Vulnerable

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

1 Those who had experienced

a
serious
illness
in which
the parent
believed
the child would
die. Even
after full recovery,
the parent, almost
invariably
the mother,
endures
the
continuing
or recurrent
undisclosed
fear that the child is unusually
vulnerable to serious illness or accident
and
is destined
to die prematurely.
2. Those
who represent
for the
parent a significant
person
from the
past who died prematurely,
eg, a
brother of the mother who at 7 years
of age died suddenly
because
of meningococcemia
or a previous
child of
the parent who died with the sudden
infant death syndrome.
3. Those
whose
life or whose
mothers
life was at risk during pregnancy or delivery,
eg, because
of an
abruptio
placenta.
4. Those whose mothers
were informed
by the physician
during their
pregnancy that the fetus might die in
utero.
5. Those
whose
mothers
have a
history
of a threatened
miscarriage,
multiple spontaneous
abortions, or a
stillbirth.
That relativelyfew children in these
five groups
develop
the manifestations of the vulnerable
child syndrome
may be the result of considerable
individual
differences
in the way parents adapt to the threatened
loss of
a child, predisposing
parental
experiences,
protective
mechanisms,
and
the preventive
efforts
of physicians,
nurses, and social workers.
Risk factors include,
for example,
older par.

* Perry
W. Lesh Professor
and Chairman,
Department
of Pediatrics,
Indiana
University
School of Medicine,
Indianapolis,
IN 46223.

ents who have had many years of

infertility
or the young single mother
without
supportive
relatives
or
friends. Protective
factors include the
mothers
ready access
to her sick
baby or child during
the serious
illness, thoughtful
explanations
of the
infants
status communicated
as optimistically
as possible
by the physician, and repeated
opportunities
during the illness for the mother to share
her fears, worries,
and feelings
with
empathetic
health professionals
who
understand
the value of discussing
these issues.
Such preventive
interventions
are now more widely
provided than they were two decades
ago.
CLINICAL

EDUCATIONAL

16. The pediatrician

should be able
to differentiate
among the various
conditions
possibly responsible
for
a child who is said to be hyperactive, has regressed
in toilet training, and does not wish to be separated from his or her mother, distinguishing
among attention
deficit
disorder with hyperactivity;
adjustment reaction due to mother working outside the home, divorce, matemal depression,
birth of a sibling,
or family illness; conduct disorder;
sexual
abuse
or vulnerable
child
syndrome;
idiosyncratic
drug reaction; or neurodegenerative
disorder, and develop
an appropriate
plan for management
(Topics,
86/
87).
The physician
should
be able to
support the parents
of a critically
ill newborn.
If the baby recovers,
the physician
should
be able to
counsel the family so as to prevent
the vulnerable
child syndrome.
If
the baby dies, the physician
should
be able to help the parents
know
what to expect
in terms of reaction
to their loss and how to master
their grief reactions.

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}

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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.

Pathologic separation problems

Sleep problems
Discipline problems
Overprotectivness
Child
physically
abusive
to
mother
6. Hyperactivity
7. Excessive
maternal
concern
about child health; overuse of
medical care services
8. School underachievement

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

little more specific about that worry?

Has Mark ever been seriously
ill?
How sick was he then?
Was he
seriously
tell you

erative. This striking

lack of discipline
or out-of-control
behavior
may be
present
only in the mothers
presence, an observation
that contributes
even further
to her sense of ineptitude. The parent
seems to lose her
parenting
presence,
that nonverbal
projection
of an effective
mother analogous to command
presence
in the
armed services.
As a result,
she is
unable to provide
the certainty,
confidence,
and security
that young children need.
4. The overprotective,
overindulgent, oversolicitous,
and over vigilant
parent,
perceiving
the
child
as
younger
than he or she actually
is,
may keep him or her in a play pen
excessively,
confine
him or her in a
fenced
yard beyond
the usual age,
and forbid bicycling or contact sports.
A mothers
expectation
of her infants
development
may be significantly
influenced
by her estimate
of him or
her as sickly or vulnerable.45
5. The child may physically
abuse
the mother,
even publicly.
Although
resentful
and embarrassed
as the
child hits, bites, scratches,
or kicks
her, she simply cannot control
him.
6. Many of these children
are described
by the parent
as hyperactive.
7. Excessive
concerns
about the
childs health and overuse
of medical

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-

you feel from

tially

certainty,
her nausea
and feeling
of
emptiness,
and her repeated
prayers
for her childs
recovery.
She is clearly

serious

illness,

she

brings

this

special child frequently

to physicians
and emergency
rooms so as not to
be too late. Although
her judgement
about the need of her other children
for medical
care may be good, that
sense seems to have been lost with
the vulnerable
child.
8. Although
school
underachievement and learning
difficulties
have a
more
subtle
association
with
the
childs fear of a premature
death, this
relationship
should
be kept in mind
as one
possible
explanation
for
school failure because
of the vulnerable childs inability to concentrate
on
learning.
DIAGNOSIS

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

vol. 8 no. 3 september

nurses

told

what

did the doctor

illness?
Did

you

the doctor
or

from

sensed that your child

In response
to such
mother

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-

able child syndrome

is recognized,
the physicians
clear statement,
following
a thorough
history
and conspicuously
meticulous
physical
examination,

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

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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

and if they are able to understand

the
causal relationship
between
present
behavior
and past experience,
the
problem
can largely
be managed
in
only one visit; on the other hand, if
the

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.

Once the mutual reenforcement

of
anxiety and symptoms
is attenuated,
the parents
are able to set disciplinary
limits,
discontinue
treating
the child

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

of the babys development

in subsequent health supervision
visits.
An early return appointment
should
be scheduled
if there are historical
factors,
such as the previous
death
of another child, that may predispose
a parent to the vulnerable
child syndrome.
Follow-up
is also indicated
when
there
is a question
as to
whether
the parents will adapt appropriately
to the crisis and when the
parents
seem unable
to accept
the
doctors assurance that the child is
now cured. Such follow-up
is especially important
if the physician
who
cared for the child during the serious
illness
is not to provide
continuing
care. In subsequent
visits for wellchild
supervision, the primary
care
physician
should regularly
check for
manifestations
of the vulnerable
child
synrome
and intervene
accordingly.
pediatrics

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

illness, parents may have a tendency

to become
overprotective
and overindulgent,
a response
that becomes
increasingly
disadvantageous
to all
concerned.

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}

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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}

and Stamm reported

that the morbidity of cardiac nondisease,
ie, children
with innocent
murmurs
who
were
mistakenly
thought
by their parents
to have heart disease,
included
needless restriction
of activity
and other
overprotective
measures.
If not given
a clear explanation,
parents
and children may confuse
an innocent
murmur with heart disease,
overestimate
the severity
of a minor congenital
defect, or believe that the child is vulnerable to a heart attack.
In these
cases,
both parents
and child need
to be firmly told that there is absolutely no reason
to restrict
activity
and that there is no danger of a heart
attack.
Nondisease
may be established
in
the patients
mind as a result of being
told of a normal
physical
variant,
a
erroneous
laboratory
result,
or a
false-positive
screening
test. A physicians
off-hand
remark,
inadequate
clarification
of what is said, self-diagnosis, or hypochondriasis
are other
possible
causes
for nondisease.
Automated
serum
laboratory
batteries
have also contributed
to the prevalence of nonnondisease,
eg, the report of a transiently
elevated
alkaline
phosphatase
level.
Unless
accomto miss?
If the physician
believes,
on the
panied by careful interpretation,
education,
and
counseling,
positive
basis of the history,
normal findings
screening
tests
such as those
for
on physical
examination,
and the
sickle cell trait, scoliosis,
or developchilds healthy appearance,
that true
mental progress
may also be misinfever of undetermined
origin is not
present,
laboratory
studies
should
terpreted
by the parent as implying
a
not be obtained.
Such procedures
serious illness or problem with resultreinforce
the parents
belief that there
ant anxiety and apprehension.21
is, indeed,
something
seriously
wrong
4. Familial
susceptibility:
When
a
with their child. In addition to a careful
serious
biomedical
or emotional
illness, especially
one that is geneticlarification
of the parents
worries
about the childs health and an explacally transmitted,
has previously
ocnation for the recurrent
or pseudocurred in the child or another
family
member,
the parents
may think of a
fever, the parents
and child should
be told authoritatively
by the physispecific
child as vulnerable
to the
cian that the child does not have a
same problem.
As a result, any comserious disease.
When the physician
plaint that might signal the onset of
is less certain, appropriate
screening
the feared disorder
carries a special
laboratory
tests may be indicated,
eg,
emotional
charge.
Because
such
symptoms
and signs as cough,
diara complete
blood cell count, sedimenrhea, irritability,
headache,
fever, failtation rate, platelet
count, urinalysis,
ure to thrive, limb pain, limp, seizures,
urine culture,
tuberculin
test, and, in
manifestations
are
endemic
areas, histoplasmin anti- and behavioral
commonplace,
such
hypervigilant
body titers.
3. Nondisease
and
non-nondisparents lead uneasy
lives. Children
who have been cured of leukemia
and
ease, terms suggested
by Meador18
and
Morrow19
respectively,
occur
their parents
may also be concerned
when a specific disorder
is suspected
about the late complications
of canbut not found.
In 1967, Bergman2#{176} cer treatment,
especially
delayed
effect of activity
and exercise
on elevation of core body temperature.
As
a result, temperatures
within the normal range were misjudged
by the parent to be low-grade
fever.
A number
of recent
family stressors may also be identified
in the
pediatric
interview.
In addition
to fever, the parent
may be concerned
about other complaints,
such as fatigue or weakness
and fear that the
child has an occult malignancy
or that
a chronic
illness such as rheumatoid
arthritis
may be developing.
Not only
is the temperature
taken frequently,
but the child
is kept
home
from
school. At times, pseudo-FUO
masks
school
refusal,
especially
when accompaned
by other complaints
such
as sore throat,
tiredness,
headache,
or recurrent
abdominal
pain. Worried
about the childs symptoms,
the parent repeatedly
asks the child questions that invite an affirmative
reply:
Do you have a headache?
Are you
tired? That the child has been absent
from school, often for weeks,
is usually not volunteered
by the parents.
This fact is usually
revealed
only in
response
to the question:
How much
school has this illness caused Johnny

vol. 8 no. 3 september

1986

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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

cess to expert medical advice around

the clock; periodic
home visits by a
physician,
social worker,
technician,
or nurse; phone check-ups
with the
hospital
staff; and opportunities
for
respite provided
by appropriately
prepared baby-sitters
or brief hospital
admissions.
The guidelines
as to
when home monitoring
may be safely
stopped
have not been clearly established, and many parents
are reluctant to discontinue
use of the device
even on the physicians
recommendation.
OTHER
DIAGNOSTIC
CONSIDERATIONS

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
.

vol. 8 no. 3 september

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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

A, et al: Morbidity in childhood-A

longitudinal
view. N
EngI J Med 1 984;31 0:824-829
13. Beautrais
AL, Fergusson
DM, Shannon
FT: Life events and childhood
morbidity:
A prospective study. Pediatrics
1982;
70:934-940
14. Haggerty
RJ: Life stress, illness, and social support.
Dev Med
Child
Neurol
1 980;22:391
-400
15. Green M: The adaptation
of children and
families:
The new pediatric
agenda, in
Green M (ed): The Psychological
Aspects
of the Family: The New Pediatrics.
Lexing-

pediatrics

in review

#{149}

vol. 8 no. 3 september

1 8.
19.
20.

21

22.

23.

24.
25.

26.

27.

28.

29.

30.

ton, MA, Lexington

Books,
1985, pp 112
Mechanic
D: The influence of mothers on
their childrens
health attitudes and behavor. Pediatrics
1964:33:444-453
Kleiman MB: The complaint
of persistent
fever: Recognition
and management
of
pseudo fever of unknown
origin. Pediatr
Clin North Am 1982:29:201-208
Meador CK: The art and science of nondisease. N Engi J Med 1 965;272:92-95
Morrow
G Ill: A case of non-nondisease.
Am J Dis Child 1 985;1 39:655
Bergman A: The morbidity
of cardiac nondisease in schoolchildren.
N Engl J Med
1967;276:1008-1
013
Whitten CF: Sickle-cell
programming-An
imperiled
promise.
N Engi J Med 1973;
288:318-319
Green M: The care of the child with a longterm life threatening
illness, in Green M,
Haggerty
RJ (eds): Ambulatory
Pediatrics,
ed 1 . Philadelphia,
WB Saunders
Co,
1968, pp 659-665
Black L, Hersher L, Steinschneider
A: Impact of the apnea monitor
on family life.
Pediatrics
1 978;62:681
-685
Nelson NM: But who shall monitor
the
monitor?
Pediatrics
1 978;61 :663-665
Cain LP, Kelly DH, Shannon DC: Parents
perceptions
of the psychological
and social impact of home monitoring.
Pediatrics
1 980;66:37-41
Southall DP: Home monitoring
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in the sudden infant death syndrome.
Pediatrics 1983;72:1 33-137
Wasserman
AL: A prospective
study of
the impact
of home monitoring
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family. Pediatrics
1 984;74:323-329
Frates RC Jr. Splaingard
ML, Smith EO,
et al: Outcome
of home mechanical
ventilation
in children.
J Pediatr
1985;106:
850-856
Green M: Commentary
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Ackerman
TJ, Patterns
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that create dependency.
Am J Dis Child
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Kaplan BH, Cassel
JC, Gore 5: Social
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Med Care 1977;
15(suppl 5):47-58

of Corrections

The correct answers to question

issue are: A,B,E, not B,E as stated.

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
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by children.
Pediatrics
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Department

PIR

1 6.

48:284-290
3. Sigal J, Gagnon P: Effects of parents and

9.

REFERENCES

PY: Psychological
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lowing

4 of the Self-Evaluation

quiz in the March

1986

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1986

Vulnerable Child Syndrome and Its Variants

Morris Green
Pediatrics in Review 1986;8;75
DOI: 10.1542/pir.8-3-75

Updated Information &

Services

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Vulnerable Child Syndrome and Its Variants

Morris Green
Pediatrics in Review 1986;8;75
DOI: 10.1542/pir.8-3-75

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://pedsinreview.aappublications.org/content/8/3/75

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned, published, and
trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove
Village, Illinois, 60007. Copyright 1986 by the American Academy of Pediatrics. All rights reserved.
Print ISSN: 0191-9601.

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