Behavior and social-emotional problems are more difficult to define clinically, and most of these data are elicited from surveys of parents and teachers. Symptoms suggestive of ADHD occur two to six times more frequently in children born preterm with birth weights of less than 1,000 grams, less than 1,500 grams, and less than 2,000 grams than in controls born full term (9 to 15 percent diagnosed with ADHD compared with 2 percent of controls born full term) (Aylward, 2002; Bhutta et al., 2002; Breslau, 1995; Levy, 1994; Pharoah et al., 1994; Saigal et al., 2001; Stjernqvist and Svenningsen, 1995; Szatmari et al., 1990; Taylor et al., 1998). Refinement of descriptions of impairments of attention and behavior provides further insight into the problems children born preterm and their families face. In a study of 8-year-old children born at less than 28 weeks of gestation or with birth weights of less than 1,000 grams, the preterm children had significantly lower scores for processing speed, attention, and working memory and higher scores for hyperactivity than those for children born with normal birth weights (Anderson and Doyle, 2003). Middle-school children who weighed less than 750 grams at birth were found to have a much higher prevalence of symptoms of executive function disorder, including difficulties with planning, problem solving, organizing, and abstracting, which can seriously influence their function and behavior at school and at home (Taylor et al., 2000).
Parents and teachers report that preterm children with birth weights of less than 1,000 or 1,500 grams lag behind their peers in social competence and behavior and that this is unrelated to their IQ scores (Anderson and Doyle, 2003; Breslau et al., 1988). It is especially true for boys. In large study of 8- to 10-year-old children born between 1978 and 1981, significantly more children with birth weights of less than 2,500 grams than children born with normal birth weights had behavioral problems, but there were no significant differences among the low-birth-weight categories (i.e., 27 to 29 percent for children with birth weights of less than 1,000, 1,001 to 1,500, and 1,501 to 2,500 grams versus 21 percent for children with birth weights of greater than 2,500 grams) (McCormick et al., 1992, 1996). Specifically, the children born preterm had higher subscores for hyperactivity and whining and were perceived to be less competent in athletics, behavior, and scholastics. Both teachers and parents rated 8- to 10-year-old children born at less than 28 weeks gestation or with birth weights less than 1,000 grams as having more behavioral symptoms (especially more somatic complaints and atypical behaviors), less adaptability, and fewer social and leadership skills than controls born with normal birth weights (Anderson and Doyle, 2003).
The evidence examining the relationship between low birthweight or preterm birth and autism is mixed. While some studies suggest a positive association (Finegan and Quarrington, 1979; Hultman et al., 2002; Indredavik et al., 2004; Larsson et al., 2005; Wilkerson et al., 2002), other studies have concluded that there is not an increased risk of autism in children born low birthweight or preterm (Deykin and McMahon, 1980; Mason-Brothers et al., 1990; Piven et al., 1993; Williams et al., 2003). One study suggests that perinatal and obstetric factors might interact to impact birth outcomes (Eaton et al., 2001).
Conduct disorders are more common in children born preterm, but so are traits such as shyness, unassertiveness, withdrawn behavior, and social skill deficits (Bhutta et al., 2002; Grunau et al., 2004; Sommerfelt et al., 1996). In a meta-analysis of 16 case-control studies of children 5 years old or older who had been born preterm, 13 (81 percent) of the studies found that children born preterm had more behavioral problems than controls born full term (Bhutta et al., 2002). Two-thirds of the studies found a higher prevalence of ADHD, 69 percent found a higher prevalence of externalizing symptoms (e.g., delinquency), and 75 percent found a significantly higher prevalence of internalizing symptoms (e.g., anxiety, depression, and phobias). Many of these children withdraw from challenging tasks. Many preterm children with nonverbal learning disabilities have social skill deficits that seriously influence their social interactions and peer relationships (Aylward, 2002; Fletcher et al., 1992). At school age, children born at less than 29 weeks of gestation were more often the target of verbal bullying by their peers than full term controls (Nadeau et al., 2004).
Adolescents and adults born preterm are less likely to demonstrate risk-taking behaviors than controls who were born full term. A recent study of young adults born from 1980 to 1983 in Britain found that fewer of those born with birth weights less than 1,500 grams than controls born full term drank alcohol or used illicit drugs, but there were no differences in the rates of smoking or sexual activity (Cooke, 2004). In the United States, young adults with birth weights less than 1,500 grams reported lower rates of alcohol and illicit drug use than controls with normal birth weights, but the two groups showed similar rates of tobacco use (57 and 50 percent of the men, respectively, and 40 and 48 percent of the women, respectively) (Hack et al., 2002). The men in the sample were also less likely to violate the law (37 and 52 percent, respectively), and this was primarily due to the lower rates of illicit drug use and truancy. The women were less likely to have had intercourse by age 20 years (65 and 78 percent, respectively) and to have had children (13 and 24 percent, respectively). These differences in risk-taking behaviors persisted even when the data for young adults with neurosensory impairments were excluded from the analysis. Both men and women with birth weights of less than 1,500 grams reported fewer delinquent behaviors, and women reported higher rates of anxiety-depression and withdrawal behaviors, fewer friends, and poorer family relationships than controls born with normal birth weights (Hack et al., 2004). An older study of Danish teenagers found no differences in the rates of alcohol or drug use between those born weighing less than 1,500 grams and controls born with normal birth weights (Bjerager et al., 1995).
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