Current survival of EP children has reached a level previously unsurpassed but with high rates of neonatal morbidity.53
As increasing numbers of these children are reaching school age, it is critical that we identify the problems they have at school entry and factors related to early educational difficulties. Our results reveal that the EP children performed more poorly on achievement tests, were making less learning progress, and had higher rates of IEPs and classroom accommodations than NBW controls. Academic problems were evident on tests of written expression and mathematics and in teacher ratings of learning progress in these areas. A recent report of academic outcomes in 6-year-olds of ≤33 weeks gestation born in the 1990s indicated higher rates of academic problems compared with NBW controls even for the subset of EP children without neurosensory deficits or low global cognitive ability.20
Our results suggest similar outcomes for children born in the 2000s. Although other studies have reported deficiencies in academic readiness or beginning achievement skills in preterm children,12,18,20,21,23,54,55
to our knowledge this is the first study to demonstrate the pervasiveness of learning deficiencies during the first year in school among EP children born since 2000. Because the EP and NBW groups were similar in sociodemographic characteristics, neonatal brain insults and subsequent abnormalities in neural development may contribute in large part to their higher rates of educational difficulties.56,57
This study is also among the first to examine educational interventions for EP children in kindergarten and the correspondence of these interventions with learning problems. More EP children than NBW controls were receiving special assistance at school, yet many EP children with low scores on an achievement test did not have an IEP. Low-achieving EP children without an IEP had higher achievement scores and lower rates of neurosensory deficit, low cognitive ability, and neonatal complications than those with an IEP, suggesting that children with less severe impairments are more likely to be under-identified. It is also possible that IEPs had not been completed for some children despite parent or teacher awareness of learning difficulties. Our results imply that the educational needs of EP children are not fully met.
Achievement deficits in the EP group were evident in mathematics and spelling but not in word recognition. When children with neurosensory deficits or low global cognitive ability were excluded from analysis, only the deficit in mathematics problem solving remained significant. These findings are consistent with other data indicating that problems among preterm children in mathematics are more prominent and selective than problems in reading.1,6,20,35,58–60
Neonatal risk factors associated with learning problems of EP children in kindergarten included gestation <25 weeks, abnormal cranial ultrasounds, bronchopulmonary dysplasia, and infection. Neurodevelopmental impairment at 20 months and lower SES also predicted learning problems. Previous studies have reported similar risks for deficits in school readiness skills and special education interventions.3,18,19,31,32,34,36,37,39–43,61,62
These risk factors may thus have utility in identifying the children most deserving of developmental monitoring and early childhood interventions prior to school entry.
A limitation of this study was that teacher ratings of educational progress were only obtained for EP children attending regular classrooms. This procedure was warranted to insure that expectations for progress could be judged relative to the general kindergarten population but is likely to have underestimated the effect of EP on learning progress. A further limitation is that information on IEPs was provided by teachers and parents and we had no means to determine the extent to which these plans were implemented or addressed the children’s learning problems. Our EP cohort was hospital-based and we were unable to follow 25% of the families. The sample was predominantly urban and African American and, although largely reflective of EP births within the region, not representative of the U.S. as a whole. Educational interventions may also vary from those provided elsewhere in the U.S. Because of privacy issues parents of NBW children were selected from among those who agreed to be contacted, introducing possible bias in selection of controls. However, the children attended a multitude of schools throughout the region, there were no differences in background factors between participants and non-participants or between the EP and NBW groups, and our results are similar to previous reports of early educational outcomes.20,21,30
Although poorer reading skills in older school-age children are associated with reduced cerebellar volume and mathematics difficulties with reduced gray matter in the left parietal lobe,63,64
further studies are need to investigate the neural basis of early academic difficulties in EP children and examine the cognitive and behavior problems associates with these difficulties. Deficits in specific skill areas, such as processing speed and working memory, may be closely related to academic difficulties, with different patterns of association for reading and mathematics disabilities.11,59,65
Additional study of environmental influences on academic achievement at school entry is also needed to identify characteristics of families and schools that buffer or exacerbate early learning progress.29,66
In conclusion, our findings reveal high rates of learning problems and special learning interventions in EP children at the time of school entry, as well as associations of these outcomes with neonatal risk factors and neurodevelopmental impairment at 20 months. The findings also underscore the fact that many EP children with learning problems in kindergarten are not receiving special interventions, and they show that teacher ratings of learning progress hold promise as a simple and effective means to screen for these problems. Efforts to minimize the adverse effects of EP on later academic achievement may need to include more extensive developmental and educational interventions beginning in kindergarten or earlier.18–21,25–27
A system of follow-up care that provides ongoing monitoring of children’s status and needs from birth through school age, such as a “medical home,” may be especially helpful in insuring early detection and intervention.26