Vulnerable Children: Parents' Perspectives and the Use of Medical Care

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Vulnerable

Children:

Parents’

Perspectives

and

the

Use

of Medical

Care

Janice C. Levy, MD, MPH

From the Department of Medicine, Children ‘s Hospital Medical Center, Boston

ABSTRACT. In a study of use of five general pediatric services, 750 parents were interviewed on site about their decisions on how and when to seek medical care for their

children. Parents’ fears that a particular child was

“vul-nerable”-ie, uniquely threatened by an episode of

ill-ness-was a recurrent concern (reported by 27%), explain-ing many of their medical visits. Medical record review indicated that in 40%, there was no clinical basis for these parent concerns. One important source of these unwar-ranted concerns was fear of recurrence of an earlier med-ical problem, long since resolved. In some families, the

role of social and environmental issues in generating a

high level of concern was evident. Vulnerable children

made more visits per year and made many more of their visits to the emergency room, and their parents more often expressed dissatisfaction with care received. Rec-ognition of reasons underlying parents’ sense of the child’s

special status may do much to allay unnecessary fears

and promote more appropriate use of health care facili-ties. Pediatrics 65:956-963, 1979; vulnerable children,

parents’ concerns, utilization ofpediatric services,

pri-mary care.

Pediatrics is unique in that it is a third

person-the parent-rather than the patient who most often

makes the decision about how, when, and where to

seek care. The logic underlying parents’ judgments

is sometimes obscure to providers, who, unaware of

the concern which triggered the visit, may fail to

deal with the central issue of the encounter.

In this study of use of pediatric services by inner

city children, 750 parents were interviewed on site,

in the waiting areas of five general pediatric

facii-ties, to explore their perspectives on how and why they choose the programs they use, and their

as-sessments of their children’s health status. Since

Received for publication April 2, 1979; accepted Aug 9, 1979. Read in part before the Annual Meeting of the Ambulatory Pediatric Association, Atlanta, May 1, 1979.

Reprint requests to (J.C.L.) Department of Psychiatry, Massa-chusetts General Hospital, Boston MA 02114.

American Academy of Pediatrics.

these interviews were conducted at the time of the

encounter, the immediacy of the perceived needs

and the events which led parents to seek care and

their views on the significance of their children’s problems were readily elicited.

The finding that some parents felt particular

children to be especially endangered or threatened

by ifiness emerged as a recurrent concern early in

the study. After 56 interviews were completed, it

was clear from the narratives that some parents

looked upon a particular child as different from other children (and from siblings) in that he or she

was likely to become very sick very fast, even

though they recognized that the present illness was

not severe. Concerns were expressed about

poten-tial seriousness, danger, or consequences of an

ifi-ness, or unpredictability of its outcome, because of

something special about the child.

This high level of concern, and the use of medical

care that results, was uniquely summarized by the

mother of a 9-year-old boy who had had multiple

revisions of a ventriculoatrial shunt for

hydroceph-alus:

Robert can become very sick in a few minutes. Headaches for him mean two different things. He has headaches

which can be caused by a virus or it may be because the

shunt in his head is blocked. . .. When he complains

about a headache it can be just a simple matter or it can

mean surgery. When he has a headache, the best thing to

do is to bring him immediately to the ER-it’s best not to take any chances.

To capture these particular concerns, a question

was added to the interview recording form: “Do you

have special worries about the child’s health or feel

the need for extra cautiousness?” Children whose

parents stated such concerns were coded as

vulner-able (researcher term). (The first 56 interviews were

reanalyzed and coded for vulnerability according to

the parents’ narrative accounts of the

circum-stances of the medical visit.) Since our goal was to

capture parent perspectives, the reasons they cited

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ARTICLES 957 interviews were completed, categories were

devel-oped from these comments to encompass the range

of explanations parents gave for these perceptions.

The observation that parents’ concerns may not

be adequately expressed in the context of the

tra-ditional medical history is not a new one. Yudkin’

first pointed out that even for patients with the

identical chief complaint, the decision to seek

pe-diatric consultation may derive from differing

un-derlying needs, made known only when the “second

diagnosis” (Why is the patient consulting with you

now?) is determined. Korsch et al,2 extending these observations to the well child visit, found that the needs and concerns of mothers, especially when

related to psychologic subjects, were seldom

ex-pressed to providers and consequently had little

influence on the content of these medical visits.

The concept of “vulnerability” was first

devel-oped by Green and Solnit3 who noted a

constella-tion of disturbances in psychosocial development

among 25 children who had sustained a

life-threatening illness in their early years. Following

recovery, these children were considered by their parents, “for reasons not founded in reality,” to be

vulnerable to serious illness or accident, or even

destined to die during childhood. These 25 cases

may be considered extreme instances of a more

general issue: that individuals differ in how they

understand their health needs and how they

eval-uate and act upon illness symptoms. While some

sociologists46 have described the importance of

such social-psychologic features as perceived

sus-ceptibiity to illness and perceived seriousness of

illness as determinants of seeking preventive ser-vices, they seldom consider these features in

rela-tion to the clinical status of the individual patient.

While few of the parents in this study expressed

the extreme concern of imminent death which

Green and Solnit described, many worried about

unpredictable and serious outcomes of even minor

illness for this particular child. This report will

detail the origins of these parent perceptions of

vulnerability, the extent to which they correspond

to professional judgments about the child’s health

status determined by medical record review, and

the associations between parents’ view of their chil-dren’s vulnerability and the nature of their use of pediatric care.

METHODS

In a comprehensive study of utilization of

pedi-atric services, 750 parents of 795 children were interviewed at the time they brought their children

for care at five facilities which form the network of

general medical services affiliated with Children’s

Hospital Medical Center. Four of the programs are

organized to deliver comprehensive primary care

services (three neighborhood health centers and the hospital-based primary care clinic) and the fifth is

the Children’s Hospital Medical Center Emergency

Room (ER). Descriptions of the study design and the form and content of data collection instruments,

which have been previously reported,7 are

summa-rized here.

Interview

Each interview took the form of a directed

con-versation in which parents were asked about the

circumstances leading to the visit, their pattern of

use of pediatric facilities, their concerns and

prior-ities about their children’s health, and their

evalu-ations of the care they received. To define parent

perspectives, an open-ended format was chosen to

permit interviewers to record parents’ comments in

their own words.

Respondents were chosen randomly from among

all those in the waiting rooms to conform to a

sampling frame designed to sample (over a

12-month period) by time of day and day of week,

including a representative proportion of weekend

and evening visits in those programs which were

open at these times. Interviews averaged 30 minutes

and informed consent was obtained. (A detailed

explanation of the study was given to each person approached and informed consent forms were

signed by those agreeing to the interview (>95%).

A separate consent form was signed for those par-ents who agreed to medical record review. Of the 795 parents interviewed, 769 (96.5%) agreed to this section of the study.)

Medical Record Abstract

Information was abstracted from medical records

at the study sites for 752 of the 795 children in the

study (94.6%). For 3.3%, permission for medical

record review was refused; for 2.1%, the medical

records could not be obtained. Primary care

pro-gram or ER encounters made during a one-year

period before the interview date, as well as all

subspecialty consultations and inpatient

hospitali-zations, were abstracted. (For the 101 children

(13.4%) who had fewer than four visits recorded at

the study sites during the 12 months preceding the

on-site interview, the review period was extended

backwards to include at least four encounters. An

additional 237 children (31.5%) had made a total of

fewer than four visits to our study sites during their lifetimes; most of these were less than 1 year old.)

Data recorded included: chief complaints,

diag-noses; laboratory tests, treatment and follow-up

plans, immunization and screening tests

adminis-tered, and a categorization of the type of visit (well

at Viet Nam:AAP Sponsored on September 7, 2020

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9.6%

19.5%

34.2%

32.9%

3.8%

TABLE

Age (yr)

child, minor acute ifiness, serious acute illness,

spe-cial problem care, follow-up visit). Chart reviews

were performed by a pediatric nurse practitioner

using structured abstract forms and separately

coded by one of two trained individuals. (One of the

study pediatricians (H.S.) reconciled uncertainties

for the chart reviewer and coders. A random

sub-sample (n = 30) of records were re-abstracted by

him, with a >95% level of agreement, and an equal

number of different abstracts were re-coded by a

second coder with a >95% level of agreement.)

To ascertain the proportion of children who had evidence in their medical records of any increased

likelihood of serious illness or evidence of ongoing

medical problems, I reviewed all abstracts of

en-counters for each of the 200 children. Taking into

account both record review and parent reports, two categories of vulnerability were developed. When

there was any indication of compromised health

status or any condition noted which might

unfavor-ably influence the course of any illness episode, the

child was classified as “medically vulnerable.”

When there was no such evidence, the subject was

classified “not medically vulnerable.”

Characteristics of Use of Care

A number of variables describing use of pediatric

services, including sites of visits, pattern of use,

number of visits, and parent evaluations of how

well their child’s health needs were being met, were noted.

From information obtained in the interviews, the

sample was categorized into five patterns of health care utilization:

I. No primary care (ER only used for

gen-eral pediatric needs)

II. Primary care only (exclusive use of pri-mary care facility)

III Comprehensive primary care (primary

. care program as major source; ER is

back-up)

IV. Limited primary care (primary care site for check-ups, immunizations, and mi-nor illness, ER for most illness care)

V. Multiple primary care (more than one

primary care program used

concur-rently)

RESULTS

This report will present a descriptive analysis of

the sociodemographic characteristics of the study

subjects and of the origins of parents’ concerns

about vulnerability, categorized by whether or not

medical record review indicated a clinical basis for

such concerns. In addition, associations between

categories of vulnerability and characteristics

de-scribing utilization of medical care will be reported.

Tests of association were done by the

x2

method,

and, where appropriate, by the calculation of the

standard residuals8 in each contingency table cell.

Snmndemnaranhic

The 795 study subjects share many of the socio-demographic characteristics of economically disad-vantaged, inner-city population groups. Most

fami-lies lived in three contiguous low-income

neighbor-hoods of Boston; the majority (60%) had lived at

their present residence for more than three years.

Many were members ofminority groups (50% black,

20% hispanic), and were medically indigent (71%

with Medicaid as payment source). The children

were young (70% less than 5 years old), lived in

family constellations that were often single parent

(41%) or extended family (13%) groupings, and were

often only children (33%). The characteristics of the

sample raise the question of whether these parents’

perceptions of their children’s vulnerability is in

some degree embedded in, or derivative of, an

eco-nomically disadvantaged environment. There was

a somewhat higher proportion of children in both

vulnerability categories (validated or not validated

by record review) with Medicaid as the third party

insurer than with other payment sources (28% as compared with 17%), suggesting some association

with poverty. Analysis of category of vulnerability

and age (Table 1) indicated that, although there

were slightly more infants (0 to 1 year olds) in the “not medically vulnerable” category, and slightly fewer infants in the group with medically validated

conditions, these differences did not approach

sta-tistical significance. Similarly, no associations

be-tween either of the two vulnerability categories and

child’s rank in family, ethnic characteristics,

house-hold composition, or mother’s age were found.

Origin of Vulnerability

“Medically Vulnerable. “ From record review and

parent information, 119 (60%) of the 200 vulnerable

1. Age of Child and Category of Vulnerabiity*

Vulnerable Not

Vulnerable

“Medically

Vulnerable”

“Not

Medically

Vulnerable”

n %

n % n %

0-1 25 21 30 37 189 33

1-2 22 19 13 16 116 19

3-5 35 29 16 20 126 21

5+ 37 31 22 27 164 27

Total 119 100 81 100 595 100

*

x2

= _10.25,

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ARTICLES 959

children were classified as having some clinical

grounds for that designation, for reasons noted in

Table 2. More than 50% of these 1 19 children

aroused parents’ concern because of asthma,

recur-rent otitis, or their combination-indicating the

high frequency of these conditions as important

causes of morbidity in the primary care setting.

Sometimes, specific fears were focal to certain

di-agnostic categories. For example, while all parents

of children with recurrent otitis mentioned the

like-lihood of recurrence as a special issue, 1 1 of the 33

parents additionally focused on their fears that

hearing loss would ensue. While all parents of

asth-matic children described their concern about the

child’s potential respiratory distress, 13 of the 32

additionally cited their experience that pneumonia

is a complication to be feared.

“Not Medically Vulnerable. “ There were 81

sub-jects (40%) who were not considered vulnerable by

clinical criteria. This group was about evenly

di-vided between those whose high level of concern

was rooted in an event in the past (which should

not have aroused ongoing concern) and those for

whom social and psychologic issues seemed

para-mount (Table 3).

Many parents cited an earlier medical problem

(judged by record review to have no ongoing

signif-icance to the child) as a root cause of their concerns.

Thus, a mother whose child was hospitalized many

years earlier, during infancy, because of

dehydra-tion following gastroenteritis reported to our

inter-viewer that she was afraid her robust, now

school-aged child, would again become severely

dehy-drated (only mild gastroenteritis was noted in the

medical record). Even more frequently, an event in

the family medical history triggered concern about

this child. This was most graphically expressed by

two mothers who had lost infants with sudden

infant death syndrome, and now were concerned

about a younger sibling. One mother described her

feelings:

I already lost one . .. she would have been 5 years old June 21st .. . I took her to the clinic. She was all right.

The same day, I lay her down, checked on her, and she

was dead. Nothing was wrong. It was nothing I did. At

the time, I was having trouble with her father. . .. It got to be a hassle, we weren’t getting along . . . it got to the point of fistfights. I guess God said there was going to be too much hell, so He took her away. ...

And about her 13-month-old who was seen in the

ER with a minor upper respiratory tract infection,

this mother said:

I didn’t want anything to happen overnight. I stayed up with her all last night. I kept giving her medicine to ease all the phlegm and for her fever, but it wasn’t helping.

Another mother, whose son had a

pneumonec-TABLE 2. “Medically Vulnerable”

n %

Asthma 32 27

Recurrent otitis media 27 23

Asthma and recurrent otitis media 6 5

Seizures 9 7.5

Prematurity 8 6.5

Recent medical illness 10 8

Lower respiratory (6)

Neonatal jaundice (2)

Recent hospitalization-incarcerated hernia and dehydration (2)

Other medical illness 27 23

Severe neurologic (7) Recurrent infections

(urinary tract, pneumonia) (5)

Hematology-oncology (7)

Cardiac (3) Other (5)

Total 119 100

tomy for congenital lobar emphysema at 2 months

of age, brought in her 2-month-old daughter with

“wheezing and choking,” and told the interviewer

she was “really scared” because “the same thing is

happening to this child.”

Parents’ unwarranted concerns were often

deriv-ative of something a physician said or did. Many of

these worries originated in minor abnormalities

dis-covered in routine screening, but incompletely

ex-plained to or understood by the parent. Three

mothers cited knowledge of sickle cell trait as a

factor in their concerns: “He has sickle cell trait

and might get sickle cell anemia,” was a

represent-ative comment. Serious concerns were also

ex-pressed by mothers whose children had minor

de-grees of anemia or minor transient elevations in

blood lead levels. An unexpected finding in this

study was that of unresolved concerns generated by

the performance of a spinal tap as part of past

work-up of unexplained fever. Five parents whose

chil-dren had negative lumbar punctures done in the

ER had been told at the time that the child might

have meningitis. In subsequent febnile episodes

(most often, benign viral illness), the mother

wor-ried that this illness, too, might be meningitis and

came rushing in to the ER.

The remaining group of parents whose concerns

were disproportionate to any medically based

judg-ments about the child’s vulnerability often offered

little specific explanation for their anxieties. Thus,

they spoke of the child being “so young and so

small” or of the fact that the child “gets a lot of

colds.” Problems which are generally considered to

be functional or psychosomatic (recurrent

abdomi-nal pain or headaches, migraine, colic) were

in-cluded in this grouping. Some of the interview

transcripts in this group suggested that severe

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n%

7 9

11 14

18 22

81 100

TABLE 3. “Not Medically Vulnerable”

960 VULNERABLE CHILDREN

_I. Concern stems from past events Past history of medical problem

Pneumonia or croup (4)

Other (3) Family history

Sudden infant death syndrome or sibling illness (4)

Asthma (3)

Other (4)

Something physician said or did (iatrogenic) Screening (10)

LPS (4) Other (4)

II. Psychosocial features predominate Overconcern about presenting symptom

Frequent colds (6)

Allergies (2)

Special senses (vision and hearing) (6) Other (3)

So young and so small Psychosomatic or behavioral Self-proclaimed worriers

Premium baby (2)

Just worry (3)

Severe psychosocial

stress-parent asking for help through child (5) Total

10 12

7 9

10 12

TABLE 4. Mean Number of Visits per Year by Category of Medical Vulnerability and Site of Interview (Emergency Room (ER) and Primary Care Programs) by Vulnerability

Vulnerable Not Vulnerable

“Medically “Not Medically

Vulnerable” Vulnerable

Mean No. of Visits* 9.96 7.88 5.97

n 118 78 576

Sitet

ER (%) 49.2 48.8 35.8

Primary care programs (%) 50.8 41.2 64.2

Total 100.0 100.0 100.0

n 119 81 595

* F (between groups) 21.95 (2 df), P < .001. t

x2

= 10.85, P < .01.

chosocial stress was a factor in parents’ anxieties.

However, this was only a qualitative impression;

data necessary to develop a systematic comparison

between groups were not available. Respondents

may have had different thresholds for

communicat-ing these issues to the interviewers, and social

prob-lems are not systematically noted in medical

rec-ords. Five mothers spontaneously spoke of the

dif-ficulties in their lives and reported fears about their

inability to mother or nurture the child or spoke of

intolerable living conditions. Medical record

re-views indicated problems such as “failure to thrive,”

“maternal-child interaction problem,” or evidence

that social service agencies, or even children’s

pro-tective services, were concurrently working with the

families. Many of this group in whom psychosocial

factors were prominent represent examples of

Bal-mt’s9 formulation of the child as the presenting

symptom of the parent’s distress (ie, of parents who

are asking for help through their children). For

example, the mother of an 8-month-old infant who

had made 16 visits for minor illnesses came to the

ER for the third time in one day. This 22-year-old

mother told our interviewer she was concerned because, “He has had a cold since he was a baby,”

but also noted that she had been having “a hard

time since she was three months pregnant with this

baby,” when the father left her with two other

children. She said, about this infant: “I’d like to

leave him in the hospital because I can’t cope any

more.”

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ARTICLES 961

were evident in some of these families. For example,

two children were “premium babies,” born after a

long period of infertility to parents who had

re-signed themselves to being childless. Many parents

were quick to assert their own sense of worry

dis-proportionate to the child’s condition.

Use of Medical Care

Parents’ perception of vulnerability was

signifi-cantly associated with how pediatric programs were

used. When the 200 “vulnerable” children were

compared with the remaining study subjects, they

made many more total visits per year and more of

these visits were to the ER (Table 4). The

statisti-cafly significant differences in these associations

persisted when subjects were separately categorized

into “medically vulnerable” and “not medically

vul-nerable” groupings. The perception of vulnerability

appears to be part of a causal complex of factors

which are associated with increased utilization.

Since the sample was not large enough to control

for possible intervening variables, quantitative

as-sessment of the magnitude of increased utilization

related to these parents’ concerns is not possible.

Sociodemographic factors which, in this study, were

not associated with vulnerability (such as family

composition, parents’ marital status, ethnicity)

can-not be implicated in explaining the differences in

number and site of visits among the vulnerability

categories.

TABLE 5. Patterns of Care and Vulnerability

Patterns of care also differed between these

vul-nerable children and the remaining study subjects

(Table 5): Children in both vulnerability categories

were more likely to be using multiple sites rather

than a single primary care source. The medically

vulnerable children differed from other study

chil-dren in that a higher proportion were using primary

care programs comprehensively, ie, for most health

care needs. In this respect, these primary care

pro-grams show evidence of reaching one high risk

group of children in special need of a comprehensive

approach to their care.

Satisfaction was another dimension of use of

medical care elicited during the interview (Table 6).

Parents were asked how well they thought their

child’s health care needs were met (coded as “very

well,” “adequately,” or “poorly”). Overall, parents

of vulnerable children more often expressed

dissat-isfaction with the child’s medical care; 15% thought

their child’s health needs were not being met, in

contrast to only 5% of their nonvulnerable cohorts

(x2

15.57, P < .001). This level of dissatisfaction

was most marked among those parents whose

con-cerns about the child’s vulnerability were not

vali-dated by medical record review. Another reflection

of the association between the not medically

vul-nerable group and satisfaction is that these parents

were much less likely to feel that medical care needs

were met “very well” (19% vs 33%). This contrasts

with the responses of parents of “medically

vulner-Vulner able (%) Not Vulnerable (%)

Totals (%)

“Medically “Not Medically Vulnerable” Vulnerable”

Pattern I: no primary care 12 5 9 9.3

Pattern II: primary care only 8t 16 22 19.5

Pattern III: comprehensive primary care 48t 30 31 33.6

Pattern IV: limited primary care 30 40 34 33.6

Pattern V: multiple primary care 2 9 4 4.1

Total 100 100 100 100.0

n 119 81 539 739

* Missing observations: 56.

x2

= 27.58 (8 df), P = .0006.

t By analysis of standard residuals,8 this cell is significantly less than expected. t By analysis of standard residuals, this cell is significantly greater than expected.

TABLE 6. Satisfaction with Care (Parents’ Response to Question: “How Well Are Your

Child’s Health Care Needs Met?”)

Vulner able (%) Not Vulnerable (%)

Total (%)

“Medically “Not Medically

Vulnerable” Vulnerable”

Very well 35 19 32 31

Adequately 53 64 63 61

Poorly 12 17t 5 8

n 104 69 453 626

* Missing observations: 113.

x2

= 20.98 (4 dl), P < .001.

t By analysis of standard residuals,8 this cell is significantly greater than expected.

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able” children; many of these children were

chron-ically ill, yet their parents more frequently

ex-pressed a higher level of satisfaction than either of

the other two groups.

DISCUSSION

In this study, parents’ perspectives that

particu-lar children were “vulnerable” were associated with

identifiable differences in health care utilization.

When the concern was not medically based,

addi-tional features of use of care included less compre-hensive use of primary care programs and more dissatisfaction with care received.

Parents’ concerns about their children’s

compro-mised health status had many disparate origins.

Clearly, some of these children were at increased

risk of developing serious sequelae to illness, but in

an important proportion (40%) there was no

dem-onstrated clinical basis for being considered

vulner-able. This “not medically vulnerable” group

war-rant special attention from medical providers

be-cause their high volume of use of expensive

hospi-tel-based emergency services does not appear to

address their concerns, respond to the spectrum of

their medical needs, or meet with their satisfactions.

For many of those whose concern about

vulner-ability was not clinically validated, something a

physician said or did, or some connection the parent

made to a past illness of the child or that of other

family members, caused their anxiety. Their

prob-lems are similar to those Bergman and Stamm’#{176}

described among children with cardiac

“non-dis-ease.” In that study, a group of Seattle

schoolchil-dren, mistakenly diagnosed as having heart disease,

had significantly greater cumulative morbidity (if

measured by restriction of activity) than

school-children with true cardiac disease. The iatrogenic

basis of parental concern points to its resolution. It

is likely that if the nature of the parents’ worries is

recognized, a careful explanation of the child’s true

health status by the physician could allay

unnec-essary concerns and promote more effective use of

health care facilities.

The role of family psychosocial stress in arousing

parental anxiety has been noted by others. Balint’s

notion of “the child as the presenting symptom”

was reemphasized by Clyne,” who described this

phenomenon as a frequent reason for requests for

night calls (house calls) in a study of general

prac-tice in England. Both researchers pointed out that

parents’ psychological distress can generate

re-quests for relief through the vehicle of the child as

patient when the parent does not feel his or her

own distress appropriate to see the doctor.

Me-chanic’2 noted that mothers who perceive life as stressful or who experience dissatisfaction in their

family relationships become more concerned with

both their own and their children’s symptoms.

Roghmann and Haggerty’3 demonstrated that

fam-ily stress not only increased the probability of a

medical encounter, but was especially likely to

in-crease use of ER services, because of its high degree

of availability. All of these factors were underlined

in the narratives of parents in the present study.

Many of the mothers who appeared to be

overcon-cerned about the child’s presenting symptoms

ex-pressed doubt, in one way or another, about their

own ability to care for the child.

Recognition of underlying psychosocial factors

among those whose frequent presence in clinics and

ERs reflects parental distress may result in

engag-ing appropriate social support services.

Unfortu-nately, in the setting of a busy hospital ER, with its

orientation toward episodic care and medical

emer-gencies, such recognition is not likely.

IMPLICATIONS

Physicians serving children and their families

devote a substantial portion of their time to the

care of “routine” or “trivial” illness. For each child

brought to the doctor with an acute self-limited

disease there are many more whose illness resolves

without medical attention, suggesting that factors

distinct from the nature of the illness play an

im-portant role in triggering a medical encounter.

In this study, there was evidence that parents’

fears, which contributed to their decision to seek

care for their children, had not been made known

to, or addressed by, medical staff. This failure in

patient-doctor communication often led to

unwar-ranted parental anxiety. Clinical experience

sug-gests that, if the “vulnerable child” is identified,

resolution of parents’ concerns is frequently

possi-ble with careful explanation and with appropriate

reassurance. Others”4 have pointed the way to

recognition of the problem: open-ended questions,

attention to the “second diagnosis” (Why is the

child here now?), understanding of parents’

expec-tations of the visit, and attention to the emotional

and social circumstances surrounding the

encoun-ter.

The time spent in fostering improved

communi-cation should not be considered a luxury in a busy

practice or hospital ER. An understanding of the

factors triggering these visits is essential to the

process of care and promises to reduce use of

ex-pensive medical services. More importantly, such

understanding should result in more effective care.

ACKNOWLEDGMENT

This investigation was supported by a grant from the

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Ser-ARTICLES 963

vices Research Grants, US Department of Health,

Edu-cation, and Welfare (MC-R-250371).

REFERENCES

1. Yudkin S: Six children with coughs: The second diagnosis.

Lancet 2:561, 1961

2. Korsch BM, Negrete VF, Mercer AS, et a!: How comprehen-sive are well child visits? Am J Dis Child 122:483, 1971

3. Green M, Solnit AJ: Reactions to the threatened loss of a child: A vulnerable child syndrome. Pediatrics 34:58, 1964

4. Rosenstock 1W: Why people use health services. Milbank Mem Fund Q 44:94, 1966

5. Kasi SV, Cobb S: Health behavior, illness behavior and sick role. Arch Environ Health 12:246, 1966

6. Becker MB, Nathanson CA, Drachman R, et al: Mothers’

health beliefs and children’s clinic visits: A prospective study.

J Community Health 3:125, 1977

7. Levy JC, Bonanno RA, Schwartz CG, et al: Primary care: Patterns of use of pediatric medical facilities. Med Care 17:

881, 1979

8. Reynolds HT: The Analysis of Cross-Classifications. New York, The Free Press, Div of Macmillan Publishing Co, mc, 1977

9. Balint M: The Doctor, His Patient, and the Illness. London,

Pitman Medical Publishing Co, Ltd, 1957

10. Bergman AB, Stamm SJ: The morbidity of cardiac non-disease in schoolchildren. N EngI JMed 276:1008, 1967 11. Clyne MD: Night Calls-A Study in General Practice.

London, Tavistock Publishers, 1961

12. Mechanic D: The influence of mothers on their children’s health attitudes and behavior. Pediatrics 33:444, 1964 13. Roghmann KJ, Haggerty 1W: Daily stress, illness and use of

health services in young families. Pediatr Res 7:520, 1973 14. Korsch B: The pediatrician’s approach to his patient. Am J

Dis Child 126:146, 1973

ENGLAND’S PLAN TO CONTROL DRUG ADVERTISING

The content and form of advertisements for medicine prescribable under the

N.H.S. are to be controlled by new regulations’ published this week and to be

introduced on December 1. They apply to any advertisement addressed to a doctor or dentist which is intended to persuade him to prescribe or supply a medicinal product. Under separate regulations2 published earlier this year by

the Department of Health and Social Security advertisements that could lead

to the use of a medicine for self-treatment of conditions unsuitable for

self-diagnosis and self-treatment have been banned from August 1. These regulations

introduced safeguards against inappropriate claims in advertisements for

over-the-counter medicines and also ageneral prohibition on advertising to the public

any medicine that is available only on prescription from a doctor or dentist. The

latest regulations aim to ensure that advertisements to doctors and dentists give

complete and accurate information about the medicinal products concerned.

Full advertisements will have to contain specific information about the active

ingredients, indications for use, dosage, major side-effects, precautions,

contrain-dications, warnings, and (except for journals with a wide circulation outside the

United Kingdom) the cost to the N.H.S. Abbreviated (“reminder”)

advertise-ments must be less than 420 cm2 (the size of an entire Lancet page is 560 cm2

and the area normally covered by print on an editorial page is approximately

367 cm2); and they must contain a certain minimum amount of information, as

detailed in the regulations. In all advertisements the generic name of the product

must appear close to the brand name. Misleading graphs and tables are

pro-hibited, and so are unsupported claims for superiority over other products and

the unqualified use of “safe.”

REFERENCES

Submitted by Student

1. The Medicines (Advertising to Medical and Dental Practitioners) Regulations 1978, s.i.1978 no. 1020. HM. Stationery Office. 30p.

2. The Medicines (Labelling and Advertising to the Public) Regulations. s.i.1978 no. 41. H.M.

Stationery Office. 35p.

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1980;65;956

Pediatrics

Janice C. Levy