26
Childhood Health Issues
Across the Life Span
Barbara G. Melamed
Barrie Kaplan
Joshua Fogel
Yeshiva University
Drotar et al. (1989) reviewed two decades of child health research and proclaimed the need for
a developmental perspective to guide the focus of health promotion. This would also pinpoint
where and by whom the site of delivery of services should occur. Some of the factors that
make children likely to develop illness are genetic (family history of disease) and
environmental (poverty, crowding, lack of nutrition). These factors are difficult to alter. In
addition, the mental health of the parents and their level of functioning at the time of their
child's incipient illness is likely to determine how soon a child receives access to health care
treatment, and how effectively the recommended treatment program can be implemented. For
instance, many parents either cannot afford or do not completely understand the concept of
prolonged medication even when the symptoms have abated (i.e., antibiotic treatment). Even
when parents are psychologically well adjusted there are numerous problems that can
exacerbate stress, including:
1. Establishing relationships with medical personnel (Moos, 1977).
2. Coping with medical procedures associated with treatment.
3. Coping with symptoms associated with the condition (whether it is acute or chronic)
(Moos, 1977).
4. Coping with the possible separation from parents, other family members, and friends.
5. Coping with the new social pressures such as being labeled as “ill” or having a medical
problem.
6. Coping with the limitations that result from a change in lifestyle (e.g., diabetic children
must change their diets, asthmatic children must exercise caution during physical
activity).
7. Stress of missing school and acclimating during the return to school.
8. Coping with the added burden facing the entire family, including time and money.

Some protection for the child is afforded by certain policy regulations. Unfortunately, access to
public health for immunization and inoculation against childhood illness is not as universal as
school requirements. Once a child has been admitted to the public school system, further
immunizations for new diseases may not be as successful as in the earlier years. In addition,
environmentally induced problems exist. Asthma or lead poisoning are difficult to change in
the absence of laws protecting children from environmental contaminants. Accidental deaths
by falling from heights and seat belt wearing are often prevented only when the absence of
window guards and wrong application or absence of seat belts are enforced by penalty. Even in
these cases, new incidents of infant death by inappropriate inflation of automobile air bags
may confuse parents about the proper precautions. Parents often misunderstand safety rule
communication and do not provide children with a model of preventive habits.
This chapter focuses on three areas of research 8s representative of some of the issues that
determine whether children can receive adequate care by retraining parents, health care
professionals, and policymakers on the importance of prevention across the life span. Studies
dealing with issues of illness onset in children diagnosed with asthma will hopefully illuminate
issues in self-management across a wide range of chronic illnesses. The issue of organ
transplantation has become a serious consideration and will continue to be prevalent in the
21st century. Therefore, it is used as a prototype to discuss issues of decision-making and
treatment compliance issues that raise the ethical and practical concerns involved in having
this choice. Finally, the issues of prevention of accident, injury, and recognition of the
precursors of child abuse are discussed. The chapter attempts to set forth a functional analysis
for use by health care professionals to help them see where to focus their efforts, whether it be


on prevention, remediation, or teaching self-care behaviors. Future directions for research are
specified.

DEVELOPMENTAL ASSESSMENT
OF COPING
Dffierences in Conceptualization and Assessment

of Coping
An understanding of coping requires knowing what the task demands of the situation involve,
as well as what resources the family has to bring to problem solving. In addition, the mental
age of the child must be considered to assess whether the illness problems overwhelm the
developmental task of that life period. As others have pointed out, there are few reliable and
valid instruments that measure children's coping (Ryan-Wenger, 1992, Wertlieb et al., 1987).
The importance of assessment is to determine which coping strategies are most suitable for
the numerous stressful events that children and adolescents confront. The difficulty of
constructing such a scale and assessing coping mechanisms can be attributed to several
causes. There is confusion about the difference between coping mechanisms and coping
styles. The two are often used interchangeably, although they relate to different types of
behavior. Coping mechanisms are the focus of this chapter and, according to Lazarus and
Folkman (1984), the term refers to constantly changing cognitive and behavioral efforts to
manage specific internal and external demands that are appraised as taxing or exceeding the
resources of the person. Implicit in this definition is the ability to deliberately alter, modify, or
adjust both behaviors and thoughts in an attempt to cope with a stressor. In contrast, a coping
style is more stable over time and reflects personality characteristics (Lazarus & Folkman,
1984). The definition really demands that the “resources of the person” be considered. This
must be applied individually because age as a proxy for developmental ability is known to be
deceptive if used without also having knowledge of conceptual level of reasoning and physical
maturation or limitations imposed by illness/accident or birth defects.

CHRONIC ILLNESS
Timing Considerations
It is often found that during a critical period at about 6 months to age 3, children separated
from a parent due to death, illness, divorce, abandonment, and so on may suffer from
attachment problems. This is particularly likely if the children are sick themselves and are in a
hospital or another institution with a low staff: children ratio for extended times.
Adaptation to chronic illness is influenced by the rate at which improvements are being made
in medical research. For example, adjustment to childhood cancer previously involved

providing assistance to families who were anticipating a child's inevitable death. Setter
survival rates for certain childhood chronic illnesses, including cancer, cystic fibrosis, and AIDS,
necessitate new models of continual adjustment to long-term changes in health status.
Despite significant medical advances, chronic illnesses still need to be conceptualized as longterm sources of stress for both children and their families. Long-term health disturbances
involve repeated hospitalizations, discomfort, uncertain outcomes, multiple diagnostic
procedures, and periodic medical evaluations. Financial resources may be severely strained in
families with a chronically ill child, diverting funds from other pursuits. Childhood stress, in
turn, may be increased without the additional resources for pursuing special needs educational
programs and recreational activities.
Siblings may resent parent's increased attention toward a chronically ill child, especially
because sibling conflicts tend to increase during middle childhood. Conflicts are affected by a


combination of children's temperaments and parental behavior. Illness changes functioning
and roles within the family.

Beliefs about Chronic Illness
Childhood chronic illnesses differ widely with regard to their complexity of medical
management. Juvenile diabetes, for example, involves daily adherence to dietary restrictions,
blood glucose testing, and insulin injections. Other diseases, such as juvenile rheumatoid
arthritis and juvenile diabetes, may involve heightened levels of discomfort. A child may suffer
in terms of feeling different from others, which is especially painful in middle childhood.
With their advancing cognitive abilities, children develop more sophisticated notions of causeand-effect processes in illness development. The cause of illness shifts from being viewed as
an external person or action, to an event located within the body. As children's cognitive
development matures to include concrete operational thinking, illness representations are
altered. Illness beliefs refer to lay understandings of the ways disease processes develop.
Children between age 7 and 10 are initially likely to conceive illness in terms of contamination;
this implies that an external person, object, or action is responsible for producing illness. Later,
children begin to explain illness in terms of internalization. Children, however, have only vague
understandings of disease processes at this point. Additional advances in cognitive

development introduce new understandings of the ways illness develops. At approximately age
11, children begin to understand how internal physiological processes are altered to produce
disease. The cause of illness shifts from being viewed as an external person or action, to an
event located within the body.
Asthma management is the focus of this section, as it is currently the fastest growing epidemic
in the United States and is diagnosed in very young children.

ASTHMA
Asthma is the most common disease of childhood and a leading cause of morbidity in adults.
Despite significant advances in medical treatment, asthma morbidity and mortality rates have
risen dramatically over the past two decades, especially in minority and socioeconomically
disadvantaged populations.
Asthma is a lung disease characterized by a variety of features, including airway obstruction or
narrowing that is reversible either spontaneously or with treatment. Pathologically, it is
characterized as a chronic inflammatory disease of the airways, with a granulocyticlymphocytic submucosal infiltration, epithelial cell desquamation, and mucus gland
hypertrophy and hyperplasia (Wamboldt & Gavin, 1991).

Prevalence
Asthma is the most common chronic disorder of childhood affecting from 4% to 9% of children
(Geller, 1996). As many as 50% of the cases are diagnosed before the child reaches age 2. The
highest incidence of asthma seems to be from birth to age 4. The estimated prevalence of
asthma among children in the United States increased by almost 40% between 1981 and 1988
and is still on the rise. Although the increase occurred mainly among White children, the
prevalence of asthma still remains higher in Black children than in White children. Factors that
have been implicated in the current rise in asthma prevalence are outdoor air pollution, the
decreasing quality of indoor environments as a result of exposure to maternal smoking, and
the high levels of dust mites. Other genetic and environmental factors that contribute to the
prevalence of childhood asthma are positive family history, male sex, low birth weight,
maternal smoking and season of birth (Arshad, Stevens, & Hide, 1993). The increased
prevalence of asthma may also be a manifestation of an increase in sensitization among

children to inhaled allergens, such as those present in house dust, cat fur, and grass pollen.


Treatment
When asthma is managed properly, hospitalization is rarely necessary. However, about 43% of
its economic impact is related to emergency department use, hospitalization, and death, all
resulting from the failure of preventive treatment (Milgrom et al., 1996). Current goals of
management of asthma are geared toward the relief of obstruction, restoration of oxygenation
and ventilation, and prevention of complications. Anti asthma medications improve pulmonary
function via three primary mechanisms: bronchodilation, protection of the airways from
allergen or histamine challenge, and resolution of airway hyperresponsiveness through
antiinflammatory properties. Selective beta agonists, corticosteroids, theophylline, and
anticholinergic agents have become the most common of the pharmacologic treatments, and
fall into the bronchodilator category. Inhalation is the preferred route because it offers rapid
onset of action, delivery directly to the airways, fewer systematic side effects and smaller
doses than would be required of oral or intravenous routes. In severe cases, intubation and
mechanical ventilation are used.
Day-to-day management of symptoms of the illness utilize educational programs involving
both the child and the parents. Physician involvement is recommended. Some of the programs
include self-charting of symptoms and medication usage. These programs are aimed at
increasing self- management knowledge and skills. The parents must understand the use of
their children's inhaled drugs, and if they are being used to prevent episodes or relieve
symptoms. Prevention by controlling cigarette smoking and dust mites might decrease the
severity of symptoms.
Clinical success is determined by the extent to which people adhere to the complex medical
regimen involved. Medical regimens for asthma care are particularly vulnerable to adherence
problems because of their duration, the use of multiple medication on both routine and pro re
nata (pm, as needed) schedules, and the periods of symptom remission (Rand & Wise, 1994).
Medical compliance is defined as the extent to which the person's behavior, in terms of taking
medications, following diets, or executing lifestyle changes, coincides with medical or health

advice (Weinstein, 1995). Some factors that would contribute to a classification of
noncompliance are complete failure to obtain or take the prescribed medication, improper
taking of medication because of patient misunderstanding of correct dosage and schedule,
omission of doses, increasing or reducing dosage or schedule of dosage, and discontinuing
therapy before the end of the recommended period. Children are at a particular risk for
nonadherence and noncompliance. It has been documented that only about 50% of inhaled
medication is taken as prescribed and compliance does not improve with rising severity of
illness (Milgrom et al., 1996). This number may be as high as 90% of pediatric asthmatics
(Wamboldt & Gavin, 1991). A common problem among children and adolescents is
nonadherence with anti- inflammatory inhalers, which are prophylactic and do not yield an
immediate improvement in symptoms. Most children are not using proper inhaler techniques,
and are not using an appropriate spaced device to maximize medication delivery to the
conducting airways. The metered dose inhaler (MDI) is the most commonly used inhalation
technique, however, considerable skill and coordination are needed to use it correctly. A study
by Boccuti, Celano, Geller, and Phillips (1996) demonstrated that a significant proportion of
children with moderate to severe asthma use poor techniques with from 14% to 26% making
critical errors. Just because children use it correctly in front of a practitioner, does not mean
they generalize it outside the office. Indirect and direct methods of obtaining information on
accuracy are available. Indirect methods use clinical judgments, self-reports, and asthma
diaries. Direct measures include biochemical assays that analyze blood or urine testing to
objectively measure levels of medication or byproducts in the body. The downside of these
methods is laboratory costs and delay in results. There are now electronic devices such as the
MDI, which are attached to aerosol inhalers. These devices record the time at which the
inhalers are used, and can track patterns of medication usage over a period of several months.
In a study (Milgrom et al., 1996) attempting to evaluate adherence in children with asthma to
regimens of inhaled corticosteroids and beta agonists, data were collected electronically by
metered dose inhaler monitors and compared with traditional diary. There was a large
discrepancy between the diary entries and chronologic records of children. Electronic
monitoring demonstrated much lower adherence to prescribed therapy than was reported by
patients on their diary cards. This important issue of compliance in children is the dependence



on their parents for the knowledge and upkeep of their regimens. The parents of an asthmatic
child are frequently faced with complex decisions that have to take into account the child's
asthma as well as more general developmental needs (Schwam, children are under so much
stress, it may be important to measure their quality of life and the quality of life of the children
to assess adherence influences. Asthma specific scales for children include the Child Asthma
Questionnaire and the Pediatric Asthma Quality of Life Questionnaire (Osman & Silverman,
1996). Other predictors of noncompliance may be the level of the stress of the parent
(Parenting Stress Index, Abidin, 1986), and the level of depression in both parents and children.
Poor symptom perception may undermine compliance (Wamboldt, 1998). Once stable
predictors of noncompliance are uncovered, then practitioners can predict who is at risk.
Reliable interventions can lower the chance of exacerbation of disease as well as reduce
hospitalizations.

TRANSPLANTATION
Psychologists perform various roles in pediatric organ and bone marrow transplants. Usually,
patient-centered consultation involves bedside consultation and other forms of patient contact.
Indirect psychological consultation relies just on the referral source without any patient
contact. Collaborative team consultation involves interaction with the patient, referral source,
and other team members (Resnick & Kruczek, 1996).
The referral sources are usually the primary clinical personnel, such as physicians and nurses.
The psychologist should balance the needs of both the patient and clinical personnel (Resnick
& Kruczek, 1996). However, collaborative relationships with the referral sources are very
important and the psychologist should not use a distant authoritarian manner. Satisfaction by
the clinical personnel is strongly related to the diagnosis agreement between the referral
source and the psychologist (Olson et al., 1988). Also, a collaborative relationship helps avoid
issues of territoriality (Carpenter, 1989).
Transplantation consultation and liaison require special skills. The first skill is a knowledge of
the biophysiologic components along with their associated psychosocial issues. The second

skill is an understanding of the hospital culture along with a tolerance for professional
ambiguity. and intrusions imposed by medical priorities. The third skill is learning to deliver
psychological services both formally and informally, with an understanding that patients and
their visiting families do not automatically want psychological services. The fourth skill is the
ability to translate and communicate psychological principles and interventions that others can
understand and even perform (Carpenter, 1989).
Possible roles associated with transplantation patients involve pre- and posttransplant
assessment of the patient and family, assisting with coping during and after the procedure,
support for the emotional needs of staff members, and sometimes grief work with the family,
sibling donor, or staff if the patient dies (Rappaport, 1988).
Behavioral intervention procedures for varying accompanying behavioral problems are often
necessary. A chart listing various suggestions for improving behavioral problems is offered by
Charlop, Parrish, Fenton, and Cataldo (1987, p. 494).

Strem
Pediatric organ transplantation (OT) can be classified into three phases. The first, or
pretransplant, phase includes the weeks and months before admission where the decision for
the transplant and then the search for the donor is made. The second, or acute, phase is the
inpatient hospitalization, which typically lasts from 1 to 3 months. The third, or the
posttransplant, phase is the time that is only relevant for transplant survivors. Posttransplant
complication monitoring continues for a few months and medical and neuropsychological
monitoring extends to a few years (Phipps, 1994).


Each phase has its own set of stressors. Some pretransplant phase stressors are the family
stress of possible sibling donors, which sibling donor is more appropriate, the patient being
indebted to the sibling, the waiting period, and the misconception that the patient will acquire
the personality characteristics of the donor (Phipps, 1994).
Some acute phase stressors are patient isolation, sterilization, physical restrictions, sensory
deprivation, and hospitalization (Andrykowski, 1994; Phipps, 1994; Phipps & DeCuir-Whalley,

1990).
Some posttransplant phase stressors are physical and social isolation, adjustment to society,
the patient's appearance, medical procedures, hospitalization, returning to school, treatmentrelated side effects, extreme dependence on the medical staff, repeated infection, and the
possibility of death (Andrykowski, 1994; Bradford & Tomlinson, 1990; Phipps, 1994; Phipps &
DeCuir-Whalley, 1990).
A model of family stress in transplantation suggests that initially there is an adjustment phase
to the news of the required transplantation. It is viewed as a stiessor that interacts with the
existing family resources and the perceptions of this stressor. This leads to the adaptation
phase where initially they treat everything as a crisis. This leads to a “pile-up.” Strategies to
deal with this pile-up involve coping methods of perception of this pile-up and use of existing
and new resources (Hare, Skinner, & Kliewer, 1989).
Various patient responses to these stressors are anxiety, depression, withdrawal, anger,
hostility, survivor guilt, noncompliance, sleep difficulties, anorexia, paranoia, and acting out
(Andrykowski, 1994).
During each of the three phases of OT, appropriate play techniques can ameliorate some
patient stress. During the pretransplant phase, children are encouraged to bring their own
materials or toys are given to them. During the acute phase, too demanding play activity
might be considered intrusive. Instead, minimal participation activities such as reading a story,
listening to an audiotape, and viewing a movie is enjoyed. During the posttransplant phase,
play interactions can combat the sensory deprivation and social isolation. Tactile activities,
such as finger painting or sand and glitter, are helpful. Fantasy play can help to cope with the
isolation where the patient can now freely experiment with feelings and situations (Gottlieb &
Portnoy, 1988).
Parental Stress. One study showed that mother's stress increased as they moved from the
pretransplantation phase to the l- and 6-month posttransplantation phases. Clinically
significant stress was found in 20%, 56%, and 41% of mothers at pretransplantation, and Imonth and 6-month posttransplantation phases, respectively. A greater financial burden,
disrupted planning, and caretaker burden stresses were greater at 1 month and 6 months
posttransplantation than pretransplantation (Rodrigue et al., 1997).
Another study showed that fathers had lower parenting stress than mothers based on the
Parenting Stress Index. This could be either because fathers coped better or fathers were not

as involved as mothers. Fathers felt financial stress, disrupted planning of family activities, and
increased family burden (e.g., travel restrictions, altering of their schedule to care for the ill
child) (Rodrigue et al., 1996).
Posttraumatic Stress Disorder (PTSD). Symptoms of PTSD are common among pediatric OT
patients. Denial and avoidance are very common. Reexperiencing of life threats is often not
noticed unless the psychologist probes the patient (Stuber, Nader, Yasuda, Pynoos, & Cohen,
1991). Girls are more at risk than boys for PTSD (Wintgens, Boileau, & Robacy, 1997).
Social Support Family members often comprise the social support system. OT patients tend to
have fewer friends and active peer experiences. Often the extensive parental social support
leads to parental overprotection and patient dependency. Separation anxiety occurs when the
patient is separated from the parent (Schweitzer & Hobbs, 1995; Stuber, 1993).


Sometimes social support is not beneficial. If the social support network is too supportive,
some patients may feel uncomfortable because they lack control (Littlefield, 1992).

Parental Psychosocial Issues
Parents react to OT issues in different ways. Some parents act in a highly assertive manner
that often presents problems to the OT team. Others act underorganized and do not become
too involved (Bradford & Tomlinson, 1990).
Preoperative psychosocial issues begin with the initial hospital experience where there is a loss
of control, denial of medical reality, and attempted trust building efforts with the hospital staff.
The wait at home has concrete issues such as a financial burden with subsequent concerns
about the need to get public involvement to raise funds. The parents feel guilt over issues such
as the death of the donor, competition for limited organs, and the burden of the informed
consent decision for the child. Anger is felt due to a loss of control and a feeling of being
forgotten and abandoned (Slater, 1994).
Perioperative psychosocial issues begin with anxiety immediately after the operation. The first
2 weeks are viewed as a possible new beginning. The remainder of hospitalization is a roller
coaster period due to the fear of rejection and infection, and the lack of control over the

ultimate outcome (Slater, 1994).
Postoperative psychosocial issues begin with the return home where they adapt a new parental
role concerning a fear of rejection and death, and a readjustment in family structure (Slater,
1994). One study of parents of bone marrow transplantation (BMT) patients done a year after
surgery showed that 37% of the parents had financial concerns, 23% had child-related
problems, and 19% had problems sleeping. Very few reported marital or social relationship
problems (Sormanti, Dungan, & Rieker, 1994).

Coping
Children can cope with either problem-focused coping (e.g., problem solving, cognitive
restructuring) or emotion-focused coping (e.g., social support, problem avoidance, religious
belief) (Kronenberger et al., 1996).
One study of children waiting for BMT showed that avoidance and distraction coping were
associated with more aggression, anxiety, withdrawal, and depression. Children who coped
with religion were less withdrawn, more aggressive, and more depressed. Problem solving and
cognitive restructuring were not related to better adjustment. This might be because the
severity of BMT overwhelmed the children (Kronenberger et al., 1996).

Developmental Considerations
OT issues are pertinent to child development, especially after a successful transplant. During
infancy, the parent should be careful about developing overprotectiveness for the child. Once
the child is a toddler, autonomy should be encouraged. Play opportunities should exist with as
little restriction as possible, although the parent might be concerned about the child's frailty.
The school-age child should, as much as possible, have a school education to allow for peer
interaction. The adolescent should be monitored for risk-taking independent behavior. This can
be dangerous if the child forgets to take the immunosuppressant medications or observe the
dietary restrictions (Sexson & Rubenow, 1992; Slater, 1994).

Cognitive Functioning



OT can affect cognitive functioning. A successful renal transplant may prevent a downward
trend in cognitive functioning associated with end-stage renal disease. Some studies suggest
that there are moderate gains (Hobbs & Sexson, 1993; Schweitzer & Hobbs, 1995; Stewart,
Kennard, Waller, & Fixler, 1994).
Liver transplants have mixed results concerning cognitive functioning. Some claim there are
improvements or no change (Hobbs & Sexson, 1993; Schweitzer & Hobbs, 1995) whereas
others claim there aredeficits (Stewart et al., 1994).
One study of heart transplant patients showed that they did not have greater cognitive deficits
than a cardiac disease/open heart surgery control group (Stewart et al., 1994).

Quality of Life
One study showed that BMT child survivors had good quality of life (physical and psychosocial
dimensions of functioning). However, the domains tested were for adults and are of
questionable use for children (Powers, Vannatta, Noll, Cool, & Stehbens, 1995).
New measures for determining quality of life have been developed specifically for children.
One is a 16. item multiple choice questionnaire in a self-report format using a Likert scale. It
takes from 5 to 10 minutes to complete. The children should do it themselves because
differences were noted when parents' responses were compared with the childrens' responses.
Each question represents one health-related sphere (e.g., mobility, friends, vision). This test
was validated on 12. to 15. year-old adolescents waiting for OT. The young adolescents rated
the positive spheres of breathing, friends, mobility, and mental function as most important.
They rated the negative sphere of death as the most important followed by unconsciousness
as the next worst. These OT patients had more problems with breathing, eating, and
elimination than the control group (Apajasalo, Sintonen, et al., 1996).
Another quality of life measure was developed for 8 to 1 l-year-old children surviving OT. It has
17 dimensions and is in the form of a structured interview. It takes from 20 to 30 minutes to
complete. The OT patients had more problems eating, eliminating, and concentrating than the
control group (Apajasalo, Rautonen, et al., 1996).


Adherence
Lack of adherence can cause a successful OT to fail. This issue is quite serious. One study
showed no adherence problems for children under age 2. However, 73% of preschoolers (age
2–6), 82% of school-age children (age 7–12), and 40% of adolescents (age 12 and up) had
adherence problems (Phipps & DeCuir-Whalley, of adolescents do not always take their
medication (Schweitzer & Hobbs, 1995).
Some factors associated with poor adherence are poor self-esteem, family conflict, and
multiple family stressors (Wainwright & Gould, 1997). One study showed that informative
support (advice or personal feedback) and emotional support (caring, sympathy, love) by
fathers were negatively related to adherence to the immunosuppressant medications of
azathioprine and cyclosporine. It is possible that this occurred either because the fathers only
became involved due to the poor adherence or perhaps this occurred because this was the
way the child was attempting to gain control (Foulkes, Boggs, Fennell, & Skibinski, 1993).

Future Directions
Many OT studies rely on small sample sizes (Schweitzer Bt Hobbs, 1995). Future research
should focus on more prospective studies that use larger sample sizes. A possible solution is
for multiple investigators in different hospitals to collaborate in their research. This will offer
more concrete and valid information on the effects of OT on children.


INJURY PREVENTION
Injuries are an important health issue for children. Injury is the third leading cause of death in
the United States and the leading cause for children, adolescents, and young adults (Irwin,
Cataldo, Matheny, & Peterson, 1992). Previous research has presented confusing and
conflicting results on the determinants of childhood injuries, particularly psychosocial
predictors. In an analysis of 532 pediatric patients at a prepaid clinic during 12 months, it was
found that four factors independently associated with the risk of at least one treated injury:
high activity level, high rate of pediatric utilization for noninjury-related visits during the followup period, occurrence of a treated injury during the preceding year, and a negative attitude
toward medical care providers by the child's mother. Mothers who work more than 15 hours a

week outside the home and who have more life events in the preceding year are more likely to
have children with serious injuries. Thus, Horwitz, Morgenstern, DiPietro, and Morrison (1988)
concluded that these characteristics must be targeted for stressed families.

Adolescents
In a study (Kolbe, 1990) conducted by the Centers for Disease Control, the behaviors that
contribute most tu adverse health and social outcomes were grouped into six categories:
behaviors that result in unintentional and intentional injury such as motor vehicle accidents,
homicide, and suicide; drug and alcohol use; sexual behaviors that result in sexually
transmitted diseases, including human immunodeficiency virus infection or unintended
pregnancy; tobacco use; dietary behaviors that contribute to adult morbidity and mortality;
and physical inactivity.
Adolescents are more prone to athletic injuries and suicide than children at other
developmental periods. In a study (Baumert, Henderson, & Thompson, 1998) surveying high
school students in grades 9 through 12, athletes and nonathletes were found to differ in
specific health risk behaviors. Adolescent athletes appear less likely to smoke cigarettes or
marijuana, more likely to engage in healthy dietary behaviors, and less likely to feel bored or
hopeless.
Peterson and Brown (1994) reviewed the literature on unintentional injuries in children. They
pointed out the similarities between factors predicting both unintentional injuries and child
neglect. It was not until the 1980s that the focus shifted from the physical environment to
sociocultural and personal factors, including the immediate environment and the skills and
abilities of the parents. A deficit in problem solving and a failure to provide appropriate
supervision appear to be difficult constructs to measure as both involve a lack of response. In
coming up with a working model to encompass all of the etiological factors for child injury,
they provide both caregiver- based and child-based variables. Several studies showed that
stress contributes to risk of child injury. Thus, families who exist in poverty, chaos, crowding,
and residence change have a higher chance of having a vulnerable child. Social isolation may
increase caregiver stress, particularly in young single mothers. Maternal depression may be a
particularly critical injury risk factor (Garbarino et al., 1991).

A recent study (Kramer, Warner, Olfson, Ebanks, Chaput, & Weissman, 1998) of the offspring of
depressed parents found that there is an increased susceptibility to specific medical conditions
and hospitalization relative to the depression status of both the parent and the offspring. The
study revealed that the offspring depression status was associated with a history of general
medical problems and hospital visits only among those offspring who also had a depressed
parent. The association was demonstrated for genitourinary disorders, headaches, respiratory
disorders, and hospitalizations. Parental depression without considering offspring depression
was limited to a report of unconsciousness in the offspring and may be related to an increased
prevalence of accidents resulting from inadequate parental monitoring among depressed
parents. These findings were consistent with a longitudinal study of children of depressed
parents (Billings & Moos, 1985). They found that the offspring of depressed parents had more
general medical problems, more health risk factors (i.e., smoking, drinking, and drug use), and
poorer functioning than children of nondepressed controls. It was further found that having a


parent with a lifetime measurement of depression even if it had remitted, still presents a risk
for medical problems. In the two-generation study, it was found that a history of depression in
both the offspring and the parents was necessary to exhibit a significant association between
depression and medical problems. However, these results may be due to either genetic or
environmental influences or both. There is some association between allergies and depression,
which may mean that both dysfunction in the adrenergic and cholinergic systems may
predispose people to both atopic disorders (e.g., allergy and asthma) and some forms of
depression. This may be passed on genetically, thus producing the medical comorbidity only
among those with two generations of depression.

CONCLUSIONS
Thus, within each of the areas of research reviewed, it is important to consider the parents'
state of stability, ongoing stressors in the home, and the childrens' developmental age in the
assessment and treatment programming of the health care team. The first task of a functional
analysis would be to view the problem within the framework of what developmental tasks need

to be accomplished during the next 5 years of the child's life. Differences between
independence struggles and age capacities will indicate how involved the parent should be in
the implementing of the medical program. Often compliance can be improved by educational
discussions and nonthreatening guidance of parents in more appropriate problem solving. In
the case of adolescents, they may be encouraged to modify the program to fit in more with
their life style and identification needs. Especially in the area of suspected child neglect when
too many visits to the emergency room with accidents or asthmatic attacks occur, the parent
needs to feel believed and not evaluated or blamed for the injury or failure of medical
compliance. A team approach by the hospital staff and health consultants would allow better
supervision and more constructive individualization of programs as multiple input will pinpoint
strengths and weaknesses in each individual involved in the care of children. When parental
depression is lifelong, it may be necessary to encourage an independent evaluation of the
suffering parent so that medication and social support from the other spouse may be
improved. In impoverished environments due to dysfunctional families, low access to health
care, poverty, crowdedness, or environmental hazards, the school could serve as an entry
point for mobilizing community resources.