A Unique Child: Prematurity - Term times

There is a growing body of research that suggests that children born pre-term are more likely to have some developmental delays and difficulties than children born full-term. Although worrying, this growing insight means that there is a greater understanding developing of why children may have specific needs - and of improved ways of helping them.

First of all, though, it is important to remember that being born prematurely is not a life sentence - it does not come with a fixed set of symptoms or outcomes. It would be wrong to alarm parents and to label pre-term children as automatically having physical, emotional or learning difficulties. But as reflective practitioners, it is our responsibility to see the individual child and to consider their needs in the context of all their experiences, so that we can best respond to them.

Raising awareness of the potential impact of pre-term birth on physical, emotional and learning development leads to increased understanding of the messages children communicate to us through their behaviour and learning responses.

INSTINCTIVE BEHAVIOURS

The NYU Child Study Center suggests that there are some instinctive behaviours that pre-tem babies (in common with babies experiencing other trauma or sickness) may use in their earliest days to protect them from the overwhelming sensations to which they could be exposed. Over time these behaviours can become habitual, even though they are no longer needed. These include:

• hypervigilance
• dissociation
• distractibility.

So how do we recognise these behaviours as the child grows older? A hypervigilant child is always on alert and finds it hard to settle and relax, especially in new or constantly changing situations.

They might be jumpy and easily startled by noise, bright lights or unexpected touch. They might be physically cautious, not wanting to expose themselves to potential hurt or discomfort.

They may struggle with any change to their routine or regular small changes during their day (for example, a different activity), and bigger transitions such as meeting new people and moving classes.

As they get older, these children might find it threatening to sit on the carpet with people behind them, or in a part of the room where they can't see everything that is going on. It is unlikely they will recognise or explain these feelings, however, so the signs are most likely to be observed in disruptive behaviour as they try to communicate their agitation in the only way available to them.

A dissociated child might seem dreamy and 'on another planet'. They have learned how to disconnect to feel safe. They might take ages to do things, sometimes almost 'freezing', and the more you hurry them, the more 'frozen' they might become.

They also dislike changes to their routines and might struggle with new people, staying distant even with people that you expect them to feel confident with. They may not cry very much, but you will know they are not very happy.

A distractible child is the 'butterfly' who won't settle. They are 'sensory seeking' - looking for constant change in sensation rather than settling to explore something deeply. This might be through constant movement (hyperactivity) or needing to touch things and other people, always talking and making sounds, or moving from one activity to another without finishing anything.

HOW TO RESPOND

The above behaviours can interfere with a child's social and emotional development as well as learning progress. However, we see children with these behaviours every day in our settings and they may not all have been born pre-term.

There are multiple factors that can contribute to these behaviours, but when we recognise the impact of pre-natal and neo-natal experiences, we begin to see the reasons why children might behave in certain ways. This helps us to respond more sensitively, and ultimately more effectively, for all our children. Good practice for these children is good practice for all:

• Recognising that a hypervigilant, dissociated or distractible child is going to struggle with change forces us to look more carefully at the small transitions that we expose our children to during the day and how we can best help them to manage them.
• It reinforces the importance of a robust key person approach that supports children to build secure relationships with practitioners who know them well and can read the subtle signs of their behaviour, and offers a secure place from which they can take small steps to stretch their tolerance levels.
• Being aware of touch-sensitive children alerts us to the fact that they may be more likely to lash out at others in response to just the slightest touch. We probably wouldn't perceive a light brush on the arm from someone walking past as a 'threat', but they might. Their 'aggressive' behaviour is more a reflex action than a will to hurt. They will respond best to firm rather than gentle touch (which can be more irritating) and will need help and understanding to soothe the intensity of their reactions.
• Sensory-seeking children can be helped to achieve the sensations they crave with lots of physical activity, indoors and out, to stimulate their vestibular and proprioceptive senses. They may be unable to tolerate long periods of sitting on the carpet or in assemblies but might be helped by leaning against an adult sat next to them or having something discreet to fidget with.
• A physically cautious child will need sensitive support to try new activities. They are helped best by people who know them well enough to 'meet them where they are at' with their physical and motor skills and bring them gently and gradually to a more robust and confident stage of physical development.

All the above strategies are relevant for all children at some stage in their development, so there is no need for these to be labelled as special strategies for pre-term children. This is important for parents who may be anxious about their child being labelled or singled out as needing special attention.

If there have been no medical issues for their pre-term child, they may not see the connection between their birth and any later issues and the subject will need to be broached sensitively and handled carefully, as with all concerns about a child's development. Handled well, however, the information about the impact of pre-term birth on children's emotional, behavioural and learning development can help calm parents' anxieties because it helps them understand the reasons behind their child's behaviours or difficulties.

Family and Baby, or FaB, projects across the country now link parents with children in neonatal units with family support in their local children's centres, ensuring that vulnerable families with pre-term babies access support even before their children have left hospital.

MATHEMATICAL AND LEARNING DIFFICULTIES

There is a growing body of research to suggest that children born pre-term are more likely to have particular problems with maths and other learning that relies on executive functions such as working memory. This is not completely understood yet but a five-year study has begun at the University of California, San Diego, which will use MRI brain scans and other research techniques to follow the development of children born pre-term as they start kindergarten.

The more we understand about how the brain develops in children born full-term and pre-term, the better we will be able to target interventions appropriately.

A cohort study based on the Avon Longitudinal Study of Parents and Children (ALSPAC) has suggested that some pre-term children may start school a whole year earlier than they would have done if they had been born on their due date. There may not be scope currently to adjust a child's admission date, but it is still an important point to remember when assessing a child's progress.

Ask what you would expect of this child if they were in the school year below. This is not about lowering expectations for these children, but about being realistic and sensitive to the added impact that their prematurity may have on their attainment.

MORE INFORMATION

• Mathematics Difficulties in Children Born Very Pre-term: current research and future directions by V Simms, L Cragg, C Gilmore, N Marlow and S Johnson, www.ncbi.nlm.nih.gov/pubmed/23759519
• Premature Infants: a later look, NYU Child Study Center, www.aboutourkids.org/articles/premature_infants_later_look
• Prematurity, part 1, www.nurseryworld.co.uk/nursery-world/feature/114056/
• Pre-term Birth, Age at School Entry and Educational Performance by D Odd, D Evans and A Emond (2013) ALSPAC, www.ncbi.nlm.nih.gov/pubmed/24146899
• The Family and Baby Project: social and psychological support for families on the NICU by Jacqui Morgan and Tracy Rimmer
• Studies of survival and later health among those born from 22 to 26 weeks, www.epicure.ac.uk

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