the childs
autonomy
and independence
with inhibiting reservations.
Such apprehension can also be observed
in the
mothers way of experiencing
separation from the child. If the separation
anxiety
is not resolved
earlier,
the
child may resist school attendance.
2. Sleep problems
are common,
and the mother
may come
to the
pediatrics
in review
OBJECTIVES
physician
in near exhaustion.
The
child often sleeps in the parents
bed
or in a crib placed next to the mother
and in her direct
line of vision.
In
addition,
she may hover about
the
child
during
naps.
Although
the
mother
may report
that the baby
does not sleep well, it is the parent
who awakens
several
times a night
to check on the child. In doing so,
she unwittingly
manages
to awaken
the baby, in that way reassuring
herself that he or she is alive. The mother
is simply
unable
to sleep at night
unless she believes
her baby is safe
and sound.
3. In many cases,
the parent
is
unable to set age-appropriate
limits,
with the result that the child is disobedient,
argumentative,
and uncoop#{149}
1986
PIR
75
Vulnerable
Child
Syndrome
mind,
TABLE
1.
At-Risk Situationsfor
the Vulnerable Child Syndrome
TABLE
1. Recovery
from an illness in
which the parent thought
the
child would die
2. Premature death of a person
significant to the parent
3. The life of the mother or the
fetus was at risk during the
pregnancy
4. The mother was told that her
baby might die in utero
Child
5. A mother
taneous
with a history
abortions
2.
Clinical
Manifestations
of the Vulnerable
Syndrome
1.
2.
3.
4.
5.
of spon-
or stillbirth
ie,
services
are
highly
characteristic
of
the vulnerable
child syndrome.
The
powerful
anticipatory
grief reaction
evoked when a parent suddenly
confronts the possible
death of the child
often is rekindled
with later illnesses,
no matter
how minor. Held hostage
by this emotional
ghost from the past,
PIR
76
pediatrics
in review
#{149}
Yudkin6
termed
the
this
this
unabetheir
pre-
mature
death,
no intimation
of this
association
is given in a routine
past
medical
history.
It is only in answer
to such questions
as, You seem very
worried
about
Mark.
Could
you be a
what
second
diagnosis
or Why is
child being brought
to you at
moment?
Because
parents
are usually
ware that a relationship
exists
tween the childs symptoms
and
long-standing
fear of the childs
ill?
during
What
Marks
the mother
thus is overconcerned
about minor respiratory
infections,
fever, diarrhea,
limb pains and abdominal pain, or headache.
She worries
inordinately
about the childs
paleness, sickly appearance,
easy fatigabihity,
circles
under
his eyes,
blueness
when
crying,
breathing
too fast, and poor resistence.
Because of the mothers
inability to differentiate
a self-limited
from a poten-
tially
certainty,
her nausea
and feeling
of
emptiness,
and her repeated
prayers
for her childs
recovery.
She is clearly
serious
illness,
she
brings
this
The
vulnerable
child
syndrome
should be considered
as a diagnostic
possibility
when the clinical manifestations listed above are encountered,
when the reason for a visit is unclear,
when a mothers
concerns
about her
child seem greater
than warranted,
when a child has been seen the same
day by other
physicians,
when
a
mother
expresses
dissatisfaction
with previous doctors, and when she
seems to have something
else on her
nurses
told
what
you
the doctor
or
from
may
recall
or the
what
you
might die?
questions,
the
vividly
and
with
considerable
emotion
the apprehension and anxiety
that engulfed
her
during
the childs
illness.
She may
describe
in minute-by-minute
or hourby-hour
detail
what
the doctor
or
nurse said, her own bewildering
un-
relieved
at long
cret fear.
last to share
her se-
MANAGEMENT
Characteristically,
such
are
their
special,
not
other
the
parents
vulnerable
experiencing
children.
problems
Once
of
children
the
with
vulner-
that
the
child
is absolutely
physically
sound represents
the first
step in management.
The next therapeutic
measure
is to help the parents understand
and accept
the notion that the symptoms
represent
a
sequela
of the acute, life-threatening
illness or one of the other
experiences noted above that predispose
to this syndrome.
This may be facilitated by a statement
such as, Mothers who have had the horrible
experience
of believing
that their child
might die during an illness often continue to fear that he will die prematurely, even many years after his re-
1986
BEHAVIORAL
covery.
I would
guess
that youve
had
similar
fears about
Johnny.
If the parents
are able
to
and
use
assurance
that
their
the
physicians
child
is physically
accept
healthy
visit
aged
hurried
of a vulnerable
in a cursory,
fashion
child
is man-
disinterested,
or the
and
parents
under-
lying anxiety
is not addressed,
the
mother
may leave the office
frustrated,
dissatisfied,
and
privately
angry.
as if he or she were
their
younger,
overprotectiveness,
reduce
initiate
de-
velopmentally
appropriate
sleeping
practices,
deal more effectively
with
separation,
judge
more
accurately
the seriousness
of the childs symptoms,
and
stop
recalling
to the
child
or to others
in the childs
hearing
the time that they almost
lost him
[her].
Not unexpectedly,
some pa
rental anxiety may remain or be reactivated
at times of illness; however,
the pediatrician
can readily help the
parents
understand
and tolerate
that
degree of discomfort.
PREVENTION
tive purpose
is served
by reminding
the parents of the seriousness
of the
illness. Such retrospective
comments
as, If he [she] had gotten
here an
hour
later,
we wouldnt
have
been
able to save him [her], or I thought
sure he [she] would die, are potentially harmful.
Because
it is not always
possible
to identify
specifically
which families
are at risk of developing
the vulnerable child syndrome,
the physicians
debriefing
of the parents
just before
the discharge
of an infant or child who
has been seriously
ill should include,
TABLE
3. Variants of the
Vulnerable
Child Syndrome
1. The illness-prone
child
2. Pseudo-fever
of unknown origin
3. Nondisease
and non-nondisease
4. Previous, serious family biomedical or psychiatric illness
5. Medically vulnerable children
VARIANTS
VULNERABLE
if true,
an unequivocable
statement
that the child is or will shortly
be fully
OF
THE
CHILD
SYNDROME
recovered,
that special
precautions
are unnecessary,
and that the child is
not destined
to be more vulnerable
to
illness in the future.
The physician
may also share his or her experience
In the families
discussed
above,
one
of the
parents,
usually
the
mother,
secretly
believes
that a specific child is destined
to die prematurely.
Her behavior,
and the response of the child, is linked to this
that,
continuing
after
a childs
recovery
from
an
In the
case
of those
infants
who
have survived
a perinatal
illness but
who remain at risk for neurologic
impairment
in the form of slow development,
cerebral
palsy, or a learning
disorder,
the pediatrician
should verbally recognize
the normalcy
of the
parents
worries,
share his or her belief that
the
provide
the assurance
infant
carefully
is doing
well,
and
that he or she
to an assessment
in review
fear.
In
variants
of
this
syndrome,
a parent may believe that
a specific child is unusually
susceptible to illness but not be especially
worried
about the possibility
of her
childs premature
death (Table 3). In
these cases, the chief manifestation
may be the especially
frequent
use of
medical care services
with behavioral
manifestations
less prominently
reported. Although
there is some overlap with what has been discussed
above, delineation
of these variations
may facilitate
their
diagnosis
and
management,
contribute
to a more
parsimonious
use of medical
services, and increase
the comfort
and
will attend
The
vulnerable
child
syndrome
dramatizes
a clear opportunity
for
prevention
of an emotional
and developmental
disorder
by helping parents adapt
successfully
during
and
following
a severe,
acute
illness
in
their child.7 Such illnesses
are psychologically
as well as physically
hazardous.
In talking with the parents
of an ill child, the physician
must convey the diagnosis,
treatment,
and
prognosis
without
overor understatement.
An occasional
physician
or nurse may tend to overestimate
the seriousness
of a childs
illness
and risk the development
of an iatrogenic disorder.
It is recognized,
however, that in the present legal climate,
physicians
may believe that the term
critically
ill must be used with all
seriously
ill children.
Once recovery
has occurred,
however,
no construc-
PEDIATRICS
function
of the
parents
and
children
affected.
1 . The illness prone child is a cornmon cause
for excessive
use of
health
services.
In a study
of 750
mothers
interviewed
at five general
ambulatory pediatric services, Lev?
found that 27% believed that the child
brought
for care was vulnerable,
ie,
uniquely threatened
by an episode
of
illness.9 Although
these patients differ
from those with the fully expressed
vulnerable
child syndrome
in that few
of the parents
express
a fear about
the childs imminent
death, they do
regard the child as special and different from
their
other
children.
Although
60% of these children
were
judged to be medically
vulnerable
because of an illness such as asthma,
no specific
illness was found in the
other 40%. The cause for this mater#{149}
1986
PIR 77
Vulnerable
Child
Syndrome
nal behavior
in the case of the illnessprone child has not been extensively
investigated.
It is well-known,
however, that anxious
or depressed
parents tend to amplify the seriousness
of symptoms
and to worry
excessively. Other nonmedically
warranted
visits are initiated
because
the possibihity of a serious
illness has been
suggested
by a relative or the mother
has convinced
herself
that the description
of a serious disease she has
just read or heard about fits her child.
It is, of course,
helpful to know this if
one is to reassure
the mother
about
her real worry.
Some children
simply
have more
illness than others,
eg, poor children
experience
more illness than those
from more economically
advantaged
families.10
Starfield
et al11 12 hypothesizes that illness-prone
children may
have a genetic or an acquired
vulnerability that causes
them to respond
to stress factors
in a physiologically
different
fashion than their peers; on
the other hand, they may just experience a greater
burden
of environmental and social stressors.
She postulates
that the vulnerability
of children whose
frequent
use of health
services
is the result
of recurrent
acute illnesses
may derive from situations in which biologic,
psychiatric,
cognitive
and psychosocial
influences
are likely to interact.12
Other investigators
have relafed
social factors and life event stressors
to the
onset of iIlness.116
2. Pseudo-FUO
is a term used by
Kleiman17
to describe
the relatively
common
situation
in which
a child
referred
because
of fever
of unknown origin does not fulfill the criteria for that diagnosis,
ie, fever of
38.3#{176}C(101#{176}F)or higher
that persists for 2 or more weeks,
an absence of localizing
findings,
and an
inability to make an etiologic
diagnosis by the usual laboratory
means.
What is reported
by the parent
as
persistent
fever
is determined
by
the physician
to be a series of selflimited, usually viral, febrile illnesses.
In some instances
in which a pattern
of frequent
temperature-taking
had
been initiated,the parent simply misunderstood
the definition
of fever (a
rectal temperature
of 38.5#{176}Cor its
equivalent),
the normal diurnal variation of body temperature,
or the efPIR
78
pediatrics
in review
#{149}
1986
BEHAVIORAL
fects on endocrinologic
function
and
the CNS as well as the possibility
of
relapse or a second malignancy.
5. Chronic
Illness:
Children
with a
variety of chronic
disorders
may be
medically
vulnerable.
Their successful adaptation
may be greatly
facihitated by the pediatricians
skilled and
thoughtful
help.22 The extent to which
the child regards
him- or herself
as
vulnerable
depends
upon the specific
disease
and organ involved,
the nature of his symptoms,
and such factors as the prognosis,
the age of the
child, personality,
intelligence,
sociocultural background,
previous
life experiences,
family relations,
and the
reactions
and support
from peers,
teachers,
parents,
and health professionals.
Patients
and parents
who understand
a disease
and its treatment
poorly may overestimate
its seriousness and, therefore,
feel highly vulnerable.
Failure and disappointment
may be built into their anticipation
of
many
new experiences.
The child
may react
more
strongly
than his
peers to changes
in school, moves of
the family, discord
between
parents,
illness or death of relatives
or friends,
a change
of physicians,
and other
stressors.
Even trivial illnesses
or injuries may be poorly tolerated.
Whether
told directly
or not, the
child knows
that the disease
is lifethreatening.
This feeling
of precariousness
is kept alive by the necessity for frequent
visits to the physician, special
diets,
warnings
about
reactions,
daily medications,
procedures, and repeated
hospitalizations.
The anxiety
of the child and family
may be dramatically
heightened
when
they learn that another
child with the
same disease has died. If the disorder
is an inherited
one, the apprehension
and sense of vulnerability
increases
exponentially when a sibling dies. Although fund-raising
activities
for specific diseases
may unwittingly
promote the anxiety of patients
and their
families by an emphasis
on the possible fatal outcome
of a disorder,
the
child and his parents
may be encouraged both by the possibility
of a cure
and the evidence
of widespread
caring and support.
Even the most mature parent finds
it difficult
to cope adequately
with
both their own feelings and the needs
of the medically
vulnerable
child. The
illness almost
always
alters their relationship.
Some parents abandon
all
discipline,
whereas
others
redouble
control. As in the vulnerable
child syndrome, a previously
secure and able
mother
may find herself
unable
to
decide whether
a symptom
is trivial
or serious,
and she may worry about
periorbital
puffiness,
circles under the
childs eyes, a change
in the color
of the childs urine, constipation,
fatigue, and shortness
of breath.
Nothing allays unwarranted
anxiety
and sense of vulnerability
as effectively as continuing,
competent,
conscientious
care. The child and his or
her family need to have prompt
access to their skilled physician
should
the need arise or have clear and defmite arrangements
for substitute
coyerage if that physician
is not to be
available.
In addition
to serving
to
demonstrate
continuing
interest,
regular return visits permit the physician
to keep posted on the familys
understanding
of the illness; the childs progress with his or her disease,
school,
and peers; parent-child
relations;
and
the adjustment
of the siblings.
Other medically
vulnerable
patients
include those who are prone to become ill very rapidly, eg, children who
have had a splenectomy,
the saltlosing form of the adrenogenital
syndrome,
sickle
cell anemia,
a CSF
shunt,
asthma,
familial
dysautonomia, an immunodeficiency
disorder,
infant apnea, or ventilatory
dependency. Home monitoring
and care of
babies with infant apnea or ventilatordependent
children are relatively
new
experiences.
Although
the benefits of
home care may include the promotion
of family unity, personal
attention
to
the childs needs,
and cost containment, it may also be accompanied
by
augmented
parental
anxieties,
inability to sleep, fatigue, disruption
of family life, and unrelenting
responsibility
as a result of which the parent finds
it difficult
to sleep, go to the bathroom, take a shower,
leave the child
with a baby-sitter,
or work outside of
the home!28
Minimal requirements
for such care
include
meticulous
preparation
and
training of the parents in resuscitation
techniques;
validation
of their ability
to perform
such interventions;
ongoing support
through
immediate
acpediatrics
in review
PEDIATRICS
In addition
to the vulnerable
child
syndrome
and its variants,
a number
of other reasons
for bringing
a child
for medical
care in the absence
of a
biomedical
or psychologic
disorder
in
the child need to be considered.
1 Family crisis:
Although
not reported by the parent unless asked, a
current family crisis such as separation, divorce,
death, or serious illness
in another family member
is often the
motivating
impetus to bring a child for
medical care in the absence
of a pediatric disorder.
2. Need for support:
Parents
may
return
repeatedly
to physicians
offices,
pediatric
clinics,
and emergency rooms because
those settings
offer the only positive support
readily
available
to them.
Such visits may
also represent
for a stressed
parent
an indirect way to deal with his or her
own unhappiness
and problems.
Kaplan
et a13#{176}
stated
it well: The
medical
system
of the future
must
consider
becoming
human
development centers
(which
attend
to) the
social, the psychological
as well as
the
biological
aspects
of human
life....
Support
therapy
is but one
type of need input that such centers
should include as part of their development-adaptation
efforts.
3. Secondary
gain:
Parental
exploitation
of a childs symptoms
may
also lead to an inappropriate
use of
medical
services.
Because
of personal or family dissatisfactions,
an
occasional
mother
may need for her
child to be regarded
as recurrently
or
chronically ill. In such instances,
having a sick child seems
to provide
her a secondary
gain in the form of
.
1986
PIR 79
Vulnerable
Child
Syndrome
the interest,
visits,
telephone
calls,
and concern
of friends and relatives.
It may also, at least temporarily,
divert attention
from serious difficulties
in the marriage
or evoke more interest from the father,
including,
perhaps, less drinking
and more time
spent at home. In divorced
families,
the child may be represented
to be ill
to prove that the custodial
or visiting
parent has been neglectful.
4.
Munchausen
syndrome
by
proxy,
in which
the symptoms
reported
by the mother
as present
in
the child are fabricated,
is another
cause for inappropriate
use of medical care. The history
may reveal repeated
visits to different
physicians
and emergency
rooms,
many hospitalizations
of the child, and multiple
invasive
procedures
without
a specific diagnoses.
2. Benjamin
mg
pediatricians
gastroenteritis
4.
5.
6.
7.
8.
SUMMARY
10.
The vulnerable
child syndrome
and
its variants
are frequent causes for
excessive
use of health services,
behavioral
symptoms,
and much family
distress. The pediatrician can play a
central
role in their primary
and secondary prevention,
early recognition,
and treatment.
11.
1. Green
M, Solnit AJ: Reactions
to the
threatened
loss of a child: A vulnerable
child syndrome.
Pediatrics
1964;34:58-66
worry
concerning
in early childhood
severe
later
behavior. J Pe-
63:633-641
12. Starfield B, Katz H, Gabriel
pediatrics
in review
#{149}
1 8.
19.
20.
21
22.
23.
24.
25.
26.
27.
28.
29.
30.
of Corrections
80
1 7.
on
disturbances
in the childs
diatr 1975;87:809-814
McCormick
MC, Shapiro
5, Staruield B:
Factors associated
with maternal opinion
of infant development-Clues
to the vulnerable child? Pediatrics
1 982;69:537543
Bentovim
A: Emotional
disturbances
of
handicapped
preschool
children and their
families-Attitudes
to the child. Br Med J
1 972;3:579-581
Yudkin 5: Six children with coughs:
The
second
diagnosis.
Lancet
1961;2:561563
Green M: The role of the pediatrician
in
the delivery of behavioral
services. J Dev
Behav Pediatr 1985;6:190-193
Levy JC: Vulnerable
children: Parents perspectives
and the use of medical care.
Pediatrics
1 980;65:956-963
Green M: The vulnerable
child: Intimations
of
mortality.
Pediatrics
1980;
65:1042-1
043
Egbuonu
L, Starfield
B: Child health and
social status. Pediatrics
1 982;69:550-557
Starfield B, van den Berg BJ, Steinwachs
DM, et al: Variations in utilization of health
services
by children.
Pediatrics
1979;
Department
PIR
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48:284-290
3. Sigal J, Gagnon P: Effects of parents and
9.
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PY: Psychological
problems
folrecovery
from acute life-threatenillness. Am J Orthopsychiatry
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lowing
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1986
1986
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