Visual and Visuocognitive Development of Children Born Very Prematurely



Visual development provides a set of milestones and sensitive methods for assessing brain development in infancy. In particular the first months of post-term life see the emergence of visual cortical function. Measures of subcortical and cortical function have led us to a detailed neurobiological model of normal visual development which gives a basis for assessing visual development in very premature infants. This chapter reviews the ocular and cerebral factors associated with preterm birth (at 32 weeks gestation or earlier) which may impair development and presents the behavioural and electrophysiological methods now available (including ‘fixation shifts’ for gauging visual attention and specific visual event-related potentials (VERP)) which allow assessment of the impact of these factors on development and the prediction of likely later neurocognitive deficits. Studies are reviewed which show that in the first year of post-term life, visual cortical development in healthy preterm-born infants is generally similar to term-born infants matched for post-term age, although there is some small relative delay in the development of motion processing in the first few months of life. However, infants in whom neonatal MRI reveals cerebral damage, in particular white matter abnormality, show deficits in visual and visuocognitive development that are graded according to the severity of the damage. These deficits are also predictive of later neurocognitive status. In the preschool years, visuocognitive functions show the impact of preterm birth. By age 6, the preterm group as a whole show selective deficits in visuomotor functions, attention, including executive control, and other aspects of spatial cognition. These deficits are primarily associated with the dorsal stream of visual, spatial, and visuomotor processing controlling actions. These dorsal stream networks are linked to and overlap with those underpinning different components of attention. However, this ‘vulnerability’ of the dorsal system is not unique to children born very preterm; it is also a feature of many neurodevelopmental disorders, e.g. autism, Williams syndrome, Fragile X, and children with congenital cataract. The main challenge for the future is to use these new measures and technologies, developed as child-friendly methods for successful assessment of developmental progress in early life, in early trials of intervention. Such early measures should, in the long term, help preterm infants develop cognitive abilities that allow them to reach their true intellectual and social potential.


Preterm Birth Visual Evoke Potential Dorsal Stream White Matter Damage Visual Development 



The authors’ research on preterm infants was done in collaboration with members of the Visual Development Unit, in particular John Wattam-Bell, Dee Birtles, Marko Nardini, and Shirley Anker; with Dr. Janet Rennie (Addenbrooke’s Hospital, Cambridge), Drs. Eugenio Mercuri, Frances Cowan, Leigh Dyet, Mary Rutherford, Ms Rachel Rathbone, and Prof. David Edwards (Imperial College, Hammersmith Hospital) and Prof. Andrew Wilkinson (John Radcliffe Hospital, Oxford). This work has been supported by Medical Research Council grants G7908507 and G0601007.


  1. Atkinson J. Human visual development over the first six months of life. A review and a hypothesis. Hum Neurobiol. 1984;3:61–74.PubMedGoogle Scholar
  2. Atkinson J. The developing visual brain. Oxford: OUP; 2000 (Oxford Psychology Series 32).Google Scholar
  3. Atkinson J, Braddick O. Research methods in infant vision. In: Carpenter RHS, Robson JG, editors. Vision research: a practical guide to laboratory methods. Oxford: Oxford University Press; 1999. pp. 161–186.Google Scholar
  4. Atkinson J, Braddick O. Neurobiological models of normal and abnormal visual development. In: De Haan M, Johnson M, editors. The cognitive neuroscience of development. Hove: Psychology Press; 2003. pp. 43–71.Google Scholar
  5. Atkinson J, Braddick O. Visual and visuocognitive development in children born very prematurely. Prog Brain Res. 2007;164:123–49.PubMedCrossRefGoogle Scholar
  6. Atkinson J, Hood B. Development of visual attention. In: Burack JA, Enns JT, editors. Attention, development, and psychopathology. New York, NY: Guilford Press; 1997. pp. 31–54.Google Scholar
  7. Atkinson J, Hood B, Wattam-Bell J, Braddick OJ. Changes in infants’ ability to switch visual attention in the first three months of life. Perception 1992;21:643–53.PubMedCrossRefGoogle Scholar
  8. Atkinson J, Weeks F, Anker S, Rae S, Macpherson F, Hughes C. VEP and behavioural measures for delayed visual development in VLBW infants. Strabismus 1994;2:42.Google Scholar
  9. Atkinson J, King J, Braddick O, Nokes L, Anker S, Braddick F. A specific deficit of dorsal stream function in Williams’ syndrome. NeuroReport 1997;8:1919–22.PubMedCrossRefGoogle Scholar
  10. Atkinson J, Anker S, Rae S, Hughes C, Braddick O. A test battery of child development for examining functional vision (ABCDEFV). Strabismus 2002a;10:245–69.PubMedCrossRefGoogle Scholar
  11. Atkinson J, Anker S, Rae S, Weeks F, Braddick O, Rennie J. Cortical visual evoked potentials in very low birthweight premature infants. Arch Dis Child Fetal Neonatal Ed. 2002b;86:F28–31.PubMedCrossRefGoogle Scholar
  12. Atkinson J, Braddick O, Anker S, Curran W, Andrew R. Neurobiological models of visuospatial cognition in children with Williams Syndrome: measures of dorsal-stream and frontal function. Dev Neuropsychol. 2003;23:141–74.Google Scholar
  13. Atkinson J, Braddick O, Anker S, Nardini M, Birtles D, Rutherford M, Mercuri E, Dyet L, Edwards D, Cowan F. Cortical vision, MRI and developmental outcome in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2008;93: F292–7.PubMedCrossRefGoogle Scholar
  14. Bassi L, Ricci D, Volzone A, Allsop JM, Srinivasan L, Pai A, Ribes C, Ramenghi LA, Mercuri E, Mosca F, Edwards AD, Cowan FM, Rutherford MA, Counsell SJ. Probabilistic diffusion tractography of the optic radiations and visual function in preterm infants at term equivalent age. Brain 2008;131:573–82.PubMedCrossRefGoogle Scholar
  15. Bhutta AT, Cleves MA, Casey PH, Cradock MM, Anand KJ. Cognitive and behavioral outcomes of school-aged children who were born preterm: a meta-analysis. JAMA 2002;288:728–37.PubMedCrossRefGoogle Scholar
  16. Birch EE, O’Connor AR. Preterm birth and visual development. Semin Neonatol. 2001;6:487–97.PubMedCrossRefGoogle Scholar
  17. Biro S, Russell J. The execution of arbitrary procedures by children with autism. Dev Psychopathol. 2001;13:97–110.PubMedCrossRefGoogle Scholar
  18. Birtles D, Braddick O, Wattam-Bell J, Wilkinson A, Atkinson J. Orientation and motion-specific visual cortex responses in infants born preterm. NeuroReport. 2007;18:1975–9.PubMedCrossRefGoogle Scholar
  19. Birtles D, Anker S, Atkinson J, Shellens R, Briscoe A, Mahoney M, Braddick O. Bimanual strategies for object retrieval in infants and young children. Exp Brain Res. 2011;211:207–18.PubMedCrossRefGoogle Scholar
  20. Botting N, Powls A, Cooke RW, Marlow N. Attention deficit hyperactivity disorders and other psychiatric outcomes in very low birthweight children at 12 years. J Child Psychol Psychiatr. 1997;38:931–41.CrossRefGoogle Scholar
  21. Braddick O, Atkinson J. Development of brain mechanisms for visual global processing and object segmentation. Prog Brain Res. 2007;164:151–68.PubMedCrossRefGoogle Scholar
  22. Braddick O, Atkinson J, Hood B, Harkness W, Jackson G, Vargha-Khadem F. Possible blindsight in infants lacking one cerebral hemisphere. Nature 1992;360:461–3.PubMedCrossRefGoogle Scholar
  23. Braddick O, Atkinson J, Wattam-Bell J. Normal and anomalous development of visual motion processing: motion coherence and ‘dorsal stream vulnerability’. Neuropsychologia 2003;41:1769–84.PubMedCrossRefGoogle Scholar
  24. Breckenridge K, Braddick O, Atkinson J. The organisation of attention in typical development: a new preschool attention test battery. 2010;submitted.Google Scholar
  25. Counsell SJ, Shen Y, Boardman JP, Larkman DJ, Kapellou O, Ward P, et al. Axial and radial diffusivity in preterm infants who have diffuse white matter changes on magnetic resonance imaging at term-equivalent age. Pediatrics 2006;117:376–86.PubMedCrossRefGoogle Scholar
  26. Daw N. Visual development. New York, NY: Plenum Press; 1995.Google Scholar
  27. du Plessis AJ, Volpe JJ. Perinatal brain injury in the preterm and term newborn. Curr Opin Neurol. 2002;15:151–7.PubMedCrossRefGoogle Scholar
  28. Fulton AB, Hansen RM, Moskowitz A. Development of rod function in term born and former preterm subjects. Optom Vis Sci. 2009;86:E653–8.PubMedCrossRefGoogle Scholar
  29. Gunn A, Cory E, Atkinson J, Braddick O, Wattam-Bell J, Guzzetta A, Cioni G. Dorsal and ventral stream sensitivity in normal development and hemiplegia. NeuroRepor. 2002;13:843–7.CrossRefGoogle Scholar
  30. Hellgren K, Hellström A, Jacobson L, Flodmark O, Wadsby M, Martin L. Visual and cerebral sequelae of very low birth weight in adolescents. Arch Dis Child Fetal Neonatal Ed. 2007;92:F259–64.PubMedCrossRefGoogle Scholar
  31. Henderson SE, Sugden DA. The movement ABC manual. London: The Psychological Corporation; 1992.Google Scholar
  32. Hood B. Gravity rules for 2–4 year olds. Cogn Dev. 1995;10:577–98.CrossRefGoogle Scholar
  33. Howland HC. Early refractive development. In: Simons K, editor. Early visual development: normal and abnormal. New York, NY: Oxford University Press; 1993.Google Scholar
  34. Inder TE, Huppi PS, Warfield S, Kikinis R, Zientara GP, Barnes PD, Jolesz F, Volpe JJ. Periventricular white matter injury in the premature infant is followed by reduced cerebral cortical gray matter volume at term. Ann Neurol. 1999;46:755–60.PubMedCrossRefGoogle Scholar
  35. Jakobson LS, Frisk V, Downie ALS. Motion-defined form processing in extremely premature children. Neuropsychologia 2006;44:1777–86.PubMedCrossRefGoogle Scholar
  36. Johnson S, Hollis C, Kochhar P, Hennessy E, Wolke D, Marlow N. Autism Spectrum Disorders in extremely preterm children. J Pediatr. 2010;Jan 5 (Epub ahead of print).Google Scholar
  37. Kastner S, Ungerleider LG. Mechanisms of visual attention in the human cortex. Annu Rev Neurosci. 2000;23:315–41.PubMedCrossRefGoogle Scholar
  38. Larsson EK, Rydberg AC, Holmström GE. A population-based study on the visual outcome in 10-year-old preterm and full-term children. Arch Ophthalmol. 2005;123:825–32.PubMedCrossRefGoogle Scholar
  39. Luoma L, Herrgård E, Martikainen A. Neuropsychological analysis of the visuomotor problems in children born preterm at < or = 32 weeks of gestation: a 5-year prospective follow-up. Dev Med Child Neurol. 1998;40:21–30.PubMedCrossRefGoogle Scholar
  40. MacKay TL, Jakobson LS, Ellemberg D, Lewis TL, Maurer D, Casiro O. Deficits in the processing of local and global motion in very low birthweight children. Neuropsychologia 2005;43:1738–48.PubMedCrossRefGoogle Scholar
  41. Manly T, Nimmo-Smith I, Watson P, Anderson V, Turner A, Roberston IH. The differential assessment of children’s attention: the test of everyday attention for children (TEA-Ch), normative sample and ADHD performance. J Child Psychol Psychiatr. 2001;42:1065–81.CrossRefGoogle Scholar
  42. Mantagos IS, Vanderveen VK, Smith LEH. Emerging treatments for retinopathy of prematurity. Semin Ophthalmol. 2009;24:82–6.PubMedCrossRefGoogle Scholar
  43. Marlow N. Outcome following extremely preterm birth. Curr Obstet Gynaecol. 2006;16:141–6.CrossRefGoogle Scholar
  44. Marlow N, Hennessy EM, Bracewell MA, Wolke D; EPICure Study Group. Motor and executive function at 6 years of age after extremely preterm birth. Pediatrics 2007;120:793–804.PubMedCrossRefGoogle Scholar
  45. McDonald MA, Dobson V, Sebris SL, Baitch L, Varner D, Teller DY. The acuity card procedure: a rapid test of infant acuity. Invest Ophthalmol Vis Sci. 1985;26:1158–62.PubMedGoogle Scholar
  46. Mercuri E, Haataja L, Guzzetta A, Anker S, Cowan F, Rutherford M, Andrew R, Braddick O, Cioni G, Dubowitz L, Atkinson J. Visual function in term infants with hypoxic-ischaemic insults: correlation with neurodevelopment at 2 years of age. Arch Dis Child Fetal Neonatal Ed. 1999;80:F99–104.PubMedCrossRefGoogle Scholar
  47. Mulder H, Pitchford NJ, Hagger M, Marlow N. Development of executive function and attention in preterm children: a systematic review. Dev Neuropsychol. 2009;34:393–421.PubMedCrossRefGoogle Scholar
  48. Nardini M, Burgess N, Breckenridge K, Atkinson J. Differential developmental trajectories for egocentric, environmental and intrinsic frames of reference in spatial memory. Cognition 2006;101:153–72.PubMedCrossRefGoogle Scholar
  49. Norcia AM, Tyler CW, Piecuch R, Clyman R, Grobstein J. Visual acuity development in normal and abnormal preterm human infants. J Pediatr Ophthalmol Strabismus. 1987;24:70–4.PubMedGoogle Scholar
  50. Palmer EA. Results of U.S. randomized clinical trial of cryotherapy for ROP (CRYO-ROP). Doc Ophthalmol. 1990;74:245–51.PubMedCrossRefGoogle Scholar
  51. Pavlova M, Sokolov A, Birbaumer N, Krageloh-Mann I. Biological motion processing in adolescents with early periventricular brain damage. Neuropsychologia 2006;44:586–93.PubMedCrossRefGoogle Scholar
  52. Petrou S, Henderson J, Bracewell M, Hockley C, Wolke D, Marlow N; EPICure Study Group. Pushing the boundaries of viability: the economic impact of extreme preterm birth. Early Hum Dev. 2006;82:77–84.PubMedCrossRefGoogle Scholar
  53. Posner MI, Petersen SE. The attention system of the human brain. Annu Rev Neurosci. 1990;13:25–42.PubMedCrossRefGoogle Scholar
  54. Rennie JM. A review of the risk of being born too soon. Fetal Maternal Med Rev. 2002;13:157–68.Google Scholar
  55. Ricci D, Cesarini L, Romeo DM, Gallini F, Serrao F, Groppo M, De Carli A, Cota F, Lepore D, Molle F, Ratiglia R, De Carolis MP, Mosca F, Romagnoli C, Guzzetta F, Cowan F, Ramenghi LA, Mercuri E. Visual function at 35 and 40 weeks’ postmenstrual age in low-risk preterm infants. Pediatrics 2008;122: e1193–8.PubMedCrossRefGoogle Scholar
  56. Robertson CMT, Watt M-J, Dinu IA. Outcomes for the extremely premature infant: What is new? and where are we going? Pediatr Neurol. 2009;40:189–96.PubMedCrossRefGoogle Scholar
  57. Stevenson RC, McCabe CJ, Pharoah PO, Cooke RW. Cost of care for a geographically determined population of low birthweight infants to age 8–9 years. I. Children without disability. Arch Dis Child Fetal Neonatal Ed. 1996;74:F114–7.PubMedCrossRefGoogle Scholar
  58. Sylvester CL. Retinopathy of prematurity. Semin Ophthalmol. 2008;23:318–23.PubMedCrossRefGoogle Scholar
  59. Van Braeckel K, Butcher PR, Geuze RH, van Duijn MA, Bos AF, Bouma A. Less efficient elementary visuomotor processes in 7- to 10-year-old preterm-born children without cerebral palsy: an indication of impaired dorsal stream processes. Neuropsychology 2008;22:755–64.PubMedCrossRefGoogle Scholar
  60. van de Weijer-Bergsma E, Wijnroks L, Jongmans MJ. Attention development in infants and preschool children born preterm: a review. Infant Behav Dev. 2008;31:333–51.PubMedCrossRefGoogle Scholar
  61. Van Hof-Van Duin J, Mohn G. The development of visual acuity in normal fullterm and preterm infants. Vis Res. 1986;26:909–16.PubMedCrossRefGoogle Scholar
  62. Wattam-Bell J, Birtles D, Nyström P, von Hofsten C, Rosander K, Anker S, Atkinson J, Braddick O. Reorganization of global form and motion processing during human visual development. Curr Biol. 2010;20:1–5.CrossRefGoogle Scholar
  63. Wood NS, Marlow N, Costeloe K, Gibson AT, Wilkinson AR; EPICure Study Group. Neurologic and developmental disability after extremely preterm birth. N Engl J Med. 2000;343:378–84.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.Visual Development Unit, Department of Developmental ScienceUniversity College LondonLondonUK
  2. 2.Department of Experimental PsychologyUniversity of OxfordOxfordUK

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