Published online September 1, 2008
PEDIATRICS Vol. 122 No. 3 September 2008, pp. 562-573 (doi:10.1542/peds.2007-3231)
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ARTICLE

Pervasive Behavior Problems at 6 Years of Age in a Total-Population Sample of Children Born at ≤25 Weeks of Gestation

Muthanna Samara, PhDa,b, Neil Marlow, MDc, Dieter Wolke, PhDa,b for the EPICure Study Group

a Department of Psychology
b Health Sciences Research Institute, Warwick Medical School, University of Warwick, Coventry, United Kingdom
c Institute of Neuroscience, University of Nottingham, Nottingham, United Kingdom


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE. The goal was to test whether extremely preterm children have more pervasive behavior problems than classroom peers, by using parent and teacher consensus reports. Is there an excess number of extremely preterm boys with behavior problems?

METHODS. A total-population study of all extremely preterm children in the United Kingdom and Ireland was performed. All children born at ≤25 weeks of gestation in the United Kingdom and Ireland between March and December 1995 were assessed at 76 months of age (range: 62–87 months) (EPICure study). Pervasive behavior problems were defined as scoring >90th percentile on parent and teacher reports with a standard behavior scale, the Strengths and Difficulties Questionnaire. Of the 241 of 308 survivors who responded (78% of survivors), 200 had full reports on behavior problems from teachers and parents; they were compared with 148 control children.

RESULTS. A total of 19.4% of extremely preterm children (boys: 23.2%; girls: 15.6%), compared with 3.4% of control children (boys: 4.6%; girls: 2.5%) had total behavior scores in the clinical range. Hyperactivity (extremely preterm: 30.6%; control: 8.8%) and conduct problems (extremely preterm: 12.5%; control: 5.4%) could be accounted for by cognitive deficits, but attention (extremely preterm: 33.3%; control: 6.8%), peer (extremely preterm: 25.4%; control: 5.4%), and emotional (extremely preterm: 13.5%; control: 4.1%) problems were not explained by poor cognitive functioning. Extremely preterm boys had behavior problems in excess of gender differences found in the control group in hyperactivity, attention, and prosocial problems, and the impact on parents and teachers was greater for extremely preterm boys than girls.

CONCLUSIONS. Pervasive behavior problems are more frequent in children born at the limits of viability than previously reported for larger preterm populations. Extremely preterm boys seem most vulnerable, and the impact on parents and teachers is considerable.

Key Words: premature birth • behavior disorders • child psychology • mood disorders • attention deficit and disruptive disorders • early diagnosis

Abbreviations: EP—extremely preterm • SDQ—Strengths and Difficulties Questionnaire • K-ABC—Kaufman Assessment Battery for Children • OR—odds ratio • CI—confidence interval

Very preterm children have been reported to be at increased risk for behavior problems and psychopathologic conditions. Most consistently, increased risks for attention problems, hyperactivity, and social and peer relationship problems have been reported for a variety of hospital and geographically defined cohorts.1–8 Studies in adolescence and early adulthood indicated that very preterm children continue to have more attention and hyperactivity problems9–13 and difficulties in relating to peers.14,15 There is mounting evidence that, as very preterm children reach adolescence, they also more often suffer internalizing problems, including anxiety and depression,9,10,12,14 in line with the onset pattern reported in the general population.16 Recent evidence, however, suggests that very preterm children or those born at the limits of viability may suffer internalizing problems more often already in middle childhood.17,18

Gender differences in behavior are consistently found in the general population19,20 and extremely preterm (EP) populations,9,17 with boys exhibiting more-frequent externalizing disorders or attention-deficit/hyperactivity disorder and girls experiencing more internalizing disorders. Few studies12 have investigated whether the gender differences in very preterm children may be in excess of those reported in the general population. There is some indication that very low birth weight boys have even more social and attention problems, whereas very low birth weight girls may be at even higher risk for internalizing problems.17 It is unclear, however, whether the behavior problems can be fully or mostly accounted for by general cognitive deficits, which are often found in very preterm children.1,21,22 Most studies in childhood relied on parent reports alone2 or parent, self, and/or teacher reports separately.3,9,10,14 However, none considered pervasive behavior problems across informants, an important criterion for less-biased, more-accurate diagnosis of behavior disorders.23–25 Finally, many of the reports on behavior problems referred to clinical populations born before the widespread introduction of prenatal corticosteroid and surfactant treatments, which are important determinants of the increased survival rates for EP infants3,26,27 and might be expected to enhance long-term outcomes and perhaps to alter patterns of disability.

In this report, we describe behavioral outcomes at 6 years of age for children born at gestational ages of ≤25 weeks, in a total-population study. We investigated whether children born EP were more likely to have clinically relevant pervasive behavior and emotional problems, compared with a term control group. Furthermore, we studied whether any gender differences were in excess of those in the control group and whether increased pervasive behavior or emotional problems could be accounted for by cognitive deficits or other neurologic disabilities.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Subjects
The derivation and characteristics of this population were described previously,28–30 as were the details of the 6-year cognitive and neurologic assessments.21,31 The population represents all surviving children in the United Kingdom and Ireland who were born at ≤25 weeks of gestation from March through December 1995. Of the 308 children known to be alive at 30 months, the parents of 241 children consented to the study. Two hundred four children were in mainstream education. Two hundred twenty-three parents and 215 teachers (of 241) completed the Strengths and Difficulties Questionnaire (SDQ)32,33; 200 children had both parent and teacher reports. For each child assessed in mainstream school, we sought an age- and gender-matched classmate as a comparison.21 One hundred sixty teachers and 148 parents completed the SDQ for comparison children within the same class (148 control children had both parent and teacher reports). The study was approved by the Trent Multicenter Research Ethics Committee and the local education authorities in Scotland.

Behavior Assessments
Parent and Teacher SDQ
Teachers and parents completed the respective versions of the SDQ.32,33 The SDQ correlates highly (r > 0.80) with the Child Behavior Checklist34 total score and discriminates between children with clinically significant behavior problems and children with no problem behavior as well as the Rutter Behavior Scales35 or the Child Behavior Checklist.36,37 The 25 SDQ items fall into 5 scales (with 5 items each), that is, emotional symptoms, conduct problems, hyperactivity, peer problems, and prosocial behavior.32,33 For each scale except prosocial behavior, higher scores indicate more problems.

Cronbach's {alpha} values for each subscale of the teacher reports were moderate to good (hyperactivity: total sample, Cronbach's {alpha} = .88; EP children, Cronbach's {alpha} = .87; classroom control children, Cronbach's {alpha} = .84; conduct problems: total sample, Cronbach's {alpha} = .63; EP children, Cronbach's {alpha} = .69; control children, Cronbach's {alpha} = .55; emotional problems: total sample, Cronbach's {alpha} = .78; EP children, Cronbach's {alpha} = .74; control children, Cronbach's {alpha} = .82; peer problems: total sample, Cronbach's {alpha} = .75; EP children, Cronbach's {alpha} = .75; control children, Cronbach's {alpha} = .55; prosocial behavior: total sample, Cronbach's {alpha} = .84; EP children, Cronbach's {alpha} = .86; control children, Cronbach's {alpha} = .77). A total difficulties score based on the first 4 subscales (total sample, Cronbach's {alpha} = .85; EP children, Cronbach's {alpha} = .83; control children, Cronbach's {alpha} = .83) and scale scores for each subscale were computed separately. An impact scale score also was computed, assessing whether the respondent thinks that the child has difficulty in the areas of emotions, concentration, behavior, or being able to get along with other people. If this is the case, then additional information is obtained about chronicity, distress, social impairment, and burden to others.32,33 The total Cronbach's {alpha} value for the impact scale was .84 (EP children, Cronbach's {alpha} = .83; control children, Cronbach's {alpha} = .88).

Additional items were adapted from the Conners Scales,38,39 the Child Behavior Checklist,34,40 the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition,41 and the International Classification of Diseases, 10th Revision, using the same Likert-scale format to assess components of attention-deficit/hyperactivity disorder (attention: teacher, 4 items; parents, 5 items; overactivity: 4 items each; impulsivity: teacher, 4 items; parents, 3 items). A principal-component factor analysis with varimax rotation was computed for teacher and parent items separately, yielding 2 factors in both analyses with distinct high loadings of ≥.50 and acceptable eigenvalues (attention problems factor: teacher, 6 items, eigenvalue = 7.2; parents, 7 items, eigenvalue = 5.7; overactivity/impulsivity problems factor: teacher, 6 items, eigenvalue = 1.2; parents, 5 items, eigenvalue = 1.0) (Appendix).


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  		APPENDIX Additional Scales

 
The reliability of the overactivity/impulsivity subscale (eg, restless, overactive, or cannot stay still for long; has difficulty waiting his or her turn in games; and constantly fidgeting or squirming) (Appendix) (total sample, Cronbach's {alpha} = .91; EP children, Cronbach's {alpha} = .91; control children, Cronbach's {alpha} = .89) and the attention subscale (eg, has a short attention span; is easily distracted or concentration wanders; and does not follow through on instruction and fails to finish school work) (total sample, Cronbach's {alpha} = .91; EP children, Cronbach's {alpha} = .90; control children, Cronbach's {alpha} = .89) was excellent. In addition, a 5-item school adaptation difficulties scale (eg, has found it difficult to settle in school; is worried about school; and needs special attention to cope with school) had moderate internal consistency (total sample, Cronbach's {alpha} = .66; EP children, Cronbach's {alpha} = .69; control children, Cronbach's {alpha} = .69) (Appendix). The internal consistency coefficients for parent reports (not shown here) were comparable to those reported above for the teacher reports.

The total scores and subscale scores were dichotomized into normal/borderline versus clinical (score of >90th percentile, with respect to the control group). If the child scored at <90th percentile in both parent and teacher reports, then the behavior was considered normal (no behavior difficulty); mild difficulty refers to classification of the behavior in the clinical range by either parent or teacher, whereas clinical pervasive behavior refers to classification of the behavior in the clinical range by both parent and teacher (severe behavior difficulty).23,41,42 Parent and teacher ratings, classified separately into normal/borderline and clinical categories, are shown in Tables 1 and 2, for comparison with other studies.


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  		TABLE 1 Parent Reports of Behavior at 6 Years for 224 Children Born at ≤25 Weeks of Gestation and 148 Age-Matched Classmates for Comparison

 

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  		TABLE 2 Teacher Ratings of Behavior at 6 Years for 215 Children Born at ≤25 Weeks of Gestation and 162 Age-Matched Classmates for Comparison

 
Cognitive Ability
Children were assessed with the Kaufman Assessment Battery for Children (K-ABC).43 Cognitive impairment or disability precluded use of the K-ABC for 41 index children.21 Those children were evaluated by using either the Griffiths Scales of Mental Development44 (35 children) or the NEPSY neuropsychology assessment45 (6 children). The Griffiths quotient or mean NEPSY standardized score was used to estimate a score. If this score was <40 (the lowest score in the K-ABC), then children were assigned a score of 39. To give a measure of cognitive function for all of the index children, these values were merged with the Mental Processing Component of the K-ABC to give an overall cognitive score. Developmental progress was assessed previously with the use of the Bayley Scales of Infant Development, Second Edition, at 2.5 years, which yielded scores for mental and psychomotor development.46

Disability Classification
Children were classified into 4 functional groups of overall disability. Severe overall disability included the child being highly dependent on caregivers and nonambulatory cerebral palsy, an IQ score >3 SD below the mean, profound sensorineural hearing loss, or blindness. Moderate disability included reasonable independence and ambulatory cerebral palsy, an IQ score 2 to 3 SD below the mean, sensorineural hearing loss that was corrected with a hearing aid, and impaired vision without blindness. Mild disability included neurologic signs with minimal functional consequences or other impairments such as squints or refractive errors.21

Statistical Analyses
All analyses were conducted by using SPSS 14.0 (SPSS, Chicago, IL). To determine selective dropout, the 200 EP children with full behavior assessment results were compared with the 108 children with no or incomplete data on social, medical, growth, or functional/disability assessments from birth to 30 months of age, corrected for prematurity.

Categorical outcomes were compared with the use of {chi}2 tests for trends, as appropriate, or Fisher's exact test. All statistical tests were 2-sided. Odds ratios (ORs) are reported with 95% confidence intervals (CIs), comparing EP and control children, boys and girls, and different types of disabilities. To test for the presence of specific behavior problems, logistic regression analyses with adjustment for overall cognitive scores were performed.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Children Lost to Follow-up Monitoring
Compared with children who were assessed, dropouts (maximum: N = 108) were more likely to be of nonwhite ethnic origin (30.6% of dropouts vs 19% of those assessed; P < .05), to have young mothers (≤21 years of age; 21.3% vs 9.5%; P < .01), to live in overcrowded homes (43.5% vs 21.5%; P < .001), to have experienced >1 serious life event by 30 months (42.4% vs 23.5%; P < .001), and to have cerebral palsy (26.4% vs 15.8%; P < .05), were less likely to have a family car (76.5% vs 87.9%; P < .05), and had a lower Psychomotor Development Index at 30 months of age (mean score: 78.8 vs 85.5; P < .01). The distributions of the other 22 variables, including social factors, all neonatal complications, and all parameters on growth or disability up to 30 months of age, were similar in the 2 groups (Table 3).


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  		TABLE 3 Distributions of Social, Medical, and Disability Variables Among Children Assessed at 6 Years and Children Lost to Follow-up Monitoring From a Cohort of 308 Surviving Children Born at ≤25 Weeks of Gestation

 
Behavior Differences
Pervasive Behavior Problems
Compared with control children, EP children had significantly more-frequent pervasive (defined by parent and teacher concurrence) behavior difficulties (P < .001), including emotional problems (P < .01), conduct problems (P < .05), hyperactivity (P < .001), poorer peer relationships (P < .001) and prosocial behavior (P < .001), and higher impact scores (P < .001) on the SDQ (Table 4). Furthermore, they had more-frequent clinical overactivity/impulsivity problems (P < .01), attention problems (P < .001), and school adaptation difficulties (P < .001).


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  		TABLE 4 Scores in the Clinical Range for Pervasive Behavioral Disorders (Denoting Agreement Between Teacher and Parent) Assessed at 6 Years for Children Born at ≤25 Weeks of Gestation and Age-Matched Classmates for Comparison

 
Both boys and girls in the EP group were significantly more likely to have results in the clinical range for pervasive total behavior difficulties, hyperactivity, peer problems, attention problems, and school adaptation problems, compared with their same-gender counterparts in the control group (Table 4). Compared with control boys, EP boys were also more likely to have pervasive emotional problems, less prosocial behavior, higher impact scores, and overactivity/impulsivity problems.

Within the control group, girls were more likely than boys to have pervasive emotional problems (P < .05). In contrast, within the EP group, boys were more likely to have hyperactivity (P < .001), prosocial problems (P < .01), higher impact scores (P < .05), and attention problems (P < .001).

To test whether the differences between EP and control children could be explained by differences in overall cognitive scores, we repeated the analysis with adjustment for overall cognitive score. Group differences in conduct problems, hyperactivity problems, overactivity/impulsivity problems, and impact on parents/teachers were explained by the lower cognitive abilities of the EP children and became nonsignificant after adjustment (Table 5). In contrast, total difficulties, emotional and peer problems, attention problems, and school adaptation problems remained significant after adjustment for cognitive abilities (Table 5). This indicates that these difficulties are specific deficits that are not explained by general cognitive deficits. Emotional problems in EP children, compared with the control group, even increased slightly after adjustment for cognitive scores (before adjustment: OR: 3.7; 95% CI: 1.5–9.2; after adjustment: OR: 4.2; 95% CI: 1.5–11.8) (Table 5).


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  		TABLE 5 ORs for Clinical Scores for Pervasive Behavioral Disorders Before and After Adjustment for General Cognitive Scores

 
Disability and Severity of Behavior Difficulties in EP Children
Table 6 shows the associations of gestational age and cognitive, neuromotor, or sensory disability with total behavior difficulties and the specific scales for attention, overactivity/impulsivity, and school difficulties. No significant association between gestational age at birth and pervasive behavior problems was found. In contrast, cognitive impairment was associated with increased prevalence of overall mild or severe pervasive behavior difficulties (P < .001) and more severe attention problems (P < .001), overactivity/impulsivity (P < .01), and school adaptation difficulties (P < .001) (Table 6); furthermore, the children had more hyperactivity (P < .001), more peer relationship problems (P < .01), and less prosocial behavior (P < .001), and parents and teachers were more severely affected by those problems (P < .001) (not shown). Neuromotor disability also was found to be significantly related to the severity of total difficulties (P < .01) and attention difficulties (P < .05) (Table 6). Conduct problems (P < .05), hyperactivity (P < .05), peer problems (P < .01), and poorer prosocial behavior (P < .001) were more frequent (not shown). Hearing disability showed significant associations with the severity of attention problems (P < .05) (Table 6), hyperactivity (P < .05), and prosocial behavior (P < .05) (not shown). In contrast, the severity of visual disability was not related significantly and consistently to the severity of behavior difficulties.


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  		TABLE 6 Severity and Type of Disability and Gestational Age Among EP Children and Severity of Behavior Difficulties at 6 Years of Age

 
Many children had multiple impairments and associated disabilities,21 summarized in the overall disability index, which was related significantly to the severity of total difficulties (P < .01), attention problems (P < .001), overactivity/impulsivity (P < .05), school adaptation problems (P < .01), hyperactivity (P < .001) (Table 6), peer problems (P < .001), prosocial behavior (P < .001), and the impact on parents/teachers (P < .001) (not shown). Neither overall disability nor the specific disabilities were found to be related to emotional problems.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
In this total-population cohort of EP children, we found a considerable excess of behavior difficulties, including problems in a range of domains such as emotion, conduct, hyperactivity, attention, peer relationships, and prosocial behavior. Parents and teachers agreed that, for 23% of the EP children, these behavior problems had a considerable impact on home or school life, compared with only 7% in the comparison group (OR: 4.0; 95% CI: 1.9–8.3), and on school adaptation (OR: 6.7; 95% CI: 2.7–16.1). However, most EP children, in particular those with no or only mild cognitive problems or neurologic disability, had no or only mild behavior problems. The pervasive behavior problems we report for this population are more pronounced than those observed in other studies of more-mature, very preterm or very low birth weight populations in childhood, for whom disadvantage was described predominately for attention and hyperactivity problems, peer relationships, and school adaptation problems.1,2,4,13 This increased prevalence of behavior problems is of concern, because we used a more-extreme definition of a disorder that was evident on both parent and teacher reports, in contrast to most previous studies, some of which relied on parent reports only and some on parent, child, and teacher reports separately.1,9,14 Parent and teacher reports correlate only moderately (r = 0.4–0.5), using the same instrument, and may be influenced by situation specificity or informant bias.47 Parent or teacher reports alone are also less sensitive in identifying clinical cases for psychiatric problems, compared with parent and teacher reports combined to assess pervasiveness,25,48 as performed here. We can be fairly certain, therefore, that the children we identified with pervasive behavior problems require psychological evaluation.

Controlling for general cognitive performance allowed us to determine whether differences in behavior and school adaptation could be explained by low IQ alone or were attributable to specific deficits in behavioral or emotional regulation. Differences in the prevalence in the behavior domains of conduct, general hyperactivity, and impulsiveness (and their impact on parents and teachers) were indeed mostly accounted for by the reduction in general cognitive abilities in the EP children. For hyperactivity, impulsivity, and conduct problems, this is a consistent finding in the general population.49,50 For important behaviors such as hyperactivity and antisocial behavior, this seems to be the consequence of global changes in cognitive functioning and not a specific feature of development after preterm birth. The origins are likely attributable to global changes in brain development, in terms of size and complexity,51–54 that affect overall cognitive development21 and executive function,55 and they are unlikely to be the result of damage to specific brain regions.31 At very low gestational ages, the changes seem to affect boys more than girls.54 This finding adds to our understanding of the neuropathologic pathways associated with hyperactivity and conduct problems in EP children.

In contrast, the excess of emotional and attention problems and difficulties in peer relationships or school adaptation could not be accounted for by general cognitive ability. Problems with maintaining sustained attention have been reported consistently for very premature children. 12,13 Our results indicate that, although impulsiveness and overactivity are explained by general cognitive ability, regulating/maintaining attention seems to be a specific functional deficit in EP children. This was reported previously for a very preterm cohort study by using the same cognitive measure (K-ABC) but only parent reports of behavior problems.56 The assessment of cognitive performance itself requires attention regulation, and this specific deficit occurs in addition to this confounding effect.

Similarly, problems in peer relationships2 are not explained by global cognitive impairment. Being "different," such as having poorer motor abilities, poor somatic growth, or even minor visual problems such as strabismus, can lead to social exclusion and victimization.57–59 These problems are common in this population.21,60 Although we found that the severity of cognitive or neuromotor disability was related to severe peer relationship problems, neither specific hearing nor vision problems were, which is reassuring. Other factors, such as working memory,61 attention deficits, peer relationship problems, and motor problems,62 and socioeconomic family factors,63–65 may exacerbate school problems in EP children and need to be explored further in longitudinal analysis, because they may have consequences for adult outcomes.66

Most notably, emotional problems such as worrying, being unhappy, and being fearful were not at all explained by the cognitive scores or overall or specific disabilities. The problems were frequent across the range of EP children, and the odds of pervasive emotional problems were increased 3.7-fold among EP children (rate: 13.5%), compared with control children (rate: 4.1%). The rate we observed among control children is similar to the prevalence in a representative community sample in the United Kingdom (4%),67 giving face validity to the composition of our comparison group. The finding strongly suggests that children born at the limits of viability already suffer more emotional problems in middle childhood than control children and the development of emotional problems is quite independent of disability.

Comparison of the rates of behavior problems for control boys and girls confirmed the trends found in community samples,19,20,65,68 with boys having more conduct, hyperactivity, and attention problems and total difficulties and girls having more emotional problems; with the small sample size, only the latter was statistically significant. A similar pattern was found in the EP group. However, comparison of the ORs for boys and girls with respect to individual behavior dimensions (Table 4) indicated that EP boys had a disproportionate increase in hyperactivity and overactivity/impulsivity problems, were less prosocial, and had more peer and school adaptation difficulties than would be expected from the gender difference in the control group. There was one exception; EP girls were reported to have more conduct problems than expected. Overall, EP boys seemed to be even more vulnerable to developing behavior difficulties, taking into account the usually reported gender differences. This finding extends those previously reported for cognitive functioning in boys, compared with girls, in this sample21,31 and is found in the context of lower survival rates and greater frequency of neonatal problems among boys in this population,28 as well as higher rates of disability.30 One may speculate that gender differences in intrauterine development or the lack of intrauterine development make the male fetus/EP infant particularly vulnerable to perinatal adversity, with important consequences for brain and later development.20,54,69

There are some limitations to this study. We were not able to recruit a classroom control child for each EP child in mainstream school. Of the parents and teachers who gave consent, up to 15% did not return the behavior scales. We found no pattern or lack of cooperation according to regional variation or social deprivation in the area the school was serving. The return rate compares well with those of other questionnaire studies.25 We thus consider any bias to be minimal. The finding of substantial pervasive behavior and emotional problems cannot be accounted for by selective dropout. There were no differences regarding medical variables, growth, or early disability between those lost to follow-up monitoring and those assessed.21 Rather, we found that dropout was more likely in disadvantaged families, which would be expected to reduce the prevalence of behavior difficulties in the assessed population.49,50,65

This large study of outcomes for such an immature population at school age indicates that the odds for clinically relevant, pervasive behavior problems are 2 to 9 times higher for EP children and problems are more frequent than in more-mature preterm populations. Some of the behavior problems are accounted for by general cognitive deficits, but problems of attention, emotion, peer relationships, and school adaptation are more common than expected from cognitive scores. These patterns of behavior difficulties may have important implications for brain imaging research,54 primary prevention of prematurity and neurodevelopmental problems, and clinical psychological care for EP children.


   ACKNOWLEDGMENTS
 
The research reported herein was supported by grants from BLISS (see www.bliss.org/uk), the premature infant charity (Drs Marlow and Wolke), the Health Foundation (Drs Marlow and Wolke), and Well-Being of Women (Drs Marlow and Wolke).

The EPICure Investigator Group included K. Costeloe (London), A. T. Gibson (Sheffield), E. M. Hennessy (London), N. Marlow (Nottingham), A. R. Wilkinson (Oxford), and D. Wolke (Warwick). Data were acquired by Drs Wolke and Marlow and the Developmental Panel researchers, as follows: psychologists: Emma Luck, Catherine Bamford, Helen Betteridge, Hanne Bruhn, Sandra Johnson, Iliana Magiati, Maria Morahan, Isabel Tsverik, and Muthanna Samara; pediatricians: Melanie Bracewell, Michele Cruwys, Ruth MacGregor, Lesley McDonald, Margaret Morton, Margaret Morris, and Sue Thomas. Administrative, technical, and material support was provided by Heather Palmer, Catherine Bamford, Emma Luck, and Melanie Bracewell.


   FOOTNOTES
 
Accepted Dec 20, 2007.

Address correspondence to Dieter Wolke, PhD, Department of Psychology, University of Warwick, Coventry CV4 7AL, United Kingdom. E-mail: D.Wolke{at}warwick.ac.uk

The authors have indicated they have no financial relationships relevant to this article to disclose.


What's Known on This Subject

Behavior problems have been reported mostly by using parent reports or teacher reports only. Few studies have focused on the behavioral development of extremely premature children (<26 weeks of gestation).

 

What This Study Adds

We used parent and teacher agreement (pervasiveness) to determine clinically significant behavior or emotional problems. Extremely preterm children had 4 times increased odds of having emotional problems, compared with control children, at 6 years of age, independent of other disabilities.

 


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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