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ADHD in Children Born Premature

By Helen Harrison

About 1/3 of VLBW preemies have behavior/psychiatric problems and the most common problem is hyperactivity or attention deficit disorder (ADD or ADDH).  A lot of the behavior described as "sensory integration problems" overlaps with this diagnosis as well as with autism, and none of these diagnoses are all that clear cut in real life.  A lot of preemies have symptoms of ADDH that don't quite reach the level of diagnosability, so it is probably better to think in terms of a behavior continuum rather than in terms of something a child for sure "has" or "doesn't have" like measles or chicken pox. 

ADDH often accompanies CP and/or MR.  People who have suffered strokes or head trauma often have problems that are remarkably similar to ADDH and "sensory integration problems" -- for example they may become easily distracted, are emotionally volatile,  find it difficult to concentrate and stay on task, need a highly ordered and calm environment in order to function, overreact to sensory stimuli, and generally feel and act "scattered."  I have days like this myself.

Here are some excerpts from chapters and studies on preemie behavior.  The first is from Maureen Hack's chapter on VLBW outcomes in The Future of Children (1).

"The majority of recent studies of behavior and social competence in low birth weight children pertain to very low birth weight [<1500g ] and extremely low birth weight [<1000 g] outcomes.  Using parent and/or teacher questionnaires, these studies document an increased risk of behavioral problems especially among boys.  McCormick and Peterson found greater rates of behavioral problems with decreasing  birthweights.  Behavioral problems have mainly been described in children with cognitive deficits and neuromotor dysfunction, suggesting brain injury as a cause of these problems.  Data relating behavioral problems to socioeconomic status of the family have been inconsistent.  A causal relationship between behavioral outcomes and maternal-infant separation and family stress has been postulated but not proven."

"The types of behavioral problems reported in low birth weight children include conduct disorder, hyperactivity, and attentional weaknesses.  Using parent and teacher behavior ratings, Szatmari and colleagues diagnosed attention deficit hyperactivity disorder (ADHD) in 16% of children born with birthweights of less than 1000 grams compared with 6.9% of the children in a matched control group.  Because the groups did not differ in rates of other behavioral and emotional problems, these researchers concluded that children with birthweights of less than 1,000 grams have specific biologically based problems in attention.  A pattern of shyness, unassertiveness, and withdrawn behavior has also been described. Parent and teacher ratings of social competence have similarly revealed that low birthweight children have more difficulty in social skills than the normal birthweight children in control groups."

When brains of children with ADDH were scanned to show metabolic activity and blood flow patterns, "hypoperfused" areas (where circulation is poor) could be seen in the frontal lobe and symmetrically throughout both hemispheres of the brain.  "The finding that hypoperfused regions in ADD seem to be located symmetrically in both hemispheres in arterial border zones is consistent with an etiologic [causal] role for early hypoxic-ischemic lesions [ eg. PVL]."  Although the children in this study were not preemies, most had data "suggesting suboptimal gestational or perinatal conditions."  (2)

A study of LBW [below 2000 g] preemies at age 6 found that 22% had at least one psychiatric disorder, the most common being ADDH (16%). The risk factors for having these disorders included ventricular enlargement and/or PVL. (3)

As a consultant to an international research group looking at school age outcomes of VLBW preemies, I am aware of the data on behavior in adolescence. Although I am not able to give the specifics yet, it is consistent with what I have quoted above.  The data also indicate, unfortunately, that behavior problems in preemies may increase or worsen with age.  However, this is contrary to my own experience with my son Edward who is much less hyper as an adult than he was as a child.

There are several other studies I should probably mention but this post is already too long.  So to conclude: Varying degrees of hyper behavior and attention problems in preemies are common and are probably related to brain injury.  New follow-up data indicates that behavior problems may worsen with age. I have been told by professionals that ADDH *in preemies* is not very responsive to drugs such as ritalin, but I have also heard from some preemie parents who say that it has worked wonders for their children.  So if any of you find that your children are having these problems, don't let anyone try tell you your child is just "spoiled" or that there is something wrong with you as a parent (although ADDH may respond better to certain types of parenting styles).  If all else fails, consider medication.  Again, I would like to stress that despite the follow-up data, my own son calmed down considerably when he entered adolescence and adulthood.


1. Maureen Hack's chapter on VLBW outcomes in The Future of Children (Low Birth Weight), Spring 1995 pp.176-196.
2. Lou et al. "Focal cerebral hypoperfusion in children with dysphasia [speech problems] and/or attention deficit disorder."  Archives of Neurology. 1984; 41:825-829.
3. Whitaker et al. "Psychiatric outcomes in low-birth-weight children at age 6 years: Relation to neonatal cranial ultrasound abnormalities. Archives of General Psychiatry 1997; 54:847-856.

Helen Harrison is the well known author of The Premature Baby Book, often referred to as the "Bible of Prematurity" by older preemie parents. These observations are excerted with permission from posts to the prematurity parents support internet mailing lists on prematurity: Preemie-child and Preemie-L.

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