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Perception of Child Vulnerability Among Mothers of Former Premature Infants


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Perception of Child Vulnerability Among Mothers of Former

Premature Infants

Elizabeth C. Allen, MD*; Janeen C. Manuel, PhD‡; Claudine Legault, PhD‡; Michelle J. Naughton, PhD‡; Carol Pivor, MSW*; and T. Michael O’Shea, MD, MPH*

ABSTRACT. Objectives. Parents of premature infants often perceive their infants as medically vulnerable. High parental perception of child vulnerability (PPCV) is associated with disproportionately high health care uti-lization. The objectives of this study were to determine whether higher PPCV is correlated with worse develop-mental outcome in premature infants at 1-year adjusted age and to identify factors, present at neonatal discharge, that predict high PPCV.

Methods. This prospective cohort study assessed mothers of 116 premature infants who were<32 weeks’ gestation and required supplemental oxygen at 36 weeks postmenstrual age. At neonatal discharge, mothers com-pleted the Spielberger State Anxiety Inventory, Beck De-pression Inventory, Impact on Family Scale, Life Orien-tation Test, General Health Survey, and Medical Outcomes Study social support survey. At 1-year ad-justed age, child development was assessed using the Bayley Scales of Infant Development and Vineland Adaptive Behavior Scales, and mothers completed the Vulnerable Child Scale, a 16-item self-report measure of PPCV. Chart review was performed to determine the presence or absence of specific indicators of medical vulnerability at 1-year adjusted age.

Results. Mean infant gestational age and birth weight were 26.52.5 weeks and 894287 g. A total of 69% of mothers were white, and 78% were high school gradu-ates. Higher PPCV (lower Vulnerable Child Scale score) was correlated with lower scores on the Vineland Adap-tive Behavior Composite and Bayley Psychomotor Devel-opmental Index but not on the Bayley Mental Develop-mental Index. After controlling for the presence of 1 or more indicators of medical vulnerability, higher PPCV was still correlated with lower adaptive development. This correlation was stronger in the group of children with no indicators of medical vulnerability. In univariate analyses, higher PPCV was predicted by nonfirstborn status; longer neonatal hospitalization; higher maternal anxiety and depression; greater impact of the illness on the family; and lower maternal optimism, life satisfac-tion, and social support. PPCV was not associated with maternal age, education, marital status, income, or eth-nicity or with child gender, gestational age, birth weight, or length of mechanical ventilation. A linear regression model containing all variables significant at the univar-iate level explained 29% of the variance in PPCV.

Mater-nal anxiety was the only variable that was statistically significant in the full model.

Conclusions. Higher PPCV is associated with worse developmental outcome in premature infants at 1-year adjusted age. Maternal anxiety at neonatal discharge pre-dicts later high PPCV. Interventions to prevent or de-crease PPCV in premature infants should be targeted at parents who are more anxious at hospital discharge. Pe-diatrics2004;113:267–273;vulnerable child syndrome, pa-rental perceptions, vulnerability, prematurity.

ABBREVIATIONS. PPCV, parental perception of child vulnerabil-ity; VCS, Vulnerable Child Scale; ABC, Adaptive Behavior Com-posite; MDI, Mental Developmental Index; PDI, Psychomotor De-velopmental Index.


hildren who are perceived by their parents as vulnerable have an increased risk of behavior problems, difficult parent– child interac-tions,1–3and disproportionately high health care

uti-lization.4 – 6 In their original description of the

vul-nerable child syndrome, Green and Solnit7

recognized that children who experience an acute, potentially life-threatening illness early in life may be perceived by their parents as being medically vul-nerable long after they have fully recovered. This heightened parental perception of child vulnerability (PPCV) was hypothesized to have long-term nega-tive effects on the parent– child relationship, leading to problems with separation, discipline, academic underachievement, and excessive health concerns. Thomasgard and Metz8 defined PPCV as “an

in-creased parental perception of child vulnerability to illness or injury, secondary to separation or loss, which is either real or feared.” Children whose moth-ers view them as vulnerable are more likely than their peers to be rated by their mother as having somatic problems, social withdrawal, and behavior problems.1–3,9Mothers who see their children as

vul-nerable feel less competent at parenting and less in control of their children’s behavior.1They also

iden-tify their children as less developmentally competent than do medical providers or objective measure-ments of cognitive development.1High PPCV is

as-sociated with increased use of health care resources, including more frequent sick, well-child, and emer-gency department visits.2,4,5,9 –11

Parents of premature infants often perceive their infants as medically vulnerable, even after their health improves.1,3,12 Among the recognized

ante-cedents of high PPCV,7,8,13,14premature birth is par-From the Departments of *Pediatrics and ‡Public Health Sciences, Wake

Forest University School of Medicine, Winston-Salem, North Carolina. Received for publication Sep 16, 2002; accepted Jun 4, 2003.

Reprint requests to (E.C.A.) Wake Forest University School of Medicine, Department of Pediatrics, 3325 Silas Creek Pkwy, Winston-Salem, NC 27103. E-mail: eallen@wfubmc.edu


ticularly important because of the dramatic increase in the survival rates of premature infants over the past decade.15Premature infants often have multiple

risk factors for high PPCV: pregnancy complica-tions,16 maternal depression,16 jaundice,4 feeding

and crying behavior,9and/or parental worry that the

child might die.2,9,13 Parents of sick premature

in-fants are faced with the possibility of serious mor-bidity and/or mortality of their infants. Therefore, it is not surprising that 64% of preschoolers who were born prematurely are still perceived by their mother as vulnerable.1

If parents of premature infants who are more likely to develop high PPCV could be identified dur-ing the first months of a child’s life— before PPCV has developed—then interventions could be targeted toward their parents to prevent PPCV. Health care providers could help parents to develop more real-istic expectations about their infants’ recovery and stress the need for the parents to treat their prema-ture infants as normally as possible.7Parents could

also be given information about supportive counsel-ing, parent support groups, and/or mentoring by experienced parents. These interventions might de-crease the child behavior problems, parent– child in-teraction problems, and unnecessary health care uti-lization attributable to high PPCV.

Because most previous studies of PPCV have used cross-sectional designs, they have not been able to examine temporal relationships between risk factors and high PPCV. Studies of PPCV in premature in-fants have involved small samples.1,3,17Little

atten-tion has been paid to the effects of maternal psycho-social factors on the later development of PPCV.8

Finally, the few studies that have assessed the rela-tionship between PPCV and development or mater-nal perception of development have not assessed adaptive or motor development.1,18 This study

ad-dresses these issues.

The study had 2 objectives: 1) to determine whether higher PPCV is correlated with worse de-velopmental outcome in premature infants at 1-year adjusted age and 2) to identify demographic, neona-tal illness severity, and maternal psychosocial fac-tors, present at neonatal discharge, that predict high PPCV.

METHODS Subjects

This prospective cohort study was part of a larger randomized clinical trial assessing outcomes of premature infants who were randomized to receive either community-based or center-based care after neonatal discharge. Infants were eligible for the study when they were born atⱕ32 weeks, had chronic lung disease (defined as the need for supplemental oxygen at 36 weeks post-menstrual age), and were admitted to 1 of 5 intensive care nurs-eries in northwest North Carolina. Infants were excluded when they had a congenital lung or brain malformation, a tracheostomy, or a mother who did not speak English or who lived⬎150 miles away. Study infants were born between March 30, 1996, and March 17, 1998. The study was approved by the Institutional Review Board of Wake Forest University School of Medicine.

Of 164 families consecutively approached about the random-ized clinical trial, 150 (92%) agreed to participate in the study. A total of 146 children survived to 1-year adjusted age, and of these, 116 (79%) mothers completed questionnaires from which data for

this study were derived. Participants and eligible nonparticipants did not differ on maternal and child demographic characteristics or indicators of neonatal illness severity. No differences were found between mothers of infants who were randomized to com-munity-based and center-based follow-up in the larger trial on demographic factors, indicators of neonatal illness severity, ma-ternal psychosocial factors, or parental perception of child vulner-ability. Therefore, the 2 groups were combined for all analyses.


Demographic and medical data about the infant (gender, birth weight, gestational age, length of mechanical ventilation, length of neonatal hospitalization, and medical complications) were col-lected by reviewing medical records. Demographic and psycho-social data about the mother (maternal age, marital status, ethnic-ity, education, anxiety, depression, optimism, life satisfaction, and social support) and the family (number of siblings, family income, and impact of the illness on the family) were collected using questionnaires completed by the mother in the week before dis-charge from the intensive care nursery. At 1-year adjusted age (adjusted for prematurity), maternal perception of child vulnera-bility and infant developmental outcomes were assessed in the Intensive Care Nursery Follow-up Clinic. Chart review was per-formed to determine the presence or absence of specific indicators of medical vulnerability at 1-year adjusted age.


Maternal perception of child vulnerability was assessed using the Vulnerable Child Scale (VCS),3a 16-item measure that asks

parents to respond to statements about their child’s health on a 4-point scale. Each item is scored from 1 (“definitely true”) to 4 (“definitely false”). Lower scores indicate greater perception of vulnerability. Sample items include, “I feel anxious about leaving my child with a babysitter or at day care,” and, “I sometimes worry that my child will die.” The VCS has good internal reliabil-ity (Cronbach’s␣⫽.75). The scale has excellent test-retest reliabil-ity, both between telephone and mailed administrations (r⫽.95) and 2 telephone administrations (r⫽.96). The validity of the VCS is supported by its significant correlation with scores on the ternalization Somatic Symptoms subscale of the Personality In-ventory for Children.3 The content of the VCS is relevant to

parents of both infants and preschoolers. Since its original stan-dardization on parents of preschoolers, reliable results have been obtained using the VCS with parents of infants as young as 3 months of age.19Our study shows that the VCS has good internal

reliability in parents of children at 1-year adjusted age (Cronbach’s ␣⫽.82).

Maternal state anxiety was measured with the Spielberger State Anxiety Inventory, Form Y-1.20Subjects are given 20 brief

state-ments and asked to rate the intensity of their feelings of anxiety “right now/at this moment” on a 4-point scale, from “not at all” to “very much so.” Typical items include, “I feel upset,” and, “I am relaxed.” Higher scores indicate greater state anxiety. The scale has good construct validity, discriminating adults with general-ized anxiety disorder.20

Maternal depressive symptoms were assessed with the Beck Depression Inventory,21a 20-item measure, for which Cronbach’s

␣has been .73 to .92 and test-retest reliability has ranged from .48 to .86. Each of the 21 items is scored from 0 to 3, with higher scores reflecting more depressive symptoms. The measure correlates well with clinical ratings22and the Hamilton Psychiatric Rating

Scale for Depression.23

Maternal optimism was measured using the Life Orientation Test, a scale measuring dispositional optimism.24This measure

consists of 8 items and 4 filler items, scored from 0 (“strongly disagree”) to 4 (“strongly agree”), with higher scores indicating higher optimism. Sample items include, “I always look on the bright side of things,” and, “If something can go wrong for me, it will.” The Life Orientation Test has adequate internal consistency (Cronbach’s␣⫽.76) and good test-retest reliability of .79. It also has adequate convergent validity, with factors that are distinct from conceptually similar variables measured by other scales.24

Maternal life satisfaction was measured using the first item of the General Health Survey.25This item, known as the “Ladder of


Maternal social support was measured with the social support survey developed for the Medical Outcomes Study.26This 19-item,

self-report measure assesses the availability of 4 dimensions of social support: emotional/information, tangible, affectionate, and positive social interaction. Items are scored from 1 (“none of the time”) to 5 (“all of the time”). Sample items include “someone who understands your problems” and “someone who shows you love and affection.” Item scores are averaged and then transformed to yield total scores ranging from 1 to 100, with higher scores reflect-ing greater availability of social support. The measure has excel-lent internal reliability, with a Cronbach’s␣of .97. Its construct validity is evident in its high correlation with a measure of lone-liness (r⫽ ⫺.67) and low correlation with a measure of physical functioning (r⫽.11).26

Impact of the illness on the family was assessed with the Impact on Family Scale,27which measures the impact on 4 components of

family life: the financial situation, social interaction, subjective distress experienced by the parent, and a positive sense of mastery of the situation (Financial, Familial/Social, Personal Strain, and Mastery). Each of 24 brief statements is scored from 1 (“strongly agree”) to 4 (“strongly disagree”), with higher scores reflecting less perceived impact on the family. Sample items include, “The illness is causing financial problems for the family,” and, “We see family and friends less because of the illness.” The scale has good internal reliability, with a Cronbach’s ␣ of .88.27 Its construct

validity is apparent in its correlations with medical and psycho-logical variables in children with different health conditions.28,29

To focus on the impact on the family, rather than the family’s coping strategies, we excluded the 5 mastery items and summed the other 19 items.29

Child adaptive development was measured using the Vineland Adaptive Behavior Scales.30 For this scale, a trained examiner

interviewed a parent at the child’s visit at 1-year adjusted age. The scale assesses 4 domains of adaptive development: communica-tion, daily living skills, socializacommunica-tion, and motor skills. Item scores indicate whether the child performs an activity “yes, usually” (2), “sometimes or partially” (1), or “no, never” (0). The overall Adap-tive Behavior Composite (ABC) is a standard score based on the child’s age, with higher scores representing better adaptive func-tioning. Interrater, test-retest, and split-half reliabilities range from 0.62 to 0.99.30

The Bayley Scales of Infant Development31were used to assess

child cognitive and motor development, reported as Mental De-velopmental Index (MDI) and Psychomotor DeDe-velopmental Index (PDI), respectively. Both the MDI and the PDI are standard scores, with higher scores reflecting higher cognitive and motor skills. In this study, we report ABC, MDI, and PDI scores for the child’s adjusted age (adjusted for prematurity). The Bayley Scales were standardized on a sample of 1700 children. Internal consistency reliability coefficients range from 0.78 to 0.93 for the Mental Scale and from 0.79 to 0.91 for the Motor Scale. Repeated measures reliability (after 1–16 days) ranged from 0.87 for the Mental Scale to 0.78 for the Motor Scale. Acceptable convergent and divergent validity of the Bayley Scales was determined in a study of at-risk children.31

For this study, we regarded infants as having objective indica-tors of medical vulnerability when they had 1 or more of the following at 1-year adjusted age: weight/length⬍5th percentile, tube feeding, home oxygen, tracheostomy, cerebral palsy, severe visual impairment (involvement with a school for the blind), severe hearing impairment (use of hearing aids), ventriculoperi-toneal shunt, or anticonvulsant use.

Statistical Analysis

Descriptive statistics were calculated on all measures to deter-mine the characteristics of the sample, check normality assump-tions, and ensure adequate variability. Univariate analyses were performed usingt tests for dichotomous variables, analyses of variance for polychotomous variables, and linear regression anal-yses for continuous variables.

Linear regression analysis was used to assess the relationship between VCS score and all of the demographic, neonatal illness severity, and maternal psychosocial variables, known at neonatal discharge, that were significant at the univariate level. Variables were entered simultaneously into the model. Linear regression analyses were used to determine the relationships between VCS score and child development outcome variables, first

indepen-dently and then while controlling for the presence of 1 or more objective indicators of medical vulnerability (listed above). All analyses were performed using SAS for Windows, version 8.

RESULTS Descriptive Statistics

Maternal and child demographic characteristics of the sample, indicators of neonatal illness severity, and indicators of medical vulnerability are shown in Tables 1, 2, and 3, respectively. In the entire sample of 116 mothers of premature infants with chronic lung disease, the mean score on the VCS was 48.6, with a standard deviation of 6.9, median score of 48.0, and range of 29 to 64. Children with at least 1 objective indicator of medical vulnerability at 1-year adjusted age were perceived by their mothers as being more vulnerable (lower mean VCS score) than were children with no indicators of medical vulner-ability (46.5⫾5.7 vs 49.6⫾7.2, respectively;P⬍.02).

Association Between PPCV and Child Developmental Outcome

For the entire sample, mean scores (ranges) for the MDI, PDI, and ABC were 88 (50 –137), 81 (50 –139), and 100 (66 –122), respectively. In univariate analy-ses, higher perceived vulnerability (lower VCS score) was significantly correlated with lower scores for adaptive development (Vineland ABC;P⫽.002) and motor development (Bayley PDI; P ⫽ .02) but not mental development (Bayley MDI; P ⫽ .08). After adjusting for the presence of 1 or more indicators of medical vulnerability, higher PPCV remained signif-icantly correlated with lower adaptive development (P⫽.03) but not with mental or motor development. Children with 1 or more indicators of medical vulnerability at 1-year adjusted age had lower adap-tive development (mean Vineland ABC score) than did children with no indicators of medical vulnera-bility (96⫾12.4 vs 102⫾8.5, respectively;P⫽.009). Because medical conditions, such as cerebral palsy, visual impairment, and growth delay, may worsen adaptive development, we performed a subset anal-ysis in which we eliminated the children who had 1 or more indicators of medical vulnerability. In the remaining 78 children, who had no objective indica-tors of medical vulnerability at 1-year adjusted age, higher perceived vulnerability (lower VCS score) was strongly correlated with worse adaptive devel-opment (lower Vineland ABC score; r ⫽ .31; P ⫽ .006).

Predictors of PPCV


child gender) or neonatal illness severity factors (ges-tational age, birth weight, or length of mechanical ventilation).

A linear regression analysis was used to assess the relationship between PPCV and all of the variables that were significant at the univariate level (firstborn status; length of hospitalization; and maternal anxi-ety, depression, optimism, life satisfaction, social support, and perceived impact of the illness on the family). The regression model containing these

vari-ables explained 29% of the variance in PPCV (P ⫽ .0003). Maternal anxiety was the only variable that was statistically significant in the full model (P ⫽ .009).


This study suggests that higher maternal percep-tion of child vulnerability is correlated with worse developmental outcome in premature infants with chronic lung disease at 1-year adjusted age. In uni-variate analyses, higher PPCV was associated with lower adaptive and motor functioning but not with lower cognitive functioning. After controlling for medical vulnerability, the negative association be-tween PPCV and adaptive functioning remained sig-nificant, consistent with previous research showing that parents who perceive their children as more vulnerable also tend to perceive them as developing more slowly.18The anxiety caused by the threatened

loss of a child may permanently change the way a parent perceives and interacts with a child.6Parents

may tend to shelter children whom they see as vul-nerable, providing fewer opportunities for them to gain independence in activities of daily living. In this TABLE 1. Descriptive Statistics and Univariate Relationships Between Demographic Factors and

VCS Score

Characteristic n* % Mean VCS† Score (SD) P

Maternal education .38

⬍High school graduate 25 22 48.6 (7.5)

High school graduate 36 31 49.4 (5.2)

⬎High school graduate 54 47 48.0 (7.7)

Maternal marital status .58

Married or living with partner 72 62 49.0 (6.6)

Other 44 38 47.9 (7.4)

Maternal ethnicity .86

White 80 69 48.6 (6.7)

Other§ 36 31 48.8 (7.3)

Family income .43

⬍$20 000/y 43 39 47.5 (7.2)

$20 000–49 999/y 50 45 49.3 (6.7)

ⱖ$50 000/y 18 16 49.5 (7.3)

Child birth order .002

Firstborn 63 54 50.4 (6.5)

Other 53 46 46.4 (6.8)

Child gender .21

Male 71 61 46.3 (7.1)

Female 45 39 47.7 (6.5)

SD indicates standard deviation.

* Because not all mothers responded to each item on the questionnaire, the frequencies do not always sum to 116.

† Lower scores indicate increased perceived vulnerability.

Pvalues are forttests for dichotomous variables and analyses of variance for variables with⬎2 categories.

§ Thirty-four mothers were black, 1 was Asian/Pacific Islander, and 1 was Hispanic.

TABLE 2. Descriptive Statistics and Univariate Correlations Between Neonatal Illness Severity Factors and Maternal Age and VCS Score

Measure Mean (SD) Range ␤*

Birth weight, g 894 (287) 460–1910 .002

Gestational age, wks 26.5 (2.46) 22–32 .12

Length of mechanical ventilation, days 30.2 (26.64) 1–158 .006 Length of neonatal hospitalization, days 92.1 (29.68) 42–224 ⫺.04†

Maternal age, y 26.9 (5.32) 16–39 .04

SD indicates standard deviation.

* Values for␤derived from univariate linear regression with VCS score as the dependent variable. †P⫽.04. All otherP⬎.05.

TABLE 3. Indicators of Child Medical Vulnerability at 1-Year Adjusted Age

Indicator of Medical Vulnerability n %

Weight/length⬍5th percentile 18 16

Tube feeding 3 3

Home oxygen 8 7

Tracheostomy 1 1

Definite cerebral palsy 5 4

Severe visual impairment 6 5

Severe hearing impairment 4 3

Ventriculoperitoneal shunt 5 4

Anticonvulsant use 1 1


study, the negative association between PPCV and motor development can be reasonably attributed to greater severity of medical illness among children with higher PPCV. Child adaptive development, measured by parent report, is inherently more strongly influenced by parental perceptions than is cognitive development, measured objectively. This may explain why we found no significant association between PPCV and cognitive development. In a study of premature infants at 3 years of age, Estroff et al1also found no relationship between PPCV and

an objective measure of cognitive development, al-though mothers who saw their children as vulnera-ble identified them as less developmentally compe-tent.

Our study also suggests that maternal anxiety and other factors identifiable at neonatal discharge pre-dict maternal perception of child vulnerability at 1-year adjusted age. Mothers who saw their children as vulnerable had more anxiety and depression; less optimism, life satisfaction, and social support; and a greater perceived impact of the illness on the family. Children who were not firstborn and who had longer neonatal hospitalizations were seen as more vulner-able.

Maternal anxiety at neonatal discharge was the strongest predictor of PPCV at 1-year adjusted age in our study. Mothers of very low birth weight infants with chronic lung disease have been shown to report more anxiety than mothers of term infants.32

Moth-ers of premature infants are also more likely to be anxious about leaving their child with a babysitter.13

Our study extends these findings by showing that maternal anxiety is associated with increased PPCV in mothers of premature infants. Mothers who are more anxious may be more likely to perceive their premature infants as medically vulnerable.

We found that higher PPCV is associated not only with higher maternal anxiety but also with higher maternal depression and lower maternal life satisfac-tion, consistent with reported associations between higher PPCV and both postpartum depression16and

lower maternal well-being.3Higher PPCV may also

explain a previous observation that mothers of pre-mature infants with low social support leave their infants less frequently and for shorter periods.33

Higher PPCV was associated also with greater im-pact of the illness on the family. Mothers of very low birth weight infants with chronic lung disease report greater impact on the family, even at 3 years, than mothers of term infants.32 Greater impact on the

family has also been shown to be associated with

lower adaptive functioning,34 poorer perceived

health, and increased health care utilization35in very

low birth weight infants. Mothers who are experienc-ing a greater impact of the illness on their family may see their infants as more vulnerable and, in turn, seek more medical services for infants whom they per-ceive as having poorer health and development.

Higher PPCV among premature infants at 1-year adjusted age was associated with longer neonatal hospitalization but not with gestational age, birth weight, or length of mechanical ventilation. This sug-gests that length of neonatal hospitalization, which was closely correlated with gestational age, birth weight, and length of mechanical ventilation in our study, is probably much more salient to parents than other indicators of neonatal illness severity, which it summarizes. The association between higher PPCV and longer neonatal hospitalization is a new finding, which is consistent with a previous report of higher PPCV in sick, premature infants than in healthy, term infants.3Like Estroff et al,1we found that PPCV

was not associated with birth weight or gestational age. We attribute this, at least in part, to the relatively narrow range of birth weight and gestational age in our sample. It is possible that the homogeneity of our sample of very low gestational age premature infants with chronic lung disease obscured the negative as-sociation between PPCV and birth weight previously reported by others.3,12,16

Contrary to our expectation, we found that prema-ture infants who were not firstborn were perceived as more vulnerable than firstborn children. It is pos-sible that mothers with healthy children at home may see their premature infant’s illness as more threatening than do mothers with less basis for com-parison. Other studies of PPCV in premature infants have found either that firstborn children were per-ceived as more vulnerable than nonfirstborn chil-dren12 or that birth order was not associated with


We found no association between PPCV and other demographic variables (maternal age, marital status, ethnicity, and education; family income; and child gender). Previous studies analyzing the relationship between PPCV and demographic factors have yielded conflicting results. A study of PPCV in pre-mature infants documented no association between PPCV and maternal age, race, or socioeconomic sta-tus.1 Studies conducted in pediatric office settings

have found that higher PPCV is associated with younger parental age,9,11 unmarried marital

sta-tus,9,16,36 and lower family income.9,16 Previous

re-TABLE 4. Univariate Correlations Between Maternal Psychosocial Factors and VCS Score

Measure Mean Score (SD) Range ␤

Spielberger State Anxiety 43.2 (13.1) 20–80 ⫺.20†

Beck Depression Inventory 9.7 (7.8) 0–43 ⫺.29†

Impact on Family Scale 45.6 (8.7) 23–69 .19*

Life Orientation Test (optimism) 18.8 (5.7) 5–32 .37*

Ladder of Life (life satisfaction) 6.4 (1.7) 1–9 1.15*

MOS Social Support 75.0 (21.4) 5–100 .08*

SD indicates standard deviation; MOS, Medical Outcomes Study. *P⬍.01.


search has shown a negative association,16,36 no

as-sociation,9 or a positive association3,12 between

PPCV and maternal education. In our study, the severity of the child’s illness and the maternal psy-chosocial response to the illness eclipsed any minor differences in PPCV attributable to demographic fac-tors.

As expected, children who had objective evidence of medical vulnerability at 1-year adjusted age (weight/length⬍5th percentile, tube feeding, home oxygen, tracheostomy, cerebral palsy, severe visual impairment, severe hearing impairment, ventriculo-peritoneal shunt, and/or anticonvulsant use) were perceived by their parents as being more vulnerable than children who had none of these indicators. Clearly, objective evidence of continued medical vul-nerability contributes to higher parental perception of child vulnerability in premature infants at 1-year adjusted age. The mean VCS scores of both our med-ically vulnerable and medmed-ically healthy premature infants (46.5 and 49.6) were lower than those of the 3-year-old formerly sick premature and healthy term infants (52.1 and 55.5, respectively) described by Perrin et al.3The fact that the premature infants with

chronic lung disease in our study were perceived by their mothers as more vulnerable at 1-year adjusted age than Perrin’s formerly sick premature infants at 3 years of age suggests that PPCV may decrease over time as children’s health improves and their parents become more confident in caring for them.

Several limitations of this study should be noted. First, all of our subjects were very low gestational age infants with chronic lung disease, limiting the extent to which our findings can be generalized to other groups of infants. Second, we did not include a control group of either term or healthier premature infants, so no inferences can be drawn about the association between prematurity and PPCV. Third, the relative homogeneity of our sample with regard to severity of illness may have masked relationships between PPCV and other variables. Fourth, we as-sessed developmental outcome at a relatively early age. Despite these limitations, our study should be of interest to professionals who care for families of chronically ill premature infants. Future research should involve longer follow-up of a larger, more diverse sample of infants and include a comparison group of healthier premature infants and/or term infants.


This study suggests that higher parental percep-tion of child vulnerability is correlated with worse developmental outcome in premature infants at 1-year adjusted age. Maternal anxiety at neonatal discharge predicts subsequent high PPCV. These findings have implications for the care of sick pre-mature infants, who are already at increased risk for adverse developmental outcome and high health care utilization. The portion of that risk that is attrib-utable to PPCV can potentially be modified in the first year of life. Interventions to prevent or reduce PPCV should be targeted toward more anxious par-ents, who can be identified using a brief,

self-admin-istered measure of anxiety. By decreasing anxious parents’ perception of child vulnerability, these in-terventions may prevent unnecessary health care uti-lization and improve developmental outcome in pre-mature infants.


This study was supported by grant R01 HS07928 from the Agency for Healthcare Research and Quality.

We thank Debbie Hiatt and Dr Robert Dillard for clinical care of the children and families described here and Drs Kurt Klinepeter and Virginia Nichols, who helped us to develop the list of indi-cators of medical vulnerability.


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“Once a population has a large number of people who are immune, the key question becomes: If the microbe finds a susceptible person in the mixed popula-tion, how many additional people is that victim likely to infect? . . . That number is called the ‘effective reproductive number.’ When it is⬍1, an outbreak will disap-pear spontaneously because the victims in each round of infection will not ‘replace’ themselves with new victims. However, if the number is ⬎1, the outbreak will sustain itself or grow. . . . In England’s recent measles outbreaks, the ‘effective reproductive number’ has been rising—a very ominous sign. . . . In the outbreaks from 1955 to 1998, the number was 0.47. For those from 1999 to 2002, it was 0.82. . . . If it reaches 1, measles will be able to find enough new victims to keep the infection moving through the population—at least until something is done to raise the percentage of people who are immune. Herd immunity will be gone.”

Jansen YAA.Washington Post Weekly. September 29 –October 5, 2003


DOI: 10.1542/peds.113.2.267



Pivor and T. Michael O'Shea

Elizabeth C. Allen, Janeen C. Manuel, Claudine Legault, Michelle J. Naughton, Carol

Perception of Child Vulnerability Among Mothers of Former Premature Infants


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DOI: 10.1542/peds.113.2.267



Pivor and T. Michael O'Shea

Elizabeth C. Allen, Janeen C. Manuel, Claudine Legault, Michelle J. Naughton, Carol

Perception of Child Vulnerability Among Mothers of Former Premature Infants


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TABLE 3.Indicators of Child Medical Vulnerability at 1-YearAdjusted Age
TABLE 4.Univariate Correlations Between Maternal Psychosocial Factors and VCS Score


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