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


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

Preterm birth + social disadvantage = extra at-risk

*Another study on social disadvantage; this time, over 100 infants studied.

We know that babies born pre-term are at a higher risk for developmental delays, including language. We also know that children born into socially disadvantaged environments are at risk for language delay. So what happens when a baby from a socially disadvantaged* background is born early? The most SLP-relevant findings include:

  • full-term infants with fewer social risk factors had the best language scores at age 5

  • but low social risk isn’t enough to make up for prematurity (< 30 week gestation)— that is, preterm infants with low social risk did not experience as much language growth from 2- to 5-years as the full-term children (thus, addressing social risk for preterm kids is good, but may not be enough to close the language gap by 5 years)

  • high social risk was associated with decreasing language scores as developmental demands increased with age (and the authors found this trajectory was associated with maternal affect and maternal intellectual ability, so parent interventions addressing affect and responsiveness may be helpful for these children)

The big picture? Just because everything looks “ok” for a child at 2 years doesn’t mean things will look that way at 5 years when cognitive, linguistic, and motor development gets more demanding. Also, very preterm infants and toddlers, at a social disadvantage or not, need our support. We can start by training parent responsivity, but it looks like some preterm children could need more intensive interventions to close the developmental gap between themselves and their full term peers.

*Their definition of social risk included factors like teen parents, single parents, no high school diploma. Refer back to the previous study, though, that shows how a healthy home environment can reduce the impact of these factors.


Lean, R. E., Paul, R. A., Smyser, T. A., Smyser, C. D., & Rogers, C. E. (2019). Social adversity and cognitive, language, and motor development of very preterm children from 2 to 5 years of age. The Journal of Pediatrics. Advance online publication. doi:10.1016/j.jpeds.2018.07.110.

Early object exploration linked to communication skills in preterm and full-term infants

A few months ago, we reviewed a study on identifying early learning delays in preterm infants. Well, this study provides us with an additional skill to keep an eye on when working with preterm and full-term infants. Keep reading to learn how object exploration at 6 months can predict communication skills at 12 months.

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Researchers observed 20 extremely preterm infants* (gestational age < 28 weeks) and 20 full-term infants engage in play with their mothers at 6 months and 12 months of age. (Note: the preterm infants were observed at their corrected ages; more on age correction here.) At 6 months, the researchers measured how often infants engaged in oral and manual exploration of toys. For example, an infant could engage in oral exploration by mouthing a rattle and manual exploration by transferring the rattle from hand to hand. Then at 12 months, the researchers measured the infants’ gestures, vocal productions, cognitive skills, and word comprehension.

Not surprisingly, the preterm infants tended to score lower on measures of cognitive skills and language skills than full-term infants. This fits with the broader findings of previous research showing that “preterm infants as a group, do not tend to catch up to peers’ language by school-age.” 

But what may take you by surprise is that neither neonatal condition (preterm vs full-term) nor cognitive performance were significant predictors of 12-month word comprehension, gestures, or vocal production when also considering object exploration. For all infants in this study, oral exploration at 6 months was a significant predictor of word comprehension at 12 months and manual exploration at 6 months was a significant predictor of gesture and vocal production at 12 months.

So what does this mean for EI SLPs? Diagnostically, we would certainly still consider preterm birth a risk factor for future language difficulties. However, we may also consider object exploration skills at 6 months as a possible predictor of communication skills at 12 months for both preterm and full-term infants. As for intervention, the authors note that supporting object exploration could enhance communication skills, but they didn’t explicitly examine whether or not this is the case. We’ll keep you posted as more comes out on this topic!

*One limitation of this study is that the extremely preterm infants selected to participate were deemed “healthy.” Many extremely preterm infants receiving EI services have health complications relating to preterm birth.

NOTE: Interested in another paper on the link between motor skills and communication? Check out this recent review on infant siblings of children with autism. 

Zuccarini, M., Guarini, A., Iverson, J.M., Benassi, E., Savini, S., Alessandroni, R., Faldella, G., & Sansavini, A. (2018). Does early object exploration support gesture and language development in extremely preterm infants and full-term infants? Journal of Communication Disorders, 76, 91–100.

And more...

Normally we try to keep this section fairly brief for you all, but holy moly there was so much research this month!

  • Bradshaw, et al. examined differences in communication and play in groups of infants at high- and low-risk for ASD. High-risk 12-month-olds who were considered “prewalkers” (who didn’t stand or walk) showed significantly lower scores on the CSBS in terms of play skills, gesture use, word use, and behavior measures such as protesting. Even though both high-risk and low-risk groups had similar numbers of prewalkers, standers, and walkers, the authors suggest their results “confirm that the lower social communication scores observed in high-risk infant prewalkers are clinically significant and suggests that these infants may be at higher risk for social communication delays.” SLPs working in the PSP model could keep this information in mind while discussing intake and evaluation plans or while reviewing quarterly updates during teaming meetings. Note: the authors caution that the participants in their study were mostly white, highly educated families, and that results may not generalize to all populations.

  • In a study of over 1200 families in poor rural regions, Burchinal et al. confirmed the presence of a large gap in school readiness skills that emerges during the first five years of life. Specifically, children who experienced poverty before the age of two had more significant delays on their language, cognitive, social, and executive functioning. Self-regulation and executive functioning skills played an important role in school readiness at age five. Check out the original article for a more in-depth analysis of the relationship between poverty & school readiness.

  • If you’re an EI therapist, you’ve most likely evaluated a child who was born premature at one time or another, so you’re also most likely familiar with the idea of age correction. You may have corrected for age on one or more assessments, but you may have also wondered if that’s best practice. And, if it is, when should we stop correcting for age? Harel-Gardassi et al. used the Mullen Scales of Early Learning (MSEL) test to see how age correction impacted the scores of preterm infants at 1, 4, 8, 12, 18, 24, and 36 months of age. Not surprisingly, corrected age scores were found to be significantly higher than chronological scores at all ages, with factors such as gestational age and birth weight affecting the level of difference between the two scores. These findings also suggest that if you use the MSEL, you should be using age correction until the adjusted age of three, not the currently recommended age of two.

  • In terms of input, the large majority of what children, including infants, are exposed to on a day-to-day basis is connected speech, while isolated words are heard infrequently and inconsistently. So, do the single words that infants are exposed to have any kind of impact on their language development? This recent study by Keren-Portnoy et al. of 12-month-olds showed that isolated words, instead of words presented at the end of an utterance, were easier for the children to recognize and remember.

  • Lim and Charlop found that speaking a child’s heritage language during play-based intervention sessions seemed to help four bilingual children with ASD play in more functional and interactive ways. The experimenters followed scripts for giving play instructions, verbal praise, and making comments related to play in both English and each child’s heritage language (in this study, Korean or Spanish). None of the children played functionally or interactively before the intervention, but all of the children showed an increase in play during and after intervention sessions in both English and the heritage language, with more impressive gains seen in heritage language sessions. More research is needed, but SLPs should keep this in mind when working with bilingual children with ASD (note: study done on older children).

  • In a qualitative study by Núñez & Hughes, Latina mothers reported higher satisfaction with early intervention services when they had bilingual support through an interpreter or bilingual SLP, received clear explanations about services and paperwork, felt the SLP respected their wishes, and were provided with strategies to work on with their children outside of SLP sessions.

  • Rague et al. found that infants with Fragile X syndrome use fewer gestures than infants at both high and low risk for ASD. Children with Fragile X who used fewer gestures tended to have lower nonverbal abilities. A lack of early gesture use in infants with Fragile X may be an indicator of the child’s broad cognitive ability.  

  • Thrum et al. found that toddlers between 18 and 24 months with language delay had significantly more socioemotional and behavioral problems compared to toddlers without language delay. At 18 months, more than half of children with language delays had scores within the range of clinical concern! These results underscore the importance of early detection & treatment for children with language delays.

  • Torrisi et al. found that toddlers’ communication scores on the Ages and Stages Questionnaire (ASQCS) were not directly associated with mothers’ diagnoses of PTSD related interpersonal violence, but communication development was affected when mothers showed more controlling behavior and were less sensitive to their toddlers. Both of these qualities of maternal behavior were also correlated with severity of PTSD symptoms. This is important information to keep in mind when providing services to families at risk for experiencing or with a history of interpersonal violence.

  • Yu, et al measured 9-month-old typically-developing infants’ attention to objects and joint attention with their parents, to tease out what exactly contributes to vocabulary growth in the first year of life. They found that sustained attention with and without joint attention predicted vocabulary size at 12 and 15 months, but joint attention alone did not predict vocabulary growth. We need more research to figure out exactly how to use this information clinically, but in the meantime, we can always continue to help caregivers make the best use of their children’s interest and attention during play to support vocabulary growth.


Bradshaw, J., Klaiman, C., Gillespie, S., Brane, N., Lewis, M., & Saulnier, C. (2018). Walking ability is associated with social communication skills in infants at high risk for autism spectrum disorder. Infancy. Advance online publication. doi: 10.1111/infa.12242.

Burchinal, M., Carr, R.C., Vernon-Feagans, L.V., Blair, C., Cox, M. (2018). Depth, persistence, and timing of poverty and the development of school readiness skills in rural low-income regions: Results from the family life project. Early Childhood Research Quarterly, 45, 115–130.

Harel-Gadassi, A., Friedlander, E., Yaari, M., Bar-Oz, B., Eventov-Friedman, S., Mankuta, D., & Yirmiya, N. (2018). Development assessment of preterm infants: Chronological or corrected age? Research in Developmental Disabilities, 80, 35–43.

Keren-Portnoy, T., Vihman, M., & Lindop Fisher R. (2018). Do infants learn from isolated words? An ecological study. Language Learning and Development. Advance online publication. doi: 10.1080/15475441.2018.1503542.

Lim, N. & Charlop, M. H. (2018). Effects of English versus heritage language on play in bilingually exposed children with autism spectrum disorder. Behavioral Interventions. Advance online publication. doi: 10.1002/bin.1644.

Núñez, G., & Hughes, M. T. (2018). Latina mothers’ perceptions and experiences of home-based speech and language therapy. Perspectives of the ASHA Special Interest Groups, 14(3), 40–56.

Rague, L., Caravella, K., Tonnsen, B., Klusek, J., & Roberts, J. (2018). Early gesture use in fragile X syndrome. Journal of Intellectual Disability Research, 62(7), 625–636.

Thurm, A., Manwaring, S.S., Jimenez, C.C., Swineford, L., Farmer, C., Gallo, R., Maeda, M. (2018). Socioemotional and behavioral problems in toddlers with language delay. Infant Mental Health Journal, 38(5), 569–580. 

Torrisi, R., Arnautovic, E., Pointet Perizzolo, V. C., Vital, M., Manini, A., Suardi, F., …, & Schechter, D. S. (2018). Developmental delay in communication among toddlers and its relationship to caregiving behavior among violence-exposed, posttraumatically stressed mothers. Research in Developmental Disabilities. Advance online publication. doi: 10.1016/j.ridd.2018.04.008.

Yu, C., Suanda, S. H., & Smith, L. B. (2018). Infant sustained attention but not joint attention to objects at 9 months predicts vocabulary at 12 and 15 months. Developmental Science. Advance online publication. doi: 10.1111/desc.12735.

Identifying early learning delays in preterm infants

Do you remember a few months back when we learned that preterm infants don’t seem to catch up to their peers’ language skills by school age? Well, this study took a look at how premature and full-term infants learn, and found some interesting differences we can add to our list of things to watch in our preterm cases.

The authors repeated assessments on 23 full term and 30 preterm infants over a period of 18 months to see if there were changes in how the infants performed on means-end tasks, which included a towel or a turntable as the means, and a fun toy as the end. In other words, the authors recorded whether the babies could pull the towel or turn the turntable to get a toy. Success requires a whole bunch of sensory, motor, and cognitive abilities to interact, and typical infants can complete a one-step means-end task like towel pulling by about 8 months (see here for an older study). They also recorded how much time the infants spent exploring, how many different ways the infants interacted with the task, and how many times the infants successfully completed the trials.


The authors found that all infants got better at getting the toy with age, but preterm infants as a group were less likely to succeed in both tasks compared to full-term infants (2.25 times less likely in the towel task and 1.55 times less likely in the turntable task). The authors also found differences in how the babies explored during the tasks. While everyone explored more over time, babies who explored more early in development had more success with the means-end tasks overall. Not only that, but preterm babies showed more variability in their exploration later in development than the full-term babies. As it turns out, we decrease the variability in exploration as we fine-tune our skills. Think about it this way—when we learn a new skill, we try it this way, try it that way, try it another way, and store maps for the most efficient ways to do the skill. We explore less as we get good at it, but pre-term babies continued to explore different behaviors longer than full-term babies in the means-end tasks.

OK, got it. But how can we use it? Diagnostically, we could use these tasks during assessments (the authors suggest the towel task for 5- to 7-month-olds and the turntable task for 11- to 13-month olds). Red flags would include lack of exploration in earlier ages and lots of variability in exploration later in infancy. For intervention, we should remember to encourage infants to explore solutions. Instead of modeling the solution, have fun in the learning process! We can also call attention to the end object so infant can see what happens to the toy when she acts on the towel or the turntable. Help these babies become the little scientists they were born to be!


Cunha, A. B., Babik, I., Ross, S. M., Logan, S. W., Galloway, J. C., Clary, E., & Lobo, M. A. (2018). Prematurity may negatively impact means-end problem solving across the first two years of life. Research in Developmental Disabilities. Advance online publication. doi: 10.1016/j.ridd.2018.03.007

Profile of preterm infants' language development

SLPs know that prematurity affects brain development, and is a risk factor for speech–language delay. But how great of a risk factor, exactly?

There are many studies of the cognitive and linguistic outcomes associated with prematurity. This study is unique, though, as a meta-analysis of available research on language outcomes in children ages 5–9 years old. This helps us to address the question of, “Do these preterm infants catch up?”

The findings show that preterm infants, as a group, do not tend to catch up to peers’ language by school-age. Specifically: “Children born VPT (very preterm) and who have VLBW (very low birth weight) do not catch up with their full-term peers at early school age in terms of their total language, receptive language, expressive language, phonological awareness, and grammar abilities...” Do note that there is quite a bit of variability within the study samples though, with many preterm children achieving normal language scores, but many not. And, not surprisingly, the more preterm or medically fragile the infant, the greater likelihood of neurodevelopmental differences.


So, early intervention SLPs—conversations, resources, and support must start in the NICU and continue through the early years (note: this article points you toward some papers on the effectiveness of EI services, as well). School-based SLPs—prematurity isn’t a “non-issue”, but still a relevant piece of the child’s case history all the way up through elementary years, and may shed light on current performance.

*Note—this article appears in both our Early Intervention and Pediatrics & School-Based SLPs’ research reviews, because we had a heck of a time trying to decide where to put it. Bonus! :)


Zimmerman, E. (2018). Do Infants Born Very Premature and Who Have Very Low Birth Weight Catch Up With Their Full Term Peers in Their Language Abilities by Early School Age? Journal of Speech, Language, and Hearing Research, 61, 53–65.