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A Literature Review: Attention Profile in Preterm Children--It's Time to Act

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Title: A Literature Review: Attention Profile in Preterm Children--It's Time to Act
Language: English
Authors: Dominique A. Jaeger (ORCID 0009-0004-4078-8995), Nina Gawehn, Boris Suchan (ORCID 0000-0003-2934-0263)
Source: Journal of Attention Disorders. 2025 29(14):1319-1344.
Availability: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com
Peer Reviewed: Y
Page Count: 26
Publication Date: 2025
Document Type: Journal Articles
Information Analyses
Descriptors: Premature Infants, At Risk Persons, Child Development, Attention Deficit Disorders, Children, Preadolescents, Attention Deficit Hyperactivity Disorder, Symptoms (Individual Disorders), Screening Tests, Behavior Problems, Child Behavior
Assessment and Survey Identifiers: Strengths and Difficulties Questionnaire
DOI: 10.1177/10870547251361222
ISSN: 1087-0547
1557-1246
Abstract: Objective: Children born preterm are at an elevated risk of developmental challenges, often exhibiting a distinct "preterm behavioral phenotype" characterized by particular attention difficulties. This review focuses on examining the phenotypical attention profile in preterm children aged 5 to 11 years, considering both clinical and neuropsychological aspects. Method: Following the PRISMA reporting guidelines, 22 peer-reviewed studies were analyzed. Result: According to behavioral-clinical aspects, preterm children appear to be at heightened risk for inattentive attention problems, including a predisposition to the predominantly inattentive presentation of ADHD. Regarding neuropsychological attention, deficits were identified in top-down controlled intensity processes as well as in certain components of selectivity and executive functioning. Conclusion: This review yields evidence that preterm children exhibit distinct and specific attention deficits during preschool and school age, characterized by a phenotypical clinical and neuropsychological attentional profile. Early identification of these issues is crucial, as it enables timely interventions to support school participation and mitigate the risk of learning difficulties, academic failure, and other secondary complications associated with attention deficits.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1488403
Database: ERIC
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  Value: <anid>AN0188923027;gs001dec.25;2025Oct30.03:45;v2.2.500</anid> <title id="AN0188923027-1">A Literature Review: Attention Profile in Preterm Children—It's Time To Act </title> <p>Objective: Children born preterm are at an elevated risk of developmental challenges, often exhibiting a distinct "preterm behavioral phenotype" characterized by particular attention difficulties. This review focuses on examining the phenotypical attention profile in preterm children aged 5 to 11 years, considering both clinical and neuropsychological aspects. Method: Following the PRISMA reporting guidelines, 22 peer-reviewed studies were analyzed. Result: According to behavioral-clinical aspects, preterm children appear to be at heightened risk for inattentive attention problems, including a predisposition to the predominantly inattentive presentation of ADHD. Regarding neuropsychological attention, deficits were identified in top-down controlled intensity processes as well as in certain components of selectivity and executive functioning. Conclusion: This review yields evidence that preterm children exhibit distinct and specific attention deficits during preschool and school age, characterized by a phenotypical clinical and neuropsychological attentional profile. Early identification of these issues is crucial, as it enables timely interventions to support school participation and mitigate the risk of learning difficulties, academic failure, and other secondary complications associated with attention deficits.</p> <p>Keywords: preterm children; phenotypical attentional profile; neuropsychological attention; behavioral-clinical aspects</p> <hd id="AN0188923027-2">Introduction</hd> <p></p> <hd id="AN0188923027-3">Brain Development and Vulnerability in Preterm Birth</hd> <p>Brain development begins shortly after conception and extends into the second decade of life ([<reflink idref="bib19" id="ref1">19</reflink>]; [<reflink idref="bib87" id="ref2">87</reflink>]). The prenatal phase, particularly the 40 weeks of pregnancy, represents the most susceptible period to exogenous disturbances, as the brain undergoes significant developmental changes during this time ([<reflink idref="bib54" id="ref3">54</reflink>]; [<reflink idref="bib97" id="ref4">97</reflink>]). Throughout this stage, the central nervous system remains insufficiently prepared to function independently outside the uterine environment.</p> <p>Preterm birth, defined as delivery before 37 completed weeks of gestation, interrupts this critical developmental period and presents significant risks to brain development. Depending on the gestational age at birth, these risks can vary in severity. Preterm births are categorized into three subgroups: extremely preterm (<28 weeks), very preterm (28–<32 weeks), and moderately to late preterm (32–<37 weeks). The earlier the gestational age, the greater the potential for long-term structural and functional brain changes. Infants born extremely preterm are at the greatest risk, followed by those born very preterm, with moderately to late preterm infants facing comparatively lower—but still elevated—risks ([<reflink idref="bib6" id="ref5">6</reflink>]; [<reflink idref="bib67" id="ref6">67</reflink>]).</p> <p>Even without the need for intensive medical intervention, the immaturity of the preterm infant brain can result in atypical neurodevelopmental trajectories that may involve cognitive and emotional impairments. ([<reflink idref="bib98" id="ref7">98</reflink>]). These risks are further compounded by medical complications requiring interventions such as mechanical ventilation, medications, resuscitation, tube feeding, and surgeries ([<reflink idref="bib15" id="ref8">15</reflink>]). In addition to these medical factors, preterm birth is often associated with psychosocial challenges, such as prolonged hospital stays and separation from primary caregivers, all of which contribute to altered neurodevelopmental trajectories ([<reflink idref="bib41" id="ref9">41</reflink>]; [<reflink idref="bib85" id="ref10">85</reflink>]).</p> <hd id="AN0188923027-4">Long-Term Neurodevelopmental Outcomes</hd> <p>A growing body of evidence associates preterm birth with adverse long-term outcomes, including neurosensory impairments ai ([<reflink idref="bib60" id="ref11">60</reflink>]; [<reflink idref="bib64" id="ref12">64</reflink>]; [<reflink idref="bib86" id="ref13">86</reflink>]; [<reflink idref="bib97" id="ref14">97</reflink>], [<reflink idref="bib98" id="ref15">98</reflink>]), cognitive deficits ([<reflink idref="bib28" id="ref16">28</reflink>]; [<reflink idref="bib60" id="ref17">60</reflink>]; [<reflink idref="bib68" id="ref18">68</reflink>]; [<reflink idref="bib96" id="ref19">96</reflink>]), neuropsychological challenges, and psychiatric conditions ([<reflink idref="bib3" id="ref20">3</reflink>]; [<reflink idref="bib9" id="ref21">9</reflink>]; [<reflink idref="bib13" id="ref22">13</reflink>]; [<reflink idref="bib50" id="ref23">50</reflink>]; [<reflink idref="bib78" id="ref24">78</reflink>]).</p> <p>Among these outcomes, attention-related difficulties are particularly prevalent, including ADHD or subclinical attention problems ([<reflink idref="bib1" id="ref25">1</reflink>]; [<reflink idref="bib9" id="ref26">9</reflink>]; [<reflink idref="bib10" id="ref27">10</reflink>]; [<reflink idref="bib91" id="ref28">91</reflink>]). However, emerging evidence suggests that the attention profile associated with prematurity may differ from that of term-born children. It is primarily marked by inattention and attentional dysregulation, rather than hyperactivity or impulsivity ([<reflink idref="bib49" id="ref29">49</reflink>]; [<reflink idref="bib79" id="ref30">79</reflink>]). Moreover, typical ADHD patterns—such as the male predominance and frequent comorbidity with conduct disorders—are less evident in preterm populations ([<reflink idref="bib50" id="ref31">50</reflink>]). Instead, preterm children with attention deficits show a stronger link to medical risk factors than to sociodemographic or familial ones ([<reflink idref="bib50" id="ref32">50</reflink>]). These findings support the concept of a distinct "preterm attentional phenotype" ([<reflink idref="bib34" id="ref33">34</reflink>]; [<reflink idref="bib51" id="ref34">51</reflink>]).</p> <hd id="AN0188923027-5">Clinical Relevance and Future Directions</hd> <p>A comprehensive understanding of attention profiles in preterm children is essential. The attention system develops relatively early and serves as a foundational neuropsychological function, supporting the later emergence of higher-order cognitive abilities such as executive functioning and cognitive control ([<reflink idref="bib75" id="ref35">75</reflink>]; [<reflink idref="bib77" id="ref36">77</reflink>]). Cognitive abilities develop hierarchically and reciprocally, making the early development of attention particularly critical ([<reflink idref="bib26" id="ref37">26</reflink>]). Suboptimal development of the attention system has been linked to educational difficulties and poorer academic outcomes ([<reflink idref="bib44" id="ref38">44</reflink>]; [<reflink idref="bib47" id="ref39">47</reflink>]).</p> <p>Attention deficits in preterm children are not only early markers of broader cognitive impairments but also significantly impact daily life. Notably, longitudinal studies suggest these difficulties persist into early adulthood ([<reflink idref="bib16" id="ref40">16</reflink>]; [<reflink idref="bib58" id="ref41">58</reflink>]). Therefore, better understanding of attention profiles in preterm populations is crucial for early detection, tailored clinical diagnostics, and intervention planning. For example, treatments designed for term-born children with ADHD may require adaptation to meet the specific needs of preterm individuals. Additionally, identifying specific areas of impairment could inform the development of targeted interventions, thereby enhancing the likelihood of meaningful improvements.</p> <hd id="AN0188923027-6">Clinical Aspects of Attention</hd> <p>From a diagnostic and screening-based perspective, attention-related functioning can be understood in two ways: as a range of behaviors that may indicate attention problems, or as a clinical condition that meets specific diagnostic criteria. The first approach involves questionnaires completed by parents or teachers, which assess symptoms such as inattentiveness or hyperactivity across a spectrum. These tools are used to identify children who may be at risk for attention difficulties, but they do not provide a formal diagnosis. This symptom-based approach is often referred to as dimensional, as it captures variation in behavior without applying a diagnostic threshold.</p> <p>In contrast, a clinical diagnosis of ADHD is made by trained professionals based on clearly defined criteria, following standardized diagnostic systems such as the DSM-5 or ICD-11. These systems describe three presentations of ADHD: inattentive (ADHD-IA), hyperactive/impulsive (ADHD-HI), and combined presentation (ADHD-C). This diagnosis-based approach is considered categorical, as it classifies individuals as either meeting or not meeting the criteria for a disorder. Table 1 provides an overview of the assessment tools used in the included studies. Notably, some widely used instruments—such as the BASC-3, Conners scales, or Continuous Performance Tests (CPT)—were not represented, as none of the reviewed studies applied these measures.</p> <p>Table 1. Identified Assessments Included in This Review Measuring Behavior and Psychopathology Regarding Aspects of Attention in Middle Childhood Grouped by Behavioral-clinical Aspects, Scales, and List of Assessments.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">Clinical domain</th><th align="center">Scales</th><th align="center">Assessment</th></tr></thead><tbody><tr><td>DSM-V diagnosis of ADHD presentations• ADHD Inattentive• ADHD Hyperactive/impulsive• ADHD Combined</td><td>ADHD Index• ADHD/IA• ADHD/HI• ADHD/C</td><td>Disruptive Behavior Disorders Rating Scale (DBD-RS): parent form (PDBD); teacher form (TDBD) Children's Interview for Psychiatric Syndromes—parent version (P-ChIPS) The Development and Well-Being Assessment (DAWBA): parent and teacher reportYale Children's Inventory (YCI): parent reportChild Symptom Inventory (CSI): parent or teacher reportKiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K-SADS-PL): parent and child report</td></tr><tr><td>Informant's report of child attention problems as a categorical variable with empirical cut-offs for identification of borderline or of abnormal scores</td><td>Attention problem scaleAttention problemInattentionHyperactivity/impulsivityHyperactivity/inattention</td><td>Achenbach System of Empirically Based Assessment (ASEBA): Child Behavior Checklist (CBCL) Achenbach System of Empirically Based Assessment (ASEBA): Teacher Report Form (TRF)/preschool (1–5) and school (6–18) Strengths and Difficulties Questionnaire (SDQ): parent or teacher report</td></tr></tbody></table> </ephtml> </p> <hd id="AN0188923027-7">Neuropsychological Aspects of Attention</hd> <p>From a neuropsychological perspective, the attention system can be categorized into three primary domains. The first domain encompasses intensity-related aspects such as alertness, vigilance, and sustained attention. The second domain refers to selection and orienting processes, including selective and divided attention. The third domain pertains to executive attention, including inhibition, interference control, and task switching ([<reflink idref="bib71" id="ref42">71</reflink>]; [<reflink idref="bib74" id="ref43">74</reflink>]; [<reflink idref="bib95" id="ref44">95</reflink>]; Figure 1).</p> <p>Graph: Figure 1. Components of the attentional system—a taxonomy of attention modified after Posner (1990), [<reflink idref="bib88" id="ref45">88</reflink>], and [<reflink idref="bib95" id="ref46">95</reflink>].</p> <p>Even before the development of the three network model, Posner and colleagues introduced the concept of a dual attention system in the 1980s ([<reflink idref="bib72" id="ref47">72</reflink>]). This model differentiates between two fundamental mechanisms of attentional control: bottom-up processes, which are stimulus-driven and automatic, and top-down processes, which are voluntary and goal-directed. This distinction laid the theoretical foundation for later neurobiological models.</p> <p>In line with this, [<reflink idref="bib73" id="ref48">73</reflink>] proposed that the attention system consists of three distinct yet interconnected networks: the alerting, orienting, and executive attention networks. These are thought to reflect both bottom-up and top-down processes to varying degrees ([<reflink idref="bib70" id="ref49">70</reflink>]; [<reflink idref="bib73" id="ref50">73</reflink>]). For instance, the orienting network is closely associated with both automatic (bottom-up) and controlled (top-down) shifts of attention, whereas the executive network predominantly reflects top-down control. Standardized assessments are employed to evaluate the various components of attention (Table 2).</p> <p>Table 2. Identified Assessments Included in This Review Measuring Attention Subcomponents Grouped by Neuropsychological Domains, Functions, and List of Tasks That Measure This Component.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" rowspan="2">Neuropsychological domain</th><th align="center" rowspan="2">Function</th><th align="center" colspan="3">Assessments</th></tr><tr><th align="center">Computer based</th><th align="center">Paper and pencil based</th><th align="center">Informant report</th></tr></thead><tbody><tr><td>Intensity</td><td /><td /><td /><td /></tr><tr><td> Alertness</td><td>Maintaining an alert state when engaged with a stimulus</td><td>ANT (alerting) TAP-C (Alertness)</td><td>TEA-Ch (same world)</td><td>Alertness subscale<xref ref-type="table-fn" rid="tfn2">a</xref></td></tr><tr><td> Arousal</td><td>Physiological and psychological state of being awoken</td><td>P3/ERP</td><td /><td /></tr><tr><td> Sustained attention/vigilance</td><td>Maintaining an alert state when engaged with a stimulus or task over a prolonged period of time</td><td>TAP-C (sustained attention)</td><td>TEA-Ch (score!)</td><td>Sustained attention subscale<xref ref-type="table-fn" rid="tfn2">a</xref></td></tr><tr><td>Selectivity</td><td /><td /><td /><td /></tr><tr><td> Visual-spatial attention</td><td>Orienting to sensory stimuli, Moving attention toward a stimulus (shifting)</td><td>ANT (orienting)</td><td>TEA-Ch (creature counting)</td><td>Covert attention shift subscale<xref ref-type="table-fn" rid="tfn2">a</xref></td></tr><tr><td> Selective/focused Attention</td><td>Orienting attention toward a stimulus among distracters</td><td>TAP-C (focused attention)</td><td>TEA-Ch (sky search, map mission); SYS/WISC</td><td>Focused attention subscale<xref ref-type="table-fn" rid="tfn2">a</xref></td></tr><tr><td> Divided Attention</td><td>The ability to deploy attentional resources to more than one stimulus at a time</td><td>TAP-C (divided attention)</td><td>TEA-Ch (sky search DT)</td><td>Divided attention subscale<xref ref-type="table-fn" rid="tfn2">a</xref></td></tr><tr><td>Executive aspects</td><td /><td /><td /><td /></tr><tr><td> Interference</td><td /><td>Erikson Flanker</td><td /><td /></tr><tr><td> Inhibition</td><td>Inhibiting responses to specific stimuli in order to attend to another, impulse control</td><td>Stop Signal Task</td><td>TEA-CH (opposite world) NEPSY (Inhibition)</td><td /></tr><tr><td> Executive Attention</td><td>Detecting stimuli for conscious processing</td><td>ANT (executive attention)</td><td /><td /></tr></tbody></table> </ephtml> </p> <p>1 <emph>Note</emph>. Components and tasks are those included in one or more of the studies reviewed here and are not necessarily exhaustive. Where appropriate, task subtests are specified within brackets. ANT = Attention Network Task; TAP-C = Tests of Attentional Performance for Children; TEA-Ch = Test of Everyday Attention for Children; ERP = Event Related Potential; SYS/WISC = Symbol Search of the Wechsler Intelligence Scale for Children.</p> <p>2 Questionnaire for rating attentional performance in children in everyday contexts.</p> <p>This review systematically examines research on attention functions and deficits in preterm children aged 5 to 11 years. This age range covers early to middle childhood—a developmental period marked by increasing attentional demands due to the transition into and progression through formal schooling ([<reflink idref="bib59" id="ref51">59</reflink>]; [<reflink idref="bib89" id="ref52">89</reflink>]). It also precedes adolescence, a phase characterized by substantial hormonal and neurodevelopmental changes that may confound the interpretation of attentional profiles ([<reflink idref="bib14" id="ref53">14</reflink>]; [<reflink idref="bib18" id="ref54">18</reflink>]). Moreover, attentional difficulties such as those associated with ADHD typically become more apparent with school entry, and diagnostic criteria (e.g., DSM-5 and ICD-11) require symptom onset before the age of 12. The objective was to provide a more detailed characterizations of the attention profile in preterm children, focusing on behavioral-clinical and neuropsychological attention impairments and their manifestations. With regard to behavioral-clinical attention impairments, this review considered two main approaches: (<reflink idref="bib1" id="ref55">1</reflink>) attention-related difficulties based on behavioral questionnaires completed by parents or teachers, which assess symptoms on a continuum (often referred to as a dimensional approach), and (<reflink idref="bib2" id="ref56">2</reflink>) formal ADHD diagnoses established according to defined criteria in diagnostic classification systems such as the DSM or ICD (a categorical approach). For neuropsychological attention aspects, the review was structured around the Attention Component Model ([<reflink idref="bib71" id="ref57">71</reflink>]; [<reflink idref="bib74" id="ref58">74</reflink>]; [<reflink idref="bib95" id="ref59">95</reflink>]), which allows attention alterations to be examined as distinct functional components from multiple perspectives, enabling the identification of specific areas of relative weakness. Additionally, we reviewed the methods employed to assess attention deficits from both clinical and neuropsychological standpoints in preterm children aged 5 to 11 years. This approach allowed us to identify the attention domains most commonly affected and provided an overview of the methods most frequently employed to evaluate attention impairments in this population.</p> <hd id="AN0188923027-8">Methodological Considerations and Quality Criteria</hd> <p>In contrast to the sections on general attention problems and ADHD diagnoses, most of the studies reviewed in the neuropsychological domain did not report psychometric properties (e.g., internal consistency, test-retest reliability, or construct validity) of the instruments used. As a result, it was not possible to systematically summarize this information. Where available, we considered established psychometric support from the broader literature (e.g., published manuals or validation studies), but such information was often not provided in the primary sources.</p> <p>To ensure transparency, we evaluated the methodological quality of the included studies based on the following criteria: (<reflink idref="bib1" id="ref60">1</reflink>) use of standardized, age-appropriate instruments; (<reflink idref="bib2" id="ref61">2</reflink>) availability of psychometric support for the measures used; (<reflink idref="bib3" id="ref62">3</reflink>) study design (e.g., cross-sectional vs. longitudinal); (<reflink idref="bib4" id="ref63">4</reflink>) clarity and completeness of reporting; and (<reflink idref="bib5" id="ref64">5</reflink>) appropriateness and interpretability of test parameters (e.g., reaction times, accuracy, omissions, or error rates). Where applicable, these criteria informed our categorization of studies as demonstrating moderate or good methodological quality.</p> <hd id="AN0188923027-9">Method</hd> <p>We present a comprehensive review of current research on attention functioning in young preterm children, aiming to offer a thorough summary of the existing findings on both attention functions and deficits in preterm children aged 5 to 11 years representing early and middle childhood. Firstly, we review the behavioral-clinical aspects of attention, focusing on attention-related problems referring to dimensional assessments of attention-related behaviors, followed by an analysis of attention-related clinical diagnoses referring to categorical ADHD diagnoses. Firstly, we review the behavioral-clinical aspects of attention, focusing first on attention-related problems identified through behavioral questionnaires completed by parents or teachers, followed by an analysis of clinically diagnosed ADHD based on DSM or ICD criteria. Subsequently, the neuropsychological aspects of attention are addressed, covering intensity (alertness, arousal, and sustained attention), selectivity (visual spatial attention, selective, and divided attention), and executive attention (inhibition and interference). Finally, we discuss findings, limitations, and implications for future research directions.</p> <p>The study adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines ([<reflink idref="bib63" id="ref65">63</reflink>]). A systematic search was conducted in the electronic databases PubMed/MEDLINE, Psyndex, APA PsycInfo, and APA PsycArticles, targeting studies published between May 2011 and May 2024. The final search was completed in May 2024.</p> <p>The search strategy included the following terms: <emph>((attention deficit hyperactivity disorder) OR (ADHD) OR (hyperactivity disorder) OR (hyperactivity) OR (impulsivity) OR (inattention)) AND ((neuropsycholog)</emph> OR (electrophysiolog*) OR (ERP)) AND ((preterm child) OR (premature child) OR (preterm birth) OR (premature birth) OR (Low Birth Weight) OR (Very Low Birth Weight) OR (VLBW) OR (Extremely Low Birth Weight) OR (ELBW)).</p> <p>Studies published prior to 2011 were excluded, as this literature has already been systematically reviewed ([<reflink idref="bib1" id="ref66">1</reflink>]; [<reflink idref="bib3" id="ref67">3</reflink>]; [<reflink idref="bib9" id="ref68">9</reflink>]; [<reflink idref="bib46" id="ref69">46</reflink>]; [<reflink idref="bib50" id="ref70">50</reflink>]). In addition, more recent birth cohorts benefit from advances in neonatal care and medical technology, increasing survival rates even at earlier gestational ages ([<reflink idref="bib69" id="ref71">69</reflink>]).</p> <p>Eligible studies were peer-reviewed, used quantitative methodologies (cross-sectional, longitudinal, prospective, or retrospective follow-up designs), and included preterm-born children aged 5 to 11 years at the time of assessment. Studies had to assess attention using standardized methods—either performance-based tasks (computerized or paper-pencil) measuring speed or accuracy, or informant-based measures such as questionnaires and interviews related to ADHD symptoms or attention-related difficulties.</p> <p>Due to the limited research available for this specific age group, broad inclusion criteria were applied, allowing the inclusion of studies regardless of language, the presence of a term-born control group, or the differentiation within the control group. As a result, some studies lacked a comparison group altogether, while others did not provide specific details on the gestational age of the term-born children (i.e., whether they included early term infants [37–38 weeks] or only full term infants [39–41 weeks]). This lack of detailed information prevented differentiation between these subgroups in the analysis.</p> <p>A total of 86 records were identified. Titles and abstracts were screened, leading to the exclusion of 46 irrelevant records. The screening of abstracts and full texts was conducted by a single author. The remaining 40 full-text articles were assessed for eligibility, of which 18 were excluded for reasons such as: participant age outside the target range, unclear definition of prematurity, or missing assessment of attentional function as a primary outcome—specifically, studies that were identified in the initial search but did not directly measure attention as an outcome variable. Ultimately, 22 studies met the inclusion criteria and were included in the review (Figure 2).</p> <p>Graph: Figure 2. PRISMA flowchart.</p> <p>From each included study, the following data were extracted: author(s) and year of publication; study design; mean birth age (in weeks) and weight (in g); age or age range at the time of assessment; and details regarding the assessment of attention (instrument type, informant source, and specific diagnostic tools used).</p> <hd id="AN0188923027-10">Results</hd> <p>In accordance with the PRISMA Flow Chart, we identified 22 peer-reviewed studies that satisfied our inclusion criteria, specifically focusing on attention functioning in preterm children aged 5 to 11 years. Eleven of these studies provided insights into neuropsychological aspects of attention ([<reflink idref="bib21" id="ref72">21</reflink>]; [<reflink idref="bib22" id="ref73">22</reflink>]; [<reflink idref="bib24" id="ref74">24</reflink>]; [<reflink idref="bib25" id="ref75">25</reflink>]; [<reflink idref="bib29" id="ref76">29</reflink>]; [<reflink idref="bib32" id="ref77">32</reflink>]; [<reflink idref="bib42" id="ref78">42</reflink>], [<reflink idref="bib43" id="ref79">43</reflink>]; [<reflink idref="bib66" id="ref80">66</reflink>]; [<reflink idref="bib100" id="ref81">100</reflink>], [<reflink idref="bib99" id="ref82">99</reflink>]). Another 10 studies focused on behavioral and clinical aspects, including attention-related problems reported through questionnaires or formal ADHD diagnoses based on DSM-IV criteria attention-related (e.g., [<reflink idref="bib2" id="ref83">2</reflink>]; [<reflink idref="bib27" id="ref84">27</reflink>]; [<reflink idref="bib45" id="ref85">45</reflink>]; [<reflink idref="bib56" id="ref86">56</reflink>]; [<reflink idref="bib81" id="ref87">81</reflink>], [<reflink idref="bib80" id="ref88">80</reflink>]; [<reflink idref="bib94" id="ref89">94</reflink>]; [<reflink idref="bib103" id="ref90">103</reflink>]). Finally, Three studies addressed both neuropsychological and behavioral-clinical perspectives, thereby integrating test-based and symptom-based approaches ([<reflink idref="bib23" id="ref91">23</reflink>]; [<reflink idref="bib35" id="ref92">35</reflink>]; [<reflink idref="bib55" id="ref93">55</reflink>]; [<reflink idref="bib76" id="ref94">76</reflink>]).</p> <hd id="AN0188923027-11">Clinical Perspectives on Attention Problems</hd> <p>A total of 13 studies examined attention functioning through informant-based reports, specifically from teachers and parents, regarding observed clinical symptoms. Seven of these studies focused on attention-related problems as reported ([<reflink idref="bib2" id="ref95">2</reflink>]; [<reflink idref="bib23" id="ref96">23</reflink>]; [<reflink idref="bib35" id="ref97">35</reflink>]; [<reflink idref="bib45" id="ref98">45</reflink>]; [<reflink idref="bib76" id="ref99">76</reflink>]; [<reflink idref="bib81" id="ref100">81</reflink>]; [<reflink idref="bib94" id="ref101">94</reflink>]). Five studies assessed attention deficits in terms of diagnoses adhering to DSM-IV criteria ([<reflink idref="bib27" id="ref102">27</reflink>]; [<reflink idref="bib55" id="ref103">55</reflink>]; [<reflink idref="bib56" id="ref104">56</reflink>]; [<reflink idref="bib80" id="ref105">80</reflink>]; [<reflink idref="bib103" id="ref106">103</reflink>]). Notably, two of these studies addressed both attention-related problems and DSM-IV-based diagnoses ([<reflink idref="bib23" id="ref107">23</reflink>]; [<reflink idref="bib81" id="ref108">81</reflink>]).</p> <hd id="AN0188923027-12">Attention-Related Problems in Preterm Children</hd> <p>Two standardized instruments were identified for assessing attention-related-related difficulties in preterm children: the Strengths and Difficulties Questionnaire (SDQ; [<reflink idref="bib36" id="ref109">36</reflink>]) and the Achenbach System of Empirically Based Assessment (ASEBA; [<reflink idref="bib4" id="ref110">4</reflink>], [<reflink idref="bib5" id="ref111">5</reflink>]). The SDQ is a brief behavioral screening tool designed to identify psychosocial difficulties in children aged 3 to 16 years. It comprises 25 items across five subscales: emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems (which together form the total difficulties score), and prosocial behavior. The five-item hyperactivity/inattention subscale serves as a brief screening measure to detect potential attention-related difficulties, but it is not intended as a diagnostic tool or substitute for the full DSM-based ADHD symptom criteria. This review focuses on the hyperactivity/inattention subscale.</p> <p>Research supports the SDQ's validity as a clinical and research outcome measure ([<reflink idref="bib37" id="ref112">37</reflink>]; [<reflink idref="bib38" id="ref113">38</reflink>]; [<reflink idref="bib39" id="ref114">39</reflink>]; [<reflink idref="bib40" id="ref115">40</reflink>]; [<reflink idref="bib92" id="ref116">92</reflink>]). Internal consistency for the SDQ is generally reported to be good, with Cronbach's alpha values ranging from.70 to.90, depending on the version and the population being assessed ([<reflink idref="bib37" id="ref117">37</reflink>]; [<reflink idref="bib39" id="ref118">39</reflink>]). According to commonly used and accepted thresholds (e.g., [<reflink idref="bib33" id="ref119">33</reflink>]), a Cronbach's alpha value between.80 and.89 is considered "good." However, the SDQ predictive algorithm should be used cautiously in clinical samples for ADHD screening, as it demonstrates good specificity (84.5%–74.5%) but low sensitivity (45.0–42.5%) for detecting ADHD ([<reflink idref="bib92" id="ref120">92</reflink>]).</p> <p>The ASEBA (Achenbach System of Empirically Based Assessment; [<reflink idref="bib4" id="ref121">4</reflink>], [<reflink idref="bib5" id="ref122">5</reflink>]) includes the Child Behavior Checklist (CBCL), completed by parents, and the Teacher Report Form (TRF), both of which assess behavioral issues and social competence in children aged between 1.5 and 18 years, depending on the version. Widely utilized in clinical and epidemiological studies, the CBCL features DSM-oriented subscales and gathers demographic information, ratings of positive behaviors, academic performance (school-aged version), and social skills. Behavioral problems are assessed using a Likert scale. There are two CBCL versions developed for different age groups (1.5–5 and 6–18 years). Scoring is based on statistically derived syndrome scales, such as Aggressive Behavior, Anxious/Depressed, Attention Problems, Rule-Breaking Behavior, Somatic Complaints, Social Problems, Thought Problems, Withdrawn/Depressed, as well as a Total Problems score. This review centers on the attention problems subscale. The English CBCL/6–18 ([<reflink idref="bib4" id="ref123">4</reflink>], [<reflink idref="bib5" id="ref124">5</reflink>]) demonstrates high methodological quality. Internal consistency for the Attention Problems subscale is good (Cronbach's alpha =.84), interrater reliability is acceptable (Pearson <emph>r</emph> =.70), and test-retest reliability is excellent (<emph>r</emph> =.85–.90). According to commonly accepted thresholds (e.g., [<reflink idref="bib33" id="ref125">33</reflink>]), a Cronbach's alpha above.90 is considered excellent, between.80 and.89 is good, and between.70 and.79 is acceptable. The interrater reliability of <emph>r</emph> =.70 is considered acceptable according to [<reflink idref="bib57" id="ref126">57</reflink>], while test-retest reliability values above.80 are considered excellent ([<reflink idref="bib33" id="ref127">33</reflink>]). These psychometric properties confirm the reliability and validity of the instrument in both clinical and epidemiological applications. CBCL scores correlate well with those of the SDQ ([<reflink idref="bib4" id="ref128">4</reflink>]; Goodman, 2001). Additionally, the TRF provides teacher-reported data on attention-related problems, distinguishing between hyperactive/impulsive and inattentive behaviors.</p> <p>Table 3 provides an overview of findings from studies assessing behavioral-clinical aspects of attention-related deficits based on informant reports. Three studies employed the SDQ to evaluate attention problems in children born preterm with a mean gestational age of 28 weeks (range = 23–35 weeks) and compared them to full-term peers ([<reflink idref="bib35" id="ref129">35</reflink>]; [<reflink idref="bib76" id="ref130">76</reflink>]; [<reflink idref="bib94" id="ref131">94</reflink>]). Specifically, [<reflink idref="bib94" id="ref132">94</reflink>] examined attention problems in 81 extremely/very preterm (E/VPT) children and 84 term-born peers through a combination of parent and teacher reports. Similarly, [<reflink idref="bib76" id="ref133">76</reflink>] assessed attention problems in 58 preterm children (gestational age = 23–35 weeks) and 61 term-born children using the SDQ parent report, with both studies reporting a higher prevalence of attention problems in preterm children irrespective of the informant. In contrast, [<reflink idref="bib35" id="ref134">35</reflink>], using parent reports, observed no significant group differences in a sample of 52 E/VPT children and 52 full-term children. However, this study reported attention problems in 17.2% of the preterm group—substantially above the average prevalence of ADHD in children—compared to 7.6% in the full-term group, which was slightly above average. Notably, 23% of the full-term children also showed conduct and prosocial difficulties, which makes this group potentially less representative due to clinical symptoms. It also raises concerns about the validity of the full-term comparison group.</p> <p>Table 3. Sample Characteristics of Clinical Studies Describing Attention-related Problems: Samples Size, Gestational Age, Age at Time of Testing, Attention Measure, and Main Findings, Organized by Measurement Type and Variable.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left">Authors</th><th align="center">Preterm (<italic>n</italic>)</th><th align="center">Term (<italic>n</italic>)</th><th align="center">GA of preterm group <italic>M</italic>, <italic>SD</italic>, range (r)</th><th align="center">Age (years)</th><th align="center">Measurement of attention</th><th align="center">Findings</th></tr></thead><tbody><tr><td colspan="7"><bold>Attention problems</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr81">Scott et al. (2012)</xref></td><td>148</td><td>111</td><td>E/VPT<italic>M</italic>: 26<italic>r</italic>: 23–32</td><td>5–6</td><td>CBCL (parent) TRF (teacher)</td><td>Attention problems: Preterm > TermAttention problems: Preterm > TermInattention: Preterm > TermHyperactivity/Impulsivity: Preterm = Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr2">Aarnoudse-Moens et al. (2013)</xref></td><td>200</td><td>230</td><td>E/VPT<italic>M</italic>: 28.1; <italic>SD</italic>: 1.4<italic>r</italic>: 24.5–30</td><td>5–10</td><td>CBCL (parent)</td><td>Attention problems: Preterm > Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr23">de Kieviet et al. (2012)</xref></td><td>66</td><td>66</td><td>VPT<italic>M</italic>: 29.3</td><td>7–8</td><td>CBCL (parent) TRF (teacher)</td><td>Attention problems: Preterm > TermAttention problems: Preterm > TermInattention: Preterm > TermHyperactivity/Impulsivity: Preterm = Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr45">Jin et al. (2020)</xref></td><td>37</td><td /><td>MLPT<italic>r</italic>: 32–36</td><td>7–10</td><td>CBCL (parent)</td><td>Attention problems: no clinical relevant symptoms</td></tr><tr><td><xref ref-type="bibr" rid="bibr94">van Hus et al. (2014)</xref></td><td>81</td><td>84</td><td>E/VPT<italic>M</italic>: 28.7; <italic>SD</italic>: 1.5</td><td>5</td><td>SDQ (parent, teacher)</td><td>Hyperactivity/Inattention: Preterm > Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr35">Giordano et al. (2017)</xref></td><td>52</td><td>52</td><td>E/VPT<italic>M</italic>: 28.7; <italic>SD</italic>: 2</td><td>5–6</td><td>SDQ (parents)</td><td>Hyperactivity/inattention: Preterm = Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr76">Réveillon et al. (2016)</xref></td><td>58</td><td>61</td><td>PT<italic>M</italic>: 28.9; <italic>SD</italic>: 3.3<italic>r</italic>: 23–35</td><td>9–12</td><td>SDQ (parents)</td><td>Hyperactivity/inattention: Preterm > Term</td></tr></tbody></table> </ephtml> </p> <p>3 <emph>Note</emph>. Only key results in terms of whether there were statistically significant group differences were presented. EPT = extreme preterm; VPT = very preterm; MLPT = moderate to late preterm; PT = preterm; CBCL = child behavioral checklist; TRF = teacher report form; SDQ = Strength and Difficulty Questionnaire.</p> <p>The remaining four studies ([<reflink idref="bib2" id="ref135">2</reflink>]; [<reflink idref="bib23" id="ref136">23</reflink>]; [<reflink idref="bib45" id="ref137">45</reflink>]; [<reflink idref="bib81" id="ref138">81</reflink>]) used the Child Behavior Checklist (CBCL) and the Teacher Report Form (TRF). [<reflink idref="bib2" id="ref139">2</reflink>] and [<reflink idref="bib23" id="ref140">23</reflink>] assessed attention problems in preterm children with a mean gestational age of 28 weeks (EPT group) and 29 weeks (VPT group), respectively. Their findings revealed that, among a total of 266 preterm children, parents reported attention problems more frequently compared to 296 full-term children. [<reflink idref="bib23" id="ref141">23</reflink>] observed similar findings based on teacher reports, highlighting that attention-related problems can be attributed primarily to inattentive behaviors when distinguishing between inattentive and hyperactive/impulsive symptoms. [<reflink idref="bib81" id="ref142">81</reflink>] found the same for 148 children born extremely preterm (<28 weeks) compared to 111 full-term children, with parent and teacher reports highlighting attention-related issues and teacher-reported inattentive behavior differences, but not hyperactive/impulsive behavior. [<reflink idref="bib45" id="ref143">45</reflink>] examined attention problems in 37 preterm children with a gestational age between 32 and 36 weeks (moderate-to-late preterm infants; MLPT), but without a comparison group of full-term infants. Compared to the normative sample, no clinically relevant attention problems were found in the parental report.</p> <p>Several studies have examined attention problems in children using the two above mentioned standardized questionnaires (SDQ and ASEBA). One study involved 37 MLPT children ([<reflink idref="bib45" id="ref144">45</reflink>]), four studies focused on VPT and EPT children ([<reflink idref="bib2" id="ref145">2</reflink>]; [<reflink idref="bib35" id="ref146">35</reflink>]; [<reflink idref="bib81" id="ref147">81</reflink>]; [<reflink idref="bib94" id="ref148">94</reflink>]), one study looked at VPT children ([<reflink idref="bib23" id="ref149">23</reflink>]), and one study included preterm children with gestational ages from 23 to 35 weeks ([<reflink idref="bib76" id="ref150">76</reflink>]). These studies examined attention-related problems in preterm children compared to their full-term counterparts. With the exception of one study on MLPT children, which compared results to normative data, and another study on E/VPT children ([<reflink idref="bib35" id="ref151">35</reflink>]), which used a full-term comparison group that may be less representative due to behavioral symptoms in 23% of the children, findings consistently indicated that preterm children exhibit more attention problems than their full-term counterparts. This pattern was evident in parent and teacher reports, using instruments such as the SDQ and CBCL, and across all preterm gestational subgroups except MLPT children. Furthermore, the teacher-report TRF, employed in two studies ([<reflink idref="bib23" id="ref152">23</reflink>]; [<reflink idref="bib81" id="ref153">81</reflink>]), distinguished between inattentive and hyperactive/impulsive behaviors, revealing differences between the groups only for inattentive behavior, but not for hyperactive/impulsive behavior.</p> <hd id="AN0188923027-13">ADHD Diagnoses in Preterm Children</hd> <p>Various standardized tools have been applied to assess ADHD diagnoses in preterm children during middle childhood, employing a diverse range of methods. This review identified six different assessment instruments.</p> <hd id="AN0188923027-14">The Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version (K...</hd> <p>The K-SADS-PL ([<reflink idref="bib53" id="ref154">53</reflink>]) is a semi-structured interview designed to screen for affective, psychotic, and other disorders, including ADHD. It demonstrates excellent psychometric properties across multiple dimensions. Internal consistency is high for both screening items (Macdonald's Omega [ω] =.89) and diagnostic supplements (ω =.95; 95% CI [0.92, 0.99]). The screening section also shows strong diagnostic performance, with high sensitivity (97.8%; 95% CI [97.2, 98.5%]) and specificity (94.0%; 95% CI [93.0, 95.0%]) for ADHD diagnoses. Moreover, test-retest and inter-informant reliability, assessed via intraclass correlation coefficients, are robust across most items ([<reflink idref="bib52" id="ref155">52</reflink>]), further supporting the methodological quality of the instrument.</p> <hd id="AN0188923027-15">The Yale Children's Inventory (YCI)</hd> <p>The YCI ([<reflink idref="bib82" id="ref156">82</reflink>]) is a parent-reported questionnaire based on DSM criteria. It is designed to identify disorders characterized by academic difficulties, hyperactivity, or attention dysfunction, including ADHD. Its internal consistency ranges between.72 and.93.</p> <hd id="AN0188923027-16">Development and Well-Being Assessment (DAWBA)</hd> <p>The DAWBA ([<reflink idref="bib39" id="ref157">39</reflink>]) integrates interviews, questionnaires, and rating techniques designed to generate ICD-10 and DSM-IV or DSM-V psychiatric diagnoses for children aged 2 to 17 years. It includes assessments for common emotional, behavioral, and hyperactivity disorders, such as ADHD. While data on internal consistency (e.g., Cronbach's alpha) are not reported for the DAWBA, the instrument shows excellent diagnostic reliability. Kappa coefficients indicate high interrater agreement for various diagnostic categories: any disorder (<emph>K</emph> = 0.83; 95% CI [0.68, 0.97]), internalizing disorders (<emph>K</emph> = 0.84; 95% CI [0.69, 0.99]), externalizing disorders (<emph>K</emph> = 0.89; 95% CI [0.77, 1.00]), and other disorders (<emph>K</emph> = 0.79; 95% CI [0.39, 1.00]; [<reflink idref="bib7" id="ref158">7</reflink>]).</p> <hd id="AN0188923027-17">Child Symptom Inventory (CSI)</hd> <p>The CSI ([<reflink idref="bib31" id="ref159">31</reflink>]) is a DSM-IV-referenced rating scale used to screen emotional and behavioral symptoms, including ADHD, in children aged 5 to 12 years. It includes both parent (97 items) and teacher (77 items) versions. The internal consistency for ADHD presentations is.91 for the parent form and.92 for the teacher form.</p> <hd id="AN0188923027-18">Children's Interview for Psychiatric Syndromes (ChIPS)</hd> <p>The ChIPS ([<reflink idref="bib102" id="ref160">102</reflink>]) is a structured interview based on DSM-IV criteria that screens for psychiatric diagnoses, including ADHD and its subtypes, in children aged 6 to 18 years. It includes both child (ChIPS) and parent (P-ChIPS) versions, with an internal consistency of.90.</p> <hd id="AN0188923027-19">The Disruptive Behavior Disorders Rating Scale (DBD)</hd> <p>The DBD ([<reflink idref="bib84" id="ref161">84</reflink>]) is a 45-item screening tool completed by parents (PDBD) or teachers (TBDB) to assess symptoms of ADHD, oppositional defiant disorder, and conduct disorder in children and adolescents. The internal consistency for ADHD symptoms is excellent, at.93 for the parent form and.96 for the teacher form.</p> <p>In summary, the literature reports ADHD symptoms in preterm children using a variety of validated tools. Five of the six identified methods demonstrated predominantly excellent internal consistency, supporting the reliability of the measurements across studies. According to commonly accepted thresholds (e.g., [<reflink idref="bib33" id="ref162">33</reflink>]), internal consistency values above.90 are considered excellent,.80 to.89 good, and.70 to.79 acceptable. The reported Cronbach's alpha values (e.g.,.93 for the parent form and.96 for the teacher form) thus indicate high methodological quality in terms of measurement reliability.</p> <p>For the DAWBA, while internal consistency was not explicitly reported, the instrument demonstrates high diagnostic reliability, as reflected in excellent interrater agreement across diagnostic categories (e.g., κ =.83–.89; [<reflink idref="bib7" id="ref163">7</reflink>]). According to standard interpretation guidelines ([<reflink idref="bib57" id="ref164">57</reflink>]), these values represent almost perfect agreement, supporting the methodological quality of the tool in diagnostic application.</p> <p>Additionally, for the K-SADS-PL, in addition to internal consistency, further psychometric properties were reported, all indicating high methodological quality. These properties include robust sensitivity (97.8%) and specificity (94.0%) for ADHD diagnosis, along with strong test-retest and inter-informant reliability, which collectively reinforce the quality of the instrument.</p> <p>Table 4 provides an overview of seven studies that investigated attention through formal ADHD diagnoses based on DSM-5 criteria. Four studies ([<reflink idref="bib27" id="ref165">27</reflink>]; [<reflink idref="bib56" id="ref166">56</reflink>]; [<reflink idref="bib80" id="ref167">80</reflink>]; [<reflink idref="bib103" id="ref168">103</reflink>]) reported ADHD diagnosis rates without differentiating between presentation types. These studies investigated children aged 4 to 10 years using various assessment methods. Across these studies, an increased prevalence of ADHD diagnoses was observed in a total sample of 1,386 preterm children, irrespective of the age at assessment, gestational age, informant, or measurement tools, compared to either full-term children ([<reflink idref="bib103" id="ref169">103</reflink>]) or reported as prevalences ([<reflink idref="bib27" id="ref170">27</reflink>]; [<reflink idref="bib56" id="ref171">56</reflink>]; [<reflink idref="bib80" id="ref172">80</reflink>]). Specifically, [<reflink idref="bib56" id="ref173">56</reflink>] reported a 30% ADHD diagnosis rate among 79 very preterm (VPT) children aged 4 to 7 years, with a mean gestational age of 30 weeks, using the K-SADS. [<reflink idref="bib27" id="ref174">27</reflink>] found a 16% ADHD diagnosis rate in 213 extremely preterm (EPT) children with gestational ages of 25 to 27 weeks, assessed at 5 years of age using the YCI. [<reflink idref="bib103" id="ref175">103</reflink>] identified higher ADHD rates in 223 VPT children with a gestational age of 28 weeks, assessed at 9 years of age using the DAWBA, compared to 110 full-term children. Lastly, [<reflink idref="bib80" id="ref176">80</reflink>] reported ADHD diagnoses in 10% of EPT children based on parental evaluation and in 13% based on the teacher evaluations, using the CSI in a sample of 871 EPT children with gestational ages below 28 weeks.</p> <p>Table 4. Sample Characteristics of Clinical Studies Using DSM Diagnoses: Samples Size, Gestational Age, Age at Time of Testing, Attention Measure, and Main Findings, Organized by Measurement Type (Informant Report, Standardized Test) and Variable.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" colspan="5"><italic>n</italic></th><th align="center" colspan="4">Measurement types</th></tr><tr><th align="left">Authors</th><th align="center">Preterm</th><th align="center">Term</th><th align="center">GA of preterm group</th><th align="center">Age (years)</th><th align="center">Measurement of attention</th><th align="center">ST</th><th align="center">IR</th><th align="center">Findings</th></tr></thead><tbody><tr><td colspan="9"><bold>Any ADHD diagnoses</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr56">Lacerda et al. (2020)</xref></td><td>79</td><td align="center">—</td><td>VPT<italic>M</italic>: 30</td><td>4–7</td><td>K-SADS-PL</td><td /><td>x</td><td>ADHD: 24 (30%)</td></tr><tr><td><xref ref-type="bibr" rid="bibr27">Elgen et al. (2015)</xref></td><td>213</td><td>—-</td><td>EPT<italic>M</italic>: 26r: 25–27</td><td>5</td><td>YCI</td><td /><td>x</td><td>ADHD: 33 (16%)</td></tr><tr><td><xref ref-type="bibr" rid="bibr103">Woodward et al. (2017)</xref></td><td>223</td><td>110</td><td>VPT<italic>M</italic>: 28</td><td>9</td><td>DAWBA</td><td /><td>x</td><td>ADHD: preterm > term</td></tr><tr><td><xref ref-type="bibr" rid="bibr80">Scott et al. (2017)</xref></td><td>871</td><td align="center">—</td><td>EPTr: 23–27</td><td>10</td><td>CSI (teacher, parent)</td><td /><td>x</td><td>Teacher ADHD: 66/634 (10%) parent ADHD: 109/871 (13%)</td></tr><tr><td colspan="9"><bold>ADHD/C</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr81">Scott et al. (2012)</xref></td><td>148</td><td>111</td><td>EPT<italic>M</italic>: 26r: 23–32</td><td>5–6</td><td>P-ChIPS (parent)</td><td /><td>x</td><td>ADHD/C: preterm > term</td></tr><tr><td><xref ref-type="bibr" rid="bibr55">Korzeniewski et al. (2017)</xref></td><td>608</td><td align="center">—</td><td>EPT</td><td>10</td><td>CSI (parent, teacher)</td><td /><td>x</td><td>Parent: ADHD/C: 4% Teacher: ADHD/C: 3%</td></tr><tr><td colspan="9"><bold>ADHD/IA</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr81">Scott et al. (2012)</xref></td><td>148</td><td>111</td><td>EPT<italic>M</italic>: 26r: 23–32</td><td>5–6</td><td>P-ChIPS (parent)</td><td /><td>x</td><td>ADHD/IA: preterm > term</td></tr><tr><td><xref ref-type="bibr" rid="bibr23">de Kieviet et al. (2012)</xref></td><td>66</td><td>66</td><td>VPT<italic>M</italic>: 29.3</td><td>7–8</td><td>PDBD (parent) TDBD (teacher)</td><td /><td>x</td><td>Parent ADHD/IA: preterm > termTeacher ADHD/IA: Preterm > Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr55">Korzeniewski et al. (2017)</xref></td><td>608</td><td align="center">—</td><td>EPT</td><td>10</td><td>CSI (parent, teacher)</td><td /><td>x</td><td>Parent ADHD/IA: 14%Teacher ADHD/IA: 16%</td></tr><tr><td colspan="9"><bold>ADHD/HI</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr81">Scott et al. (2012)</xref></td><td>148</td><td>111</td><td>EPT<italic>M</italic>: 26r: 23–32</td><td>5–6</td><td>P-ChIPS (parent)</td><td /><td>x</td><td>ADHD/HI: preterm > term</td></tr><tr><td><xref ref-type="bibr" rid="bibr23">de Kieviet et al. (2012)</xref></td><td>66</td><td>66</td><td>VPT<italic>M</italic>: 29.3</td><td>7–8</td><td>PDBD (parent) TDBD (teacher)</td><td /><td>x</td><td>Parent ADHD/HI: preterm = termTeacher ADHD/HI: preterm = term</td></tr><tr><td><xref ref-type="bibr" rid="bibr55">Korzeniewski et al. (2017)</xref></td><td>608</td><td align="center">—</td><td>EPT</td><td>10</td><td>CSI (parent, teacher)</td><td /><td>x</td><td>Parent ADHD/HI: 7%Teacher ADHD/HI: 4%</td></tr></tbody></table> </ephtml> </p> <p>4 <emph>Note</emph>. Only key results in terms of whether there were statistically significant group differences were presented. IA = Inattentive presentation; HI = Hyperactive - Impulsive presentation; C = Combined presentation; EPT = Extreme Preterm; VPT = Very Preterm; MLPT = Moderate to Late Preterm; PT = Preterm; K-SADS-PL = Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version; YCI = Yale Children's Inventory; DAWBA = The Development and Well-Being Assessment; CSI = Child Symptom Inventory; P-ChIPS = Children's Interview for Psychiatric Syndromes—parent version; PDBD = Parent form of the Disruptive Behavior Disorders Rating Scale; TDBD = Teacher form of the Disruptive Behavior Disorders Rating Scale.</p> <p>Examining the three distinct ADHD presentations, three studies have reported ADHD diagnoses in relation to these subtypes ([<reflink idref="bib23" id="ref177">23</reflink>]; [<reflink idref="bib55" id="ref178">55</reflink>]; [<reflink idref="bib81" id="ref179">81</reflink>]). Among children aged 5 to 6 years, the ADHD combined (ADHD-C) and hyperactive-impulsive (ADHD-HI) presentations were observed more frequently in 148 extremely preterm (EPT) children compared to 111 full-term children, as assessed with the P-ChIPS. However, in children older than 5 to 6 years, no significant differences in ADHD/C or ADHD/HI prevalence were found between preterm and full-term children ([<reflink idref="bib23" id="ref180">23</reflink>]). Specifically, [<reflink idref="bib23" id="ref181">23</reflink>] examined psychiatric disorders in 66 very preterm (VPT) children aged 7 to 8 years compared to 66 full-term peers, using the parent and teacher forms of the DBD, and reported no significant differences in ADHD/C or ADHD/HI prevalence. Similarly, studies using the parent and teacher form of the CSI in 10-year-old EPT children (<emph>N</emph> = 608) also found no significant group differences ([<reflink idref="bib55" id="ref182">55</reflink>]; [<reflink idref="bib81" id="ref183">81</reflink>]). [<reflink idref="bib55" id="ref184">55</reflink>] reported ADHD/C prevalence rates of 4% (parent report) and 3% (teacher report), and ADHD/HI prevalence rates of 4% (teacher report). These figures align with or slightly exceed the average ADHD prevalence in the general population. In contrast, the ADHD inattentive (ADHD/IA) presentation findings was reported more frequently in preterm children across three studies, regardless of whether comparisons were made with full-term peers or general population prevalence ([<reflink idref="bib23" id="ref185">23</reflink>]; [<reflink idref="bib55" id="ref186">55</reflink>]; [<reflink idref="bib81" id="ref187">81</reflink>]). This trend was consistent across ages (5–10 years), gestational age groups (VPT and EPT), and informants (parent and teacher reports), using various assessment tools (CSI, P-ChIPS, and DBD). Specifically, [<reflink idref="bib81" id="ref188">81</reflink>] identified a higher prevalence of ADHD/IA in EPT children (<28 weeks' gestation) compared to 111 full-term children aged 5 to 6 years using the parent form of the ChIPS. Similarly, [<reflink idref="bib23" id="ref189">23</reflink>] reported higher ADHD-IA prevalence in 7- to 8-year-old VPT children compared to full-term peers using the parent and teacher forms of the DBD. and found the ADHD/IA presentation more often in the preterm group. [<reflink idref="bib55" id="ref190">55</reflink>] observed ADHD/IA prevalence rates of 14% (parent report) and 16% (teacher report) in 10-year-old EPT children, exceeding population norms. Overall, findings from seven studies indicate an elevated risk for ADHD diagnoses in preterm children, irrespective of assessment method, age at testing, or gestational age ([<reflink idref="bib27" id="ref191">27</reflink>]; [<reflink idref="bib56" id="ref192">56</reflink>]; [<reflink idref="bib80" id="ref193">80</reflink>]; [<reflink idref="bib103" id="ref194">103</reflink>]). These studies employed six different measurement tools, yet consistently demonstrated an increased ADHD risk associated with preterm birth, reinforcing this conclusion.</p> <hd id="AN0188923027-20">Neuropsychological Aspects</hd> <p>The neuropsychological dimensions of attention functioning were assessed using a diverse range of tests and subtests. These included (<reflink idref="bib1" id="ref195">1</reflink>) standardized computer-based tests such as subtests of the Attentional Network Task (ANT), the Test of Attentional Performance for Children (TAP-C), the Test of Attentional Performance (TAP), a modified version of the TAP-C, the Erikson Flanker Task, and the Stop Signal Task; (<reflink idref="bib2" id="ref196">2</reflink>) paper-and-pencil-based subtests from the Test of Everyday Attention for Children (TEA-Ch) and the Developmental Neuropsychological Assessment, Second Edition (NEPSY-II); (<reflink idref="bib3" id="ref197">3</reflink>) subscales from a questionnaire assessing attentional performance in children within everyday contexts (Weiler et al., unpublished data); and (<reflink idref="bib4" id="ref198">4</reflink>) electrophysiological methods, specifically EEG recordings of the P3 amplitude. Given the application of varying assessment modalities (paper-and-pencil, computer-based, informant reports, and EEG recordings), multiple parameters were employed, including cued and non-cued reaction times, anticipations, omissions, errors, hits, P3 amplitude, and reported scores. This methodological diversity poses significant challenges for the comparability of results.</p> <hd id="AN0188923027-21">Intensity Aspects of Attention (Alertness, Arousal, and Sustained Attention)</hd> <p>A total of ten studies ([<reflink idref="bib21" id="ref199">21</reflink>]; [<reflink idref="bib23" id="ref200">23</reflink>]; [<reflink idref="bib25" id="ref201">25</reflink>]; [<reflink idref="bib32" id="ref202">32</reflink>]; [<reflink idref="bib35" id="ref203">35</reflink>]; [<reflink idref="bib42" id="ref204">42</reflink>], [<reflink idref="bib43" id="ref205">43</reflink>]; [<reflink idref="bib66" id="ref206">66</reflink>]; [<reflink idref="bib100" id="ref207">100</reflink>], [<reflink idref="bib99" id="ref208">99</reflink>]; [<reflink idref="bib100" id="ref209">100</reflink>]) were identified that examined the intensity aspects of attention—namely alertness, arousal, and sustained attention—in preterm children compared to their full-term counterparts. These studies employed standardized testing methods and informant-based reports to evaluate these aspects. A summary of the findings is presented in Table 5.</p> <p>Table 5. Sample Characteristics of Intensity Studies: Samples Size, Gestational Age, Age at Time of Testing, Attention Measure, and Main Findings, Organized by Measurement Type and Variable.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" colspan="5"><italic>n</italic></th><th align="center" colspan="5">Measurement types</th></tr><tr><th align="left">Authors</th><th align="center">Preterm</th><th align="center">Term</th><th align="center">GA of preterm group <italic>M</italic>, <italic>SD</italic>, range (<italic>r</italic>)</th><th align="center">Age (years)</th><th align="center">Measurement of attention</th><th align="center">CB</th><th align="center">PP</th><th align="center">IR</th><th align="center">Findings</th></tr></thead><tbody><tr><td colspan="10"><bold>Alertness</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr32">Geldof et al. (2013)</xref></td><td>108</td><td>72</td><td>E/VPT<italic>M</italic>: 30.1; <italic>SD</italic>: 2.3</td><td>5</td><td>ANT</td><td>x</td><td /><td /><td>Alertness: Preterm = Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr100">Walczak-Kozłowska et al. (2020)</xref></td><td>26</td><td>31</td><td>VPT<italic>M</italic>: 30; <italic>SD</italic>: 1.4</td><td>5</td><td>ANT</td><td>x</td><td /><td /><td>Alertness: Preterm = Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr99">Walczak-Kozłowska et al. (2021)</xref></td><td>47</td><td>53</td><td>E/VPT<italic>M</italic>: 30.7; SD: 1.6<italic>r</italic>: 26–31</td><td>5</td><td>ANT</td><td>x</td><td /><td /><td>Alertness: Preterm = Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr23">de Kieviet et al. (2012)</xref></td><td>66</td><td>66</td><td>VPT<italic>M</italic>: 29.3</td><td>7</td><td>ANT</td><td>x</td><td /><td /><td>Alertness: Preterm = Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr35">Giordano et al. (2017)</xref></td><td>52</td><td>52</td><td>E/VPT<italic>M</italic>: 28.7; <italic>SD</italic>: 2</td><td>5–6</td><td>TAP-CQFAP-CH</td><td>x</td><td /><td>x</td><td>Alertness: TAP-C: Preterm = TermParent report: Preterm < Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr43">Jaeger et al. (2021)</xref></td><td>31</td><td>22</td><td>MLPT/VPT<italic>M</italic>: 32r: 28–36</td><td>5–6</td><td>modified version of the TAP-C</td><td>x</td><td /><td /><td>Alertness phasic: Preterm = TermTonic: Preterm < Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr21">Cserjesi et al. (2012)</xref></td><td>248</td><td>130</td><td>MLPT<italic>r</italic>: 32–35+6</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Alertness: Preterm < Term</td></tr><tr><td colspan="10"><bold>Arousal</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr42">Jaeger et al. (2019)</xref></td><td>27</td><td>20</td><td>MLPT/VPT<italic>M</italic>: 31r: 28–36</td><td>5–6</td><td>ERP: P3</td><td>x</td><td /><td /><td>Arousal: Preterm < Term</td></tr><tr><td colspan="10"><bold>Sustained attention</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr35">Giordano et al. (2017)</xref></td><td>52</td><td>52</td><td>E/VPT<italic>M</italic>: 28.7; <italic>SD</italic>: 2</td><td>5–6</td><td>TAP-CQFAP-CH</td><td>x</td><td /><td>x</td><td>Sustained attention: TAP-C: Preterm < TermParent report: Preterm < Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr25">Delane et al. (2017)</xref></td><td>77</td><td>74</td><td>E/VPT<italic>M</italic>: 27<italic>r</italic>: 24–32</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Sustained attention: Preterm = Term (trend <italic>p</italic> =.064)</td></tr><tr><td><xref ref-type="bibr" rid="bibr66">Murray et al. (2014)</xref></td><td>198</td><td>70</td><td>E/VPT<italic>M</italic>: 27.4</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Sustained attention: Preterm < Term</td></tr><tr><td><xref ref-type="bibr" rid="bibr21">Cserjesi et al. (2012)</xref></td><td>248</td><td>130</td><td>MLPT<italic>r</italic>: 32–35+6</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Alertness: Preterm = Term</td></tr></tbody></table> </ephtml> </p> <p>5 <emph>Note</emph>. Only key results in terms of whether there were statistically significant group differences, regardless of variable (e.g., accuracy and reaction time) were presented. EPT = Extreme Preterm; VPT = Very Preterm; MLPT = Moderate to Late Preterm; ANT = Attention Network Task; TAP-C = Tests of Attentional Performance for Children; TEA-Ch = Test of Everyday Attention for Children; ERP = Event Related Potential; QFAP-CH = Questionnaire For Attentional Performance in Children; CB = Computer Based assessment; PP = Paper and Pencil based assessment, IR = Informant Report.</p> <hd id="AN0188923027-22">Alertness</hd> <p>A range of studies has explored alertness using various standardized methodologies, including computer-based tests, paper-and-pencil tests, and questionnaires. Of these, five studies focused on preterm children born at less than 32 weeks gestational age (E/VPT; [<reflink idref="bib23" id="ref210">23</reflink>]; [<reflink idref="bib32" id="ref211">32</reflink>]; [<reflink idref="bib35" id="ref212">35</reflink>]; [<reflink idref="bib100" id="ref213">100</reflink>], [<reflink idref="bib99" id="ref214">99</reflink>]), one study examined preterm children with a gestational age between 28 and 36 weeks ([<reflink idref="bib43" id="ref215">43</reflink>]), and one study investigated moderate-to-late preterm (MLPT) children ([<reflink idref="bib21" id="ref216">21</reflink>]). Four studies employed the alertness task from the child-adapted version of the Attentional Network Task (ANT) to assess alertness ([<reflink idref="bib23" id="ref217">23</reflink>]; [<reflink idref="bib32" id="ref218">32</reflink>]; [<reflink idref="bib100" id="ref219">100</reflink>], [<reflink idref="bib99" id="ref220">99</reflink>]). In these studies, an alertness score was calculated based on reaction times under cued (phasic alertness) and non-cued (tonic alertness) conditions. Tonic alertness represents top-down controlled attention, whereas phasic alertness is stimulus-driven and reflects bottom-up processes ([<reflink idref="bib72" id="ref221">72</reflink>]). Most studies using the ANT approach found no significant differences in alertness scores between preterm and full-term children ([<reflink idref="bib23" id="ref222">23</reflink>]; [<reflink idref="bib32" id="ref223">32</reflink>]; [<reflink idref="bib100" id="ref224">100</reflink>]). Similarly, [<reflink idref="bib99" id="ref225">99</reflink>] did also not account for differences in alertness when controlling for IQ. However, their reported alertness scores combined both tonic and phasic alertness reaction times without distinguishing between them. This approach may have overlooked potential deficits in either tonic or phasic alertness, as highlighted by [<reflink idref="bib43" id="ref226">43</reflink>]. Jaeger and colleagues specifically differentiated between tonic and phasic alertness using a modified version of the alertness subtest from the TAP-C and an auditory cue. They studied preterm children born at less than 36 weeks' gestation, excluding those born extremely preterm (EPT), and found no significant differences in phasic alertness but identified impairments in tonic alertness.</p> <p>[<reflink idref="bib35" id="ref227">35</reflink>] employed subscales from an alertness questionnaire designed to evaluate attentional performance in children during everyday activities, alongside the alertness subtest of the computer-based TAP-C. The QFAP-CH (Questionnaire of Focused Attention Performance in Children), which was used as an informant-based measure of attentional performance, is a non-standardized instrument for which no peer-reviewed psychometric validation has been published to date. As such, findings based on this measure must be interpreted with caution, and its methodological contribution to the overall evidence base is limited. The questionnaire revealed significant differences in two alertness subscales between full-term and preterm children. In the TAP-C alertness subtest, measures included reaction time, its standard deviation, and anticipatory responses in a non-cued (tonic) alertness task. Contrary to the findings of [<reflink idref="bib43" id="ref228">43</reflink>], no group differences were observed in the tonic alertness task. However, the authors noted that this subtest was administered at the beginning of the testing session when all participants were still highly motivated to complete the task. Furthermore, the comparison group appeared to be less representative because the parents in this group reported behavioral and prosocial problems in 23% of the children and hyperactivity issues in 7.6%, rendering the control group clinically conspicuous itself. These factors may account for the absence of group differences in the tonic alertness task.</p> <p>Additionally, the authors employed a subtest of the TAP-C (covert attentional shift), which primarily assesses the ability to focus visual attention while also distinguishing between exogenous and endogenous attention. Endogenous attention, akin to tonic alertness, represents top-down attentional processes, whereas exogenous attention, similar to phasic alertness, is stimulus-driven and reflects bottom-up processes ([<reflink idref="bib72" id="ref229">72</reflink>]). The results indicated that preterm children exhibited a significantly greater disparity between endogenous and exogenous attentional shifts compared to full-term children, with particular, children born preterm showed difficulties in enhancing endogenous attention. This aligns with findings from Jaeger et al., who also reported deficits in top-down attention among preterm children.</p> <p>[<reflink idref="bib21" id="ref230">21</reflink>] investigated moderate-to-late preterm (MLPT) children using the TEA-Ch alertness subtest, a paper-and-pencil task measuring reaction times in a non-cued, top-down controlled, alertness task. Their findings revealed significant differences, with preterm children underperforming compared to their full-term peers. These results are consistent with broader findings presented here as well as prior literature ([<reflink idref="bib8" id="ref231">8</reflink>]; [<reflink idref="bib11" id="ref232">11</reflink>]; [<reflink idref="bib83" id="ref233">83</reflink>]).</p> <p>In summary, across seven studies and four distinct measurements of moderate methodological quality, reaction times served as the primary parameter for assessing attentional performance. Variations in findings may stem from differences in task formats (computer-based, paper-and-pencil, and questionnaires), test parameters (reaction times, standard deviations, and anticipations), and the attentional subcomponents examined (top-down controlled phasic alertness and bottom-up controlled tonic alertness). Overall, there is mixed evidence for a deficit in top-down controlled alertness in preterm children.</p> <hd id="AN0188923027-23">Arousal</hd> <p>To date, only one study has investigated attentional functioning using EEG measures during a tonic alertness task (a non-cued oddball task). [<reflink idref="bib42" id="ref234">42</reflink>] examined preterm children with a mean gestational age of 31 weeks, excluding extremely preterm (EPT) cases, and compared them to full-term children. The findings suggest a deficiency in top-down mechanisms for controlling arousal, as the task required participants to mentally respond to targets while ignoring non-targets, without the presence of cues. Analysis of the EEG responses to targets revealed a significant group difference, specifically a reduction in the top-down regulate P3 amplitude among preterm children. Given that this is the only available study on arousal in this age group, any conclusions must be interpreted cautiously. Nonetheless, the findings indicate impaired top-down attentional control in preterm children, aligning with previously reported results.</p> <hd id="AN0188923027-24">Sustained Attention</hd> <p>Four studies were identified that examined sustained attention. Three of these focused on preterm children with an average gestational age of 27 to 28 weeks ([<reflink idref="bib25" id="ref235">25</reflink>]; [<reflink idref="bib35" id="ref236">35</reflink>]; [<reflink idref="bib66" id="ref237">66</reflink>]), while one compared moderate-to-late preterm (MLPT) children to full-term peers ([<reflink idref="bib21" id="ref238">21</reflink>]).</p> <p>[<reflink idref="bib25" id="ref239">25</reflink>] and [<reflink idref="bib66" id="ref240">66</reflink>] utilized the paper-and-pencil-based subtest (Score!) of the TEA-Ch to assess sustained attention, measuring the number of correct responses (hits). Overall, the results indicate a reduced number of hits among 7-year-old preterm children compared to full-term counterparts. Specifically, [<reflink idref="bib66" id="ref241">66</reflink>] reported statistically significant results in a sample of 198 preterm children versus 70 full-term children. Conversely, [<reflink idref="bib25" id="ref242">25</reflink>] observed a notable trend (<emph>p</emph> =.064) in a comparison of 77 preterm and 74 full-term children.</p> <p>[<reflink idref="bib35" id="ref243">35</reflink>] employed the sustained attention subscale of the QFAP-CH alongside the computer-based sustained attention subtest of the TAP-C, which measured reaction times, omissions, and errors. This study included 52 preterm and 52 full-term children aged 5 to 6 years. Questionnaire results revealed significant differences in sustained attention between the groups. For the computer-based task, preterm children exhibited a greater variability in performance during the initial 5 min of testing, although no group differences emerged over the full 10-min duration. Notably, only 42% of the preterm children completed all tasks compared to 100% of the full-term group, suggesting a potential bias as the fittest preterm children were overrepresented in the final analysis. Within the preterm group, children born before 28 weeks of gestation demonstrated poorer sustained attention compared to those born after 28 weeks.</p> <p>Interestingly, [<reflink idref="bib21" id="ref244">21</reflink>] found no significant differences in sustained attention between MLPT children (born after 34 weeks of gestation) and full-term peers. This study used the sustained attention subtest (Score!) of TEA-Ch to compare the mean number of correct responses between 248 MLPT children and 130 full-term children. In summary, these four studies employed three different assessment tools with moderate to good quality criteria, using test parameters such as correct responses, reaction times, omissions, and errors. Nevertheless, the findings are mainly consistent and substantial evidence indicates that preterm birth is associated with impairments in sustained attention, with the degree of impairment closely linked to the gestational age. The earlier a child is born, the greater the risk of deficits in this specific attentional domain.</p> <hd id="AN0188923027-25">Selectivity Aspects of Attention (Visual Spatial Attention, Selective/Focused Attention, Divi...</hd> <p>Eight studies examined selectivity aspects of attention, specifically visual spatial attention, selective or focused attention and divided attention, in preterm children in comparison to full-term peers. These studies utilized standardized assessments and informant reports to evaluate attention performance ([<reflink idref="bib21" id="ref245">21</reflink>]; [<reflink idref="bib23" id="ref246">23</reflink>]; [<reflink idref="bib25" id="ref247">25</reflink>]; [<reflink idref="bib32" id="ref248">32</reflink>]; [<reflink idref="bib35" id="ref249">35</reflink>]; [<reflink idref="bib66" id="ref250">66</reflink>]; [<reflink idref="bib100" id="ref251">100</reflink>], [<reflink idref="bib99" id="ref252">99</reflink>]). The findings are summarized in Table 6.</p> <p>Table 6. Sample Characteristics of Selectivity Studies: Samples Size, Gestational Age, Age at Time of Testing, Attention Measure, and Main Findings, Organized by Measurement Type and Variable.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" colspan="5"><italic>n</italic></th><th align="center" colspan="5">Measurement types</th></tr><tr><th align="left">Authors</th><th align="center">Preterm</th><th align="center">Term</th><th align="center">GA of preterm group <italic>M</italic>, <italic>SD</italic>, range (r)</th><th align="center">Age (years)</th><th align="center">Measurement of attention</th><th align="center">CB</th><th align="center">PP</th><th align="center">IR</th><th align="center">Findings</th></tr></thead><tbody><tr><td colspan="10"><bold>Orienting</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr32">Geldof et al. (2013)</xref></td><td>108</td><td>72</td><td>EPT/VPT<italic>M</italic>: 30.1 <italic>SD</italic>: 2.3</td><td>5</td><td>ANT</td><td>x</td><td>X</td><td /><td>Orienting: Preterm = term</td></tr><tr><td><xref ref-type="bibr" rid="bibr100">Walczak-Kozłowska et al. (2020)</xref></td><td>26</td><td>31</td><td>VPT<italic>M</italic>: 30; <italic>SD</italic>: 1.4</td><td>5</td><td>ANT</td><td>x</td><td>X</td><td /><td>Orienting: Preterm = term</td></tr><tr><td><xref ref-type="bibr" rid="bibr99">Walczak-Kozłowska et al. (2021)</xref></td><td>47</td><td>53</td><td>EPT/VPT<italic>M</italic>: 30.7; <italic>SD</italic>:1.6<italic>r</italic>: 26–31</td><td>5</td><td>ANT</td><td>x</td><td>X</td><td /><td>Orienting: preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr23">de Kieviet et al. (2012)</xref></td><td>66</td><td>66</td><td>VPT<italic>M</italic>: 29.3</td><td>7</td><td>ANT</td><td>x</td><td>X</td><td /><td>Orienting: Preterm = term</td></tr><tr><td colspan="10"><bold>Shifting</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr35">Giordano et al. (2017)</xref></td><td>52</td><td>52</td><td>E/VPT<italic>M</italic>: 28.7 <italic>SD</italic>: 2</td><td>5–6</td><td>TAPQFAP-Ch</td><td>x</td><td /><td>x</td><td>Covert attention shifting: TAP-C: preterm < termQFAP-CH: preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr66">Murray et al. (2014)</xref></td><td>198</td><td>70</td><td>E/VPT<italic>M</italic>: 27.4</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Shifting: preterm < term</td></tr><tr><td colspan="10"><bold>Selective/focused attention</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr35">Giordano et al. (2017)</xref></td><td>52</td><td>52</td><td>E/VPT<italic>M</italic>: 28.7 <italic>SD</italic>: 2</td><td>5–6</td><td>QFAP-Ch</td><td /><td /><td>x</td><td>Focused attention: QFAP-CH: preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr25">Delane et al. (2017)</xref></td><td>77</td><td>74</td><td>E/VPT<italic>M</italic>: 27<italic>r</italic>: 24–32</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Selective attention: Preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr66">Murray et al. 2014</xref></td><td>198</td><td>70</td><td>E/VPT<italic>M</italic>: 27.4</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Selective attention: Preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr21">Cserjesi et al. (2012)</xref></td><td>248</td><td>130</td><td>MLPT<italic>r</italic>: 32–35+6</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Selective attention: Preterm = term</td></tr><tr><td colspan="10"><bold>Divided attention</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr35">Giordano et al. (2017)</xref></td><td>52</td><td>52</td><td>E/VPT<italic>M</italic>: 28.7 <italic>SD</italic>: 2</td><td>5–6</td><td>TAP-CQFAP-CH</td><td>x</td><td /><td>x</td><td>Divided attention: TAP-C: preterm < termParent: preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr25">Delane et al. (2017)</xref></td><td>77</td><td>74</td><td>E/VPT<italic>M</italic>: 27<italic>r</italic>: 24–32</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Divided attention: preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr66">Murray et al. 2014</xref></td><td>198</td><td>70</td><td>E/VPT<italic>M</italic>: 27.4</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td /><td>Divided attention: Preterm < term</td></tr></tbody></table> </ephtml> </p> <p>6 <emph>Note</emph>. Only key results in terms of whether there were statistically significant group differences, regardless of variable (e.g., accuracy and reaction time) were presented. EPT = Extreme Preterm; VPT = Very Preterm; MLPT = Moderate to Late Preterm; ANT = Attention Network Task; TAP-C = Tests of Attentional Performance for Children; TEA-Ch = Test of Everyday Attention for Children; ERP = Event Related Potential; QFAP-CH = Questionnaire For Attentional Performance in Children; SYS/WISC = Symbol Search of the Wechsler Intelligence Scale for Children; CB = Computer Based assessment; PP = Paper and Pencil based assessment, IR = Informant Report.</p> <hd id="AN0188923027-26">Visual-Spatial Attention (Orienting and Shifting)</hd> <p>Research on visual-spatial attention in preterm children has produced mixed findings. While three studies reported weaker performance in preterm children ([<reflink idref="bib35" id="ref253">35</reflink>]; [<reflink idref="bib66" id="ref254">66</reflink>]; [<reflink idref="bib100" id="ref255">100</reflink>]), another three found no significant differences ([<reflink idref="bib23" id="ref256">23</reflink>]; [<reflink idref="bib32" id="ref257">32</reflink>]; [<reflink idref="bib99" id="ref258">99</reflink>]).</p> <p>Four studies utilized the orienting task from the child version of the Attentional Network Test (ANT), comparing very preterm (VPT) children with full-term peers ([<reflink idref="bib23" id="ref259">23</reflink>]; [<reflink idref="bib32" id="ref260">32</reflink>]; [<reflink idref="bib100" id="ref261">100</reflink>], [<reflink idref="bib99" id="ref262">99</reflink>]). In this test, an orienting score is derived from the reaction time difference between spatially cued and central cued targets, with exogenous cues accelerating attention. Reaction times to spatially cued targets are measured to assess performance.</p> <p>Three of the these studies ([<reflink idref="bib23" id="ref263">23</reflink>]; [<reflink idref="bib32" id="ref264">32</reflink>]; [<reflink idref="bib100" id="ref265">100</reflink>]) found no significant differences in orienting scores between 200 VPT children and 169 full-term children aged 5 to 7 years. However, [<reflink idref="bib100" id="ref266">100</reflink>] reported significant differences when comparing 26 preschool-aged VPT with 31 full-term controls, despite using the same parameters. The authors stated that the reason for the suboptimal orienting of attention in preschool-aged VPT children remains unclear; they discuss whether it is possible that it might result from underdeveloped neural substrates during this developmental stage.</p> <p>[<reflink idref="bib35" id="ref267">35</reflink>] investigated covert attention shifting using the corresponding subtest from the Test of Attentional Performance (TAP) and the shifting attention subscale of the QFAP-CH. Validity effects for invalid cues were calculated as test parameters. Both the TAP and the questionnaire subscale revealed significant results, indicating that preterm children exhibit a more pronounced distinction between endogenous (top-down) and exogenous (bottom-up) attentional shifts compared to full-term children. Notably, preterm children struggled to enhance attention through internal effort.</p> <p>[<reflink idref="bib66" id="ref268">66</reflink>] assessed attentional shifting using the "Creature Counting" subtest of the TEA-Ch, a paper-and-pencil task requiring children to count objects along a trail and change direction when cued by arrows. Results demonstrated impaired shifting in 198 extremely/very preterm children compared to 70 full-term controls. This task, however, relies on numeracy skills and involves a distinct type of attention control, differing from the visual attention shifting measured by the ANT. The shifting required in this subtest may thus reflect broader attentional control processes rather than visual-spatial attention alone.</p> <p>In the context of visual-spatial attention, six studies employing four distinct methodologies were identified, generally meeting moderate quality criteria but utilizing varied and often non-comparable test parameters. The results lack consistency, making direct comparisons challenging due to the diversity of measurement approaches. Studies relying on reaction times as the basis for outcome variables predominantly reported no significant differences between preterm and term-born children. Conversely, research employing accuracy rates as test parameters often found significant differences between these groups. However, additional cognitive factors, such as numeracy skills and attention control mechanisms, may have influenced these outcomes. Therefore, the current body of research does not allow for a definite conclusion regarding visual-spatial attention.</p> <hd id="AN0188923027-27">Selective/Focused Attention</hd> <p>Four studies examined selective attention in preterm children in comparison to their full-term peers, employing either subtests (e.g., "Map Mission" or "Sky Search") from the paper-and-pencil-based TEA-Ch ([<reflink idref="bib21" id="ref269">21</reflink>]; [<reflink idref="bib25" id="ref270">25</reflink>]; [<reflink idref="bib66" id="ref271">66</reflink>]) or a questionnaire-based approach ([<reflink idref="bib35" id="ref272">35</reflink>]). In the "Sky Search" subtest, critical parameters include reaction times and the number of correct responses. [<reflink idref="bib25" id="ref273">25</reflink>] identified significant deficits in both reaction times and number of correct responses among 77 extremely/very preterm (E/VPT) 7-year-old children compared to 74 term-born children. The slower reaction times observed may reflect impairments in endogenous attention, as previously described. In contrast, [<reflink idref="bib66" id="ref274">66</reflink>] focused solely on the number of correct responses, also finding significant deficits among 198 E/VPT 7-year-olds compared to 70 term-born children.</p> <p>In the "Map Mission" subtest, children are instructed to identify as many targets as possible within a set timeframe, with the number of correct responses serving as the primary parameter. [<reflink idref="bib21" id="ref275">21</reflink>] found no significant differences in performance between moderate-to-late preterm (MLPT) children (<emph>n</emph> = 248) and their full-term counterparts. [<reflink idref="bib35" id="ref276">35</reflink>] used the focused attention subscales of the shifting attention subscale of the QFAP-CH, comparing 52 E/VPT children with 52 term-born children aged 5 to 6 years. Significant differences were reported in focused attention scores between the two groups. Overall, four studies utilized two distinct measurement methods with moderate quality criteria and diverse test parameters. Discrepancies in findings may stem from differences in gestational age, as E/VPT cohorts consistently exhibited deficits regardless of the assessed variables (reaction times and accuracy) or the measurement approach (paper-and-pencil tests vs. informant-reported questionnaires). In contrast, selective attention, when measured using accuracy rates in MLPT children, appears to remain unaffected.</p> <hd id="AN0188923027-28">Divided Attention</hd> <p>Three studies ([<reflink idref="bib25" id="ref277">25</reflink>]; [<reflink idref="bib35" id="ref278">35</reflink>]; [<reflink idref="bib66" id="ref279">66</reflink>]) examined divided attention using a dual-task paradigm that simultaneously presented visual and auditory stimuli. [<reflink idref="bib35" id="ref280">35</reflink>] also incorporated the divided attention subscale of the QFAP-CH. Across these investigations, deficits in divided attention were consistently observed in the preterm population. Specifically, [<reflink idref="bib25" id="ref281">25</reflink>] and [<reflink idref="bib66" id="ref282">66</reflink>] employed the divided attention subtest ("Sky Search Dual Task") from the paper-and-pencil-based TEA-Ch, evaluating performance in 275 early/very preterm (E/VPT) children. This task requires children to identify visual targets while concurrently counting auditory stimuli. To determine the test parameter, participants first complete the "Sky Search" subtest, a measure of selective attention. As preterm children have already been shown to perform worse in the selective attention subtest (as outlined in earlier sections), the divided attention results may be influenced by these pre-existing deficits. [<reflink idref="bib35" id="ref283">35</reflink>] compared 52 E/VPT children aged 5 to 6 years with 52 term-born children, using the divided attention subtest of the computer-based TAP-C and reaction times as the key parameter. Furthermore, the divided attention subscale of the QFAP-CH was included. Results from the TAP-C and the questionnaire's divided attention subscale indicated significant deficits in the preterm group, highlighting impairments in this attentional domain.</p> <p>Three studies, each employing different measurement methods and meeting moderate quality criteria, were identified. These studies examined varying test parameters. It is possible that preterm children at this developmental stage have not yet developed the ability for divided attention, causing them to prioritize either auditory or visual tasks. Furthermore, as divided attention was assessed through reaction times in all three studies, and given the established link between prematurity and slower processing speeds ([<reflink idref="bib66" id="ref284">66</reflink>]), the findings may be biased, with preterm children likely underperforming on tasks that emphasize speed or reaction time. As discussed earlier, slower reaction times in preterm children may stem from deficits in endogenous attention control and tonic alertness. This raises questions about the specificity of divided attention tasks in distinguishing between the constructs of divided attention, processing speed, and reaction time. Poor performance on tasks involving speed or reaction time, such as the divided attention tasks utilized in these studies, may be attributable to impairments in endogenous alertness observed in the preterm cohort.</p> <p>Table 6 summarizes the sample characteristics related to selectivity aspects of attention (including visual-spatial, selective/focused, and divided attention). It provides details such as samples size, gestational age, age at testing, the specific attention measures employed, and the primary findings, categorized by measurement type and variable. Only key outcomes, indicating whether statistically significant group differences were observed—irrespective of the specific variable (e.g., accuracy or reaction time)—are reported.</p> <hd id="AN0188923027-29">Executive Attention: Inhibition and Interference Control</hd> <p>The majority of studies on executive attention in preterm children utilized standardized assessments, with a primary focus on the ability to inhibit responses. Commonly employed tools included the executive attention subtests of the Attention Network Task (ANT), measuring inhibition of incongruent cues; the Erikson-Flanker Task; the Stop-Signal Task; and the Inhibition subtests from the NEPSY-II and TEA-Ch batteries. Participants in these studies were preterm children aged 5 to 12 years, with gestational ages ranging from 23 to 36 weeks. Performance was compared either with full-term peers or with normative values.</p> <p>Studies using the ANT predominantly involved younger preterm children aged 5 to 7 years. These studies generally reported no significant differences between preterm and full-term groups in terms of reaction times ([<reflink idref="bib23" id="ref285">23</reflink>]; [<reflink idref="bib32" id="ref286">32</reflink>]; [<reflink idref="bib100" id="ref287">100</reflink>], [<reflink idref="bib99" id="ref288">99</reflink>]) or accuracy ([<reflink idref="bib32" id="ref289">32</reflink>]; [<reflink idref="bib100" id="ref290">100</reflink>], [<reflink idref="bib99" id="ref291">99</reflink>]). An exception was noted in one study, where differences in accuracy but not reaction time were observed ([<reflink idref="bib32" id="ref292">32</reflink>]). Data processing methods, including the exclusion of anticipatory and unusually slow responses, may have contributed to these findings. Given that executive functions develop progressively with age, assessing such skills at this age is challenging, which may explain the lack of observed differences in this age group.</p> <p>In contrast, studies of preterm children beyond this age consistently indicated poorer inhibition compared to full-term peers ([<reflink idref="bib21" id="ref293">21</reflink>]; [<reflink idref="bib22" id="ref294">22</reflink>]; [<reflink idref="bib29" id="ref295">29</reflink>]; [<reflink idref="bib76" id="ref296">76</reflink>]). These studies included participants with gestational ages ranging from 23 to 36 weeks and employed diverse assessment tools, including computer-based and paper-and-pencil measures. For example, [<reflink idref="bib29" id="ref297">29</reflink>] examined inhibition in 89 preterm children (gestational ages = 24–36 weeks; age = 7 years) using the NEPSY-II Inhibition subtest, which assesses a child's ability to suppress automatic responses in tasks involving shapes or directional arrows. Preterm children scored lower on inhibition compared to normative data.</p> <p>Similarly, [<reflink idref="bib21" id="ref298">21</reflink>] compared the accuracy of the paper-and-pencil response inhibition subtest ("Opposite World") of the TEA-Ch in 7-year-old moderate to late preterm (MLPT) children (gestational ages = 32–35 + 6 weeks) and found poorer performance among the 248 preterm participants compared to 130 full-term peers. The task involved naming the opposite of the numbers "1" and "2" when presented sequentially.</p> <p>[<reflink idref="bib22" id="ref299">22</reflink>] employed an fMRI adaptation of the Erikson Flanker task to investigate interference control in a sample of 29 extremely/very preterm (E/VPT) children compared with 47 full-term children aged 8 to 9 years. The Erikson Flanker task is commonly utilized to assess cognitive processing, including attentional and control mechanisms such as interference, activation, inhibition, and memory. During this task, sequences of flanker stimuli are presented, consisting of a target stimulus requiring participant processing and flanking distractor stimuli. Participants are typically instructed to respond to the target stimuli as rapidly and accurately as possible. Performance is generally faster and more accurate during congruent trials. The study observed that E/VPT children exhibited slower reaction times compared to their full-term peers in the presence of interfering stimuli, indicative of reduced interference control. Similarly, [<reflink idref="bib76" id="ref300">76</reflink>] examined inhibitory control in 58 preterm children born at 23 to 35 weeks' gestation by comparing their accuracy and reaction times on a stop-signal task with those of 61 full-term children. The stop-signal task, a variant of the go/no-go task, requires participants to initiate a response to "go" stimuli but to withhold the response when a "stop" signal is presented after the initial stimulus. Preterm children demonstrated significantly lower accuracy on "go" trials and slightly reduced accuracy on "stop" trials compared to full-term controls, although no significant group differences in reaction times were identified.</p> <p>Overall, nine studies employing five distinct measures and test parameters were identified. The methodological quality of these studies was generally moderate. Findings consistently highlight a disadvantage for preterm children in standardized assessments of inhibitory control in middle childhood, suggesting a role for executive attention in the attentional profiles of preterm children. The absence of such effects in younger children may relate to the age at which testing was conducted, as previously discussed. it is possible that the tests employed lack the sensitivity required to detect impairments in younger age groups (Table 7).</p> <p>Table 7. Sample Characteristics of Executive Studies: Samples Size, Gestational Age, Age at Time of Testing, Attention Measure, and Main Findings, Organized by Measurement Type and Variable.</p> <p>Graph</p> <p> <ephtml> <table><colgroup><col align="left" /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /><col align="char" char="." /></colgroup><thead><tr><th align="left" colspan="5"><italic>n</italic></th><th align="center" colspan="4">Measurement types</th></tr><tr><th align="left">Authors</th><th align="center">Preterm</th><th align="center">Term</th><th align="center">GA of preterm group</th><th align="center">Age at time of testing (years)</th><th align="center">Measurement of attention</th><th align="center">CB</th><th align="center">PP</th><th align="center">Findings</th></tr></thead><tbody><tr><td colspan="9"><bold>Inhibition</bold></td></tr><tr><td><xref ref-type="bibr" rid="bibr32">Geldof et al. (2013)</xref></td><td>108</td><td>72</td><td>E/VPT<italic>M</italic>: 30.1 <italic>SD</italic>: 2.3</td><td>5</td><td>ANT</td><td>x</td><td /><td>Executive: RT: preterm = termError: preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr100">Walczak-Kozłowska et al. (2020)</xref></td><td>26</td><td>31</td><td>E/VPT<italic>M</italic>: 30; <italic>SD</italic>: 1.4</td><td>5</td><td>ANT</td><td>x</td><td /><td>Executive: preterm = term</td></tr><tr><td><xref ref-type="bibr" rid="bibr99">Walczak-Kozłowska et al. (2021)</xref></td><td>47</td><td>53</td><td>E/VPT<italic>M</italic>: 30.7; <italic>SD</italic>:1.6;<italic>r</italic>: 26–31</td><td>5</td><td>ANT</td><td>x</td><td /><td>Executive: preterm = term</td></tr><tr><td><xref ref-type="bibr" rid="bibr23">de Kieviet et al. (2012)</xref></td><td>66</td><td>66</td><td>E/VPT<italic>M</italic>: 29.3</td><td>7</td><td>ANT</td><td>x</td><td /><td>Executive: preterm = term</td></tr><tr><td><xref ref-type="bibr" rid="bibr29">Fernandez-Baizan et al. (2021)</xref></td><td>89</td><td>----</td><td>E/VPT<italic>M</italic>: 30.1; <italic>SD</italic>: 2.8;<italic>r</italic>: 36–24</td><td>7</td><td>NEPSY-II</td><td /><td>X</td><td>Inhibition: lower scores than normative values</td></tr><tr><td><xref ref-type="bibr" rid="bibr21">Cserjesi et al. (2012)</xref></td><td>248</td><td>130</td><td>MLPT<italic>r</italic>: 32– 35+6</td><td>7</td><td>TEA-Ch</td><td /><td>X</td><td>Inhibition: preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr22">de Kieviet et al. (2014)</xref></td><td>29</td><td>47</td><td>E/VPT<italic>M</italic>: 28.9</td><td>8–9</td><td>fMRI version of the Eriksen Flanker task</td><td>x</td><td /><td>Interference control: preterm < term</td></tr><tr><td><xref ref-type="bibr" rid="bibr76">Réveillon et al. (2016)</xref></td><td>58</td><td>61</td><td>PT<italic>M</italic>: 28.9; <italic>SD</italic>: 3.3;<italic>r</italic>: 23–35</td><td>9–12</td><td>Stop Signal Task</td><td>x</td><td /><td>Inhibition: preterm < term</td></tr></tbody></table> </ephtml> </p> <p>7 <emph>Note</emph>. Only key results in terms of whether there were statistically significant group differences, regardless of variable (e.g., accuracy and reaction time) were presented. EPT = extreme preterm; VPT = very preterm; MLPT = moderate to late preterm; PT = preterm; ANT = attention network task; TEA-Ch = test of everyday attention for children; CB = computer based assessment; PP = paper pencil test.</p> <hd id="AN0188923027-30">Discussion</hd> <p>The review examined studies investigating attention functioning in preterm children of preschool and school age to characterize the attention profile associated with the preterm phenotype, considering both behavioral-clinical and neuropsychological dimensions. Clinically, children born at less than 32 weeks' gestation appear to be at elevated risk for attention-related difficulties, with a particular predisposition toward inattentive behaviors. Moreover, the prevalence of ADHD diagnoses, particularly the inattentive presentation, is notably higher in this group compared to term-born peers or population averages. From a neuropsychological perspective, deficits were primarily observed in intensity-related aspects of attention, particularly those requiring top-down regulation (tonic alertness), whereas intensity processes driven by bottom-up mechanisms (phasic alertness) seemed relatively unaffected. Findings regarding selectivity and executive aspects of attention were more variable, with selective/focused attention and divided attention emerging as relevant components of the neuropsychological attention profile. However, evidence on orienting/shifting and inhibitory control remained inconsistent. While the precise attention profile of the preterm phenotype has not to be fully delineated yet, the present findings suggest a heightened vulnerability to attention-related impairments and ADHD, especially the inattentive presentation in preterm children born before 32 weeks' gestation. Neuropsychologically, impairments are evident in top-down controlled processes related to the intensity aspect, as well as in divided and focused attention within the selectivity dimension. In contrast, findings for visual-spatial attention and inhibitory control remain inconclusive.</p> <p>In terms of clinical considerations, the literature indicates that very preterm (VPT) and extremely preterm (EPT) children face an increased risk of attention-related difficulties, particularly inattentive behavior. This aligns with earlier findings ([<reflink idref="bib1" id="ref301">1</reflink>]; [<reflink idref="bib9" id="ref302">9</reflink>]; [<reflink idref="bib46" id="ref303">46</reflink>]; [<reflink idref="bib49" id="ref304">49</reflink>]; [<reflink idref="bib50" id="ref305">50</reflink>]). However, research on attention functions in moderate-to-late preterm (MLPT) children is limited, with only one study identifying no significant differences in attention performance compared to term-born peers. Notably, attention problems in the literature are frequently identified through screening tools (CBCL, TRF, SDQ), which are DSM-oriented but do not equate to clinical ADHD diagnoses. Despite this, evidence suggests a heightened risk of perceived attention difficulties, particularly inattentiveness, in preterm children. For instance, the SDQ hyperactivity scale exhibits high specificity (84.5%–74.5%) but low sensitivity (45.0%–42.5%) for ADHD diagnoses ([<reflink idref="bib92" id="ref306">92</reflink>]), implying that the prevalence of attention problems in preterm populations might be underestimated.</p> <p>Regarding the risk of DSM ADHD diagnoses in preterm children, existing literature includes extremely preterm (EPT) and very preterm (VPT) populations, but data on moderate-to-late preterm (MLPT) children are lacking. Preterm birth is associated with an increased risk of ADHD diagnoses, consistent to earlier findings ([<reflink idref="bib30" id="ref307">30</reflink>]; [<reflink idref="bib49" id="ref308">49</reflink>]; [<reflink idref="bib65" id="ref309">65</reflink>]). Notably, the inattentive presentation is reported more frequently, aligning with prior studies ([<reflink idref="bib30" id="ref310">30</reflink>]; [<reflink idref="bib44" id="ref311">44</reflink>]; [<reflink idref="bib48" id="ref312">48</reflink>], [<reflink idref="bib49" id="ref313">49</reflink>]; [<reflink idref="bib51" id="ref314">51</reflink>]).</p> <p>Younger preterm children (aged 5–6 years) exhibit symptoms of all three ADHD presentations, whereas older preterm children (aged 7–10 years) predominantly only display inattentive presentations. This pattern suggests a developmental trajectory in which inattentive symptoms become more pronounced and impulsive behavior diminish, potentially due to typical maturation processes like the development of inhibitory control, which continues throughout childhood and reaches maturity around age 12 years or later ([<reflink idref="bib20" id="ref315">20</reflink>]; [<reflink idref="bib17" id="ref316">17</reflink>]; [<reflink idref="bib90" id="ref317">90</reflink>]; [<reflink idref="bib93" id="ref318">93</reflink>]). As children age and impulsive behavior decrease, potentially explaining the absence of group differences in younger age groups, it is important to note that impulsive behaviors are typical for children in this developmental stage, regardless whether they were born preterm or at term. Both groups exhibit similar impulsivity in early childhood, which reflects normal developmental processes, such as the maturation of inhibitory control. As a result, the absence of group differences in impulsivity in younger age groups does not suggest a developmental disorder, but rather indicates that these behaviors are a typical part of childhood development. Environmental influences, such as school, where children learn to inhibit or regulate excessive motor activity, may also contribute to reduced hyperactive and impulsive behaviors. Such behaviors often perceived as disruptive, tend to draw greater attention from parents and teachers, leading to increased intervention efforts. In contrast, inattentive behavior frequently goes unnoticed in younger children because it is less disruptive in daily life until the demands of schooling highlight its impact. Consequently, inattentive behavior in early childhood may remain unaddressed, allowing it to persist over time.</p> <p>Within the neuropsychological framework of attention, research suggests that deficits primarily affect the intensity aspect, particularly those processes governed by top-down control, whereas bottom-up processes appear largely intact. Evidence regarding selectivity and executive attention is less consistent. While impairments in divided and selective/focused attention are well-documented, findings on visual-spatial attention—encompassing orienting and shifting—and executive attention exhibit significant heterogeneity. For visual-spatial attention, comparisons are hampered by diverse measurement tools with varying test parameters and often moderate quality criteria. Notably, studies using reaction time as an outcome often report no significant differences between preterm and full-term children, whereas those relying on accuracy measures frequently find significant group differences. Additional cognitive factors, such as numeracy skills and attention control mechanisms, may influence these results, complicating conclusions about visual-spatial attention. Regarding executive attention, evidence supports a persistent disadvantage for preterm children on standardized tests of inhibitory control in middle childhood. However, variability in measurement tools and test parameters complicates interpretations. The quality criteria of the tests described above was generally moderate. The absence of reported deficits in younger children may be attributed to their age at the time of assessment. According to the taxonomy of attention proposed by [<reflink idref="bib101" id="ref319">101</reflink>]—which organizes models of attention previously discussed in literature (e.g., [<reflink idref="bib62" id="ref320">62</reflink>]; [<reflink idref="bib73" id="ref321">73</reflink>]) into a hierarchical structure—all attention components are linked to overarching dimensions. Components lower in the hierarchy, such as the intensity aspect, serve as the foundation for more complex forms of attention, including selectivity and executive attention. Deficits in the foundational intensity aspect could increase the risk of impairments in these higher-order forms of attention.</p> <p>Executive attention, including inhibition, develops progressively throughout childhood and is closely linked to the maturation of the prefrontal cortex, which continues into adolescence ([<reflink idref="bib17" id="ref322">17</reflink>]). While inhibitory control can be reliably assessed in younger children ([<reflink idref="bib12" id="ref323">12</reflink>]), such assessments require age-appropriate paradigms and are often subject to high variability and floor effects in this age group. These methodological challenges can make it difficult to detect subtle group differences in inhibitory control among young children, including between full-term and preterm children. This limitation applies to both full-term and preterm children. However, deficits in attention processes have been identified in adulthood ([<reflink idref="bib34" id="ref324">34</reflink>]), potentially originating from early-life disruptions in foundational attention processes like intensity.</p> <p>Moreover, tests designed to measure executive attention may lack the sensitivity required to detect possible impairments in young children. Executive attention is arguably the least well-defined of the three primary attention domains, often overlapping with other cognitive functions such as executive functioning and processing speed. This overlap complicates the interpretation of results, as it is difficult to disentangle which cognitive processes are being measured by a specific task. Discrepancies between studies may reflect variations in task formats (e.g., paper-and-pencil, computer-based, informant reports, and EEG recordings), test parameters (e.g., reaction time, accuracy, omissions, and anticipations), and their reliance on different attention subcomponents (e.g., exogenous vs. endogenous attention) and additional cognitive skills (e.g., numeracy, processing speed, and fine motor abilities). For instance, paper-and-pencil tasks can be influenced by fine motor skills, timed tasks by processing speed, and specific tasks like the "Sky Search" dual-task (which involves divided attention) by both sustained and selective attention skills. Similarly, the shifting subtest from the TEA-Ch, which requires counting, depends on numeracy skills.</p> <p>For certain attention components, numerous measurements exist, often with scarcely comparable test parameters and, in some cases, only moderate quality standards. The choice of test parameters is influenced by the tasks employed and the specific domain of attention being assessed. In the case of the intensity aspect, reaction times are most frequently used, resulting in findings that are generally more comparable and reliable. Indeed, results regarding the intensity aspect exhibit the highest degree of consistency. However, for some components of attention, only a limited number of studies are available, rendering overarching conclusions uncertain. Conversely, findings related to broadly described attention difficulties and the risk of clinically relevant diagnoses are considered reliable. This is due to the predominantly good to excellent quality of measurements. Despite the use of varied measurement approaches and sample differences in size, age at testing, and gestational age, comparisons with full-term children or normative values have yielded highly consistent results.</p> <p>In summary, the attention profile associated with the preterm phenotype remains inconclusive. However, evidence from this review indicates an elevated risk of attention-related difficulties and ADHD diagnoses, with inattentive symptoms and the ADHD/IA presentation more frequently reported in clinical contexts. From a neuropsychological perspective, deficits in the intensity dimensions of attention appear to be particular significant. Regarding selectivity and executive aspects of attention, conclusions should be drawn cautiously due to the considerations outlined above.</p> <hd id="AN0188923027-31">Limitations</hd> <p>This review provides evidence of attention difficulties in children born preterm during preschool and school years. While the clinical profile of attention deficits appears consistent and comparable, drawing definite conclusions about the neuropsychological profile of attention remains challenging. Several factors complicate the interpretation of findings. Firstly, it is difficult to select tasks that are independent of confounding deficits often associated with preterm birth, such as impairments in global cognition, working memory, or fine motor skills ([<reflink idref="bib61" id="ref325">61</reflink>]). Secondly, the preterm population is a heterogeneous group characterized by diverse risk factors, including deficits in cognition, motor abilities, and memory. This heterogeneity is further compounded by variations in the gestational age of preterm infants. Studies often fail to differentiate between different categories of preterm infants, such as very preterm (<32 weeks) or moderate-to-late preterm (32–36 weeks), as well as a different categorization for term-born comparison groups (i.e., early term [37–38 weeks] and full term [39–41 weeks]), which could have an impact on attention outcomes. A more precise reporting of gestational age categories would help clarify how these differences affect attentional difficulties.</p> <p>Thirdly, the complex and interrelated nature of cognitive functions can lead to task impurity, where performance on a given task reflects variations in lower-level processes as well as the specific cognitive processes being assessed. Fourthly, individual differences in attentional abilities may result from intricate interactions between neurological, biological, and social factors, such as gestational age, birth weight, medical complications, infant temperament, socioeconomic status, maternal characteristics, and parenting, which were not fully accounted for. Fifthly, alterations in whole-brain connectivity might contribute to global attention problems that cannot be reliably attributed to specific domains. Diffusion Tensor Imaging (DTI) techniques could provide further insight into this issue. Sixthly, the use of different types of tests and subtests to measure the same component, such as traditional paper-and-pencil-based versus computerized neuropsychological tests, adds complexity. Seventh, the inclusion of non-standardized instruments such as the QFAP-CH (Questionnaire of Focused Attention Performance in Children) presents an additional limitation. While this questionnaire was used in otherwise eligible studies, no peer-reviewed psychometric validation is currently available. As a result, findings based on this instrument must be interpreted with caution and were not included in any conclusive evaluations of methodological quality within this review. Lastly, varying test parameters, such as response speed versus accuracy, further complicate the comparison and interpretation of results.</p> <hd id="AN0188923027-32">Conclusion and Future Perspectives</hd> <p>Despite the precautions and limitations inherent in this review, we are confident that it provides valuable insights by systematically expanding the phenotypic understanding of attention deficits in preterm children, both clinically and neuropsychologically. Preterm children exhibit distinct attention deficits during preschool and school years, with a characteristic phenotypic attention profile. They are at an increased risk for attention-related problems, particularly inattentive behavior, and are more frequently diagnosed with ADHD, specifically the inattentive presentation (ADHD/IA). Moreover, they struggle with activating and sustaining attention through internal effort (tonic alertness) and exhibit partial deficits in selective and executive attention, possibly stemming from broader intensity-related attention issues.</p> <p>The early identification of attention difficulties is crucial, as timely detection enables preventive interventions and rehabilitative measures, potentially averting negative developmental cascades that may impact learning. Neuropsychological assessments and parental evaluations could help to uncover a broader range of attention deficits that may not align with the criteria for the more commonly recognized ADHD presentations. Diagnoses, interventions, and support strategies should be tailored to meet the unique needs of preterm children, alongside psychoeducational resources and guidance for parents. Over the past decade, advances in understanding the specific attention profiles of preterm children have expanded awareness of their unique challenges, encouraging the development of clinical and educational practices that emphasize regular follow-ups and tailored support.</p> <p>However, several important research directions should be pursued to further advance the field: To advance the field of attention research in preterm children, future studies should prioritize the standardization of neuropsychological assessments using age-adapted, harmonized measures, including also methods like Electroencephalography (EEG), functional Magnetic Resonance Imaging (fMRI), and behavioral tasks, to enable more reliable cross-study comparisons. Reducing sample heterogeneity is also essential. This should include a more precise categorization of both preterm subgroups (e.g., very vs. moderate-to-late preterm) and term-born controls, especially distinguishing between early term (37–38 weeks) and full term (39–41 weeks), as these subtle differences may significantly impact attention outcomes. Large-scale longitudinal studies are needed to trace developmental trajectories of attentional difficulties, clarify their emergence, and evaluate the long-term effects of early interventions. In addition, neuroimaging techniques such as Diffusion Tensor Imaging (DTI) and resting-state fMRI could shed light on the neural mechanisms underlying attention deficits. 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Jaeger</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0009-0004-4078-8995 Boris Suchan</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0003-2934-0263</bibtext> </blist> <blist> <bibtext> The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> The author(s) received no financial support for the research, authorship, and/or publication of this article.</bibtext> </blist> </ref> <aug> <p>By Dominique A. Jaeger; Nina Gawehn and Boris Suchan</p> <p>Reported by Author; Author; Author</p> <p></p> <p>Dominique A. Jaeger, M.Sc. Psychology – Doctoral candidate in clinical neuropsychology at Ruhr University Bochum, specializing in attentional development following preterm birth. Works at the Developmental Neuropsychological Outpatients' Department at the Children's Hospital Dortmund with extensive experience in clinical assessment, counseling, and intervention planning for children and their families.</p> <p>Dr. Nina Gawehn – Professor of psychology at Hochschule für Gesundheit in Bochum and head of the Developmental Neuropsychological Outpatients' Department for children at risk. Research and teaching focus on developmental pathways under biological and psychosocial risk conditions, early intervention, resilience, and parent–child interaction. She has extensive clinical expertise in diagnostics, counseling, and family-centered interventions.</p> <p>Dr. Boris Suchan – Professor of clinical neuropsychology at Ruhr University Bochum and director of the Neuropsychological Therapy Center. Research focuses on neural mechanisms of memory, mental time travel, and perception of faces and bodies, using fMRI and EEG, with long-standing expertise in assessment, training, and rehabilitation of patients with neurological and psychiatric disorders.</p> </aug> <nolink nlid="nl1" bibid="bib19" firstref="ref1"></nolink> <nolink nlid="nl2" bibid="bib87" firstref="ref2"></nolink> <nolink nlid="nl3" bibid="bib54" firstref="ref3"></nolink> <nolink nlid="nl4" bibid="bib97" firstref="ref4"></nolink> <nolink nlid="nl5" bibid="bib67" firstref="ref6"></nolink> <nolink nlid="nl6" bibid="bib98" firstref="ref7"></nolink> <nolink nlid="nl7" bibid="bib15" firstref="ref8"></nolink> <nolink nlid="nl8" bibid="bib41" firstref="ref9"></nolink> <nolink nlid="nl9" bibid="bib85" firstref="ref10"></nolink> <nolink nlid="nl10" bibid="bib60" firstref="ref11"></nolink> <nolink nlid="nl11" bibid="bib64" firstref="ref12"></nolink> <nolink nlid="nl12" bibid="bib86" firstref="ref13"></nolink> <nolink nlid="nl13" 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  Data: A Literature Review: Attention Profile in Preterm Children--It's Time to Act
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  Data: <searchLink fieldCode="AR" term="%22Dominique+A%2E+Jaeger%22">Dominique A. Jaeger</searchLink> (ORCID <externalLink term="https://orcid.org/0009-0004-4078-8995">0009-0004-4078-8995</externalLink>)<br /><searchLink fieldCode="AR" term="%22Nina+Gawehn%22">Nina Gawehn</searchLink><br /><searchLink fieldCode="AR" term="%22Boris+Suchan%22">Boris Suchan</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0003-2934-0263">0000-0003-2934-0263</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Attention+Disorders%22"><i>Journal of Attention Disorders</i></searchLink>. 2025 29(14):1319-1344.
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  Label: Abstract
  Group: Ab
  Data: Objective: Children born preterm are at an elevated risk of developmental challenges, often exhibiting a distinct "preterm behavioral phenotype" characterized by particular attention difficulties. This review focuses on examining the phenotypical attention profile in preterm children aged 5 to 11 years, considering both clinical and neuropsychological aspects. Method: Following the PRISMA reporting guidelines, 22 peer-reviewed studies were analyzed. Result: According to behavioral-clinical aspects, preterm children appear to be at heightened risk for inattentive attention problems, including a predisposition to the predominantly inattentive presentation of ADHD. Regarding neuropsychological attention, deficits were identified in top-down controlled intensity processes as well as in certain components of selectivity and executive functioning. Conclusion: This review yields evidence that preterm children exhibit distinct and specific attention deficits during preschool and school age, characterized by a phenotypical clinical and neuropsychological attentional profile. Early identification of these issues is crucial, as it enables timely interventions to support school participation and mitigate the risk of learning difficulties, academic failure, and other secondary complications associated with attention deficits.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2025
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1488403
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1488403
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1177/10870547251361222
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 26
        StartPage: 1319
    Subjects:
      – SubjectFull: Premature Infants
        Type: general
      – SubjectFull: At Risk Persons
        Type: general
      – SubjectFull: Child Development
        Type: general
      – SubjectFull: Attention Deficit Disorders
        Type: general
      – SubjectFull: Children
        Type: general
      – SubjectFull: Preadolescents
        Type: general
      – SubjectFull: Attention Deficit Hyperactivity Disorder
        Type: general
      – SubjectFull: Symptoms (Individual Disorders)
        Type: general
      – SubjectFull: Screening Tests
        Type: general
      – SubjectFull: Behavior Problems
        Type: general
      – SubjectFull: Child Behavior
        Type: general
      – SubjectFull: Strengths and Difficulties Questionnaire
        Type: general
    Titles:
      – TitleFull: A Literature Review: Attention Profile in Preterm Children--It's Time to Act
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Dominique A. Jaeger
      – PersonEntity:
          Name:
            NameFull: Nina Gawehn
      – PersonEntity:
          Name:
            NameFull: Boris Suchan
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 01
              M: 12
              Type: published
              Y: 2025
          Identifiers:
            – Type: issn-print
              Value: 1087-0547
            – Type: issn-electronic
              Value: 1557-1246
          Numbering:
            – Type: volume
              Value: 29
            – Type: issue
              Value: 14
          Titles:
            – TitleFull: Journal of Attention Disorders
              Type: main
ResultId 1