Effect of preterm birth on motor development, behavior, and school performance of school-age children: a systematic review

Moreira, Rafaela S.; Magalhães, Lívia C.; Alves, Claudia R.L.

doi:10.1016/j.jped.2013.05.010

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Review Article • J. Pediatr. (Rio J.) 90 (02) • Mar-Apr 2014 • https://doi.org/10.1016/j.jped.2013.05.010 copy

Effect of preterm birth on motor development, behavior, and school performance of school-age children: a systematic review^☆ ☆ Please cite this article as: Moreira RS, Magalhães LC, Alves CR. Effect of preterm birth on motor development, behavior, and school performance of school-age children: a systematic review. J Pediatr (Rio J). 2014;90:119-34. , ^{☆ ☆} ☆ ☆ Study conducted at the Post-Graduation Program in Health Sciences, Faculty of Medicine, Universidade Federal de Minas Gerais.

Authorship SCIMAGO INSTITUTIONS RANKINGS

OBJECTIVES:

to examine and synthesize the available knowledge in the literature about the effects of preterm birth on the development of school-age children.

SOURCES:

This was a systematic review of studies published in the past ten years indexed in MEDLINE/Pubmed, MEDLINE/BVS; LILACS/BVS; IBECS/BVS; Cochrane/BVS, CINAHL, Web of Science, Scopus, and PsycNET in three languages (Portuguese, Spanish, and English). Observational and experimental studies that assessed motor development and/or behavior and/or academic performance and whose target-population consisted of preterm children aged 8 to 10 years were included. Article quality was assessed by the Strengthening the reporting of observational studies in epidemiology (STROBE) and Physiotherapy Evidence Database (PEDro) scales; articles that did not achieve a score of 80% or more were excluded.

SUMMARY OF FINDINGS:

the electronic search identified 3,153 articles, of which 33 were included based on the eligibility criteria. Only four studies found no effect of prematurity on the outcomes (two articles on behavior, one on motor performance and one on academic performance). Among the outcomes of interest, behavior was the most searched (20 articles, 61%), followed by academic performance (16 articles, 48%) and motor impairment (11 articles, 33%).

CONCLUSION:

premature infants are more susceptible to motor development, behavior and academic performance impairment when compared to term infants. These types of impairments, whose effects are manifested in the long term, can be prevented through early parental guidance, monitoring by specialized professionals, and interventions.

Premature birth; Dexterity; Behavior; Learning disorders

Article	Year	Country	Type of study	Population (general characteristics)	Children's age (years)	STROBE score
Roze et al.³⁸	2009	The Netherlands	Cohort	21 children born prematurely (< 37 weeks), with periventricular hemorrhagic infarction admitted between 1995 and 2003.	4 to 12	93.18%
Svien ¹⁰	2003	USA	Cross-sectional	22 children born prematurely (30 to 35 weeks) adequate for gestational age without congenital anomalies and 22 children born at term.	7 to 10	81.81%
Purdy et al. ³⁷	2008	USA	Historical cohort	44 children born prematurely (24 to 32 weeks). Multiple births or congenital anomalies were excluded.	8	95.45%
Goyen et al. ³⁹	2011	Australia	Case-control	50 children born prematurely (< 29 weeks or birth weight < 1,000 g), with IQ > 85 without neurosensory deficiencies, and 50 children born at term.	8	88.63%
Rademaker et al. ³⁶	2007	The Netherlands	Cohort	226 children born prematurely (= 32 weeks and/or body weight = 1,500 g) born between 1991 and 1993.	7 to 10	86.36%
Schneider et al. ⁴⁶	2008	Canada	Cross-sectional	Three groups: 1) children born prematurely with mean GA of 26 weeks; 2) children born prematurely with mean GA of 31 weeks and 6 days; and 3) children born at term: born between 1992 and 1993 from a cohort. 14 children born prematurely and nine children born at term.	8	81.81%
Rademaker et al. ²	2004	The Netherlands	Cohort	204 children born prematurely (GA = 32 weeks and/or birth weight < 1,500 g) and 21 children born at term.	7 and 8	81.81%
Goyen & Lui ⁴⁰	2009	Australia	Case- control	50 very preterm (< 29 weeks GA) or very low birth weight (< 1,000 g) infants; IQ > 84 and without disabilities at 5 years, and 50 infants born at term matched for gender and age.	8	90.90%
Karemaker et al. ³⁴	2006	The Netherlands	Historical cohort	149 preterm infants (< 32 weeks) born between December of 1993 and July of 1997, and 43 control children.	7 to 10	95.45%
Sherlock et al. ³¹	2005	Australia	Regional cohort	270 very low birth weight (< 1,000 g) or very preterm (< 28 weeks GA) infants born in 1991/1992 from the VICS cohort.	8	84.09%
Kan et al.³⁰	2008	Australia	Regional cohort	179 very preterm (GA < 28 weeks) born in 1991 and 1992, with no neurosensory disabilities from the VICS cohort.	8	97.72%
Guellec et al. ²⁴	2011	France	Cohort	2,846 preterm infants between 24 and 32 weeks of gestation selected from nine regions of France in 1997, and 666 born at term from the EPIPAGE cohort.	5 and 8	88.63%
Chyi et al.³	2008	USA	Cohort	970 moderately preterm infants (32 to 33 weeks) and late preterm infants (34 to 36 weeks), and 13,671 children born at term from the Early Childhood Longitudinal Study Kindergarten	10 and 11	93.18%
D'Angio et al. ³²	2002	USA	Cohort	132 preterm infants (< 29 weeks), born between 1985-1987.	0 to 15	86.36%
Charkaluk et al. ¹	2011	France	Cohort	244 preterm infants born after 22 to 32 weeks gestation in 1997, with no disabilities or developmental impairment from the EPIPAGE cohort.	2 to 8	86.36%
van Baar et al. ²⁹	2006	The Netherlands	Cohort	34 preterm infants (< 32 weeks) and 34 children born at term.	10	81.81%
Msall et al.³³	2004	USA	Cohort	222 preterm infants with birth weight < 1,251 g and retinopathy of prematurity and no other malformations from a multicentric study (CRYO-ROP)	5, 5 and 8 respectively	90.90%
Casey et al. ⁹	2006	USA	Cohort	221 preterm infants with birth weight = 2,500 g, gestational age = 37 weeks, without severe medical impairments, and 434 controls from the IHDP program.	8	84.09%
Larroque et al. ³⁵	2011	France	Cohort	1,439 preterm infants between 22 and 32 weeks, born in 1997, and 327 infants born at term from the EPIPAGE cohort.	8	84.09%
Kirkegaard et al. ⁶	2006	Denmark	Cohort	211 preterm and 4,897 term children. GA was stratified: 33-36, 37-38, 39-40, and = 41 weeks, and GA from 39 to 40 weeks from the Aarhus Birth Cohort.	9 to 11	90.90%
Mathiasen et al. ²⁸	2010	Denmark	Cohort	All live births in 1988 and 1989: 118,891 preterm or term children. Population-based study.	0 to 15	84.09%
Linnet et al. ²⁰	2006	Denmark	Case-control	All children born between 1980 and 1994 with hyperkinetic disorder; 834 cases (preterm and low birth weight), and 20,100 controls.	2 to 18	88.63%
Gurka et al. ²⁷	2010	USA	Cohort	53 late preterm children (34 to 36 weeks) and 1,245 children born at term (37 to 41 weeks) from the SECCYD cohort.	4 to 15	81.81%
Whiteside-Mansell et al. ²⁶	2009	USA	Longitudinal	728 children < 37 weeks and low birth weight (most had < 2,000 g, but some children had between 2,001 to 2,500 g) from the IHDP program.	8	81.81%
Jeyaseelan et al. ⁵	2006	Australia	Cross-sectional	45 children with extremely low birth weight (< 1,000 g) or preterm (GA < 27 weeks).	7 to 9	84.31%
Conrad et al. ²³	2010	USA	Cross-sectional	49 children with extremely low birth weight (< 1,000 g) or very low birth weight (1,000 to 1,499 g), and 55 children born at term.	7 to 16	81.81%
Purdy et al. ⁴⁴	2013	USA	Cohort	45 preterm children with mean GA of 28 weeks.	8	81.81%
Farooqi et al. ⁴³	2007	Sweden	Cohort	86 preterm children born before 26 weeks of gestation between 1990 and 1992, and 86 controls.	10 to 12	88.63%
Gray et al.²⁵	2004	USA	Cohort	985 Preterm children (GA < 37 weeks) and birth weight < 2,500 g at birth from the IHDP program.	3.5 and 8	81.81%
Yu et al. ⁴⁵	2006	USA	Data analysis	713 preterm children with < 2,500 g and < 37 weeks GA from the IHDP program.	8	84.09%
Anderson et al. ⁴²	2003	Australia	Regional cohort	298 children with extremely low birth weight (< 1,000 g) or very preterm (< 28 weeks GA). 262 control infants with birth weight > 2,499 g.	0 to 8	93.18%
Crombie et al. ²¹	2011	England	Cross-sectional	196 preterm (< 36 weeks GA) and/or low birth weight (< 2,500 g) children were classified as "at risk", and 1,704 control infants were classified as "no risk".	9 to 10	88.63%
Lindström et al. ²²	2011	Sweden	National cohort	67,543 preterm children with GA between 23 and 36 weeks, and 1,113,163 born at term (> 37 weeks).	6 to 19	81.81%

Article	Outcomes	Tools	Results/Conclusions
Roze et al.³⁸	1) Motor 2) Cognitive 3) Behavior	1) GMFCS, MACS, and VMI 2) Touwen and WISC III 3) CBCL and BRIEF	Most preterm infants with periventricular hemorrhagic infarction had cerebral palsy with limitations in functional performance at school age. Visual-motor integration was normal in 74%, visual perception in 88%, behavior in 53%, verbal memory in 50%, and normal executive functions in 65%. Characteristics of hemorrhagic infarction were not associated with motor outcome and level of intelligence. Post-hemorrhagic ventricular dilation was considered a risk factor for a worse repertoire of manipulative skills and intelligence performance. The functional outcome at school age of these children was better than previously thought.
Svien ¹⁰	1) Motor: components of health-related fitness	1) BOTMP; Treadmill and Physical activity questionnaire.	No differences were observed between groups in total skinfold thickness measurements, flexibility, O₂consumption, or level of physical activity. There were significant differences in all BOTMP test subtests. Despite significant differences in motor performance of infants born preterm, they showed no limitations in activities or participation restrictions at school age.
Purdy et al. ³⁷	1) Behavior 2) Motor 3) Language 4) Daily and social life 5) Clinical life-threatening condition	1, 2, 3, and 4) VABS 5) CRIB	Children who received higher doses of perinatal steroids were more likely to have low scores of overall development, especially lower social skills. Higher doses of perinatal steroids resulted in a more severe condition during the first day of life based on CRIB and a smaller head size at birth, and these were related to worse behavioral outcomes.
Goyen et al. ³⁹	1) Motor 2) Sensory-motor skills	1) MABC-1 2) VMI, MVPT-R, KST, and SIPT	Significantly lower scores were found for visual processing and praxis test, except for verbal command. Preterm children with developmental coordination disorders (DCD) had greater difficulty with visual processing tasks. Motor planning represented a special challenge for these children. Motor dysfunction in extremely preterm children was related to poorer visual processing and motor planning, which may be related to cognitive processing problems.
Rademaker et al. ³⁶	1) Intelligence 2) Motor 3) Memory	1) WISC 2) VMI and MABC-1 3) 15-Word Memory Test	Children treated with hydrocortisone were younger, weighed less, and were sicker when compared to the control group. There were no differences in the occurrence of brain lesions. Neonatal treatment with hydrocortisone for bronchopulmonary dysplasia showed no long-term effects on neurodevelopment and on the motor performance of preterm infants at school age.
Schneider et al. ⁴⁶	1)Visual-motor skills (fine motor skill)	1) Visuo-manual pointing-task and Reaction time test	There were significant differences in fine motor skills between the groups of preterm infants of 26 and 31 weeks. There were no significant differences between the control group and the 31-week preterm children group. The reaction times in the visual-motor task were significantly increased in preterm infants with GA of 26 weeks. Preterm children with GA of 26 weeks showed increased interhemispheric time, suggesting alterations in callosal pathways. Programming time was significantly longer for the dominant hand and unilateral. The existence of failed programming in visual-manual tasks is suspected in preterm infants with GA < 26 weeks.
Rademaker et al. ²	1) Motor 2) Size of corpus callosum	1) MABC and VMI 2) Magnetic resonance	There is a strong association between the size of the corpus callosum (mean total sagittal cross-sectional area, as well as frontal, middle, and posterior regions) and motor function in preterm infants assessed at school age. A worse score on MABC was associated with a smaller size of the corpus callosum. A larger corpus callosum was strongly associated with better scores on the VMI. The authors demonstrated a strong association between motor performance and size of the corpus callosum, which suggests that children who have corpus callosum abnormalities may benefit from early intervention.
Goyen & Lui ⁴⁰	1) Motor	1) MABC; Peabody Motor Scales, and Griffith scale (locomotor)	"Apparently normal" children at high-risk in early childhood are also at risk for motor dysfunction in their school years. Most of these children with motor problems at school age could be identified at the age of 3 years. Developmental coordination disorder was independently associated with prolonged rupture of membranes and retinopathy of prematurity, but not with parental education or occupation.
Karemaker et al. ³⁴	1) Motor 2) Behavior 3) School performance	1) MABC 2) CBCL 3) TRF	Children treated with dexamethasone in the neonatal period had lower school performance and presented more behavioral problems than children treated with hydrocortisone. Furthermore, the motor impairment appears to be significantly higher in the group treated with dexamethasone than in the control group. Children who used hydrocortisone did not differ from untreated children, except for ball skills. The results suggest that hydrocortisone is a safe alternative for treatment.
Sherlock et al. ³¹	1) Motor 2) Cognitive 3) School performance	1) MABC-1 2) WISCIII, TOL, RCF 3) WRAT3	Neurodevelopmental dysfunction in school-age children with extremely low birth weight and/or very premature varied in relation to the severity of intraventricular hemorrhage, except for grade 4 intraventricular hemorrhage. The higher the degree of hemorrhage, the higher the motor and school impairment.
Kan et al.³⁰	1) Motor 2) School performance 3) Cognitive	1) MABC 2) WRAT3 3) WISCIII	Very premature children had lower weight and head circumference at all ages tested. Head circumference at birth was not related to outcomes at school age, but changes in head circumference at ages 2 and 8 years were associated with worse performance on most evaluated measurements, including motor performance. Intrauterine growth restriction was not related to the child's cognitive skills at age 8 years. Weight at hospital discharge had little influence on neurodevelopment, but head circumference was important in early childhood.

Article	Evaluated outcomes	Tools	Results/Conclusions
Guellec et al. ²⁴	1) Cognitive 2) Behavior 3) School performance	1) KABC 2) SDQ 3) Questionnaire sent by mail to parents.	In preterm children, birth weight was not associated with cognitive, motor, behavioral outcomes, or academic performance. Growth restrictions (small for gestational age) were associated with mortality, cognitive and behavioral outcomes, and learning impairment.
Chyi et al.³	1) School performance	1) Specific tests were created for the study and included reading and math	Moderately and late preterm infants had lower reading and math scores than control children. Moderately preterm children had twice the risk of needing special education. Due to the concerns of teachers with these children and the test results, the need for educational support was observed for moderately and late preterm children (32-36 weeks gestation) through monitoring, guidance, and school interventions.
D'Angio et al. ³²	1) School performance 2) Cognitive	1) Teacher questionnaire 2) MCSA, CALVT-2, PPVT-R, VMI, and VABS	Intraventricular hemorrhage in the neonatal period and low socioeconomic status were the strongest predictors of adverse outcomes related to school and cognitive performance. Preterm infants in the surfactant era remain at high risk for neurodevelopmental impairment. Although most of these children are well, a significant minority will need special education services until high-school age.
Charkaluk et al. ¹	1) Mental health 2) Quotient of development 3) Schooling 4) Cognitive	1) MPC 2) Brunet-Lezine scale 3) Questionnaire sent by mail to parents. 4) KABC	Schooling was considered adequate if the child was attending a level of education in age-appropriate regular grade, without the need for any additional academic support. Schooling was considered appropriate for 70% of preterm infants assessed. Using only the development quotient level showed not to be the best alternative for predicting adequate schooling at eight years. Other factors should be considered, such as maternal education, gestational age, and head circumference at the age of 2. These factors can be used to individualize the follow-up of these children.
van Baar et al. ²⁹	1) Cognitive 2) School performance 3) Behavior 4) Social-emotional	1) WISC III and MND 2) TRF 3) CBCL 4) Interview with psychologist and SES	The preterm and children born at term differed in all developmental domains (cognitive, academic, behavior, and social-emotional), always to the disadvantage of the preterm group. The subgroup of preterm children without school problems was characterized by less severe neonatal difficulties, better capacity to feed, faster and early growth of the head circumference, and better mental and motor development. Cognitive development differed during the first 2 years of among preterm subgroups and appeared to stabilize after that age.
Msall et al.³³	At 8 years:1) School performance	1) Structured questionnaire created for this research	Preterm infants with retinopathy of prematurity showed significant differences in mental development, educational and social skills. Among children who had better visual acuity, 52% were in the appropriate grade for their academic skills, and only about one quarter needed special education services. Most children with poorer visual acuity needed special education; they had lower than expected academic skills and had more social challenges (independence, peer-interaction, and participation in sports).
Casey et al. ⁹	1) Growth 2) Cognitive 3) Behavior 4) Health status 5) School performance	1) Weight (kg), height (cm), head circumference (cm), and body mass index (kg/m²) 2) WISCIII, VMI, and PPVT-3 3) CBCL 4) Child General Health Survey 5) WJ3	Children who were small for gestational age and had failed to properly develop had lower results in all indicators of growth at 8 years of age, as well as lower cognitive and academic performance scores. There were no differences between the groups regarding behavior or general health. Preterm newborns with low birth weight that developed postnatal growth problems, especially when associated with prenatal growth problems, were shown to have a smaller physical size and lower cognitive and academic performance scores at 8 years.
Larroque et al. ³⁵	1) School performance 2) Behavior	1) Structured postal questionnaire created for the study 2) SDQ	Among the very preterm children, 5% were in a special school or class, 18% had repeated a grade in regular school, and 77% were in the appropriate grade. Furthermore, 15% of very preterm children in a conventional class received some support in schoolversus 5% in the control group. Most very preterm children received special care (55%) when compared with children born at term (38%) between the ages of 5 and 8 years; very preterm children (21%) had more behavioral problems when compared to the reference group (11%). Most very preterm children attended regular schools. However, they had a high risk of difficulty in school, with over half of that population requiring additional support at regular school and/or special school.
Kirkegaard et al. ⁶	1) School performance	1) Structured questionnaires for parents and teachers created for the study	Compared to children born at term, reading and spelling difficulties were more frequent among children with gestational age between 33 and 36 weeks and 37 and 38 weeks, but there was no association between gestational age or birth weight and difficulty in mathematics.
Mathiasen et al. ²⁸	1) School performance	1) Governmental data	Among children born before 37 weeks of gestation, 11.5% had not completed elementary school compared to 7.5% of children born at term. The risk of not completing elementary school increased with decreasing gestational age. The risk was moderate for those born at = 31 weeks of gestation, and increased dramatically for infants born at < 31 weeks of gestation. The increased risk in a gestation < 31 weeks was only partially explained by cerebral palsy.
Linnet et al. ²⁰	1) Behavior (attention deficit hyperactivity disorder)	1) Governmental records	Compared with children born at term, infants with gestational age 34 to 36 weeks had a 70% higher risk of hyperkinetic disorder (e.g., attention deficit hyperactivity disorder). Children with gestational age < 34 weeks had a risk nearly three times higher. Children born at term and low birth weight (1,500 to 2,499 g) had a 90% higher risk of hyperkinetic disorder, and children weighing 2,500 to 2,999 g had a 50% higher risk.
Gurka et al. ²⁷	1) Cognition 2) Social skills 3) Behavior	1) WJ3 2) SSRS 3) CBCL and STRS	No significant difference was observed among late preterm and at-term children at ages 4 to 15 years regarding the assessed skills. Healthy late preterm infants appeared to have no real impact on cognition, achievement, behavior, and social-emotional development throughout childhood.
Whiteside-Mansell et al. ²⁶	1) Family environment 2) Behavior 3) Temperament	1) FES 2) CBCL 3) ICQ	Children exposed to high levels of family conflict had more internalization problems. Underweight/preterm children with a difficult temperament had a higher risk of poor developmental outcomes, such as externalization problems; when exposed to family conflicts, they show less difficult temperament.
Jeyaseelan et al. ⁵	1) Attention 2) Motor	1) CRSR, ADHD Rating Scale, and psychometric measures 2) NSMDA at 12 and 24 months	NSMDA (motor test at 12 months) was only associated with psychometric measures of verbal attention at school age regardless of the presence of social and biological factors. NSMDA at 24 months was strongly associated with specific clinical measures of attention at school age. It was not associated with psychometric measures of attention. The main finding of this study was that the motor difficulties in children with extremely low birth weight at 2 years will be later associated with clinical measures of attention at school age.
Conrad et al. ²³	1) Cognitive 2) Behavior evaluated by parents and teachers	1) WISC 2) Pediatric Behavior Scale-30	Children born at term had fewer parental reports of hyperactivity/inattention and depression/anxiety when compared to children of extremely low birth weight and very low birth weight. There were no significant differences between the groups in teachers' evaluations. Birth weight was the strongest predictor of behavioral outcomes that appears not to be influenced by the child's intelligence. It was observed that negative behavioral sequelae of preterm birth remain significant in childhood and adolescence.
Purdy et al. ⁴⁴	1) Behavior 2) Stress at birth 3) Perinatal factors	1) CBCL 2) CRIB, SNAPPE-II, and NBRS 3) Review of retrospective records (sepsis, retinopathy, and other neonatal variables)	There were significant associations between CBCL and sepsis, cumulative exposure to steroids in the perinatal period, time from initial exposure to steroids, and height percentile at discharge. There was also a strong association between problems of social and school competence and activities assessed by the CBCL and the variable cumulative exposure to steroids, height percentile of children in the intensive care unit, sepsis, retinopathy, CRIB score, hearing loss, and biological markers. Children in the group with higher exposure to steroids presented more behavioral problems, but it was not possible to detect significant differences. The results are reassuring regarding the long-term effects of cumulative exposure to steroids on the behavioral outcomes of preterm infants.
Farooqi et al. ⁴³	1) Behavioral problems 2) Adaptive behavior at school 3) Family function (environment) 4) Depression	1) CBCL for parents and teachers 2) Structured questionnaire and TRF 3) Nordic Health and Family Questionnaire 4) DSRS	Compared with control children, parents of premature infants reported more internalization behavior, attention, and social problems. Teachers had a similar opinion. Reports from the children showed a trend of increased symptoms of depression compared to the control group. However, the majority of extremely preterm children (85%) were studying in regular schools without major adjustment problems. Although these results appear favorable, teachers report that these children have poorer adjustment to the school environment and are at risk of mental health problems.
Gray et al.²⁵	1) Maternal psychological problems 2) Behavior	1) GHQ 2) CBCL	The prevalence of behavioral problems was approximately 20% at all ages tested (3, 5, and 8 years). This sample had twice the prevalence of behavioral problems expected in children. The significant predictors of these problems were smoking during pregnancy, maternal psychological distress, maternal age, and Hispanic ethnicity.
Yu et al. ⁴⁵	1) Behavior 2) Learning failure	1) CBCL 2) WISC III and WJ3	Compared with children with verbal and nonverbal learning disability, children with verbal disability were twice as likely to have behavioral problems, and were 89% more likely to have externalization behavior problems. No association was found between learning difficulties in nonverbal disability and behavioral problems. Analysis of specific behavioral subscales showed significant association with behaviors of anxiety/depression, as well as an increased likelihood of attention problems in children with verbal disability. These results provide evidence that there are differences between learning subtypes regarding behavioral outcomes and the effects of early intervention services at 8 years of age.
Anderson et al. ⁴²	1) Cognitive 2) School performance 3) Behavior	1) WISC III 2) WRAT-3 and CSSA 3) BASC	Extremely preterm or underweight children had lower scores than the control group in IQ, verbal comprehension, perceptual organization, distractibility, and processing speed. Attention difficulties, internalization problems, and adaptive skills were higher in the group of preterm/low birth weight children. In addition, this group showed worse performance on tests of reading, spelling, and arithmetic compared to the control group. School-age children with extremely low birth weight or very preterm infants born in the 1990s continue to have cognitive, educational, and behavioral disabilities.
Crombie et al. ²¹	1) Mental health 2) Early risk assessment	1) SDQ 2) Structured questionnaire completed by parents	Children with early biological risk (preterm or low birth weight) were shown to be more vulnerable to mental health problems when exposed to the effects of noise from aircraft or road traffic noise in the school area. However, these children were more likely to have mental health problems. Children who were "at risk" (i.e., low birth weight or preterm birth) were classified as having more behavioral problems and emotional symptoms and poorer overall mental health than children without these risks.
Lindström et al. ²²	1) Psychiatric disorders 2) Perinatal and social factors	1 and 2) Governmental records	Preterm and early-term birth increases the risk of attention deficit hyperactivity disorder (ADHD). The socioeconomic context modifies the risk of ADHD in moderately preterm births.

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[1] * Corresponding author. E-mail: rafaelafisioterapia@yahoo.com.br (R.S. Moreira).