Early Intervention Improves Behavioral Outcomes for
Preterm Infants: Randomized Controlled Trial
WHAT’S KNOWN ON THIS SUBJECT: Prematurely born children have an increased prevalence of behavioral problems in the long term. Knowledge regarding the effects of early intervention programs is sparse, and more randomized controlled trials are warranted.
WHAT THIS STUDY ADDS: A modified version of the Mother-Infant Transaction Program showed beneficial effects on behavioral outcomes reported by both parents of preterm infants with birth weights of,2000 g at a corrected age of 5 years.
abstract
OBJECTIVES:The aim of this study was to examine the effectiveness of an early intervention program on behavioral outcomes at corrected age of 5 years for children with birth weights (BWs) of,2000 g.
METHODS:A randomized controlled trial of a modified version of the Mother-Infant Transaction Program was performed. Outcomes were measured by the Child Behavior Check List report (parents) and Strengths and Difficulties Questionnaire at 5 years (parents and preschool teachers).
RESULTS:A total of 146 infants were assigned randomly (intervention group: 72 infants; reference group: 74 infants). A term group was re-cruited (75 infants). The mean BWs were 13966429 g for the inter-vention group, 13816436 g for the control group, and 36196490 g for the term reference group. Parents in the intervention group reported significantly fewer behavioral problems measured by both instruments at 5 years. There were no differences in behavior problems reported by preschool teachers. Significantly more children in the preterm control group scored within the clinical area of both instruments.
CONCLUSION:This modified version of the Mother-Infant Transaction Program led to fewer behavioral problems reported by parents at corrected age of 5 years for children with BWs of,2000 g.Pediatrics 2012;129:e9–e16
AUTHORS:S. Marianne Nordhov, MD, PhD,a,b
John A. Rønning, PhD,a,bStein Erik Ulvund, PhD,b,c
Lauritz B. Dahl, MD, PhD,a,band Per Ivar Kaaresen, MD, PhD,a,b
aDepartment of Pediatrics, University Hospital of North Norway Trust, Tromsø, Norway;bInstitute of Clinical Medicine, University of Tromsø, Tromsø, Norway; andcDepartment of Educational Research, University of Oslo, Oslo, Norway
KEY WORDS
preterm infants, early intervention, behavior, randomized controlled trial, Mother-Infant Transaction Program
ABBREVIATIONS
BW—birth weight
CBCL—Child Behavior Check List CI—confidence interval EI—early intervention ES—effect size GA—gestational age LBW—low birth weight
MITP—Mother-Infant Transaction Program
NIDCAP—Newborn Individualized Developmental Care and Assessment Program
OR—odds ratio PC—preterm control PI—preterm intervention
SDQ—Strengths and Difficulties Questionnaire TR—term reference
Dr Nordhov analyzed and interpreted the data, drafted the article, and critically revised it for intellectual content; Dr Rønning substantially contributed to conception, design, and implementation of the study and critically revised the article for interpretation of the data and intellectual content; Dr Ulvund substantially contributed to conception and design of the study and critically revised the article for intellectual content; Dr Dahl substantially contributed to the design and implementation of the study and critically revised the article for the intellectual content; and Dr Kaaresen substantially contributed to the design and performance of the study and critically revised the statistical analyses and the article for intellectual content.
This trial has been registered at www.clinicaltrials.gov (identifier NCT00222456).
www.pediatrics.org/cgi/doi/10.1542/peds.2011-0248
doi:10.1542/peds.2011-0248
Accepted for publication Sep 15, 2011
Address correspondence to Dr Nordhov, Department of Pediatrics, University Hospital of North Norway, N-9038 Tromsø, Norway. E-mail: [email protected] and solveig. [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE:The authors have indicated they have nofinancial relationships relevant to this article to disclose.
incidence of behavior and emotional problems1,2and psychiatric disorders,3 which persist into adolescence and young adulthood.4,5 It is well docu-mented that preterm born children have an increased prevalence of attention problems,1,2but results on the preva-lence of internalizing (eg, withdrawn, anxious/depressed behavior) and exter-nalizing (eg, aggressive and delinquent behavior) problems are less consis-tent.1,2 However, shyness, conduct disorders, unassertiveness, withdrawn behavior, and social skills deficits occur more frequently in LBW children com-pared with normal birth weight (BW) children.3,5,6Among different etiological factors there is increasing evidence that parenting is important and that behav-ior problems in children, at least partly, are mediated by the mother-child re-lationship and the family environment.7 Crucial factors in infant development are parental responsiveness and their ability to respond contingently to their child’s behavior and initiatives.8,9 How-ever, as preterm infants are described to be more fussy, give less eye contact, are easily overaroused, and have less capacity for social interaction,10,11 re-sponsive parenting is often more diffi -cult and challenging. The combination of insecure parenting and a vulnerable preterm infant may forestall a down-ward spiral of negative transactions and thereby contribute to the devel-opment of child behavior problems in the long term.12,13
In an attempt to improve capabilities in LBW infants, early intervention (EI) pro-grams have been developed to improve the parent-infant interaction,14–16 re-duce parenting stress,17and emphasize self-regulation in the infant.18 A review showed that programs focusing on parent-infant interaction are more effec-tive than EI focused only on infant stim-ulation or parent support.19 However,
study by Achenbach et al,21 which revealed that children had significantly fewer behavior problems at 9 years after their mothers had received the Mother-Infant Transaction Program (MITP).21 The theoretical framework for the MITP is the transactional model of development where infant develop-ment is seen as a product of mutual transactions between the child and the environment involving complex feedback systems and with equal em-phasis put on both parts.22
Project “Early Intervention 2000” was designed to test the efficacy of a modi-fied version of the MITP on long-term infant development. We hypothesized that this sensitizing EI program would promote better parenting and thereby optimize long-term child cognitive and behavioral development. We found no significant effects on behavioral out-comes at corrected age of 2 years, but children in the intervention group scored consistently lower on all symp-tom scales compared with controls.23 The main purpose of this report is to evaluate the effects of the MITP on be-havioral and emotional outcomes re-ported by both parents and preschool teachers at corrected age of 5 years.
METHODS
Study Groups and Randomization
Detailed descriptions of participant characteristics, the randomization pro-cess, and the intervention program have been published previously.23,24In sum-mary, preterm infants with BW,2000 g born at the University Hospital of North Norway between March 1999 and Sep-tember 2002, with no major neurologic impairments and whose mothers first language was Norwegian were eligible for this study. Within gestational age (GA) strata of ,28 and $28 weeks, infants were randomly assigned to a preterm intervention (PI) or a preterm
allocated to the same group, and trip-lets were excluded. A group of term infants (GA of $37 weeks and BW
.2800 g) were recruited to a term reference (TR) group. This group was recruited by using the hospital’s birth registry; the parents of thefirst term in-fant born after a preterm inin-fant allocated to the PI group were asked to participate. If they declined, parents of the next born infant were approached and so on. The study was approved by the regional committee for medical ethics and the Norwegian Data Inspectorate.
Intervention
The home visits addressed topics such as adjustment to the home environ-ment, parent-infant interaction through play, discussion of self-regulation, and temper. To maintain the consistency of the intervention, a detailed logbook of every intervention session was regu-larly reviewed and supervised by the by the coordinating nurse and a clinical child psychologist. The participants in the PI group did not have access to the intervention nurses outside the sched-uled intervention dates. The PC group followed the department’s standard protocol for discharge of preterm in-fants (discharge consultation for the infant and their parent with a medical doctor, offer of training in infant mas-sage by a physiotherapist, and visual/ hearing screening), and the TR group was examined routinely on the third day of life only. For the purpose of the study, all participants received the same med-ical, developmental, and psycho-social assessments (corrected ages of 6, 12, 24, 36, and 60 months) with referrals to other services if needed. All assessors were blinded to the children’s group allocation.
Baseline Data
Perinatal variables were collected from medical records. GA was based on ul-trasound examination at 16 to 18 weeks of gestation. The Score of Neonatal Acute Physiology25and the Clinical Risk Index for Babies26were calculated as a measure of the severity of initial illness. Small for GA was defined as BW more than 2 SD below mean for GA. Norwegian BW data were used.27 Intraventricular hemorrhage was graded according to Papile28 and periventricular leukoma-lacia was defined by the presence of echolucencies by cerebral ultrasound. Transient fluid attenuated inversion recovery29 as a sign of white-matter injury was not evaluated. Social vari-ables used in the analyses were col-lected from parents at discharge in a separate questionnaire.
Main Outcomes
The main outcomes for this study were differences in behavioral problems re-ported by parents and preschool teach-ers at corrected age of 5 years.
Outcome Measures
Behavioral outcomes were assessed by the Norwegian translation of the Child Behavior Check List (CBCL)/4-18 (parents)30 and the extended version of the Strengths and Difficulties Ques-tionnaire (SDQ; parents and preschool teachers).31The 2 questionnaires have been described to be equally useful for detecting children in need for psycho-logical support32; however, the SDQ care-taker report is more specific and the CBCL more sensitive in detecting be-havioral problems.33The problem items of the CBCL are scored on a Likert scale from 0 to 2 and yield 9 narrow-banded syndrome scales: withdrawn, somatic complaints, anxious/depressed, delin-quent and aggressive behavior, social, thought, attention, and sex problems. The syndrome scales withdrawn, somatic complaints, and anxious/depressed yields the internalizing broadband syn-drome, whereas aggressive and delin-quent yields the externalizing broadband syndrome. Higher score indicates more problems. Cutoff for borderline and clin-ical ranges on the main scales was scores$82nd and $90th percentiles, and on the subscales$95th and$98th, respectively.30
The extended SDQ consists of a 25-item informant rated questionnaire and an impact supplement. The 25 items generate 5 subscales: emotional symptoms, con-duct problems, hyperactivity-inattention, peer problems, and prosocial behav-ior; all but the last one is summed to a total difficulties score.31Scores$90th percentile were considered to be in the clinical range.34Thefirst question (per-ceived difficulties) of the impact sup-plement asks if the respondent thinks the child has a problem in 1 or more of
the following areas: emotions, concen-tration, behavior, or being able to get along with others. Perceived difficulties were dichotomized into low (0–1) and high (2–3).31The scores in the TR group were used to derive cutoffs for both the CBCL and SDQ.
Power Calculations
The study size was originally calculated to detect a difference in Bayley Scales of Infant Development II, Mental Develop-mental Index at corrected age of 2 years of ∼0.5 SD (a = .05; b = .80). This analysis indicated that 63 infants were needed in each preterm group. To allow for withdrawals, the target size was 70 infants in each group.
Statistical Analyses
Differences in continuous variables be-tween the preterm groups were tested by using linear mixed models, which make it possible to account for the potential clustering effects by including twin pairs when family is included as a random effect. Differences in contin-uous variables are given as mean dif-ferences with 95% confidence intervals (CIs). Binary outcomes were analyzed through logistic regression, with robust SEs and differences given as odds ratios (ORs) with 95% CIs. Cohen’sdwas used as an estimate of effect sizes (ESs) and is the ratio between the mean differ-ence and the pooled SDs for the sam-ple. An ES of 0.20 was considered small; 0.50, moderate; and 0.80, large.35 P values of,.05 were considered sig-nificant. All tests were 2-sided. All results are reported on the basis of intention to treat. Stata 10 (Stata Corp, College Station, TX) was used for the analyses.
RESULTS
A total of 203 infants with BWs of,2000 g were born during the study period. One hundred sixty-eight infants fulfilled the inclusion criteria, and 146 infants
line characteristics were similar in the preterm groups except a slight differ-ence in maternal education (Table 1). In the TR group, 75 infants were recruited. At corrected age of 5 years, 133 (91%) children were assessed. Parents not in-cluded in the analyses due to incomplete questionnaires had shorter education and lower income compared with those completing the questionnaires (data not shown), but there were no differences in GA and BW. All mothers in the PI group participated in every intervention
terquartile range: 4–9 sessions).
OUTCOMES
CBCL scores reported by mothers at 5 years are presented in Table 2. The results remained essentially unchanged after adjusting for maternal education and other potential confounders such as GA, BW, number of siblings, and maternal age. The ESs were small to moderate, and the largest ES of 0.56 was found on the subscale attention. Thirty (48%) of
problems compared with 19 (29%) in the PI group (OR: 0.44 [95% CI: 0.21–0.92];P= .03). On the subscale attention, children in the PI group were less likely to have scores$95th percentile (cutoff 5.0) (OR: 0.25 [95% CI: 0.08–0.81];P= .02). Fathers in the PI group reported significant lower scores on attention and aggres-sive behaviors (Table 3).
SDQ scores reported by both parents are presented in Table 4. There were significant differences in favor of the PI group on total problems, and the sub-scale hyperactivity reported by both parents. Additionally, fathers in the PI group reported significantly fewer con-duct problems compared with controls. Mothers of 20 (34%) children in the PC group scored$90th percentile (cutoff 10.0) on total problems compared with 14 (21%) of the mothers in the PI group (OR: 0.50 [95% CI: 0.22–1.12];P = .09). Significantly fewer mothers in the PI group reported SDQ scores within the clinical range (cutoff 5.0) on the hyper-activity subscale (OR: 0.39 [95% CI: 0.18– 0.85];P= .02) compared with controls. There were no significant differences between the 2 preterm groups in be-havior problems reported by preschool teachers (Table 5). Ten (17%) mothers in the PC group reported high perceived difficulties scores compared with 4 (6%) in the PI group (OR: 0.32 [95% CI: 0.09– 1.07];P= .06). Similarly, 6 (12%) fathers in the PC group compared with 1 (2%) in the PI group reported high perceived difficulties (OR: 0.13 [95% CI: 0.15–1.12]; P= .06). Preschool teachers reported high perceived difficulties scores in 12 (22%) children in the PC group com-pared with 10 (17%) in the PI group (OR: 0.73 [95% CI: 0.28–1.9];P= .51).
DISCUSSION
In this study, we documented that par-ents who received this modified version of the MITP reported significantly
fewer behavior problems at 5 years compared with parents in the PC group and there was reported lower perceived difficulties in the PI group. This might
be important as both a high per-ceived difficulty score and CBCL scores predict the risk of later psychiatric illness.31,36
To our knowledge, the only interven-tion study that has shown beneficial effects on parent-reported behavioral outcomes in the long term (9 years) is the Vermont study.37The authors sug-gested that the intervention facilitated infant development indirectly through more favorable mother–infant trans-action patterns, the“sleeper effect” (when transactions cause change over time)38 or both.21 However, there are several limitations of this study such as few rather mature infants born in the presurfactant era and before antenatal steroids were widely used. Among other studies, Westrup et al39found a positive impact on behavior 5.5 years after Newborn Individualized Developmental Care and Assessment Program (NID-CAP) care, and Newnham et al40found higher scores in the“communication” dimension of Ages and Stages41after a modified version of the MITP. In a study by Spittle et al,16parents reported less externalizing and dysregulation behav-ior at 2 years corrected age after receiving an educating intervention program (Victorian Infant Brain Studies Plus). Other studies have revealed ben-eficial effects of EI in the preschool age,19,42but at 5 years the effects were not sustained.43,44The investigators have suggested that the programs might have been more effective if they were intro-duced before discharge43or targeted heavier LBW infants.45
The main goals of EI programs are to enhance parent-infant interactions and thus stimulate the wiring process of the neurons in the immature brain in a beneficial way.46 Thefirst study to doc-ument that interventions could alter brain structure and function was repor-ted by Als et al.47They followed up 30 low-risk preterm infants who received NIDCAP and found better neurobehavioral scores, more mature white matter at corrected age of 2 weeks, and behav-ioral advantages at the corrected age of 9 months.47Milgrom et al48demonstrated
TABLE 1 Perinatal and Social Data
PI Group, N= 72
PC Group, N= 74
TR Group, N= 75
Infant characteristics
BW, mean6SD, g 13966429 13816436 36196490 400–1000 g,n(%) 20 (28) 20 (27)
1001–1500 g,n(%) 15 (21) 20 (27) 1501–2000 g,n(%) 37 (51) 34 (46)
GA, mean6SD, wk 30.263.1 29.963.5 39.361.3 ,28 wk,n(%) 17 (24) 19 (27)
28–32 wk,n(%) 36 (50) 37 (50) $33 wk,n(%) 19 (26) 18 (24)
Boy,n(%) 38 (53) 39 (53) 40 (54)
Twin,n(%) 16 (22) 14 (19) 0
Prenatal steroid use,n(%) 53 (74) 57 (77) SNAP II, mean6SD 8.3610.9 10.4611.3 CRIB score, mean6SD,N= 85 3.262.8 2.762.9 Received ventilation,n(%) 29 (40) 37 (50) Duration of ventilation, mean6SD, d,N= 62 7.0618.6 7.1617.3 Postnatal steroid use,n(%) 9 (13) 10 (14) Oxygen therapy at 36 wk of gestation,n(%) 11 (15) 14 (19) Abnormal cerebral ultrasound,n(%)
IVH grade 1 or 2 7 (10) 8 (11) IVH grade 3 or 4 3 (4) 5 (7) Periventricular leukomalacia 4 (6) 8 (11) Maternal and social characteristics
Mother’s age, mean6SD, y 30.866.1 29.166.4 29.766.1 Firstborn child,n(%) 40 (56) 37 (54) 27 (37) Mother’s education, mean6SD, y,N= 131a,b 14.662.8 13.563.2 14.962.8
Father’s education, mean6SD, y,N= 131a 13.863.1 13.563.2 14.463.2
Mother’s monthly income, mean6SD, 1000 Norwegian kroner,N= 131a
15.867.7 14.666.7 15.968.0
Father’s monthly income, mean6SD, 1000 Norwegian kroner,N= 131a
21.168.7 19.968.1 21.969.8
CRIB, Clinical Risk Index for Babies (includes BW, GA, congenital malformations, maximum base deficit in thefirst 12 hours, minimal appropriate fraction of inspired oxygen in thefirst 12 hours, and maximal appropriate fraction of inspired oxygen in thefirst 12 hours); IVH, intraventricular hemorrhage; SNAP II, Score of Neonatal Acute Physiology II (includes mean blood pressure, lowest temperature, PO2/fraction of inspired oxygen ratio, serum pH, multiple seizures, and urine output). aCalculated for 131 families due to 15 twin pairs.
bMean difference: 1.1 years (95% CI: 0.03–2.2 years);P= .04.
TABLE 2 Behavioral Outcomes (CBCL) Reported by Mothers at Corrected Age of 5 Years
PI Group,
N= 65
PC Group,
N= 62
Adjusted Difference, Mean (95% CI)a
Pa d TR Group,
N= 65
Total, mean (SD) 16.7 (12.0) 22.8 (17) 26.1 (211.3 to20.8) .02 0.42 13.5 (8.9) Internalizing 3.6 (3.5) 4.6 (4.4) 21.1 (22.6 to 0.3) .1 0.28 2.8 (3.2) Externalizing 5.8 (5.0) 8.0 (6.7) 22.0 (24.1 to 0.1) .06 0.34 5.1 (3.8) Withdrawn 0.9 (1.0) 1.5 (1.7) 20.6 (21.2 to20.02) .04 0.45 0.8 (1.0) Social 1.1 (1.5) 1.8 (2.2) 20.7 (21.4 to20.2) .04 0.38 0.7 (1.2) Thought 0.2 (0.6) 0.6 (1.4) 20.5 (20.9 to20.08) .02 0.50 0.08 (0.3) Attention 1.7 (2.0) 3.2 (3.4) 21.5 (22.5 to20.5) .003 0.56 1.3 (1.5) Aggressive 4.8 (4.1) 6.8 (6) 21.8 (23.6 to20.02) .05 0.36 4.2 (3.4) Somatic 1.0 (1.5) 1.0 (1.4) 20.2 (20.8 to 0.3) .4 0.14 1.0 (1.5) Anxious/depressed 1.7 (2.0) 2.0 (2.2) 20.3 (21.0 to 0.4) .4 0.11 1.1 (1.8) Delinquent 1 (1.2) 1.2 (1.3) 20.2 (20.7 to 0.2) .4 0.16 0.9 (1.0) Sexual problems 0.2 (0.6) 0.3 (0.7) 20.02 (20.3 to 0.3) .8 0.03 0.2 (0.5)
aAdjusted for clustering effect of twin pairs.
that preterm infants in an intervention group had better maturation and con-nectivity of the white matter at 40 weeks postmenstrual age compared with controls after the parents had re-ceived a modified version of the MITP. Such changes in the white matter have been shown to predict more favorable neurodevelopmental
outcomes in the long term.49 One suggested cause of white matter in-jury is alterations of the hypothalamic-pituitary-adrenal axis50due to chronic stress.51As both NIDCAP and the MITP aim to reduce chronic stress and opti-mize the interaction between the care-giver and the preterm infant, this may at least partly explain the beneficial
We speculate that the MITP sensitize parents to the infants cues, which leads to more adjusted and dynamic parent-infant interactions, and thereby en-hanced infant development according to the transactional model of develop-ment.22 Furthermore, we suggest that the increasing intervention effect over time might be consequence of the“the Matthew effect,”52 in which small dif-ferences in early development amplify through positive feedback mechanisms into larger differences across time.
We found no differences between the preterm groups in behavioral problems reported by preschool teachers. Reports from different informants are important and may contribute to get a better pic-ture of behavior problems in children.31 However, a meta-analysis33revealed that the correlations between different infor-mants are low due to the fact that chil-dren behave differently in different situations, the informants perceive behavior differently, or the informant is influenced by the relationship with the child. Another possible explanation of our findings is parental bias due to lack of blinding for the intervention. Further-more, our results are in line with a study with similar aims and methods where child behavior was evaluated with a neuropsychological test battery.39
Few EI studies have actively involved fathers, and to our knowledge this is thefirst study to report father-reported behavioral outcomes in preterm children. Unfortunately, an attrition of fathers in the intervention group may have infl u-enced the results. An interestingfinding, however, was that fathers scored their children consistently lower in all sub-groups regardless of group affiliation. This may illustrate that fathers perceive behavior based on a cultural or societal context and not prematurity per se.
Major strengths of this study are that it is a population-based randomized
N= 59 N= 49 Mean (95% CI)a N= 57
Total, mean (SD) 13.0 (9.0) 17.6 (16.3) 24.7 (29.6 to 0.3) .07 0.38 10.7 (10.6) Internalizing 2.8 (2.6) 3.0 (3.2) 20.3 (21.4 to 0.8) .6 0.10 2 (3.0) Externalizing 4.4 (3.5) 6.4 (7.3) 21.9 (24.0 to 0.2) .08 0.36 4.0 (4.2) Withdrawn 0.8 (1.0) 1.2 (1.5) 20.3 (20.8 to 0.2) .2 0.24 0.5 (1.0) Social 1.2 (1.4) 1.6 (2.2) 20.4 (21.1 to 0.3) .3 0.23 0.6 (1.5) Thought 0.1 (0.5) 0.4 (0.8) 20.3 (20.5 to 0) .06 0.47 0.1 (0.2) Attention 1.7 (2.2) 3.0 (3.3) 21.2 (22.2 to20.1) .04 0.44 1.4 (2.0) Aggressive 3.5 (0.6) 5.3 (0.7) 21.7 (23.4 to20.04) .04 0.64 3.3 (3.6) Somatic 0.7 (1.1) 0.7 (1.3) 0.001 (20.5 to 0.5) .9 0.01 0.7 (1.3) Anxious/depressed 1.3 (1.4) 1.2 (1.7) 20.03 (20.6 to 0.6) .9 0.02 0.9 (1.5) Delinquent 0.8 (1.1) 1.1 (1.9) 20.2 (20.7 to 0.4) .6 0.14 0.8 (1.0) Sexual problems 0.2 (0.6) 0.3 (0.7) 20.16 (20.4 to 0.1) .2 0.26 0.1 (0.6)
aAdjusted for clustering effect of twin pairs.
TABLE 4 Behavioral Outcomes (SDQ) Reported by Mothers and Fathers at Corrected Age of 5 Years
PI Group PC Group Adjusted Difference, Mean (95% CI)a
Pa d TR Group
Mothers N= 67 N= 59 N =64
Total, mean (SD) 6.7 (5.3) 9.0 (5.5) 2.1 (0.1 to 4.1) .04 0.43 4.9 (3.3) Emotion 1.8 (3.1) 2.0 (1.9) 0.2 (20.7 to 1.2) .6 0.08 1.0 (1.4) Conduct 1.1 (1.5) 1.5 (1.1) 0.3 (20.2 to 0.8) .2 0.30 0.7 (0.9) Hyperactivity 2.8 (2.2) 4.1 (2.8) 1.3 (0.4 to 2.1) .01 0.52 2.5 (1.9) Peer 1.0 (1.6) 1.5 (1.8) 0.5 (20.1 to 1.1) .1 0.30 0.6 (1.0) Prosocial 7.9 (2.1) 7.6 (2.1) 0.1 (20.9 to 0.7) .8 0.14 8.2 (1.4)
Fathers N= 60 N= 51 N= 59
Total, mean (SD) 6.1 (3.6) 8.0 (5.1) 1.6 (20.03 to 3.3) .05 0.44 4.9 (3.7) Emotion 1.5 (1.4) 1.6 (1.6) 0.1 (20.5 to 0.7) .7 0.07 0.7 (1.1) Conduct 0.8 (0.9) 1.4 (1.5) 0.5 (0.0 to 0.9) .04 0.52 0.8 (0.8) Hyperactivity 2.7 (2.0) 3.8 (2.4) 0.9 (0.1 to1.8) .03 0.51 2.4 (1.8) Peer 1.2 (1.4) 1.4 (1.7) 0.2 (20.4 to 0.7) .6 0.13 1.0 (1.5) Prosocial 7.9 (1.7) 7.5 (2.0) 0.2 (20.9 to 0.5) .5 0.22 8.0 (1.6)
aAdjusted for clustering effect of twin pairs.
TABLE 5 Behavioral Outcomes (SDQ) Reported by Preschool Teachers at Corrected Age of 5 Years
PI Group,
N =60
PC Group,
N =56
Adjusted Difference, Mean (95% CI)a
Pa TR Group,
N= 60
Total, mean (SD) 7.0 (5.7) 7.1 (6.5) 0.7 (23.0 to 1.7) .6 4.4 (3.6) Emotion 1.6 (1.8) 1.5 (1.9) 0.3 (21 to 0.4) .4 0.8 (1.2) Conduct 1.2 (1.7) 1.1 (1.6) 0.3 (20.9 to 0.4) .4 0.6 (1.0) Hyperactivity 3.2 (2.8) 3.6 (3.1) 0.4 (20.8 to 1.5) .5 2.5 (2.6) Peer 1.1 (1.9) 1.2 (1.9) 0.2 (21 to 0.5) .5 0.6 (1.1) Prosocial 7.8 (2.2) 7.5 (2.1) 0.2 (20.6 to 1.1) .6 8.2 (1.7)
clinical trial with a high overall follow-up rate at 5 years. Additional strengths are the multi-informant approach and the use of 2 different questionnaires. One limitation is the use of BW rather than GA as the inclusion criterion, which led to the inclusion of more mature small for GA infants. However, they were evenly distributed between the groups and should not bias the group difference. Another limitation is possible parental bias due to the lack of blinding. We do not exactly know if the positive effects in the PI group were due to the EI or the inter-action with the intervention nurses per
se. To clarify this, a randomized clinical trial with a dummy-treated control group must be performed.
CONCLUSIONS
This EI demonstrated a reduction of parent-reported behavioral problems in LBW infants. The largest effects were seen in the attention and aggressive subscales, which is important as these are among the most prevalent behavior problems in preterm born children.1The increasing intervention effect during the study period underlines the
impor-tance of long-term follow-up when eval-uating the effectiveness of EI programs.
ACKNOWLEDGMENTS
This study was funded by grants from the Norwegian Research Council, The Norwegian Council for Mental Health, the Norwegian Foundation for Health and Rehabilitation, and the Northern Regional Health Authority. We thank the families and infants for participat-ing in this study. In addition, we thank the neonatal nurses who implemented the intervention program and the study coordinating nurse, Mrs J. Tunby.
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DOI: 10.1542/peds.2011-0248 originally published online December 19, 2011;
2012;129;e9
Pediatrics
Ivar Kaaresen
S. Marianne Nordhov, John A. Rønning, Stein Erik Ulvund, Lauritz B. Dahl and Per
Randomized Controlled Trial
Early Intervention Improves Behavioral Outcomes for Preterm Infants:
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DOI: 10.1542/peds.2011-0248 originally published online December 19, 2011;
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Ivar Kaaresen
S. Marianne Nordhov, John A. Rønning, Stein Erik Ulvund, Lauritz B. Dahl and Per
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