Extreme prematurity and behavioral problems: When is it a problem?

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We know that children born extremely preterm (less than 27 weeks gestational age) are at risk for a whole host of developmental problems, including cognitive, language, motor, and feeding delays, but the relationship between these delays and behavior problems are not well studied…yet. In this study, authors tried to better understand the relationship between global development (using the Bayley Scales of Infant and Toddler Development – III) and behavior problems (using the Child Behaviors Checklist, CBCL) in more than one thousand toddlers born extremely preterm.

You probably won’t be shocked to learn that toddlers with a higher total behavior score (meaning more problems) were more likely to have lower cognitive, language, and motor scores. But some types of behavioral problems weren’t significant after researchers controlled for certain different factors.

Behaviors that were categorized as externalizing, anxiety, attention/hyperactivity, and oppositional defiant only had a statistically significant relationship with low cognitive and/or language scores before researchers adjusted for socio-economic factors. On the other hand, internalizing, affective, pervasive developmental, and total behavior scores were all correlated with lower cognitive, language and motor scores even after the researchers controlled for things like socio-economic factors, medical diagnoses and sex. 

That means if you’ve got a little one on your caseload that was born before 27 weeks gestation, these behavior categories (internalizing, affective, pervasive developmental, and total behaviors*) should set off red flags for you!

Now, the authors acknowledge that we still aren’t sure if these behavior issues cause developmental delays or the other way around (or maybe they both feed off of each other in a vicious cycle), but including a measure of behavior in your evaluations could help you describe behaviors more accurately, determine how at-risk a given toddler is and set goals that are truly impactful for the family. For more on assessing risk in preterm infants, see our previous reviews here, here, and here.

*If the names for behavior types from the CBCL are a bit confusing, it might help to know that they are aligned with DSM-5 criteria for corresponding diagnoses. Or you can get more information from the CBCL manual.

Lowe, J. R., Fuller, J. F., Do, B. T., Vohr, B. R., Das, A., Hintz, S. R., Watterberg, K. L., & Higgins, R. D. (2019). Behavioral problems are associated with cognitive and language scores in toddlers born extremely preterm. Early Human Development. doi:10.1016/j.earlhumdev.2018.11.007