Questions and Answers
Question # 35
What is the estimated probability that an experienced clinician would be able to assert with considerable confidence that significant perinatal complications have caused NLD in a particular case?
Background. There are certainly many conditions that present at birth that
have NLD as their phenotype (see NLD and
Neurological Disease). But, the usual meaning of "perinatal complications"
applies to a neonate whose intrauterine development had been normal and who
experiences various conditions (e.g., anoxia/hypoxia) during the perinatal period
that are deemed to be significant. The next question to ask is whether these
complications eventuate in any limitations/deficits over the course of post-natal
A Clinical Example. In order to address these issues, let us take the
example of a 10-year-old child who exhibits the syndrome of NLD. It is known
that he experienced documented perinatal complications, including significant
hypoxia. What is the probability that one would be able to tie his current
NLD to these perinatal complications?
Short answer to the latter and the main questions: Very low to zero. The
rationale for this is as follows.
It is certainly conceivable that a child who experienced significant perinatal
complications could be shown to exhibit neuropsychological deficits at age 10
years as a probable direct result of these complications. That said, it is
highly unlikely that one could infer, with any degree of confidence, that a
child with NLD at the age of 10 years exhibits NLD due solely to such perinatal
There are several (some, yet-to-be-demonstrated) clinical and scientific reasons
why such an inference would be shaky at best. Some of these are as follows:
(1) Almost all children who exhibit NLD did not experience any significant
(2) Almost all children who experience significant perinatal complications do
not exhibit NLD.
(3) To my knowledge, there has been no detailed documentation of any case of
NLD where the syndrome has been tied unequivocally to significant perinatal
(4) The neuropathological impacts and dynamics of most perinatal complications
(e.g., significant degrees of hypoxia/anoxia) are likely to have a direct and
negative impact on cerebral grey matter. This would not appear to be the
case for white matter.
That said, consider the case of a 10-year-old child who suffers from one of
the cerebral palsies that (a) can be tied to perinatal complications, and (b)
involves outstanding deficits in somatosensory and motor/psychomotor
functioning on the left side of the body. If this child exhibits NLD and
is free of the genetic disorders that have NLD as part of their phenotype
(see NLD and Neurological Disease),
it would seem probable that his NLD could be tied quite directly to one
or more perinatal complications. This opinion would be bolstered by
the following: (a) neuroimaging findings that point to pathology of
structures and/or systems within the right cerebral hemisphere and/or
callosal fibers, and/or (b) significant white matter perturbations,
especially within the right cerebral hemisphere and/or corpus callosum.
(Sorry about all the and/ors.)
An Important Clinical Implication. It is not uncommon for parents of
youngsters with NLD to search assiduously for reasons (etiologies) for
the condition exhibited by their child. Some latch on to untoward
events that have transpired during the perinatal period (almost always
in the absence of any evidence that these events and their child's NLD
are connected). Having identified what they consider to be the cause
of their child's NLD, they may blame themselves for not weathering the
birth process better (e.g., by retaining more competent obstetrics personnel; by preparing more diligently for the vicissitudes surrounding
the birth process; and so on). Given what we know about the probable
cause-effect relationships operative in these cases, and all other
things being equal, it should be a relatively straightforward and easy
process to assuage the parents' guilt regarding their role in this
scenario. Parents of children with NLD have a tough enough time
dealing with their child's nurturance and care without having to
grapple with the excess baggage that unfounded guilt constitutes.
For a similar state of affairs (viz., dealing with guilt engendered
by attributions of "over-protection") see
Forensic Implications. It is clear that there are some important
forensic implications surrounding these issues. A future Q & A will
attempt to address such issues within a broader context.