Subclinical but significant: A multi-informant perspective on early socio-emotional difficulties in preterm preschoolers

Introduction: Children born preterm face increased risks of neurodevelopmental difficulties, comprised within the “preterm behavioral phenotype”. This study examined behavioral and socio-emotional development in preterm preschoolers using a multi-informant approach to characterize behavioral profiles, mental health outcomes, and their associations with prematurity severity and early medical experiences. Methods: 102 five-year-old children (70 preterm, 32 full-term) were assessed using standardized measures, including parent and teacher questionnaires (Child Behavior Checklist, Teacher Report Form, Social Responsiveness Scale, ADHD Questionnaire) and direct clinical observation (Autism Diagnostic Observation Schedule-2). Analyses examined group differences and associations with gestational age, birth weight and neonatal intensive care unit (NICU) parameters, including early procedural pain, respiratory support and kangaroo care. Results: Preterm children demonstrated a predominantly subclinical phenotype, characterized by elevated difficulties across domains. Marked informant discrepancies emerged: parents reported more internalizing symptoms, attention deficits, social-communication difficulties, and autism-related traits in the PT group, whereas teacher ratings showed stronger associations with prematurity severity and early medical procedures. Early NICU experiences were linked to later outcomes: greater exposure to skin-breaking procedures and longer ventilation duration predicted higher reported behavioral problems, whereas more kangaroo care was associated with fewer reported social difficulties. Discussion: Preterm preschoolers display subtle yet meaningful socio-emotional vulnerabilities that manifest below clinical thresholds, but still warrant continued surveillance. Divergence between parent and teacher perspectives underscores the importance of multi-informant assessment across contexts. Associations between early procedural pain and later behavioral outcomes identifies a modifiable risk factor, emphasizing the importance of optimized neonatal pain management and minimizing medical intensity.