Tài liệu tâm lý học sức khỏe: Tâm lý học sức khỏe trẻ em

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 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: Establishing relationships with medical personnel (Moos, 1977) Coping with medical procedures associated with treatment Coping with symptoms associated with the condition (whether it is acute or chronic) (Moos, 1977) Coping with the possible separation from parents, other family members, and friends Coping with the new social pressures such as being labeled as “ill” or having a medical problem 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) Stress of missing school and acclimating during the return to school 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 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 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 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 The highest incidence of asthma seems to be from birth to age 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 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 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 to 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 month and 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 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 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 to 10 minutes to complete The children should 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 to 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 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 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 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 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  ... phase stressors are physical and social isolation, adjustment to society, the patient's appearance, medical procedures, hospitalization, returning to school, treatmentrelated side effects, extreme... 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... 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