Issues in Child Health and Adolescent Health

Handbook of Psychology and Health, Volume 2

A. Baum, J. E. Singer, Jerome L. Singer

• Publisher: Psychology Press
• Year: 2013
• Topic: Psychology
• eBook ISBN:
  9781134920570
• Subtopic: History & Theory in Psychology
• Index: Psychology

Published in 1982, Issues in Child Health and Adolescent Health is a valuable contribution to the field of Psychology PP.

1	Prenatal and Neonatal Issues in Pediatric Practice

Paul Buck
University of Oklahoma Health Sciences Center

Logan Wright
The Wright Foundation
Oklahoma City, Oklahoma

INTRODUCTION

Watson (1925) stated that psychological science can shape the life and training of any child. It is unlikely that many psychologists today would make a statement of Watson's degree, that is that all learning and development can be totally controlled, but certainly the psychologist has much to offer in studying the early influences of various conditions on the child and in providing appropriate and timely interventions in the life of the child to foster healthy development. This can be done to affect both the psychological and the physical health of the human. The role of the psychologist in the neonatal pediatric case, in or out of the hospital, is one mechanism for these contributions, and the functions of the psychologist are widely varied in this time. His or her responsibility to the well-being of the child may well extend to the stage of conception or before (Wright, Schaefer, & Solomons, 1979), and certainly extends through various aspects of the pregnancy and into the independent life of the child.

The present chapter attempts to explore some of the issues in research and clinical intervention in prenatal and neonatal pediatric cases. One cannot avoid considering the impact of perinatal variables upon the subsequent growth and development of the infant.

It is the purpose of this chapter to provide the practitioner an introduction to the basic and/or most prevalent issues in these periods of the human infant. As a handbook resource it is hoped that the present chapter will constitute a practical introduction with specific resources for the extremely wide variety of research and technique already published. At appropriate times references to already available resources will be noted in an effort to maintain a moderately comprehensive introduction without becoming overly involved with specific details. In a practical sense, various examples are used to illustrate issues or principles. The authors hope it will provide a starting point for practitioners not previously exposed to neonatal practice, and as a basic resource to finding techniques for the clinician facing these issues in practice.

The work of the second author, with his various colleagues, is already extensive and has naturally been drawn upon for research resources and clinical technique. This chapter has in no way attempted to reproduce that work or its comprehensiveness. Rather, it has been the goal to return to many of the original sources of the work, particularly the Handbook of Pediatric Psychology (Wright, et al., 1979) with the first author trying to extract those sources most pertinent to a general understanding of the issues and to supplement those references with additional information not available at that time.

GENETIC COUNSELING AND BIRTH DEFECTS

Gordon (1971) presented comparisons of infant mortality rates for congenital malformations and diarrheal infections or diseases. In the period from 1910 to 1965 the relative proportions of actual deaths for these causes reversed. In 1965 six infants died from various congenital causes for each one from infections. At the same time, deaths from congenital malformation dropped by 3.2%, from 6.8 to 3.6%. Clearly there are now more surviving congenitally malformed infants than previously, with similar statistics reported by Estes (1970).

Saxén and Rapola (1969) place the total incidence of congenital defect at approximately ten percent of human embryos, stillbirths and live births. Half of these defects are embryonic, with the other half detected at birth or in follow-up studies. This five % of embryonic defects is also found in the estimates of morbid and mortal defects at birth or in follow-up reported by Golub (1969), Gordon (1971), and Townes (1970). Accurate data on the lethality of embryonic defects is not known, but is estimated at about 25% of spontaneous abortions. Carr (1967) and Inhorn (1967) estimate that twenty % of human pregnancies abort spontaneously. Statistics on stillbirths are of questionable value (Saxén and Rapola, 1969), but these same authors suggest that approximately .5 percent of the total liveborn population presents potentially lethal congenital defect.

Murphy and Chase (1975) present a current review of genetics and the influence upon these statistics, as well as upon prenatal diagnosis. Gordon (1971) covers similar topics. Wright et al. (1979) present a brief review of the material from a variety of sources. Gordon (1971) states that a 2.5% risk factor is used for the general population probability, to compare the specific risk for problems in a single family. Genetic counseling becomes appropriate when the probability of defect passes this point. The potential benefit of genetic counseling is seen when one considers that 6% of hospital admissions in pediatrics involve a condition with a definite genetic origin and another 15% have a questionable genetic cause (Lynch & Harlan, 1972).

Wright et al. (1979) suggest that cooperation between genetic counselors and psychologists might improve the effectiveness of counseling and reduce the incidence of congenital defects. They cite evidence collected by Carter (1969) that the goals of counseling are not adequately met in that a high proportion of parents at low risk for producing a malformed infant choose not to conceive after counseling, while a fairly high proportion of high risk parents choose to conceive, although the frequency of deciding not to conceive remains higher in the high risk group. Although genetic counseling has been compared to brief psychotherapy (Lynch & Harlan, 1972; Rainer, 1967) the primary definition of qualification has been a geneticist/physician, with collaboration from other professionals (Murphy & Chase, 1975). Although recognizing that the counselor should be aware of the psychological reactions of consultands, psychologists are not listed in the other professions included by Murphy and Chase. With the expanding role of psychologists in medical settings involvement in genetic counseling and research is to be considered.

A number of psychological factors affecting the outcome of genetic counseling have been proposed. Pearn (1973) cites preconceived notions both of the odds and of the meaning of odds as influencing parental decisions. In the same paper it is suggested that the very discussion of risk may increase the probability of taking that risk. Pearn suggests that this is further influenced by the character of the consultand. On the other hand, “risk” does not refer only to the production of a defective fetus or infant, but also to the impact of the defect upon the family. Psychological consultation may well help in reducing these risks.

Wright et al., citing numerous previous studies, (1979) state that the majority of persons seeking genetic counseling are parents of a previously affected child. Rainer (1967) states that the most frequent causes are mental illness, neurologic disease, mental retardation, and deafness. Even in these groups the rate of consultation is low. Reisman and Matheny (1969) report that the majority of families presenting a history of familial retardation are not referred and do not seek counseling. Thus the population facing a psychologist in a consultation situation is not necessarily the group most in need of help.

The major psychological distresses of genetic disorders for the parents, as summarized by Wright et al. (1979), are related to guilt. There is, they state, a secondary fear of producing another affected child. This may eventually lead to sexual disturbance (Emery, Watt, & Clack, 1973; Tips & Lynch, 1963) and other factors seriously affecting the marriage and family (Gordon, 1971; Lynch, 1969; Lynch & Harlan, 1972).

While the primary professional in counseling probably should remain the physician, the psychologist has two major roles in genetic counseling. First, the psychologist needs to be aware of the various personal, characterologic, and experiential variables which affect the outcome of counseling and thus provide therapeutic work with the family or potential parents in decision making in a supportive and reassuring way. (Fraser, 1970; Lynch, 1969; Sly, 1973). Second, given the fact that the persons most likely to seek counseling are already parents of an affected child (Estes, 1970; Wright et al., 1979), the psychologist will help the parents in exploring and ventilating feelings about the affected child to aid in realistic decisions about the future risks (Gordon, 1971). At a less direct level the psychologist can provide consulting services to the geneticist in manners similar to those of other professionals as in Murphy and Chase (1975). In this consulting role the psychologist can help the geneticist in dealing with the family and in planning research follow-up of families receiving counseling and also to assess reactions of the families and of counseling outcome. (Wright et al., 1979). With respect to future pregnancy or risk evaluation, new methods of evaluating counseling outcome could be provided (Wright et al., 1979) and adjustment following the production of an affected child is an additional avenue for the psychologist (Sly, 1973).

PRENATAL CONDITIONS

Monie (1963) has cited three levels of prenatal environment which affect the developing infant. The immediate environment, or microenvironment, includes the placenta and amniotic fluid, and is connected to the greater environment of the mother's body, or macroenvironment. These two levels interact through the biochemical exchange of many compounds. Congenital syphilis, discussed later as an example, illustrates some of the significance of this interaction. Rh incompatibility, prenatal malnutrition, drug ingestion by the mother, and maternal disease also affect this interaction (Mussen, Conger, & Kagan, 1979). The third level of the prenatal environment is seen in the external environmental situation. This may act upon the fetus directly, as through trauma or radiation exposure, or indirectly by way of the macroenvironment as in the case of oxygen deprivation. Certain prenatal conditions have been shown to have significant effect upon the developmental integrity of the fetus.

Pasaminick and Lilienfield (1955) proposed a model of general maternal insufficiency, or reproductive causality, to account for much of the similarity seen between the various environmental levels in their effects upon the fetus. The effects of nutrition, ingestion, illness, and emotional characteristics, if they affect the fetus, tend to produce similar effects of small size, minor neurological impairment, and differences in temperament in infants (Mussen, et al., 1979). Under this insufficiency model there is a continuum of fetal and infant development ranging from fetal and neonatal death to subtle sublethal effects (Wright et al., 1979), and the model suggests that the probability of any of these factors appearing in the mother increases as others appear.

The major factors relating to this insufficiency syndrome, according to Wright et al. (1979), are drugs and ingestions (illicit drugs, substance abuse, prescription and over-the-counter drugs, tobacco, and alcohol), maternal health and development (infectious diseases, diabetes, seizure disorder, hypertension, maternal toxemia), maternal condition in general (genetic characteristics, Rh incompatibility syndromes), nutrition, external environmental conditions (radiation, trauma, living conditions) and emotional status of the mother. In general the collected data suggest that most of these conditions, other than general biological and genetic status of the mother, show greatest risk to the fetus in the third to the twelfth week of pregnancy, sometimes before the mother is even aware of pregnancy. The most frequent fetal/neonatal effects described include prematurity, low weight for gestational age, increased neonatal illness and jaundice, and varying degrees of mental or cognitive impairment. At the most impaired end of the continuum are microcephaly and other major birth defects, severe mental retardation, and spontaneous abortion or stillbirth. Specific effects besides those noted above in the general insufficiency syndrome are also reported, including cleft lip and/or palate and congenital heart disease with epilepsy in the mother (Meadow, 1968), respiratory distress and large—for-gestational-age—birth-weight with poorly controlled maternal diabetes (Gellis & Hsia, 1959), and the more specific fetal alcohol syndrome (Mussen et al., 1979). Sawin, Hawkins, Walker, and Penticuff (1980) describe a taxonomy of risk factors including fetal environmental factors.

At an intervention level, management of these various conditions is often a medical issue. There remain, however, two major foci for the psychologist. The first relates to the direct emotional status of the mother prior to conception and during pregnancy. Fertility and spontaneous abortion have been documented in relation to disturbance on psychometric testing, with improvement with psychotherapy (Grimm, 1962; Rothman, Kaplan & Nettles, 1962; Weil & Tup-per, 1960). The principal emotional variable requiring intervention in these studies is anxiety.

The second avenue for the psychologist in dealing with various maternal issues lies in maintaining compli...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• Contents
• Preface
• 1. Prenatal and Neonatal Issues in Pediatric Practice
• 2. Developmental Jeopardy in the First Year of Life: Behavioral Considerations
• 3. Hypertension in Adolescents
• 4. Developmental Antecedents of Schizophrenia
• 5. The Type A Behavior Pattern in Children and Adolescents: Assessment, Development, and Associated Coronary-Risk
• 6. Developmental Processes in the Experience of Menarche
• 7. Behavior Management in Pediatric Dentistry
• 8. Coping With Juvenile Onset Diabetes Mellitus
• 9. The Behavioral Disorders of Children with Spina Bifida
• 10. Modifying Health Lifestyles in Children and Adolescents: Development and Evaluation of a Social Psychological Intervention
• 11. Environment and Children’s Mental Health: Residential Density and Low Income Children
• Author Index
• Subject Index