There are two parts to this assignment: A critical appraisal of Whitfield, M.F., Grunau, R.V.E., Holsti, L. (1997), Extremely premature (≤800g) schoolchildren: multiple areas of hidden disability from Archives of Disease in Childhood (77:F85-F90), followed by an exemplar information leaflet based on the study, to be given to parents.

Please remember that this is merely a medical school assignment, and does not constitute medical advice.

Critical Appraisal

The authors of this paper are attempting to explore the educational needs of extremely low birthweight (ELBW) children. They consider this to be an important area for research since many more of these children are now surviving to school age, and yet little work has been completed in this field with reference specifically to children of birthweights lower than 800g; other work has tended to focus on children of birthweight ≤1000g. The authors concluded that “the most likely outcome for ELBW survivors at school age is a learning disorder, often multiple, or borderline intellectual functioning, combined with behavioural and motor risk factors rather than severe/multiple disability”. I do not think that the methods that have been used to reach this conclusion are entirely satisfactory, but the evidence found is, for the most part, so overwhelming that the relatively small errors in their method are offset by the level of evidence, particularly as some of the methods lead to underestimates of learning disorders.

In order to assess the educational needs of these ELBW children, the authors have chosen to compare a group of 119 ELBW children to 50 full-term children. The authors have chosen not to include details about the birthweights of these children, which makes it difficult to assess the validity of the comparison since various complications during pregnancy can lead to full-term babies having abnormal birthweights – for example, gestational diabetes can lead to children with higher birthweights than those considered to be within the ‘normal’ range, and preeclampsia can lead to full-term babies with low birth weights. Perhaps a more valid comparison would be between those born, say, eight weeks premature and those born at full-term. Furthermore, the comparison of 119 children in the former category and only 50 in the latter is not good practice; groups of the same size would make for a more valid comparison.

The age range of children in the ELBW group (7.9 years) was much greater than the age range in the comparison group (5.6 years), which again makes for a somewhat invalid comparison, since advances in care for ELBW children made in those 7.9 years would not be taken into account. That is to say, if the children born earlier were given less effective treatment than those born later, the lower scores of those born earlier would reduce the average score for the group.

Both groups of children underwent various tests, and the average results for each group were calculated and compared. Given that the authors themselves criticise earlier work for using “mean values and ranges [which] mask the complex profiles of individual children”, it seems an unusual choice to make for their own comparison. When fine and gross motor skills were assessed for example, the very lower scores which would presumably be obtained by those children with severe neural problems would lower the average score, thus not giving an accurate reflection of the perhaps normal scores obtained by the normal children. In order to combat this problem, children with severe or multiple disabilities were excluded from some of the tests. Whilst removing one potential problem, however, this introduces another two: firstly, the results will not be applicable to the group as a whole, as they will not now take account at all of those children deemed ‘unsuitable’ for the test. Secondly, they are required to define ‘severe disability’. The authors state that their criteria for a severe disability were “conservative”, trying to exclude only those that were “functionally affected”. Overall, their solution to an inherent problem with examining groups of children where specific analysis of each child one is preferable seems to raise more problems than it solves.

The particulars of the testing conducted upon the children appear to contain a number of apparent irregularities: Firstly, the measurement of the children’s intelligence appears to have been conducted in a rather non-standard fashion, with different children given one of three different tests. One would expect that the children would all be given the same test so that any difference in performance between each of the children could be attributed directly to the child rather than the structure of the particular test taken. The fact that test scores were not adjusted for prematurity also seems unusual, but this is, perhaps, due to the nature of the study: school starting ages are not adjusted for prematurity, and so it is logical that the tests should also not be adjusted for this factor. This is, perhaps, a strength of this particular study, rather than a weakness.

A major weakness of this research is identified by its authors: Their calculation of “functional disability” ignores a number of factors which would be of importance in a classroom situation. Firstly, “children with low average intelligence and low academic achievement are viewed as progressing commensurate with their intelligence”. Whilst this may be appropriate for assessing the function disability of an individual child, it is of little help in a classroom situation. “One result of being born very small is an overall reduction in IQ”, therefore these ELBW children are likely to have a lower IQ that the majority of their class. Therefore, whilst their academic achievement will be commensurate with their own intelligence, it will be slower than that of the rest of the class, meaning that they would effectively have a functional disability in comparison with their peers. This is not identified in this study. Furthermore, behavioural problems and fine motor coordination were not included in the assessment. Clearly, a child with behavioural problems will not find the classroom to be as effective a working environment as an unaffected child, whilst the child with fine motor coordination problems is unlikely to be able to write clearly, and so will, again, have difficulty in a classroom situation. For these reasons, the researcher’s findings are likely to be conservative figures, which only serve to add weight to their generalised conclusion.

If the authors’ conclusions are indeed valid, then there is clearly a need to ensure that appropriate funding is in place to deal with the educational needs of ELBW children as they reach school age. Clear support mechanisms should be established to ensure that parents have somewhere to turn if they feel there is a difficulty, and so that they receive regular feedback on their child’s school progress so that they can help to provide the extra encouragement that this paper identifies as necessary. If possible, the parents should also be actively involved in helping their child reach their ability in school.

Therefore, whilst the methods used are, in some cases, not to the highest standards, it would appear that the wider, generalised conclusion made (that “the most likely outcome for ELBW survivors at school age is a learning disorder, often multiple, or borderline intellectual functioning, combined with behavioural and motor risk factors rather than severe/multiple disability”) is supported by the evidence found, and likely to be satisfactory, meaning that funding and support mechanisms in schools need to be put in place to deal with the educational needs of these children.

Handout

More and more very premature children are surviving to school age these days, and so a group of children’s doctors from the University of British Columbia, and the British Columbia Children’s Hospital, have recently done some research into the educational needs of very premature babies. This leaflet is designed to tell you what they found.

For their research, the scientists took a group of school children whose birthweight was 800g (1lb 2oz) or below, and compared these with a group of school children who were born at full-term. They asked each of the children to complete a series of tests, including an IQ test and a psychological assessment, and compared the results for the two groups.

The first thing the scientists found was that very premature children that survived to school age were far more likely to have a learning or behavioural difficultly rather than a severe disability. It is worth noting that four in ten of the premature children showed no learning difficulties at all, and one in four showed no learning difficulties or disabilities whatsoever.

About one in five of the full-term children showed learning difficulties, and so these are by no means exclusive to premature children. Having ‘learning difficulties’ means that the child will normally receive extra help at school, because, for example, it sometimes takes them a bit longer to understand maths, or they have trouble writing. Very premature children tend to have problems in more than one area academically, perhaps struggling with both maths and English, for example. Support in school for children with learning difficulties will be paid for and provided by the child’s school, so it should not present any financial burden to the parents.

The research also identifies that, in general, the intelligence of extremely premature children tends to be slightly lower than that of most full-term children, but the very premature children tended to perform better in intelligence tests than those full-term children from poorer backgrounds.

The researchers also found that children born very prematurely are more likely to have behavioural difficulties that might affect their performance at school, particularly needing constant praise and encouragement to work well. Again, schools can help to make sure that the child performs to the best of their ability, perhaps by providing a learning assistant to work with the child and give encouragement and help with work.

Similarly, parents can work with their child to help them reach their potential, perhaps by helping with homework and giving some of the extra encouragement their child needs.

It is important to note that research like this groups many children together to examine their needs. It is impossible to say exactly what individual difficulties each unique child may or may not face as they reach school age, whether the child is born prematurely or at full-term. Whatever the outcome, there are always people available to help you and your child to overcome any difficulty. If you would like to know more about this research, or you are worried about any aspect of child birth or parenting, please contact the National Childbirth Trust.