Adult psychiatric outcomes of very low birth weight survivors

Elizabeth M. Westrupp, Elisabeth Northam, Lex W. Doyle, Catherine Callanan, Peter J. Anderson

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Background: Childhood studies have identified relationships between low birth weight and a variety of psychological disorders. However, very few studies have prospectively followed VLBW survivors into adulthood and none have examined adult psychiatric disorders in this population. Objective: This exploratory study sought to determine the rates and nature of psychiatric disorders in very low birth weight (VLBW, birth weight 1500 g) adults. Method: 117 VLBW participants and 32 normal birth weight (NBW, birth weight 2499 g) controls, born 1977-1982, were assessed in early adulthood (2429 years). Participants were first screened for psychopathology using the Symptoms Checklist (SCL-90-R). Participants who were elevated on this measure were eligible for a Structured Clinical Interview for DSM-IV-TR (SCID-I/NP) to determine a formal psychiatric diagnosis. Results: VLBW adults were more likely than controls to be elevated on the Global Severity Index (odds ratio (OR) 4.29, 95% confidence interval (CI) 0.96, 19.14) and the depression (OR 5.17, 95%CI 1.17, 23.00), paranoid ideation (OR 4.08, 95%CI 0.91, 18.23), hostility (relative risk (RR) 1.34, 95%CI 1.21, 1.49), and interpersonal sensitivity (OR 3.80, 95%CI 1.08, 13.32) subscales of the SCL-90-R. VLBW adults were also more likely to be diagnosed with a current mood disorder than NBW adults (RR 1.36, 95%CI 1.22, 1.51). Conclusions: VLBW adults are at greater risk of psychopathology than NBW peers. Key words: perinatal, longitudinal, very low birth weight, adult, psychiatric, psychopathology Australian and New Zealand Journal of Psychiatry 2011; 45:10691077 DOI: 10.3109/00048674.2011.620561 Children born at very low birth weight (VLBW; birth weight 1500 g) and/or very preterm (gestational age 32 weeks) are known to be at increased risk for a range
Elizabeth M. Westrupp, Research Fellow and Clinical Psychologist (Correspondence), Lex W. Doyle, Head, Clinical Research Development, Peter J. Anderson, Principal Research Fellow Murdoch Childrens Research Institute, Melbourne, Australia; University of Melbourne, Melbourne, Victoria, Australia; Royal Womens Hospital, Melbourne, Victoria, Australia; Email: ewestrupp@ parentingrc.org.au Elisabeth Northam, Senior Research Fellow and Co-ordinator, Academic & Research Murdoch Childrens Research Institute, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia; Royal Childrens Hospital, Melbourne, Victoria, Australia Catherine Callanan, Research Nurse Murdoch Childrens Research Institute, Melbourne, Victoria, Australia; Royal Womens Hospital, Melbourne, Victoria, Australia 2011 The Royal Australian and New Zealand College of Psychiatrists

of cognitive, academic, behavioural, and psychological problems [13]. Although there is an extensive body of research examining child and adolescent outcomes, follow up into adulthood is rare. Some studies have reported that VLBW adults are more likely to be hospitalized with a psychiatric disorder [4] and score higher on screening measures for psychopathology [5] compared with their normal birth weight (NBW; birth weight 2499 g) peers. More specically, research suggests an increased risk for mood disorders [6] and other internalizing symptoms [7]. However, this is not a universal nding as other studies have reported no differences in rates of psychopathology between VLBW and NBW adults [8,9]. Research in this area is characterized by methodological limitations such as reliance on screening measures to assess psychopathology [8,10], lack of a comparison control group [8],

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PSYCHIATRIC OUTCOMES OF VLBW ADULTS

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and cross-sectional or retrospective data collection methods [4,11]. The present study sought to determine the rates of psychiatric disorders in VLBW adults. We addressed the limitations of previous research by using a prospective, longitudinal study design that incorporated a NBW control group, and by combining screening measures with semi-structured clinical interviews for psychiatric assessment. It was hypothesized that VLBW adults would have higher levels of psychopathology on screening measures and higher rates of psychiatric diagnoses on assessment than NBW adults. As internalizing disorders have been reported to be more prevalent in VLBW women at age 20 [10], it was expected that VLBW adult women would have higher levels of psychopathology relative to VLBW men and NBW peers.

invited to attend an appointment at the Royal Womens Hospital, Melbourne, during which they were asked to complete a psychiatric screening questionnaire (Symptoms Checklist (SCL-90-R)). In the second phase, participants who scored above the specied cut-off point on the screen were re-contacted and invited to attend a structured clinical interview (Structured Clinical Interview for DSM-IV-TR for Axis I Disorders, research non-patient version (SCID-I/NP)). Perinatal and demographic data Demographic (race, gender, family structure, maternal education and primary income earners employment and occupation) and perinatal (birth weight and gestational age) data had been collected at birth. Social demographic data were collected at age 18 (highest grade completed in high school) and at the adult assessment (relationship status single or other; relationship with parents - adequate or poor). Psychiatric symptoms

Methods Participants VLBW participants were consecutive survivors from two overlapping cohorts born at the Royal Womens Hospital in Melbourne, Australia. The rst comprised 86 consecutive survivors of birth weight 1000 g, born between 1 January 1977 and 31 March 1982. The second comprised 124 consecutive survivors of birth weight 10001500 g born between 1 October 1980 and 31 March 1982. A randomly selected comparison cohort was also recruited, comprising term, normal birth weight (NBW) infants with birth weights 2500 g, born between 1 October 1981 and 31 March 1982. These participants were randomly selected using hospital unit record numbers, whereby 1 in every 100 births was invited to be in the study, until 60 participants were successfully recruited. The cohorts had been assessed at ages 2, 5, 8, 14, 1822 years, and most recently, aged 2529 years. However, follow up was not identical for all cohorts at all ages and thus, only data from the birth and adult assessments will be described in the current study. In total, 117 of 210 (56%) VLBW participants and 32 of the 60 (53%) NBW controls were successfully followed up in the most recent data collection period. Procedure The study was approved by the Research and Ethics Committees of the Royal Womens Hospital. Participants were sent information on the study and invited to participate in the adult follow up assessment. After written informed consent was obtained, data collection took place in two phases. In the rst phase, participants were

The Symptoms Checklist (SCL-90-R) [12,13] was administered as a screening measure for psychopathology. The SCL-90-R assesses the following nine primary symptom dimensions: somatization, obsessivecompulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. Internal reliability for each measure has an alpha coefcient range of 0.66 to 0.90. Global and subscale scores were used in analyses to provide an overall estimate of psychopathology as well as an estimate of impairment within specic dimensions (such as anxiety). The Global Severity Index (GSI) is the mean score of all responses. The SCL-90 and SCL-90-R both have adequate validity (specicity and sensitivity) in predicting DSM-IV psychiatric disorders [14,15]. A clinical cut-off score was set as a T-score of 65 (1.5 standard deviations above the mean) on any of the 10 scales of the SCL-90-R. See Figure 1 for a ow chart of the recruitment and follow up process. Psychiatric diagnosis VLBW and NBW participants who scored in the clinical range on any of the 10 scales of the SCL-90-R were contacted and invited to attend an interview. The SCID-I/NP [16] was used to determine a formal clinical diagnosis for these participants. The SCID-I/NP is a semi-structured diagnostic interview, which takes 6090 min in duration to complete over a single sitting. A qualied psychologist who had completed formal training in the SCID-I/NP

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VLBW groups Infants born <1000 g 1 Jan 197731 Mar 1982 n = 86 Infants born 1000-1500 g 1 Oct 198031 Mar 1982 n = 124

NBW group 1 in 100 infants >2499 g 1 Oct 198131 Mar 1982 n = 60

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Excluded (n = 5) died (n = 2) severe physical disability (CP) (n = 3)

Excluded (n = 2) died (n = 1) severe physical disability (CP) (n = 1)

Participants eligible to participate in adult assessment (n = 205) Excluded (n = 88) not located or declined (n = 63) inaccessible (n = 20) did not complete mental health screen or interview (n = 5)

Participants eligible to participate in adult assessment (n = 58)

Excluded (n = 26) not located or declined (n = 23) inaccessible (n = 3)

Participants consented and participated in current study (n = 117)

Participants consented and participated in current study (n = 32)

Figure 1. Flow diagram of participant recruitment at birth and retention at adult follow up, when participants were 2429 years of age. interview technique, and blinded to participant group membership, administered all interviews. Given that research suggests comparability of inperson and telephone SCID-I/NP diagnoses [17], participants unable to attend a SCID-I/NP interview in person were invited to complete the interview over the phone. The inter-rater and testretest reliability of the SCID-1/NP varies across different diagnoses and studies, and ranges from 0.53 (inter-rater) for dysthymic disorder [18] to 0.96 (inter-rater) for other substance abuse/dependence [19]. Acceptable validity has also been demonstrated over standard clinical interviews at intake episode [20,21]. The SCID-I/NP investigates 37 major disorders across ve broad categories: depressive, anxiety, bipolar/ psychotic, eating, and drug/alcohol disorders. Two estimates of depressive disorders were calculated for analyses. Both included current dysthymic disorder diagnoses. In addition, current estimates included current minor depressive episode (mDE) and major depressive episodes (MDE) only, while the inclusive estimates of internalizing disorder included both current and past mDE and MDE. Two (current and inclusive) total number of diagnoses categories also reect this distinction. Statistical analysis Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS, Chicago, IL) version 18 for Windows. P values 0.05 were regarded as statistically signicant across all analyses as the study was considered to be hypothesis-generating rather than hypothesis-proving, and analyses primarily were focused on comparing the magnitude of birth weight group differences. Given the small relative sample size of the

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PSYCHIATRIC OUTCOMES OF VLBW ADULTS

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NBW control group, Cohens d effect size calculation was used as an index of strength of association between independent and dependent variables; effect sizes of 0.2 were classed as small, 0.30.7 medium, and above 0.7 as large [22]. Independent samples t-tests were used to assess birth weight group differences (VLBW versus NBW) for subscale scores on the SCL-R-90 and chisquare for categorical variables. When data were nonnormally distributed the MannWhitney U-test was used. Yates continuity correction was not reported for 2 2 group 2 analyses given that this statistic tends to overcorrect and was considered too conservative [23]. Analyses compared rates of participants who met criteria for a diagnosed disorder across the VLBW and NBW groups. Odds ratios (OR) and 95% condence intervals (CI) were calculated for signicant results, or relative risks (RR) where cells contained zero. Participants who were not elevated on either of the screening measures were treated as not having a diagnosed disorder.

been from a family where the primary income earner was employed. For current participants there were no signicant differences between VLBW and NBW groups for gender (2 1.72, p 0.19) or whether mothers were born in Australia (2 2.69, p 0.10). There were also no group differences for indicators of socioeconomic status within the family at birth: primary income earners employment status (2 1.19, p 0.27), occupation (2 0.13, p 0.72), and maternal education (2 1.24, p 0.27). The majority of primary income earners within families of current participants, for both birth weight groups, identied as being in professional, skilled or semi-skilled work at the time of birth. Group differences were also tested for three social demographic variables collected at the adult assessment. While there were no birth weight group differences on how participants rated their current relationship with their parents, or on participants current relationship status, VLBW participants had spent signicantly fewer years in high school (VLBW mean 11.53, SD 0.9; NBW mean 11.93, SD 0.4, p 0.001; note missing data VLBW n 26; NBW n 9). Psychopathology outcomes by birth weight groups

Results Perinatal and demographic characteristics While there were no differences between VLBW participants and non-participants at this adult follow up for birth weight or gestational age, VLBW participants were signicantly more likely to be female (Table 1). For both VLBW and NBW groups, participants were more likely than non-participants at adult follow up to have a mother who completed at least 11 years of education and to have Table 2 presents the data for the NBW and VLBW groups across subscales of the SCL-90-R. The VLBW group scored signicantly higher than controls on the interpersonal sensitivity and hostility scales, indicating greater psychopathology. Further, there were low to medium effect sizes for birth weight group differences, in the same direction, across the depression, anxiety, phobic anxiety, paranoid ideation, and psychoticism subscales

Table 1. Perinatal and birth social demographic characteristics (mean differences between groups or odds ratios) of VLBW/NBW participants and non-participants at the adult follow up
Birth data Birth weight (g), mean (SD, N) Gestational age, mean (SD, N) Female Mother born in Australia/UK Mothers years school, mean (SD, N) Primary income earner employed Primary income earner semi-skilled/ skilled/professional Group VLBW NBW VLBW NBW VLBW NBW VLBW NBW VLBW NBW VLBW NBW VLBW NBW Non-participants 1130 3556 29.0 39.7 35/93 11/28 67/92 13/28 9.41 8.05 72/88 16/23 47/88 6/23 (244, 93) (642, 28) (2.3, 92) (1.08, 22) (38%) (39%) (73%) (46%) (2.6, 88) (3.0, 22) (82%) (70%) (53%) (26%) Participants 1080 3453 28.6 39.88 70/117 15/32 93/117 21/32 10.03 10.20 105/116 29/30 85/116 21/30 (230, 117) (451, 32) (2.1, 117) (1.16, 32) (60%) (47%) (80%) (66%) (1.8, 115) (1.9, 30) (91%) (97%) (73%) (70%) Mean difference or OR (95%CI) 51.2 103 0.34 0.15 0.41 0.73 0.69 0.45 0.6 2.2 0.47 0.01 0.42 0.15 ( 14, 116) ( 181, 387) ( 0.27, 0.95) ( 0.77, 0.48) (0.23, 0.71) (0.26, 2.05) (0.36, 1.31) (0.16, 1.29) ( 1.2, 0.005) ( 3.5, 0.8) (0.21, 1.08) (0.01, 0.70) (0.23, 0.75) (0.04, 0.51) p 0.12 0.47 0.27 0.64 0.01 0.55 0.26 0.13 0.05 0.01 0.07 0.01 0.01 0.01

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Table 2. Group means and standard deviations for VLBW and NBW groups on SCL-90-R subscale scores
VLBW mean (SD) Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism Global Severity Index 51.4 (10.7) 55.3 (12.0) 56.9 (12.4) 55.6 51.4 52.6 51.3 52.9 53.5 54.1 (11.7) (11.7) (12.9) (9.4) (12.2) (11.7) (13.1) NBW mean (SD) 50.8 (9.7) 55.2 (8.7) 53.0 (8.3) 52.9 47.6 47.4 49.0 50.1 49.8 51.9 (8.9) (10.9) (7.7) (8.1) (9.5) (9.1) (9.1) Mean group difference (95%CI) 0.6 ( 3.6, 4.7) 0.1 ( 3.7, 3.9) 3.9 (0.1, 7.6) 2.7 3.7 5.2 2.3 2.8 3.7 2.2 ( 1.7, 7.1) ( 0.8, 8.3) (1.6, 8.8) ( 1.1, 5.6) ( 1.8, 7.4) ( 0.2, 7.6) ( 1.8, 6.3) Cohens d effect size 0.05 0.01 0.33 0.25 0.33 0.44 0.25 0.24 0.33 0.18 p 0.79 0.96 0.04 0.22 0.11 0.01 0.18 0.23 0.06 0.27

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and the Global Severity Index, though these differences did not reach statistical signicance. Birth weight group proportions of clinical elevation on the SCL-90R are shown in Table 3. There were a number of signicant group differences across the psychopathology subscales: compared with NBW peers, VLBW participants were signicantly more likely to be in the clinical range on the interpersonal sensitivity, depression, hostility, paranoid ideation and global severity index scales of the SCL-90-R. A signicantly higher percentage of VLBW participants were elevated on at least one of the SCL-90-R scales, compared with NBW participants (43% versus 22%; Table 3). Further, the average number

of elevated SCL-90-R scales was signicantly greater in the VLBW group, MannWhitney U-test, z 2.19, p 0.03. VLBW birth weight distributions for each of the screening subscales were also examined for those scales showing signicant birth weight group differences for binary outcomes but non-signicant differences when comparing mean scores (depression, paranoid ideation, Global Severity Index); there was no relationship between birth weight and scores on these three scales, and no evidence of extreme score clusters. Gender effects were also tested. There were no differences between how men and women scored on any subscales of the SCL-90-R for either of the birth weight groups.

Table 3. Percentages, odds ratios (OR) and 2 analyses for birth weight group comparisons on binary rates of clinical elevation on SCL-90-R scales
95%CI for OR % VLBW (n 117) Somatization Obsessive compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism Global Severity Index Any SCL-90-R scale elevated
Risk

% NBW (n 32) 9.4 12.5 9.4 6.3 12.5 0.0 9.4 6.3 6.3 6.3 21.9

2 0.08 0.69 4.86 5.60 0.39 7.82 0.08 3.87 3.55 4.20 4.63

OR 1.21 1.62 3.80 5.17 1.44 1.34 1.21 4.08 3.87 4.29 2.67

Lower 0.32 0.52 1.08 1.17 0.46 1.21 0.32 0.91 0.86 0.96 1.07

Upper 4.53 5.01 13.32 23.00 4.57 1.49 4.53 18.23 17.35 19.14 6.65

p 0.78 0.41 0.03 0.02 0.53 0.01 0.78 0.05 0.06 0.04 0.03

11.1 18.8 28.2 25.6 17.1 20.5 11.1 21.4 20.5 22.2 42.7

estimate is a relative risk ratio.

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Formal psychiatric diagnoses on clinical interview Eight NBW and 50 VLBW participants were eligible for the SCID-1/NP interview. Of these, all of the NBW and 41 of the VLBW participants successfully completed the clinical interview. Participants who were eligible for an interview but who did not complete the formal interview process were excluded from analyses. However, for ve of the nine eligible participants who were not interviewed, ongoing phone contact was maintained for up to 3.5 years. Of these, four participants self-reported signicant stressful life events (social or medical) or mental health problems that made it difcult for them to complete the interview. Data from the SCID-1/NP clinical assessment interviews are presented in Table 4. The percentages in the table represent the proportion of participants who met criteria for a diagnosed disorder, from the total number of participants who completed all assessments. Approximately one third of VLBW participants met criteria for a past or present (inclusive denition) psychiatric diagnosis compared with 22% of their NBW peers. Further, 24% of VLBW participants met criteria for a current psychiatric diagnosis compared with 12% of NBW participants. There was only one signicant group difference between the VLBW and NBW groups on rates of specic disorders; for current depressive disorder. Group medians for the

number of past or present (inclusive) SCID-1/NP diagnoses were also compared. Though VLBW participants had almost twice as many diagnoses (median 0.78, n 41) compared with NBW controls (median 0.47, n 8), this difference failed to reach signicance, MannWhitney U-test, z 1.20, p 0.23.

Discussion The VLBW adults had more abnormalities compared with NBW controls on several subscales of the Symptom Checklist (SCL-90-R). Further, structured clinical interviews revealed VLBW adults were more likely to be diagnosed with a current depressive psychiatric disorder, which included current diagnoses of major and minor depression and dysthymic disorder. VLBW participants scored higher than their NBW peers on the interpersonal sensitivity and hostility subscales and were more likely to be elevated on hostility, interpersonal sensitivity, depression, paranoid ideation and the Global Severity Index of the SCL-90-R. With the exception of the Global Severity Index, this set of SCL-90R scales measure problems related to social and emotional functioning; how individuals feel about themselves and how they relate to others in the social world. For example, items in the interpersonal sensitivity scale ask whether individuals

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Table 4. Number and percentage of VLBW and NBW participants meeting criteria for at least one SCID-1/NP diagnosis across eight disorder categories
95%CI for OR VLBW (n 108) Any diagnosed disorder (inclusive) Any diagnosed disorder (current) Depressive disorder (inclusive) Depressive disorder (current) Anxiety disorder Psychotic or bipolar disorder Drug/alcohol disorder Eating disorder
Relative

NBW (n 32) 7 (21.9%)

2 1.52

p* 0.22

OR 1.79

Lower 0.71

Upper 4.52

36 (33.3%)

26 (24.1%)

4 (12.5%)

1.96

0.16

2.22

0.71

6.92

31 (28.7%)

6 (18.8%)

1.26

0.26

1.75

0.65

4.65

18 (16.7%)

0 (0%)

6.12

0.02

1.36

1.22

1.51

19 (17.6%) 2 (1.9%)

4 (12.5%) 1 (3.1%)

0.47 0.19

0.50 0.66

1.49 0.59

0.47 0.05

4.76 6.67

6 (5.6%) 3 (2.8%)

2 (6.2%) 0 (0.0%)

0.02 0.91

0.88 0.34

0.88 1.31

0.17 1.19

4.60 1.43

risk.

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[feel] inferior, easily hurt or [feel that] others do not understand [them]. The current study ndings provide evidence that while the increased risk for psychopathology persists into adulthood in the VLBW population, the severity of psychopathology may reduce over the transition from childhood to adulthood. Previous research exploring child and adolescent VLBW outcomes suggests a strong birth weight effect, where preterm or VLBW children and adolescents have signicantly higher rates of behaviour problems [3,24,25] and mood and anxiety disorders [26] than NBW or term controls. While the current study found that VLBW participants were more likely to be elevated on 5 of 10 psychopathology subscales, in the clinical range on one or more screening subscale, and more likely to be elevated on a greater number of scales than NBW peers, the magnitude of these effects tended to be small to moderate. Further, while there was a consistent pattern whereby the VLBW group had higher mean scores across all of the psychopathology subscales, these birth weight group differences did not reach signicance for the majority (8 out of 10) of the scales. Finally, the proportion diagnosed with a psychiatric disorder in the VLBW group did not differ signicantly from NBW peers. No gender effect was evident, which is inconsistent with previous research where gender effects have been reported across different ages. For example, Hack et al. reported that VLBW women were rated higher than either NBW controls or VLBW men on a range of internalizing scales, while parents of VLBW men reported signicantly more thought problems for their sons than parents of NBW adults [10]. Patton and colleagues also found differential rates of mood disorder for preterm female and male adolescents [39]; and Dahl and colleagues found that parents reported more social and attention problems in VLBW boys and more internalizing behaviour in VLBW girls [40]. However, the current study ndings are consistent with much of the previous VLBW outcome research, which suggests that VLBW children/adolescents are at risk of mood disorders [27], more likely to be socially immature, rejected by peers [28] and to experience isolation [29] and peer victimization [30]. Research has also shown that VLBW young adults tend to be slower in beginning romantic partnerships and sexual activity, delay leaving the family homeof-origin for longer, and are more likely to have social problems than their NBW peers [31]. Studies have also reported subtle birth weight effects in terms of education, psychological well-being and personality, where VLBW adults tend to be more risk avoidant, less satised with their physical appearance, less likely to be in higher education and more likely to be unemployed than their NBW

peers [9,3133]. This was consistent with the current study nding that VLBW adults had fewer years of schooling in high school. While it was beyond the scope of the current study to assess Axis II (personality) disorders or social functioning, these are important areas that should be addressed in future research. It is possible that the nature of VLBW vulnerability is inuenced by the very specic social and environmental context of preterm/VBLW birth, in addition to possible alteration to developing, internal biological systems, such as the hypothalamicpituitaryadrenocortex (HPA)-axis [34,35]. VLBW survivors begin life with an immature biological system and are more susceptible to medical complications. Although intensive medical care is necessary for VLBW infants immediate survival, the NICU environment is not ideal for creating a secure, positive attachment relationship between VLBW infant and parents. Preterm infants are also forced to participate in the social world before they are developmentally ready. It is possible that this early environmental context plays a role in determining the nature of the vulnerability associated with VLBW birth. In addition, numerous factors, such as other perinatal risk, socioeconomic position, family structure, parenting practices and home environment, have been identied as important in determining long-term outcomes for VLBW children [3638]. It is likely that many of these factors remain important in terms of predicting adult psychiatric outcomes. It will be important for future research to explore longitudinal predictors of adult psychiatric outcomes in VLBW survivors, in order to identify and support those individuals most at risk of poor psychological outcomes. The relatively low follow up rate in our prospective, longitudinal study was the primary limitation of the current study. However, this study is one of the rst to follow VLBW survivors from birth and over such a long period. At every follow up assessment, including the nal adult assessment with psychiatric interview, participants were required to attend an appointment at the Royal Womens Hospital in Melbourne. For participants who were interstate or overseas, this was usually not possible. In comparison with mailed questionnaire-based studies, this is likely to have contributed to participant attrition. However, the most common reason for non-participation was the inability to locate adult participants, given that many participants and their families had moved house without updating their contact details with the study, and were not locatable using Australian electoral rolls. This is expected, given the mobility of this age group. The power of the current study was also limited by the comparatively small NBW group size, though ndings indicated small birth weight group (VLBW versus NBW)

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differences on the majority of psychopathology subtests and for many of the psychiatric disorder categories. The study ndings may also have been inuenced by a natural bias from participant attrition over time. In both VLBW and NBW groups, participants differed from non-participants in that they were more likely to have come from a higher socioeconomic status family background. Therefore, it may be that the rates of psychopathology reported in this study for the VLBW group are an underestimation of the true morbidity in the overall cohort. It is also possible that the NBW rates of psychiatric disorder were somewhat articially lowered by an under-representation of participants with higher social risk. Further, given that clinical interviews were only offered to participants who were elevated on the SCL-90-R screening questionnaire, it is possible that there may have been some false negatives, reducing the number of participants identied with a psychiatric disorder. In summary, technological advances over the last few decades have resulted in an unprecedented survival rate of babies born very small and/or preterm. However, research continues to show that these individuals may have ongoing challenges during their development and into adulthood. Although research has become increasingly comprehensive in the assessment of developmental outcomes in the last decade, long-term psychiatric follow up remains rare. Improved understanding of mental health outcomes for VBLW adults is important in order to provide the most accurate picture of life-long morbidity and to allow the subsequent development of targeted, cost-efcient intervention programmes to prevent and treat long-term psychopathology. However, current understanding of both the trajectory and mechanisms associated with psychopathology is lacking. Future research needs to utilize longitudinal study designs in order to delineate factors inuencing developmental pathways and to achieve the goal of minimizing long-term impairment associated with socioemotional impairment and psychiatric disorder. Declaration of interest: This research was supported by the Australian Rotary Foundation, the Victorian Government (Department of Innovation, Industry and Regional Development), and the Australian National Health & Medical Research Council (Senior Research Fellowship to P.J.A.). The authors alone are responsible for the content and writing of the paper.

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