169 20%. 1,2 However, less is known about the longer-term outcome at school age. There is a high prevalence of learning and behavior problems and early school failures, even in preterm chil- dren who are neurologically normal. 3,4 Both biological and social factors deter- mine these suboptimal outcomes. 3,5,6 Medical factors may be less critical and social factors more influential as the child develops. 7,8 Social factors found to be associated with school-age outcomes tend to be “distal” markers of social risk such as parental race, education, mari- tal status, and income. Moreover, few studies have assessed the family envi- ronment in which the preterm child is reared. 8 See editorial, p 153. We describe a longitudinal, prospec- tive follow-up to age 10 years of a re- gional cohort of children born at <32 weeks’ gestational age and a socioeco- nomically matched term control group born in the mid 1980s. The effect of the child’s family composition, extent of in- volvement of each biological parent in child rearing, and changes in family res- idence on school performance were ex- amined. We anticipated that the preterm children would have poorer cognitive and academic performance and more behavior problems than would term control subjects. Further, we hypothe- sized that in preterm children, environ- mental factors would be stronger pre- dictors of school performance than Improvements in perinatal care during the past 2 decades have resulted in sig- nificantly increased survival for very premature infants. This trend has gen- erated substantial interest in the sub- sequent developmental outcome of re- Impact of family structure and stability on academic outcome in preterm children at 10 years of age Steven J. Gross, MD, Barbara B. Mettelman, PhD, Timothy D. Dye, PhD, and Terri A. Slagle, MD cent preterm survivors. A large body of evidence suggests that early neu- rodevelopmental outcome is favorable, with the proportion of children surviv- ing with severe cognitive or neurologic disorders remaining at about 10% to From the Departments of Pediatrics and Psychiatry, State University of New York, Upstate Medical University, Syracuse, New York; Department of Community and Preventive Medicine, University of Rochester, Rochester, New York; Department of Pediatrics, California Pacific Medical Center, San Francisco. Submitted for publication Mar 31, 2000; revisions received Aug 2, 2000, Sept 12, 2000, and Sept 25, 2000; accepted Sept 25, 2000. Reprint requests: Steven J. Gross, MD, Crouse Hospital, Department of Neonatology, 736 Irving Ave, Syracuse, NY 13210. Copyright © 2001 by Mosby, Inc. 0022-3476/2001/$35.00 + 0 9/21/111945 doi:10.1067/mpd.2001.111945 NHIS National Health Interview Survey OR Odds ratio Objective: To compare school performance at age 10 years in a cohort of extremely preterm children and term control subjects and to examine the impact of family composition and stability on performance. Study design: Prospective, longitudinal follow-up from birth to 10 years of age of a regional cohort of children born at 24 to 31 weeks of gestational age and sociodemographically matched term control subjects. Family composition, extent of parental care giving, and family moves were tracked sequentially. At 10 years, academic achievement and school performance were ascertained for 118 of 125 (94%) preterm survivors and 119 of 125 (95%) term children. Results: Term children were more likely to demonstrate optimal school outcome (appropriate grade level without additional classroom assistance) than were preterm children (odds ratio 3.4, 95% CI 1.9-6.0). Medical complications related to prematurity had little impact on school outcome. Among preterm children, optimal school outcome was significantly associated with increased parental education, child rearing by 2 parents (regardless of marital status), and stability in family composition and geographic residence over 10 years. These environmental influences were less pronounced among term control subjects. Conclusion: Although preterm children performed less well in school than term children, family factors were stronger predictors of school perfor- mance than were perinatal complications. (J Pediatr 2001;138:169-75) ORIGINAL ARTICLES