Neurocognitive processes underlying academic difficulties in very preterm born adolescents

Visuospatial Perception in Prematurely Born Children Without Cerebral Palsy or Retinopathy but With Scholar Complaints

In the absence of any complaints in early childhood, preterm children remain more at risk of encountering academic difficulties, but their clinical picture remains not well characterized. We screened visuospatial perception in 70 children born preterm consulting for scholar complaints. Developmental Coordination Disorder (with or without comorbidities) was associated with high prevalence (27%) of impaired perception of spatial relationship. Prematurely born children who obtained no diagnosis of Neuro-Developmental Disorder exhibited a high prevalence (31%) of impaired perception of object magnitude. Regression revealed that low gestational age and fetal growth restriction significantly predicted the magnitude but not the spatial relationship perception.

Preschool Mathematics and Literacy Skills and Educational Attainment in Adolescents Born Preterm and Full Term

OBJECTIVES

To test whether preschool academic skills were associated with educational attainment in adolescence and whether associations differed between individuals born preterm and at full term.

STUDY DESIGN

This prospective cohort study comprised 6924 individuals, including n = 444 (6.4%) adolescents born preterm (<37 weeks of gestation) from the Avon Longitudinal Study of Parents and Children. Preschool academic (mathematics and literacy) skills were rated by teachers at 4-5 years. Educational attainment at 16 years was informed by attaining a General Certificate of Secondary Education (GCSE) in key subjects mathematics and English. Logistic regressions assessed the association between preterm birth, preschool mathematics, and GCSE Mathematics and between preterm birth, preschool literacy, and GCSE English.

RESULTS

Similar numbers of adolescents born preterm and at term achieved a GCSE in mathematics and English (53.6 % vs 57.4% and 59.5% vs 63.9%, respectively; P values > .05). Higher preschool academic skill scores in mathematics were associated with greater odds of attaining GCSE Mathematics and preschool literacy skills were associated with GCSE English. Adolescents born preterm with higher preschool mathematics (OR: 1.51, CI: 1.14, 2.00) and literacy skills (OR: 1.57, CI: 1.10, 2.25) were more likely to attain GCSEs in the respective subject than their term-born counterparts with equal levels of preschool skills.

CONCLUSIONS

Preschool academic skills in mathematics and literacy are associated with educational attainment of preterm and term-born individuals in adolescence. Children born prematurely may benefit more from preschool mathematics and literacy skills for academic and educational success into adolescence than term-born individuals.

The interrelatedness of cognitive abilities in very preterm and full-term born children at 5.5 years of age: a psychometric network analysis approach

BACKGROUND

Very preterm (VP) birth is associated with a considerable risk for cognitive impairment, putting children at a disadvantage in academic and everyday life. Despite lower cognitive ability on the group level, there are large individual differences among VP born children. Contemporary theories define intelligence as a network of reciprocally connected cognitive abilities. Therefore, intelligence was studied as a network of interrelated abilities to provide insight into interindividual differences. We described and compared the network of cognitive abilities, including strength of interrelations between and the relative importance of abilities, of VP and full-term (FT) born children and VP children with below-average and average-high intelligence at 5.5 years.

METHODS

A total of 2,253 VP children from the EPIPAGE-2 cohort and 578 FT controls who participated in the 5.5-year-follow-up were eligible for inclusion. The WPPSI-IV was used to measure verbal comprehension, visuospatial abilities, fluid reasoning, working memory, and processing speed. Psychometric network analysis was applied to analyse the data.

RESULTS

Cognitive abilities were densely and positively interconnected in all networks, but the strength of connections differed between networks. The cognitive network of VP children was more strongly interconnected than that of FT children. Furthermore, VP children with below average IQ had a more strongly connected network than VP children with average-high IQ. Contrary to our expectations, working memory had the least central role in all networks.

CONCLUSIONS

In line with the ability differentiation hypothesis, children with higher levels of cognitive ability had a less interconnected and more specialised cognitive structure. Composite intelligence scores may therefore mask domain-specific deficits, particularly in children at risk for cognitive impairments (e.g., VP born children), even when general intelligence is unimpaired. In children with strongly and densely connected networks, domain-specific deficits may have a larger overall impact, resulting in lower intelligence levels.

Cognitive Training for Visuospatial Processing in Children Aged 5½ to 6 Years Born Very Preterm With Working Memory Dysfunction: A Randomized Clinical Trial

Importance

Compared with term-born peers, children born very preterm generally perform poorly in executive functions, particularly in working memory and inhibition. By taking advantage of neuroplasticity, computerized cognitive training of working memory in those children could improve visuospatial processing by boosting visual inhibition via working memory.

Objective

To evaluate the long-term effect of cognitive working memory training on visuospatial processing in children aged 5½ to 6 years born very preterm who have working memory impairment.

Design, Setting, and Participants

This multicenter (18 French university hospitals), open-label randomized clinical trial with 2 parallel groups (EPIREMED) was conducted from November 2016 to April 2018, with the last follow-up during August 2019. Eligible children from the EPIPAGE 2 cohort were aged 5½ to 6 years, were born between 24 and 34 weeks' gestation, and had a global intelligence quotient greater than 70 and a working memory index less than 85. Data were analyzed from February to December 2020.

Intervention

Children were randomized 1:1 to standard care management and a working memory cognitive training program (Cogmed software) for 8 weeks (25 sessions) (intervention) or to standard management (control).

Main Outcomes and Measures

The primary outcome was the visuospatial index score from the Wechsler Preschool and Primary Scale of Intelligence, 4th Edition. Secondary outcomes were working memory, intellectual functioning, executive and attention processes, language skills, behavior, quality of life, and schooling. Neurobehavioral assessments were performed at inclusion and after finishing training at 6 months (intermeditate assessment; secondary outcomes) and at 16 months (final assessment; primary outcome).

Results

There were 169 children randomized, with a mean (SD) age of 5 years 11 months (2 months); 91 (54%) were female. Of the participants, 84 were in the intervention group (57 of whom [68%] completed at least 15 cognitive training sessions) and 85 were in the control group. The posttraining visuospatial index score was not different between groups at a mean (SD) of 3.0 (1.8) months (difference, -0.6 points; 95% CI, -4.7 to 3.5 points) or 12.9 (2.6) months (difference, 0.1 points; 95% CI, -5.4 to 5.1 points). The working memory index score in the intervention group significantly improved from baseline at the intermediate time point (difference, 4.7 points; 95% CI, 1.2-8.1 points), but this improvement was not maintained at the final assessment.

Conclusions and Relevance

This randomized clinical trial found no lasting effect of a cognitive training program on visuospatial processing in children aged 5½ to 6 years with working memory disorders who were born very preterm. The findings suggest that this training has limited long-term benefits for improving executive function. Transient benefits seemed to be associated with the developmental state of executive functions.

Trial Registration

ClinicalTrials.gov Identifier: NCT02757794.

Inhibitory control as a significant predictor of academic performance in Chinese high schoolers

Studies investigating the relationship between cognitive function and academic performance have recently shifted focus from differences in intelligence to executive function. To date, these studies have focused disproportionately on samples recruited from Western countries, despite evidence in support of cultural differences in the development of executive function. To address this gap, the present study investigated whether differences in two dimensions of executive function, inhibitory and attentional control, could predict academic performance in a sample of Chinese adolescents (n = 42). Participants reported on demographic details and completed both the Simon task and Attention Network Test. Data were analyzed using multiple linear regression controlling for gender, age, SES, English language proficiency, processing speed, and fluid intelligence. Results showed that one index of inhibitory control derived from non-cue trials on the Attention Network Test explained a significant amount of unique variance in academic performance. Our findings provide evidence that executive function, specifically inhibitory control, plays a significant role in academic performance.

Neurocognitive function and associations with mental health in adults born preterm with very low birthweight or small for gestational age at term

Objectives

To assess neurocognitive function in adults born with low birthweight compared with controls and to explore associations between neurocognitive function and psychopathology in these groups.

Methods

In this prospective cohort study, one group born preterm with very low birthweight (VLBW: birthweight <1,500 g, n = 53), one group born small for gestational age at term (SGA: birthweight <10th percentile, n = 63) and one term-born control group (birthweight ≥10th percentile, n = 81) were assessed with neurocognitive tests, diagnostic interviews, and self-report questionnaires at 26 years of age.

Results

The VLBW group scored significantly below the control group on several neurocognitive measures, including IQ measures, psychomotor speed, verbal fluency, aspects of visual learning and memory, attention, social cognition, working memory and fine motor speed. The SGA group consistently scored at an intermediate level between the VLBW and the control group and had significantly lower scores than controls on Performance IQ and psychomotor speed, including switching. In the VLBW group, associations were found between lower spatial working memory and the presence of anxiety disorders, internalizing and attention problems, and autistic traits. Furthermore, lower Full scale IQ was associated with attention problems when adjusting for sex and parental socioeconomic status.

Conclusion

Adults born preterm with VLBW or born term SGA displayed neurocognitive difficulties. Spatial working memory was associated with difficulties with attention, anxiety, and social function of VLBW adults. The finding and its clinical applicability should be further explored.

Gestational age at birth and academic attainment in primary and secondary school in England: Evidence from a national cohort study

Preterm birth (<37 weeks’ gestation) is a risk factor for poor educational outcomes. A dose-response effect of earlier gestational age at birth on poor primary school attainment has been observed, but evidence for secondary school attainment is limited and focused predominantly on the very preterm (<32 weeks) population. We examined the association between gestational age at birth and academic attainment at the end of primary and secondary schooling in England. Data for children born in England from 2000–2001 were drawn from the population-based UK Millennium Cohort Study. Information about the child’s birth, sociodemographic factors and health was collected from parents. Attainment on national tests at the end of primary (age 11) and secondary school (age 16) was derived from linked education records. Data on attainment in primary school was available for 6,950 pupils and that of secondary school was available for 7,131 pupils. Adjusted relative risks (aRRs) for these outcomes were estimated at each stage separately using modified Poisson regression. At the end of primary school, 17.7% of children had not achieved the expected level in both English and Mathematics and this proportion increased with increasing prematurity. Compared to full term (39–41 weeks) children, the strongest associations were among children born moderately (32–33 weeks; aRR = 2.13 (95% CI 1.44–3.13)) and very preterm (aRR = 2.06 (95% CI 1.46–2.92)). Children born late preterm (34–36 weeks) and early term (37–38 weeks) were also at higher risk with aRR = 1.18 (95% CI 0.94–1.49) and aRR = 1.21 (95% CI 1.05–1.38), respectively. At the end of secondary school, 45.2% had not passed at least five General Certificate of Secondary Education examinations including English and Mathematics. Following adjustment, only children born very preterm were at significantly higher risk (aRR = 1.26 (95% CI 1.03–1.54)). All children born before full term are at risk of poorer attainment during primary school compared with term-born children, but only children born very preterm remain at risk at the end of secondary schooling. Children born very preterm may require additional educational support throughout compulsory schooling.

Neuropsychological abilities underpinning academic attainment in children born extremely preterm

Children born extremely preterm (EP) have poorer academic attainment than their term-born peers. There is a need to identify the specific cognitive mechanisms that are associated with poor academic attainment in preterm populations to inform the development of intervention strategies. A parallel mediation analysis was conducted with cross-sectional data from 152 EP children (< 27 weeks of gestation) and 120 term-born controls who were assessed at age 11. Mathematics and reading attainment was assessed using the Wechsler Individual Achievement Test 2nd Edition. Controlling for sex and socio-economic status we evaluated the following mediators: verbal working memory, visuospatial working memory, verbal processing speed, attention, and visuospatial processing. These were assessed using subtests from the standardized NEPSY-II test and Wechsler Intelligence Scale for Children-5th Edition. Verbal working memory, visuospatial working memory, visuospatial processing and verbal processing speed, but not attention, were significant independent mediators between EP birth and attainment in reading. No direct relationship between EP birth and reading attainment remained in the mediated model. All five neuropsychological variables mediated the relationship between EP birth and attainment in mathematics, but a direct effect of EP birth on mathematics remained in the mediated model. Together, all five neuropsychological abilities indirectly explained 44% of the variance in reading and 52% of the variance in mathematics. Visuospatial processing was the strongest mediator of both mathematics and reading. Components of executive function, especially visuospatial processing, are important predictors of academic attainment. Interventions to improve visuospatial skills could be trialed in EP populations.

Mathematical skills of 11-year-old children born very preterm and full-term

Preterm birth affects the academic development of children, especially in mathematics. Remarkably, only a few studies have measured specific effects of preterm birth on mathematical skills in primary school. The aim of this study was to compare 11-year-old children, with an IQ above 70, born very preterm (N = 64) and full-term (N = 72) on a variety of 5th grade mathematical skills and cognitive abilities important for mathematical learning. The measures were spontaneous focusing on numerosity (SFON), spontaneous focusing on quantitative relations (SFOR), arithmetic fluency, mathematics achievement, number line estimation, rational number magnitude knowledge, mathematics motivation, reading skills, visuospatial processing, executive functions, and naming speed. The children born very preterm and full-term differed in arithmetic fluency, SFON and SFOR. Domain general cognitive abilities did not fully explain the group differences in SFON and SFOR. Retrospective comparisons of the samples at the age of five years showed large group differences in early mathematical skills and cognitive abilities. Despite lower early mathematical skills, the children born very preterm reached peer equivalent performance in many mathematical skills by the age of 11 years. Nevertheless, they appear less likely to focus on implicit mathematical features in their everyday life.

Neurobehavioral Phenotype and Dysexecutive Syndrome of Preterm Children: Comorbidity or Trigger? An Update

Premature birth is a worldwide public health priority. One in ten children is born before 37 weeks of gestational age and, in developed countries, survival rates without major neonatal morbidity are increasing. Although severe sequelae associated with these births have decreased, their neurobehavioral difficulties, often associated in multiple fields, remain stable but still widespread. These neurobehavioral difficulties hamper the normal development of academic achievements and societal integration and intensify the children's needs for rehabilitation during their preschool and academic years. Severe sequelae increase when gestational age decreases. This is even truer if the socio-cultural background is impeded by low income, education and language skills as compared with defined averages. However, moderate and/or minor neurocognitive and/or behavioral difficulties are almost identical for a moderate or a late preterm birth. Obtaining a better clinical description of neurobehavioral characteristics of those pretermly born, once they reach preschool age, is essential to detect behavioral issues as well as early specific cognitive difficulties (working memory, planning, inhibition, language expression and reception, attention and fine motor skills, etc.). Such information would provide a better understanding of the executive functions' role in brain connectivity, neurodevelopment and neuroanatomical correlation with premature encephalopathy.

Cognitive flexibility in 12-month-old preterm and term infants is associated with neurobehavioural development in 18-month-olds

There is growing evidence that preterm children are at an increased risk of poor executive functioning, which underlies behavioural and attention problems. Previous studies have suggested that early cognitive flexibility is a possible predictor of later executive function; however, how it develops in infancy and relates to the later neurobehavioural outcomes is still unclear in the preterm population. Here, we conducted a longitudinal study to investigate oculomotor response shifting in 27 preterm and 25 term infants at 12 months and its relationship with general cognitive development and effortful control, which is a temperamental aspect closely associated with executive function, at 18 months. We found that moderate to late preterm and term infants significantly inhibited previously rewarded look responses, while very preterm infants did not show significant inhibition of perseverative looking at 12 months. Moreover, lower inhibition of perseverative looking was significantly associated with lower general cognitive development and attentional shifting at 18 months. These findings suggest that the early atypical patterns of oculomotor response shifting may be a behavioural marker for predicting a higher risk of negative neurobehavioural outcomes, including attention-related problems in preterm children.

Visuospatial functions in preterm schoolchildren without cognitive delay: Using Pascual's Graphomotor test as a screening method

BACKGROUND

Preterm children obtain worse scores in tests that evaluate visuospatial functions. Pascual's graphomotor test (PGMt) assesses maturity in copying drawings in childhood, quickly evaluating the graphomotor aptitude that is a partial aspect of non-verbal intelligence.

AIMS

To evaluate visuospatial functions in preterm children compared to full-term children. To assess the capacity of the Pascual graphomotor test (PGMt) to detect visuospatial disorders more specifically than non-verbal intelligence quotient (IQ).

STUDY DESIGN AND SUBJECTS

case and control study.

CASES

preterm children between 5 and 11 years of age without cognitive delay; controls: full-term children with the same characteristics. For each child clinical history, neurological examination, language-free intelligence test Toni 2 (IQ) and Pascual's graphomotor test (PGMt) were carried out.

RESULTS

135 children were enrolled (59 cases vs. 79 controls). The mean age was 7.4 years. 55% were male. The mean gestational age of cases was 30.5 weeks with 34% extremely preterm. Cases obtained worse mean scores in both tests. The mean IQ scores were: cases 117.4, controls 125.0 (p = 0.004). The mean graphomotor quotient (GQ) scores were statistically and clinically significant (cases 76.8; controls 98.3, p = 0.001). Although we have found a positive correlation between IQ and GQ scores (cc = 0.31 p = 0.01), the differences found in the GQ between groups have been maintained regardless of the IQ in the multivariate analysis (GQ: cases 78.3 (SD 14.8), controls 98.3 (SD 12.5), p = 0.04).

CONCLUSIONS

GQ is a useful tool for screening for visuospatial anomalies. GQ more specifically measures the visuoperceptive disorder regardless of non-verbal cognitive level.

Etiology of persistent mathematics difficulties from childhood to adolescence following very preterm birth

Children born very preterm (VP; <32 weeks' gestation) have poorer mathematics achievement than term-born peers. This study aimed to determine whether VP children's mathematics difficulties persist from primary to secondary school and to explore the nature of mathematics difficulties in adolescence. For this study, 127 VP and 95 term-born adolescents were assessed at age 11-15 years. Mathematics achievement was assessed using the Wechsler Individual Achievement Test-II. Specific mathematics skills and general cognitive skills were assessed using standardized and experimental tests. VP adolescents had poorer mathematics achievement than term-born adolescents (-10.95 points; 95% CI -16.18, -5.73) and poorer number fact knowledge, understanding of arithmetic concepts, written arithmetic, counting, reading and writing large numbers, and algebra. Between-group differences in mathematics skills were no longer significant when working memory and visuospatial skills were controlled for (p's >0.05), with the exception of writing large numbers and conceptual understanding of arithmetic. In a previous study, 83 of the VP adolescents and 49 of the term-born adolescents were assessed at age 8-10 years using measures of the same skills. Amongst these, the between-group difference in mathematics achievement remained stable over time. This study extends findings of a persistent deficit in mathematics achievement among VP children over the primary and secondary school years, and provides evidence of a deficit in factual, procedural and conceptual mathematics skills and in higher order mathematical operations among VP adolescents. We provide further evidence that VP children's mathematics difficulties are driven by deficits in domain-general rather than domain-specific cognitive skills.

Heterogeneity of the attentional system's efficiency among very prematurely born pre-schoolers

Very preterm birth increases the risk of ADHD as well as other neurodevelopmental disorders. Deficits within the attentional system were previously signaled in preterm children; however, studies lacked in consideration of an intragroup differentiation. Thus, this study aimed to verify whether deficits in the attentional mechanisms are inter-individually differentiated among very prematurely born children and if so, which biomedical and non-biomedical factors are associated with the profile of deficits within the attentional system. We tested the efficiency of attentional processes among 5-year-old children with the Attention Network Task - Child Version. The results have indicated that 26% of very preterm children presented with the suboptimal functioning of the attentional system (more than 1 SD below mean score of full-term children in attentional alerting and orienting), whereas 74% were characterized by the normal efficiency of attention. The profile of attentional deficits observed among very preterm preschoolers was associated with significantly lower birth weight and decreased family living standard. Very prematurely born children are thus a relatively heterogeneous group in terms of the efficiency of attentional system and deficits apply to only some of those children. Early developmental support aimed at enhancing attentional functioning should be addressed to children with lower birth weight in the first place.

Exploring predictors at toddler age of distinct profiles of attentional functioning in 6-year-old children born moderate-to-late preterm and full term

OBJECTIVE

Examining relationships of toddler abilities in attention, cognitive, motor, and language development, and behavioral problems, with distinct attention profiles at 6 years of age in children born moderate-to-late preterm and full term.

METHOD

Longitudinal study with a cohort of 88 moderate-to-late preterm and 83 full term born children. At 18 months attention abilities were assessed. At 24 months cognitive, motor, and language development was examined and behavioral problems were screened. At 6 years ten measures of attention were administered, which were used to classify children in one of four attentional functioning profiles (normal attention, overall poorer attention, poorer cognitive attention, and behavioral attention problems). Performance at 18 and 24 months was examined in relation to these four distinct attention profiles, as well as in relation to normal (first profile) versus subaverage attention (second, third, and fourth profiles) using multinomial logistic regressions.

RESULTS

Orienting and alerting attention, and receptive language were related to distinct attention profiles. Specifically, children with an overall poorer attention profile at 6 years were differentiated by lower orienting attention and receptive language scores at toddler age, while those with a poorer cognitive attention profile showed lower early alerting attention at 18 months. Children with a behavioral attention problems profile at 6 years were differentiated by lower orienting attention but higher alerting attention scores at toddler age. Orienting attention and receptive language, but not alerting attention, at toddler age were related to normal versus subaverage attention, with lower scores predicting subaverage attention.

CONCLUSIONS

Children at risk of poorer attentional functioning at school-age, expressed in distinct attention profiles, already showed differentiated functioning in attention abilities and in language comprehension as toddlers. Distinguishing distinct attention profiles could be important for future research and clinical practice, as is early monitoring of attention and language abilities in children at risk.

Functional Connectivity Network Disruption Underlies Domain-Specific Impairments in Attention for Children Born Very Preterm

Attention problems are common in school-age children born very preterm (VPT; < 32 weeks gestational age), but the contribution of aberrant functional brain connectivity to these problems is not known. As part of a prospective longitudinal study, brain functional connectivity (fc) was assessed alongside behavioral measures of selective, sustained, and executive attention in 58 VPT and 65 full-term (FT) born children at corrected-age 12 years. VPT children had poorer sustained, shifting, and divided attention than FT children. Within the VPT group, poorer attention scores were associated with between-network connectivity in ventral attention, visual, and subcortical networks, whereas between-network connectivity in the frontoparietal, cingulo-opercular, dorsal attention, salience and motor networks was associated with attention functioning in FT children. Network-level differences were also evident between VPT and FT children in specific attention domains. Findings contribute to our understanding of fc networks that potentially underlie typical attention development and suggest an alternative network architecture may help support attention in VPT children.

Social Adjustment in Adolescents Born Very Preterm: Evidence for a Cognitive Basis of Social Problems

OBJECTIVE

To increase the understanding of social adjustment and autism spectrum disorder symptoms in adolescents born very preterm by studying the role of emotion recognition and cognitive control processes in the relation between very preterm birth and social adjustment.

STUDY DESIGN

A Dutch cohort of 61 very preterm and 61 full-term adolescents aged 13 years participated. Social adjustment was rated by parents, teachers, and adolescents and autism spectrum disorder symptoms by parents. Emotion recognition was assessed with a computerized task including pictures of child faces expressing anger, fear, sadness, and happiness with varying intensity. Cognitive control was assessed using a visuospatial span, antisaccade, and sustained attention to response task. Performance measures derived from these tasks served as indicators of a latent cognitive control construct, which was tested using confirmatory factor analysis. Mediation analyses were conducted with emotion recognition and cognitive control as mediators of the relation between very preterm birth and social problems.

RESULTS

Very preterm adolescents showed more parent- and teacher-rated social problems and increased autism spectrum disorder symptomatology than controls. No difference in self-reported social problems was observed. Moreover, very preterm adolescents showed deficits in emotion recognition and cognitive control compared with full-term adolescents. The relation between very preterm birth and parent-rated social problems was significantly mediated by cognitive control but not by emotion recognition. Very preterm birth was associated with a 0.67-SD increase in parent-rated social problems through its negative effect on cognitive control.

CONCLUSIONS

The present findings provide strong evidence for a central role of impaired cognitive control in the social problems of adolescents born very preterm.