Behavioural and emotional outcome of very low birth weight infants – literature review

Behavioural and emotional outcome of very low birth weightinfants – literature review

BREDA HAYES & FARHANA SHARIF

Department of Paediatrics, Midland Regional Hospital, Mullingar, Ireland

(Received 18 August 2008; accepted 10 May 2009)

Abstract

Objective. To examine whether low birth weight (LBW) children are at greater risk for behavioural and emotional problemsthan normal birth weight children.

Methods. Electronic databases (PubMed, Google) were searched. Key search terms (LBW, emotional behaviouraloutcome) were used to identify possible studies. Selection of studies was limited to those including detailed assessment ofbehavioural and/or emotional outcome of very low birth weight or very preterm infants with normal term infants as controls,published from the year 2000 to date. A total of 20 studies were identified for inclusion in our review.

Results. Overall studies showed a significant increase in behavioural problems in particular poor attention span, withdrawnbehaviour and poorer adaptive functioning. Rates of a clinically significant neurobehavioural impairment in cases rangedfrom 25% to 55% with controls displaying a relatively constant rate of around 7%. Attention problems without hyperactivity(ADD) were more common than ‘classical attention deficit/hyperactivity disorder’ in LBW children. Only 4% of the LBWchildren had previously been referred to a consultant psychiatric suggesting that at present these problems are being under-recognised.

Conclusion. VLBW or very preterm infants are at significant risk of behavioural and emotional problems. The risk is furtherincreased when cognitive or motor difficulties are present or when social circumstances are poor.

Keywords: VLBW, emotional, behavioural, outcome

Introduction

Survival in very low birth weight (VLBW) infants has

improved dramatically over the past two decades as a

result of improved perinatal and neonatal care.

However, the rates of disability and neurodevelop-

mental problems are still high [1].

In addition to the neurosensory and cognitive

deficits, VLBW children are at risk of developing

behavioural and mental health disorders, especially

symptoms of attention deficit/hyperactivity disorder

(ADHD), anxiety, poor social skills, and can suffer

depression and thought processing problems. These

behavioural and emotional problems often manifest

in the early school years and may hamper academic

functioning and result in poor performance at school

[2]. When present, behavioural problems limit

benefits from interventional therapies and are there-

fore important to recognise and treat. Behavioural

problems, which are not recognised and therefore

not treated, can seriously affect the quality of life of

both the child and that of the family. Quality of life is

viewed by many as being more important than the

actual level of disability present in the child [3].

Methods

Study identification

Electronic databases [PubMed, Cochrane, and

Google] were searched using key search terms such

as low birth weight (LBW) and emotional behaviour-

al outcome, to identify possible studies. [PubMed

(19 citations), Cochrane (7 citations) and Google

(91,200 citations)].

Selection was limited to case–control studies of

LBW or preterm infants published from the year

2000 to date. Studies were excluded if they did not

Correspondence: B. Hayes, Department of Paediatrics, Midland Regional Hospital, Mullingar, Co.West Meath., Ireland. E-mail: [email protected]

The Journal of Maternal-Fetal and Neonatal Medicine, October 2009; 22(10): 849–856

ISSN 1476-7058 print/ISSN 1476-4954 online � 2009 Informa UK Ltd.

DOI: 10.1080/14767050902994507

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contain a detailed assessment of behavioural and/or

emotional outcome.

A total of 20 studies were identified for inclusion

in our review.

Results (see Table I)

Most studies used cohorts identified through hospital

records or through their participation in a parallel

study. Two studies included population-based infor-

mation being obtained through National Health

Surveys. In five studies, cohorts were delivered in the

1990s, two studies spanned both the 1980s and 1990s.

The remaining studies looked at cohorts delivered in

the 1980s apart from three studies, which assessed the

same cohort, delivered in the 1970s. Different methods

of behavioural assessments were used. All but two

studies used a validated questionnaire; only one study

included an assessment by a psychiatrist. The most

common questionnaires used were the child behaviour

checklist (CBC), behavioural assessment system for

children (BASC) and the strengths and difficulties

questionnaire (SDQ).

18 studies controlled for socio-economic factors

such as family poverty, parental smoking, maternal age

and education, only four studies excluded children

with major neurosensory impairments [16,19,20,23].

Monset-Couchard et al. [14] also controlled for

genetics by studying sets of co-twins/co-triplets.

While children with low IQ were more at risk of

emotional and behavioural problems, LBW children

with normal IQ were still at a significantly higher risk

of these problems when compared to controls [9,10].

LBW appears to be one of biggest risk factors for the

subsequent development of behavioural problems.

Kelly et al. [22] showed that even when adjustments

are made for social factors there is an *30%

increased risk of overall behavioural problems per

kilogram drop in birth weight.

Overall studies showed a significant increase in total

behavioural problems and in particular problems with

attention, withdrawn behaviour and poorer adaptive

functioning for VLBW or very preterm children. In

addition, these children also displayed poorer quality

family and social relationships.

Rates of a clinically significant neurobehavioral

impairment in cases ranged from 25% [10] to 55%

[17] with controls displaying a relatively constant

rate of around 7%. Birth weight of cases differed

between studies, which could account for some of

the heterogeneity in outcome. Chaudhari et al. [12]

did not show any statistically significant difference in

emotional instability probably reflecting that only

three infants in his cohort were 51000 g.

Attention problems without hyperactivity (ADD)

were common being more typical than ‘classical

ADHD’ in LBW children. Only 4% of the LBW

children had previously been referred to a psychiatric

specialist suggesting that at present these problems are

being under recognised or under-treated. (Table II).

Discussion

VLBW or very preterm infants are at increased risk

for developing behavioural and emotional problems.

Not only does this interfere with the child and

family’s quality of life but it also decreases the

effectiveness of intervention programmes if these

problems go unrecognised or untreated [24].

Of interest, Elgen et al. [19] showed that none of

the prenatal or neonatal variables were predictors of

behavioural problems or psychiatric disorders at 11

suggesting that later environment plays a key role in

the development of these problems. Hille et al. [21]

showed that behavioural problems seen in ELBW

children were very similar across the four countries

studied suggesting that these problems are universal

perhaps due to the preterm brain developing ex utero.

Multiple studies have shown that physical or social

problems increase the risk of emotional and beha-

vioural problem even further [4,19,22]. Hence, it is

important to relieve the frustration relating to

difficulties by providing social interventions and

adequate funding for intervention services and

creche placement.

While previous follow up studies on children born

in the 1970s by Hack et al. [13,18], reported fewer

delinquent behaviours in VLBW men; this difference

is less evident in recent studies. Indredavik et al. [10]

showed that parents stated more delinquent beha-

viour in the VLBW group. Stoelhorst et al. [15]

found significantly higher rates of aggressive and

destructive behaviours. Family dynamics have chan-

ged greatly in the last decade. Whether this could

have led to a change in behaviour from being more

withdrawn to aggressive is unclear.

While VLBW adolescents often do not report

more emotional or behavioural problems, parents

consistently report lower general health and beha-

viour scores than for controls [10,13]. This suggests

that these problems often have a greater impact on

the parents’ and families’ quality of life. Moore et al.

[6] showed significant long-term burden and par-

ental psychological distress for families of children

with VLBW infants.

In comparison to follow-up studies post-school

entry, a study by Stoelhorst et al. [15] where children

were assessed at 2 years of age showed the percentage

of children with a total problem score in the clinical

range was comparable to that of the general

population sample. It is suggested that behavioural

difficulties could be a consequence of inability to

cope with the expectations of others and therefore

not present until after school entry. Therefore,

850 B. Hayes & F. Sharif

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Tab

leI.

Ch

arac

teri

stic

san

das

sess

men

tto

ols

of

incl

ud

edst

ud

ies.

Stu

dy

Age

atfo

llo

wu

p(y

ears

)C

rite

ria

Yea

rb

orn

Nu

mb

ero

fca

ses

Ass

essm

ent

too

ls

[4]

8–9

51

00

0g;5

28

wee

ks

19

92

–1

99

32

55

EL

BW

BA

SC

[5]

41

50

0g

(20

02

Nat

ion

al

Hea

lth

Inte

rvie

wS

urv

ey)

46

7M

LB

WS

urv

eyq

ues

tio

ns

bas

edo

nC

BC

;S

DQ

[6]

11–1

55

150

0g

19

82

–1

98

66

8E

LB

W;

65

VL

BW

Fam

ily

Bu

rden

Inte

rvie

w;

Bri

efS

ymp

tom

Inve

nto

ry

[7]

13–1

85

150

0g

19

78

–1

98

98

2V

LB

WY

ou

thS

elf

Rep

ort

;C

BC

[8]

11

(Mea

nT

1);

17

(Mea

nT

2)

51

50

0g

19

82

–1

98

64

8E

LB

W;

46

VL

BW

Co

nfl

ict

Beh

avio

ur

Qu

esti

on

nai

re;

CB

C;

Tea

cher

Rep

ort

Fo

rm

[2]

55

150

0g

19

92

–1

99

54

02

VP

/VL

BW

CB

C

[9]

14

51

50

0g

19

86

–1

98

85

6V

LB

W;

60

SG

AC

hild

Hea

lth

Qu

esti

on

nai

re,

Par

enta

lB

on

din

g

Inst

rum

ent;

Sym

pto

mC

hec

klist

-90

[10]

14

51

50

0g

19

86

–1

98

85

6V

LB

W;

60

SG

AA

chen

bac

hS

yste

mof

Em

pir

ical

lyB

ased

Ass

essm

ent,

SD

Q

[11]

20

51

50

0g

19

77

–1

97

91

18

VL

BW

YA

SR

;Y

AB

CL

[12]

12

52

00

0g

19

87

–1

98

93

EL

BW

;7

5V

LB

W;

10

2L

BW

Dra

wa

per

son

scre

enin

gp

roce

du

refo

rem

oti

on

al

dis

turb

ance

[13]

20

s5

150

0g

19

77

–1

97

92

41

VL

BW

Ach

enb

ach

you

ng

adu

ltse

lf-r

epo

rto

fb

ehav

iou

r

[14]

3–1

75

100

0g

19

81

–1

99

93

6E

LB

W(t

win

s/tr

iple

ts)

No

velle

Ech

elle

Met

riq

ue

deL

’In

tellig

ence

/Car

net

de

San

te

[15]

25

32

wee

ks

19

96

–1

99

72

06

CB

C

[16]

11

52

50

0g

19

86

–1

98

82

9V

LB

W;

74

LB

WC

BC

[17]

85

10

00

g;5

28

wee

ks

19

90

s2

75

EL

BW

/VP

Beh

avio

ur

asse

ssm

ent

syst

emfo

rch

ild

ren

[18]

20

51

50

0g

19

77

–1

97

92

42

VL

BW

Su

bst

ance

abu

sech

ecklist

,S

exu

alE

xp

erie

nce

Sca

le

[19]

11

52

00

0g

19

86

–1

98

81

30

LB

WC

BC

,P

sych

om

etri

csc

ales

of

the

Yal

ech

ild

ren

’s

inve

nto

ry,

child

ren

asse

ssm

ent

sch

edu

le

[20]

2–8

Fir

st-b

orn

sin

gle

ton

so

fG

erm

an

spea

kin

gp

aren

tsw

ith

no

seve

rep

hys

ical

dis

abilit

ies

19

86

–1

98

87

9L

BW

;4

0V

LB

WM

ann

hei

mp

aren

tin

terv

iew

[21]

8–1

0U

SA

:5

20

00

g;

Can

ada:

51

00

0g;

Ger

man

y:5

15

00

go

r5

32

wee

ks;

Net

her

lan

ds:

51

50

0g

or5

32

wee

ks

US

A:

19

84

–1

98

7;

Can

ada:

19

77

–1

98

2;

Ger

man

y:1

98

5–1

98

6;

Net

her

lan

ds:

19

83

US

A:

80

EL

BW

;

Can

ada:

15

0E

LB

W;

Ger

man

y:7

8E

LB

W;

Net

her

lan

ds:

10

0E

LB

W

CB

C

[22]

4–1

51

99

7H

ealt

hsu

rvey

for

En

gla

nd

19

82

–1

99

34

20

LB

W;

40

VL

BW

SD

Q

[23]

Mid

dle

sch

oo

lag

e5

150

0g

19

82

–1

98

66

0E

LB

W;

55

VL

BW

CB

C;

Tea

cher

Rep

ort

Fo

rm;

Hyp

erac

tivi

tyin

dex

;

Ch

ild

ren

’sD

epre

ssio

nIn

ven

tory

;

So

cial

Skills

Rat

ing

Sca

le

Very low birth weight infants – literature review 851

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Table II. Summary outcomes of included studies.

Study Outcome

Behaviour Assessment Scale for Children p-value*

[4] Teacher

Adaptive functioning 0.191

Total behaviour problems 0.003

Externalising problems 0.010

Internalising problems 0.465

Parent

Adaptive functioning 0.029

Total behaviour problems 0.024



[5] MLBW children were significantly more likely than

NBW children to have ADD/ADHD; once one

controlled for sociodemographic, they were no

longer more likely to have other emotional/

behavioural problems

[7] High behavioural problem scores as reported by

parents and concurrently recorded low self-

reported behavioural problems by VLBW

adolescents

[8] 5750 g increasing adolescent – perceived conflict

was associated with significant increases in total

behaviour problems and externalising problems

CBC p-value{

[2] Withdrawn 50.001

Somatic complaints 50.001

Anxious/depressed 0.062

Social problems 50.001

Thought problems 50.001

Attention problems 50.001

Delinquent problems 50.01

Aggressive problems 50.001

Sex problems 50.111

Total problems 50.001



Child Health Questionnaire

[9] VLBW and SGA adolescents did not report more

emotional or behavioural problems nor did they

differ on self-esteem or family functioning. VLBW

parents reported lower general health and

behaviour scores (p5 0.001)

ELBW adolescents had more behavioural

problems

Symptom Checklist -90-R: VLBW and SGA

mothers did not report more psychological

symptoms. Fathers had a tendency of more phobic

anxiety but not after exclusion of adolescents

with low IQ

VLBW Controls

[10] Psychiatric symptoms 26 (46%) 11 (13%)

Psychiatric disorder 14 (25%) 6 (7%)

Anxiety disorder 8 (14%) 3 (4%)

Attention problems 14 (25%)

ADHD 4 (7%)

ASEBA

(continued)


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Table II. (Continued).

Study Outcome

VLBW adolescents themselves did not report more

psychiatric symptoms than controls. In contrast,

both teachers and parents reported higher scores

for VLBW adolescents on anxious/depressed,

social problems and attention problems. Both

parents also stated more delinquent behaviour

while teachers did not

SDQ

Both parents and teachers reported higher scores on

the hyperactivity scale as did the parents on the

emotional symptom scale and mothers on the

conduct problems scale

[11] VLBW status was a significant predictor of parent

reported internalising symptoms, but only among

subjects who were white and had mothers with

high levels of psychological distress. Additional

significant predictors of internalising symptoms

included child I.Q., internalising symptoms

assessed at 8 years and family expressiveness

[12] Emotional Instability – Cases 70(42.9%); Controls

30(32.7%) – not statistically significant

[13] VLBW men reported significantly less delinquent

behaviour than their NBW peers, but the groups

did not differ in terms of problem behaviours or in

the overall internalising, externalising, or total

behaviour problems reported

Parents of VLBW men reported significantly more

thought problems and withdrawn behaviour for

their sons

VLBW women reported significantly more

withdrawn behaviours and less delinquent

behaviour than their NBW peers

Rates of internalising behaviours were also higher

They also reported fewer friends and poorer family

relationships

Parents of VLBW women reported significantly

higher scores on the anxious/depressed,

withdrawn and attention problem subscales

Behaviour disturbances SGA (Twin) AGA (Twin)

[14] Normal 18/34 29/34 (p5 0.01)

Mild disturbances 9 2

Moderate disturbances 5 1

Severe disturbances 2 2

Study population

(mean score, (SD) {p50.05

General population

(mean score, SD)

[15] Anxious/depressed 3.1 (2.5) 3.8 (2.8){

Withdrawn 3.1 (2.9) 3.3 (2.8)

Sleep problems 2.5 (2.9) 2.1 (2.5)

Somatic problems 2.7 (3.0) 0.3 (0.7){

Aggressive 7.7 (5.5) 9.1 (4.9){

Destructive 3.7 (3.3) 3.9 (2.6)

Total problem score 29.5 (19.8) 32.8 (16.5){

[16] CBCL: On all scales other than the aggressive

behaviour scale, LBW children had more

problems. Univariate ANCOVAs and single

comparisons revealed that these differences

reached significance on the attention problems

scale (p¼ 0.007) and the social problems scale

(p¼0.013)

(continued)


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Table II. (Continued).

Study Outcome

p-value{

[17] BASC – Parent Scale



Behavioural Symptoms Index 0.02

Adaptive skills 0.006

BASC – Teacher Scale



Behavioural Symptoms Index 0.001

Adaptive skills 50.001

[18] VLBW group reported significantly lower rates of

alcohol and marijuana

Fewer VLBW men than male controls had ever had

contact with the police

Fewer VLBW women than female controls reported

ever having intercourse, being pregnant or

delivering a live born infant

Child psychiatric problems p-valuex

[19] Depression 0.52

Separation anxiety 0.66

Phobia 0.87

Enuresis 0.52

ADHD 0.04

Total number of diagnoses 0.047

40% of LBW children compared to 7% of controls

were classified as having behavioural problems

[20] At 8 years VLBW children of non-responsive

mothers exhibited the highest internalising scores.

In addition, at 8 years a near significant

(p¼ 0.058) effect of birth weight group on hyper

kinetic problems was found

[21] Similar types of behavioural problems identified in

all four countries, despite cultural differences in

mean scores

Birth weight (kg) N OR (95% CI)

[22] Relationship between total difficulties score and birth weight

44 701

3.5, 3.99 1858 1.1 (0.8, 1.6)

3.0, 3.49 2422 1.4 (1.0, 2.2)

2.5, 2.99 1113 1.4 (1.0, 2.1)

2.0, 2.49 333 1.9 (1.2, 3.1)

1.5, 1.99 87 2.2 (1.1, 4.6)

51.5 40 3.0 (1.2, 7.8)

In girls, birth weight predicted high scores on the

peer relationship scale (OR 1.24, 95% CI 0.99,

1.53) and in boys birth weight predicted high

scores on the hyperactivity (OR 1.25, 95%

CI 1.05, 1.51) and total difficulties

(OR 1.31, 95% CI 1.06, 1.63)

[23] 5750 g – higher parent ratings of behaviour

problems, than did both other groups on nearly

all measures

Higher sociodemographic risk was associated with

less positive change over time

*Comparing ELBW/very preterm children impaired and not impaired on Movement Assessment Battery for children.{Comparing very preterm or VLBW children with children from the Dutch general population.{Comparing behavioural outcome at 8 years of the ELBW or very preterm to NBW cohort.xComparing infants 52000 g and 43000 g.


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perhaps follow up of VLBW infants to detect

behavioural and/or emotional problems should con-

tinue up to 5 years and beyond as assessments at a

younger age may fail to detect future problems.

Limitations

Some cohorts were delivered in the 1970s and early

1980s therefore may not be comparable to infants

being treated in the current medical era. However,

these temporal differences may not significantly

influence results as Achenbach and Howell [25]

assessed differences between two normative samples

of 1976 and 1989 and concluded that, unlike the

case for cognitive outcome, in which temporal trends

in score have been described, secular changes were

small for behaviour. Our review may also be limited

by heterogeneity among studies with regard to the

method of assessment and age at the time of

assessment. Only two studies included child psy-

chiatrist review [14,19]. While validated question-

naires are good screening tools for many diagnoses

such as ADD, standardised assessments remain the

golden standard. Questionnaires may also introduce

selective bias as those likely to return completed

forms are often those parents with children still

within the medical system or of higher social class.

There is heterogeneity also regarding the selection of

control groups. Some studies used population

studies as controls [2]; in doing so they may have

inadvertently included infants of LBW or early

gestation as controls. Four of the studies

[16,19,20,23] exclude infants with severe physical

disability perhaps attenuating the incidence of

behavioural conditions.

Conclusion

VLBW or very preterm infants are at significant risks

of behavioural and emotional problems. This risk is

further increased when cognitive or motor difficulties

are present or when social circumstances are poor.

Under-recognition and inadequate treatment of

these may hamper both interventional input as well

as quality of life for the child and the family involved.

Declaration of interest: The authors report no

conflicts of interest. The authors alone are respon-

sible for the content and writing of the paper.

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Behavioural and emotional outcome of very low birth weight infants – literature review

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Transcript of Behavioural and emotional outcome of very low birth weight infants – literature review