Child Psychiatry Hum Dev DOI 10.1007/s10578-014-0475-1
ORIGINAL ARTICLE
Psychiatric Diagnoses, Emotional–Behavioral Symptoms and Functional Outcomes in Adolescents Born Preterm with Very Low Birth Weights Pinchen Yang • Yu-Hsien Chen • Cheng-Fang Yen Hsiu-Lin Chen
•
Springer Science+Business Media New York 2014
Abstract Children born preterm with very low birth weight (VLBW; birth weight B1,500 g) run risks of neurodevelopmental disorders. Studies of adolescent outcome are relatively few. In this follow-up survey, we examined the emotional–behavioral symptoms, psychiatric diagnoses and functional status in a geographically-based birth cohort of VLBW adolescents (average 13.4 years) as registered in a level III center of a recently developed Asian country. Psychiatric interviews were conducted. Parents were asked to fill out the Child Behavioral Checklist and the Current Status Survey. Results revealed that neonatal survival rate was 75.7 % (112/148). In the follow-up, 26.2 % of the adolescents required individualized educational plan; 52.5 % were with at least one neuropsychiatric diagnosis (e.g. cerebral palsy 24.6 %, intellectual disabilities 21.3 %, attention deficit/hyperactivity disorder 19.7 %), and 32.8 % of the participants were disabled. Logistic
P. Yang C.-F. Yen Department of Psychiatry, College of Medicine, Kaohsiung Medical University, 100, Shin-Chuan 1st Rd, Kaohsiung 807, Taiwan P. Yang C.-F. Yen H.-L. Chen (&) Kaohsiung Medical University Hospital, Kaohsiung, Taiwan e-mail: [email protected] Y.-H. Chen Graduate Institute of Psychology, Kaohsiung Medical University, Kaohsiung, Taiwan H.-L. Chen Department of Pediatrics, Kaohsiung Medical University, Kaohsiung, Taiwan H.-L. Chen Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
regression found that neonatal sepsis and grade III/IV intraventricular hemorrhage were most predictive of a disabled status in adolescence. Keywords Emotional–behavioral symptoms Outcome Psychiatric diagnosis Very low birth weight Adolescent
Introduction In humans, birth weight generally correlates to gestational age and is easy to determine. It is estimated that one-third of low birth weight (\2,500 g) deliveries are preterm. Weight-based classification of newborns further recognizes very low birth weight (VLBW) which is less than 1,500 g, and extremely low birth weight (ELBW) which is less than 1,000 g at birth. Almost all neonates in these two categories are born preterm. Preterm infants are vulnerable to brain injuries which consist primarily of cerebral white matter injury frequently accompanied by neuronal/axonal disease, affecting the cerebral white matter, thalamus, basal ganglia, cerebral cortex, brain stem, and cerebellum. This spectrum of brain injuries is a complex amalgam of primary destructive disease and secondary maturational and trophic disturbances [1]. Among this spectrum of encephalopathy related to preterm birth, periventricular hemorrhagic infarction (PVHI) in association with intraventricular hemorrhage (IVH) is the most severe, though quantitatively less common lesion in premature infants. Guzzetta et al. [2] first reported major long-term disabilities in up to 90 % of PVHI survivors two decades ago and findings were replicated by subsequent reports [3]. Despite the recent advances in neonatal critical care with increasing survivors, researchers still found PVHI to be a major risk factor for
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adverse neurodevelopmental outcome in survivors [4, 5]. One study found the majority of the surviving children have cerebral palsy, but they are mildly affected in functional motor outcome at school age. [6]. In addition to the most severe PVHI, brain injuries of the preterm infants have a constellation of pathophysiology and resulting sequelae. Population-based cohort studies have demonstrated that cognitive deficits and behavior, social and emotional problems are far more prevalent and contribute to a substantial proportion of long term impairment [7–9]. Cognitive deficits without major motor deficits are by far the dominant sequelae in infants with VLBW. The reported significant cognitive, behavioral, attention, and socialization deficits occurred in 25–50 % and serious motor deficits in 5–10 % of children born preterm [1, 10]. Numerous factors have shown correlations with these neurological and emotional–behavioral impairments, including birth weight, gestational age, social-cultural level of the family, postnatal steroid use, prolonged ventilation, inotrope use and male gender [11–14]. However, these perinatal risk factors correlate only modestly with the childhood outcomes, and the major neural mechanisms leading to these impairments are not yet understood. In addition, though preterm birth is known to be associated with a high risk of residual disability across multiple functional domains which affects individuals throughout their lifespan [15], functional outcome beyond early childhood is still largely unknown. Literature review have demonstrated that preterm birth does not appear to confer a general risk for behavioral morbidity at follow-up, but a specific risk for a triad of disorders and symptoms [16, 17]. Consistency has been noted in the pattern of behavioral morbidities identified which has led to the proposition that there is a ‘preterm behavioral phenotype’ characterized by inattention, anxiety and social problems [7]. As for outcome by psychiatric diagnosis, a longitudinal United Kingdom and Ireland study [18] has found preterm children three times more likely to have a psychiatric disorder than term-born classmates [19]. Besides, both clinical cohort studies and epidemiological investigations have demonstrated increased risk for behavioral problems associated with decreasing gestational age at birth [20–23] . In Taiwan, a recently developed Asian country, approximately 0.76–0.90 % of all live births from 2004 through 2011 were preterm babies with VLBW, a proportion that is not insignificant [24]. Previous western outcome surveys of infants born preterm during the preschool or early school years have repeatedly shown significantly increased prevalence of cognitive and behavioral problems compared with term-born peers [23]. As for outcome at early adolescence, the few existing studies of late preterm
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adolescent outcome as compared to the term controls have inconsistent findings [25, 26]. In this study, we attempted to examine the prevalence of emotional–behavioral problems, psychiatric diagnoses and functional outcome in a cohort of 12–15-year-old adolescents born preterm with VLBW from 1996 through 1999. The hypothesis was that cognitive, behavior, social and emotional problems were prevalent in this group of adolescents and there was substantial proportion of long term impairment. In addition, we also proposed that those born with birth weight less than 1,000 g (i.e. ELBW) would be more disadvantaged at adolescence as compared with those with birth weight more than 1,000 g.
Methods Study Design This study was a follow-up survey at early adolescence of a geographically-based birth cohort of preterm with VLBW in southern Taiwan. The present study was carried out between August, 2011 and July, 2012. The Ethics Committee of Kaohsiung Medical University Hospital approved the study (Registration number: KMUH-IRB-990296). Informed consents were obtained from parents and the adolescents themselves gave their assents. Subjects The subjects were recruited from a data bank of the Kaohsiung Medical University Hospital-Premature Baby Registry. This data bank has detailed records of children born preterm who were referred to the level III neonatal intensive care unit (NICU) at Kaohsiung Medical University Hospital. (Of note, the requirement of personnel and equipment of a level III NICUs in Taiwan follows the regulation made the American Pediatric Association. There were total eighteen NICUs in Taiwan by the time this study conducted. Children born preterm with VLBW in Taiwan are routinely transferred to a level III NICU for care as the current practice guideline of the Taiwanese Society of Neonatology mandated.) In 1996–1999, a total of 148 babies were admitted. The range of this cohort was chosen so that subjects joining this survey would be adolescents from 12 to 15 years old by 2011. Procedures At follow-up, we first checked with the Death Registry of the Ministry of the Interior of Taiwan to confirm the survivorship of the 148 children, and found 37 subjects had died. Then we reviewed the medical chart for each eligible
Child Psychiatry Hum Dev Table 1 Prenatal, perinatal and neonatal characteristics in adolescents born VLBW
1996-1999 VLBW N=148
ORIGINAL ARTICLE
Psychiatric Diagnoses, Emotional–Behavioral Symptoms and Functional Outcomes in Adolescents Born Preterm with Very Low Birth Weights Pinchen Yang • Yu-Hsien Chen • Cheng-Fang Yen Hsiu-Lin Chen
•
Springer Science+Business Media New York 2014
Abstract Children born preterm with very low birth weight (VLBW; birth weight B1,500 g) run risks of neurodevelopmental disorders. Studies of adolescent outcome are relatively few. In this follow-up survey, we examined the emotional–behavioral symptoms, psychiatric diagnoses and functional status in a geographically-based birth cohort of VLBW adolescents (average 13.4 years) as registered in a level III center of a recently developed Asian country. Psychiatric interviews were conducted. Parents were asked to fill out the Child Behavioral Checklist and the Current Status Survey. Results revealed that neonatal survival rate was 75.7 % (112/148). In the follow-up, 26.2 % of the adolescents required individualized educational plan; 52.5 % were with at least one neuropsychiatric diagnosis (e.g. cerebral palsy 24.6 %, intellectual disabilities 21.3 %, attention deficit/hyperactivity disorder 19.7 %), and 32.8 % of the participants were disabled. Logistic
P. Yang C.-F. Yen Department of Psychiatry, College of Medicine, Kaohsiung Medical University, 100, Shin-Chuan 1st Rd, Kaohsiung 807, Taiwan P. Yang C.-F. Yen H.-L. Chen (&) Kaohsiung Medical University Hospital, Kaohsiung, Taiwan e-mail: [email protected] Y.-H. Chen Graduate Institute of Psychology, Kaohsiung Medical University, Kaohsiung, Taiwan H.-L. Chen Department of Pediatrics, Kaohsiung Medical University, Kaohsiung, Taiwan H.-L. Chen Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
regression found that neonatal sepsis and grade III/IV intraventricular hemorrhage were most predictive of a disabled status in adolescence. Keywords Emotional–behavioral symptoms Outcome Psychiatric diagnosis Very low birth weight Adolescent
Introduction In humans, birth weight generally correlates to gestational age and is easy to determine. It is estimated that one-third of low birth weight (\2,500 g) deliveries are preterm. Weight-based classification of newborns further recognizes very low birth weight (VLBW) which is less than 1,500 g, and extremely low birth weight (ELBW) which is less than 1,000 g at birth. Almost all neonates in these two categories are born preterm. Preterm infants are vulnerable to brain injuries which consist primarily of cerebral white matter injury frequently accompanied by neuronal/axonal disease, affecting the cerebral white matter, thalamus, basal ganglia, cerebral cortex, brain stem, and cerebellum. This spectrum of brain injuries is a complex amalgam of primary destructive disease and secondary maturational and trophic disturbances [1]. Among this spectrum of encephalopathy related to preterm birth, periventricular hemorrhagic infarction (PVHI) in association with intraventricular hemorrhage (IVH) is the most severe, though quantitatively less common lesion in premature infants. Guzzetta et al. [2] first reported major long-term disabilities in up to 90 % of PVHI survivors two decades ago and findings were replicated by subsequent reports [3]. Despite the recent advances in neonatal critical care with increasing survivors, researchers still found PVHI to be a major risk factor for
123
Child Psychiatry Hum Dev
adverse neurodevelopmental outcome in survivors [4, 5]. One study found the majority of the surviving children have cerebral palsy, but they are mildly affected in functional motor outcome at school age. [6]. In addition to the most severe PVHI, brain injuries of the preterm infants have a constellation of pathophysiology and resulting sequelae. Population-based cohort studies have demonstrated that cognitive deficits and behavior, social and emotional problems are far more prevalent and contribute to a substantial proportion of long term impairment [7–9]. Cognitive deficits without major motor deficits are by far the dominant sequelae in infants with VLBW. The reported significant cognitive, behavioral, attention, and socialization deficits occurred in 25–50 % and serious motor deficits in 5–10 % of children born preterm [1, 10]. Numerous factors have shown correlations with these neurological and emotional–behavioral impairments, including birth weight, gestational age, social-cultural level of the family, postnatal steroid use, prolonged ventilation, inotrope use and male gender [11–14]. However, these perinatal risk factors correlate only modestly with the childhood outcomes, and the major neural mechanisms leading to these impairments are not yet understood. In addition, though preterm birth is known to be associated with a high risk of residual disability across multiple functional domains which affects individuals throughout their lifespan [15], functional outcome beyond early childhood is still largely unknown. Literature review have demonstrated that preterm birth does not appear to confer a general risk for behavioral morbidity at follow-up, but a specific risk for a triad of disorders and symptoms [16, 17]. Consistency has been noted in the pattern of behavioral morbidities identified which has led to the proposition that there is a ‘preterm behavioral phenotype’ characterized by inattention, anxiety and social problems [7]. As for outcome by psychiatric diagnosis, a longitudinal United Kingdom and Ireland study [18] has found preterm children three times more likely to have a psychiatric disorder than term-born classmates [19]. Besides, both clinical cohort studies and epidemiological investigations have demonstrated increased risk for behavioral problems associated with decreasing gestational age at birth [20–23] . In Taiwan, a recently developed Asian country, approximately 0.76–0.90 % of all live births from 2004 through 2011 were preterm babies with VLBW, a proportion that is not insignificant [24]. Previous western outcome surveys of infants born preterm during the preschool or early school years have repeatedly shown significantly increased prevalence of cognitive and behavioral problems compared with term-born peers [23]. As for outcome at early adolescence, the few existing studies of late preterm
123
adolescent outcome as compared to the term controls have inconsistent findings [25, 26]. In this study, we attempted to examine the prevalence of emotional–behavioral problems, psychiatric diagnoses and functional outcome in a cohort of 12–15-year-old adolescents born preterm with VLBW from 1996 through 1999. The hypothesis was that cognitive, behavior, social and emotional problems were prevalent in this group of adolescents and there was substantial proportion of long term impairment. In addition, we also proposed that those born with birth weight less than 1,000 g (i.e. ELBW) would be more disadvantaged at adolescence as compared with those with birth weight more than 1,000 g.
Methods Study Design This study was a follow-up survey at early adolescence of a geographically-based birth cohort of preterm with VLBW in southern Taiwan. The present study was carried out between August, 2011 and July, 2012. The Ethics Committee of Kaohsiung Medical University Hospital approved the study (Registration number: KMUH-IRB-990296). Informed consents were obtained from parents and the adolescents themselves gave their assents. Subjects The subjects were recruited from a data bank of the Kaohsiung Medical University Hospital-Premature Baby Registry. This data bank has detailed records of children born preterm who were referred to the level III neonatal intensive care unit (NICU) at Kaohsiung Medical University Hospital. (Of note, the requirement of personnel and equipment of a level III NICUs in Taiwan follows the regulation made the American Pediatric Association. There were total eighteen NICUs in Taiwan by the time this study conducted. Children born preterm with VLBW in Taiwan are routinely transferred to a level III NICU for care as the current practice guideline of the Taiwanese Society of Neonatology mandated.) In 1996–1999, a total of 148 babies were admitted. The range of this cohort was chosen so that subjects joining this survey would be adolescents from 12 to 15 years old by 2011. Procedures At follow-up, we first checked with the Death Registry of the Ministry of the Interior of Taiwan to confirm the survivorship of the 148 children, and found 37 subjects had died. Then we reviewed the medical chart for each eligible
Child Psychiatry Hum Dev Table 1 Prenatal, perinatal and neonatal characteristics in adolescents born VLBW
1996-1999 VLBW N=148
