Chart-recorded psychiatric diagnoses in women giving birth in California in 1992.

OBJECTIVE: Although major advances have been made in the diagnosis and treatment of mental disorders in primary care, few population-based investigations have focused on the obstetrical sector. This study examines the occurrence of chart-recorded psychiatric discharge diagnoses among all women delivering in California hospitals in 1992. METHOD: The authors undertook an archival analysis of the California Health Information for Policy Project data set, which consists of linked hospital discharge and birth certificate data for 580,282 deliveries. Frequencies of ICD-9 psychiatric diagnoses were ascertained. RESULTS: Among all women delivering, 1.5% received psychiatric or substance use diagnoses. Of diagnoses recorded, 75% were substance use disorders, 21% were classified generically as "mental disorder of pregnancy," and other psychiatric disorders accounted for 4%. CONCLUSIONS: The occurrence of psychiatric diagnoses in these women is markedly lower than expected, suggesting an underreporting of psychiatric disorders at delivery. Further investigations into the detection of mental disorders in the obstetrical sector are needed.

Child psychiatry and pediatrics: the state of the relationship.

A great deal of attention has been focused on the notion that child psychiatry and pediatrics should develop strong ties. Yet, a review of the literature suggests that, in spite of exhortations to the contrary, little true collaboration has developed between the two disciplines. This study surveys the major pediatric teaching and training centers throughout the country in an attempt to assess the current state of the relationship between child psychiatry and pediatrics. Of the 82 centers surveyed, 68% responded. Although enthusiasm and desire for closer collaboration were expressed repeatedly, actual successful efforts remain minimal. Psychiatric consultations on pediatric inpatient units continue to be the predominant child psychiatry service provided. A method for achieving closer relationships between the two disciplines is proposed.

Sleeping through the night: a developmental perspective.

This study examines falling asleep and night waking in human infants during the first 8 months of life. All-night time-lapse video recordings were obtained at 3 weeks and 3 months of age; a Sleep Habits Interview was completed at these ages and repeated at 8 months of age by telephone interview. At the 3-week and 3-month ages, self-report measures of maternal psychologic distress, depression, and self-esteem were also obtained. The data are examined from both cross-sectional (age group) and longitudinal (individual) perspectives. Parent-infant interactions at bedtime and during the middle of the night changed significantly with increasing age. At 3 weeks of age, most infants were put into their cribs for the night already asleep. When they awakened in the middle of the night, they were removed from their cribs. By the time they returned to their cribs, they were again asleep. By 3 months of age, infants who were put into the crib awake at bedtime and allowed to fall asleep on their own were more likely to return to sleep on their own after awakenings later in the night. In contrast, infants who were put into the crib already asleep at the beginning of the night were significantly more likely to be removed from the crib following a subsequent nighttime awakening. Thus, the pattern of bedtime sleep onset was related to sleep onset following an awakening in the middle of the night. This association was present at 8 months as well.(ABSTRACT TRUNCATED AT 250 WORDS)

Infant temperament, sleep organization, and nighttime parental interventions.

Objective measures of sleep-wake organization derived from time-lapse video recordings were compared with parental perceptions of infant temperament in 23 infants 6 months of age. Although both mothers' and fathers' ratings of infant temperament were correlated with variables reflecting sleep continuity, results for fathers were much more striking. Infants who required care giving during the night were rated as significantly more difficult and arrhythmic by fathers than by mothers. All infants awakened during the night. Some of them soothed themselves and returned to sleep; however, others signaled and required care giving interventions from their parents before returning to sleep. No differences in variables reflecting the biology of sleep distinguished "signaling" infants and "self-soothing" infants, although feedings at bedtime (breast or bottle) were more common in the signaling group.

Developmental course of nighttime sleep-wake patterns in full-term and premature infants during the first year of life. I.

Two groups of infants (40 normal full-term, 24 prematurely born infants) were matched on conceptional age and were studied at seven ages during the first year of life. All-night time-lapse video somnography was obtained n the home at 2, 4, 8, 20, 24, 36, and 52 weeks of age. The developmental course of sleep-wake state proportions, sleep onset indices, and special variables assessing temporal organization are compared. Age-appropriate developmental norms for sleep-wake state assessment during the first year of life are presented, using video somnography. In general, sleep-wake state ontogenesis is comparable in the two groups. The premature group is more variable from one age to the next, even though both groups demonstrate significant individual stability of some sleep-wake variables over the first year of life.

Sleep-wake state organization, neonatal assessment and development in premature infants during the first year of life. II.

Twenty four premature infants were evaluated in their homes at seven ages during the first year of life to determine whether sleep-wake state organization was related to either neonatal assessment or short-term developmental outcome measures. A model assessing environmental and biological influences on the maturational course of selected sleep-wake state parameters was also evaluated. Sleep-wake state variables and neonatal assessment items were related to each other, and both predicted developmental quotients at 6 months and 1 year of age. Concordance was present primarily in the domain of motor activities. Waking motor behaviors and motor activity in sleep seem to independently reflect an infant's level of developmental organization. Individual sleep-wake state variables were influenced by both biological and environmental factors during maturation. The developmental course of quiet sleep is primarily biologically determined, as evidenced by its relationship to the infant's birth status (gestational age or birth weight); the infant's behavior that results in being taken from the crib during the night, and the course of his/her sleep that occurs between midnight and morning are dependent on both biological factors (perhaps infant irritability), and post-birth experiences (perhaps the caregiver's response to infant irritability). The course of active sleep and wakefulness are dependent solely on environmental influences, and not on maturity at birth.

The detection of behavioral state cycles and classification of temporal structure in behavioral states.

Previous methods for the analysis of temporal structure in sleep and other state time series have described cycles, rhythms, and semi-Markov chains. Methods, however, have been subjective and arbitrary. We propose an objective system of classification for these series, based on definitions of temporal structure which are consistent with those long used in the analysis of quantitative series. An ordered sequence of statistical tests is described which classifies observed behavioral state time series into four primary categories. The system is illustrated with examples from normal infant sleep. The results show that some infant sleep series are cycles, as previously reported, some are semi-Markov chains, and some are neither. The proposed objective methods promise consistency, clarity, and a richer understanding of behaviors such as sleep.

Pubertal changes in daytime sleepiness.

Nineteen children (8 girls, 11 boys) were evaluated in a total of 47 three-day sessions across three summers. Children were ranked according to Tanner's stages of secondary sexual characteristics. Nocturnal sleep was recorded from 2200 to 0800 hr each night. Multiple sleep latency tests were given at 2 hr intervals from 0930 each day. Nocturnal sleep time and REM sleep time remained constant across Tanner stages. Slow wave sleep time declined progressively across Tanner stages, with a 40% reduction from prepuberty to maturity. Daytime sleepiness was significantly greater in subjects at Tanner stages 3 and 4 than at Tanner stages 1 and 2. Subjects at Tanner stage 5 tended to be as sleepy as Tanner stage 3 and 4 subjects but did not differ significantly from the less mature subjects. No gender differences were found in daytime sleepiness for children at similar Tanner stages. More mature children were significantly sleepier at 1330 and 1530 than in the late afternoon and evening.

Infant-parent co-sleeping in an evolutionary perspective: implications for understanding infant sleep development and the sudden infant death syndrome.

Evidence suggests that infant-parent co-sleeping represents the species-wide pattern of sleep in which human infant physiology evolved. The hypothesis evaluated in this manuscript is that the co-sleeping environment may foster development of optimal sleep patterning in infants and confer other benefits, including reducing the risk of the sudden infant death syndrome (SIDS). These postulations by McKenna are considered from different perspectives by the coauthors. Using evolutionary, cross-species, crosscultural, physiological and behavioral data, our objective was to present a conceptual framework for assessing the developmental consequences of solitary sleeping and infant-parent co-sleeping.

Pediatric sleep disorders: a review of the past 10 years.

OBJECTIVE: To provide a 10-year review of pediatric sleep disorders medicine. METHOD: DSM-IV is used to organize the presentation from a developmental perspective. RESULTS: Pediatric sleep disorders can be subdivided into four broad categories: Primary Sleep Disorders that include two subcategories, Dyssomnias and Parasomnias; Sleep Disorder Related to Another Mental Disorder; Sleep Disorder Due to a General Medical Condition; and Substance-Induced Sleep Disorder. Behavioral and supportive methods of treatment remain the most useful methods for treating primary sleep disorders in childhood.

Case study: sleep and aggressive behavior in a blind, retarded adolescent. A concomitant schedule disorder?

Blind people are prone to suffer from sleep-wake schedule disorders. This report describes 2 months of monitoring of sleep patterns and aggressive behaviors in a totally blind, severely retarded adolescent boy, hospitalized in a psychiatric hospital. The documented sleep-wake patterns seem to portray a sleep-wake schedule disorder with a monthly periodicity. Aggressive behaviors seem to echo the same periodicity, suggesting that a common or linked biobehavioral timing mechanism may underlie both sleep and episodic aggressive outbursts. The need to consider sleep schedule disorders as a primary process underlying some psychopathological disorders, and the related risks of misdiagnosis and mistreatment, are highlighted.

Classification of young children's sleep problems: a pilot study.

OBJECTIVES: This study examines videotaped sleep in infancy in an attempt to predict the development of disturbed sleep during toddlerhood. In addition, a tentative classification scheme that quantifies night waking and sleep onset problems in young children is proposed. METHOD: The sleep patterns of 33 children were assessed at two points in time. At 12 months of age (time 1), sleep was videotaped on two consecutive nights. A self-soothing/signaling index for 12-month-olds was constructed. At time 2 (mean age = 39 months), a follow-up telephone interview assessed current sleep patterns and the presence or absence of sleep problems. RESULTS: The data suggest that the self-soothing/signaling index obtained at 12 months of age predicts night waking approximately 2 years later. CONCLUSIONS: The preliminary classification scheme for night waking and sleep onset problems in young children warrants further study. Night waking in toddlers might be predictable from sleep behaviors at 1 year of age.

Implications of research on infant development for psychodynamic theory and practice.

Recent research on infant development is reviewed to consider its implications for psychodynamic theory and practice. To address the question of the importance of early experiences for development, research on continuities and discontinuities in development, temperament, motivational systems in infancy, affect development and regulation, development of the sense of self, and infant-caregiver attachment are reviewed. Two major implications emerge, both emphasizing the need for more complexities in our conceptualizations. First, research on infant development underscores the importance of context in development and cautions about the limits of reductionistic thinking and theories. Second a major paradigmatic shift away from the fixation-regression model of psychopathology and development is indicated. A new model that better fits available data is proposed instead. In this continuous construction model, there is no need for regression, and ontogenetic origins of psychopathology are no longer necessarily tied to specific critical or sensitive periods in development. Implications for psychodynamic treatment are also described.

Intrinsic and extrinsic determinants of neuronal development: relation to infantile autism.

This paper attempts to view the autistic syndrome in the context of a disorder of brain development. The authors review some of the known or suspected causes of the autistic syndrome: maternal rubella, metabolic diseases, and heredity. Some basic principles of cellular neuroanatomy and chemical neurotransmission are sketched. The stages of human brain development from neurulation through histogenesis, cell migration, and elaboration of dendritic trees and axonal projections are described. The authors conclude that there are a limited number of developmental loci that could be disrupted and lead to the autistic syndrome, and that these most probably occur in the end stages of neuronal development, after the migrating neurons have reached their final place in the brain and have begun to elaborate communicative processes. Finally, the authors speculate on how neurochemical disturbances might alter end stage neuronal differentiation leading to the pathology of infantile autism.

Empirically derived subclassification of the autistic syndrome.

A method is presented for empirical subclassification of autistic and autisticlike children, based on observations of current behavior. The advantage of the method is that it identifies profiles of co-occurring behaviors and accordingly assigns children to subtypes. The subtypes are more clinically homogeneous than the overall sample of autistic children. Preliminary findings are presented, including an effort to validate the subclasses by suggesting possible relationships between subtype membership and perinatal markers, developmental milestones, and independent measures of concurrent behavior.

Sleep and sleepiness in children and adolescents.

We have attempted to review the current "state of the art" regarding the ontogenetic course of sleep-wake state organization and possible disruptions in this course from infancy through adolescence. It is becoming increasingly important for clinicians to learn about physiologic functioning during sleep. Much more research is required, directed at the relationship between waking behaviors and sleeping behaviors. Investigations of daytime sleepiness in adolescence, of the relationship of hyperactivity to excessive sleepiness, of the relationship between disorders such as depression and anorexia nervosa with disturbed sleep state organization, and of primary sleep disorders such as narcolepsy and the sleep apnea syndrome only scratch the surface in terms of the future work that needs to be done.

Adequacy of prenatal care among women with psychiatric diagnoses giving birth in California in 1994 and 1995.

OBJECTIVE: Although poor prenatal care is detrimental to maternal and infant health, few studies have assessed the adequacy of prenatal care among women with psychiatric diagnoses. This investigation examined the association between chart-recorded psychiatric and substance use diagnoses at the time of delivery and adequacy of prenatal care among all women delivering babies in California hospitals during 1994 and 1995. METHODS: The authors undertook an archival analysis of data from the California Health Information for Policy Project (CHIPP), which consists of linked hospital discharge and birth certificate data for 1,094,178 deliveries in 1994 and 1995. The associations between International Classification of Diseases, 9th Revision, Clinical Modification psychiatric and substance abuse diagnoses and level of prenatal care were examined. Logistic regression analyses were conducted to assess the association between maternal diagnostic category and inadequate prenatal care while controlling for payment source, age, education, race, marital status, and parity (previous births). RESULTS: Women who received psychiatric and substance use diagnoses demonstrated significantly increased risk of inadequate prenatal care compared with women without those diagnoses. CONCLUSIONS: Psychiatric diagnoses were associated with an increased risk of inadequate prenatal care; the association between psychiatric and substance use diagnoses and poor prenatal care persisted even after the analysis controlled for known risk factors. Future investigations will need to elucidate the processes of prenatal care for women with psychiatric disorders so that preventive interventions can be developed.

Measuring difficult temperament in infancy.

Thirty-four couples rated their 6-month-old first-born infants' temperaments with Bates' Infant Characteristics Questionnaire (ICQ) and Carey's Infant Temperament Questionnaire (ITQ). Mothers and infants were videotaped in their homes during feedings on two consecutive days to assess mother and infant behavior. Results indicated that parents had moderate agreement about their own infant's temperament on the ICQ. There was little convergence between the ICQ and the ITQ measures of infant difficulty. ICQ parent-rated unpredictable infants were rated by observers as less responsive during the feedings. These results are discussed in the context of the meaning and measurement of infant temperament.

Night waking, sleep-wake organization, and self-soothing in the first year of life.

Few objective data are available regarding infants' night waking behaviors and the development of self-soothing during the first year of life. This cross-sectional study examined 80 infants in one of four age groups (3, 6, 9, or 12 mo) for four nights by using videosomnography to code nighttime awakenings and parent-child interactions. A large degree of variability was observed in parents' putting the infant to bed awake or asleep and in responding to vocalizations after nighttime awakenings. Most infants woke during the night at all ages observed. Younger infants tended to require parental intervention at night to return to sleep, whereas older infants exhibited a greater proportion of self-soothing after nighttime awakenings. However, even in the 12-month-old group, 50% of infants typically required parental intervention to get back to sleep after waking. Results emphasize the individual and contextual factors that effect the development of self-soothing behavior during the first year of life.

Relationship disturbances and parent-child therapy. Sleep problems.

This article has attempted to establish the importance of considering behavioral disturbances in infancy and early childhood as disturbances of the parent-child relationship. When the psychologic and mental mechanisms of the individual infant are too immature to sustain disturbed behavior across several settings and when the behavioral disturbance seems to be specific to a particular relationship, it is more appropriate to diagnose the pathology as being in the relationship. The article has offered a diagnostic framework of relationship pathology that spans the spectrum from normal variation (relationship perturbation) to relationship behaviors that are at risk of becoming a disorder (relationship disturbance) to significant relationship disorders that most likely require a professional intervention. A multiaxial assessment protocol is recommended that evaluates primary relationships (Axis I), parent-infant interaction styles (Axis II), the parent and infant as individuals (Axis III), and more distal contextual factors that affect the relationship (Axis IV). Sleep disturbances in infancy have been used as an example to demonstrate the spectrum of relationship pathology. Additional research is needed to develop more precise, age-relevant cut points for the spectrum of relationship pathology for sleep problems and for other parent-infant relationship disturbances in the areas of feeding, excessive crying, and limit setting or tantrums. More research is also needed to define better when and how relationship pathology becomes transformed into individual pathology and how early intervention may alter the course of this trajectory.