Jack Maypole, MD
Jack Maypole, MD
Comprehensive Care Program, Boston Medical Center

Where Teamwork Matters

The complicated case of preemies and ADHD

If your child was born premature, know that chances are high he or she will grow up healthy and well-adjusted. “It is amazing how well almost all preemies do in the end,” as Steve Parker, M.D., the late developmental pediatrician and author, used to say. “But,” he added, “clearly, the smaller a preemie was, the more likely there could be long-term developmental challenges.” Here, pediatrician Jack Maypole describes one such ex-preemie challenge—ADHD—and its unique causes and effects.

Trey and his mom had come for a checkup here at Boston Medical Center, and we didn’t have a lot of time. Her 5-year-old was hale and well met, a great specimen of a boy, complete with the classic buzz cut and cherubic cheeks. And born at 25 weeks, Trey had only some mild asthma to show for it. His teachers delighted in his manners, intelligence and winning smile, and you’d be forgiven for thinking he escaped any consequences of being a preemie.

Father with Child in Doctor's OfficeBut if you spent some time with Trey in an enclosed space—an exam room, say—you’d start to wonder if something was amiss. Trey moves. Constantly.  If we didn’t move chop-chop, he might just disassemble my exam room; as if propelled by jet pack, our little man bounced from otoscope to exam table to my computer, smiling, poking and futzing. All the while his mother redirected him with excellent focus and cleverness…to little avail.

Trey’s mom filled me in; his teachers, so impressed with him in September, were having trouble with Trey during activities and circle time. With trepidation, his mom asked: “Does Trey have ADHD?” Though he’d defied expectations, emerging from the NICU with an excellent bill of health, medically and developmentally, could his jet-pack ways and inattentiveness be a result of his prematurity? Or, could it be something he might have had anyway?

The answer is yes. To both. As it happens, ex-preemies like Trey (those born before 36 weeks of gestational age) pose a splendid dilemma for parents, educators and health care providers. Advances in medical technology have established a cohort of children (and increasingly, adults) the world has never seen before. These children, who now constitute about 12 percent of all births, have had increased survival rates—more than 85 percent for those born smallest and earliest. Historically, a significant number never would have made it out of infancy.

To be sure, a lot of preemies have minimal issues in childhood and into adulthood. That is the good news. Commenting on a 2002 study, the American Psychological Association’s former chair on Children, Adolescents and Their Families, Dr. David Fassler, noted, “The good news we can tell parents is that there are many children who are born at very low birth weight who appear to do quite well. That is an important and encouraging message. Now we need to figure out which kids are at relatively greater risk and find interventions that are effective for those children.”

More to the point with kids like Trey, some have behavior problems that aren’t apparent until they reach school age. Why? Neurodevelopmental specialists posit that a premature birth disrupts the “finishing phase” in a preemie’s central nervous system, since a critical stage of nerve connection and wiring occurs in the last trimester of pregnancy.  In particular, ex-preemies appear to face greater challenges in skills especially required of children in school, most of which fall under the umbrella of executive function, including verbal fluency, working memory and cognitive flexibility.

And like my man Trey, they may face greater challenges in paying attention. In short, studies of ex-preemies like those done by Maureen Hack and colleagues at Case Western, as summarized in an article in the New York Times, hold that preemies may have a unique form of ADHD. My Boston Medical Center colleague, developmental pediatrician Marilyn Augustyn, estimates that school-age ex-preemies with inattentiveness may respond to ADHD medications less well than their peers—with only about a 60 percent success rate, she reckons, versus for more than 80 percent with “healthy” kids.

What to do? Parents need to partner with the circle of providers working with their child—primary care doctor, teacher, special education staff—to optimize his social and educational experience. Fortunately for all, there are age-appropriate tools, including questionnaires that parents and teachers can use to help clinch the diagnosis.

As for me, the doc who gamely tried to hold Trey at bay, here’s what I tell parents: It’s our shared responsibility to hope for the best, identify success when we see it and never stop watching.