The immune system and psychiatric disease: a basic science perspective

Mental illness exerts a major burden on human health, yet evidence-based treatments are rudimentary due to a limited understanding of the underlying pathologies. Clinical studies point to roles for the immune system in psychiatric diseases, while basic science has revealed that the brain has an active and multi-cellular resident immune system that interacts with peripheral immunity and impacts behavior. In this perspective, we highlight evidence of immune involvement in human psychiatric disease and review data from animal models that link immune signaling to neuronal function and behavior. We propose a conceptual framework for linking advances in basic neuroimmunology to their potential relevance for psychiatric diseases, based on the subtypes of immune responses defined in peripheral tissues. Our goal is to identify novel areas of focus for future basic and translational studies that may reveal the potential of the immune system for diagnosing and treating mental illnesses.

Stimulant medication for the child with attention-deficit/hyperactivity disorder

Stimulant medications have been used to manage the associated symptoms of ADHD including inattention, developmentally inappropriate levels of activity, distractibility, and impulsivity. To date, clinical trials clearly have established the efficacy of the stimulants on the core symptoms of ADHD and associated aggression. Although the stimulants improve classroom productivity and behavior, few data have demonstrated the effectiveness of the stimulants on academic achievement. Finally, there has been a paucity of data on the long-term efficacy and safety of stimulants. Recommendations are made for future research studies that examine the integration of stimulant medication with other psychosocial therapies, particularly behavior management.

Developmental delay in fetal aminopterin/methotrexate syndrome

Maternal exposures to aminopterin and methotrexate have been associated with a pattern of malformation which includes prenatal-onset growth deficiency, severe lack of ossification of the calvarium, hypoplastic supraorbital ridges, small, low-set ears, micrognathia, and limb abnormalities. We report on a patient whose mother received methotrexate during the first trimester of pregnancy and who, in addition to the structural anomalies typical of maternal methotrexate exposure, has significant developmental delay. This is the third patient exposed to folic acid antagonists with mental retardation, providing further evidence that developmental delay is one feature of fetal aminopterin-methotrexate syndrome. Therefore, it is recommended that formal developmental testing be performed in all patients prenatally exposed to methotrexate.

Parents' perceptions of helpful vs unhelpful types of support in managing the care of preadolescents with chronic conditions

OBJECTIVE

To identify parents' perceptions of helpful vs unhelpful types of social support received in managing the care of preadolescents with chronic conditions.

DESIGN

Multimethod cohort study with 1-year follow-up.

SETTING

General community.

PARTICIPANTS

Volunteer, consecutive sample of parents of 124 preadolescents with a variety of chronic conditions.

METHODS

In-depth, in-home interviews conducted with parents. Quantitative data from the Social Support Assessment questionnaire was used to assess and compare sources and types of helpful support at baseline and 1 year later. Content analytic methods were used to categorize unsupportive behaviors described by parents during the first interview.

RESULTS

Both mothers and fathers reported that other family members were the primary source of helpful emotional and tangible support, while health care providers were the primary source of helpful informational support. The amount of perceived support from family members, community members, and service providers stayed relatively stable over time, except that fathers reported a significant increase in helpful emotional and informational support from extended family members from baseline to 1 year later. Also, 388 incidents of unsupportive behaviors were identified; the majority of these behaviors were attributed to health professionals and extended family members.

CONCLUSION

While patterns of perceived support remained relatively stable over a 1-year period, reports of unsupportive behaviors suggest gaps in service and problems that must be addressed to improve the care that children with chronic conditions and their families receive.

Social support in families of children with chronic conditions: supportive and nonsupportive behaviors

We questioned parents of 182 young children with a variety of chronic health conditions concerning the amount of emotional, informational, and tangible social support they received from the family, community, and service providers. We also asked parents to describe nonsupportive or hurtful behaviors received from family or community members. Both mothers and fathers reported that family members provided the most emotional and tangible social support and service providers the most informational support. The amount of perceived support from all sources increased over time, but 78% of mothers and 60% of fathers reported at least one instance of nonsupport from these same sources, primarily from extended family members and health professionals. We encourage health professionals to show respect and to provide timely, accurate information in a sensitive manner to parents whose child has a chronic health condition and to assist parents in handling nonsupportive behaviors from family and friends.

Long-term perspective on premature infant outcome and contemporary intervention issues

Despite improvements in survival rates for low birthweight (LBW) infants, the prevalence among survivors of major neurodevelopmental impairment seems relatively stable. Cerebral palsy, the most common major impairment, can usually be ruled out by 18 months corrected age. Minor impairments such as learning disabilities cannot be ruled out until much later. The efficacy of interventional services in this population was addressed by a national randomized trial. The intervention produced large treatment effects for heavier LBW infants and moderate effects for lighter infants. Five years later, modest residual effects were found for heavier LBW infants, but not for the lighter, suggesting that 0 to 3 services alone are not sufficient to prevent scholastic disadvantage in this population.

Experimental production and modulation of human cytotoxic dermatitis in human-murine chimeras

Human dermatitis-involving cytotoxic interaction between effector lymphocytes and epithelial target cells has thus far been documented in vivo only as naturally occurring disease or as an iatrogenic complication of organ engraftment. In this report, we reproduce human cytotoxic dermatitis via local microinjection of heterologous human lymphocytes into human skin xenografted to mice with severe combined immune deficiency syndrome. Injection sites develop progressive T cell epidermotropism culminating in cytotoxic dermatitis resembling human lichen planus within 4 weeks. Effector T cells express a CD8+, TIA-1+ phenotype, proliferate locally, express interleukin-2 surface receptors, and demonstrate interferon-gamma mRNA induction after microinjection. Migration of these T cells into the epidermis is closely linked to experimental induction and coincident expression of intercellular adhesion molecule by keratinocytes. T cell apposition to keratinocytes is associated with endonuclease-mediated DNA fragmentation (apoptosis) in the latter cell type. Intraepidermal T cell migration and related lesion formation is partially abrogated by systemic administration of antisense oligonucleotide to ICAM-1 mRNA. These findings demonstrate that human cytotoxic tissue injury directed against epithelial targets can be produced and modulated in chimeric mice.

Results at age 8 years of early intervention for low-birth-weight premature infants. The Infant Health and Development Program

OBJECTIVE

To reevaluate at age 8 years children who had participated during the first 3 years of life in a randomized clinical trial of special services for low-birthweight (LBW) premature infants.

DESIGN

Follow-up of a randomized controlled trial of premature infants (< or = 37 weeks' gestation), stratified by 2 LBW groups (lighter [< or = 2000 g] and heavier [2001-2500 g]) and divided into intervention (n=377) and follow-up only (n=608) groups.

SETTING

Eight sites serving diverse populations.

PARTICIPANTS

At age 8 years, 874 children were assessed: 336 in the intervention group and 538 in the follow-up only group.

INTERVENTION

The 3-year intervention consisted of home visits (birth to 3 years), child development center services (ages 1 to 3 years), and parent group meetings (ages 1 to 3 years).

PRIMARY OUTCOME MEASURES

Cognitive functioning (Weschler Intelligence Scale for Children-III; Peabody Picture Vocabulary Test-Revised); academic achievement (Woodcock-Johnson Tests of Achievement-Revised); and parental reports of school performance, behavior (Child Behavior Checklist), and health (Child General Health Survey).

RESULTS

At age 8 years, in the entire cohort and in the lighter LBW stratum, the intervention and follow-up only groups were similar on all primary outcome measures. Differences favoring the intervention group were found within the heavier LBW group: full-scale IQ score (4.4 points higher, P=.007), verbal IQ score (4.2 points higher, P=.01), performance IQ score (3.9 points higher, P=.02), mathematics achievement score (4.8 points higher, P=.04), and receptive vocabulary score (6.7 points higher, P=.001). On a physical functioning subscale, the whole intervention group received less favorable ratings, while the lighter LBW intervention group had lower maternal ratings assessing social limitations caused by behavior.

CONCLUSION

Although at age 8 years there were modest intervention-related differences in the cognitive and academic skills of heavier LBW premature children, attenuation of the large favorable effects seen at 3 years was observed in both the heavier and lighter LBW groups. This indicates a need to develop additional intervention strategies for LBW premature children that can provide sustained benefits.

Effect of incremental time experience on the results of in vitro fertilization with intracytoplasmic sperm injection (ICSI)

PURPOSE

Our objective was to determine the effect of experience on the results with intracytoplasmic sperm injection.

METHODS

The quarterly outcome with both ICSI and traditional in vitro fertilization (IVF) in 1994 was analyzed in 475 patients under age 40 undergoing 595 oocyte retrievals. The data represent 307 patients undergoing 379 retrievals for IVF and 165 patients undergoing 216 retrievals for ICSI.

RESULTS

Fertilization rates with ICSI improved significantly each quarter (52.96, 62.17, 70.17, and 74.87% in Q-I, Q-II, Q-III, and Q-IV, respectively), while the rate with IVF improved significantly between Q-I (69.9%) and Q-II (80.10%) and slightly but significantly between Q-II and Q-IV (82.88%). The implantation rate per embryo after ICSI improved significantly after Q-I (6.17%) compared to Q-II (10.70%) and Q-IV (12.14%). The pregnancy rate per transfer with ICSI increased steadily after Q-I (13.79, 21.88, 23.53, and 25.00% in Q-I through Q-IV), reaching statistical significance between Q-I and Q-III and between Q-I and Q-IV.

CONCLUSIONS

Although acceptable results can be obtained with ICSI after a relatively short period of time, optimum results require substantial experience.

Early intervention for low-birth-weight premature infants: what can we achieve?

Low-birth-weight (LBW) premature infants are at increased risk for abnormal development. It is unclear whether intervention programs designed to prevent the disabilities in preterm children are efficacious. This paper reviews the settings in which interventions take place (e.g. nursery, home) and to whom they are directed (e.g. infant, parent). One intervention program, the Infant Health and Development Program (IHDP) is reviewed in detail. The IHDP was a multisite randomized clinical trial to evaluate the efficacy of combining developmental and support services along with paediatric follow-up to reduce the developmental problems seen among LBW preterm infants. Results from all studies suggest that preventive developmental interventions for LBW, premature infants have thus far demonstrated only modest success. Future research endeavours should investigate the type, duration, critical age onset, and intensity of the intervention as well as which subgroups of LBW infants most benefit from such programs.

Breaking the news. How families first learn about their child's chronic condition

OBJECTIVE

To develop recommendations for effectively informing families about their child's chronic illness or disability.

METHODS

The sample included 43 families of infants with Down syndrome and/or congenital heart disease who were participating in Project Resilience, which is a multisite longitudinal research project. Family interviews were transcribed verbatim and coded by two raters. Qualitative techniques were used to identify the factors that influenced family caregivers' reactions to learning that their child had been diagnosed as having a chronic condition.

RESULTS

Family caregivers clearly distinguished their personal emotional reactions to the diagnosis from their reactions to how providers informed them about their child's condition. Families emphasized the quality of information that they received as well as the manner in which they were told about the condition. Although two thirds of the informing incidents were positive, families also reported negative reactions to outdated and inadequate information as well as to professionals who were insensitive to their needs.

CONCLUSIONS

Resident and continuing education programs need to prepare physicians who can sensitively and effectively "break the news" to diverse families who have children with chronic conditions. At the time of diagnosis, clinicians need to PACE the news by (1) planning the setting, (2) assessing the family's background knowledge and experience, (3) choosing strategies that best fit the family's particular situation, and (4) evaluating the family's understanding of the information.

Outcome of infants weighing less than 800 grams at birth: 15 years' experience

OBJECTIVE

Mortality and neurodevelopmental morbidity among infants weighing less than 800 g at birth are compared in three separate studies from the same intensive care nursery during an almost 15-year period.

METHODS

The survival and neurodevelopmental outcome of 210 infants with birth weights less than 800 g admitted to the University of Washington neonatal intensive care unit between 1986 and 1990 are compared with those of two previous cohorts (1977 through 1980 and 1983 through 1985) of extremely low birth weight (ELBW) infants from the same nursery.

RESULTS

Annual admissions of these ELBW infants nearly doubled from 1977 to 1990, whereas nursery survival rose from 20% between 1977 and 1980, to 36% between 1983 and 1985, to 49% in this current study of births between 1986 and 1990. The greatest increase in survival among the three studies occurred among infants with birth weights less than 700 g. Female survival was 20% higher than male survival in each of the time periods. The prevalence of major neurosensory impairments did not differ significantly among the three study groups (19%, 21%, and 22% respectively); male survivors were more commonly affected across time periods. There were no differences in mean cognitive test scores between the current 1986 through 1990 birth cohort (94) and the two previous cohorts (1977 through 1980, 98; 1983 through 1985, 89).

CONCLUSIONS

The experience of our center with these ELBW infants over time seems reassuring to the extent that progressive increases in nursery survival have not resulted in increased neurodevelopmental morbidity.

Preventive interventions with low birth weight premature infants: an evaluation of their success

The outcome literature on low birthweight (LBW) premature children indicates that they are at risk for a variety of neurodevelopmental impairments throughout childhood. To prevent such disabilities, numerous interventions have been initiated with LBW children. Nineteen intervention programs designed for LBW preterms that have published study results dating from 1971 are reviewed. Included are interventions in the neonatal nursery, at home, and at centers as well as interventions that are both child-focused and parent-focused. One randomized clinical trial evaluating comprehensive intervention services, the Infant Health and Development Program, is described in detail. Conclusions from the studies reviewed indicate that intervention programs have had only modest success in altering neurodevelopmental outcomes, although parent-child interaction has often been facilitated. Future research on the effects of preventive intervention needs to examine long-term developmental competencies and to replicate positive findings in multiple settings.

Early intervention in low-birth-weight premature infants. Results through age 5 years from the Infant Health and Development Program

OBJECTIVE

To evaluate the persistence of effects on health and development at age 5 years of the Infant Health and Development Program, an early childhood intervention that was provided to low-birth-weight (LBW) premature infants from neonatal discharge through age 3 years.

DESIGN

Randomized, controlled, multicenter trial, stratified by two LBW groups: lighter (< or = 2000 g) and heavier (2001 to 2500 g).

SETTING

Eight socioeconomically heterogeneous clinical sites.

PARTICIPANTS

Of 985 eligible infants weighing 2500 g or less and at 37 weeks' or less gestational age, 377 infants were randomly assigned to the intervention group and 608 to the follow-up only group. About two thirds of the infants in each group were in the lighter LBW stratum, and one third were in the heavier LBW stratum.

INTERVENTION

The intervention group received home visits (from neonatal discharge through age 3 years) as well as center-based schooling (from 1 to 3 years of age). Children in both groups received pediatric surveillance.

MAIN OUTCOME MEASURES

Cognitive development, behavioral competence, and health status.

RESULTS

At age 5 years, the intervention group had full-scale IQ scores similar to children in the follow-up only group. However, in the heavier LBW stratum, children in the intervention group had higher full-scale IQ scores (3.7 points higher; P = .03) and higher verbal IQ scores (4.2 points higher; P = .02). No significant differences between intervention and follow-up only groups in cognitive measures at age 5 years were noted in the lighter LBW infants. The intervention and follow-up groups were similar in behavior and health measures regardless of LBW stratum.

CONCLUSION

The early childhood intervention provided in the first 3 years of life had effects on heavier LBW premature infants' IQ and verbal performance at age 5 years that were not observed for lighter LBW premature infants. The intervention did not affect health or behavior at age 5 years in either LBW stratum.

Melittin-induced changes in lipid multilayers. A solid-state NMR study

Solid-state 1H, 13C, 14N, and 31P NMR spectroscopy was used to study the effects of the bee venom peptide, melittin, on aligned multilayers of dimyristoyl-, dilauryl- and ditetradecyl-phosphatidylcholines above the gel to liquid-crystalline transition temperature, Tc. Both 31P spectra from the lipid headgroups and 1H resonances from the lipid acyl chain methylene groups indicate that the peptide does not affect the mosaic spread of the lipid molecules at lipid:peptide molar ratios of 10:1, or higher. None of the samples prepared above Tc showed any evidence of the formation of hexagonal or isotropic phases. Melittin-induced changes in the chemical shift anisotropy of the headgroup phosphate and the lipid carbonyl groups, and in the choline 14N quadrupole splittings, show that the peptide has effects on the headgroup order and on the molecular organization in the sections of the acyl chains nearest to the bilayer surface. The spin-lattice relaxation time for the lipid acyl chain methylene protons was found to increase and the rotating-frame longitudinal relaxation time to markedly decrease with the addition of melittin, suggesting that motions on the nanosecond time scale are restricted, whereas the slower, collective motions are enhanced in the presence of the peptide.

Effects of ethanol and its fluorinated analogues on the calcium ATPase of sarcoplasmic reticulum

The effects of ethanol, monofluoro- and trifluoroethanol on the hydrolysis of ATP and coupled Ca2+ translocation by sarcoplasmic reticulum Ca(2+)-ATPase (EC 3.6.1.38) were measured. All three alcohols had parallel effects on the enzyme activities at concentrations up to 200 mM, suggesting a similar mechanism of action. 19F nuclear magnetic resonance spectroscopy was used to investigate their site of action in the purified enzyme.

Identification of neurodevelopmental abnormality at four and eight months by the movement assessment of infants

The predictive validity of infant neuromotor evaluation by the Movement Assessment of Infants (MAI) was investigated in low-birthweight infants. Motor performance at four and eight months was examined in relation to neurodevelopmental outcome at 18 months of age. Correlations were equally strong between total MAI risk scores at four and eight months and performance on the Bayley Scales. Muscle tone observations were more discriminating at four months, and automatic reactions and volitional movement were most predictive at eight months. The MAI was highly sensitive to neurodevelopmental abnormality at four and eight months and more sensitive than the Bayley Motor Scale; both assessment tools had lower specificity at eight months. The high false-positive rate is attributed to transient neuromotor abnormalities and immaturity of motor function in low-birthweight infants with normal outcome.

Effectiveness of developmental intervention in the first five years of life

Developmental intervention in the first 5 years of life is an expanding, complex enterprise. Documenting efficacy by traditional scientific methods has proven to be elusive for a number of practical reasons, e.g., target population heterogeneity, methodology variability, inadequate outcome measures, and cost of longitudinal cohort designs. Nevertheless, despite these shortcomings, there is accumulating research information as to which types of intervention approaches are likely to be most beneficial to specific groups of infants and children and their families. It is quite clear that preventive strategies for at-risk children and families are different than ameliorative strategies for children with established disabilities. It is also clear that comprehensive evaluation of effectiveness must include consideration of both functional child gains (e.g., social, communication, mobility, and adaptive skills) and enhancement of family function. It is the pediatrician's responsibility to be adequately informed about contemporary developmental interventions in order to balance parental hopes and needs with potential benefits.

Predictors of neurodevelopmental outcome following bronchopulmonary dysplasia

In infants with bronchopulmonary dysplasia, the influence of the severity of their pulmonary disease on neurodevelopmental outcome is unknown. Neurodevelopmental outcomes at a mean age of 36 months were assessed in 27 premature subjects who had bronchopulmonary dysplasia. Subjects had a mean birth weight of 940 g (range, 540 to 1690 g) and a mean gestational age of 27 weeks (range, 25 to 31 weeks). The duration of mechanical ventilation ranged from 22 to 128 days, and the duration of requirement of supplemental oxygen ranged from 34 to 1033 days. No significant correlations were found between duration of mechanical ventilation or oxygen therapy and overall neurodevelopmental outcome. In contrast, cranial ultrasound findings of intracranial hemorrhage and/or periventricular echodensity related specifically to poorer cognitive outcome. By age 3 years, severity of bronchopulmonary dysplasia is not a sufficient predictor of neurodevelopmental outcome. Intracranial hemorrhage and periventricular echodensity continue to be important predictors.

Diet and female sex hormone concentrations: an intervention study for the type of fat consumed

A possible mechanism by which dietary fat may influence the development of breast cancer is by influencing the concentration of female sex hormones. This study investigated the effect of alteration in the type of fat consumed on concentrations of female sex hormones in serum. Female volunteers were randomly assigned to continue on their usual meat-eating diet, change to a vegetarian diet, or change to a diet that was predominantly vegetarian but where fish was consumed at least three times per week. Change to the vegetarian or fish diet had little effect on diet total hormone concentrations; however, the amount of estradiol was significantly decreased in the vegetarian group. When nutrient consumption was correlated with hormone concentrations, prolactin was directly associate with fat consumption, sex-hormone-binding globulin was inversely associated with fat consumption (particularly cholesterol consumption), and the proportion of nonprotein-bound estradiol was directly associated with complex carbohydrate consumption.

Birth weight less than 800 grams: changing outcomes and influences of gender and gestation number

Mortality and neurodevelopmental morbidity were compared in two cohorts of neonates with birth weights of less than 800 g. The neonates, born in the years 1977 through 1980 (original cohort) and 1983 through 1985 (current cohort), were patients in the same university intensive care nursery. Mortality was 80% in the original cohort and 64% in the current cohort (P = .01). In the current cohort, survival was significantly better for neonates with birth weights of more than 749 g (58% vs 27%; P = .001). Survival was also significantly associated with gender and with gestation number (female survival was 48% and male survival was 23%, P = .003; singleton survival was 41% and twin survival was 21%, P = .03). Prevalence of major central nervous system handicaps did not significantly differ between the two study groups, but severity of handicap was worse for the current study group. Morbidity in the current cohort was most severe for twins (67% with a major central nervous system handicap) and was least severe for singleton girls (4% with a major central nervous system handicap, P = .002). Delivery mode appeared to affect outcome. Although there were more nursery admissions and more survivors among neonates with birth weights of less than 800 g during the period 1983 through 1985 compared with the period 1977 through 1980, overall neurodevelopmental morbidity worsened.

Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants

In a multicenter, randomized clinical trial, we assessed the early neurologic development of 93 children born prematurely whose heart rates were monitored electronically during delivery and compared it with that of 96 children born prematurely whose heart rates were periodically monitored by auscultation. All the children were singletons with cephalic presentation, and all weighed less than or equal to 1750 g at birth. The mental and psychomotor indexes of the Bayley Scales of Infant Development (standardized mean score +/- SD, 100 +/- 16) and a formal neurologic examination were administered at three follow-up visits (at 4, 8, and 18 months of age, corrected for gestational age). At 18 months, the mean mental-development scores in the groups receiving electronic fetal monitoring and periodic auscultation were 100.5 +/- 2.4 and 104.9 +/- 1.8, respectively (P greater than 0.1). The mean psychomotor-development scores in the two groups at 18 months were 94.0 +/- 2.4 and 98.3 +/- 1.8, respectively (P greater than 0.1). The incidence of cerebral palsy was higher in the electronically monitored group--20 percent as compared with 8 percent in the group that was monitored by auscultation (P less than 0.03). In the electronic-fetal-monitoring group (but not in the periodic-auscultation group), the risk of cerebral palsy increased with the duration of abnormal fetal-heart-rate patterns, as assessed by retrospective review (chi 2 trend = 12.71, P less than 0.001). The median time to delivery after the diagnosis of abnormal fetal-heart-rate patterns was 104 minutes with electronic fetal monitoring, as compared with 60 minutes with periodic auscultation. We conclude that as compared with a structured program of periodic auscultation, electronic fetal monitoring does not result in improved neurologic development in children born prematurely.

Periventricular echodensities detected by cranial ultrasonography: usefulness in predicting neurodevelopmental outcome in low-birth-weight, preterm infants

Forty-eight low-birth-weight, preterm graduates of the University of Washington's neonatal intensive care unit who had received periodic, serial scanning by means of cranial ultrasonography during the first 4 to 6 weeks of life were longitudinally observed in an interdisciplinary neurodevelopmental follow-up program to a mean corrected age of 18 months. Mean birth weight for the sample was 1286 g; mean gestational age was 29 weeks. Periventricular echodensities were graded from 0 to 3, with 0 indicating no densities and 3 indicating cystic formation. Intracranial hemorrhage was graded in the conventional manner from 0 to IV. Neurodevelopmental outcome was assessed by means of a neurologic examination and the Bayley Scales of Infant Development. To synthesize the results, neurodevelopmental outcome for each subject was classified as normal, demonstrating minor abnormalities, or demonstrating major abnormalities. Multiple statistical analyses with various subgroupings of subjects consistently indicated severe intracranial hemorrhage (grades III and/or IV) to be a better predictor of overall neurodevelopmental outcome than grade of periventricular echodensity, including small cysts. These results suggest a wide range of outcomes after detection of periventricular echodensities and caution against communicating overly pessimistic prognoses in many cases.

Preschool motor skills of children born prematurely and not diagnosed as having cerebral palsy

To evaluate the preschool motor skills of children born prematurely, we examined 90 children who were participating in a longitudinal follow-up program at 4 1/2 years corrected age. Children with major neurological impairments, such as cerebral palsy, were excluded from this investigation. Study subjects' gestational ages ranged from 24 to 36 weeks. Both gross and fine motor function were assessed with standardized instruments. Overall, the later motor development of these children was reassuringly intact and within the average range on all measures. Nevertheless, extremely low birth weight (less than 1000 g) children as a group displayed significantly inferior skills in all motor functions. Symptomatic intracranial hemorrhage was also associated with significantly poorer motor performance.

Pediatricians' perceptions of the effectiveness of early invention for at-risk and handicapped children

To evaluate pediatricians' perceptions of the effectiveness of early intervention for handicapped and at-risk children, all board-certified pediatricians in the state of Ohio were surveyed. A detailed questionnaire was developed which included the use of brief but specific cases identifying eight different children with documented handicaps and two cases of children at developmental risk. Overall, the results indicated that pediatricians judged early intervention to produce at least a modest effect on children's general development and function. A more optimistic perspective was held for families in that involvement in early intervention was viewed as improving substantially the ability of families to cope with the problems of a handicapped or at-risk child and to provide a supportive and stimulating environment. However, perceptions of effectiveness did vary for specific disability and at-risk groups. The correspondence between perceived effectiveness and existing research findings also was discussed.

Effect of low-fat diet on female sex hormone levels

The hypothesis that dietary fat acts as a promotional agent for the development of breast cancer by influencing sex hormone levels was tested in a dietary intervention study. Thirty-three women in good health were randomly allocated to commence either a standard diet (deriving 40% of their energy from fat) or a low-fat diet (deriving 20% of their energy from fat). After 2 months, the women were crossed over to the alternative diet for another 2 months. Serum hormone and lipid levels were measured in the middle and at the end of each dietary period. In premenopausal women, the low-fat diet appeared to decrease levels of both non-protein-bound estradiol (1.48 down to 1.27%; P = .07) and non-protein-bound testosterone (1.06 down to 0.86%; P = .11). Cholesterol levels were lowered by the low-fat diet and were significantly associated with estradiol, testosterone, and dehydroepiandrosterone. High-density lipoprotein (HDL) cholesterol was associated with estradiol and prolactin. For the postmenopausal women, the low-fat diet lowered cholesterol and HDL cholesterol levels, but there were not the same associations with the hormones. These findings add weight to the concept that attention to diet may be a means of reducing the incidence of breast cancer in our community.

Training residents in developmental pediatrics: results from a national replication

This investigation examined the extent to which a structured curriculum in developmental pediatrics could be applied effectively to a wide range of pediatric residency training programs. Residents drawn principally from sites not involved in the original development of a curriculum in developmental pediatrics were assigned randomly to prerotation control or postrotation experimental groups. Based on an objective case management test, residents who had participated in the rotation defined by the curriculum scored significantly higher than those who had not. Differences between experimental and control groups were similar for both the first and second evaluation years and for residents drawn from the original and new sites (total n = 161). Subjective evaluations by residents and faculty preceptors confirmed the utility of curriculum.

Status of infants at birth and risk for adverse neonatal events and long-term sequelae: a study in low birth weight infants

We evaluated the relationship of infant status at birth to neonatal morbidity and long-term development in 246 low birth weight infants (600 to 1750 gm). Nineteen percent of infants had 1-minute Apgar scores of less than or equal to 3, and 8% had an umbilical artery pH of less than or equal to 7.2. Acidosis was associated with an increased risk of grade 3 to 4 intracranial hemorrhage (odds ratio = 3.3). Low 1-minute Apgar score was associated with an increased risk of death (odds ratio = 4.8). Grade 3 to 4 intracranial hemorrhage was a strong risk factor for cerebral palsy among survivors (odds ratio = 16.1), as was low 1-minute Apgar score (odds ratio = 2.9). Only 15% of cases of cerebral palsy in this study were associated with acidosis at birth.

Williams syndrome: features in late childhood and adolescence

Nine children with the Williams syndrome were evaluated for physical, neurodevelopmental, and behavioral characteristics to record the natural history of this disorder. The study subjects, who ranged in age from 10 years to 20 years, generally showed lower than expected cognitive functioning with four of the nine functioning in the severely retarded range. However, all the children showed uneven developmental profiles, compared to measured IQ, with reading abilities exceeding the expected level and visual-motor skills deficient for overall performance expectations. All but one child had evidence of supravalvular aortic stenosis on echocardiography, but there was little morbidity from cardiovascular disease in this group of patients. Although all had grown at or below the fifth percentile in early childhood, seven now were above the fifth percentile for height. Personality attributes that characterize younger children with Williams syndrome persisted in this group of older children.

The relationship between the Bayley Scales of Infant Development and preschool gross motor and cognitive performance

Early identification of disabilities enables early intervention by occupational therapists and other health professionals. Because the number of children who can be seen in therapy is limited, it is important to be able to identify those infants most likely to have deficits at a later age. Therefore, it is necessary to study and understand the relationship between infants' scores on early developmental assessments and later developmental outcomes. The purpose of this study was to determine the extent to which scores on the Bayley Scales of Infant Development (BSID) during the first 2 years of life are related to motor and cognitive performance at 4 1/2 years for a sample of children identified at birth as biologically high risk. This retrospective study involved 70 children who were evaluated at corrected ages of 4 months, 1 year, 2 years, and 4 1/2 years. The 4-month BSID Mental and Motor Scale scores did not relate significantly to later cognitive motor performance. In contrast, the 12-month BSID Mental Scale scores related significantly to preschool scores on both the motor and cognitive measures. However, the 24-month BSID Mental Scale scores related significantly only to scores on the preschool cognitive measures. Though significant, these correlation coefficients had small magnitudes. Thus, therapists should be cautious about using BSID testing at 4 months, 1 year, and 2 years when attempting to predict later preschool performance.

Use of physical and neurologic observations in assessment of gestational age in low birth weight infants

The relative validities of three clinical assessment methods for estimating gestational age in newborn low birth weight infants were evaluated with reference to estimates based on the date of the mother's last menstrual period. For 1246 infants in eight diverse institutions, estimates based on physical criteria correlated more strongly with dates estimates, yielded estimates more similar on average to dates estimates, and yielded higher proportions of correct classifications of prematurity and small for gestational age than did estimates based on neurologic criteria or neurologic and physical criteria combined. These results support the use of physical criteria rather than neurologic or combined criteria for the clinical assessment of gestational age in low birth weight infants. In a subsample of 511 black and white infants, there were no ethnic differences in mean error of estimate for any of the three methods.

Neurodevelopmental outcome following persistent pulmonary hypertension of the neonate

The neurodevelopmental status of 12 children with persistent pulmonary hypertension of the newborn (PPHN) was examined. All had neonatal documentation of PPHN by echocardiogram, and all were ventilated at least 72 hours. The mean age at follow-up was 20 months (range, 12-28). Five of the 12 subjects were normal at follow-up, three were felt to be suspect but not clearly abnormal, and four had neurodevelopmental abnormalities, including three with sensorineural hearing impairment (25 per cent incidence in this study). These findings represent a concerning frequency of neurodevelopmental dysfunction and support early routine hearing evaluation in this unique subgroup of neonatal intensive care unit survivors.

The high risk infant: transitions in health, development, and family during the first years of life

Greater numbers of preterm, low birth weight ("high risk") infants are surviving than ever before. It has become increasingly important for physicians and other health care professionals to become familiar with the many real and potential problems seen in this population of children during the first years of life and beyond. The residue of illnesses that are presented in the neonatal intensive care nursery and major health vulnerabilities of the early years are discussed in this article. Normal variations in neurodevelopmental patterns unique to preterm infants and neurodevelopmental disabilities which have a higher prevalence in this population are presented. The impact of a high risk infant on the family unit is described. Finally, resources and interventions available to the child, family, and health care provider during and following the transition from the hospital to home are reviewed.

Neuromotor development of graduates of the neonatal intensive care unit: patterns encountered in the first two years of life

The neurodevelopmental course of 219 Neonatal Intensive Care Unit graduates followed prospectively over 2 years was determined on retrospective chart review. Mild neuromotor abnormalities during the first year were identified in 50%, three-quarters of which proved transient with normal development at 2 years of age. Moderate abnormalities were identified in 7%, half of which proved transient. Severe neuromotor abnormalities were identified in 20%, two-thirds of whom had cerebral palsy at 2 years. Persistent noncerebral palsy neuromotor abnormalities remained in one-third of those in the severe abnormality group, one-half of those in the moderate abnormality group, and one-quarter of those in the mild abnormality group. As birthweight decreased, the incidence of always normal development and transient neuromotor abnormalities decreased while the incidence of persistent neuromotor abnormalities increased. Small for gestational age infants demonstrated a slightly higher incidence of persistent abnormalities than their appropriate for gestational age counterparts. No significant sex differences were observed.

Co-localization of non-histone protein BA with U-snRNPs to the same regions of the cell nucleus

Using indirect immunofluorescence, nuclear non-histone protein BA was localized in a normal rat liver cell line. Protein BA antibodies immunostained nuclear structures producing a speckled immunofluorescent staining pattern. Nuclear structures stained with protein BA antibodies were sensitive to DNase I digestion, but not to RNase. The speckled pattern of nuclear fluorescence observed with protein BA antibodies was similar to that reported earlier for Sm antibodies, which react with U-snRNPs. Using double-label indirect immunofluorescence, the Sm antigen was shown to be concentrated in the same regions of the nucleus which contain protein BA. Immunoblot analysis of total nuclear proteins with the two antibodies demonstrated that protein BA and the major Sm antigen have similar molecular weights, but are antigenically distinct. In addition, they differ in their extractabilities from the cell nucleus.

Follow-up of infants receiving cranial ultrasound for intracranial hemorrhage

Intracranial hemorrhage (ICH) was detected in 38 preterm neonates, using cranial ultrasonic (US) scanning. Forty-three preterm neonates examined during the same period but who had no cranial US evidence of ICH were also identified. Neurodevelopmental follow-up was performed at a mean age of 22.3 months on these 81 children. As a group, children with ICH demonstrated developmental indexes in the normal range but about ten points lower than children without ICH. The outcome in survivors of grade III ICH was quite similar to the outcome in survivors of grades I and II ICH. Survivors of grade IV (intraparenchymal) hemorrhage had a worse outcome. Cerebral palsy was significantly more prevalent in children with ICH. Only two thirds of children without ICH had a completely normal outcome, reinforcing the concept that factors other than ICH alone contribute to neurodevelopmental morbidity in this population.

Predictive validity of the "Movement Assessment of Infants"

Early identification of neuromotor deficits, cerebral palsy or other neurological handicaps, is a focus of concern for neurologists, pediatricians, and developmental therapists. Among infants at risk for developing these handicaps are those with low birthweight, idiopathic respiratory distress syndrome, and early central nervous system insults. The Movement Assessment of infants (MAI), a neuromotor assessment tool, was developed for the purpose of evaluating high-risk infants participating in the University of Washington's Neonatal Intensive Care Unit Followup Clinic. The predictive validity of the MAI was evaluated for 246 infants for whom assessments had been completed at four months and for whom at least one set of followup data was available at either one or two years of age. Correlations between the MAI total risk score and all five of the outcome measures at one and two years were highly significant. The clinical relevance of this study in the use of the MAI as an evaluation tool for identifying infants with neuromotor dysfunction is discussed.

Teaching developmental pediatrics to pediatric residents: effectiveness of a structured curriculum

A national Task Force on Developmental Pediatrics was convened in 1979 to produce a curriculum for pediatric residents pertaining to the detection, assessment, and management of children with atypical development. During a 2-year period, the task force developed a structured curriculum composed of specific goals, educational objectives, and matched learning activities that identified and described the basic knowledge, skills, and attitudes of developmental pediatrics to be acquired during a pediatric residency. Subsequently, the curriculum was implemented and evaluated in 11 pediatric programs with a developmental pediatrics rotation. On a seven-point subjective scale, the mean resident (n = 64) rating of the curriculum's usefulness was 6.0 and of their perceived competence in the skills of developmental pediatrics was 5.2; the mean percent of this competence attributed to the curriculum-based rotation was 56.6. On an objective case management test, residents who used the curriculum scored significantly (P less than .005) higher than those who did not. These results suggest the efficacy of structured curricula in pediatric resident education.

Antibodies to a nucleolar protein are localized in the nucleolus after red blood cell-mediated microinjection

To determine whether red blood cell-mediated microinjection of antibodies can be used to study nuclear protein localization and function, we microinjected antibodies that have been shown to react specifically with nucleolar acidic phosphoprotein C23 into Walker 256 cells. The intracellular distribution of microinjected anti-C23 antibodies and preimmune immunoglobulins were determined by immunofluorescence. At 3 h after microinjection, affinity-purified anti-C23 antibodies were localized in the cytoplasm and nucleolus. At 17 h after microinjection, the affinity-purified antibody was localized to those nucleolar structures previously shown to contain protein C23. Furthermore, the antibody remained localized in the nucleolus for at least 36 h after microinjection. In contrast to the results obtained with specific antibodies, preimmune immunoglobulins remained in the cytoplasm 36 h after microinjection. These results indicate that red blood cell-mediated microinjection of antibodies can be used to study nucleolar and nuclear antigens.

Vitamin and mineral supplementation in Down's syndrome

The claim that large, nonspecific doses of vitamins and minerals improve the performance of mentally retarded children has recently reappeared in both the scientific literature and the public media. This hypothesis was examined in a double-blind, case-control study involving 20 home-reared children with Down's syndrome between 5 and 13 years of age. Children were randomly assigned by matched pairs to either a vitamin/mineral group or placebo group for an 8-month study period. No significant group differences or suggestive trends were found in any tested area of development or behavior, including intelligence (IQ), school achievement, speech and language, and neuromotor function. No group differences in appearance, growth, or health were seen. No support was found for the orthomolecular hypothesis in school-aged children with Down's syndrome.

An improved procedure for the 'dot immunobinding' analysis of hybridoma supernatants

The recently introduced dot immunobinding assay is well suited as a rapid and sensitive procedure for the analysis of those hybridoma clones that are producers of a specific antibody. We present a modification of the dot immunobinding assay which utilizes a single nitrocellulose sheet for up to 96 assays. By using a single nitrocellulose sheet, sample manipulation is greatly reduced, reaction conditions can be better standardized and a comparison of background reactivities is provided. Results are presented which demonstrate the effectiveness of this modified dot immunobinding assay.

Management of childhood "hyperactivity" by primary care physicians

A questionnaire assessing current clinical approach to the problem of childhood hyperactivity was mailed to 910 primary care physicians in the state of Washington. A response of 462 (50.8%) was obtained. Pediatricians assess and manage hyperactivity in a manner significantly different from that of family physicians or general practitioners. Age of physician also accounted for significant differences, although to a lesser degree than type of training. Few differences were determined by size of community. An overall high prevalence of the problem of hyperactivity was apparent. Combined use of stimulant medications, behavioral programs, and special diets was common.