Longitudinal follow-up of children born preterm: somatic and mental health, self-esteem and quality of life at age 19

Subjective Well-Being and Self-Esteem in Preterm Born Adolescents: An Individual Participant Data Meta-Analysis

OBJECTIVE

To study self-reported well-being and self-esteem among adolescents born very preterm (VPT; <32 wk of gestation) and moderate to late preterm (MLPT; 32-36 wk of gestation) compared with those born full-term (FT) in an individual participant data (IPD) meta-analysis.

METHODS

We obtained IPD from the following 4 data sources: The Avon Longitudinal Study of Parents and Children (United Kingdom), the Millennium Cohort Study (United Kingdom), the Basel Study of Preterm Children (Switzerland), and the Bavarian Longitudinal Study (Germany) and conducted two-step random-effects IPD meta-analysis. A total of 986 MLPT, 412 VPT, and 12,719 FT born adolescents reported on subjective well-being and 927 MLPT, 175 VPT, and 13,312 FT born adolescents reported on global self-esteem.

RESULTS

Adolescents born VPT or MLPT were not different from those born FT regarding general subjective well-being; family, school, and physical appearance-related well-being; and global self-esteem. However, adolescents born VPT reported lower well-being in peer relationships than those born FT (β = -0.209, 95% confidence interval = -0.336 to -0.082). There was no main effect of fetal growth restriction (FGR) and no moderation by FGR, sex, parental education, and ethnicity. No significant heterogeneity between cohorts was found, although some heterogeneity estimates were moderate.

CONCLUSION

Adolescents born preterm mostly report no lower well-being and self-esteem than adolescents born FT. However, they perceive their peer relationships as poorer than those born FT.

Gestational age and adolescent mental health: evidence from Hong Kong's 'Children of 1997' birth cohort

BACKGROUND

Preterm, and more recently early term, birth has been identified as a risk factor for poor health. Whether the sequelae of late preterm or early term birth extends to poor mental health and well-being in adolescence is unclear and has not been systematically assessed.

METHOD

Linear regression was used to assess the adjusted associations of gestational age (very/moderate preterm (<34 weeks, n=85), late preterm (34-36 weeks, n=305), early term (37-38 weeks, n=2228), full term (39-40 weeks, n=4018), late term (41 weeks, n=809), post-term (≥42 weeks, n=213)) with self-reported self-esteem at ∼11 years (n=6935), parent-reported Rutter score assessing the common emotional and behavioural problems at ∼7 years (n=6292) and ∼11 years (n=5596) and self-reported depressive symptoms at ∼13 years (n=5795) in a population-representative Hong Kong Chinese birth cohort 'Children of 1997' where gestational age has little social patterning.

RESULTS

Very/moderate preterm birth was associated with higher Rutter subscore for hyperactivity (ß coefficients 0.5, 95% CI 0.01 to 1.00) at ∼7 years but not at ∼11 years, adjusted for sex, age, socio-economic position, parents' age at birth, birth order and secondhand smoke exposure. Similarly adjusted, late preterm, early term, late term and post-term birth were not associated with self-esteem or depressive symptoms.

CONCLUSIONS

In a population-representative birth cohort from a non-Western-developed setting, gestational age had few associations with mental health and well-being in adolescence, whereas very preterm birth was specifically associated with hyperactivity in childhood. Inconsistencies with studies from Western settings suggest setting specific unmeasured confounding may underlie any observed associations.

Mental health, quality of life and social relations in young adults born with low birth weight

Background

Being born with low birth weight may have an impact on different aspects of mental health, psychosocial functioning and well-being; however results from studies in young adulthood have so far yielded mixed findings. The aim of this study was to assess the long-term impact in young adulthood on self-reported mental health, health-related quality of life, self-esteem and social relations by investigating differences between two low birth weight groups and a control group.

Methods

In a follow-up at 20 years of age, 43 preterm VLBW (birth weight ≤ 1500 g), 55 term SGA (birth weight < 10th percentile) and 74 control subjects completed the Adult Self-Report (ASR) of the Achenbach System of Empirically Based Assessment, the Adult Autism Spectrum Quotient (AQ), the Short Form 36 Health Survey, the Self-Perception Profile for Adolescents-Revised, and the Wechsler Adult Intelligent Scale III assessment.

Results

The VLBW and SGA groups reported significantly more mental health problems than controls. The VLBW group predominantly had internalizing problems, and the non-significant association with ASR Total score was reduced by the Intelligence Quotient (IQ). The SGA group had increased scores on both internalizing and externalizing problems, and the association with ASR Total score remained significant after adjusting for IQ in this group. Both low birth weight groups reported less interaction with friends and lower quality of life related to mental health domains than controls. Self-esteem scores were lower than in the control group for athletic competence (VLBW) and social acceptance (SGA).

Conclusion

Our findings suggest that self-reported mental health and well-being in young adulthood may be adversely affected by low birth weight, irrespective of whether this is the result of premature birth or being born SGA at term.

Eight-Year Developmental Follow-up in Children with Birthweights 1,251–1,500g in KK Women's and Children's Hospital

Background:

Children of very low birth weight (VLBW, birth weight <1,500g) are at risk of developmental disability and learning difficulties. Regular follow-up to a school-going age allows timely diagnosis and intervention.

Methods:

The duration, developmental assessment and service utilisation of 41 VLBW children with birth weights between 1,251–1,500g born in 2001 were retrospectively analysed.

Results:

The median follow-up duration was 5 years 11 months. 56% were followed-up till preschool entry. Gross motor, fine motor and language domains were assessed in more than 95% of children. Information on behavioural and learning problems was only sought for in approximately 50% of children.

Conclusions:

A significant proportion of these high-risk children were either not followed-up long enough or were not adequately assessed for learning and behavioural problems, thus justifying the development of a new standardised follow-up program for larger VLBW children.

Quality of life of adolescents and young adults born at high risk

Research on quality of life (QoL) of adolescents and young adults born preterm and those with congenital heart disease (CHD) was systematically reviewed, and factors associated with QoL were identified. Forty-five studies met the inclusion criteria for review. Although the majority of studies found that self-reported QoL of adolescents and young adults born preterm did not differ from term controls, several studies reported lower QoL among individuals born preterm, especially those who had additional impairments. Most studies on adolescents and young adults with CHD reported lower QoL compared with healthy peers, which may be in part due to real or perceived physical activity limitations of individuals with CHD. Overall, parents reported that their adolescents born at high risk had a less favorable QoL compared with those who served as controls. Encouraging age-appropriate, safe, and enjoyable physical activity and avoiding unnecessary restrictions and overprotection are considerations for optimizing QoL.

Health-related quality of life, emotional and behavioral problems in mild to moderate prematures at (pre-)school age

BACKGROUND

There is a gap in the knowledge of longterm outcome of mild to moderate prematures compared to the extreme prematures or very low birth weight infants.

AIM

Determine health-related quality of life (HRQoL) and prevalence of emotional and behavioral problems in (pre-)school age children born at 32 to 36 weeks' gestation.

STUDY DESIGN

A descriptive cohort study in a non-Neonatal Intensive Care Unit. Patient characteristics, diagnoses, treatment and social economic status (SES) were analyzed. Study tools were the TNO-AZL Preschool Quality of Life (TAPQoL) and Child Behavior Checklist (CBCL).

SUBJECTS

362 children born between 32 and 36 weeks' gestation who had a follow-up evaluation at 2-5 years of age.

OUTCOME MEASURE

Health-related quality of life and the occurrence of emotional and behavioral problems.

RESULTS

Main characteristics (mean±SD) were: gestation 34.7±1 weeks and birth weight 2360±444 g. Most families were two-parent middle-class households with parents employed at their educational level. Questionnaire response rate was 62.7%. The 12-item TAPQoL showed significantly lower scores for stomach and liveliness, while scores for behavior, communication and sleep were significantly higher compared to the general population. The TAPQoL subscale score for lung problems was significantly lower for children who had received continuous positive airway pressure (CPAP). CBCL scores were within the validated normal range although the study-population scored higher on emotionally reactive, somatic complaints and attention problems compared to their full-term peers.

CONCLUSION

Children born at 32 to 36 weeks' gestational age do not experience an overall lower HR-QoL at 2 to 5 years of age. CPAP results in lower HRQoL scores for lung problems. The overall occurrence of behavioral and emotional problems does not differ from the general term-born pediatric population. Several subitems need further attention.

Mental health concerns of the premature infant through the lifespan

Because of increased survival rates, neurodevelopmental issues, chronic medical problems, and sometimes complex family issues involved with prematurity, mental health clinicians commonly assess preterm clients and manage their behavioral and mental health problems. Understanding prematurity survival and neurodevelopmental outcomes is important for contextualizing the mental health problems seen in this high-risk population. This article provides a brief overview of prematurity outcomes in the domains of prematurity relevant to practicing child psychiatrists. Prematurity is also examined as it relates to parental mental health challenges, infant mental health outcomes, high frequency attention problems, and psychiatric disorders. The complex interactions between prematurity and family well-being are also highlighted. Finally, evidence-based treatment modalities involved in prevention and management are explored.

Adolescents born extremely preterm: behavioral outcomes and quality of life

Fifty-two extremely premature born and 54 full-term controls were assessed regarding behavioral outcomes, risk-taking and self-perceived quality of life. Behavioral outcomes were assessed with the Achenbach Youth Self Report; risk-taking was estimated regarding alcohol and nicotine use; self-perceived quality of life and future expectations were rated; and attention and hyperactivity problems were surveyed retrospectively with the Wender Utah Rating Scale. The prematurely born reported fewer problems than full-term born on the externalizing scale (delinquent behavior and aggressive behaviour); and they reported less alcohol consumption. No difference was observed between the two groups concerning nicotine use, views about quality of life and expectations for the future or in the retrospective assessment of attention and hyper-activity problems. Conclusively, the prematurely born adolescents described a quality of life and future expectations comparable to full-term born controls. They also reported fewer behavioral problems and less risk-taking behavior.

Mental health concerns of the premature infant through the lifespan

Because of increased survival rates, neurodevelopmental issues, chronic medical problems, and sometimes complex family issues involved with prematurity, mental health clinicians commonly assess preterm clients and manage their behavioral and mental health problems. Understanding prematurity survival and neurodevelopmental outcomes is important for contextualizing the mental health problems seen in this high-risk population. This article provides a brief overview of prematurity outcomes in the domains of prematurity relevant to practicing child psychiatrists. Prematurity is also examined as it relates to parental mental health challenges, infant mental health outcomes, high frequency attention problems, and psychiatric disorders. The complex interactions between prematurity and family well-being are also highlighted. Finally, evidence-based treatment modalities involved in prevention and management are explored.

Adult outcomes of preterm children

The survivors of the initial years of neonatal intensive care of preterm infants reached adulthood during the last decade. Reports of their adult outcomes examined have included neurodevelopmental, behavioral and health outcomes as well as social functioning and reproduction. Despite statistically significant differences between preterm young adults and controls in most outcomes studied, the majority of preterm survivors do well and live fairly normal lives. The two major predictors of adult outcomes are lower gestational age that reflect perinatal injury and family sociodemographic status which reflects both genetic and environmental effects.

Most very low birth weight subjects do well as adults

AIM

To study health, quality of life, educational level and occupation in very low birth weight (VLBW) children in early adulthood and the relationship of the findings to neonatal risk factors and later handicap.

METHODS

This is a prospective long-term follow-up study of a regional cohort of 20-year-old VLBW subjects (n = 77) of all surviving VLBW children (n = 86) and 69/86 term controls born in 1987-1988 in the south-east of Sweden. Postal questionnaires were used: 1. A study-specific form, 2. Medical Outcomes Study, Short Form (SF-36), 3. Sense of Coherence.

RESULTS

VLBW subjects did not differ significantly from their controls in self-perceived health, use of tobacco, education, occupation and way of living, or scoring on SF-36 and Sense of Coherence. Sixteen had cerebral palsy, attention deficit hyperactivity disorder or isolated mental retardation, and these subjects differed significantly from controls on SF-36 in physical functioning and physical health score, but not on Sense of Coherence. VLBW subjects were significantly lighter and shorter than their controls. Extremely low birth weight (ELBW), bronchopulmonary dysplasia and intraventricular haemorrhage were significantly associated with poorer scores on physical function.

CONCLUSION

The 20-year old VLBW subjects reported perceived health and managed transition to adulthood similar to controls. Handicapped subjects had poorer self-perceived physical function. ELBW and severe neonatal complications were associated with poorer self-perceived physical health.

The Cues and Care Trial: a randomized controlled trial of an intervention to reduce maternal anxiety and improve developmental outcomes in very low birthweight infants

BACKGROUND

Very low birthweight infants are at risk for deficits in cognitive and language development, as well as attention and behaviour problems. Maternal sensitive behaviour (i.e. awareness of infant cues and appropriate responsiveness to those cues) in interaction with her very low birthweight infant is associated with better outcomes in these domains; however, maternal anxiety interferes with the mother's ability to interact sensitively with her very low birthweight infant. There is a need for brief, cost-effective and timely interventions that address both maternal psychological distress and interactive behaviour. The Cues and Care trial is a randomized controlled trial of an intervention designed to reduce maternal anxiety and promote sensitive interaction in mothers of very low birthweight infants.

METHODS AND DESIGN

Mothers of singleton infants born at weights below 1500 g are recruited in the neonatal intensive care units of 2 tertiary care hospitals, and are randomly assigned to the experimental (Cues) intervention or to an attention control (Care) condition. The Cues intervention teaches mothers to attend to their own physiological, cognitive, and emotional cues that signal anxiety and worry, and to use cognitive-behavioural strategies to reduce distress. Mothers are also taught to understand infant cues and to respond sensitively to those cues. Mothers in the Care group receive general information about infant care. Both groups have 6 contacts with a trained intervener; 5 of the 6 sessions take place during the infant's hospitalization, and the sixth contact occurs after discharge, in the participant mother's home. The primary outcome is maternal symptoms of anxiety, assessed via self-report questionnaire immediately post-intervention. Secondary outcomes include maternal sensitive behaviour, maternal symptoms of posttraumatic stress, and infant development at 6 months corrected age.

DISCUSSION

The Cues and Care trial will provide important information on the efficacy of a brief, skills-based intervention to reduce anxiety and increase sensitivity in mothers of very low birthweight infants. A brief intervention of this nature may be more readily implemented as part of standard neonatal intensive care than broad-based, multi-component interventions. By intervening early, we aim to optimize developmental outcomes in these high risk infants.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN00918472. The Cues and Care Trial: A randomized controlled trial of an intervention to reduce maternal anxiety and improve developmental outcomes in very low birthweight infants.

Perinatal characteristics and parents' perspective of health status of NICU graduates born at term

OBJECTIVE

Long-term outcomes of preterm infants have been extensively studied, but few studies have examined long-term outcomes of term infants who require neonatal intensive care unit (NICU). Our objectives were to assess perinatal characteristics and health status of preschool age term babies using data from a population-based study of NICU graduates.

STUDY DESIGN

Retrospective cross-sectional survey. All babies were born in 1996 to 1997 in BC (Canada). The Health Status Classification System Preschool (HSCS-PS) questionnaire was completed by parents at 42 months of age. HSCS-PS was grouped in four categories (neurosensory, learning, motor and quality of life). Logistic regression was used to identify perinatal risk factors associated with moderate/severe problems at 42 months of age.

RESULT

Completed surveys were received for 261 term NICU survivors and 393 control children. Term infants represent 32% of all NICU admissions. Mean birth weight of NICU graduates was 3458 g (s.d.=600 g). Median length-of-stay in NICU was 5 days. At 42 months, the NICU group had significantly more problems on the HSCS-PS as compared to the full-term healthy infants in neurosensory, motor and learning/remembering. Moderate/severe health status problems were associated with congenital anomalies (odds ratio (OR), 3.2; confidence interval (CI): 1.3 to 7.8); smoking status (OR, 2.7, CI: 1.1 to 6.6) and SNAP score (OR, 1.04; CI: 1.0 to 1.1).

CONCLUSION

Term babies admitted to NICUs may have significant health issues in childhood. Greater attention needs to be paid to long-term outcomes of term NICU graduates. Further study is warranted to address which NICU term survivors warrant secondary and/or tertiary-level neurodevelopmental follow-up.

Measurement of quality of life of survivors of neonatal intensive care: critique and implications

In recent years, an increasing number of studies on the quality of life (QoL) of adults and children have been published, mostly describing outcomes of various medical conditions. Yet, despite the wide interest, there is no universal consensus even on the very definition of what constitutes QoL, particularly for children. Herein, we discuss the conceptual framework and operational definitions of QoL and health-related quality of life (HRQL), address some methodological issues, and review the literature on QoL studies among premature infants. We also describe areas of research that are likely to be fruitful in advancing the consideration of QoL in future studies and in clinical practice.

Self-perceived health, functioning and well-being of very low birth weight infants at age 20 years

OBJECTIVE

To examine the self-perceived health of very low birth weight (VLBW; <1.5 kg) infants during young adulthood.

STUDY DESIGN

The population included 241 VLBW and 232 normal birth weight (NBW) controls who completed the Child Health and Illness Profile: Adolescent Edition (CHIP-AE) at 20 years of age. The CHIP-AE includes six domains: Satisfaction, Comfort, Resilience, Achievement, Risk Avoidance, and Disorders, and 13 profiles that characterize patterns of health. Results were compared between VLBW and NBW subjects adjusting for sex and sociodemographic status.

RESULTS

VLBW subjects did not differ from NBW controls in the domains of Satisfaction or Comfort but reported less Resilience (effect size [ES] -0.19, P < .05), specifically in physical activity and family involvement. They reported better Achievement, specifically in work performance (ES 0.28, P < .05), more Risk Avoidance (ES 0.43, P < .001), and significantly more long-term medical, surgical, and psychosocial disorders. Similar proportions of VLBW and NBW subjects reported Excellent (15% vs 11%), Average (27% vs 34%), and Poor (12% vs 13%) profiles of health.

CONCLUSIONS

VLBW subjects report similar health, well-being, and functioning compared with NBW controls and greater risk avoidance. However, we are concerned that their lesser resilience may prove detrimental to their future adult health.

Cognitive and behavioural outcomes following very preterm birth

This paper provides a review of the cognitive and behavioural outcomes of very preterm children in middle childhood. Case-controlled studies have shown that very preterm children have intelligence quotient (IQ) scores significantly lower than term peers, even for those who are free of severe disability. Authors have noted a gestational age-related gradient in IQ for those born before 33 weeks and studies have revealed particular problems in non-verbal reasoning and simultaneous information processing. Very preterm children are also at risk for behavioural problems. There is little consensus regarding the presence of internalising or externalising behaviours, but most studies show an increased risk of attentional and social problems. Studies have also shown a greater prevalence of psychiatric disorders and, specifically, an increased risk for ADHD. Methodological issues are discussed and suggestions are made for improving the reporting of outcomes to facilitate cross-study comparisons.

Functional outcomes and participation in young adulthood for very preterm and very low birth weight infants: the Dutch Project on Preterm and Small for Gestational Age Infants at 19 years of age

OBJECTIVE

Young adults who were born very preterm or with a very low birth weight remain at risk for physical and neurodevelopmental problems and lower academic achievement scores. Data, however, are scarce, hospital based, mostly done in small populations, and need additional confirmation.

METHODS

Infants who were born at < 32 weeks of gestation and/or with a birth weight of < 1500 g in The Netherlands in 1983 (Project on Preterm and Small for Gestational Age Infants) were reexamined at age 19. Outcomes were adjusted for nonrespondents using multiple imputation and categorized into none, mild, moderate, or severe problems.

RESULTS

Of 959 surviving young adults, 74% were assessed and/or completed the questionnaires. Moderate or severe problems were present in 4.3% for cognition, 1.8% for hearing, 1.9% for vision, and 8.1% for neuromotor functioning. Using the Health Utility Index and the London Handicap Scale, we found 2.0% and 4.5%, respectively, of the young adults to have > or = 3 affected areas in activities and participation. Special education or lesser level was completed by 24%, and 7.6% neither had a paid job nor followed any education. Overall, 31.7% had > or = 1 moderate or severe problems in the assessed areas.

CONCLUSIONS

A total of 12.6% of young adults who were born very preterm and/or with a very low birth weight had moderate or severe problems in cognitive or neurosensory functioning. Compared with the general Dutch population, twice as many young adults who were born very preterm and/or with a very low birth weight were poorly educated, and 3 times as many were neither employed nor in school at age 19.

Self-reported health status and health-related quality of life of teenagers who were born before 29 weeks' gestational age

OBJECTIVE

The objective of this study was to describe the self-reported health status and health-related quality of life of British teenagers who are in mainstream schooling and were born before 29 weeks' gestational age compared with British teenagers who were born at term.

METHODS

All surviving children who were born at <29 weeks' gestation in the former Northern Region of England in 1983 and in the former Oxford Region of England and in Scotland in 1984 were eligible. A comparison group of teenagers who were born at term were also recruited. Children's responses to the Health Utilities Index Mark III were compared.

RESULTS

A total of 218 of the original 535 children who were born in the 3 regions during the study period were alive at 15 to 16 years of age. A complete Health Utilities Index Mark III record was available for 140 children in mainstream schools and for 108 control subjects. In 7 of the 8 attributes (vision, hearing, speech, emotion, pain, ambulation, and dexterity), there were no statistically significant differences in any functional impairment between the comparator groups. However, the preterm group did report a higher level of functional impairment in the cognition attribute (40.7% vs 25.0%). Although there was no difference in the median Health Utilities Index Mark III utility score between the 2 groups (0.93), there was a broader range of utility scores for the preterm group (0.07-1.0 vs 0.45-1.0 for the control group).

CONCLUSIONS

Despite objective evidence that children and teenagers who were born preterm have poorer health on average than term-born control subjects, this is not reflected in their own ratings of their health status and health-related quality of life at 15 to 16 years of age. The reasons for these differences need to be further explored.

Cognitive function in young adults following intrauterine growth restriction with abnormal fetal aortic blood flow

OBJECTIVE

Intrauterine growth restriction (IUGR) is a recognized risk factor for neurological deficits later in life. Abnormal fetal blood flow in the presence of IUGR helps to distinguish fetuses with true growth impairment from those that are small but normally grown. This study aimed to evaluate the influence of IUGR with abnormal fetal blood flow on cognitive function and psychological development in young adults.

METHODS

Cognitive capacity (Wechsler adult intelligence scale-III (WAIS-III)) and psychological development (symptom check-list and Wender Utah rating scale) were evaluated at 18 years of age in 19 subjects who had had IUGR (abnormal fetal blood flow in the descending aorta and birth weight small-for-gestational age) and in 23 control subjects who had had normal fetal aortic blood flow and birth weight appropriate-for-gestational age (AGA). School grades at 16 years of age were also recorded.

RESULTS

The IUGR subjects had significantly lower results at 18 years of age in the combined subtests of the WAIS-III measuring executive cognitive functions (P = 0.03) and lower school grades at 16 years of age (P = 0.03) compared with the AGA group. IUGR subjects did not exhibit significantly more psychological distress symptoms.

CONCLUSION

IUGR with abnormal fetal blood flow is associated with impaired executive cognitive function in young adults.

Self-perceived health-related quality of life of former extremely low birth weight infants at young adulthood

OBJECTIVES

The goals were to compare the self-reported, health-related quality of life of former extremely low birth weight and normal birth weight infants at young adulthood and to determine whether there were any changes over time.

METHODS

A prospective, longitudinal, population-based study with concurrent control subjects was performed. We interviewed 143 of 166 extremely low birth weight survivors (birth weight: 501-1000 g; 1977-1982 births) and 130 of 145 sociodemographically comparable, normal birth weight, reference subjects. Neurosensory impairments were present for 27% extremely low birth weight and 2% normal birth weight young adults. Health Utilities Index 2 was used to assess health status, and standard gamble technique was used to measure directly the self-reported, health-related, quality of life and 4 hypothetical health states.

RESULTS

Extremely low birth weight young adults reported more functional limitations in cognition, sensation, mobility, and self-care, compared with control subjects. There were no differences between groups in the mean self-reported, health-related, quality of life or between impaired (n = 38) and nonimpaired (n = 105) extremely low birth weight subjects. However, with a conservative approach of assigning a score of 0 for 10 severely disabled, extremely low birth weight subjects, the mean health-related quality of life was significantly lower than control values. Repeated-measures analysis of variance to compare health-related quality-of-life measurements obtained for young adults and teens showed the same decline in scores over time for both groups. There were no differences between groups in the ratings provided for the hypothetical health states.

CONCLUSIONS

At young adulthood, health-related quality of life was not related to size at birth or to the presence of disability. There was a small decrease in health-related quality-of-life scores over time for both groups.

Emotional, behavioral, social, and academic outcomes in adolescents born with very low birth weight

BACKGROUND

Very low birth weight survivors are at increased risk of developing emotional and behavioral problems and low social and academic competencies. Information on such problems in very low birth weight adolescents is still sparse.

OBJECTIVES

Our purpose for this work was to study gender-specific emotional and behavioral problems and social and academic competencies in a cohort of very low birth weight adolescents in north Norway.

METHODS

Families with very low birth weight adolescents aged 13 to 18 years, born between 1978 and 1989 (n = 162) were addressed by mail and asked to complete the Child Behavior Check List and the Youth Self-Report. Data were compared with 2 normative adolescent populations (Child Behavior Check List, n = 540; Youth Self-Report, n = 2522). Scores given by very low birth weight adolescents and their parents on identical items in Child Behavior Check List and Youth Self-Report (cross-informant syndrome constructs) were compared in pairs. To explore predictive effects, demographic and early medical characteristics were entered into a hierarchical multiple regression analysis.

RESULTS

There were 156 eligible families, and 99 (63.5%) responded. All completed the Child Behavior Check List, and 82 (52.6%) completed the Youth Self-Report. Very low birth weight boys reported less externalizing and internalizing behaviors and thought and attention problems and higher activity score, whereas very low birth weight girls reported less externalizing behavior and less social, thought, and attention problems and higher activity score compared with normative adolescents. Very low birth weight parents, however, reported more social and attention problems and less social and school competence in boys and more internalizing behavior and social and attention problems and less school competence in girls compared with normative parents. They scored high proportions of both genders within the borderline/clinical range on all of the scales, except for externalizing behavior and social problems in girls. Female very low birth weight adolescents, in contrast to males, reported more problems than parents when compared in pairs, and externalizing problems in particular were not recognized by parents.

CONCLUSIONS

From parents' point of view, significant proportions of very low birth weight adolescents experience more emotional and behavioral problems and less competence than normative adolescents. In contrast, very low birth weight adolescents state less problems and similar or higher competence than normative adolescents. Very low birth weight adolescent girls report more emotional and behavioral problems compared with their parents than very low birth weight adolescent boys do. Externalizing problems in very low birth weight adolescent girls are often not recognized by parents. To better understand these seemingly paradoxical findings and to develop adequate intervention programs, there is a need for prospective longitudinal studies.

Young adult outcomes of very-low-birth-weight children

Information on the young adult outcomes of the initial survivors of neonatal intensive care has been reported from the United States, Canada, Australia, Great Britain and other European countries. The studies have varied with regard to whether they were regional or hospital-based, their birth-weight group and gestational age, rates of survival, socio-demographic background, and measures of assessment and types of outcome studied. Despite these differences the overall results reveal that neurodevelopment and growth sequelae persist to young adulthood. Very-low-birth-weight young adults have, with few exceptions, poorer educational achievement than normal-birth-weight controls, and fewer continue with post-high-school study. Rates of employment are, however, similar. There are no major differences in general health status, but the young adults demonstrate poorer physical abilities, higher mean blood pressure and poorer respiratory function. There is no evidence of major psychiatric disorder, although anxiety and depression are reported more often. The young adults report less risk-taking than control populations. They report fairly normal social lives and quality of life. When differences are noted they are usually due to neurosensory disabilities. Longer-term studies are needed to evaluate ultimate educational and occupational achievement. It will also be important to assess the effects of preterm birth, early growth failure and catch-up growth on later metabolic and cardiovascular health.

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

OBJECTIVE

To compare academic and cognitive ability, attention, attitudes, and behavior of extremely low birth weight (ELBW) adolescents who are free of major impairments at 17 years of age with term-born control subjects.

METHODS

Between January 31, 1981, and February 9, 1986, 250 infants of < or =800 g were admitted for intensive care in British Columbia, 98 (39%) of whom survived to late adolescence. Teens with major sensorimotor handicaps and/or IQ <70 were excluded (n = 19). Of the 79 eligible ELBW teens, 53 (67%) were assessed at 17.3 (16.3-19.7) years (birth weight: 720 [520-800 g]; gestation: 26 [23-29] weeks). The test battery screened the following areas: cognitive (Wechsler Intelligence Scale for Adults Third Edition, 3 subtests), academic (Wide Range Achievement Test-3), attention (Connors' Continuous Performance Task), self-report (Harter Self-Perception Profile for Adolescents; Job Search Attitude Inventory), and parent report (Child Behavior Check List). A comparison group of term born control subjects (n = 31) were also assessed (birth weight: 3506 [3068-4196] g; gestation: 40 [39-42] weeks) at age 17.8 (16.5-19.0) years. Multivariate analysis of variance (group x gender) was conducted for each domain (cognitive, academic, self-report, and parent report).

RESULTS

The ELBW group showed lower cognitive scores (vocabulary, block design, and digit symbol) and academic skills (reading and arithmetic) compared with control subjects, with no gender differences. There were no differences in attention between the 2 groups using a repetitive computer task. ELBW teens reported lower scholastic, athletic, job competence, and romantic confidence and viewed themselves as more likely to need help from others in finding a job. In the behavioral domain, parents reported their ELBW teens to display more internalizing, more externalizing, and more total problems than the control teens, with ELBW boys showing more problems. ELBW teens showed a higher percentage of clinically significant behavior problems than control subjects.

CONCLUSIONS

In a provincial cohort of unimpaired survivors of birth weight < or =800 g, psychosocial and educational vulnerabilities persist into late adolescence and may complicate the transition to adult life compared with their peers.

Behavioral outcomes and evidence of psychopathology among very low birth weight infants at age 20 years

OBJECTIVE

Information on the mental health of very low birth weight (VLBW; <1500 g) children in young adulthood is sparse. We thus sought to examine gender-specific behavioral outcomes and evidence of psychopathology in a cohort of VLBW young adults at 20 years of age.

METHODS

We compared a cohort of 241 survivors among VLBW infants who were born between 1977 and 1979 (mean birth weight: 1180 g; mean gestational age at birth: 29.7 weeks), 116 of whom were men and 125 of whom were women, with 233 control subjects from the same population in Cleveland who had normal birth weights (108 men and 124 women). Young adult behavior was assessed at 20 years of age with the Achenbach Young Adult Self-Report and the Young Adult Behavior Checklist for parents. In addition, the young adults and parents completed the ADHD Rating Scale for Adults. Gender-specific outcomes were adjusted for sociodemographic status.

RESULTS

VLBW men reported having significantly fewer delinquent behaviors than normal birth weight (NBW) control subjects, but there were no differences on the Internalizing, Externalizing, or Total Problem Behavior scales. Parents of VLBW men reported significantly more thought problems for their sons than did parents of control subjects. VLBW women reported significantly more withdrawn behaviors and fewer delinquent behavior problems than control subjects. Their rates of internalizing behaviors (which includes anxious/depressed and withdrawn behaviors) above the borderline clinical cutoff were 30% versus 16% (odds ratio: 2.2; 95% confidence interval [CI]: 1.2-4.1). Parents of VLBW women reported significantly higher scores for their daughters on the anxious/depressed, withdrawn, and attention problem subscales compared with control parents. The odds ratios for parent-reported rates above the borderline-clinical cutoff among women for the anxious/depressed subscale was 4.4 (95% CI: 1.4-13.5), for thought problems was 3.7 (95% CI: 1.2-11.6), and for attention problems was 2.4 (95% CI: 1.0-5.5). There were no differences in the young adult self-report of attention-deficit/hyperactivity disorder (ADHD). Parents of VLBW men reported higher mean scores on the attention subtype of ADHD but not higher rates of ADHD.

CONCLUSION

The increase in psychopathology among VLBW survivors in young adulthood indicates a need for anticipatory guidance and early intervention that might help to prevent or ameliorate potential psychopathology.

Behavioral and emotional adjustment of teenagers in mainstream school who were born before 29 weeks' gestation

OBJECTIVES

To investigate behavioral and emotional problems and positive adjustment of 15-to 16-year-olds who were born at extremely low gestational age (ELGA), from the perspective of parents, teachers, and teenagers.

METHODS

Prospective follow-up was conducted of birth cohorts, with classroom control subjects. All infants who were born before 29 weeks in 1983-1984 (mean gestational age: 27 weeks) to mothers who resided in 3 regions of the United Kingdom were studied. A total of 82% (179 of 218) of survivors were traced at age 15 to 16. The 150 in mainstream school were compared with age- and gender-matched classroom control subjects (n = 108). Behavioral and emotional problems, delinquency, peer relations, self-esteem, and hobbies, were assessed by standardized, well-validated instruments, including the Strengths and Difficulties Questionnaire, administered by mail to parents, teenagers, and teachers.

RESULTS

Parents were more likely to rate ELGA teenagers than control subjects as in the "abnormal" range for hyperactivity (8% vs 1%; difference: 7%; (95% confidence interval [CI]: 2-12), peer relationship problems (19% vs 5%; difference: 14%; 95% CI: 6-21), and emotional problems (18% vs 7%; difference: 11%; 95% CI: 3-19), but not conduct problems (10% vs 5%; difference: 5%; 95% CI: -1 to 12)). Teachers reported a similar pattern. In contrast, compared with control subjects, ELGA teenagers did not rate themselves as having more problems with peers, hyperactivity, conduct, depression, or low self-esteem. They reported more emotional problems but less delinquency, alcohol, cannabis, and other drug use.

CONCLUSIONS

Compared with mainstream classmates, children who are born extremely early continue to have higher levels of parent- and teacher-reported emotional, attentional, and peer problems well into their teens. However, despite these problems, they do not show signs of more serious conduct disorders, delinquency, drug use, or depression.

Health status and health-related quality of life in a population-based sample of neonatal intensive care unit graduates

OBJECTIVE

To measure the health status (HS) and health-related quality of life (HRQL) of preschoolers who were admitted to a neonatal intensive care unit (NICU) at birth and their family caregivers and to investigate differences in HS and HRQL in relation to gestational age and major morbidity experienced during the NICU stay.

METHODS

Retrospective cross-sectional survey was conducted in the province of British Columbia, Canada. A total of 1140 of 2221 children who were admitted at birth to the 3 tertiary care NICUs in the province and 393 of 718 healthy full-term children recruited from 2 of these hospitals were studied. The main outcome measures were Infant and Toddler Quality of Life Questionnaire (ITQOL), Health Status Classification System Preschool Version (HSCS-PS), and Child Behavior Checklist/1.5-5 (CBCL) RESULTS: The overall response rate was 55%; the response rate for families that we located was 67.1%. NICU children differed from healthy children on the ITQOL in physical abilities, growth and development, temperament/moods, behavior, and general health perceptions, and caregivers differed on both parent-impact scales. On the HSCS-PS, proportionally more NICU children had a health problem in the following areas: sight, speech, getting around, using hands and fingers, taking care of self, learning and remembering, thinking and solving problems, pain and discomfort, general health, and behavior. The NICU sample reported more behavioral problems on the CBCL/1.5-5. Poorer HS and HRQL were reported for infants who were born at <27 weeks' gestation and for children who experienced > or =1 major morbidities during their NICU stay.

CONCLUSIONS

Preschool-aged children with conditions that require NICU care and their family caregivers had poorer HS and HRQL in a range of domains compared with healthy children. There were also differences within the sample by gestational age and major morbidity. The differences in health were small using the ITQOL and CBCL/1.5-5 but larger using the HSCS-PS.

The neurodevelopmental progress of infants less than 33 weeks into adolescence

BACKGROUND

Several studies have shown an increased incidence of neurodevelopmental impairment in very preterm survivors at school age compared with controls.

AIM

To compare findings in the same cohort at 8 years and 15 years.

METHODS

A total of 151 of the 224 eligible infants born before 33 weeks of gestation from 1979 to 1982, and who were living in the UK, were assessed at 8 and 15 years. Items common to both assessments were compared to evaluate changes in neurodevelopmental function. The assessment included a structured neurological examination, psychometric tests using the WISC-R (in subjects born in 1981-82), a test of visuomotor integration (Beery), and a school questionnaire.

RESULTS

There was a significant increase in the proportion of subjects classified as impaired with disability from 11% at 8 to 22% at 14-15 years of age. The proportion of subjects classified as impaired without disability increased from 16% at 8 to 26% at 14-15 years of age. Full scale IQ decreased from 104 to 95 from childhood to adolescence, and more adolescents (24%) were requiring extra educational provision than they had at the age of 8 years (15%).

CONCLUSION

Results indicate that between the ages of 8 and 15 years in this cohort of very preterm survivors there is an apparent deterioration in neurodevelopmental outcome category, cognitive function, and extra educational support. It is not clear whether this represents a genuine deterioration in neurocognitive function or whether it represents the expression of pre-existing cerebral pathology in an increasingly complex environment.

Cognitive outcomes in school-age children born prematurely

The purpose of this article is to discuss findings in the literature regarding long-term developmental outcomes of infants born prematurely, to examine potential causes of individual differences in these outcomes, and to explore directions for future research. An extensive table summarizes recent (1996-2002) international studies of developmental outcomes among children of school age and older who were born with low birth weight, especially as the studies relate to cognitive development and academic performance. The discussion then examines how characteristics of the child and the environment may interact to produce individual differences in outcomes. Processes of attention regulation within the context of the psychosocial environment are examined as an important possible direction for future research. When designing and implementing interventions aimed at improving outcomes in this and other groups of children at risk for delays and deficits, it is important to consider how various factors affect development.