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The preschool edition of Promoting Alternative THinking Strategies (PATHS®) is a school-based, teacher implemented universal intervention developed in the United States designed to promote social emotional competence (SEC) in children as a foundation for improved mental health. PATHS is delivered as a curriculum and it is based on theories and research regarding SEC, brain development, and optimal school environments. A majority of children in Sweden attend preschool, which is government-subsidized and follows a national curriculum focusing on both academic and social emotional learning. However, there is not so much focus on formal instruction nor manual-based lessons. The purpose of this study was to assess the short-term (pre- to post-test) effects of PATHS in the Swedish preschool setting. Using a two-wave cluster randomized trial with multi-method and informant assessment (N = 285 4 and 5-year-old Swedish children; n = 145 wait-list control; n = 140 intervention; K = 26 preschools; k = 13 intervention; k = 13 control) we assessed changes in child emotional knowledge, emotional awareness, social problem solving, prosocial play, inhibitory control, and working memory using structural equation modeling (SEM). We included schools with at least one classroom of 4–5-year-old children from three municipalities. We excluded open preschools, parent cooperative preschools, and family day homes. After random assignment, schools were informed of condition assignment. Research team members were not blind to assignment. We hypothesized that relative to children in control schools, children in intervention schools would evidence improvements in social emotional competence as well as other outcomes. Children in PATHS, relative to children in the control, evidenced improvements in working memory and prosocial play, but also showed an increase in hyperactive behaviors. Girls in PATHS, relative to girls in the control, showed improvement in emotional knowledge and reduced anxiety. These results are considered in light of efforts to promote positive development and mental health. The trial registration number at ClinicalTrials.gov is NCT04512157. Main funding was from Swedish Council for Working Life and Social Research, the Swedish Research Council, Formas, and VINNOVA (dnr: 259-2012-71).

Executive function deficits are often reported as a specific weakness in preterm children. Yet, executive function development is still not fully understood. In a prospective longitudinal study, 115 preterm born children, ≤31 weeks of gestation, were recruited at birth and subject to neuropsychological assessments at ages 5.5 and 18 years. By applying Miyake and colleagues' integrative framework of executive function to our data, two core components of executive function, working memory and cognitive flexibility, were identified through confirmatory factor analysis. Developmental stability was investigated in a serial multiple mediator structural equation model. Biological, medical, and social factors as well as mental development at 10 months were entered as predictors. Both components of executive function were highly stable from 5.5 to 18 years. Gestational age, intrauterine growth, lack of perinatal medical complications, and female sex were positively related to mental development at 10 months, which together with parental education influenced both core executive functions at 5.5 years. Working memory at 5.5 years mediated outcome in working memory at 18 years. In addition to the mediation of cognitive flexibility at 5.5 years, perinatal medical complications and restricted intrauterine growth had a continued direct negative impact on cognitive flexibility at 18 years. The application of a theoretical framework added to our understanding of executive function development in preterm born children. The study supports early identification of executive deficits among children born preterm, as deficits are unlikely to diminish with maturation.

Background Improved neonatal care has resulted in increased survival rates among infants born after only 22 gestational weeks, but extremely preterm children still have an increased risk of neurodevelopmental delays, learning disabilities and reduced cognitive capacity, particularly executive function deficits. Parent-child interaction and parental mental health are associated with infant development, regardless of preterm birth. There is a need for further early interventions directed towards extremely preterm (EPT) children as well as their parents. The purpose of this paper is to describe the Stockholm Preterm Interaction-Based Intervention (SPIBI), the arrangements of the SPIBI trial and the chosen outcome measurements. Methods The SPIBI is a randomized clinical trial that includes EPT infants and their parents upon discharge from four neonatal units in Stockholm, Sweden. Inclusion criteria are EPT infants soon to be discharged from a neonatal intensive care unit (NICU), with parents speaking Swedish or English. Both groups receive three initial visits at the neonatal unit before discharge during the recruitment process, with a strengths-based and development-supportive approach. The intervention group receives ten home visits and two telephone calls during the first year from a trained interventionist from a multi-professional team. The SPIBI intervention is a strengths-based early intervention programme focusing on parental sensitivity to infant cues, enhancing positive parent-child interaction, improving self-regulating skills and supporting the infant’s next small developmental step through a scaffolding process and parent-infant co-regulation. The control group receives standard follow-up and care plus extended assessment. The outcomes of interest are parent-child interaction, child development, parental mental health and preschool teacher evaluation of child participation, with assessments at 3, 12, 24 and 36 months corrected age (CA). The primary outcome is emotional availability at 12 months CA. Discussion If the SPIBI shows positive results, it could be considered for clinical implementation for child-support, ethical and health-economic purposes. Regardless of the outcome, the trial will provide valuable information about extremely preterm children and their parents during infancy and toddlerhood after regional hospital care in Sweden. Trial registration The study was registered in ClinicalTrials.gov in October 2018 (NCT03714633).

BackgroundExtremely preterm (EPT) born children are at increased risk of cognitive and neurodevelopmental impairment, neuropsychiatric disorders and academic difficulties. Parents of EPT born child ...

Main objectives: executive functions are frequently a weakness in children born preterm. We examined associations of executive functions and general cognitive abilities with brain structure in preterm born adolescents who were born with appropriate weight for gestational age and who have no radiological signs of preterm brain injury on neuroimaging. Methods: The Stockholm Neonatal Project (SNP) is a longitudinal, population-based study of children born preterm (Results: significant differences in grey and white matter regional volumes and widespread differences in FA were seen between the two groups. No significant correlations were found between cognitive measures and brain volumes in any group after correction for multiple comparisons. However, there were significant correlations between FA in projection fibres and long association fibres, linking frontal, temporal, parietal, and occipital lobes, and measures of executive function and general cognitive abilities in the preterm born adolescents, but not in the term born adolescents. Overall significance of the study: in persons born preterm, in the absence of perinatal brain injury on visual inspection of MRI, widespread alterations in regional brain tissue volumes and microstructure are present in adolescence/young adulthood. Importantly, these alterations in WM tracts are correlated with measures of executive function and general cognitive abilities. Our findings suggest that disturbance of neural pathways, rather than changes in regional brain volumes, are involved in the impaired cognitive functions.

OBJECTIVE: The Stockholm Neonatal Project involves a prospective, cross-sectional, population-based, cohort monitored for 12 to 17 years after birth; it was started with the aim of investigating the long-term structural correlates of preterm birth and comparing findings with reports on similar cohorts. METHODS: High-resolution anatomic and diffusion tensor imaging data measuring diffusion in 30 directions were collected by using a 1.5-T MRI scanner. A total of 143 adolescents (12.18–17.7 years of age) participated in the study, including 74 formerly preterm infants with birth weights of ≤1500 g (range: 645–1486 g) and 69 term control subjects. The 2 groups were well matched with respect to demographic and socioeconomic data. The anatomic MRI data were used for calculation of total brain volumes and voxelwise comparison of gray matter (GM) volumes. The diffusion tensor imaging data were used for voxelwise comparison of white matter (WM) microstructural integrity. RESULTS: The formerly preterm individuals possessed 8.8% smaller GM volume and 9.4% smaller WM volume. The GM and WM volumes of individuals depended on gestational age and birth weight. The reduction in GM could be attributed bilaterally to the temporal lobes, central, prefrontal, orbitofrontal, and parietal cortices, caudate nuclei, hippocampi, and thalami. Lower fractional anisotropy was observed in the posterior corpus callosum, fornix, and external capsules. CONCLUSIONS: Although preterm birth was found to be a risk factor regarding long-term structural brain development, the outcome was milder than in previous reports. This may be attributable to differences in social structure and neonatal care practices.

Background Preventing externalizing problems in children is a major societal concern, and a great number of intervention programs have been developed to this aim. To evaluate their preventive effects, well-controlled trials including follow-up assessments are necessary. Methods This is a systematic review of the effect of prevention programs targeting externalizing problems in children. The review covered peer reviewed publications in English, German, French, Spanish and Scandinavian languages. Experimental studies of standardized programs explicitly aiming at preventing externalizing mental ill-health in children (2–19 years), with outcome assessments at ≥6 months post intervention for both intervention and control groups, were included. We also included long-term trials with consecutive observations over several years, even in the absence of follow-up ≥6 months post intervention. Studies of clinical populations or children with impairments, which substantially increase the risk for mental disorders, were excluded. Results Thirty-eight controlled trials assessing 25 different programs met inclusion criteria. Only five programs were supported by scientific evidence, representing selective parent training (Incredible Years and Triple-P), indicated family support (Family Check-Up), and school-based programs (Good Behavior Game, universally delivered, and Coping Power, as an indicated intervention). With few exceptions, effects after 6–12 months were small. Long-term trials showed small and inconsistent effects. Conclusions Despite a vast literature, the evidence for preventive effects is meager, largely due to insufficient follow-up post intervention. Long-term follow up assessment and effectiveness studies should be given priority in future evaluations of interventions to prevent externalizing problems in children.

Epidemiological studies based on Scandinavian national registers have shown that adults born preterm tend to attain lower than average education and income and to have a higher degree of welfare support 1. Numerous follow-up studies in school-aged children have reported lower cognitive performance and more learning problems in preterm children 2,3, even among those born moderately preterm 4. Population-based longitudinal studies have shown that cognitive level in childhood, in particular with respect to executive functions, is related to social outcome in adulthood, as reflected by indices of health, wealth and public safety 5. It is reasonable to assume that a less successful social outcome in adults born preterm may be partially attributed to cognitive deficits. Several factors are known to contribute to suboptimal cognitive development after preterm birth. The lower the gestational age at birth, the higher the risk of subsequent cognitive deficits and learning difficulties 6. The effect is partially mediated by neonatal complications, such as intraventricular haemorrhage, white matter disease, chronic lung disease and retinopathy of prematurity. These complications have been related to distinct neurodevelopmental disorders, such as cerebral palsy, and also to poor cognitive development in the absence of such disorders 7,8. Furthermore, large cohort studies 9,10 have shown that children born small for gestational age have learning problems and inferior school outcome, indicating that intrauterine growth restriction has a long-term negative impact on cognitive development. Longitudinal studies of children born preterm indicate that the effect of preterm birth varies with age 11. For some children, the negative influence may become more obvious over time when increasing demands are put on the child, as indicated by higher needs for special education and lower school achievement 12. However, there are few follow-up studies on adolescents and young adults 10,13–15 and our knowledge about long-term cognitive outcomes after preterm birth is therefore still limited. The study was conducted as part of the Stockholm Neonatal Project, a longitudinal population-based study of children born preterm in 1988–1993, with a very low birthweight of

Influence of childhood traumatic brain injury (TBI) on cognitive recovery and subsequent development is poorly understood. In this longitudinal study we used cluster analysis to explore acute stage individual profiles of injury age and cognition in 118 children with traumatic brain injury. Repeated measures of cognitive function were conducted at 30 months, indicating recovery, and 10 years post-injury, indicating development. Nine clusters were identified. Recovery was evident in three clusters, two of them with low functioning profiles. Developmental gains occurred for three clusters and an acute profile of higher freedom from distractibility (FFD) and lower processing speed (PS) was related to positive differences. One cluster, average low functioning and especially low verbal comprehension, demonstrated a slower development than peers. This suggests that developmental change after TBI in childhood takes place on a continuum, with both chance of long-term catching up, and risk of poor development. An acute profile of higher FFD and lower PS seemed to reflect injury consequences and were followed by developmental gains. These results challenge previous findings, and warrant further investigation.

Stem cell transplantation involves conditioning with TBI and/or intensive chemotherapy, which may cause long-term neuropsychological deficits, particularly in children treated at a very young age. The aim of this study was to investigate whether very young children who receive chemotherapy-based conditioning only (BUCY) may have a more favorable neuropsychological outcome than children conditioned with TBI-CY. Twenty-two children who underwent allogeneic SCT at 0.4-3.6 years of age were subject to an extensive neuropsychological assessment at an average of 6.5 years post-therapy. The test results of 10 children exposed to BU were compared to the results of 12 children who had received TBI. Ten of them had received single-dose TBI, whereas two had received fractionated TBI. The BU group performed at age level on verbal measures, but tended to score below age level in the executive and visuo-spatial domains (P

Objective To investigate whether repeat courses of antenatal corticosteroids have long-term effects on cognitive and psychological functioning. Study design In a prospective cohort study, 58 adolescents and young adults (36 males) who had been exposed to 2-9 weekly courses of betamethasone in utero were assessed with neuropsychological tests and behavior self-reports. Unexposed subjects (n = 44, 25 males) matched for age, sex, and gestational age at birth served as a comparison group. In addition, individuals exposed in utero to a single course (n = 25, 14 males) were included for dose-response analysis. Group differences were investigated using multilevel linear modeling. Results Mean scores obtained in 2 measures of attention and speed were significantly lower in subjects exposed to 2 or more antenatal corticosteroids courses (Symbol Search, P = .009; Digit Span Forward, P = .02), but these were not dose-dependent. Exposure to repeat courses of antenatal corticosteroids was not associated with general deficits in higher cognitive functions, self-reported attention, adaptability, or overall psychological function. Conclusions Although this study indicates that repeat exposure to antenatal corticosteroids may have an impact on aspects of executive functioning, it does not provide support for the prevailing concern that such fetal exposure will have a major adverse impact on cognitive functions and psychological health later in life.

Background Preterm birth is associated with later hypertension and diabetes. One explanation for this association could be that exposure to antenatal corticosteroids (ACS), especially if repeated, induce adverse long-term effects. There are no data on whether repeat courses of ACS are associated with health problems later in life. The aim of this study was to assess whether repeat courses of ACS correlate to metabolic syndrome later in life. Methods In a population-based cohort we measured BMI, blood pressure, arterial stiffness, blood lipids and glucose tolerance in 58 subjects (36 boys, age 14 to 26 years) exposed to 2–9 weekly courses of antenatal betamethasone. Subjects exposed to a single course (n=25, 14 boys) and unexposed subjects (n=44, 25 boys) were included as comparison groups. Results As compared to unexposed controls, subjects exposed to repeat courses of ACS did not differ in BMI (mean difference 0.6kg/m 2 , p=0.5), mean systolic or diastolic blood pressure (mean diff 1mmHg, p=0.78–0.83), arterial stiffness assessed by pulse wave analysis (mean diff 0.1%, p=0.50), triglyceride (mean diff 0.1mmol/L), total cholesterol (mean diff 0mmol/L), LDL/HDL ratio (mean diff 0.1), Lipoprotein(a) (mean diff. 61mg/L), ApolipoproteinB/ApolipoproteinA1 ratio (mean diff 0.01), (p=0.33–0.91) or glucose tolerance assessed by HOMA-index (mean diff 0, p=0.84). Subjects exposed to a single course of ACS did not differ from the other groups in any of the variables above. Conclusions Repeat courses of ACS do not correlate to metabolic syndrome in young adulthood. This observation has clinical implications for the ongoing discussion about safety of antenatal steroids.

Preterm children appear to develop a different neurobehavioral organization from children born at term, and executive function (EF) has repeatedly been cited as an area of specific weakness. Likewise, neuroimaging studies have shown that the majority of very preterm infants display structural abnormalities, including white matter injury and volumetric differences (Nagy et al., 2003, 2009). Based on the analysis of the effects of lesion in adults, Stuss & Alexander (2007) have proposed a theoretical model, relating discrete categories of EF to regions within the frontal lobes. These EF categories and their coarse frontal localizations are: Executive cognition – dorsolateral prefrontal cortex (DLPFC), Behavioral / emotional self regulation – Ventral prefrontal cortex (VPFC) and Energization- superior medial frontal gyrus. The aim of this study was to identify preterm young adults’ strengths and weakness in terms of EF categories, and investigate their brain structural correlates. Preterm children appear to develop a different neurobehavioral organization from children born at term, and executive function (EF) has repeatedly been cited as an area of specific weakness. Likewise, neuroimaging studies have shown that the majority of very preterm infants display structural abnormalities, including white matter injury and volumetric differences (Nagy et al., 2003, 2009). Based on the analysis of the effects of lesion in adults, Stuss & Alexander (2007) have proposed a theoretical model, relating discrete categories of EF to regions within the frontal lobes. These EF categories and their coarse frontal localizations are: Executive cognition – dorsolateral prefrontal cortex (DLPFC), Behavioral / emotional self regulation – Ventral prefrontal cortex (VPFC) and Energization- superior medial frontal gyrus. The aim of this study was to identify preterm young adults’ strengths and weakness in terms of EF categories, and investigate their brain structural correlates. As a part of the longitudinal Stockholm Neonatal Project, 62 preterm and 38 term children were administered the Delis-Kaplan Executive Function System (D-KEFS) and behavioral self-reports (YSR and SDQ) as indices of EF at age 18. To investigate structural brain correlates, T1 and T2 weighted and diffusion weighted magnetic resonance images have been collected using a 1.5 T scanner. Results showed that preterm children had deficits primarily in Executive cognition and Energization, and less so in Behavioral self-regulation, with the extremely preterm children, born GA 23-28, having the most marked deficits also when controlling for overall cognitive level. Structural brain correlates are presently analyzed and preliminary findings are presented. Conclusion: A theory-based and interdisciplinary approach promotes our understanding of executive dysfunction in preterm children.