**9. Psychosocial aspect**

Along with the management of classic cardiovascular risk factors, psychosocial aspects should also be evaluated. They can be partly responsible for disease development or can be a consequence of a chronic disease.

Early-life psychosocial factors that may influence cardiovascular health in adulthood include self-regulation (the ability to manage behavior, emotion, attention and social interactions), cognitive ability and aspects of home environment. They influence life-long health by facilitating education, problem solving, memory, communication, sense of control and ability to cope with stressful situations. Higher levels of psychosocial features were associated with greater likelihood of favorable cardiovascular state in adulthood with healthy levels of blood pressure, cholesterol, body mass index, cardiovascular-related medication status, smoking and blood sugar [46].

On the other hand, a chronic disease present in a child can have an important impact in a child's life and his or her family. Psychosocial issues are under-recognized, persist into adulthood and may impede optimal outcome. Children with chronic illness are at increased risk for mental health and adjustment problems. Child's adjustment depends mostly on the way the family copes with the child's condition. In young people, especially adolescents, underlying psychosocial issues can be suggested when new medical symptoms arise that cannot be explained by organic disease, when poor compliance to therapy is evident, when school refusal is present and when risky behavior involving excessive use of substances or excessive sexual behavior arises. These signs should alert the pediatrician to refer the patient to psychological treatment in time. Interventions are family-based, educational and are building on strengthening relationships and positive support [47].

Childhood obesity, a major contributor to CVD risk in modern society, can profoundly affect a child's social and emotional well-being and self-esteem. Obesity is associated with increased anxiety, body dissatisfaction and lower self-esteem. In obese, higher prevalence of eating disorder is present. In addition, obesity affects children's and adolescent's social and emotional health. Obese children are often bullied for their weight, excluded from activities, particularly physical, and face numerous negative stereotypes, discrimination and social marginalization, leading to further lower self-esteem, self-confidence, negative body image and negative effect to academic performance. The latter is in part due to chronic health-related conditions responsible for missing school [48].
