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Premature birth and the link to ADHD

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Preterm baby


Studies1 indicate children born very preterm are showing rates of attention deficit hyperactivity disorder (ADHD), three times higher than the general population, however monitoring can assist health care professionals with early intervention.

While the rate varies across age and region, roughly one in 20 children (5%) in Australia have symptoms of ADHD, and in children born very preterm (prior to 32 weeks) in Victoria the rate is reported to be 11%.

Genetic and environmental factors play a part

Professor Peter Anderson from the Turner Institute for Brain and Mental Health at Monash University and the MCRI Centre for Research Excellence in Newborn Medicine, says science does not fully understand the causes of ADHD, however both genetic and environmental factors play a part.

Professor Anderson says researchers also don’t understand why the rate of ADHD is higher in children born very preterm.  

“Being born early can injure the brain and disrupt the normal sequence of brain development processes. Therefore, we speculate that an event during early brain development associated with being born early contributes to the development of ADHD symptoms,” Professor Anderson says.

“Both boys and girls are diagnosed with ADHD but the diagnosis is more common in boys. There is some suggestion that girls diagnosed with ADHD are more likely to have inattentive symptoms while boys commonly have the hyperactive symptoms, however these profiles are not gender specific.

“In terms of individuals born very preterm, both males and females are more likely to be diagnosed with ADHD when compared with their peers in the general population.

“Health professionals generally report that children born very preterm are more likely to present with an inattentive subtype of ADHD rather than the hyperactive or combine subtypes of ADHD, and there is some evidence to support this view particularly as children get older.

“The rate of ADHD tends to increase with decreasing maturity at birth. Given the strong relationship between gestational age at birth and birth weight, the rate of ADHD also tends to increase with decreasing birth weight.”

In terms of individuals born very preterm, both males and females are more likely to be diagnosed with ADHD when compared with their peers in the general population.
Professor Peter Anderson

ADHD and preterm birth

Attention Deficit Hyperactivity Disorder, is a neurodevelopmental disorder, which means that the symptoms are likely to be triggered by genetic or environmental events early in development. 

Children with ADHD have poor concentration, and/or are hyperactive and impulsive. ADHD tends to be more common in some families, and events at key times in development may increase the risk for ADHD such as very preterm birth or prenatal exposure to excessive levels of alcohol.

A birth prior to 37 completed weeks of pregnancy is considered preterm. This occurs in approximately 8-9% of births in Australia. Most preterm births occur between 32 and 36 weeks of gestation, and these babies have excellent survival rates and long-term outcomes. 

Births prior to 32 completed weeks of gestation are referred to as very preterm, and occur in approximately 1.5% of births in Australia (5,000 babies per year). Due to advances in medical care, the majority of babies born very preterm now survive and have good outcomes, although survival and disability rates increase with decreasing gestational age at birth.

Professor Anderson says it is important for health professionals dealing with children born very preterm to know that there is a link with ADHD. 

“This knowledge will hopefully encourage them to monitor the child’s behaviour closely, and organise appropriate assessments and interventions when appropriate.”

Diagnosis of ADHD

He says the diagnosis of ADHD can be made by a paediatrician, child psychiatrist or psychologist based on criteria developed by an international mental health expert group.

There are three subtypes of ADHD, predominantly inattentive, predominantly hyperactive/impulsive, or combined (both inattentive and hyperactive/impulsive).

To fulfil the criteria for the inattentive or hyperactive/impulsive subtypes, the child must exhibit at least six pre-specified symptoms that have persisted for at least six months which are inconsistent with their developmental level.

“The child must have a persistent pattern of inattention symptoms and/or hyperactivity/impulsivity symptoms that interfere with functioning or development, with several symptoms present before age 12 years and observed in two or more settings,” Professor Anderson says.

“The symptoms must be severe enough to interfere with functioning, and cannot be explained by another disorder.”

Parenting a child with ADHD

Professor Anderson says children with ADHD can behave in a way that is challenging for parents and teachers. 

“Understanding the child’s abilities and limitations will assist in developing a behaviour management plan to help deal with the challenging behaviours,” he says.

“Each child is different, so there is no standardised behaviour management program, but developing routines, rules and consequences is important.

“Ensuring good sleep, a healthy diet and plenty of exercise may also help to reduce challenging behaviours. 

“Some doctors also prescribe stimulant medication for children diagnosed with ADHD.  While these medications can have some mild side-effects, they help some children with their attention and self-regulation.”

Professor Anderson says the challenging behaviours associated with ADHD can be difficult for families, with the potential to cause stress for parents and siblings. 

“Seeking professional support is important to optimise the functioning and development of children with ADHD, but is also important to address family stressors,” he says.

Deakin University Clinical Psychologist and Murdoch Children’s Research Institute Health Services Research Team Leader, Associate Professor Emma Sciberras says it that ADHD is not caused by bad parenting. However, it can be tricky to parent children with ADHD as their behaviours can be hard to manage.

“Warm and consistent parenting strategies can help to contain the behavioural difficulties that often go along with ADHD,” she says.

“Use of positive parenting strategies may also make you feel more connected and in tune with your child.”

“Generally, having lots of structure, understanding situations that are likely to trigger difficult behaviour and giving yourself some time out can help.”

Associate Professor Sciberras says children with ADHD can have a great deal of difficulty regulating their behaviour, which is likely linked to the delay in brain maturation.

“Parents may need some extra support to implement parenting strategies to contain challenging behaviours. The nature of ADHD (e.g. impulsivity, poorer emotional regulation) can lead children to make poor decisions and exhibit challenging behaviours; children aren’t generally trying to be naughty. Seeing your child’s behaviour through this lens can help.”

Associate Professor Sciberras says children with ADHD and their families may be supported by a health professional like a paediatrician or psychologist, and that families can be referred by a GP.

“Parents should also speak to their child’s school to see what supports might be available within the school system.

“An individual learning plan may be considered, as well as regular meetings each term with school staff to monitor progress and assess whether further classroom strategies might be needed. Some families also are supported by an ADHD coach.”

1 Franz AP, Bolat GU, Bolat H, et al. Attention-Deficit/Hyperactivity Disorder and Very Preterm/Very Low Birth Weight: A Meta-analysis. Pediatrics. 2018;141(1):e20171645