Early intervention of premature infants
less than 2000 grams.
John A. Rønning¹² Stein Erik Ulvund³ Per
Ivar Kaaresen¹² Lauritz B. Dahl¹²
Jorunn Tunby²
¹Institute of Clinical Medicine, University
of Tromsø ²Department of Pediatrics,
University Hospital, Tromsø ³Institute of
Educational Research, University of Oslo
Developmental, educational and psychiatric problems of expremature children
Serious Disabilities
< 1000 g
< 28 weeks
1000-1500 g
28-31 weeks
Total
15-30%
10-15%
Cerebral Palsy
10-20%
5-10%
< 5%
1‰
90
95
98
103
Mild Disabilities
40-50%
30-40%
20-30%
10-15%
Psychiatric diagnosis
20-30%
15-25%
10-20%
5-10%
10-20%
10-15%
5-10%
1-4%
Learning Disabilities
30-50%
15-20%
15-20%
ca.10%
Special Educational
Programs
40-50%
30-40%
20-30%
10-20%
15-20%
10-20%
10-15%
ca. 5%
Mean IQ
ADHD
Motoric Disabilities
1500-2500 g
32-36 weeks
5%
Term
3%
Mother:
Avoids contact
With child
Anxious
Consequence:
Child:
Time
Birth
complications
t1
Difficult
temperament
t2
Delayed language
t3
t4
Sameroff 1995
6
The Vermont Study (Achenbach et
al., 1990)
Inclusion- and exclusion criteriae

Birth weight < 2000 gram

Exclusion:



Congenital anomalies
Non-Norwegian speaking parents
Triplets or higher plurality
Baseline characteristics
Preterm Intervention
N=72
Birth weight, mean (SD)
400 – 1000 g
1001 – 1500 g
1501 – 2000 g
Gestational age, mean (SD)
< 28 w
28 – 32 w
≥ 33 w
Preterm Control
N=74
1396 (429)
1381 (436)
20 (28)
15 (21)
37 (51)
20 (27)
20 (27)
34 (46)
30.2 (3.1)
29.9 (3.5)
17 (24)
36 (50)
19 (26)
19 (27)
37 (50)
18 (24)
14.6 (2.8)
13.8 (3.1)
15.8 (7.7)
21.1(8.7)
13.5 (3.2)
13.5 (3.2)
14.6 (6.7)
19.9 (8.1)
Term reference group
N=75
3619 (490)
39.3 (1.3)
Social Factors (n=199)
Mother’s education (y)
Father’s education (y)
Mother’s income†
Father’s income†
14.9 (2.8)
14.4 (3.2)
15.9 (8.0)
21.9 (9.8)
The Tromsø-version of
the Vermont-program
First:
Introduction / grief handling
Day 1: Getting acquainted with the baby
Day 2: Homeostatic systems / internal ”bodylanguage”
Day 3: Motor system
Day 4: State observation and regulation
Day 5: Attention-interaction system
Day 6: Recognizing and responding to cues
Day 7: Getting ready to play at home
1. Home visit: Consolidation and adjustment
2. Home visit : Mutual enjoyment through play
3. Home visit : Temperamental patterns
4. Home visit : Review of program and
termination
of the intervention
Baby is now about 3mnds
The goal of the intervension
Teach parents to read the childs reactions to
internal and external stimuli
Teach parents to understand the childs natural
changes in state levels
And understand when the baby is receptive for
social interaction
- recognice the ”golden moments”
Background




A preterm birth is a stressful event for the
parents and family relations
Many studies have shown increased stress in
mothers during the NICU stay
Longitudinal studies are few and the results are
conflicting
Fathers less studied
Background

Increased parenting stress has been associated
with later behavioral problems in both preterm
and other children

No studies has examined the effects of an early
intervention program in reducing parenting stress
in both mothers and fathers after a preterm birth
Hypothesis

Parents of preterm infants experience increased
parenting stress during the first year after a
preterm delivery compared to their term peers

An early intervention program will reduce
parenting stress in both mothers and fathers of a
preterm infant
Instrument

Parenting Stress Index (PSI)





Self-reported questionaire
101 questions measured on a 5-point scale
Child Domain: Measures stress related to the child’s
characteristics
Parent Domain: Measures stress related to the parents
themselves
Total Stess is the sum of Child and Parent Domain
PSI

The PSI was administered to the mothers at 6
and 12 months corrected age and the fathers at
12 months corrected age
Patients

203 infants with birth weight<2000 g born from
March 1999 to August 2002

146 were randomized (14 died,13 non-Norwegian
speking parents, 22 parental refusals, 8 other)

6 were later withdrawn
PSI at 6 months - mothers
Preterm control
n
Mean (SD)
Preterm
intervention
n
Mean (SD)
Preterm control vs.
Full term control
intervention
Mean difference p-values n
Mean (SD)
(95% CI)
(t-test)
6 months
Child Domain
63
94.8 (15.2)
67
88.0 (14.6)
6.8 (1.6 – 12.0)
0.01
71
84.3 (13.3)
Parents Domain
61
117.0 (20.9)
63
108.6 (19.4)
8.4 (1.2 – 15.6)
0.02
72
110.4 (20.3)
Total Stress
59
212.2 (34.2)
62
195.4 (30.3)
16.9 (5.2 – 28.5)
0.005
69
194.8 (30.5)
PSI at 12 months
Preterm control
n
Mean (SD)
Preterm
intervention
n
Mean (SD)
Preterm control vs.
intervention
Mean difference
p-values
(95% CI)
(t-test)
Full term control
n
Mean (SD)
12 months
mothers
Child Domain
61
92.5 (14.6)
69
87.2 (17.6)
5.0(- 0.6 – 10.7)
0.08
71
86.1 (15.4)
Parents Domain
61
116.5 (20.7)
69
107.8 (20.7)
8.7 (1.5 – 15.9)
0.02
71
110.1 (20.5)
Total Stress
59
208.6 (33.2)
68
194.9 (35.5)
13.7 (1.6 – 25.9)
0.03
70
195.3 (33.0)
12 months
fathers
Child Domain
51
96.0 (13.9)
59
89.3 (15.8)
6.7 (1.0 – 12.3)
0.02
58
89.3 (12.3)
Parents Domain
51
113.5 (21.2)
59
105.3 (19.6)
8.2 (0.5 – 15.9)
0.02
57
106.3 (15.3)
Total Stress
51
209.4 (32.3)
57
194.6 (33.9)
14.8 (2.1 – 27.6)
0.02
57
195.7 (24.9)
Conclusion

Parents in the preterm control group experienced
increased parenting stress during the first year
after a preterm birth compared to their term
peers

An early intervention program can reduce
parenting stress in both mothers and fathers of
preterm infants to a level comparable to their
term peers
PSI scores at 3 years CA
Unpublished
PSI scores at 3 years corrected age
Intervention
group mean (SD)
Mothers
Control Group
mean (SD)
Mean difference (95%CI)
Effect size
N=69
N=67
84.5 (16.3)
94.6 (20.1)
Parent
Domain
107.0 (20.3)
113.7 (21.5)
6.7 (-1.1 to 14.5)
p=0.10
0.32
Total Stress
191.1 (34.4)
208.2 (38.6)
17.1 (3.5 to 30.5)
p=0.01
0.48
N=61
N=54
86.6 (16.6)
93.5 (14.8)
6.9 (0.8 to 13.0) p=0.03
0.44
Parent
Domain
103.7 (23.9)
106.0 (17.8)
2.3 (-5.9 to 10.5)
p=0.58
0.11
Total Stress
189.8 (37.8)
199.4 (29.3)
9.6 (-3.7 to 23.0)
p=0.16
0.28
Child Domain
Fathers
Child Domain
*Mixed models with family as a random effect
10.1(3.2 to 16.6)
p=0.002
0.55
Changes over time
95
90
85
80
6m
12 m
Time
24 m
Fitted line for Preterm control
Fitted line for Preterm Intervention
36 m
Preterm control
Preterm Intervention
190
200
210
220
Mother reported Total stress
180
Repeated measures
analyses showed a
significant time by group
interaction in mother
reported Child domain
(p=0.01) and Total stress
(p=0.047)
Mean Total stress

Mean Child domain
100
Mother reported Child domain
6m
12 m
Time
Fitted line for Preterm control
Fitted line for Preterm Intervention
24 m
36 m
Preterm control
Preterm Intervention

Early intervention and social
communication at 12 months of life
for preterm and term infants.

Kåre S. Olafsen, John A. Rønning, Stein
Erik Ulvund, Per Ivar Kaaresen, Bjørn
Helge Handegård, Lauritz Bredrup Dahl
(Infant Behavior & Development, 2006)

Center for Child and Adolescent Mental Health, Medical
Faculty, University of Tromsø. Department of Pediatrics,
University Hospital for Northern Norway, Tromsø.
Department of Educational Research, University of Oslo.
Joint Attention in preterm and term infants
The capacity to coordinate attention to a
social partner.
 Associated with linguistic and cognitive,
as well as social development


Important milestone in development;
emerges normally at about 9 months,
and fully developed at about 18 months.

Developmental course from face-to-face
social play (3 months) and interest in
objects (6 months).

Basis for verbal language.

Medium for understanding social acts,
perspectives of others, flexibility in giveand-take transactions.
JA integrative functions?

Reflect processes associated with selfmonitoring, emotional reactivity, and
prosocial affiliative tendencies –
importance for emerging regulatory
competence?
Research questions



Could an early intervention designed to increase
the parents’ sensitivity to the infants’ individual
patterns enhance
JA performances at 12 months of age?
Would there be gender differences in
JA performances?
Would early intervention be differentially
favorable for the different weight groups?
Table 2.
Joint Attention at 12 months for girls and boys in preterm control, intervention, and term group.
ESCS
dimensions
Preterm control
Girls (31) Boys (35)
Means (SD)
Preterm intervention
Girls (32) Boys (35)
Means (SD)
Term
Girls (32) Boys (38)
Means (SD)
Main effects
Gender Treatm.
2
2
Interaction
GxT
2
IJA
22.23
(12.70)
15.89
(7.74)
29.59
(15.83)
21.69
(15.60)
24.75
(10.22)
23.74
(15.80)
.036**
.043*
.012
RJA
7.03
(2.30)
5.89
(2.37)
7.56
(2.61)
6.14
(2.60)
9.56
(2.23)
7.55
(2.58)
.090***
.125***
.006
IOR
13.35
(5.15)
10.91
(7.13)
15.06
(6.90)
13.69
(6.34)
17.69
(7.56)
13.03
(6.80)
.043**
.039*
.010
RR
2.61
(2.20)
1.80
(1.95)
3.63 (3.02)
2.46
(2.36)
3.09
(2.95)
2.74
(2.96)
.022*
.020
.004
RSI
7.65
(3.77)
6.43
(3.40)
12.16
(4.52)
8.54
(5.00)
10.94
(4.85)
9.61
(5.70)
.048**
.101***
.014
Abbreviations: ESCS Early Social Communication Scales. IJA Initiating Joint Attention. RJA Responding to Joint Attention. IOR Initiating
Object Requesting. RR Responding to Requesting. RSI Responding to Social Interaction. * p  0.05 ** p  0.01 *** p  0.0005
Table 3.
Joint Attention at 12 months for preterm control and intervention infants in different weight groups.
ESCS
dimensions
ELBW
 1000 g
Intervention Control
Means (SD)
N = 17
N = 17
VLBW
1001 – 1500 g
Intervention Control
Means (SD)
N = 16
N = 19
LBW
1501 – 2000 g
Intervention
Control
Main effects
W.group Treatm.
2
2
Means (SD)
N = 34
N = 30
Interaction
WG x T
2
IJA
23.00
(15.91)
14.82
(8.59)
23.38
(14.79)
16.37
(9.43)
27.68
(16.89)
22.73
(11.61)
.046
.055*
.003
RJA
6.47
(1.66)
6.06
(2.36)
7.44
(3.01)
6.84
(2.27)
6.71
(2.95)
6.37
(2.53)
.017
.007
.000
IOR
10.06
(5.69)
9.41
(4.64)
16.50
(6.63)
13.05
(7.83)
15.47
(6.72)
12.93
(5.91)
.098**
.028
.007
RR
1.82
(2.07)
1.12
(1.49)
3.56
(2.83)
2.53
(1.98)
3.35
(2.88)
2.57
(2.30)
.075**
.029
.001
RSI
8.35
(3.87)
6.12
(3.91)
10.56
(5.29)
7.63
(3.04)
11.09
(5.38)
7.10
(3.76)
.035
.104***
.007
Abbreviations: ESCS Early Social Communication Scales. IJA Initiating Joint Attention. RJA Responding to Joint Attention. IOR Initiating
Object Requesting. RR Responding to Requesting. RSI Responding to Social Interaction. * p  0.05 ** p  0.01 *** p  0.0005
Summary


Significantly higher scores for the preterm
intervention group in all weight groups compared
to the preterm control group on Initiating JA
(small to medium ES).
The term group had significantly higher scores
than preterm control and preterm intervention
groups on Responding to JA (medium to large
ES).
Summary II


The term group had significantly higher scores
than the preterm control group on IOR
(Initiating Object Request). There was no
difference between the preterm intervention
and preterm control group (low to medium
ES).
Intervention was not associated with either of
the imperative elements (IOR, RR-Responding
to Request) for ELBW group. LBW and VLBW
groups had significantly higher scores than
ELBW group for both comparisons (medium to
large ES).
Summary III


The preterm intervention group scored higher
than the preterm control group on RSI
(Responding to Social Interaction) in all weight
groups (medium to large ES). The term group
had also higher scores than the preterm control
group.
Girls outperformed boys on all aspects of social
communication, particularly on the element
responding to joint attention, where the
difference was a medium to large effect size.
Child rearing

Child rearing practices report (CRPR)
Block
1965

Results:



Significant more nurturing child rearing
practice in mothers at 12 and 24 m
No difference in restrictive child rearing
practices, by genders or in nurturing child
rearing practice by fathers
Significant higher agreement on child rearing
practices in preterm parents
Cognitiv score 3 og 5 years
Prematur
intervention
Prematur
control
Prematur
intervention vs
prematur control
Term control
5.7 (0.9 – 10.5)
p=0.02
104.3 (8.9)
N=68
N=67
N=67
97.9 (11.1)
92.3 (15.6)
N=66
102.3 (13.5)
N=65
95.6 (19.2)
Verbal IQ
102.4 (14.0)
96.3 (18.1)
6.2 (0.4 – 11.9)
p=0.04
109.2 (12.9)
Performance IQ
101.3 (15.8)
95.3 (18.4)
6.9 (0.8 – 13.0)
p=0.03
106.7 (14.9)
3 years
MDI
5 years
Total IQ
7.2 (1.3 – 13.0)
p=0.02
N=68
109.1 (13.2)
46
Social-clinical significance of
cognitive effects
A 5-point difference is considered to be of
social-clinical significance (Vanderveen et
al., 2009)
 According to Vohr et al., (2006) this
means later significant difference in use of
special education services


Usually, in early intervention programs,no
cognitive effects are observed after 3years-of-age.




CBCL mothers: Significant difference on
total (ES 0.42), attention, thought,
social, withdrawn and aggressive.
CBCL fathers: attention and aggressive
SDQ Significant differences for both on
total and hyperactivity; fathers also on
conduct
No differences in Kindergarten on SDQ
Thanks for the attention!
Thank you
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