Background: Interactional models of the development of neonatally at risk infants propose that a good social environment provides protection against longterm adverse developmental outcome. Using data from the Bavarian Longitudinal Study that investigated the cognitive and behavioural development in neonatal at risk children, the interrelationship between medical and social risk factors was re-inspected. Cognitive and school outcome was better predicted by neonatal risk than social factors in the VLBW population (<32 weeks gestation) while the reverse was true for infants born at moderate to low neonatal medical risk. Less plasticity of the organism was found if subjected to a high level of neonatal risk and the infants showed poorer recovery in early growth and cognitive functioning. Discussion: It is concluded that developmental models of medically high risk infants born some 30 or 40 years ago cannot be uncritically applied to neonatal high risk infants in the 21st century. Implications for early intervention strategies and clinical follow-up of neonatal at risk infants are discussed.