is in response to a href="http://scienceblogs.com/corpuscallosum/2007/05/childhood_ptsd.php#comment-439606">comment
from a prior post. There are a few related questions here.
Can preemies develop PTSD, can
they be labeled with PTSD, if they can get PTSD is it fundamentally the
same as it is in adults, and if it is different, should we call it
The comment was left by Stacy, the author of a blog,
Experiment. I spent a bit of time on href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi">Medline
trying to come up with a concise, direct answer. Didn’t find
The question interests me for a number of reasons.
When I was in the third year of medical school, I spent the required
two months in Pediatrics. I had some exposure to very low
birth-weight babies, and asked the attending, basically, “what happens
to these people when they grow up?” The answer?
That would have been in 1984. Looking quickly through
Medline, the earliest use I saw of the acronym, VLBW, occurs in 1987.
The phrase “very low birthweight” occurs starting around
1982. It appears that there was disagreement about the exact
definition of the term VLBW at first, being various considered 1.8 kg,
or 1.5 kg, now it appears that the most common definition is 1.25 kg or
less (2.75 pounds). Those dates might not be exact, because I
did not spend a lot of time on the search, but it gives you a rough
historical perspective. (The farther back you go, the less complete the
Now, the big confession. I almost became a pediatrician.
In fact, I did my subinternship in pediatrics, spending one
of the months on the unit for infants. May of them had been
transferred from the neonatal ICU, so some of them had been VLBW
infants. I asked the question a few more times, but always
got the same answer.
Fast forward to 2007. I have had the opportunity to see a few
adults who were born prematurely, although none at a very low weight.
I’ve also seen a few who had serious congenital heart
defects, who spent a lot of time in hospitals in their first few years
of life. It is not a random sample, obviously, and it is not
enough of a sample for me to even try to draw any general conclusions.
Browsing through the literature, just looking at abstracts, I do notice
a few things. For one, it was believed for a long time that
infants do not feel pain, or if they they do feel pain, it was believed
that it was not very important. This has been proven to be
nonsense, but the medical community did believe it not too long ago.
Of course they also believed that circumcision did not hurt.
What that tells us is that our understanding of the field is evolving,
but is not evolving very quickly. The most pertinent article
I could find is three and a half years old:
Dianne I Maroney
Extensive research of the long-term outcomes of premature infants has
shown significant risk for emotional, behavioral, and psychological
problems. Chronic stress and trauma have not been researched
specifically in this population, however, studies of the
neurobiological impact of traumatic stress on infants and children in
the general population show noteworthy parallels in symptomotology.
Careful consideration should be given to practitioner caregiving,
parent education, future research, assessment, and interventions while
being mindful of the impact that chronic stress and trauma may have on
the developing brain of the premature infant.
Journal of Perinatology (2003) 23, 679-683.
Unfortunately, you need subscriber or academic access to read the whole
thing. It does tell us that, 3.5 years ago, there still was a
paucity of research on the subject. Again, I did not spend a
lot of time searching, but I am pretty sure that if there were several
more recent articles, I would have found one of them.
Does Dr. Maroney tell us anything specifically about psychiatric
are also developing a better understanding of the greater risk that
premature infants have of developing psychological, emotional, and
behavioral disturbances. One study carried out by Botting et al.
looking specifically at psychiatric outcomes in very low birthweight
infants (VLBW, less than 1250 g at birth) at age 12 found these former
premature infants to be ‘‘more vulnerable to
psychiatric sequelae.’’ This study showed a
significantly greater risk of attention-deficit/
hyperactivity disorder (ADHD), generalized anxiety, and symptoms of
depression. In all, 28% displayed some type of psychiatric disorder
compared to nine percent of their peers.
This, however, does not tell us what we really want to know.
Assuming, that is, that we specifically want to know whether
VLBW kids are at risk for developing PTSD. However, Dr.
Maroney points out that that might not be the right question.
In fact, it probably is not:
using an exclusive diagnosis of PTSD when diagnosing and treating
children with trauma symptoms is not recommended because most children
exposed to traumatic events never develop PTSD. Understanding the
long-term effects of trauma without committing specifically to a PTSD
diagnosis is even more important, because traumatized children who do
not fit the criteria for PTSD often have as many or more overall
problems than those who do fit the criteria.
This, incidentally, points out one of the big pitfalls in interpreting
psychiatric studies. The vast majority of studies use strict
diagnostic criteria for inclusion and exclusion of the patient
population. But that often is not what is clinically
What I care about is this: does the person have a significant problem,
and is there some intervention that is appropriate and worthwhile to
provide? Whether the problem has a fancy name, is irrelevant.
Another pitfall: making assumptions about what can and cannot happen,
leading to incorrect conclusions.
Over the years, I have become something of a causality nihilist,
meaning that I am increasingly reluctant to think it terms of cause and
effect when it comes to mental health/mental illness. What I
want to do, is describe the problem, and figure out
what (if anything) to do about it. The cause of the problem
is important only insofar as it 1) gives a clue about the appropriate
intervention, and 2) guides the interview process, by giving the
diagnostician some ideas about what questions to ask next.
And, the question of whether a given intervention is appropriate or
not, is determined only by empirical validation. That is, you
test the intervention to see if it works. Knowing the cause,
or having an hypothesis about the cause, may help guide research into
what interventions to try. So it is not irrelevant in a
research setting. But in a clinical setting, it can be
terribly misleading to link cause –> effect –>
Dr. Maroney, intentionally or not, addresses this very problem:
many years, conventional wisdom declared that infants and small
children could not cognitively remember chronic stress or trauma. As a
result, professionals assumed that children would not experience
long-term problems from traumatic incidents that occurred before their
cognitive memory was functioning (around the age of 3). In the past
decade, researchers have made tremendous strides in negating this
belief based on their improved understanding of the long-term
physiological impact that chronic stress, as well as traumatic
incidents, have on the developing brain.
“Conventional wisdom” told us that memory had something to do with the
development of posttraumatic symptomatology (as distinct from
Posttraumatic Stress Disorder). Perhaps it does have something
to do with it, but it is not the entire story. It probably
has something to do with the patient-specific manifestations of the
problem, but it is not necessarily an essential part of the cause
of the problem.
In summary, I do think neonatal ICU experiences, and the inevitable
cascade of subsequent medical interventions, can be correlated with
posttraumatic symptoms in people. I think it is likely, in
fact. So far I am not aware of definitive research on the
subject. I can say that it is important to think critically
about the subject, because it is much more complex than it may seem.