Inattention in very preterm children: implications for screening and detection

Effect of Pediatric Rehabilitation on Children With Attention Deficit Hyperactivity Disorder (ADHD): A Case Report

This case study examines a three-year-old male child with attention deficit hyperactivity disorder (ADHD) who exhibits fine motor impairments, language and speech delays, and delayed social milestones. The therapeutic intervention included a comprehensive program involving parent education, parental behavioral therapy, sensory integration therapy, treadmill walking, music therapy, and the Picture Exchange Communication System (PECS). The results showed significant improvements in the child's functional independence, behavioral management, and communication abilities, highlighting the efficacy of the multifaceted physiotherapy approach.

Neurobehavioral symptoms in children born extremely preterm: A Swedish National Study

AIM

To determine the prevalence of neurobehavioral symptoms at 6.5 years in children born extremely preterm (EPT, <27 weeks' gestation).

METHODS

Population-based cohort study of infants born EPT in Sweden from 2004 to 2007. Of 486 survivors 375 were assessed and compared with 369 matched term-born controls. EPT children free from neurosensory and intellectual disabilities (neurodevelopmental disabilities [NDD]-free, n = 236) were compared separately. Standardised questionnaires were used to assess parental ratings of hyperactivity and attention, emotional, peer-relation, conduct and social problems; and deficits in perception, language and memory.

RESULTS

EPT children had more reported problems in all assessed neurobehavioral domains than controls, with more than three times greater odds for most outcomes. Except for conduct problems, increased problems were identified also in NDD-free children. The odds of having neurobehavioral problems in ≥3 co-occurring domains were five (whole EPT group) and three (NDD-free group) times higher than in controls.

CONCLUSION

EPT children with or without NDD have more neurobehavioral problems in multiple domains than term peers. Ongoing assessments of behaviour until school age or beyond should recognise early symptoms of attention, everyday social problems, perceptual, emotional or language difficulties.

Impaired pulmonary function mediates inattention in young adults born extremely preterm

AIM

To test whether poor childhood pulmonary function explains the relationship between extremely preterm (EP) birth and attention-deficit/hyperactivity disorder (ADHD) symptoms in young adulthood.

METHODS

EPICure birth cohort participants include children born <26 weeks' gestation in the United Kingdom and Ireland in 1995 and their term-born classmates. Predictor was EP birth. Outcomes were inattention/hyperactivity subscale z-scores at 19 years. Forced expiratory volume (FEV1) z-scores in childhood and young adulthood were mediators. We used recursive path analysis to determine the direct effect of EP birth on inattention/hyperactivity and its indirect effect through pulmonary function.

RESULTS

Ninety EP and 47 term-born participants had pulmonary function testing at 11 and 19 years. Inattention z-scores were higher in the EP group (mean difference 0.55 [95% CI 0.11, 0.99]) but not hyperactivity. Compared to term-born peers, EP participants had lower FEV1 z-scores at 11 (mean difference-1.35 [95% CI -1.72, -0.98]) and 19 (mean difference-1.29 [95% CI -1.65, -0.92]). Path models revealed that childhood pulmonary function explained the relationship between EP birth and inattention.

CONCLUSIONS

Extremely preterm young adults have increased risk for inattention compared to term-born peers. Poor pulmonary function appears to underlie this risk. The mechanisms responsible remain unclear and warrant further study.

A comparative analysis of children born with low birthweight and attention deficit hyperactivity disorder

BACKGROUND

We aimed to compare the profile of the Wechsler Intelligence Scale for Children Fourth Edition (WISC-IV) between Japanese schoolchildren born very preterm (VP) and with very low birthweight (VLBW) and those with attention deficit hyperactivity disorder (ADHD), and to identify the specific neurocognitive characteristics of VLBW/VP children.

METHODS

The VLBW/VP group in the present study included 50 (19 male, 31 female) first- to third-grade elementary school children born between January 2008 and February 2013 at Osaka Medical and Pharmaceutical University Hospital and Saiseikai Suita Hospital with birthweights <1,500 g and <32 gestational weeks. The ADHD group included 18 (13 male, 5 female) first- to third-grade elementary school children who visited Osaka Medical and Pharmaceutical University Hospital between January 2019 and October 2021. Full-scale intelligence quotient scores, four indices, and 12 subtests of the WISC-IV were calculated for all participants and compared between the VLBW/VP and ADHD groups. We assessed whether the patients' clinical history was associated with a low score on the cancellation task in the VLBW/VP group.

RESULTS

The WISC-IV profiles showed similar between-group patterns, and the VLBW/VP group had lower cancellation task scores than the ADHD group.

CONCLUSIONS

This is the first study to compare WISC-IV profiles between VLBW/VP children and those with ADHD. Further investigation is needed on the association between academic performance and the score of the cancellation task, and the neural mechanism of low performance for cancellation tasks in VLBW/VP children.

Teachers' knowledge and approaches to supporting preterm children in the classroom

BACKGROUND & AIMS

Teachers in the UK receive little training about the long-term consequences of preterm birth on children's development. Our aim was to assess knowledge and elicit suggestions for improving educational practice in the US by means of a mixed-method study.

METHODS

246 US teachers (92.7% female) completed the validated Preterm Birth - Knowledge Scale (PB-KS). Of the participating teachers, 50.9% reported professional experience with preterm born children. A representative subsample of 35 teachers responded to a case vignette by describing how they would support the child in the classroom. Answers were coded using thematic content analysis.

RESULTS

Overall, the mean PB-KS score was 15.21 (SD = 5.31). Participating teachers who had professional experience with a preterm child had higher mean PB-KS scores than teachers without (16.95 vs. 15.24, p = .012). Qualitative responses provided specific content for classroom intervention.

CONCLUSIONS

Our findings show that US teachers have limited knowledge of the long-term impact of preterm birth. They provided important indicators for the design of targeted classroom interventions to support the learning of preterm children.

Phasic and tonic alertness in preterm 5-year-old healthy children

Preterm delivery may interrupt the intrauterine brain development and implies a risk factor for the developing brain. In the long term, most frequently particular forms of attention deficits are described which refer to the basic aspects of attention i.e., arousal or tonic alertness. As this reflects top-down processes, the current study focuses on bottom-up processed phasic alertness in preschool aged preterm children. Additionally, we made a division of response times into decision and movement time to quantify more exactly the contribution of cognitive and motor performance to reaction times. We investigated basic aspects of attention functioning and contrasted phasic and tonic alertness in 31 low-risk healthy preterm (28-36 weeks of gestation) and 22 term children of five to 6 years of age by using a self-designed computerized test. Preterm children exhibited delayed decision and reaction time in the tonic non-cued alertness condition but not in the phasic cued alertness condition compared to term children. Current results suggest that preterm birth, even when clinically relevant symptoms are absent, may have long-term consequences on basic aspects of attention functioning. Results further suggest that preterm children may profit from auditory cues to overcome these deviations, which yield evidence for a clear distinction between impaired top-down and intact bottom-up controlled processes. These findings might provide a promising groundwork for the development of therapeutical interventions and prevention strategies, whose use and impact to support preterm children should be addressed in further investigations.

Gestational age is related to symptoms of attention-deficit/hyperactivity disorder in late-preterm to full-term children and adolescents with down syndrome

Attention-deficit/hyperactivity disorder is frequently reported in individuals with Down syndrome, with considerable variation in the expression and severity of the symptoms. Despite growing evidence that gestational age predicts later symptoms of attention-deficit/hyperactivity disorder in the euploid population, this has not been studied in down syndrome. The current study is designed to investigate the influence of gestational age in later symptoms of attention-deficit/hyperactivity disorder in 105 individuals (49 males and 56 females; aged 6–18 years) with Down syndrome who were born at or after 35 weeks gestation. Maternal age at birth, maternal level of education, household income, as well as sex, chronological age, and cognitive level of the participant with Down syndrome were considered in our analysis. Results from this study show that gestational age is related to inattentive and hyperactive/impulsive symptoms in children and adolescents with Down syndrome. Therefore, gestational age should be addressed when considering symptoms of attention-deficit/hyperactivity disorder, as it may have implications for early interventions. More attention is needed toward the advancement of care and follow-up for infants with down syndrome who are born even late preterm or early term.

Predictive Value of the Global School Adaptation Questionnaire at 5 Years of Age and Educational Support at 7 Years of Age in Very Preterm Children

OBJECTIVE

To assess the Global School Adaptation (GSA) questionnaire of children's abilities and classroom behavior administered to teachers of very preterm children at 5 years of age as a predictor of the need for educational support (grade retention, special class, learning support) at age 7.

STUDY DESIGN

We assessed 858 very preterm children (<33 weeks of gestation) at 5 years of age using the GSA and again at 7 years to determine the use of educational support. We examined the association between the GSA score and educational support at 7 years and performed a receiver operating characteristic curve analysis.

RESULTS

At 7 years of age, 130 children had educational support (15.2%). Children with a nonoptimal GSA score (<45) at 5 years required educational support more often (57.7%) than children with a GSA score of 45 or greater (15.4%) (OR, 7.5; 95% CI, 5.02-11.21). The need for educational support was associated with male sex; a low parent socioeconomic level; lower birth weight, birth head circumference, or gestational age (28-30 weeks of gestation); severe neurologic complications; patent ductus arteriosus ligation; and the use of therapy services at 5 years of age. After adjustment, only the GSA score was associated with educational support at 7 years of age (OR, 0.86; 95% CI, 0.84-0.88). A receiver operating characteristic curve analysis of the GSA performance revealed an optimal cut-off at 48, with a sensitivity of 70.8%, a specificity of 73.5%, and an area under the curve of 0.79.

CONCLUSIONS

Using a cut-off score of 48, the GSA at 5 years of age may be a useful tool to identify children born preterm at risk of school-based learning difficulties.

Is association of preterm birth with cognitive-neurophysiological impairments and ADHD symptoms consistent with a causal inference or due to familial confounds?

BACKGROUND

Preterm birth is associated with an increased risk for cognitive-neurophysiological impairments and attention-deficit/hyperactivity disorder (ADHD). Whether the associations are due to the preterm birth insult per se, or due to other risk factors that characterise families with preterm-born children, is largely unknown.

METHODS

We employed a within-sibling comparison design, using cognitive-performance and event-related potential (ERP) measures from 104 preterm-born adolescents and 104 of their term-born siblings. Analyses focused on ADHD symptoms and cognitive and ERP measures from a cued continuous performance test, an arrow flanker task and a reaction time task.

RESULTS

Within-sibling analyses showed that preterm birth was significantly associated with increased ADHD symptoms (β = 0.32, p = 0.01, 95% CI 0.05 to 0.58) and specific cognitive-ERP impairments, such as IQ (β = -0.20, p = 0.02, 95% CI -0.40 to -0.01), preparation-vigilance measures and measures of error processing (ranging from β = 0.71, -0.35). There was a negligible within-sibling association between preterm birth with executive control measures of inhibition (NoGo-P3, β = -0.07, p = 0.45, 95% CI -0.33 to 0.15) or verbal working memory (digit span backward, β = -0.05, p = 0.63, 95% CI -0.30 to 0.18).

CONCLUSIONS

Our results suggest that the relationship between preterm birth with ADHD symptoms and specific cognitive-neurophysiological impairments (IQ, preparation-vigilance and error processing) is independent of family-level risk and consistent with a causal inference. In contrast, our results suggest that previously observed associations between preterm birth with executive control processes of inhibition and working memory are instead linked to background characteristics of families with a preterm-born child rather than preterm birth insult per se. These findings suggest that interventions need to target both preterm-birth specific and family-level risk factors.

ADHD symptoms and their neurodevelopmental correlates in children born very preterm

This study investigated the association between attention-deficit/hyperactivity disorder (ADHD) symptomatology in preschool-aged children who were born very preterm (<33 weeks) and cognitive outcomes, clinical risk and socio-demographic characteristics. 119 very preterm children who participated in the Evaluation of Preterm Imaging Study at term-equivalent age were assessed at a mean age of 4.5 years. Parents completed the ADHD Rating Scale IV, a norm-referenced checklist that evaluates ADHD symptomatology according to diagnostic criteria, and the Behavior Rating Inventory of Executive Function-Preschool version. Children completed the Wechsler Preschool and Primary Scales of Intelligence and the Forward Digit Span task. Longitudinal data including perinatal clinical, qualitative MRI classification, socio-demographic variables and neurodevelopmental disabilities were investigated in relation to ADHD symptomatology. All results were corrected for multiple comparisons using false discovery rate. Results showed that although the proportion of very preterm children with clinically significant ADHD did not differ from normative data after excluding those with neurodevelopmental disabilities, 32.7% met criteria for subthreshold ADHD inattentive type and 33.6% for combined type, which was higher than the expected 20% in normative samples. Higher ADHD symptom scores (all) were associated with greater executive dysfunction (inhibitory self-control, flexibility, and emergent metacognition, corrected p<0.001 for all tests). Higher inattentive ADHD symptom scores were associated with lower IQ (ρ = -0.245, p = 0.011) and higher perinatal clinical risk (more days on mechanical ventilation (ρ = 0.196, p = 0.032) and more days on parenteral nutrition (ρ = 0.222, p = 0.015). Higher hyperactive ADHD symptom scores instead were associated with lower socio-economic status (ρ = 0.259, p = 0.004). These results highlight the importance of monitoring and supporting the development of very preterm children throughout the school years, as subthreshold ADHD symptoms represent risk factors for psychosocial problems and for receiving a future clinical diagnosis of ADHD.

Using drift diffusion modeling to understand inattentive behavior in preterm and term-born children

Objective: Children born very preterm are at increased risk of inattention, but it remains unclear whether the underlying processes are the same as in their term-born peers. Drift diffusion modeling (DDM) may better characterize the cognitive processes underlying inattention than standard reaction time (RT) measures. This study used DDM to compare the processes related to inattentive behavior in preterm and term-born children. Method: Performance on a cued continuous performance task was compared between 33 children born very preterm (VP; ≤32 weeks’ gestation) and 32 term-born peers (≥37 weeks’ gestation), aged 8–11 years. Both groups included children with a wide spectrum of parent-rated inattention (above average attention to severe inattention). Performance was defined using standard measures (RT, RT variability and accuracy) and modeled using a DDM. A hierarchical regression assessed the extent to which standard or DDM measures explained variance in parent-rated inattention and whether these relationships differed between VP and term-born children. Results: There were no group differences in performance on standard or DDM measures of task performance. Parent-rated inattention correlated significantly with hit rate, RT variability, and drift rate (a DDM estimate of processing efficiency) in one or both groups. Regression analysis revealed that drift rate was the best predictor of parent-rated inattention. This relationship did not differ significantly between groups. Conclusions: Findings suggest that less efficient information processing is a common mechanism underlying inattention in both VP and term-born children. This study demonstrates the benefits of using DDM to better characterize atypical cognitive processing in clinical samples.

Less efficient information processing during a sustained attention task explained individual differences in inattentive behavior. This was true both in 8- to 11-year-olds born very preterm and their term-born peers. Drift diffusion modeling provides a way to help us better characterize the processes that underlie task performance. This is valuable for understanding processing differences that affect clinical groups.

Executive Function Profiles at Home and at School in 11-Year-Old Very Low Birth Weight or Very Low Gestational Age Children

OBJECTIVE

Executive function (EF) problems of children born at very low birth weight (VLBW; ≤1500 g) or very low gestational age (VLGA; <32 gestational weeks) may present differently at school compared to the home environment. Ecological assessment of EF including parent- and teacher-rated profiles and associated risk factors of 11-year-old children born at VLBW or VLGA was evaluated.

METHODS

A total of 125 VLBW or VLGA children and 132 controls were assessed using the Behavior Rating Inventory of EF, which includes 8 subscales that form the Behavioral Regulation and Metacognition Indexes. For VLBW or VLGA children, full-scale intelligence quotient (IQ) was assessed using the Wechsler Intelligence scale for Children, Fourth Edition. Neonatal data were collected systematically.

RESULTS

VLBW or VLGA children with full-scale IQ ≥ 70 had clinically significant problems in the Working Memory subscale at school. Although they had clinically significant problems at home in the Behavioral Regulation Index, the difference disappeared when adjusted for paternal education. Lower gestational age, lower birth weight z-score, surgical necrotizing enterocolitis, low paternal and maternal education, and lower full-scale IQ were identified to be risk factors for higher scores in ecological assessment of EF.

CONCLUSION

VLBW or VLGA children in this cohort exhibit fewer EF problems in ecological assessment of EF compared to previous literature. EF problems of this study population vary by home and school setting and are emphasized in working memory at school. Screening for EF problems in school environment is recommended to target the support.

Developing routinely recorded clinical data from electronic patient records as a national resource to improve neonatal health care: the Medicines for Neonates research programme

Background

Clinical data offer the potential to advance patient care. Neonatal specialised care is a high-cost NHS service received by approximately 80,000 newborn infants each year.

Objectives

(1) To develop the use of routinely recorded operational clinical data from electronic patient records (EPRs), secure national coverage, evaluate and improve the quality of clinical data, and develop their use as a national resource to improve neonatal health care and outcomes. To test the hypotheses that (2) clinical and research data are of comparable quality, (3) routine NHS clinical assessment at the age of 2 years reliably identifies children with neurodevelopmental impairment and (4) trial-based economic evaluations of neonatal interventions can be reliably conducted using clinical data. (5) To test methods to link NHS data sets and (6) to evaluate parent views of personal data in research.

Design

Six inter-related workstreams; quarterly extractions of predefined data from neonatal EPRs; and approvals from the National Research Ethics Service, Health Research Authority Confidentiality Advisory Group, Caldicott Guardians and lead neonatal clinicians of participating NHS trusts.

Setting

NHS neonatal units.

Participants

Neonatal clinical teams; parents of babies admitted to NHS neonatal units.

Interventions

In workstream 3, we employed the Bayley-III scales to evaluate neurodevelopmental status and the Quantitative Checklist of Autism in Toddlers (Q-CHAT) to evaluate social communication skills. In workstream 6, we recruited parents with previous experience of a child in neonatal care to assist in the design of a questionnaire directed at the parents of infants admitted to neonatal units.

Data sources

Data were extracted from the EPR of admissions to NHS neonatal units.

Main outcome measures

We created a National Neonatal Research Database (NNRD) containing a defined extract from real-time, point-of-care, clinician-entered EPRs from all NHS neonatal units in England, Wales and Scotland (n = 200), established a UK Neonatal Collaborative of all NHS trusts providing neonatal specialised care, and created a new NHS information standard: the Neonatal Data Set (ISB 1595) (see http://webarchive.nationalarchives.gov.uk/±/http://www.isb.nhs.uk/documents/isb-1595/amd-32–2012/index_html; accessed 25 June 2018).

Results

We found low discordance between clinical (NNRD) and research data for most important infant and maternal characteristics, and higher prevalence of clinical outcomes. Compared with research assessments, NHS clinical assessment at the age of 2 years has lower sensitivity but higher specificity for identifying children with neurodevelopmental impairment. Completeness and quality are higher for clinical than for administrative NHS data; linkage is feasible and substantially enhances data quality and scope. The majority of hospital resource inputs for economic evaluations of neonatal interventions can be extracted reliably from the NNRD. In general, there is strong parent support for sharing routine clinical data for research purposes.

Limitations

We were only able to include data from all English neonatal units from 2012 onwards and conduct only limited cross validation of NNRD data directly against data in paper case notes. We were unable to conduct qualitative analyses of parent perspectives. We were also only able to assess the utility of trial-based economic evaluations of neonatal interventions using a single trial. We suggest that results should be validated against other trials.

Conclusions

We show that it is possible to obtain research-standard data from neonatal EPRs, and achieve complete population coverage, but we highlight the importance of implementing systematic examination of NHS data quality and completeness and testing methods to improve these measures. Currently available EPR data do not enable ascertainment of neurodevelopmental outcomes reliably in very preterm infants. Measures to maintain high quality and completeness of clinical and administrative data are important health service goals. As parent support for sharing clinical data for research is underpinned by strong altruistic motivation, improving wider public understanding of benefits may enhance informed decision-making.

Future work

We aim to implement a new paradigm for newborn health care in which continuous incremental improvement is achieved efficiently and cost-effectively by close integration of evidence generation with clinical care through the use of high-quality EPR data. In future work, we aim to automate completeness and quality checks and make recording processes more ‘user friendly’ and constructed in ways that minimise the likelihood of missing or erroneous entries. The development of criteria that provide assurance that data conform to prespecified completeness and quality criteria would be an important development. The benefits of EPR data might be extended by testing their use in large pragmatic clinical trials. It would also be of value to develop methods to quality assure EPR data including involving parents, and link the NNRD to other health, social care and educational data sets to facilitate the acquisition of lifelong outcomes across multiple domains.

Study registration

This study is registered as PROSPERO CRD42015017439 (workstream 1) and PROSPERO CRD42012002168 (workstream 3).

Funding

The National Institute for Health Research Programme Grants for Applied Research programme (£1,641,471). Unrestricted donations were supplied by Abbott Laboratories (Maidenhead, UK: £35,000), Nutricia Research Foundation (Schiphol, the Netherlands: £15,000), GE Healthcare (Amersham, UK: £1000). A grant to support the use of routinely collected, standardised, electronic clinical data for audit, management and multidisciplinary feedback in neonatal medicine was received from the Department of Health and Social Care (£135,494).

Improving developmental and educational support for children born preterm: evaluation of an e-learning resource for education professionals

OBJECTIVES

Children born preterm are at higher risk for special educational needs and poor academic attainment compared with term-born peers, yet education professionals receive limited training and have poor knowledge of preterm birth. We have developed an interactive e-learning resource and evaluated its efficacy in improving teachers' knowledge of preterm birth and their confidence in supporting the learning of children born preterm.

SETTING

Eight primary, infant or junior schools in England.

PARTICIPANTS

61 teachers of children aged 4-11 years, of which 55 (90%) were female.

INTERVENTION

Interactive e-learning resource designed to improve education professionals' knowledge of long-term outcomes following preterm birth and strategies that can be used to support children's learning (www.pretermbirth.info). In a repeated measures design, participants were given up to 30 days access to the e-learning resource, before and after which they completed the Preterm Birth Knowledge Scale (PB-KS; scores 0-33; higher scores indicate greater knowledge) to assess knowledge of outcomes of prematurity. Four Likert scale items were used to assess confidence in supporting children's learning and 10 items were used to evaluate the utility of the resource. PB-KS scores and responses on confidence item were compared pre-resource and post-resource use.

RESULTS

PB-KS scores significantly increased after accessing the e-learning resource (median (95% CI): pre-resource 13 (11 to 14); post-resource 29 (28 to 30)), equating to a 2.6 SD increase in PB-KS scores. Teachers' confidence in supporting children born preterm was also significantly improved after using the resource. The utility of the resource was evaluated positively by participants with 97% reporting that they would recommend its use to others.

CONCLUSIONS

The e-learning resource substantially improved teachers' knowledge of preterm birth and their confidence in supporting preterm children in the classroom. Use of this resource may represent a key advance in improving educational outcomes for children born preterm.

Cognitive predictors of parent-rated inattention in very preterm children: The role of working memory and processing speed

Inattention is one of the most common neurobehavioral problems following very preterm birth. Attention problems can persist into adulthood and are associated with negative socio-emotional and educational outcomes. This study aimed to determine whether the cognitive processes associated with inattention differ between term-born and very preterm children. Sixty-five children born very preterm (<33+0 weeks' gestation) aged 8-11 years were recruited alongside 48 term-born controls (?37 20 +0 weeks' gestation). Both groups included children with a wide spectrum of parent-rated inattention (above average attention to severe inattention) measured as a continuous dimension using the Strengths and Weaknesses of ADHD and Normal-Behavior (SWAN) scale. The children completed tests to assess basic cognitive processes and executive function. A hierarchical multiple regression analysis was implemented to assess which neurocognitive processes explained variance in parent-rated inattention and whether these differed between preterm and term-born children. In both groups, poorer verbal and visuospatial short-term memory and poorer visuospatial working memory independently explained variance in parent-rated inattention. Slower motor processing speed explained variance in inattention among very preterm children only. The cognitive mechanisms associated with parent-rated inattention were predominantly overlapping between groups, but relationships between motor processing speed and inattention were unique to very preterm children. These associations may reflect risk factors for inattention in term and very preterm children. Future research should assess the efficacy of these cognitive processes as potential targets for intervention.

Association of Gestational Age at Birth With Symptoms of Attention-Deficit/Hyperactivity Disorder in Children

Importance

Preterm birth is associated with an increased risk of attention-deficit/hyperactivity disorder (ADHD); however, it is unclear to what extent this association can be explained by shared genetic and environmental risk factors and whether gestational age at birth is similarly related to inattention and hyperactivity/impulsivity and to the same extent in boys and girls.

Objectives

To investigate the association between gestational age at birth and symptoms of ADHD in preschool and school-age children after adjusting for unmeasured genetic and environmental risk factors.

Design, Setting, and Participants

In this prospective, population-based cohort study, pregnant women were recruited from across Norway from January 1, 1999, through December 31, 2008. Results of a conventional cohort design were compared with results from a sibling-comparison design (adjusting for genetic and environmental factors shared within families) using data from the Norwegian Mother and Child Cohort Study. Data analysis was performed from October 1, 2017, through March 16, 2018.

Exposures

Analyses compared children and siblings discordant for gestational age group: early preterm (delivery at gestational weeks 22-33), late preterm (delivery at gestational weeks 34-36), early term (delivery at gestational weeks 37-38), delivery at gestational week 39, reference group (delivery at gestational week 40), delivery at gestational week 41, and late term (delivery after gestational week 41).

Main Outcomes and Measures

Maternally reported symptoms of ADHD in children at 5 years of age and symptoms of inattention and hyperactivity/impulsivity at 8 years of age. Covariates included child and pregnancy characteristics associated with the week of delivery and the outcomes.

Results

A total of 113 227 children (55 187 [48.7%] female; 31 708 [28.0%] born at gestational week 40), including 33 081 siblings (16 014 female [48.4%]; 9705 [29.3%] born at gestational week 40), were included in the study. Children born early preterm were rated with more symptoms of ADHD, inattention, and hyperactivity/impulsivity than term-born children. After adjusting for unmeasured genetic and environmental factors, children born early preterm had a mean score that was 0.24 SD (95% CI, 0.14-0.34) higher on ADHD symptom tests, 0.33 SD (95% CI, 0.24-0.42) higher on inattention tests, and 0.23 SD (95% CI, 0.14-0.32) higher on hyperactivity/impulsivity tests compared with children born at gestational week 40. Sex moderated the association of gestational age with preschool ADHD symptoms, and the association appeared to be strongest among girls. Early preterm girls scored a mean of 0.8 SD (95% CI, 0.12-1.46; P = .02) higher compared with their term-born sisters.

Conclusions and Relevance

After accounting for unmeasured genetic and environmental factors, early preterm birth was associated with a higher level of ADHD symptoms in preschool children. Early premature birth was associated with inattentive but not hyperactive symptoms in 8-year-old children. This study demonstrates the importance of differentiating between inattention and hyperactivity/impulsivity and stratifying on sex in the study of childhood ADHD.

Attention deficit hyperactivity disorder and autism spectrum disorder symptoms in school-age children born very preterm

BACKGROUND

Very preterm (VP) children face a broad range of neurodevelopmental sequelae, including behavioral problems.

AIM

To investigate prevalence, pervasiveness and co-occurrence of symptoms of attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) in school-age children born very preterm.

METHODS

Using questionnaire and diagnostic interview data, parent and teacher reported symptoms of ADHD and ASD of 57 VP-children (mean age = 9.2 years) were compared with 57 gender and age matched full-term children using t-tests. Intra-class correlation coefficients quantified parent-teacher agreement. Correlation analysis investigated co-occurrence of ADHD/ASD symptoms. ADHD/ASD measures were aggregated using principal component analysis. Regression analyses investigated the contribution of perinatal risk factors, sex and SES to ADHD/ASD symptoms.

RESULTS

VP-children showed higher levels of parent and teacher reported attention problems, social impairment and compromised communication skills. Fair to strong agreement was found between parent and teacher reported ADHD and ASD symptoms, indicating pervasiveness of observed difficulties. Co-occurrence of ADHD and ASD symptoms in VP-children was found. Lower gestational age was associated with higher ADHD and ASD symptom levels, male sex with higher ADHD symptom levels and lower SES with higher ASD symptom levels.

CONCLUSION

School-age VP-children show higher levels of ADHD and ASD symptoms, and attention, socialization and communication difficulties in particular. Routinely screening for these problems is recommended in follow-up care.

Attention-Deficit/Hyperactivity Disorder and Very Preterm/Very Low Birth Weight: A Meta-analysis

CONTEXT

Although very preterm (VP), extremely preterm (EP), very low birth weight (VLBW), and extremely low birth weight (ELBW) newborns seem to have a higher risk of later attention-deficit/hyperactivity disorder (ADHD), the magnitude of the risk is not well-defined.

OBJECTIVE

To systematically review and meta-analyze the risk of VP/VLBW and EP/ELBW individuals to develop a ADHD categorical diagnosis or dimensional symptomatology compared with controls with normal weight and/or birth age.

DATA SOURCES

We used PsycINFO, Medline, Embase, and Cochrane databases.

STUDY SELECTION

We selected cross-sectional, prospective, or retrospective studies with no time or language restriction.

DATA EXTRACTION

Independent reviewers screened and extracted data using predefined standard procedures.

RESULTS

In 12 studies (N = 1787), researchers relying on a categorical diagnosis showed that both VP/VLBW and EP/ELBW subjects have a higher ADHD risk (odds ratio [OR] = 3.04 higher than controls; 95% confidence interval [CI] 2.19 to 4.21). In subgroup analyses, we demonstrated that the more extreme the cases, the higher the ORs (VP/VLBW: OR = 2.25 [95% CI 1.56 to 3.26]; EP/ELBW: OR = 4.05 [95% CI 2.38 to 6.87]). We drew data from 29 studies (N = 3504) on ADHD symptomatology and found significant associations with inattention (standardized mean difference [SMD] = 1.31, 95% CI 0.66 to 1.96), hyperactivity and impulsivity (SMD = 0.74, 95% CI 0.35 to 1.13), and combined symptoms (SMD = 0.55, 95% CI 0.42 to 0.68) when compared with controls.

LIMITATIONS

Heterogeneity was significantly high for all analyses involving the 3 ADHD dimensions.

CONCLUSIONS

With our results, we provide evidence that VP/VLBW subjects have an increased risk of ADHD diagnosis and symptomatology compared with controls, and these findings are even stronger in the EP/ELBW group. Future researchers should address which risk factors related to prematurity or low birth weight lead to ADHD.

Moving to Capture Children's Attention: Developing a Methodology for Measuring Visuomotor Attention

Attention underpins many activities integral to a child's development. However, methodological limitations currently make large-scale assessment of children's attentional skill impractical, costly and lacking in ecological validity. Consequently we developed a measure of 'Visual Motor Attention' (VMA)-a construct defined as the ability to sustain and adapt visuomotor behaviour in response to task-relevant visual information. In a series of experiments, we evaluated the capability of our method to measure attentional processes and their contributions in guiding visuomotor behaviour. Experiment 1 established the method's core features (ability to track stimuli moving on a tablet-computer screen with a hand-held stylus) and demonstrated its sensitivity to principled manipulations in adults' attentional load. Experiment 2 standardised a format suitable for use with children and showed construct validity by capturing developmental changes in executive attention processes. Experiment 3 tested the hypothesis that children with and without coordination difficulties would show qualitatively different response patterns, finding an interaction between the cognitive and motor factors underpinning responses. Experiment 4 identified associations between VMA performance and existing standardised attention assessments and thereby confirmed convergent validity. These results establish a novel approach to measuring childhood attention that can produce meaningful functional assessments that capture how attention operates in an ecologically valid context (i.e. attention's specific contribution to visuomanual action).

Antecedents of Attention-Deficit/Hyperactivity Disorder Symptoms in Children Born Extremely Preterm

OBJECTIVE

To investigate antecedents of attention-deficit/hyperactivity disorder (ADHD) symptoms in children born extremely preterm (EP; <26-wk gestation).

METHOD

The EPICure study recruited all babies born EP in the United Kingdom and Ireland in March-December 1995. Neurodevelopmental outcomes were assessed at 2.5 (n = 283; 90%), 6 (n = 160; 78%), and 11 (n = 219; 71%) years of age. Parents and teachers completed the DuPaul Rating Scale IV to assess inattention and hyperactivity/impulsivity symptoms at 11 years. Regression analyses were used to explore the association of neonatal, neurodevelopmental, and behavioral outcomes to 6 years with ADHD symptoms at 11 years.

RESULTS

Extremely preterm (EP) children had significantly more inattention (mean difference, 1.2 SD; 95% CI, 0.9-1.5) and hyperactivity/impulsivity (mean difference, 0.5 SD; 95% CI, 0.2-0.7) than controls, with a significantly greater effect size for inattention than hyperactivity/impulsivity. Significant independent predictors of inattention at 11 years included smaller head circumference, lower intelligence quotient (IQ), and pervasive peer relationship problems at 6 years, and motor development at 2.5 years. In contrast, significant independent predictors of hyperactivity/impulsivity included lower IQ, pervasive conduct problems and ADHD symptoms at 6 years, externalizing problems at 2.5 years, and non-white maternal ethnicity.

CONCLUSIONS

Extremely preterm children are at increased risk for ADHD symptoms, predominantly inattention, for which the antecedents differ by symptom domain. Attention deficits after EP birth were associated with poor brain growth and neurological function. Cognitive and behavioral assessments in early and middle childhood to identify neurodevelopmental and peer relationship problems may be beneficial for identifying EP children at risk for inattention.

Reading deficits in very low birthweight children are associated with vocabulary and attention issues at the age of seven

Aim

This Swedish study compared reading skills between seven‐year‐old children with a very low birthweight (VLBW) and controls with a normal birthweight, exploring associations between reading variables and cognition, parent‐rated behaviour, perinatal factors and family factors.

Methods

We studied 51 VLBW children, with no major neurodevelopmental impairments and attending their first year at a regular school, and compared them with the 51 sex‐ and age‐matched controls. The test battery, carried out at 7.8 ± 0.4 years of age, included reading skills, the Wechsler Intelligence Scale for Children – III and the Child Behaviour Checklist.

Results

Very low birthweight children with a mean birthweight of 1105 g (±291 g) and a gestational age of 28.8 (±2.2) weeks scored significantly lower in all reading subtests and cognition and demonstrated more behavioural problems than normal birthweight controls. We also found significant associations between poor vocabulary, combined with attention problems, and phonological awareness, rapid naming and spelling control. Perinatal factors had no association with reading function, and socio‐economic factors had very few.

Conclusion

Very low birthweight children demonstrated deficits in all reading domains and had poorer cognition and more behavioural problems at the age of seven, with reading ability related to vocabulary and attention.

The long-term consequences of preterm birth: what do teachers know?

AIM

The knowledge and information needs of education professionals were assessed to determine how prepared they feel to support the growing number of preterm children entering schools today.

METHOD

In a national survey, 585 teachers and 212 educational psychologists completed the Preterm Birth-Knowledge Scale (PB-KS) to assess knowledge of outcomes following preterm birth. Total scores (range 0-33) were compared between groups and the impact of demographic characteristics on knowledge was analysed. Training and information needs were also assessed.

RESULTS

Teaching staff (mean 14.7, SD 5.5) had significantly lower knowledge scores than educational psychologists (mean 17.1, SD 5.0; p<0.001); both had significantly lower scores than neonatal clinicians surveyed previously (mean 26.0, SD 3.6; p<0.001). Education professionals' poorest areas of knowledge related to the most frequent adverse outcomes following preterm birth. Only 16% of teaching staff had received training about preterm birth and more than 90% requested more information. Having a special educational needs role and being employed at least 16 years were associated with higher knowledge scores.

INTERPRETATION

Education professionals have poor knowledge of the needs of children born preterm and most feel ill-equipped to support them in school. As teachers have primary responsibility for providing long-term support for children born preterm, this is of significant public health and educational concern.

Specialization and integration of functional thalamocortical connectivity in the human infant

Connections between the thalamus and cortex develop rapidly before birth, and aberrant cerebral maturation during this period may underlie a number of neurodevelopmental disorders. To define functional thalamocortical connectivity at the normal time of birth, we used functional MRI (fMRI) to measure blood oxygen level-dependent (BOLD) signals in 66 infants, 47 of whom were at high risk of neurocognitive impairment because of birth before 33 wk of gestation and 19 of whom were term infants. We segmented the thalamus based on correlation with functionally defined cortical components using independent component analysis (ICA) and seed-based correlations. After parcellating the cortex using ICA and segmenting the thalamus based on dominant connections with cortical parcellations, we observed a near-facsimile of the adult functional parcellation. Additional analysis revealed that BOLD signal in heteromodal association cortex typically had more widespread and overlapping thalamic representations than primary sensory cortex. Notably, more extreme prematurity was associated with increased functional connectivity between thalamus and lateral primary sensory cortex but reduced connectivity between thalamus and cortex in the prefrontal, insular and anterior cingulate regions. This work suggests that, in early infancy, functional integration through thalamocortical connections depends on significant functional overlap in the topographic organization of the thalamus and that the experience of premature extrauterine life modulates network development, altering the maturation of networks thought to support salience, executive, integrative, and cognitive functions.