Neonatal brachial plexus palsy is a common occurrence. Some children have complete spontaneous recovery without long-term sequelae and others have life-altering functional limitations and appearance differences between their arms. The permanent nature of these limitations and appearance differences can be quite taxing to new parents who were expecting a “normal” newborn child. Beck interviewed twenty-three mothers of children with neonatal brachial plexus palsy and found that six themes emerged: “(a) In an Instant: Dreams Shattered; (b) The Arm: No Escaping the Reality; (c) Tormented: Agonizing Worries and Questions; (d) Therapy and Surgeries: Consuming Mothers’ Lives; (e) Anger: Simmering Pot Inside; and (f) So Much to Bear: Enduring Heartbreak.”

The first theme, “In an Instant: Dreams Shattered,” identifies with the fact that these new parents have lost their “perfect” child. The loss of a “perfect” child can lead to a parent experiencing intrapsychic problems including mourning, regression, rage, and, ultimately, depression. Depression has been shown to negatively correlate with self-reported upper extremity health status, specifically as measured by the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Ultimately, many parents of children with neonatal brachial plexus palsy may have underlying depression, or even posttraumatic stress disorder, following their intense experience of labor and delivery and subsequent upbringing of a child who has differences that require constant health care. Beck quoted one mother as saying, “Being a mother of an OBPI [a child with obstetric brachial plexus injury, also known as neonatal brachial plexus palsy] could bring as much heartache as it does joy. I cannot tell you how often I come home from playgroups…and sob until I feel like my body is breaking.” Another mother said that she was tired of fighting insurance companies, doctors, her child to wear splints, and so forth, and finally stated that she was “tired of fighting just to make it through another day.” Although we are trained as orthopaedic surgeons, we do not need psychology training to realize that these mothers have underlying depression symptomatology.

Neuroticism is a term that is used to describe a person’s tendency toward negative mood, negative self-concept, distress, and dissatisfaction. The concept of neuroticism has been shown to explain differences between self-reported and observer-reported depression symptom severity. In cases in which a person has a tendency toward neuroticism and then experiences the loss of a “perfect” child, the parent may be more “traumatized” than the patient. This result may lead to the parents pursuing litigation, even before the potential of the child is realized. In this study, litigation was filed at a median patient age of 2.0 years. Obviously, the child could not describe pain or suffering at this point and therefore the rationale for pursuing litigation is based mainly on the parents’ beliefs of how the child is functioning and is feeling.

The current study demonstrates that parents involved in litigation report worse outcomes for their children with neonatal brachial plexus palsy compared with parents who did not pursue litigation, even when accounting for injury severity and the patients’ own report of their function. The pursuit of litigation, especially when the child is still young, may be a proxy for a parent who has a tendency toward neuroticism. This would explain why, despite similar injury patterns, some families of children with neonatal brachial plexus palsy pursue litigation and some do not.

The fact that a family with a child with neonatal brachial plexus palsy is involved in litigation may be an opportunity for health-care providers to treat the patient and the family as a whole. It is quite apparent that parents of patients with neonatal brachial plexus palsy are considerably stressed and are even clinically depressed. Some families may be able to cope via various positive mechanisms, and yet others may have an underlying sense of neuroticism, which ultimately leads them to pursue litigation.

Once a family is involved in litigation, additional stress may be present, causing worsening depression and/or neuroticism. Because of these factors, this family may have lower self-reported patient outcomes compared with a family in a similar scenario with better coping and support mechanisms. As doctors, we should screen families and patients for psychological stressors and available coping mechanisms to provide complete, overall care for both the patient and the family. The necessary resources and referral base should be part of all neonatal brachial plexus palsy clinics.

It is ultimately the responsibility of all health-care providers to provide complete, overall care for both the patient and the family, even if we cannot see the problem. The delivery team may decrease the chance of litigation and may improve the care of the patient and family if coping mechanisms, including support groups and/or psychological evaluations, are available for parents and children with neonatal brachial plexus palsy, as well as all parents and family members of newborns who are not “perfect.”

In conclusion, this study demonstrates that parents with children with neonatal brachial plexus palsy involved in litigation self-report worse outcomes for their children. Therefore, when critically evaluating treatment for neonatal brachial plexus palsy, care should be taken when assessing self-reported outcome measures alone, as the presence of litigation is a confounding factor akin to Workers’ Compensation for hand surgery. In the future, new neonatal brachial plexus palsy outcome measures should be created to combine objective and subjective assessments, permitting the ability to minimize confounding factors such as litigation.