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CHIEF EXECUTIVE, Sue Williamson 5th Floor, 142 Central Street, London, EC1V 8AR

T: 020 7802 2300 F: 020 7802 2345 E: [email protected]

SSAT (The Schools Network) Ltd, A PRIVATE COMPANY LIMITED BY SHARES REGISTERED IN ENGLAND AND WALES, COMPANY NO. 8073410

National Forum for Neuroscience in Special Education

STATEMENT ON THE EDUCATIONAL NEEDS OF CHILDREN BORN PRETERM

This statement is a joint parent-‐ and professional-‐instigated outcome from the National Forum for Neuroscience in Special Education’s Second Annual Conference: ‘The learning and neurodevelopmental needs of children born pre-‐term – a conference to bridge thinking and understanding between education and neuroscience across the school years’ (Institute of Education, London, 31 January 2013). This Conference was given in partnership with Bliss, the special care baby charity, and generously funded by The Waterloo Foundation. Background With improving medical skill and knowledge, more children born premature1 or with low birth weight2 are surviving than ever before (Reijneveld et al., 2006), and greater numbers are arriving in our schools. Yet, the teachers in our schools do not have the information or tools to support their learning needs (Carpenter, 2013; Wolke, 2013). A survey by the University of Warwick (Henderson et al. 2012) found that although 89% of 120 teachers said they were likely to teach a child born prematurely, only 6% felt they had received sufficient training. Approximately 1 in 8 (80,000 per annum) children are born preterm in the UK every year (Medical Research Council, 2008). There are likely to be four children born preterm in every classroom, and two in every 100 children are born extremely preterm (Hornby and Woodward, 2009). In addition to neurodevelopmental impairments (e.g. visual, hearing and motor disabilities), premature birth can result in (Poehlmann et al, 2011; Wolke, 2010): • Reduced cognitive capacity • Social and behavioural difficulties • Learning disabilities • Poor academic outcomes, especially in the areas of mathematics and literacy. Pritchard et al. (2009) note:

By middle childhood, children born very preterm (VPT) are 3 to 5 times more likely to show difficulties across a range of school based skills and educational domains… As a consequence, it is estimated that 60–70% of VPT children will require support from special education services by middle school age. (Pritchard et al., 2009)

Even even children born premature who are unaffected by neurodevelopmental impairments and who have IQ within the normal range are at risk of poorer school performance than children born at term with a normal birth weight (Lee et al., 2011; Marlow, 2005).

1 Full-‐term -‐ Over 37 weeks; Preterm -‐ Less than 37 weeks; Very preterm -‐ Less than 32 weeks; Extremely preterm – Less than 28 weeks 2 Normal birth weight (NBW) -‐ Greater than 2,500g; Low birth weight (LBW) -‐ Less than 2,500g; Very low birth weight (VLBW) -‐ Less than 1,500g; Extremely low birth weight (ELBW) -‐ Less than 1,000g




Sensitive and responsive parenting and teaching can ameliorate disadvantages. However, children’s difficulties are often ‘invisible’ to educators who lack the information and training to recognise them. Lack of support in childhood has been linked with detrimental life outcomes for young people born preterm – school underachievement, unemployment, poor social and psychological well being (Woythaler et al., 2011). Although incidence of neurodevelopmental disabilities, such as sensory impairment and cerebral palsy is falling, the levels of cognitive, social and behavioural impacts remain largely unchanged (Wolke, 2013). These learning problems persist throughout childhood and adolescence, therefore cannot be explained solely by developmental delay (Anderson et al., 2004; Kierkegaard et al., 2006). With Department for Education support and guidance, schools need to: • Raise educator knowledge and understanding of the potential difficulties of children and young

people born preterm, and of the need for proactive educational responses • Promote best outcomes for children born preterm and their families. Preterm birth – Educational risk Premature birth may result in smaller brain volume, which impacts on verbal and performance IQ scores at school age and is associated with poorer neurodevelopmental outcomes in adolescence. (Skiold, 2011). The longitudinal Epicure study (Marlow et al., 2005), following all children born premature in 1995, found that of those surviving at age 6 years, 32% of had mild disabilities, 24% had moderate disabilities and 22 % had severe disabilities (Johnson et al., 2009). The Epicure study has identified a clear phenotype for very and extremely preterm children (Wolke, 2010) which carries increased risk of: • Pervasive cognitive processing difficulties • Learning problems: reading and maths • Educational problems and high special education resource needs • High service costs. At 11 years, extremely preterm children continue to have much poorer school performance and a high level of special educational needs, including (Johnson et al., 2009): • Need for additional support (in mainstream schools -‐ £53%; in special schools – 13%) • Serious impairment in maths (44%) • Serious impairment in reading (25%). Nosarti et al (2012) have also identified significant executive function difficulties in young adulthood. These difficulties can intensify with age associated with increasing educational support needs (Reijneveld et al., 2006; Wolke, 2010). Preterm birth – Social and emotional risk Children born very or extremely preterm are 50% more likely than their full-‐term peers to have behaviour difficulties in the clinical range, both at preschool and school ages (Reijneveld et al.,




2006). They are also at increased risk of developing social and emotional problems (Elgen et al., 2012; Reijneveld et al., 2006; Skiöld, 2011; Wolke, 2010) including significantly more symptoms of:

• ADHD (inattention type) • Autistic spectrum symptoms

• Social phobia/peer interaction • Depression/anxiety • Emotional/conduct disorders or problems.

Young people born at 32 to 36 weeks’ gestation are also at greater risk than full-‐term peers for development of mental health issues (Nosarti et al., 2012):

• Psychosis: 1.6 times more likely (below 32 weeks, 2.5 times more likely) • Depressive disorder: 1.3 times more likely (below 32 weeks, 2.9 times more likely)

• Bipolar: 2.7 times more likely (below 32 weeks, 7.4 times more likely). It is likely that, as children get older, behavioural and emotional problems may affect academic functioning (Reijneveld et al., 2006; Wolke, 2010). Call to action Professionals agree that, In order to divert bleak outcomes for children born preterm, ‘it is imperative that their health and educational needs are identified and resources are committed to address their needs’ (Mandy, 2011). They suggest the following provisions to support the child’s education (Anderson et al., 2004; Carpenter, 2013; Hack et al., 2005; Munck, 2012; Nosarti et al., 2012; Reijneveld et al., 2006; Tutt et al., 2012): • School-‐held developmental record of the child • Appropriate personalised decisions on school entry (e.g. consideration of deferred/delayed

school entry) • Regular cognitive/social/emotional assessment of children born preterm to allow early

identification and intervention of educational need, and long-‐term follow up • Targeted, personalised educational assistance to overcome learning barriers (e.g. attention,

executive function issues, etc.) to enable the young person to achieve their potential • Development of interdisciplinary, evidence-‐based education pathways • Support, guidance and involvement of families • Continuing professional development to enable staff to recognise and respond proactively to the

learning difficulties and disabilities associated with premature birth • Support for educational research to improve life chances for these children. Conclusion Educator knowledge and awareness are key to the diagnosis, assessment and successful intervention of young people born preterm. This needs targeted support and guidance around educational provision for this very vulnerable group of children to ensure their positive life outcomes.




The facts in this statement are corroborated by research carried out in countries around the world, including in UK and Ireland, Canada, France, New Zealand, Sweden and the USA among many others. References Anderson, P.J., Doyle, L.W. and the Victorian Infant Collaborative Study Group (2004) ‘Executive

functioning in school-‐aged children who were born very preterm or with extremely low birth weight in the 1990s’, NeoReviews, 114 (1), 50-‐57.

Carpenter, B. (2013) ‘The emerging new SENs of students born prematurely’, SecEd Magazine, 10.1.13 [Online at: http://www.sec-‐ed.co.uk/best-‐practice/the-‐emerging-‐new-‐sens-‐of-‐students-‐born-‐prematurely/; accessed: 13.5.13]

Elgen, S.K., Leversen, K.T., Grundt, J.H., Hurum, J., Sundby, A.B., Elgen, I.B. and Markestad, T. (2012) ‘Mental health at 5 years among children born extremely preterm: a national population-‐based study’, European Child and Adolescent Psychiatry, 21 (10), 583-‐589.

Hack. M., Taylor, H.G., Drotar, D., Schluchter, M., Cartar, L., Andreias, L., Wilson-‐Costello, D. and Klein, N. (2005) ‘Chronic conditions, functional limitations, and special health care needs of school-‐aged children born with extremely low-‐birth-‐weight in the 1990s’, Journal of the American Medical Association, 294 (3), 318-‐325.

Henderson, D., Beer, C., Wolke, D. and Johnson, S. (2012) ‘Supporting the schooling of very preterm children: education professionals’ opinions and information needs’ (abstract), Archives of Diseases in Childhood, 97 (Suppl 2).

Hornby, G. and Woodard, L.J. (2009) ‘Educational needs of school-‐aged children born very and extremely preterm: a review’, Educational Psychology Review, 21 (3), 247–266.

Kirkegaard, I., Obel, C., Hedegaard, M. and Henriksen, T.B. (2006) ‘Gestational age and birth weight in relation to school performance of 10-‐year-‐old children: a follow-‐up study of children born

after 32 completed weeks’, Pediatrics, 118 (4), 1600-‐1606. Lee, E.S., Yeatman, J.D., Luna, B. and Feldman, H.M. (2011) ‘Specific language and reading skills in

school-‐aged children and adolescents are associated with prematurity after controlling for IQ’, Neuropsychologia, 49 (5), 906–913.

Mandy, G.T. (2011) ‘Long-‐term complications of the premature infant’. In: O. Battisti (2011) Prematurity and Brain. [Online at: http://orbi.ulg.ac.be/bitstream/2268/114039/2/battisti_prematurity_brain_lungs.pdf; accessed: 14.4.13]

Medical Research Council (2008) ‘New data to inform clinical practice around preterm labour’ (Medical Research Council Media Release). [Online at: http://multimedia.thelancet.com/pdf/ORACLE/MRC-‐press.pdf; accessed: 2.4.13]

Johnson, S., Fawke, J., Hennessy, E., Rowell, V., Thomas, S., Wolke, D., et al. (2009) ‘Neurodevelopmental disability through 11 years of age in children born before 26 weeks of gestation’, Pediatrics, 124 (2), e249-‐e257.

Kirkegaard, I., Obel, C., Hedegaard, M. and Henriksen, T.B. (2006) ‘Gestational age and birth weight

in relation to school performance of 10-‐year-‐old children: a follow-‐up study of children born after 32 completed weeks’, Pediatrics, 118 (4), 1600-‐1606.

Marlow, N., Wolke, D., Bracewell, M.A. and Samara, M. (2005) ‘Neurologic and developmental disability at six years of age after extremely preterm birth’, The New England Journal of Medicine, 352 (1), 9–19.

Munck, P. (2012) Cognitive Development of Very Low Birth Weight Children from Infancy to Pre-‐School Age. Turku, Finland: University of Turku.




Nosarti, C., Reichenberg, A., Murray, R.M., Cnattingius, S., Lambe, M.P., Yin, L., MacCabe, J., Rifkin, L. and Hultman, C.M. (2012) ‘Preterm birth and psychiatric disorders in young adult life’, Archives of General Psychiatry.

Poehlmann, J., Miller Schwichtenberg, A.J., Shlafer, R.J., Hahn, E., Bianchi, J.-‐P. and Warner, R. (2011) ‘Emerging self-‐regulation in toddlers born preterm or low birth weight: differential susceptibility to parenting?’, Developmental Psychology, 23 (1), 177-‐193.

Pritchard, V.E., Clark, C.A.C., Liberty, K., Champion, P.R., Wilson, K. and Woodward, L.J. (2009) ‘Early school-‐based learning difficulties in children born very preterm’, Early Human Development, 85, 215–224.

Reijneveld, S.A., de Kleine, M.J.K., van Baar, A.L., Kollée, L.A.A., Verhaak, C.M., Verhulst, F.C. and Verloove-‐Vanhorick, S.P. (2006) ‘Behavioural and emotional problems in very preterm and very low birthweight infants at age 5 years’, Archive of Diseases in Childhood (Fetal and Neonatal

Edition), 91, F423–F428. Skiöld , B. (2011) Brain Imaging and Outcome in Extremely Preterm Infants. Stockholm, Sweden:

Department of Women’s and Children’s Health, Karolinska Institutet. Tutt, R., Kirby, A., Grant, A. and Truman, J. (2012) ‘Insights from Neuroscience (Module 4.3):

Premature birth – Implications for education’. In: Teaching Agency (Ed.) Training Materials for Teachers of Learners with Severe, Profound and Complex Learning Difficulties. London: Teaching Agency. [Online at: http://www.education.gov.uk/complexneeds/modules/Module-‐4.3-‐Insights-‐from-‐neuroscience/All/m15p480b.html#; accessed: 16.4.13]

Williams, B.L. (n.d.) ‘Prematurity and academic achievement’ (PowerPoint presentation). Atlanta, GA: Emory University.

Wolke, D. (2010) ‘Small beginnings – large impact: development of preterms and implications for early childhood intervention’. Presentation to the Complex Learning Difficulties and Disabilities Research Project, Wolverhampton.

Wolke, D. (2013) ‘Pre-‐term birth: the implications for learning’. Presentation to the National Forum for Neuroscience in Special Education’s Second Annual Conference: ‘The learning and neurodevelopmental needs of children born pre-‐term – a conference to bridge thinking and understanding between education and neuroscience across the school years’, Institute of Education, London (31 January).

Woythaler, M.A., McCormick, M.C. and Smith, V.C. (2011) ‘Late preterm infants have worse 24-‐month neurodevelopmental outcomes than term infants’, NeoReviews, 127 (3), e622-‐e630.

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