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Preterm Birth & Behavioral Outcomes

Preterm Children & Behavioral Outcomes

Just like full term babies, preterm children can develop behavioral difficulties. It is not always known why children develop behavioral problems, which can be a great cause of concern for parents. It is important to understand that most preterm children will grow up without any major difficulties but remember being born too early means sometimes children need more support to reach their goals.

Overview of Behavior Outcomes for Preterm Children

Over the years many research teams have investigated the long-term outcomes of children born preterm. Results are not always consistent between studies and may differ for a variety of reasons, however it is generally accepted that preterm children are at greater risk for behavioral difficulties. These include hyperactivity and inattention problems such as ADHD/ADD, depression and anxiety, as well as autism and conduct disorders. Importantly, these difficulties and the incidence of such difficulties can vary according to the source of the information. For example there is often a discrepancy between what parents and teachers report, or how children rate themselves in comparison with their teachers and parents. In fact, children born preterm often report more favorable outcomes even compared with their peers.

It is important to remember that most preterm children will not grow up to have serious behavioral difficulties, however it is also important to understand why they may develop problems, so ways of limiting their negative affect, both academically and socially, can be researched.

As with other long-term outcomes, preterm children who have experienced early biological hazards, such as extreme prematurity, extremely low birth weight, chronic lung disease, and brain injury appear to be at even greater risk for behavior problems.

(Laucht, et al., 2000)
preterm children are at greater risk for behavioral difficulties

Psychiatric Disorders & Preterm Children

The term psychiatric disorder refers to a mental disorder or illness that affects the way a person behaves, interacts with others, and functions in daily living. Preterm children free from major neurosensory disorders, such as intellectual impairment, cerebral palsy, and blindness, show more psychiatric disorders than children born full term or with normal birth weight (NBW). Very low birth weight and/or very preterm children at school age have a five-fold risk (53% versus 10%) and adolescents a four-fold risk (38% versus 10%) of psychiatric problems compared with children who were born full term.

(S. Johnson, 2007; Schothorst, Swaab-Barneveld, & van Engeland, 2007)(Bhutta, et al., 2002)

Internalizing Problems & Preterm Children

Internalizing means to make personal or subjective, making something part of one’s attitudes or beliefs.

Research: Preterm Children

A meta-analysis, which combines the results of a number of studies on the same topic, found that 9 of 12 studies (75%) reported a significantly higher incidence of internalizing problems and 9 of 13 studies (69%) reported a significantly higher incidence of externalising symptoms for preterm children.

Internalizing problems most commonly reported in preterm children are depression, anxiety, and social withdrawal, which some have argued are more frequent in adolescence, particularly for girls. One study documented clinically significant levels of internalizing problems in 30% of an extremely low birth weight (ELBW) group of adolescents, which was 4 times higher than term born adolescents.

School-age: Preterm Children

Another study found that the main diagnoses in preterm children with a psychiatric disorder requiring treatment at school age were;.

  • 33.3% anxiety disorders,
  • 33.3% disruptive disorders, and
  • 33.3% other disorders,
  • none were diagnosed with depressive disorders

Adolescence: Preterm Children

Of adolescents with psychiatric disorders, preterm children requiring treatment suffered from;

  • 30.8% of depressive disorders,
  • 53.8% from anxiety disorders,
  • 7.7% from disruptive disorders, and
  • 7.7% from other disorders

This study also reported that of the preterm children with psychiatric disorders (mild or serious) at school age, the majority (70%) still had psychiatric symptoms that fulfil the criteria for a DSM IV classification into adolescence.

Additionally, the rate of very low birth weight and/or very preterm (VLBW/VP) children with psychiatric disorders requiring treatment occurs about 3 to 4 times more often than in the general population.

(S. Johnson, 2007; Schothorst, Swaab-Barneveld, & van Engeland, 2007)(Bhutta, et al., 2002)(Hack, et al., 2004; Schothorst, et al., 2007) (Grunau, Whitfield, & Fay, 2004)

Externalizing Problems & Preterm Children

Externalizing means to attribute something to an external or outside cause, such as explaining your feelings based on your surroundings.

The most common psychiatric problem associated with preterm birth are externalizing problems, typically reported as Attention Deficit Hyperactivity Disorders (ADHD).


preterm children and behavioral outcomes, externalizing problems, internalizing difficulties, and social problems

Incidence: Preterm Children

The symptoms of ADHD are examined by using standardized questionnaires administered to parents and teachers. According to research the incidence of ADHD in preterm and/or low birth weight (LBW) children and adolescents has ranged from approximately 16% to 23%. An estimated 14% of all cases of ADHD have been attributed to preterm birth.

The global incidence of ADHD in the “normal” population is 3 to 5%.

Symptoms of hyperactivity and impulsivity reportedly occur more frequently in preterm boys than in preterm girls, which is consistent with gender differences in the normal population. ADHD in the general population is a known risk factor for co-morbidity in conduct disorder but several studies have found no such pattern in preterm children and have suggested a “purer” form of ADHD in this population.

Risk Factors for ADHD & Preterm Children

Decreasing birth weight, and to a lesser extent gestational age, have been found to be associated with increased rates of ADHD. Neonatal white matter injuries, particularly parenchymal lesions and ventricular enlargement, have been found to be strongly predictive of ADHD in low birth weight (LBW) and extremely low birth weight (ELBW) children.

Thinking & Learning & ADHD

ADHD has been associated with other important cognitive and academic outcomes such as lower IQ scores, motor inhibition dysfunction, problems with executive functions (e.g. planning and regulation of behavior), and difficulties with arithmetic.


Social Outcomes & Preterm Children

Several studies have also investigated social skills, temperament, and personality differences in preterm children. Preterm babies, particularly those who have been in intensive care units have been described as being more “difficult” and score less favorably in mood, adaptability, persistence, rhythmicity and distractibility than full term infants in standardized measures of temperament.

School-age: Preterm Children

  • The pattern of arrhythmia, and less persistence and adaptability reportedly continues through pre-school years of preterm children.
  • Preterm children may also be less likely to be rated as “difficult”
  • Preterm children more likely to have behavioral and emotional problems that negatively influence academic functioning

Adolescence: Preterm Children

Very low birth weight (VLBW) adolecents report;

  • significantly fewer risk-taking behaviors
  • greater antisocial behavior
  • lower sociability and social competence
  • lower self-esteem
  • higher levels of social rejection
  • higher scores on lie-scales
  • more shyness
  • more neuroticism

Risk Factors for Social & Behavioral Problems

A number of different factors have been linked to behavioral and social difficulties in preterm children and adolescents, such as;

  • lower birth weight
  • smaller head circumference
  • dexamethasone treatment (corticosteroid used to help develop preterm babies with immature lungs)
  • neonatal cranial ultrasound abnormality
  • neurological dysfunction
  • perinatal or early postnatal exposure to stress
(Hughes, Shults, McGrath, & Medoff-Cooper, 2002; Langkamp, Kim, & Pascoe, 1998; Spungen & Farran, 1986)(Goldstein & Bracey, 1988)(Reijneveld et al., 2006)(Allin et al., 2006; Botting, et al., 1997; S. Johnson, 2007; L. A. Schmidt, Miskovic, Boyle, & Saigal, 2008)(Bohnert & Breslau, 2008; Nomura, Brooks-Gunn, Davey, Ham, & Fifer, 2007; L. A. Schmidt, et al., 2008), (Allin, et al., 2006), (Trautman, Meyer-Bahlburg, Postelnek, & New, 1995)(Schothorst, et al., 2007)

Summary of Behavioral Outcomes in Preterm Children

Preterm children are at risk for behavioral problems, ADHD is the most thoroughly studied as well as the most common psychiatric problem affecting children born preterm. Difficulties with social functioning are commonly reported by parents and teachers of preterm children/adolescents. Preterm children tend to view themselves as having more emotional problems, whereas parents and teachers report hyperactivity, peer problems, and emotional problems. Several perinatal factors have been identified to be related to behavior, social, and emotional difficulties, however it is unclear why this is the case.


Technical Reference List

Allin, M., Rooney, M., Cuddy, M., Wyatt, J., Walshe, M., Rifkin, L., et al. (2006). Personality in young adults who are born preterm. Pediatrics, 117(2), 309-316.
Bhutta, A. T., Cleves, M. A., Casey, P. H., Cradock, M. M., & Anand, K. J. S. (2002). Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis. Jama, 288(6).
Bohnert, K. M., & Breslau, N. (2008). Stability of psychiatric outcomes of low birth weight: a longitudinal investigation. Archives of General Psychiatry, 65(9), 1080-1086.
Botting, N., Powls, A., Cooke, R. W., & Marlow, N. (1997). Attention deficit hyperactivity disorders and other psychiatric outcomes in very low birthweight children at 12 years. Journal of Child Psychology and Psychiatry and Allied Disciplines, 38(8), 931-941.
Gardner, F., Johnson, A., Yudkin, P., Bowler, U., Hockley, C., Mutch, L., et al. (2004). Behavioral and emotional adjustment of teenagers in mainstream school who were born before 29 weeks' gestation. Pediatrics, 114(3), 676-682.
Goldstein, D. J., & Bracey, R. J. (1988). Temperament characteristics of toddlers born prematurely. Child: Care, Health and Development, 14(2), 105-109.
Grunau, R. E., Whitfield, M. F., & Fay, T. B. (2004). Psychosocial and academic characteristics of extremely low birth weight (< or =800 g) adolescents who are free of major impairment compared with term-born control subjects. Pediatrics, 114(6), e725-732.
Hughes, M. B., Shults, J., McGrath, J., & Medoff-Cooper, B. (2002). Temperament characteristics of premature infants in the first year of life. Journal of Developmental and Behavioral Pediatrics, 23(6), 430-435.
Johnson, S. (2007). Cognitive and behavioural outcomes following very preterm birth. Semin Fetal Neonatal Med, 12(5), 363-373.
Langkamp, D. L., Kim, Y., & Pascoe, J. M. (1998). Temperament of preterm infants at 4 months of age: maternal ratings and perceptions. Journal of Developmental and Behavioral Pediatrics, 19(6), 391-396.
Reijneveld, S. A., de Kleine, M. J. K., van Baar, A. L., Kollee, L. A. A., Verhaak, C. M., Verhulst, F. C., et al. (2006). Behavioural and emotional problems in very preterm and very low birthweight infants at age 5 years. Archives of Disease in Childhood. Fetal and Neonatal Edition, 91(6), F423-428.
Schmidt, L. A., Miskovic, V., Boyle, M. H., & Saigal, S. (2008). Shyness and timidity in young adults who were born at extremely low birth weight. Pediatrics, 122(1), e181-187.
Schothorst, P. F., Swaab-Barneveld, H., & van Engeland, H. (2007). Psychiatric disorders and MND in non-handicapped preterm children. Prevalence and stability from school age into adolescence. European Child and Adolescent Psychiatry, 16(7), 439-448.
Laucht, M., Esser, G., Baving, L., Gerhold, M., Hoesch, I., Ihle, W., et al. (2000). Behavioral sequelae of perinatal insults and early family adversity at 8 years of age. Journal of the American Academy of Child and Adolescent Psychiatry, 39(10), 1229-1237.
Trautman, P. D., Meyer-Bahlburg, H. F., Postelnek, J., & New, M. I. (1995). Effects of early prenatal dexamethasone on the cognitive and behavioral development of young children: results of a pilot study. Psychoneuroendocrinology, 20(4), 439-449.



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