EDITORIAL

The Neonatal Intensive Care Unit:Attending to Mental Health Outcomes

Joan L. Luby, M.D.

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T hat fact that premature birth is a major riskfactor for poor basic developmental and gen-eral health outcomes has been a widely rec-

ognized and highly prioritized public health issuefor decades. Increasing concern about this high-riskpopulation has further escalated based on the im-proved survival rates currently achievable at evenyounger gestational ages.1 In stark contrast, despitethe rich body of data on outcomes such as speech,language, and motor skills, strikingly little has beenknown about the behavioral, emotional, and men-tal health sequelae of prematurity. In keeping withthis dearth of information, early intervention pro-grams targeting emotional and behavioral out-comes in neonatal intensive care unit (NICU) set-tings have been rare and becoming increasingly soin the context of shrinking health care budgets. Inthis issue of the Journal, new findings from theEPICure study, the largest and longest investiga-tion of psychiatric outcomes in premature infantsconducted to date, demonstrate marked increasedbehavioral risks in this population, thereby shed-ding some of the brightest and most elucidatinglight on this area yet available. These findingsprovide the scientific stimulus for neonatal healthcare programs to now attend to these previouslyneglected developmental domains. Study findingssupport the need for application and testing ofmental health prevention for infants born prema-turely.

Based on longitudinal data from an 11-yearfollow-up of 219 extremely preterm children (�26weeks’ gestation) and 153 term controls, Johnson etal.2 report a threefold overall greater risk of sub-sequent mental health problems in those childrenborn prematurely. These findings provide clearand powerful evidence for the need for applicationand testing of early intervention and preventionprograms focused on facilitating emotional andbehavioral development in preterm populations.

Although preterm birth has long been suspected to c

JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

VOLUME 49 NUMBER 5 MAY 2010

e a risk factor for subsequent childhood mentalisorders, most of the evidence available before thiseport, although highly suggestive, was based onmaller samples, had shorter follow-up periods,nd was lacking in diagnostic specificity.3-5 Thendings of Johnson et al.2 should leave no doubt

hat subsequent childhood psychiatric disordershould be added to the list of serious potential risksor children born extremely pre-term.

In addition to a higher risk for subsequentttention-deficit/hyperactivity disorder (ADHD;articularly the inattentive type), a finding previ-usly reported in several investigations, this studyighlights an increased risk for anxiety and autisticpectrum disorders. The finding of increased ratesf anxiety disorders is relatively new in this popu-

ation and had not been previously reported. How-ver, increased rates of autistic spectrum disordersave also been reported in several recent indepen-ent investigations.6-8 Providing data to inform theechanism of risk for ADHD, the authors report

hat ADHD at age 11 years was strongly related toognitive impairment at 2.5 and 6 years of age.lthough further direct investigation of this issue iseeded, these findings suggest that alterations inarly neurodevelopment related to preterm birthay be a key component of the etiology of ADHD

n this population. Anxiety disorders, which re-arkably occurred at a rate four times higher in the

reterm versus term population, were less stronglyelated to cognitive impairment, suggesting thathe alterations in early life experience may be antiologic factor in these outcomes.

Advances in our knowledge about the associa-ion between alterations in early brain develop-

ent and risk for later psychopathology9 suggesthat preterm infants, a group with known alter-tions in early brain development,10 would be atigher risk for mental disorders. Findings from thePICure study provide the most robust data to date

onfirming this suggestion. Future studies that in-

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clude measurements of early neuropsychiatric, so-cial, and emotional functioning and neuroimagingare now needed to elucidate the developmentaltrajectory and mechanisms of risk for subsequentpsychiatric disorders in preterm populations. Alsoof interest are alterations in the early sensory andinterpersonal experiences of preterm infants in theNICU environment, which may have more potenteffects on socioemotional and neural developmentthan previously appreciated.11 Further study of theeffects of the NICU environment on early develop-ment is clearly warranted.

Pending these investigations, the current studyprovides sufficient evidence to inform changes inclinical care in the NICU setting and in the earlychildhood follow-up care of preterm infants. Inaddition to implementation of preventive interven-tions, testing of their efficacy would be critical.Further, following the finding that symptoms ap-pearing as young as 2.5 years of age predicted riskfor later mental disorders, future studies should

investigate whether mental disorders can be de-

Behavioral outcomes of extremely low birth weight children atage 8 years. J Dev Behav Pediatr. 2009;30(2):122-130.

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ected even earlier in this high-risk population.dvances in our ability to reliably detect andiagnose mental disorders at earlier points in de-elopment will enable study designs to assess andrack the earliest development of mental disordersfter the neonatal period. As more is known abouthese risk trajectories, more informed designs ofreventive interventions to facilitate emotion regu-

ation and cognitive and attentional control in earlyhildhood will become possible. &

Accepted February 2, 2010.

Dr. Luby is with the Washington University School of Medicine.

Disclosure: Dr. Luby receives funding from the National Institutes ofMental Health (NIMH), the National Alliance for Research on Schizo-phrenia and Depression (NARSAD), and Communities Healing Ado-lescent Depression and Suicide (CHADS) for research on earlychildhood depression.

Correspondence to Joan L. Luby, M.D., Department of Psychiatry(Child), Washington University School of Medicine, Campus Box8134, 660 South Euclid Ave., St. Louis, MO 63110-1093; email:lubyj@psychiatry.wustl.edu

0890-8567/10/©2010 American Academy of Child and Adoles-cent Psychiatry

DOI: 10.1016/j.jaac.2010.01.015

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Improved survival rates with increased neurodevelopmentaldisability for extremely low birth weight infants in the 1990s.Pediatrics. 2005;115(4):997-1003.

2. Johnson S, Hollis C, Kochhar P, Hennessy E, Wolke D, Marlow N.Psychiatric disorders in extremely preterm children. J Am AcadChild Adolesc Psychiatry. 2010;49:453-463.

3. Allin M, Rooney M, Cuddy M et al. Personality in young adultswho are born preterm. Pediatrics. 2006;117(2):309-316.

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0. Inder TE, Warfield SK, Wang H, Huppi P, Volpe JJ. Abnormalcerebral structure is present at term in premature infants. Pedi-atrics. 2005;115(2):286-294.

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AL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

VOLUME 49 NUMBER 5 MAY 2010