Actu Pzdiatr Scund 68: 531-539. 1979

SOCIAL BACKGROUND AND LIFE EVENTS OF CHILDREN ADMITTED TO A PAEDIATRIC DEPARTMENT J. AAGAARD From the Deparimeni of Paediatrics, Randers Centralsygehus, Randers, and the Institute of Social Medicine, University of Aarhus, Aarhus, Denmarh

ABSTRACT. Aagaard, J. (Department of Paediatrics, Randers Centralsygehus, Denmark, and Institute of Social Medicine, University of Aarhus, Denmark). Social background and life events of children admitted to a paediatric department. Acta Paediatr Scand, 68: 531, 1979.-During a period of one year a questionnaire was filled in by parents of children who were more than one year old and admitted to the paediatric department in Randers, Denmark. The questionnaire was especially concerned with factors describing the social background of the family and with selected life events. Family background variables such as low level of parents’ education and low income were found to be associated with psychosomatic and psychic diseases of the children. No associations between these negative family hackground variables and respiratory tract infections were found. The data show a strikingly high frequency of selected life events. Noticeable intercorrelations were found between social factors, life events, and diagnostic groups. In the light of this, it was not considered meaningful to analyze life events independently of the family background variables. A combined measurement for family background variables and selected life events was strongly associated with psychosomatic and psychic diseases. The additional information due to life events over the information due to family background variables was pronounced. It was remarkable that stressful life events also were frequent among children with some somatic diseases. The inference of these results is a plea for application of analysis of individual social history to more hospitalized children. The results might further have implications for preventive work with respect to the changes which seem to have taken place in important social conditions.

KEY WORDS: Social paediatrics, life events, hospital admission

Many investigations have dealt with social background factors for children admitted to hospital (1 1 , 14). The reported investigations are, however, criticizable from a methodological point of view. One usually notes especially, that only more stable social variables are taken into account, and there is no attempt to evaluate the relative significance of the elements in the social history of the child. It has been shown in some investigations, that many children in a paediatric department have prior psychic deviating development and/ or emotional disturbances (9, 13). Thus, Apley & McKeith (1) have emphasized, that various organic symptoms often have a psychic background. In addition to this aspect there seems in some cases to be a connection between earlier

diseases, deviating development, and later symptoms in pedagogic, social, or health areas (3). It must, however, be stressed, that information dealing with prediction of later illness or impaired development from essential elements in the social history is only available for certain diagnoses (10, 12).

Purpose and definitions In this part of the investigation the purpose was to estimate the relative significance of social background factors and life events for certain diagnostic groups of children admitted to the department. By social .fuctors is meant relatively stable aspects of the parents’ situation such as level of education, income, social status, and residence. A ( f i t l’uvdiolr S ( ( i i i 0 bH

532

J . Aagaard

By life events is meant social events such as divorce, unemployment, and changes in interpersonal relationships.

METHOD The investigation consisted of questionnaires filled in by parents of children admitted to the paediatric department or admitted to the surgical department for herniotomy. The hospital receives children from a geographically relatively well-defined area. There is no paediatric outpatients’ clinic in the area. There is no social selection for admission to hospital. Prior to this investigation a pilot study was undertaken and published (15, 16). The questionnaire dealt with relatively stable social background variables and changes in the circumstances of life which had occurred during the year prior to admission. A slightly modified edition of Coddington’s life event list was used (4, 5 ) . A critical evaluation of Coddington’s life eventllife-change-unit (LCU) method has bee7 published earlier (17). The questionnaires were distributed by the head-nurse of the department. The procedure followed was in accordance with the demands of the Helsinki-11-Declaration (8). For the non-response group selected social variables were obtained from the medical record. For all patients diagnosis, admission type, and duration of stay were recorded. The validity of each diagnosis was confirmed by the chief physician of the department. The main diagnoses were aggregated in diagnostic groups. The group respiratory tract infections consisted of 38 preschool children (age 1-6) of whom 25 had lower and 13 had upper respiratory tract infections; and 9 elementary school children (age 7-14) of whom 7 had lower and 2 had upper respiratory tract infections. The group of infections outside the respiratory tract consisted of 31 preschool children of whom 8 had gastroenteritis and 1 1 had urinary tract infections; and 16 elementary school children of whom 5 had infections of the urinary tract and 5 had meningitislsepsis. The group psychosomatic and psychic diseases consisted of 20 preschool children of whom 7 had enuresis and 6 encopresis; and 35 elementary school children of whom 13 had abdominal colic, 12 had enuresis, and 6 had infantile neurosis. The group “other diseases” consisted of 139 preschool children of whom 5 had a diagnosis of accidental drug poisoning, 12 had other forms of poisoning, 12 had various symptoms from the gastrointestinal tract, 30 had febrile convulsions, and 9 had epilepsy; and 67 elementary school children of whom 9 had epilepsy, 10 had asthma bronchiale, 5 were admitted for herniotomy, and 5 had diabetes mellitus. The reliability of the information given in the questionnaire was judged by comparing this information with the analogous data from the medical record. Social background variables showed a great deal of agreement between the record data and questionnaire data. The reliability of the information concerning life events could not be estimated, as the majority of records was incomplete on this point.

Statisticul procrdlrres The material was processed at the Regional EDP-Center University of Aarhus (RECAU). The program for appropriate scoring was written by Professor Johs. Ipsen. A further description of the statistical procedures is published elsewhere (17). By a profile of a diagnostic group is meant the array of normalized mean for the independent variables. The variables used in this investigation were all dichotomized. The normalized means are random variates of a normal distribution with mean equal to zero and unit standard error. Combined variables were computed. These variables were the sum of selected profile elements multiplied by the appropriate coefficient for the individual element. The appropriate coefficients were calculated by a process, which corrected for intercorrelations between the independent variables. The combined measurements might in this connection be understood as a weighted index, which takes negative social factors and selected life events into account.

MATERIAL The patient group consisted of all children over one year of age, who were admitted in the period Oct. 1st 1976Sept. 30th 1977. Excluded from participation in the investigation were: I ) Children of foreign language speaking parents. 2) Institutionalized children. 3) Children transferred to another hospital within the first day after admission. 4) Children who were readmitted during the period of investigation. 5 ) Children who stayed in hospital less than 24 hours. 6) Children who had participated in the pilot study (16). In the period of investigation 482 children were admitted and 22 (4.6%) were excluded. The occupational group distribution of the fathers of the children corresponded to that of men in the same age group in the population of the area (6). Five ( I . 1 %) of the children’s parents did not want to participate in the investigation. 455 questionnaires were distributed, 375 (82.4%) of these were returned. 14 (3.7%) of the returned questionnaires were incompletely filled in. Family background variables did not differ significantly between response and non-response groups. Of the response group’s 361 patients, 187 were boys and 174 were girls. The average age was 5.3 years (S.D.= 3.8). The average stay in hospital was 6.9 days (S.D.= 4.6). 228‘(63.2%) of the children were at preschool age, 127 (35.2%) were at elementary school age, and 6 (1.6%) were older. As the significance of life events among other things is age dependent ( 3 ,the children over 14 years of age were excluded from the following analysis. The reduced study population then consisted of 355 patients.

RESULTS Diagnostic groups by social factors The children’s main diagnoses at time of discharge from hospital are in Tables 1 and 2 reduced to three groups and a remainder group.

Children admitted t o a paediatric department

533

Table 1. Diagnostic group by the parents’ education Parents’ education

Respiratory tract infections

Father’s school education ~9 years 21 >9 years 19 Not statedhot relevant 7

Total

47 (13.2)

Infections outside respiratory tracts

Psychosomatic and psychic diseases

Other diseases

Total number, per cent

X’-test (corrected)

32

44 2

135 54

232 (65.4) 85 (23.9)

xz=21.0 d:f. =3

38 (10.7)

p I year 26 Not stated 1 Total 47 (13.2)

10

5

1

47 (13.2)

17

82 3 206 (58.0)

204 (57.5) 144 (40.6) 7 (1.9) 355 (100.0)

x2=21.7 d.f. =3

p0.05

206 (58.0)

37 (10.4) 316 (89.0) 2 (0.6) 355 (100.0)

49 153 4

100 (28.2) 248 (69.9) 7 (1.9)

x2=17.2 d.f. =3 p0.05

Among elementary school children the anal- vorce or separation of parents during the year ogous percentages were 15.7 and 16.5. The prior to admission. 17.7% of the children had reasons for hospitalization of relatives were o r had had a single supporter. Remarkably not explored. high frequencies of increased interpersonal Among the preschool children, five (2.2%) conflicts were found. 12 % reported “increase had experienced death in the near family. in number of arguments between parents”. Among elementary school children only one Among preschool children the percentage of had lost a parent by death. “increase in number of arguments with parents Many of those life events, which were re- o r with peers” was 5 , the analogous percentlated to the parents’ occupation, also had a ages for elementary school children were 14.2 relatively high frequency. Among wage earn- and 26.5. ers with preschool children 14.9% of the fathers and 19.5% of the mothers had been unemployed in the year prior to admission of Correlations between selected social the child. For 4-8 % of the children there was factors, life events, and diagnostic groups information concerning the parents’ increased As expected, there were positive intercorreabsence from home due to work. Remarkably lations between the parents’ school education, many mothers of preschool children (15.5%) occupational education and income. Lower inhad started working during the year prior to come was among other things correlated to admission. Changes in the parents’ financial increased conflicts with and between parents status were as frequent as 30% among the and to increased conflict with peers. There parents of preschool children, and 20 % of the were also positive correlations between lower parents of elementary school children stated income and broken home, hospitalization of parents and changes in parents’ financial stachange in financial status. 6.6 % of preschool children and 3.9 % of ele- tus. Unemployment of fathers was positively mentary school children had experienced di- correlated with broken home and lower inActcr Poedicrtr Sccrtid 6R

Lriildren admitted to a paediatric department

Family background variables.

Respiratory tract infections -2

0

t2

Infections outside respiratory tract -2

0

Psychosomatic and psychlc diseases -2

t2

0

t2

Other diseases

p T2

;2

I ----LA _ ( 1 , I I

School education: Father‘s 5 9 years Mother’s 5 9 years Occupational education:

I

a

* l I

Mother’s 5 year

1

**

Crowded Income:

< -

60,000 Dkr.

Combined measurement of family background variables Combined measurements of family background variables and life events ______----___-

b

9

I

d

4

4

I

I I

I

Not married

Residence:

p *d

4.0

3.1*

7.8

6.2**

6.0

4.8**

4.3

3.4’

5.3

4.2**

1.8

1.4

0.6

0.4

7.3

5.8**

11.7

9.9**

I

1

No siblings

I

I I I I

I

Father’s 5 year

Number of siblings:

Information per cent F

I

**

Marital status:

535

1 I

I

$ d I

I

1

a

b

fl

I

I

I

I

I

I

I

I I

d

:*

I

G

I

I

I I

4

q

4

I

I I

I

I

p I

I

I

I

d

I

I

!

q

I I

I

Fig. 1 . Normalized means for single and combined measurements of family background variables and life events for preschool children.

come; and mothers’ unemployment was positively correlated to fathers’ unemployment. It is of special interest, that psychosomatic diseases are positively correlated to low level of education and broken home and to events as “hospitalization of siblings” and “increase in number of arguments with peers”. The psychosomatic diseases were negatively correlated with “only child”. Consideration of correlation matrix might then suggest that an analysis necessarily must take into account

~~~~~

*** ** *

Significant on 1

O/OO

level.

Significant on 1% level. Significant on 5% level.

the intercorrelations between social factors and life events. Combined measurements of social factors and life events by diagnostic groups Preschool children’s diagnostic groups are profiled in Fig. 1 by selected family background variables. The group of respiratory tract infections were characterized by higher level of education of the parents, but the other parameters did not deviate significantly. The Actti Prirdiritr Sciind 68

536

J . Aagaard __

tract

Infections outside respiratory

infections

tract

Respiratory

Life events

____

-2

0

+2

----Lt_l-

-2

0

+2 I

-

Psychosomat i c and psychic diseases

-2

0

+2

I

-L. 1 - .

I

Other diseases -2

O

Infor-

mation +2_eer c e n t F

I n c r e a s e i n numb e r of a r g u m e n t s : With p a r e n t s

9 9

Between p a r e n t s With p e e r s Hospitalization of: -

2 d

2.9

2.3

3.5

2.1*

1.6

1.2

I

I

Parents

2.0

1.5

Siblings

0.3

0.2

Child

1.9

1.4

In family

1.2

0.9

Outside family

0.9

0.7

Father

1.2

0.9

Mother

0 9

.

0.7

Mother betjln work

Death:

Loss a j o b o f :

0.0

0.0

Broken home

2.6

2.0

Begin s c h o o l o r other institution __

2.0

1.5

B i r t h of s i s t e r or brother

0.8

0.6

1.1

0.8

9.4

1.7

~

d

Change i n p a r e n t s financial status

___ Combined measurement of l i f e e v e n_ ts _ _ _ ~

I

I

_

p

4

Fig. 2. Normalized means for single and combined meas-

urements of life events for preschool children.

I

I

***Significant

I

*iIj

**

on 1 o/oo l e v e l .

**.‘;?.qnificant on 1% l e v e l . “ S i q n i f i c a n t o n 5% l e v e l .

group of psychosomatic and psychic diseases was characterized by low level of education, “not-married’, and “low income”. The selected family background variables were employed to create a combined measurement, which took into account the correlations between the independent variables. As shown in Fig. 1 the group of psychosomatic and psychic diseases deviated significantly. A < to P~rrdiotr.ScL/m/68

A new combined measurement including family background variables and life events increased the information a great deal. The additional information was essentially due to the further significant deviation of the group of psychosomatic and psychic diseases. Elementary school children’s diagnostic groups were profiled in the same way. It is characteristic that the individual social factors

Children admitted to a paediatric department

only yield moderate information in this age group. By combining the measurements for family background variables it was found that the tendency was the same as in the group of preschool children, but not so pronounced. It is essential to note, however, that life events did yield significant additional information, and that this was related to a further significant deviation for the group of children with psychosomatic and psychic diseases. It is now natural to ask how the selected life events are distributed on the diagnoses in the two age groups. Preschool children’s aiagnostic groups are profiled in Fig. 2 by selected life events. The individual life events showed no clear tendency, but there were significantly more children with respiratory tract infections who had had “increased number of arguments with parents”. The combined measurement for life events revealed high values among respiratory tract infections as well as psychosomatic and psychic diseases, most pronounced for the latter diagnostic group. Elementary school children’s diagnostic groups were profiled in the same way by selected life events. More life events show significant deviations. Especially conflict with peers and “hospitalization of siblings” should be emphasized. The maximal information due to life events was significantly greater in this age group than among preschool children. The combined measurement for life events shows strong positive significant deviation in the group of psychosomatic and psychic diseases.

DISCUSSION The investigation has a relatively large nonresponse group. However, there was no significant difference between composition of the response group and the non-response group. The questions which describe the social background were relatively simple, and a further simplification occurred during data processing. For those reasons such a design can

531

only point to statistical associations between the independent variables, but beyond this a statistical estimation of the relative weight of these is possible. In other words, one cannot demonstrate causal relations, but only associations with possible etiological determinants. The classification into diagnostic groups is relatively coarse, but nevertheless there was a great deal of clinical homogeneity within groups, which makes meaningful explanations possible. The remainder group did not deviate significantly in any respect. It was characteristic that the selected social factors had greatest significance among preschool children, but the diagnostic groups for elementary school children tended towards the same type of profile. That negative social factors such as low level of education and relatively low income were frequent among children with psychosomatic and/or psychic diseases, and that the opposite was the case within the group of respiratory tract infections, is an observation which is contrary to earlier investigations in social medicine ( 2 ) . This suggests that the significance of social factors has changed in recent time. As an example residence might be mentioned. Nearly 3/4 of the children lived in residences with more than 3 rooms and only 1/10 lived in a crowded residence. Neither number of rooms nor crowded residence seemed to be of significance in differing between groups. This has naturally something to do with these essential improvements in the technical and hygienic condition of housing, which have taken place during the last generation. That does not mean that a poor residence cannot be a health risk, but at present relatively few children grow up in unhealthy residences. The absolute frequency of selected life events were relatively high, but only for a few of the selected life events was there a significant association with diagnostic groups. The combined measurement for life events, however, showed a positive significant deviation Acrtr Prrc,drotr S c r i n i l 68

538

J . Aagaard

for the group of psychosomatic and psychic diseases. It was remarkable that there was also a tendency towards large numbers of life events among preschool children who had a respiratory tract infection as main diagnosis. These children were nearly all admitted as emergencies. However, this investigation cannot clarify whether large numbers of life events had true etiologic significance or only influenced the indication for admission to hospital. The combined measurement was computed on the background of the intercorrelations by applying the method of appropriate scoring. The applied method differs from life event/ life-change-unit (LCU) procedure, where preassigned life event scores usually are applied. With a few exceptions (7) life event/LCUresearch did not take into account the possible intercorrelations between life events and social factors. Noticeable correlations between social factors and life events were found in this study. On this basis it can hardly be doubted that life events should not be considered alone, but must be evaluated in connection with the family background variables. It was not contrary to expectation that the combined measurement for family background variables and life events were strongly associated with psychosomatic and psychic diseases, but it was remarkable that the additional information from life events appeared so strongly. The results suggest that stressful life events in combination with negative social factors increases the risk of developing a psychosomatic or psychic disease of such a severity, that the child has to be admitted to hospital. Consequences of the results The new aspect to which this study has contributed is to clarify the relative weight of family background variables and life events for various disease categories. As stressful life events also frequently occur prior to admission of children with some somatic diseases, there is a consequent plea Ac,ttr

Prredintr Scrind 68

for a detailed recording of the social history of the individual child. The purpose of this is to identify those children whose symptoms or disease are better understood within a social or sociopsychological framework. Furthermore, the results of the investigation might have implications for the preventive work, with an understanding of those changes which seem to have taken place in important social conditions, and the role which stressful life events might have as a precipitant of disease. ACKNOWLEDGEMENT This study was made possible through grant from the Danish Medical Research Council.

REFERENCES 1. Apley, J. & McKeith, R.: The child and his symp-

toms. Blackwell Scientific Publications, Oxford 1968. 2. Christensen, V .: Boligforhold og b0rnesygelighed. Munksgaard, Copenhagen 1956. 3 . Christensen, V.: Trivselsproblemer og sygdomsreaktioner i fsrskolealderen. Ugeskr Laeger. 136: 1897, 1974. 4. Coddington, R. D.: The significance of life events as etiologic factors in the diseases of children. J Psychosom Res, 16: 7, 1972. 5. Coddington, R. D.: The significance of life events as etiologic factors in the diseases of children. 11. J Psychosom Res, 16: 20, 1972. 6. Folke- og boligtiellingen. Danmarks Statistik, Copenhagen 1973. 7. Gersten, J. C., Langner, T. S., Eisenbern, J. G. & Simcka-Fugan, 0.: An evaluation of the etiologic role of stressful life change events in psychological disorders. J Health Soc Behav,.lS: 228, 1977. 8. Helsinki-11-Declaration. Ugeskr Laeger, 138: 399, 1976. 9. Robertson, J.: Young children in hospital. Tavistock Publications, Baltimore 1958, 10. Robing, B. N.: Deviant children grow up. The Williams & Wilkins Company, Baltimore 1966. 11. Rosberg, G.: Social and psychological factors influencing hospital admission of children. Actu Paediatr Scand, Suppl. 196, 1969. 12. Rutter, M.: Psychosocial disorders in childhood and their outcome in adult life. J R Coil Physicians London, 4:211, 1970. 13. Stocking, M., Rothney, W., Grosser, G. & Goodwin, R.: Psychopathology in the paediatric hospital. Implication for community health. Am J Public Health, 62:551. 1972.

Children admitted t o a paediatric department 14. Straus, P., Coiffard, N., Marzo-Weyl, S . & Lenoir,

M.: L’hospitalisution des enfants. U n e Ptude d e pkdiatrie sociule d a m l‘agglomerution parisirnne. Monographie de I’Institut National d’Hygiene, No. 23. Paris 1961. 15. Aagaard, J.: Psykosocial belastning og sygdom hos barn. Metodediskussion. Ugeskr Larger, 139: 2961, 1977. 16. Aagaard, J. & Bro, P.: Psykosocial belastning og sygdom hos barn. Evaluering af pilot materiale. Ugeskr Larger, 139: 2966, 1977. 17. Aagaard, J.: Admission t o hospitul. A n analysis of the

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social history of children admitted to a paediairic department. Institute of Social Medicine, University of Aarhus. No. 18. 1978.

Submitted Aug. 21, 1978 Accepted Oct. 23, 1978

(J. A.) Institute of Social Medicine University of Aarhus Vesterbro Torv 1-3, 6 DK-8000 h h u s C Denmark

Social background and life events of children admitted to a paediatric department.

Actu Pzdiatr Scund 68: 531-539. 1979 SOCIAL BACKGROUND AND LIFE EVENTS OF CHILDREN ADMITTED TO A PAEDIATRIC DEPARTMENT J. AAGAARD From the Deparimeni...
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