Frontiers of Infant Psychiatry - Vol. 2

By Justin D. Call; Eleanor Galenson et al. | Go to book overview

Discussion

Heidelise Als, Ph.D.

The developmental sequelae of prematurity are becoming increasingly apparent in the follow-up studies from various medical centers. The common theme that emerges points to significant decrease of mortality and the grosser morbidities of Cerebral palsy and mental retardation over the last ten years, presumably due to improved neonatal care (Brown, 1980; Davies and Tizard, 1975; Pape et al., 1978). The gestational age at birth and the weight at birth of babies that can be kept alive now have also significantly decreased over the last ten years. Twenty-five- and twenty-six-week-old preterms have a chance at survival now, when ten years ago survival at twenty-eight and twenty‐ nine weeks was an extraordinary feat. While these improvements are impressive, an increase in subtler dysfunctions such as learning disabilities and behavior problems is noted and is obviously cause for concern (Drillien et al, 1980; Herzig, 1981; Rubin and Balow, 1977; Saint-Anne D'Argassies, 1977). It appears that the prematurely born baby is not as easily able to take advantage of environmental opportunities, nor as readily able to express him- or herself gesturally, posturally, and vocal-verbally as flexibly and modulatedly as his or her full‐ term, full-weight peer. Although survival is increasingly assured, the quality of survival is still far from perfect. What is going awry in the unfolding of the organism's functioning?

Various factors may be at play, singly or, more likely, interactively, which make documentation of etiology very difficult. These factors can be seen to be of three basic kinds: first, focal insults, often directly to the brain, or if to other organ systems, indirectly to the brain (for a review, see Chiswick, 1982; Cloherty and Stark, 1980); second, the effects of a hypothesized mismatch of CNS readiness of the immature brain in development and the demand of the nursery environment and care (Duffy and Als, in press); and third, the disruption of parental emotional competence and confidence due to having prematurely to let go completely of the up-to-then internalized child. Exacerbating factors presumably are the cumulative effect of already difficult social circumstances and/or the presence in the caregiver of physical, emotional, and mental stress of an ongoing nature.


Focal Insults to the Premature Brain

For many prematures, especially the younger age group (less than thirty-two weeks), there is the great danger of intraventricular hemorrhage frequently associated with subsequent ventricular dilatation, necessitating at times heroic efforts at spinal tapping or the insertion of a shunt. The formation of cysts is not uncommon after resolution of the acute bleed. The high incidence of intraventricular bleeds points to the great vulnerability of a brain in the process of massive cell proliferation when suddenly moved from an intrauterine environment, to

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