Fifty years ago, social support was often the only therapeutic modality a physician had to offer a sick or dying child. Today, after several decades of biomedical research and technological advances, the traditional "laying on of the hands" is generally upstaged by highly effective immunizations, an endless succession of "wonder drugs," and dramatic surgical interventions. As patterns of childhood mortality and morbidity have changed, however, the importance of social support has re-emerged as a promising conceptual framework for thinking about issues of health promotion and disease prevention. In fact, a growing body of research on the relationship between stress and social support, and their interactive effects on the physical and emotional well-being of children, provides a strong argument for renewed emphasis on this "soft" but potent element of clinical pediatrics. 1
CONCEPTS OF SOCIAL SUPPORT, STRESS, AND VULNERABILITY
Social support has been defined as "information leading the subject to believe that he is cared for and loved, esteemed, and a member of a network of mutual obligations."2 Its essence is focused on the availability of meaningful and enduring relationships that provide nurturance, security, and a sense of interpersonal commitment. The specific benefits that individuals derive from supportive social networks can be described within three categories of assistance: instrumental supports, such as material goods and services (eg, child care, income assistance); emotional support (eg, friendships, religious affiliation and practice); and referral or information (eg, community "grapevines," organization newsletters).
Social support may operate on a number of ecological levels, and encompass both formal and informal networks. The spectrum of informal support includes the most intimate relationships and close friendships as well as the benefits of casual acquaintances and participation in community groups such as religious organizations, social clubs, and neighborhood school activities. Formal supports, on the other hand, are typically defined by professional helping relationships, and may include health care providers, public assistance programs, and professionally organized selfhelp groups. Each person's network of social support includes a variety of individuals, groups, and/or institutions that may provide assistance of varying sorts and degrees at any given time. People with limited access to supportive resources are described as isolated, and are considered to be vulnerable to the adverse effects of stressful life events.
Stress is an inevitable part of the life of all children and their families. ' Children today appear to be faced with greater degrees of stress (eg, divorce, working parents) than youngsters in the past, and a number of investigators have documented the increasing prevalence of psychosocial problems confronting the primary care pediatrician. Theorists of the stress process often distinguish between normative stressors, which are predictable or expected (eg, sibling rivalry, minor illness, beginning school), and non-normative stressors, which are unanticipated or crisis-oriented (eg, divorce, physical or sexual abuse, death of a family member). There is considerable evidence in the literature that demonstrates a small but reliable relationship between cumulative life stresses, and both the utilization of medical services and specific health outcomes.
Among children, this association manifests itself in a higher frequency and longer duration of minor illnesses, more frequent injuries, and greater overall morbidity among those experiencing more stresses.4 Issues of differential vulnerability based on social experiences are discussed in greater detail by Boyce and Masten in this issue.
SOCIAL SUPPORT AS IMMUNIZATION AGAINST VULNERABILITY
The role of social support as a mediator of positive health outcomes is receiving increased attention among investigators. Although a great deal of basic research remains to be done to explain the underlying physiological mechanisms, several correlational studies have documented convincing associations between degrees of support and a variety of health-related indices. In adult populations, for example, higher levels of social support have been shown to correlate with lower mortality rates across a broad age range, independent of socioeconomic status, year of death, or any of a number of important health-related behaviors, such as smoking, alcohol consumption, physical activity, obesity, and use of preventive health services.5 Other studies have documented lesser morbidity for a variety of specific disorders (eg, heart disease, asthma, arthritis) among individuals with supportive social networks and close personal relationships. 2
The health promoting aspects of social suppott in children, although less extensively studied, appear to be equally promising. Nuckolls, Cassel, and Kaplan, for example, reported lower rates of gestational and perinatal difficulties among women with access to higher levels of support.6 Boyce, Schaefer, and Uitti replicated these findings by demonstrating a fourfold increase in the rate of neonatal complications among single, adolescent mothers with average to low support compared to those reporting high levels of support.7 The benefits of more open communication and emotional support for hospitalized children, and theit effects on the promotion of fewer complications and more rapid recovery, have been empirically studied and are widely acknowledged.8
The protective effects of social support beyond the realm of physical and emotional health, and into the domain of parent-child interaction and early childhood development, are particularly salient in view of the changing agenda for pediatric primary care in the US. Although traditional health concerns have not disappeared, increasing demands are made on the practicing pediatrician to deal with issues related to the behavior and development of children, as well as to the stresses of contemporary family life. Cochran and Brassard have suggested that personal support networks influence parental attitudes and behaviors, and have both direct and indirect effects on children's development.9 Crnic et al found stress and support to be significant predictors of maternal attitudes at I month, and behavioral interactions at 4 months, in families with premature or full-term infants. Although mothers under greater stress showed less positive attitudes and behaviors, those with the strongest supports were significantly more positive. 10 Crockenberg demonstrated a clear and consistent association between the adequacy of maternal social support and the security of the infant-mother attachment at 12 months of age, with the strongest effects found in irritable infants.11 Thus, data from these and similar studies suggest that social support is particularly important when a family is under stress.
The extraordinary stresses of poverty, social disorganization, or chronic impairment make the issue of social support, and its potential benefits, even more critical for high-risk groups. In a study of lower-income black mothers and their preschool children, Slaughter demonstrated superior ratings on observational measures of maternal teaching style among women who participated in a supportive discussion group that served as a "substitute family."12 Waisbren studied the effects of extended family contact on parents of disabled infants and found positive correlations between high support and both mothers' and fathers' interactions with their children. I3 In a study of children with Down's syndrome, Gath found the highest levels of maternal distress in those with the least support from their extended families and the weakest ties to both formal and informal sources of assistance. 14 Pless and Satterwhite demonstrated the value of nonprofessional support by documenting better psychological outcomes in children with chronic illness whose families were provided lay counseling by experienced mothers of older disabled children.15
In summary, relationships among stress, illness, and developmental vulnerability have been demonstrated by investigators in a variety of professional disciplines. Preliminary evidence suggests that social support may provide a protective buffer that can serve to immunize children against a variety of stress-related problems, or at least ameliorate the effects of others.1,2,4 The potential significance of such associations, and the mechanisms through which they operate, offer exciting challenges for further study. Current knowledge, however, despite its limitations, has important immediate implications for the delivery of pediatric primary care.
SOCIAL SUPPORT AS A STRATEGY FOR HEALTH MAINTENANCE, DISEASE PREVENTION, AND THE MANAGEMENT OF CHRONIC IMPAIRMENT- Role of the Pediatrician
The practicing pediatrician is ideally situated to evaluate the level and quality of social support available to children and their families. Beginning with the prenatal visit, and extending well into the adolescent years, detailed information on family and social context must be included as an integral part of the evolving data base that makes up a child's health history. As the physician-child-family relationship matures, the pediatrician should gather data on the size, density (degree of inter-relatedness), degree of intimacy, and individual perceptions of value of a family's social support networks. A finding of absent or minimal supports may indicate increased risk for a variety of pediatric difficulties (eg, accidents, developmental attrition, abuse, or neglect), and is worthy of special attention in a problem-oriented record.
In addition to his/her role in evaluating the social networks available to children and their families, the primary care pediatrician is in a critical position to enhance personally that support system in a number of important ways. Perhaps one of the most significant supportive roles that the pediatrician can offer is to provide specific information. This may cover a wide range of topics that extend into the realms of health maintenance, disease prevention, and anticipatory guidance in the behavioral/developmental area. Information on feeding practices, developmental expectations, behavioral management, care and treatment of illness, and accident prevention are some aspects of the typical pediatric agenda that provide valued support for families with young children.
Beyond the provision of practical information, the primary care pediatrician can also be an important source of emotional support. This can be provided in the form of reassurance for the inexperienced parent adjusting to the routine challenges of child care, as well as through more intense support for the overwhelmed parent who is struggling to cope with the extraordinary responsibilities of caring for a child with a serious chronic illness or handicapping condition. In many cases, the provision of emotional support and specific information is interrelated.
The role of referral is another aspect of social support whose potential contribution within a pediatric practice is becoming increasingly valued. Contemporary families need access to a variety of concrete resources, many of which may be difficult to locate or assess. Infant day care, after-school programs, counseling services, specialized respite care for disabled children, support groups for parents and siblings of youngsters with chronic impairments, and a wide range of community-based social services are some of the many resource needs that a pediatrician can help families find and evaluate.
In summary, a pediatric practice can be a critical source of social support for children and their families. This support can be transmitted through providing information, assisting in the search for other needed community resources, and extending emotional support. Recent research suggests that the availability of such support may have a measurable influence on physical and emotional well-being. As pediatricians approach the 21st century, and continue to incorporate the fruits of a rapidly expanding technology into practice routines, attention must be refocused on the degree to which the health care setting contributes to the network of formal and informal supports that affect the health and development of children and families.
1. Shonkoff J: Social support and the development of vulnerable children. Am J Public Health 1984; 74:310-312.
2. Cobb S: Social support as a moderator of life stress. PsychosomMed 1976; 38:300-314
3. Rutter M: Stress, coping and development: Some issues and some questions. J Child Psychol Psychiatry 1981; 22:323-356.
4. Haggerty R: Lille stress, illness and social supports. Dev Med Child Neurol 1980; 22:391-400.
5. Berkman L, Syme SL: Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents. Am J Epidemiol 1979; 109:186-204.
6. Nuckolls KB, Casse! J, Kaplan BH: Psychosocial assets, life crisis and the prognosis of pregnancy. Am J Epidemiol 1972; 95:431-441.
7. Boyce WT, Schaefer C, Uitti C: Permanence and change: Psychosocial factors in the outcomes of adolescent pregnancy. Presented a; rhe Annusi Meeting of the Society for Behavorial rVdiarrics. San Francisco. April 1984.
8. Skipper JK, Leonard RC: Children, stress, and hospitalization: A field experiment. Journal of Health and Human Behavior 1968; 9:274-287.
9. Cochran M. Brassard J: Child development and personal social networks. Chad Dev 1979; 50:601-616.
10. Cmic K, Greenberg M. Ragozin A, et al: Effects of stress and social support on mothers and premature and full-term infants. Child Dev 1983; 54:209-217.
11. Crockenberg S: Infant irritability, mother responsiveness, and social support influences on the security of infant-mother attachment. Child Dev 1981; 52:857-865.
12. Slaughter D: Early intervention and its effects on maternal and child development. Monographs of the Society for Resanen in Child Development 1 983 ; Serial No 202 . Vol 48. No 4.
13. Waisbren S: Parents' reactions after the birth of a developmentally disabled child. AmJ Mem Defk 1980; 84:345-351.
14. Gath A: Down's Syndrome and the Fornii·»: The Earl·» Years. New York. Academic Press, 1978.
15. Pless IB, Satterwhite B: Chronic illness in childhood: Selection, activities and evaluation of non-professional family counselors. CIm Pediarr 1972; 1 1 :403-410.