The Extent To Which Neurological Status, Gross Motor, and Executive Processing Support Growth in Daily Living Skills Across Elementary School Ages For Children Who Vary in Biological Risk

THE EXTENT TO WHICH NEUROLOGICAL STATUS, GROSS MOTOR, AND EXECUTIVE PROCESSING SUPPORT GROWTH IN DAILY LIVING SKILLS
ACROSS ELEMENTARY SCHOOL AGES FOR CHILDREN WHO VARY IN BIOLOGICAL RISK
A Dissertation Presented to the Faculty of the College of Education University of Houston
In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy
by Isa Fernandez Frangente August, 2007
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
UMI Number: 3272585
INFORMATION TO USERS
The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleed-through, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion.
UMI
UMI Microform 3272585 Copyright 2007 by ProQuest Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code.
ProQuest Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346
THE EXTENT TO WHICH NEUROLOGICAL STATUS, GROSS MOTOR, AND EXECUTIVE PROCESSING SUPPORT GROWTH IN DAILY LIVING SKILLS ACROSS ELEMENTARY SCHOOL AGES FOR CHILDREN WHO VARY IN BIOLOGICAL RISK
A Dissertation for the Degree Doctor of Philosophy by Isa Fernandez Frangente
Approved by Dissertation Committee:
Dr. Stewart Pisecco, Chairperson
Dr. Consuelo Arbona, Committee Member
Anu# & hie ' U t f

Dr. Sara McNeil, Committee Member
Paul Swank, Committee Member
Jr. Karen E. Smith, Committee Member Dr. Robert K. Wirppelberg, D^an College o f Education August, 2007
ACKNOWLEDGEMENTS I would like to thank my committee members, Dr. Karen Smith, Dr. Paul Swank, Dr. Stewart Pisecco, Dr. Consuelo Arbona, and Dr. Sara McNeil for their guidance and encouragement during this process. I am especially indebted to my mentor. Dr. Karen Smith, for working with me for hours at a time and for remaining enthusiastic about my research topic all ihe way to the end (and beyond). Her commitment to research has left a lasting mark on me and it is a irue privilege to have worked under her supervision. In addition to Dr. Swank's statistical assistance, I am grateful that he stuck with me in this process as my advisor even when his career path shifted away from the university setting. I would like to thank my parents, husband, and friends for their unselfish love and patience. I am forever grateful to my parents for teaching me the value of an education, for setting a good example, and for believing in me. My sincere gratitude also goes to my husband. Scott, for being supportive and encouraging as I worked to reach my goal and for being a model daddy to our children, Caden and Cali, who ironically were bom premature, 30 weeks and 36 weeks respectively. Finally, the acknowledgements wouid not be complete without a heart felt thanks to Jackie, our nanny and family friend, for loving and caring for my children while 1 was committed to completing this project.
iii
THE EXTENT TO WHICH NEUROLOGICAL STATUS, GROSS MOTOR, AND EXECUTIVE PROCESSING SUPPORT GROWTH IN DAILY LIVING SKILLS ACROSS ELEMENTARY SCHOOL AGES FOR CHILDREN WHO VARY IN BIOLOGICAL RISK
An Abstract Of A Dissertation Presented to the F aculty of the College of Education University of Houston
In Partial Fulfillment of the Requirements for the Degree
Doctor of Philosophy
byIsa Fernandez Frangente August, 2007
Frangente, Isa F. The extent to which neurological status, gross motor, and executive processing support growth in daily living skills across elementary school ages for children who vary in biological risk. Unpublished Doctoral Dissertation, University o f Houston, August, 2007. Abstract The establishment of neonatal intensive care units and advances in neonatal care have resulted in improved survival for infants born preterm, but their developmental outcomes remain a serious concern. While research is focusing on cognition, motor, and language skills, studies to date have rarely focused on the development of daily living skills in children bom preterm. In addition, information is not available regarding the development of daily living skills in children 6-12 years and little is known as to what predicts age appropriate competence in this area. Such knowledge would allow for early intervention for the targeting of specific skill development in an attempt to decrease later difficulties in this important area of functioning. More information is needed to determine what characteristics may contribute to poorer skill development in children bom preterm. Specifically, more research is needed to determine the extent to which motor, neurological abnormalities, and executive processing influence daily living skills into the school age years, in which greater independence in completing daily living tasks are required for higher levels of competency. One of the study objectives was to examine, through the use of a series of mixed model analyses, early predictors (e.g., 2 and 3 year neurological abnormalities, 3 year gross motor and executive processing skills) of the level and growth in Daily Living Skills as measured by the Vineland (V-DLS). In addition to examining factors evident in the preschool period that uniquely predict variability in development of V-DLS, it was
also important to determine whether this was similar or different for children who varied in biological risk. Such knowledge allows for the targeting of specific skill areas for early intervention. It was hypothesized that: 1) neurological abnormalities at 2 years would predict level and growth in V-DLS across 6 to 12 years, 2) neurological abnormalities at 3 years would not provide unique information above and beyond 2 year scores in predicting VDLS (mediation model), 3) executive processing skills would provide unique information above and beyond 3 year neurological scores in predicting V-DLS, and 4) gross motor arm and 5) gross motor leg skills would provide unique information above and beyond early neurological scores in predicting V-DLS. Childrens 2 year neurological scores were found to predict level, but not growth, in V-DLS across elementary school ages. Also, neurological abnormalities at 3 years did provide unique information above and beyond the 2 year neurological scores. Together these results provide evidence for a mediation model where 2- year neurological scores predict the level o f V-DLS through its relation with 3 year neurological scores. These findings suggest that neurological evaluations conducted at 3 years of age will provide better information than earlier testing regarding later functioning in V-DLS. While executive processing skills did not provide unique information above and beyond 3 year neurological scores in predicting V-DLS, it did indicate a trend in predicting level of VDLS. Gross motor arm skills did not provide unique information above and beyond 3 year neurological scores in predicting level of V-DLS and the hypothesis that gross motor leg skills would provide unique information above and beyond early neurological scores in predicting V-DLS was not supported.
vi
ta ble o f c o n tents
Chapter I.
Page INTRODUCTION AND REVIEW OF LITERATURE............................. 1 Medical Advances in Treatm ent........................................... 1 Lung Physiology and Treatment.....................;................................ 3 Developmental Outcomes............................... 5 Are Problems Lags or Persistent Delays? ............................. 8 Adaptive Behavior.............................................................................9 Defining Daily Living . . . . ...............................................................10 ........... 11 What is known regarding children bom PT and D L S Executive Processing....................................................................... 12 Research on Executive Processing.................................................. 14 Research on Motor and Neurological Abnormalities................... 15 Purpose of the S tudy...................................... 18 Hypotheses................................................ 19 METHODOLOGY .......................................................................21 Participants...................................................... :...............................21 Procedure...................................... :........22 M easures .................................................................................. 22 RESULTS...................... 28 Descriptive Statistics........................................................................28 Measurement M odel........................................................................29 Alternative Data Analyses.............................................................. 35 Results of Mixed M odel . . .36 Follow up Analyses................. 38 DISCUSSION...................................... 41 Study Limitations ........................................ .................................... 49 Future Directions for Research.......................................................49 Summary...........................................................................................50
It.
III.
IV.
REFERENCES....................................................................................................................... 5! APPENDIX A APPENDIX B Neuroiogical Assessment Items............................................................. 62 Correlation Matrix. ......................................................... ..65
vii
LIST OF TABLES Table 1. Page Medical and Demographic Characteristics of Sample by Birth Status Group.......................................................................................................................... 30 Descriptive Statistics (Mean, Standard Deviation) for the Indicator Variables at Each Timepoint for Constructs........................................... 31 Exploratory Factor Analyses.................................................................................... 34 Significant results: Model 1, 2 and Final.................................................................39
2.
3. 4.
viii
LIST OF FIGURES Figure Page
1. Hypothesized model...................................................................................................20 2. Model including indicators used to form each construct........................................ 27
CHAPTER 1 INTRODUCTION AND REVIEW OF LITERATURE
Introduction: Medical Advances in the Treatment of Infants Bom Preterm Since the ! 970s, historical changes have occurred in the care of infants born premature and of low birth weight (LBW), in which great improvements have been made in the survival of lower birthweight and more medically fragile infants. The increase in survival rates at decreasing birthweights brought about much interest and research regarding the developmental outcomes for these infants. The next section provides a historical overview on the medical therapies that led to the increased survival of premature and low birth weight infants. The follo wing section contains descriptions of the literature on developmental outcomes with a critical review. The establishment of neonatal intensive care units in the 1970s and advances in neonatal care in the early 1980s resulted in improved survival for all infants, but especially for infants born preterm and of increasingly lower birth weights. Nomenclature for birthweight classifications have evolved to include low birthweight (EBW weighing <2500 grams), very low birthweight (VLBW weighing < 1500), and extremely low birthweight (ELBW weighing < 100O) The infant mortality rate in the United States has decreased from more than 12 per 1000 live births in 1980 to approximately 7 per 1000 live births in 1998. It is important to note that this reduction in mortality has occurred during a time period in which an increasing percentage of children have been bom preterm with low birth weights or ELBW. In the 1990s, over 90% of very low' birth weight infants survived and over 80% of ELBW infants survived (Lorenz,
Wooliever, & Jetton, 1998). Neonatal advances contributing to the survival have included regionalization of neonatal transport with emphasis on maternal transport, the use of maternal corticosteroids, aggressive delivery room management, surfactant replacement therapies, prevention of severe intraventricular hemorrhage, and improved ventilatory, nutrition, and infectious disease management practices (McCormick, ' 992). In addition, a broader range of ncninvasive diagnostic tests, such as ultrasounds and echocardiography that permitted more accurate assessment, such as the presence of intracranial insult of the newborns, became available (McCormick, 1992).' In an infant bom premature, body systems are often underdeveloped. In most cases, the more premature, the less developed. For example, there is less muscle tone, the respiratory system (ability to breathe) is not fully developed, the brain may not oe ready to control breathing and sucking yet, and an immature nervous'system may inhibit the feeding process. The infant may also experience jaundice (a yellowing of tissue because the liver is unable to regulate the secretion of bilirubin), hypoglycemia (too little glucose in the blood), and hypothermia (an inability to maintain body temperature because there is a lack of insulating fatty tissue). Advanced medieai procedures can manage these factors in many' infants bom premature, but careful monitoring (typically in a neonatal intensive care unit, or NIC L i ) is needed until the infant's body systems mature enough to function on their own. The medical complications associated with prematurity often lead to central nervous system damage, either through lack of adequate oxygenation of the brain (hypoxia) secondary to respiratory problems such as respiratory distress syndrome (RDS) dr bronchopulmonary dysplasia (BPD), or from direct brain injury , as with
intraventricular hemorrhage (IVK) or periventricular leukomalacia (PVL). While mild IVH (intraventricular hemorrhage) is confined to the germinal matrix, severe hemorrhages involve the adjacent ventricular system and/or white matter. The more severe insults and chronic iung disease have a strong link to long term neurodevelopmental deficits (Cooke & Abemethy, 1999; Vohr, Wright, Dusick, Mele, Verter, Steichen, Simon. Wilson, Broyles, Bauer, Delanev-Black. Yolton, Fleisher, Papile, & Kaplan, 2000; Smith, Landry, Denson, Miller-Loncar, & Swank, 1999). However, those who experience mild lung disease also show patterns of neurological abnormalities across early childhood. Thus, their development may be negatively impacted as well. Luna Physiology and Treatment The cells in the lungs of infants bom premature may be too immature to produce substances called pulmonary surfactants. The role of these substances is to help keep open the small air sacs where oxygen transfer occurs. The sacs collapse without surfactants and cause the infant to exert more effort to keep the remaining sacs open and to effect gas exchange (Avery & Mead, 1959). A breakthrough in management of this problem occurred with the realization that increasing the pressure of the air mixture being breathed helped to keep the lungs extended (Gregory, Kitterman, Phibbs, Tcolev. & Hamilton, 1971). Over the next decade, this approach was refined in order to achieve adequate ventilation. The idea was to balance the intensity of the pressure required, the concentration of oxygen, and the rate at which the ventilators cycled to maintain appropriate concentrations of oxygen and carbon dioxide in the blood (Carlo & Martin, 1986). However, not all infants responded. Very high pressures and/or levels of oxygen
4 are often required to achieve adequate blood gas concentrations in severe cases of Hyaline Membrane Disease/Respiratory Distress Syndrome (HMD/RDS). Infants who require prolonged mechanical ventilation may develop bronchopulmonary dysplasia (BPD), a chronic lung disease characterized by pulmonary parenchymal injury and need for prolonged oxygen and ventilation therapy (Northway, 1979). In addition, increased oxygen pressure for extended durations increase the risks of pre-term complications such as intraventricular hemorrhage and retinopathy of prematurity (ROP). As severity of lung disease increases, so do developmental problems (Saigal & O Brodovich, 1987; Smith, et al., 1999). An innovation in neonatal intensive care, in response to some infants lack of response, was the modification of artificial ventilatory support to provide high frequency ventilation. The idea was to supply amounts of inspired gas at very high frequency, such as 150-3000 cycles per minute. Conventional ventilation only provides 20-40 cycles per minute. The high frequency approaches have been shown to provide adequate gas exchange at much lower airway pressures, and offer an alternative in infants at risk of BPD or who have already developed air leaks in the lungs due to high pressures on conventional ventilation (Carlo & Martin, 1986). While early works support the use of high frequency ventilation, criticisms regarding the technique include possible tracheal damage and the potential for other side effects, especially intracranial bleeding (Carlo & Martin, 1986). Another innovation in neonatal intensive care is surfactant replacement, which improved ventilatory function with rapid decreases in the pressure required for ventilation and in oxygen concentrations but has not decreased the incidence of severe lung disease (Carlo & Martin, 1986).
After being discharged from the Neonatal Intensive Care Unit, children bom very prematurely can be expected to differ from healthy full-term babies in many aspects of their development. Most notably, the development of most pretemi babies follows more closely expectations for age "corrected for prematurity than for actual age (Kamiski, Blair, & Vitucci, 1987). Even when compared with other children of their corrected age, however, most children bom more than a few weeks early will have at least some additional developmental differences associated with prematurity during infancy. Some of these differences are considered subtle, but can be associated with long-term problems (Aylward, Pfeiffer, Wright, & Verhulst, 1989). Developmental Outcomes With the survivai of children bom preterm increasing dramatically, their developmental outcomes remain a serious concern. In the 1960s and eariy 1970s; the outcome studies of infants bom early usually consisted of those weighing between 1500 and 2500 grams (i.e. Low Birthweight-LBW). In the 1970s, variables such as gestational age and birth weight were used to predict developmental outcomes (DriUien, 1972: Wiener, 1970). In general, while children bom early were documented to have more health and developmental problems than term children c f normal birth weight, the cognitive development of the children bom premature fell within the average range (C'aputo & Mandell, 1970; Weiner, 1970). However, difficulties with motor skills were evident (Aylward et al, 1989). During this time period (1960-early !970s), research involved methodological approaches that relied primarily on cross-sectional research and relatively short term loiiow-up (e.g., 2-3 yearsof age). Also, many of the studies were retrospective in nature,
had small sample sizes, treated infants bom premature as a homogeneous group, and did not systematically explore the relation between early risk factors and longer term developmental outcomes (Jongmans, Mercuri. de Vries, Dubowit?., & Henderson, 1997). Questions regarding the long-term developmental outcome of low birth weight children remained unanswered because few studies followed these children past early childhood. In the early 1980's, environmental variables such as socioeconomic status (SES) and parental education were included. As expected more limited economic resources was associated with poorer development for infants bom preterm (Beckwith & Cohen, 1980). Also, longitudinal studies during the early 1980's began to follow children bom preterm through the school age years. Four cohorts have been followed into adolescence and one cohort into adulthood (Cooke & Abemethy, 1999; Hack, Flannery, Schluchter, Cartar. Borawski. & Klein, 2002). While subtle developmental difficulties seemed insignificant during infancy and early childhood, they became significant during the school age years. These difficulties included poor visual-motor integration, spatial relations deficits, reading and language problems, math difficulty, and behavioral problems (Aylward et al, 1989; Vohr & Garcia-Coll, 1985). By the 1980s and 1990s, researchers began to recognize the different populations of infants bom premature and the fact that they constituted a very heterogeneous group (Mazer, Piper, Sc Ramsay, 1988; Vohr & Garcia-Coll, 1985). In addition, the medical characteristics of infants born preterm shifted due to advances in medical care. Studies focused on the developmental outcomes of infants who were bom much earlier , had lower birth weights, and were placed on oxygen for e^en ionger durations (Hack, Klein,
& Taylor, i 995). Moreover, researchers realized that this population had a broad spectrum of growth, health, and developmental outcomes (Hack et ah, 1995). Severe respiratory problems requiring prolonged ventilation therapy have been associated with poorer outcomes than milder respiratory conditions in some samples (Teberg, Wu, Hodgman, Mich, Garfinkle, Aztn. & Wingert, 1982), but not in others (Nars, Schubarth. kindier, Werthemann, & Stalder, 1981). Both mental and motor development, however, have consistently been shown to be affected by BPD (Landry, Leslie, Fletcher, & Francis, 1985; Landry & Chapieski. 1988). During the 1980s, studies also attempted to relate outcome to the severity of IVH, but inconsistent results w'ere produced (Papile. Burstein, Burstein, Koffler, & Koops, 1978; Schub, Ahmann, Steele, & Hoffman, 1981). In a study adequately controlling for SES and including a full term comparison group Landry et al. (1988) found a significant relation between severity of IVH and poor cognitive, language, and motor outcome at 3 years of age. The concerns of the research during this period included use of small sample sizes, heterogeneity of populations, short-term follow-up, lack of comparison groups, and lack of consistency in assessment of outcome and definitions of handicap (Hack et ah, 1995). Other concerns included problems with study design, nonrepresentative study samples, inadequate demographic data, high attrition rates, poor selection of comparison groups, lack of long-term follow-up, and the systematic exclusion of subgroups of patients (Flack et ah , 1995). Other researchers have recommended using medical stratification as opposed to birthweight to divide the study sample (McCormick, 1993; McGrath, Sullivan, Brem. & Rocherohe, 1995; Landry et ah. 1988).
Additionally, older studies have tended to use the test norms for comparison rather than including a comparison group, which is not appropriate given that test norms do not necessarily match the demographics of infants bom preterm (Aylward et al, 1989). More sophisticated, longitudinal prospective studies with children bom premature are now being conducted and many are using demographically matched comparison groups of full-term, normal birthweight children to compare with the group born preterm (Landry, Denson, & Swank, 1997: Landry, Smith, Miller-Loncar, Swank, 1998; Taylor, Minich, Klein, & Hack, 2004). With more sophisticated research design, children bom premature continue to be shown at increased risk for a variety of later developmental problems including cognitive (Landry, Chapieski, Richardson. Palmer. & Hall. 1990; Landry et al.. 1997), motor (Saigal, Szatmari, Rosenbaum, Campbell & King, 1991; Siegel, 1983a; Frangente, Hebert, Swank* Landry, Smith, 2005), neurological (Anderson. Swank,
Wildin, Landry, & Smith, 1999; Frangente et al., 2005), behavior (McCormick, 1990), and language (Bendersky & Lewis, 1994). Are Developmental Problems Lags or Persistent Delays? Oider studies suggest that children bom preterm "catch up" to their normal birth weight peers by the age of 2 years (Siegel, 1983a). However, it is important to note that childrens development was not usually observed beyond 2 to 3 years. More lecent research documents problems that continue into the school-age years (Cohen. Parmelee, Sigman, & Beckwith, 1988; Luoma, Herrgard, & Martikainen, 1998; Landry, Smith, Swank, Assel, & Yellet, 2001), and adolescence (Saigal, Hoult, Streiner, Stoskopf, < fc Rosenbaum, 2000).
Anderson et al. (1999) concluded that there are both delays and persistent deficits in neurological functioning in infants bom preterm that are related to the severity of neonatal complications. For example, a higher percentage of infants bom preterm with more severe neonatal complications (e.g., intracranial insults, BPD) were found to have persistent neurologic deficits through 54 months compared to those with less complications and those bom term, suggesting that this could be a persistent deficit (Anderson et al., 1999). A.cross 6 to 40 months of age, the patterns of change in neurologic abnormalities in the infants with less severe medical risk decreased to levels comparable to that measured in the term group. However, across 40 to 54 months, these infants again showed an increase ir, neurological abnormalities that appeared to normalize prior to entering Kindergarten (Anderson et ai., 1999). Thus, while some infants may catch up in their development, as they enter school, demands of this setting may result in weaknesses or deficits becoming more apparent. Adaptive Behavior While research is focusing on cognition, motor, and language skills, very little is known about the application of these skills in everyday settings. Such skills have been called adaptive behaviors/functioning. Adaptive behavior is a multidimensional construct that includes skills in communication, socialization, and daily living (Sparrow, Balia, & Cicchetti,1984). Studies targeting this skill have tended to focus on children bom at term who experience a stressful event (e.g., divorce: Guidubaldi & Perry, 1985). or children who have a specific developmental disorder, such as mental retardation (Carter & Sparrow, 1989; Dykens, Hodapp, & Leckman, 1989), autism (Freeman, Ritvo, Yokota, Childs, & Pollard. 1988; Anderson & Romanczyk, 1999), or Down syndrome (Loveland
10 & Kelley, 1988), Studies to date have rarely focused on the development of daily living skills in children bom preterm. Defining Daily Living Skills Daily living skills are functional, practical behaviors that enable children to interact and live within their physical and social environments (Cohen, 1986). These include, for example, awareness of safety issues (e.g.; understanding of dangers with strangers, look both ways before crossing the street), the ability to take care of one's personal'hygiene, perform household chores, and manage money. With adequate development, daily living skills promote children's ability to function more independently, thus permitting involvement in less restrictive environments and enabling family members to share responsibilities with children (Dailey & Wolery, 1992). The few available studies have documented that children bom preterm have significantly lower daily living skills than term children at school entry (Frangente et a! ., 2005) and the development of these differ across preschool to mid-elernentary school age (Dieterich, Hebert, Landry. Swank, & Smith, 2004). However, information is not available regarding the development of the skill across elementary school. By early school age, children are expected to transition developmentally to seli-reiiance in daily living skills. However, such findings indicate that children born pretenn are less likely to have developed age appropriate competencies in these skills such as knowing'how to more independently wash hands, tie their shoelaces, arid, care for toileting needs. Thus, at school entry, they may require continued help with this set of skills. Childrens increasing self-reliance in daily living skills becomes particularly important as they enter formal schooling. In one study, teachers consider skills related to
independence in daily living skills as a more critical component of school readiness than those known to more directly influence academic readiness (e.g., phonological awareness) (Johnson, Gallagher, Cook, & Wong, 1995). In addition, Johnson et al (1995) suggest that such independence can serve to reduce childrens stress and ease the transition from one setting to another (e.g., home to school). For instance, a child with limited skills in personal hygiene or cooperating with clean up tasks may have trouble adjusting to the school routine and thus, less able to focus on academic learning activities. Similarly teachers can focus more time on academic endeavors if children are more competent in basic self-care skills. Widaman and McGrew (1996) point out that adaptive behaviors, such as daily living skills, are related to other developmental and physical abilities, such as cognitive skills (Dietrich et al., 2004). Tasks reflective of competency in early school aged daily living skills include the ability to follow school rules, manage personal hygiene, and assist with household chores. What is known regarding children bom preterm and daily living skills? Little is known as to what predicts age appropriate competence in daily living skills. While it is important to know that children bom preterm are at risk for developmental delays in daily living skills, it is even more important to understand factors in early development that predict better versus less optima) development. As impaired adaptive abilities do not appear to diminish with age in other populations (Schothorst & van Engeland. 1996), such knowledge would allow for the targeting of specific skill areas for early intervention in an attempt to decrease later difficulties in this important nonacademic area of functioning.
Dietrich et al.. (2004) examined relations between maternal expectations and daily living skills and highlighted several parenting factors that are important in understanding the differences in the development of this skill. While motor and neurological variables have also been examined in relation to skills of daily living (Frangente et al.. 2005), more information is needed to determine what other child characteristics may contribute to pooter skill development. Two areas to consider are delays in executive processing and motor skills. Executive Processing Current research has moved beyond assessment of global skills (e.g., cognition) and is beginning to understand the impact of prematurity on more specific skills such as executive processing. Executive processing incorporates a range o f skills including planning, attentional control, and cognitive flexibility, as well as the ability to adopt and maintain an appropriate problem-solving set to obtain a future goal (Welsh & Pennington, 1988). Executive processing includes anticipation, goal selection, planning, and monitoring. It is important tor ongoing cognitive development and academic achievement (Pernei & Lang. ! 999). Children with executive impairments'may be inflexible and rigid, which is often manifested by a resistance to change activities, an inability to modify previously learned behaviors, and a failure to learn from mistakes. As children develop these skills, they move from being highly dependent upon adults and the structure provided in cheir environments to organize their behavior toward functioning with greater independence and self-direction. During the first three years of age, behavior is directed outwardly to others and the world in relationship with bodily and emotional needs. In terms of brain functions,
the lower brain system, including the brainstem, are responsible for stabilizing the body's physiology to environmental stimulus (Lezak. .1995). At this stage the pre-front al brain is developing, which is responsible for complex thinking. Infants and toddlers are expected to focus on immediate needs, wants and activities. The executive skills they are developing relate primarily to regulating behaviors for brief periods of time including focusing their attention (again, for brief, but increasing amounts of time) (Barkley, 2001). As with language, cognitive and motor development, there is a wide range of what is considered normal development of motor control and attention. Most 2- and 3-year-olds should be able to delay gratification (wait for a desired object or activity) for at least a few minutes. Their play may also involve increased planning and organization (Barkley. 2001). Preschoolers are still heavily reliant on adults to nrovide clear guidelines for, and feedback about, their behavior. Between 3 to 5 years old, as the pre-frontal cognitive brain progressively develops, behavior becomes more and more self-directed, yet remains public in expression (Barkley, 2001). Speech gradually develops with the ability to describe and demand to satisfy bodily and emotional needs. At this stage, behavior is engaged in the temporal-now with the control of others for immediate gratification a preoccupation (Barkley, 2001). This ability to gain self-control over human behavior through the normal development of self-regulation of cognitive or 'thinking' abilities emerges in stages, as in a hierarchy (Barkley, 1995). Each requires that the earlier stage be fully activated before the latter can be effective. So, these stages move from external (overt) events to internal (covert) or mental events; from the control of others to self-control; from existing in the temporal-now to thinking towards the anticipated future; and from demanding immediate
gratification to delaying and planning the provision for satisfying needs (Barkley, 1995). Thus, it is thought that early executive processing skills set the trajectory for later development. Given the demands of daily living skills, it is possible that deficits in executive processing are related to other skills, such as tasks of daily living. In order to independently cairy out a task such as dressing in anticipation of changes in weather, planning and follow through are required. Little information is known about the relation between executive processing and later daily living skills. Therefore, the assessment in the preschool period, if found to predict daily living skills, would provide another avenue for intervention. Research on Executive Processing and Preterm Development In addition to global cognitive deficits, children bom premature also demonstrate specific cognitive problems. For example, poorer attention and executive processing skills in relation to children bom full term have been documented (Taylor et al., 2004; Landry, 1985). A study by Wall (1996) found that 5 to 7 year old children bom preterm performed significantly worse than full term controls on executive processing tasks requiring visual search skills and verbal fluency. Executive processing necessary for effective information processing, attention, and emotions may be of primary importance for interacting with others and objects in their environment (Hebert-Myers, Guttentag, Swank, Smith, & Landry, 2006). Children who demonstrate more effective control of their regulatory' capacities may be better able to negotiate and learn from their environments, and thus are handling more self care or functions of daily living. Given the daily living skill demands in the 6-12 year old period include tasks such as ordering a complete meal in a restaurant, using the stove or
microwave oven for cooking, and sweeping or vacuuming the floor carefully it is likely that executive processing skills may influence success in this area. For example, when using the stove, the child has to select something to cook, select the appropriate cookware, turn the heat to a desired temperature based on what is being cooked, stir the food while cooking and transfer it to a plate when finished. Skills that would be important in accomplishing these tasks include the childs ability to identify a goal, detemiine important information to attend to in establishing a strategy for reaching the goal, and carry cut a sequence of behavior that would allow the child to efficiently complete the task. Such skills are likely influenced by development at earlier ages; however, the extent to whicii these skills influence later daily living skills is not known. The development of early executive processing may lay the foundation for* later daily living skills. More research is needed to determine whether and how' factors in infants, or early childhood, including regulatory capacities, such as executive processing skills, might contribute to vulnerabilities developing daily living skills in high-risk children. It is likely that deficits in executive processing are related to other skills, such as tasks of daily living. Research on Motor and Neurological Abnormalities and Preterm Development Motor problems continue to be documented for children born preterm (Fits van der & Hadders-Algra, 1998; de Groot, Hopkins, & Touwen, 1997; de Groot. Hopkins & Touwen, 1995; Samsom, de Groot, & Hopkins, 1998). Direct brain insult can have long term consequences such as the motor deficits known as cerebral palsy (Hack & Fanaroff, 1999). Motor development over the first year may become motor patterns of cerebral palsy, which is associated with patterns of brain Insult. However, those with indirect
insults via respiratory disorders also are at risk for motor impairments in preschool and during the school years (Bracewell and Marlow, 2002). In a previous study, we investigated which preschool motor related skills would be predictive of daily living skills at school entry (Frangente et al., 2005). Contrary to expectations, gross motor rather than visual motor integration skills was found to be significant. When considering the tasks involved in daily living skills (e.g., dressing, toileting), it seems intuitive that early motor provide a foundation for the gross motor skills required to develop age appropriate competence in such skills. Preschool gross motor skills have been found as important for the development of later daily living skills (Frangente et al., 2005). Flowever, these findings may have been due to the inclusion of children with more severe brain insults who are most likely to have severe deficits in gross motor skills. Children bom preterm also are known to have greater neurological abnormalities than those bom at term (Anderson et al., 1999). Patterns of change suggest that neurological abnormalities can persist across early childhood and, thus are not simply maturational lags for some infants bom preterm. Flowever, it is well known that some neurological problems will diminish across the first 2 years of life and have been described as "transient neurological abnormalities (Anderson et al., 1999). Because motor skills and neurological functioning were both assessed at the same timepoint, the paths of influence could not be adequately determined. However, it is expected that neurological functioning would predict gross motor skills, and thus indirectly influence daily living skills
By 2 years of age. transient neurological problems are most likely to have resolved. At 2 years, neurological status involves evaluating the ability to walk up and down stairs, turn a door knob, turn pages of a book, and build a tower with cubes. The persistent presence of neurological abnormali ties, particularly with respect to reflexes, motor tone, and motor coordination, likely interferes with higher order skills such as sequencing and planning motor movements necessary to carry out a goal; thus, children with greater early neurological abnormalities may be expected to have greater difficulties functioning in situations that involve motor and executive processing. However, the extent to which such neurological deficits negatively influence growth in daily living skills indirectly through a negative influence ori preschool gross and executive processing is yet to be determined. In our previous study, vve investigated whether 6 year daily living skills *
would be predicted by three aspects of motor-related functioning (i.e.. gross and visual motor integration skills, neurological functioning) at 3-years o f age (Frangente et al, 2005). Children wrho scored higher on 3-year gross and visual-motor integration skills and had fewer neurologic abnormalities were expected to have higher 6-year daily living skills, irrespective of their birth status. However, higher risk birth status (i.e., VLBW) wras expected to predict neurological and motor skill scores and thus, indirectly effect school age daily living skills through problems in preschool age motor related abilities. A regression analyses based on a general linear model were used to determine whether the 3-year scores for the neurological, visual-motor integration and gross motor skills predicted the 6-year daily iiving skill scores, irrespective of birth status. As many daily living skill tasks require motor related skills, it w'as expected that difficulty in skill development would be predicted by early motor functioning and
presence of neurological deficits. However, there was little empirical evidence to support this notion. Based on our results, knowledge of gross motor skills and neurological functioning during the preschool years provided unique information for predicting childrens ability to develop competence in daily living skills at school entry while visual-motor integration was not found to be significant. While it seems intuitive that neurological abnormalities should underlie difficulty with development of gross motor skills, this could not be determined as the two skills were measured at the same point in time. More research is needed to determine the extent to which these factors (motor, neurological abnormalities, executive processing) influence daily living skills into the school age years, in which greater independence in completing tasks of daily living are required for higher levels of competency. Purpose of the Study The study objective is to determine the extent to which early neurological status provides a foundation for the development of gross motor and executive processing that, in turn, support higher levels and faster rates of growth in Vineland Daily Living Skills (V-DLS) across elementary -school ages. The indirect influence of early neurological status on V-DLS is expected to occur through a direct relation with 3-year gross motor and executive processing and is expected to occur even when controlling for neurological abnoimalities at 3 years. Gross motor and executive processing skills are, in turn, expected to impact childrens V-DLS across the elementary school years. Children bom at VLBW have greater neurological abnormalities and patterns of change indicate that for some children these may r esolve by 2 years of age, while for others they persist across early childhood. Thus, in the present study, neurological functioning could serve as a
19 marker for preterm birth status. The model to be examined is depicted in depicted in Figure 1. The following hypotheses will be examined through structural modeling analyses:
Insert Figure 1 about here
Hypotheses 1.) Fewer neurological abnormalities at age 2 will predict higher 3-year gross motor and executive processing skills. 2.) Higher 3-year gross and executive processing will predict higher levels and greater increases in V-DLS across 6 through 12 years of age. 3.) Fewer neurological abnormalities at age 2 will indirectly influence greater growth in V-DLS through its direct effect on 3-year gross motor and executive processing and this will be evident even when controlling tor neurological abnormalities at 3 years. In order to determine whether it is the presence of 2-year rather than preschool neurological status, it is important to control for 3-year neurological abnormalities when examining this hypothesis.
20
Figure 1
2 years
3 years
6-12 years
Intercept Daily Living Skills
Fxecutive Processing
^Growth ^
Daily Living Skills '
CHAPTER 2 METHODS Participants Study subjects are participants in a longitudinal study of parenting and biological risk on childrens development and were recruited in 1991 and 1992 from three hospitals in the Houston-Galveston area. Preterm infants (n = 224) were recruited if they had a gestational age of < 3 6 weeks and 1600 gms birth weights. These infants varied in
severity of their medical complications from severe complications that included bronchopulmonary dysplasia, periventricular leukomalacia, and grade II and IV intraventricular hemorrhage (higher biological risk, n - 90), to less severe complications, such as respiratory distress syndrome and grade I or II intraventricular hemorrhage (lower biological risk, n = 138). Infants diagnosed with significant sensory impairments, meningitis, encephalitis, symptomatic congenita! syphilis, congenital abnormality of the brain, short bowel syndrome, or positive for the HIV antibody, were excluded from the study. Infants also were excluded from participation if the primary caregiver was younger than 16 years of age, used drugs, or spoke only Spanish. A demographicallv similar group of term infants (n = 136) also were recruited from the same hospitals. As a group, the cohort is of lower middle to low economic backgrounds, which is consistent with epidemiological studies of children bom preterm (e.g., Niswander & Gordon, 1972). Of the parents asked to participate in the study, eleven percent declined, with no demographic differences found between those who chose to participate and those who did not. This report includes all preterm (n =129) and teim (n =89) children seen from 2 to 12 years of age, or 72% of the original sample. Because the neurological assessment
22
required a clinic visit, some children were unable to attend and did not receive the early neurological exam. Attrition was due primarily to families relocating out of the study area without providing information on how to contact them. Procedure Medical and demographic information was obtained through review of medical records. Childrens 2 and 3-year gross and executive processing skills were assessed in the home by trained research assistants. Neurological status also was examined at these ages by a developmental pediatrician or pediatric neurologist in the clinic setting for those w'ho had transportation. The physicians and research assistants were blind to the childrens biological risk status (i.e., preterm vs. term). Researchers obtained information to score the Vineland Daily Living Skills (V-DLS) subscale during using a standardized, a semi-structured interview protocol with the female primary caregiver during home visits at 6, 8, 10, and 12 years of age. Measures Neurological Functioning. A systematic neurological examination developed for this study was based on the scales of Amiel-Tison (1976), Baird and Gordon (1983), and Swaiman (1989). Children were examined by either a developmental pediatrician or pediatric neurologist, both of whom were trained to criteria and maintained good reliability based on generalizability coefficients (Fieiss, 1986; Frick & Semmel, 1978). The 3 year generalizability coefficient for the neurological score was 0.93. The examination consisted of 56 items, divided across seven subscales that evaluated global and specific abnormalities (i.e., head circumference, general state, cranial nerves, motor tone, motor coordination, reflexes, and a neuro-sensory examination). The responses
23 elicited from children for each item were scored from 0 to 2 ((fo appropriate performance, 1= intermediate performance, 2~ clearly abnormal). Previous analyses examining neurological abnormalities across time indicated that the majority of variability among children was found on three subscales: Motor Tone, Motor Coordination, and Reflexes (Anderson et al., 1996). The scores for items on these 3 subscales were summed to obtain a composite score (TCR) that was used in data analyses. On this measure, higher scores indicated greater abnormality. Gross Motor Skills. Arm and leg coordination items from the McCarthy Motor subscale were used to assess this skill area. These 12 items involve tasks such as catching a bean bag, throwing it through a required target, standing on one foot, walking in a straight line and skipping. The McCarthy Scales of Childrens Abilities was a widely used instrument for children 2 Vi to 8 V2 years (McCarthy, 1972; Culbertson & Gyurke, 1990), although it is less frequently used now due to lack of updating the normative sample since 1972. However, it is one of the few available standardized measures of motor coordination (Culbertson & Gyurke, 1990). For the purposes of our study, we used this scale to measure gross motor functioning and not the combination of gross and visual-motor functioning. Therefore, a standardized score could not be used. Instead, two gross motor raw' scores were obtained by summing the score for items on the arm and leg coordination separately. These two scores were used for data analyses. Executive Processes. The delayed search task has frequently used by researchers to measure executive processing skills in young children as this task has been found useful in understanding how' children maintain awareness of a goal, form mental representations, regulate behavior, and demonstrate flexibility and efficiency in task
completion (Diamond, 1988; McEvoy, Rogers, & Pennington, 1993). In this study the delayed search task involved children searching for rewards in a group of three and six boxes. The child watched as the examiner hid a Cheerio in each box and the child was allowed to search one box (1 trial) until all rewards were found. A 5 second delay between each search trial was required and children were allowed a maximum of 20 trials for the three box task and 30 trials for the six box task. Higher scores on this task indicate poorer performance, as more searches represents less efficiency in completing the task. For data analysis, the two indicators for the executive processing construct were the number of trials for each task (i.e., number of searches for 3 and 6 boxes). Daily Living Skills. The Daily Living skills (DLS) subscale from the Vineland Adaptive Behavior Scale (Sparrow et al., 1984) was used to evaluate daily living skills, as it is a well-accepted, valid and reliable measure of adaptive behaviors. The Vineland was standardized on a representative national sample (3000) selected to match U.S. census data. The sample was stratified for age, race, gender, region, parental education, and community size. The internal consistency, split half means for domains, is .83 to .90 and test-retest means for domains is .81 to .86. The V-DLS has 92 items that evaluate activities including personal hygiene, domestic knowledge and skill (e.g., cooking, cleaning, telephone skills), safety, handling money, etc;. Based on information obtained in an interview with the childs caregiver, each item is scored by the examiner as 2 if the child 'usually does the task, 1 if sometimes cr partially does, and 0 if ho never. "No opportunity (N) and dont know (DK) scorings are available, but these are scored a 0 according to the test manual. Raw scores for all items are summed to
25
obtain the total raw score, that is then converted to an age equivalency. In order to show growth over time, the age equivalency will be used in data analyses. Design and Analysis To address the hypotheses a structural equation model was selected as this approach allows for examination of direct and indirect influences on the outcome variables. The first step m structural equation modeling requires an assessment of the measurement model in order to determine if the indicators chosen to measure the underlying constructs are adequate. The measurement model restricts the relation of the indicators to the latent constructs but not the relations among the latent constructs. As shown in Figure 2, the indicators for the neurological constructs include the motor tone, coordination, and reflex (TCR subscales) scores at the 2 and 3 year timepoints. The gross motor construct was measured by motor arm and leg coordination raw scores from the McCarthy Motor subscale at the 3 year timepoint. The two indicators for the executive processes construct were the total number of trials for the 3 and 6 box search tasks. A latent growth model with Vineland Daily Living Skills (V-DLS) at 6, 8, 10, and 12 years was used to obtain the intercept and slope parameters that were included as the two outcome measures. insert Figure 2 Because the hypothesized model is saturated, the measurement model, if found to be adequate, will be the model used to test the hypotheses regarding direct as compared to indirect influences o f early motor related and executive processing skills on level and growth in V-DLS. After determining the significance'uf the direct paths, the indirect
26 paths will be examined. Indirect effects are estimated by summing the products of all the adjacent pathway coefficients.
Figure 2. Proposed indicators for constructs in measurement model
2 years
3 years
6-12 years
Neurological Complications,
3 Box S earch Task
110 Y ear V ineland j
Tone / '
6 Box S earch Task
Ton*
Growth Daily Living Skills Neurological
V
J
^^Com plication:
jrdination
R eflexes
CHAPTER 3 RESULTS
Descriptive Statistics Table 1 displays the results of the demographic characteristics of the sample (i.e., ethnicity, gender, birthweight, gestational age, and socioeconomic status). Expected differences across the three study groups (HR, LR, and full term) on medical variables were found. As summarized in Table 1, the birthweight means ranged from 3200 grams (full term) to 932 grams (high risk group) and the gestational age means were 40 weeks for full term, about 30 weeks for the low risk group, and about 28 weeks for the high risk group. The majority of mothers included in this report were African American (62%) and families were from lower middle to low economic backgrounds (Hollingshead, 1975). These demographics are consistent with epidemiological studies of children bom preterm (e.g., Niswander & Gordon, 1972). Descriptive statistics for the indicator variables at each timepoint are displayed in Table 2. A neurological score of 0 indicates no abnormalities, thus the scores at 2 years, overall, reflect mild difficulties in the neurological skills evaluated. A comparison between 2 and 3 year scores shows a decline in neurological abnormalities in all areas. Executive processing scores at 3 years indicates that, on average, children took slightly more than 3 trials for the 3 box task and 9 trials for the 6 box task. At this age, the gross motor average leg score of 7.6 is consistent with the normative sample of 5.9 (S.D. = 3). The gross motor average arm score of 3.3 is consistent with the normative sample raw score of 2.5 (S.D = 3). On the Vineland-Daily Living Skills (V-DLS), children, as a
29 group, had age equivalents about 1 year behind at the 6 year timepoint and by age 12 the scores were delayed by 2 years. In a previous study, we reported significant differences in similar predictor and outcome variables (Frangente et al., 2005). Children bom preterm were found to have significantly lower V-DLS than children bom at term. However, in the previous study children bom preterm were analyzed as a single group and not divided into subgroups according to their neonatal medical complications as done in the present study. Insert Table 1 & 2 about here Measurement Model The first step in examining the proposed model was to evaluate the adequacy of the measurement of the proposed constructs. The measurement model restricts the relation of the indicators to the latent constmcts but not the relations among the latent constructs. As shown in Figure 2 in the Methods section, the indicators for the neurological constmcts include the motor tone, coordination, and reflex (TCR subscales) scores at the 2 and 3 year timepoints. The gross motor construct was measured by motor arm and leg coordination raw scores from the McCarthy Motor subscale at the 3 year timepoint. The two indicators for the executive processes construct were the total number of trials for the 3 and 6 box search tasks. A latent growth model with Vineland Daily Living Skills (VDLS) at 6, 8, 10, and 12 years was used to obtain the intercept and slope parameters that were included as the two outcome measures.
30
Table 1. Medical and Demographic Characteristics of Sample by Birth Status Group Preterm _______________________________ Term_______ LR_________ HR 57 63 Ethnicity' % AA 66 Hisp Cauc Other Gender1 % M/F 16 18 0 52/48 25.5 (8.6)a 3200 (728)a 40 (0)a 89 17 18 1 64/36 28.1 (11.2)b 1232 (206)b 30.7 (2.1 )b 76 17 23 4 46/64 27.7 (10.6)b 932 (240)c 28.2 (2.2)b 53
Socioeconomic status Birthweight2 (g) Gestational age (wk) n

'y
1 Data are average proportions with statistical significance based on Chi square analyses Data are mean, (s.d.) with statistical significance based on t-test; Different letters indicate significant differences among groups
Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission.
Table 2. Descriptive Statistics (Mean, Standard Deviation) for the Indicator Variables at Each Timepoint for Constructs Childs Chronological Age Skill Area Motor Tone 2 Neurological Scores 0.61 (1.66) .06 (.20) .28 (.27) 3 6 8 10 12
Coordination 1.06 (2.89) Reflex
1.36(2.76) .18 (.33) Executive Processing 3.46(1.15) 9.07 (3.84) Gross Motor
Three Box Six Box
Leg Arm Months Years
7.66 (2.53) 3.39 (2.05) Adaptive Behavior 59.92 (12.33) 78.46(17.48) (5) (614) 107.87 (20.12) (9) 121.37(23.82) (10)
32 As the interest is in predicting individual differences, growth curve modeling procedures were chosen because these yield individual growth curves for the V-DLS with growth parameters (i.e., intercept, slope). This allows for predictors of differences at a specific timepoint (i.e., level) and in the rate of change (i.e., slope) across the timepoint. Growth curve modeling requires that an age point be selected to set as the intercept. The intercept of 9.5 year was chosen because it is a midway point in the age range study and thus reduces multicollinearity in the prediction equation (Bryk & Raudenbush, 1992). Although a curvature parameter could be included to nonlinear growth in V-DLS, predictors of changes in the rate of increase were not included in any models as this was not central to our question. The statistics used to determine adequacy of fit in the measurement model included the chi-square, goodness-of-fit test, root mean square error of approximation (RMSEA), the Nonnormed fit index (NNFI) or Tucker-Lewis Index (TLI), and the comparative fit index (CFI). Hu and Bentler (1999) suggest that a cutoff value of .95 for TLI and CFI and a cutoff value of .06 for RMSEA are recommended in order to claim that there is a relatively good fit. A review of these fit indices for the measurement model in the present study indicates that there was a poor fit, (X2 = 69.51, CFI = .87, TLI = .81, RMSEA = .08). That is, the indicator variables chosen were not sufficiently related to define an underlying construct. Thus, the model, as proposed, could not be used. To better understand why the proposed indicators were not sufficiently related to use in estimating the underlying constructs, an exploratory factor analysis was conducted. As summarized in Table 3, four factors were found. The first factor was comprised of the
2 and 3 year motor tone subscales, the 3 year motor coordination subscale, and the 3 year gross leg score (inverse relation). The second factor was only comprised of one of the 3 year executive processing task (3 boxes task). Factor 3 included the 2 year motor coordination score and the other 3 year executive processing task (6 boxes task). The final, Factor 4, included the 2 and 3 year motor tone subscale scores as well as the 3 year reflex subscale score. The 2 year reflex subscale score did not load significantly on any factor although it had a positive association with Factor 4. Similarly, the gross arm score did not load significantly on any factor but had a negative association with Factor 1. Table 3 about here These results suggest shared variance between the 2 and 3 year neurological subscale scores for motor tone and, to a lesser extent in the reflex subscale score. In contrast, the 2 and 3 year motor coordination subscale scores, although measured with a similar tool, shared minimal variance. The lack of shared variance between the two executive processing tasks at the same point in time suggests that increased complexity may have contributed to these being independent indicators. In support of this idea was the variance shared by early motor coordination and greater competency on the more complex 3 year executive processing task. Thus, the lack of shared variance among indicators as evidenced by loading on separate factors assists in understanding why the indicators chosen could not be used to develop an underlying construct. It also suggests the need to include birth status as an independent predictor as no one factor could be considered to capture the types of neurological abnormalities that would represent a higher risk birth status.
34 Table 3. Exploratory Factor Analyses
Variable 2 yr Neuro Tone 2 yr Neuro Coordination 2 yr Neuro Reflexes 3 yr Neuro Tone 3 yr Neuro Coordination 3 yr Neuro Reflexes Three Box Six Box Leg Arm
1 0.376 0.018 0.013 0.389 0.743 -0.092 -0.033 0.029 -0.604 -0 .28 8
2 0.025 0.078 -0.072 -0.038 0.052 -0.001 -1.009 -0.085 0.027 0.049
3 0.060 0.720 0.210 -0.167 0.019 0.103 -0.039 0.510 -0.040 -0.085
4 0.388 0.178 0.282 0.458 0.016 0.735 0.005 -0.125 0.080 0.024
35 Alternative Data Analyses An alternative means of examining similar study questions is through the use of a series of mixed model analyses that allow for examining early predictors (e.g., 2 and 3 year neurological abnormalities, 3 year gross motor and executive processing skills) of the level and growth in V-DLS. However, mixed model analyses do not allow for the examination of direct versus indirect paths of influence, but rather the extent to which predictors provide unique information in explaining the outcome variables. The outcome measures of level and growth in V-DLS in the alternative model continued to be obtained through the intercept and slope parameters. Because differences in predictor and outcome variables have been reported for preterm versus term, models also included biological status (high risk, low risk, term bom) and the interaction of biological status with the predictor variables. A series of models was conducted in order to address each hypothesis and determine what predictor variables should remain in the model when testing subsequent hypotheses. The hypotheses that can be addressed with these analyses are: Hypothesis 1: Neurological abnormalities at 2 years will predict level and growth in V-DLS across 6 to 12 years. Hypothesis 2: Neurological abnormalities at 3 years will not provide unique information above and beyond 2 year scores in predicting V-DLS (mediation model). Hypothesis 3: Executive processing skills will provide unique information above and beyond 3 year neurological scores in predicting V-DLS. Hypothesis 4: Gross motor arm skills will provide unique information above and beyond early neurological scores in predicting V-DLS.
36 Hypothesis 5: Gross motor leg skills will provide unique information above and beyond early neurological scores in predicting V-DLS. Results of Mixed Model Hypothesis 1. The first model included 2 yr neurological functioning and birth status as predictors of level and growth in V-DLS (model 1). Childrens 2 year neurological scores predicted level of skill in daily living across elementary school ages, F (l, 363) = 32 .3 0 , p < .0001, but not growth. Greater neurological abnormalities predicted lower levels of V-DLS. Childrens biological risk level predicted both the intercept F(2, 363) = 8.79, p < .0002, and growth F(2, 363) = 13.00,/? < .0001. The group bom at term had higher levels of V-DLS at 9.5 years as compared to high risk bom children, t(363) = 3.87,/? <.0001, while those bom at low risk had scores comparable to those bom at high risk, t(363) = 1.25, p = .2124. In predicting growth in V-DLS, the group of preterm children with higher biological risk status showed slower rates of growth when compared to the group bom at term, t( 363) = 5.06,/? <.0001, and the preterm group at low biological risk, t(363) = 2.11, p = .006. Because both predictors were significant, they were included in Model 2. Hypothesis 2. To address the hypothesis that neurological abnormalities at 3 years would not provide unique information above and beyond 2 year scores in predicting V-DLS, a mixed model analysis that added 3 year neurological scores to the previous model was analyzed (model 2). The results revealed that 3 year neurological scores predicted level, F (l, 326) = 29.47,/? < .0001, but not growth in V-DLS. As scores in neurological abnormalities increased, skills in daily living decreased. In the presence of
37 3 year neurological scores, 2 year scores were not significant for either level or growth, which indicates potential mediation of the relation of the 2 year neurological scores to VDLS scores by the 3 year neurological scores. Birth status continued to predict both VDLS level, F ( 2, 326) = 5.1 \ , p < .007, and growth, F(2, 326) = 10.13, p < .0001. Because it w'as not significant, the 2 year neurological scores were dropped from subsequent models. Hypothesis 3. The next mixed model (model 3) was used to address the hypothesis that executive processing skills would provide unique information above and beyond 3 year neurological scores in predicting V-DLS. This model also included birth status as it remained significant in model 2. The analysis revealed that in the presence of the 3 year neurological scores and birth status, 3 year executive processing scores only showed a trend in predicting level of V-DLS, F(l,337) = -1.81,/? < .08, but did not predict growth. Children with less skill in solving the executive processing task (i.e., higher scores) showed less skill in completing tasks of V-DLS (i.e., lower scores). Because executive processing was not significant, no further analyses included this variable. The relation between biological risk status and 3 year neurological scores remained similar to that in model 2. Hypothesis 4 & 5. The next mixed models were used to address the hypotheses that gross motor arm and leg skills would provide unique information above and beyond 3 year neurological scores in predicting V-DLS. In model 4, gross motor arm skills were added to model 2 and the results revealed that arm scores did not predict level in V-DLS, but significantly predicted growth, F (l, 329) = 7.73, p < .004. The results indicate that as
38 arm scores increase, growth in V-DLS decreases. This model included the same variables as model 2 and added the gross motor arm scores. In Model 5, the final model analyzed, gross motor leg scores significantly predicted level of V-DLS, F ( 1, 328) = 5.84,/? <.02, and showed a trend in predicting growth F ( 1, 328) = 2.99, p <.09. This final model included biological risk, 3 year neurological scores, as well as leg and arm scores. The analysis revealed that all of the variables continued to provide unique information in the prediction of level and/or growth in V-DLS, except for the gross motor leg scores. Risk significantly predicted level, F ( 2, 328) = 5.69, p = .004, and growth F(2, 328) = 11.05,/? = .0001. Three-year neurological predicted level of V-DLS, F (l, 328) = 11.98,/? = .0006, and gross motor arm continued to predict growth in V-DLS, F (l, 328) = 7.14,/? = .008. All relations were in the expected direction with the exception that lower 3 year, gross motor arm scores predicted higher rates of growth in V-DLS. The significant results from Model 1, 2, and the Final Model are summarized in Table 4. Table 4 about here Follow up Analyses Because of the unexpected, inverse, relation between 3 year gross motor arm scores with growth in V-DLS, first order correlations were obtained in order to better understand these findings (see Appendix B). A review' of these correlations revealed scores in expected directions, that is, as arm scores increased, V-DLS scores increased, but only at 6 years, r(231) = .24, p <.001, and 8 years, r(217) = .17, p <05. At 10 and 12 years, the correlations were essentially zero. Thus, while in expected directions, the association appears to be declining over time.
39 Table 4. Significant results: Model 1, 2 and Final Model 1 Results Intercept 2 year Neurological Biological Risk F (l, 363) = 32.30,/? <.0001 F (2, 363) = 8.79,p < .0002 ns F (2 , 363) = 13.00,/? < .0001 HR vs. LR HR vs Term f(363) = 1.25, p = .2124 f(363) = 3.87, p <.0001 f(363) = 2.11, p = .006 /(363) = 5.06, p <.0001 Slope
Model 2 Results 3 year Neurological Biological Risk F ( 1,326) = 29.47, ^ < .0001 F (2, 326) = 5.11,/7 < .007 ns F (2, 326) = 10.13,/? < .0001
Final Model 3 year Neurological Biological Risk .F(l, 328) = 11.98, p = .0006 F (2, 328) = 5.69,/? = .004 ns F (2 , 328)= 11.05, p = .0001 Gross Motor Arm Ns F (l, 328) = 7 . \ 4 , p = .008
40 Given the above correlations, the possibility of shared variance between the gross arm scores and the 3 year neurological subscales contributing to the unexpected finding needed to be considered. Examination of the first order correlations between the arm and neurological subscale scores revealed significant associations for motor tone, r{ 224) = .20, p <.003, and coordination. r(224) = -0.22, p <.0009, but not reflexes (see Appendix B). As expected, as arm scores increased, motor tone and coordination subscale scores decreased. Thus, it is possibility that the variance in arm scores not shared with that of the combined neurological score is likely predicting growth in V-DLS scores in an anomalous manner. In model 5, due to the shared variance between 3 year leg and 3 year neurological scores, especially motor coordination, gross motor leg scores do not add information in the presence of 3 year neurological scores.
CHAPTER 4 DISCUSSION
Previous studies of children bom at VLBW have described their functioning in important developmental domains including cognitive, language, motor, social, attention, behavior and educational status (Landry et al, 1990; Landry et al., 1997; Saigal et al., 1991; McCormick, 1990). However, there is limited information regarding daily living skills in this growing population of children. In a previous study, we found that children bom preterm with more severe medical complications had the lowest early school age Vineland daily living skills (V-DLS) when compared to those bom with less severe medical complications. Those bom term had the highest V-DLS skills. For all children, V-DLS was predicted, in pan. by delays in development of motor related skills during the preschool period including presence of neurological abnormalities and coordination in extremities (i.e., legs, arms) (Frangente et al., 2005). By early school age, children are expected to transition developmentally to self-reliance in daily living skills activities such as buttoning, tying shoes, toileting, and assisting with clean-up tasks. Our previous results indicated that children bom preterm are less likely to have developed age appropiiate competencies at school entry, and. thus may require continued help with this set of skills. However, differences between children bom preterm who vary in biological risk was not determined as the analyses included these children as one group. In addition, the extent to which delays in motor related skills provided unique information in predicting self-care skills could not be determined from the previous study. The current study builds upon this previous work through examination of level and growth in V-DLS across elementary school ages with consideration of the relation of preschool age motor
42 related and executive processing skills as well as biological risk status as unique predictors of chiidrens V-DLS across this age period. Across 6 to 12 years of age. the results of the present study showed lower levels of daily living skills for both groups of children bom preterm when compared to term bom. However only those preterm bom children with more severe neonatal medical complications showed slower rates of growth when compared to term bom children. At 6 years of age, self-care skills that are required include the ability to adequately use eating utensils, dress completely including tying shoelaces and fastening fasteners (e.g., jackets'). By 8 years of age, addi tional tasks include independently dressing in anticipation of changes in weather and avoidance of others who appear ill (e.g., colds). By i() years of age, competence in telling time in five-minute segments is expected and use of cleaning products. By 12 years of age, independence is expected in correctly counting change (e.g., purchase > $1.00), using the telephone for all kinds of calls, and prepare foods that require mixing and cooking. Thus, while all children bom preterm are at risk for developmental delays in daily living skills, those more medically fragile children appear significantly more likely to evidence greater gaps in this skill area from term bom children over time. Childrens increasing self-reliance in daily living skills becomes particularly important as they enter formal schooling. It has been reported that teachers consider independence in dailydiving skills as a critical component of school readiness (Johnson, Gallagher, Cook, & Wong, 1995). In addition, these researchers suggest that such independence can serve to reduce children' s stress and ease the transition from one setting to another (e.g., home to school). For instance, a child with limited skills in
personal hygiene or cooperating with clean up tasks may have tiouble adjusting to the school routine and thus, less able to focus on academic learning activities. Similarly teachers can focus more time on academic endeavors if children are more competent in basic self-care skills. An additional objective of the present study was to examine for factors evident in the preschool period that would uniquely predict variability in development of V-DLS and whether this was similar or different for children who varied in biological risk. Based on previous results, gross motor skills as measured through a combination of arm and leg coordination skills, and neurological functioning during the preschool years were significant predictors. These preschool skills were inc luded in the present study with examination of the potential independent influence of gross motor skill in legs as compared to arm coordination. In addition, two and three year measures of neurologicai abnormalities were included to better understand the potential role of neurological maturation in understanding competence in V-DLS across the elementary school age years. Because visual-motor integration skills were not significant in the previous work these were not included. Knowledge of early precursors to later daily living skill competence would allow early intervention programs to target foundational skills that may riot be developing well in an attempt to decrease later difficul ties. In addition to previously examined skills, in the present study the extent to which executive processing skills may be an important predictor of V-DLS was evaluated. Childrens ability to identify goals, develop strategies to attain the goal, and the ability to shift strategies when unsuccessful (i.e., executive processing skills), potentially could be important to the development of self care skills. This may be even more essential across
44 the elementary school period studied given that greater independence in completing tasks of daily living are required for higher levels of competency. Thus, the current study investigated three preschool age skills, presence of neurological abnormalities, gross motor arm coordination, gross motor leg coordination, motor, and executive processing in their ability to uniquely predict level and growth in VDLS across the elementary school age years. Considering the tasks involved in daily living skills (e.g., dressing, cooking) and that preschool gross motor skills had been found as important for the development of 6 year V-DLS (Frangente et al., 2005), it was expected that early gross motor skills would provide unique information in predicting VDLS across the elementary school ages. In addition, it was expected that children who demonstrated more effective control of their regulatory' capacities (i.e., executive processes) would be better able to negotiate and learn from their environments, and thus handle more self care or functions of daily living, particularly given that the demands across the elementary school age period include tasks such as ordering a complete meal in a restaurant and using the stove or microwave oven for cooking. The original hypothesis regarding fewer neurological abnormalities at age 2 indirectly influencing greater growth in (V-DLS) through its direct effect on 3-year gross motor and executive processing couid not be answered as the indicators chosen for each of the constructs were not sufficiently related. An exploratory factor analyses provided important information as to why this occurred raising multiple important points. First, neurological abnormalities were expected to be a marker for preterm birth status including severity of biological risk. However, the neurological subscales of reflexes, motor tone, and motor coordination at 2 or 3 years of age did not comprise a single factor
at either age. For example, ar 2 years of age each of the three subscales loaded on different factors. By 3 years of age, abnormalities in motor tone and coordination shared significant variance but reflex abnormalities did not. Even more perplexing was that the preschool executive processing skills were independent measures, in spite of being similar tasks. This may have been due, in part, to differences in complexity. In retrospect, the finding that leg and arm coordination were independent may be explained by differences in relation to neurological abnormalities. For example, the leg coordination score loaded on the same factor as two of the 3 year neurological subscale scores. Due to an inability to develop underlying constructs from proposed indicator variables, structural equation modeling as originally proposed could not be used. Grow th curve modeling was chosen as an alternate means of examining a similar set of hypothesis to those originally proposed. This statistical approach was originally proposed to quantify the two outcome measures; level and growth in daily living skill. Thus, the originally proposed outcomes were still evaluated. Growth curve modeling allows for examination of unique predictors of parameters of growth, although it is a less robust method of determining the extent of direct as compared to indirect influences on the outcomes Finally, given that neurological scores co ild not be used as a ' proxy for biological risk status, risk status was included in the analyses. Based on the growth curve analyses, children's 2 year neurological scores were found to predict level of skill, or competence at the 9.5 age, but not growth, in V-DLS acr oss elementary school ages pro viding partial support o f Hypothesis 1. Contrary to what was expected, neurological abnormalities at 3 years did provide unique information above and beyond the 2 year neurological-scores (Hypothesis 2). T ogether these results
46 provide support for a mediation mode! where 2- year neurological scores predict the level of V-DLS through its relation with 3 year neurological scores. In addition, because these relations were with level of development and not change over time, the relation can be interpreted as being consistent across the developmental period studied (i.e., 6 to 12 years of age). Some neurological problems will diminish across the first 2 years of life and have been described as "transient neurological abnormalities (Anderson et al., 1999). By 2 years of age, transient neurological problems are likely to have resolved and, certainly, more so by 3 years of age, particularly for motor tone and reflexes. Thus, level being significant rather than growth may represent abnormalities that are the basis for the difficulties and that the neurological skills problem may be influencing skills sim ilarly over time (e.g., growth). These findings suggest that neurological abnormalities that are present at 2 years of age are likely to remain at 3 years of age, particularly with respect to motor tone and reflex abnormalities. These, in turn, are associated with lower competence in daily living skills across elementary school ages While executive processing skills did not provide unique information above and beyond 3 year neurological scores in predicting V-DLS (Hypothesis 3), a trend w? as found. It was expected that a child's ability to identify a goal, determine important information to attend to in establishing a strategy for reaching the goal, and carry out the task would be important in determining performance of later V-DI.S tasks. Executive processing skills that appear necessary for effective sharing of information, attention, and emotional regulation has been found to be important for interacting with others and objects in their environment (Hebert-Myers et al., 2006). Daily living skills would
appear to require a need to sequence behaviors in order to achieve necessary goals of dressing, cleaning, and care of hygiene needs. Thus, it was surprising that the results do not support this position. However, there may be multiple explanations as to why this relation was not significant. First, research on the skill development for executive processing tasks indicates that skill improves considerably between 3 and 5 years of age (Zelazo, Muller, Frye, & Marcovitch. 2003). An additional measure of executive processing skills at 5 yeafs of age would be needed to determine if assessment at a iater time would be more predictive. Second, the executive processing measure chosen may not have been the most sensitive with respect to predicting V-DLS (e.g., searching for rewards- (i.e., Cheerios) that had been observ ed when placed in a set of three or six boxes with brief delays between search trials). The demands associated with competence in daily living skills across elementary school ages, in part, involve increasing independence in completing tasks, thus, these may be more associated with early executive processing measures that involve less external structure, such as an independent goal-directed play. A third possibility is that, over time, daily living tasks are repeated so often that they become more rote with little novelty involved. Thus, behavioral sequences involved in competence in daily living skills may not be dependent upon planning and sequencing skills that are the hallmark of executive processing. Childrens ability to coordinate their arm skills did not provide unique information above and beyond o year neurological scores in predicting the level of VDLS (Hypothesis 4). A perplexing finding was a positive relation between early gross motor arm skills and slower growth in V-DLS. indicating that greater arm coordination was associated with slower growth. A review of simple order correlations at each age
revealed associations in the expected direction, that is, as arm scores increased, V-DLS scores -increased. However, this was apparent at 6 and 8 years but not at 10 and 12 years, where there was virtually no correlation. Although arm coordination skill shared less variance with other predictors, correlations with neurological scores were in expected directions, that is, as arm coordination skill increased, neurological scores decreased. The arm coordination items included bouncing, catching, and throwing, items that also are included as items on the neurological motor coordination subscales. However, the motor coordination neurological subscale includes many more items than those associated with arm coordination Thus, it may be that the variance in arm coordination not shared with neurological scores is predicting gro wth in V-DLS scores in an anomalous maimer. An additional speculation is that arm coordination may be more predictive of daily living skills in early elementary school years as suggested by the correlations with 6 and 8 year skill, but not at later ages. This, in part, may contribute to the difficult to explain findings. The hypothesis that gross motor leg skills would provide unique information above and beyond early neurological scores in predicting V-DLS was not supported (Hypothesis 5). A review of the factor analysis involving all 3 year measures revealed shared variance between 3 year leg and 3 year neurological scores, especially motor coordination. For example, some items that are the same or overlap on the gross motor leg assessment and the neurological exam include the ability to v/alk without wide gait and keeping balance and the ability to stand on one foot (See appendix). Thus, unlike the finding for arm coordination, the leg coordination skills appears to be evaluating similar skills to that found in the motor coordination and/or motor tone subscales. This may help
49
explain why gross motor leg scores do not add information in the presence of 3 year neurological scores. Study Limitations Given the demographic characteristics of the study participants, it is important to recognize that these results may not generalize to children growing up in more affluent families. In addition, because the Vineland depends on caregivers reports regarding the behavior of children, this assessment can be subject to the biases of the person supplying the information. However, such biases can be minimized through careful adherence to the interview format required by standardization procedures as was done in this study (Sparrow et al., 1984). In addition, the psychometric properties of the Vineland supports the stability of results found when the standardized interview format is used. It continues to be a well-accepted, valid and reliable measure of adaptive behaviors. Data analyses used are based on regression models and thus, directionality cannot be established although the use of longitudinal data lends some support for directionality. However, a Stronger test of the model would come from the used of structural equation modeling that allows for the identification of underlying constructs. Future Directions for Research Skills on the executive processing task may not have influenced V-DLS in predicted ways because the search task used was not a sensitive indicator of the types of executive processing demands required to effectively carry out requirements of the VDLS. Perhaps other measures of executive functioning (e.g., independent goal directed play) which involve greater demands on independence might predict V-DLS more effectively. Further research is needed to determine other skills as well as the
50
environmental influences that will increase our ability to determine which childten are more at risk and increase the effectiveness of early intervention approaches. Given the practical and psychological importance of daily living skills, better understanding of factors that support its development are needed. Summary In summary, this study documents the association between preterm birth status and V-DLS and provides evidence that those with more severe neonatal complications are at significant risk for problems in growth of elemen tary school age skills. Three year neurological functioning was a consistent predictor in the development of school age daily living skills and was the primary unique predictor suggesting it may be a marker" for later problems. These results suggest that the result:s from a neurological evaluation to assess for the presence of abnormalities in reflexes, motor tone, and motor coordination will provide important information about who is at risk for delays in development of competence in daily riving skills. Preteim birth status also is a unique predictor of developmental difficulties with this being of particul ar concern for those who experience more severe neonatal Complications. These two factors can assist in identifying those in need of intervention. However, further research is needed to determine if other specific early developmental skills can be found in order to better inform intervention practices
References Am id-Ti son, C. (1976). A method for neurologic evaluation within the first year of life. C u rre n t P ro b le m s in P e d ia tric s ; 7, 1-50. Anderson. S. R., & Romanczvk. R. G. (1999). Early intervention for young children with autism: Continuum-based behavioral models. J o u rn a l o f th e A sso cia tio n fo r P e rso n s w ith S e v e re h a n d ic a p s, 24, 162-173. Anderson. A, Swank, P., Wildin. S., I.andry, S., Smith, K. (1999). Modeling analysis of change in neurologic abnormalities in children bom prematurely: a novel approach. J o u rn a l o f C h ild N eu ro lo g y> , 14, 502-508. Avery, M. E., & Mead, J. (1959). Surface properties in relation to atelectasis and hyaline membrane disease. A m e ric a n J o u rn a l o f D isea ses o f C h ild ren , 97, 517523. Aylward, G. P., Pfeiffer, S. L, Wright, A., & Verhulst, S. J. (1989). Outcome studies of low birth weight infants published in the last decade: A meta-analysis. J o u rn a l o f P e d ia tric s, 115, 515-520. Bailey, D. B. & Wolery, M. (1992). T e a c h in g in fa n ts a n d p r e s c h o o le r s w ith d isa b ilities. NY: Merrill. Baird, H., & Gordon, E. (1983) N e u ro lo g ic a l e v a lu a tio n o f in fa n ts a n d ch ild ren : C lin ics in D e v e lo p m e n ta l M ed icin e. Philadelphia, Lippincott, 20-106. Barkley, R. A. (1995). T a k in g ch a rg e o f A D H D . New York: Guilford. Barkley, R. A. (2001). The executive functions and self-regulation: an evolutionary neuropsychological perspective. N e u ro p sy c h o lo g y R e v ie w , //, 1-29
52 Beckwith, I,., & Cohen, S. E. (198:)). Interactions of preterm infants with theii caregivers and test performance at age two. In T. M. Filed, S. Goldberg, D. Stem, & M. Sostek (Eds.). H ig h r is k in fa n ts a n d c h ild ren : A d u lt a n d p e e r in te ra ctio n s (pp. 155-i 80). New York: Academic Press. Bendersky, M , & Lewis. M. (1994). Environmental risk, biological risk, and developmental outcome. D e v e lo p m e n ta l P sy ch o lo g y , 3 0 . 484-494. Bracewell, M & Marlow, M. (2002). Patterns of motor disability in very preterm children. M e n ta l R e ta rd a tio n a n d D e v e lo p m e n ta l D isa b ilitie s R e sea rc h R eview s. 8 , 241-248. Bryk, A. S., & Raudenbush, S. W. (1992). H ie ra rc h ica l lin e a r m o d e ls: A p p lic a tio n s a n d d a ta a n a ly sis m e th o d s c h a n g e. Newbury Park, CA: Sage. Caputo, D.V., & Mandell, W. (1970). Consequences of low birth weight. D e v e lo p m e n ta l P sy c h o lo g y , 3, 363-383 Carlo, W. A., & Martin, R. J. (1986). Principles of neonatal assisted ventilation. P e d ia tric C lin ic s o f N o rth A m e ric a , 33, 221-237. Carter, A., & Sparrow, S. (1989). The acquisition of adaptive behavior in infancy: Developmentally at risk infants. S e m in a rs in P e r in a to lo g y , 13, 474-481. Cohen, S. E. (1986). The low-birthweight infant and learning disabilities. In M. Lewis (Ed.), P re n a ta l a n d p e r in a ta l fa c to r s re le v a n t to le a rn in g d isa b ilitie s (pp. 153193). Urbana, IE: University of Illinois Press. Cohen, S. E., Parmelee. A. H., Sigman, M., & Beckwith, L. (1988). Antecedents of school problems in children bom preterm. J o u r n a l o f P e d ia tric P sy ch o lo g y , 13, 393-508.
Cooke. R. W. & Abernethv, L. J. (1999). Cranial magnetic resonance imaging and school performance in very low birth weight infants in adolescence. A rc h iv e s o f D isea se in C h ild h o o d , F e ta l a n d N e o n a ta l E d itio n , 81, 116-121. Culbertson, J. L., Gyurke. J. (1990). Assessment of cognitive and motor development in infancy and childhood. In J. H. Johnson, J. H.. & J. Goldman (Eds). D e v elo p m e n ta l a s se ss m e n t in c lin ic a l c h ild p sy c h o lo g y ; A h a n d b o o k (pp. 100-131). Pergamon Press, de Groot, L., Hopkins, B., & Touwen, B.C.L. (1995). Muscle power, sitting unsupported and trunk rotation in preterm infants. E a rly H u m a n D e v e lo p m e n t, 43, 37-46. de Groot. L., Hopkins, B., & Touwen, B.C.L. (1997). Motor asymmetries in preterm infants at 18 weeks corrected age and outcomes at 1 year. E a rly H u m a n D e v e lo p m e n t, 48, 35- 46. Diamond, A. (1988). Abilities and neural mechanisms underlying AB performance. C h ild D e v e lo p m e n t, 5 9 , 523-527. Dieterich. S. E., Hebert, H. M., Landry, S. H., Swank, P. R., & Smith, K. E. (2004). Maternal and child characteristics that influence the growth of daily living skills from infancy to school age in preterm and term children. E a rly E d u c a tio n & D e v e lo p m e n t, 15, 283-303. Drillien, C. M. (1972). Abnormal neurologic signs in the first year of life in lowbirthweight infants: possible prognostic significance. D e v e lo p m e n ta l M e d ic in e & C h ild N e u ro lo g y , 172, 575-584.
Dykens. E. M., Hodapp, R. M., & Leckman. J. F. (1989). Adaptive and maladaptive functioning of institutionalized and noninstitutionalized Fragile X males. J o u rn a l o f th e A m e r ic a n A c a d e m y o f C h ild a n d A d o le s c e n t P sy c h ia try , 28, 427-430. Fits van der, I. B., Hadders-Algra, M. (1998). The development of postural response patterns during reaching in healthy infants. R eview N e u ro sc ie n c e B io b e h a v io r R e v ie w , 2 2 , 521-526. Fleiss, J.L. (1986). The d e sig n a n d a n a ly sis o f c lin ic a l e xp erim en ts. New York: Wiley. Frangente, I., Hebert, H Swank, P.. Landry, S., & Smith, K. E. (2005). The relation of early gross and visual motor integration skills and presence of neurological abnormalities to school age daily living skills. Unpublished masters thesis, University of Houston, Houston, Texas. Freeman, B. J.. Ritvo, E. R. Yokota, A., Childs, J., & Pollard, J. (1988). WISC-R and Vineland Adaptive Behavior Scales scores in autistic children. J o u rn a l o f the A m e r ic a n A c a d e m y o f C h ild a n d A d o le sc e n t P sy ch ia try , 27, 428-429. Frick, T., & Semmel, M.I. (1978). Observer agreement and reliabilities of classroom observational measures. R eview o f E d u c a tio n a l R e sea rc h , 48, 157-184. Gregory, G. A., Kitterman, J. A., Pbibbs, R. H., Tooley, W. H., & Hamilton, W. K. (1971). Treatment of idiopathic respiratory distress syndrome with continuous positive airway pressure. N e w E n g la n d J o u rn a l o f M e d ic in e , 2 8 4 , 1333-1340. Guidubaldi, J., Perry, J. D. (1985). Divorce and mental health sequelae for children: A two-year follow-up of a nationwide sample. J o u rn a l o f th e A m e ric a n A c a d e m y o f C h ild P sy c h ia try , 24, 531-537.
Hack. M., Si Fanaroff, A. A. (1999). Outcomes of children of extreme!}, low birthweight and gestational age in the 1990*s. E a rly H u m a n D e v e lo p m e n t, 53, 193-218. Hack, M.. Fiannery, D. j., Schluchter, M Cartar, L.. Borawski. E., & Klein, N. (2002). Outcomes in young adulthood for very low birth weight infants. N e w E n g la n d J o u rn a l o f M e d ic in e , 3 4 6 , 149-157 Hack, M., Kiein, N. K., Si Taylor, H. Ct. (1995). l ong-term developmental outcomes of low birthweight infants. The F u iu re o f C h ild ren , 5, 176-V96. Hebert-Myers, H,, Guttentag, C. E., Swank, P. R., Smith, K. E. < fc Landry, S. H (2006). The importance oflanguage, sociai, and behavioral skills across early and later childhood as predictors of social competence with peers. A p p lie d D e v e lo p m e n ta l S c ien c e , 10, 174-187. Hu, L., & Bentler. P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new .alternatives. S tr u c tu ra l E q u a tio n M o d e lin g , 6, 1-55. Johnson, L. J,, Gallagher, R. J., Cook, M., & Wong, P. (1995) Cntical skills for kindergarten: Perceptions from kindergarten teachers. J o u r n a l o f E a rly In te rv e n tio n , 19, 315-327. Jongmans, M., Mercuri, E., de Vries, L., Dubowitz, L . & Henderson, S. E. (1997). Minor neurological signs and perceptual-motor difficulties in prematurely bom children. A r c h iv e s o f D isea se in C h ild h o o d F e ta l a n d N e o n a ta l E d itio n , 76, F9F14.
Kamiski, W., Blair, C. & Vi luce i. J. S. (1987). The illusion of catch-up growth in premature infants: Use of growth index and age correction. P e d ia tric s a n d A d o le sc e n t M e d ic in e . 141, 520-526. Landry, S. H., & Chapieski. I. . (1988). Visual attention directing exploration in preterm infants: Effects of medical risk and maternal interactions. In fa n t B e h a v io r a n d D e v e lo p m e n t, 5 3 , 174-182. Landry, S. H., Chapieski. L., Richardson, M.. Palmer. J., & Hall, S. (1990). The social competence of children bom prematurely: Effects of medical complications and parent behaviors. C h ild D e ve lo p m e n t, 61. 1605-1616. Landry. S. IT, Denson, S. E.. & Swank, P. R. (1997). Effects of medical risk and socioeconomic status on the rate of change in cognitive and social development for low birth weight children. J o u rn a l o f C lin ic a l a n d E x p e rim e n ta l N e u ro p sy c h o lo g y , 19, 261-274. Landry, S. H., Leslie, N. A., Fletcher, J M., & Francis, D. J. (1985). Visual attention skills of premature infants with and without intraventricular hemorrhage, in fa n t B e h a v io r a n d D e v e lo p m e n t, S, 309-321. Landry, S. H.. Smith, K. E , Muler-Loncar, C. L., & Swank, P. R. (1998). The relation of change in the maternal styles to the developing social competence of full-term and preterm children. C h ild D e ve lo p m e n t, 69, 105-123. Landry, S. H., Smith, K. E., Swank. P. R., Assel, M. A., Vellet. S. (2001). Does early
57
responsive parenting have a special importance for childrens development or is consistency across early childhood necessary? D e v e lo p m e n ta l P sy c h o lo g y , 37, 387-403. Lezak, M. D. (1095). N e u ro p sy c h o lo g ic a l A s s e s sm e n t - T h ird E d itio n . New York: Oxford University Press. Lorenz, J.M., Wooliever, D.E., & Jetton, F.R. (1998). A quantitative review of mortality and developmental disability in extremely premature newborns. A rc h iv e s o f P e d ia tric s & A d o le s c e n t M edicine, 152, 425-435. Loveland, K. A., Kelley. M. L. (1988). Development of adaptive behavior in adolescents and young adults with autism and Downs Syndrome. A m e ric a n .Journal o f M e n ta l R e ta rd a tio n , 93, 84-92. Luoma, L., Herrgard, E.. &. Martikainen, A. (1998). Neuropsycholgical analysis of the visuomotor problems in children bom preterm at <=32 weeks of gestation: A 5 year prospective follow-up. D e v e lo p m e n ta l M e d ic in e & C h ild N eu ro lo g y , 40, 2130. Mazer, B., Piper, M., & Ramsay. M. (1988). Developmental outcome in very low birth weight ipf'ants 6 to 3b months old. J o u rn a l o f D e v e lo p m e n ta l a n d B e h a v io ra l P e d ia tric s, 9, 293-297. McCarthy, D. (1972). M c C a rth y S c a le s o f C h ild r e n s A b ilitie s. New York, NY: Psychological Corporation. McCormick, M. C. (1990). Very low birthweight children: Behavior problems and school difficulty in a national sample. J o u rn a l o f P e d ia tric s . 117, 687-692.
58 McCormick, M. C. (1992). Advances in neonatal intensive care technology and their possible impact on the development of low-birthweight infants. In S.L. Friedman & MD Sigman (Eds.). The p sy c h o lo g ic a l d e v e lo p m e n t o f low b irth w e ig h t c h ild re n (pp. 37-60). Ablex Publishing Corporation, EUA. McCormick, M. C. (1993). Mas the prevalence of handicapped infants increased with improved survival of the very low birthweight infant? C .lm ics in P erin a to lo g y, 20, 263-277. McEvoy, R. E., Rogers, S. J., & Pennington, B. F. (1993). Executive function and social communication deficits in young, autistic children. J o u rn a l o f C h ild P sy ch o lo g y a n d P sych ia try. 34. 563-578. McGrath, M., Sullivan, M. C., Brern, F., &. Rocherolle, K. C. (1995). Mastery motivation and cognitive development in 4-year-old children bom at various degrees of medical risk. J o u rn a l o f P e d ia tric N u rsin g . 10, 287-295. Nars, P. S., Schubarth, L., Kindler, R Werthemann, U., & Stalder, G. (1981). Systematic follow-up of newborns with idiopathic respiratory distress syndrome. Results in 197 patients born 1971 to 1976. H e lv e tic a P a e d ia tric a A c ta , 36, 389-404. Niswander, K. R. Sc Gordon, M. (1972). The C o lla b o t a tive P e rin a ta l S tu d y o f the N a tio n a l In stitu te o f N eu ro lo g ic a l D isea se s a n d Stro ke: T he w o m e n a n d th eir p r e g n a n c ie s. Philadelphia: Saunders. Northway, W. H. (1979). Observations on bronchopulmonary dysplasia. The J o u rn a l o f P e d ia tric s. 9 5 , 815-818. Papile, L. A., Burstein, J., Burstein. R., Koffler, H., & Koops, B. (1978). Relationship of
59 intravenous sodium bicarbonate infusions and cerebral intraventricular hemorrhage. The J o u r n a l o f P e d ia tric s. 93, 834-836.
P ern er, .L & L a n g . B . (1 9 9 9 ) . D e v e lo p m e n t o f th e o r y o f m in d a n d e x e c u t iv e c o n tr o l.
Trends in Cognitive Sciences. 3, 3 3 7 - 3 4 4 .
Saigal, S., Hoult., L. A., Streiner, D. L., Stoskopf, B. L., & Rosenbaum, P. L. (2000). School difficulties at adolecence in a regional cohort of children who were extremely low birth weight. P e d ia tric s, 105, 325-331. Saigal, S.. & OBrodovich, H. (1987 ). Long-term outcomes of preterm infants with respiratory disease. C lin ic s in P e rin a to lo g y , 14, 635-650. Saigal, S., Szatmari, P., Rosenbaum, P., Campbell, D. & King, S. (1991). Cognitive abilities and school performance of extremely low birth weight children and matched term control children at age 8 years: A regional study. J o u rn a l o f P e d ia tric s, 118, 751-760. Samsom J. F., de Groot, L, & Hopkins, B. (1998). Muscle power and medical history in high risk preterm infants at 3 months of corrected age. N e u ro p e d ia tric s, 29, 127-132. Schothorst, P. F., & van Engeland, H. (1996). Long-term behavioral sequelae of prematurity. J o u r n a l o f the A m e ric a n A c a d e m y o f C h ild a n d A d o le sc e n t P sy c h ia try , 3 5 , 175-18.3. Schub, H. S., Ahmann, P. A., Steele, J. R., & Hoffman, J. C. (1981). Transient diffuse computed tomographic scan enhancement in multifocal seizures. A m e ric a n J o u r n a l o f D ise a se s o f C h ild ren , 135, 799-801.
Siege!. L S (1983a ). The prediction of possible learning difficulties in preterm and fullterm children. In T. Field & A. Sostek (Eds.), In fa n ts b o rn a t risk: P h ysio lo g ica l, p e r c e p tu a l a n d c o g n itiv e p ro c e sse s (pp. 295-316). New York: Grune & Stratton. Smith, K.E., Landry, S.H.. Denson, S.E., Miller-Loncar, C.L., Swank, P. (1999). Is severity of chronic lung disease associated with differences in neurodevelopmentaj patterns in preterm infants? D e v e lo p m e n ta l N e u ro p sy c h o lo g y , !6.t 59-77; 1999.' Sparrow, S., Balia, D., & Cicehetti, D. (1984). V in ela n d A d a p tiv e B e h a v io r S ca les. Circle Pines, MN: American Guidance Service. Swaiman, K. (1989). Neurologic examination after the newborn period until 2 years of age. In K. Swaiman (Ed), P ed ia tric n e u r o lo g y P rin c ip le s a n d p r a c tic e (pp. 3544). St.I ouis: CV Mosby ' '
Taylor, H: G.. Mrnich, N. M., Klein, N., & Hack, M. (2004). Longitudinal outcomes of very low birthweighr: neuropsychological findings. J o u rn a l o f th e In te rn a tio n a l Society> . 10 , 149-1.63. Teberg, A.J., Wu, P.Y.. Hodgman, J. E.. Mich, C., Garfinkle, J., Azen, S. & Wingert, W. A. (1982). Infants with birth weight under 1500 grams: physical, neurological, and developmental outcome. C ritic a l C a re M e d ic in e , 10, 10-14. Vohr, B. R., & Garcia-Coli, C T (1985). Neurodevelopmental and school performance of very iow-birth-weight infants: a seven-year longitudinal study. P e d ia tric s , 76, 345-50. Vohr, B. R., Wright, L. L.,, Dusick, A. M , Mele, L., Verter, J., Steichen, J. J., Simon, N. P., Wilson , I). C., Brbyie's, S., Bauer, C. R., Delaney-Black, V., Yoiton, K. A.,
Fleisher, B. E., Papile, L.-A.. Kaplan. M. D. (2000). Neurodevelopmentai and functional outcomes of extremely low birth weight infants in the national institute of child health and human development neonatal research network, 1993 -1994. P e d ia tr ic s , 105, 1216-1226. Wall, B. M. (1996). Executive function of children bom preterm. D isse rta tio n A b stra c t In te rn a tio n a l, 5 7 , 1491. Welsh, M. C., & Pennington, B. F. (1988). Assessing frontal lobe functioning in children; Views from developmental psychology. D e v e lo p m e n ta l N e u ro p sy c h o lo g y , 4, 199-230. Widaman, K. F., & McGrew. K. S. (1996). The Structure of Adaptive Behavior. In J. W. Jacobson & J. A. Mulick (Eds.), The m a n u a l o f d ia g n o sis a n d p ro fe ssio n a l p r a c tic e in M e n ta l R e ta rd a tio n (pp. 97-110). Washington, DC: APA Wiener, G. (1970). The relationship of birth weight and length of gestation to intellectual development at ages 8 to 10 years. The J o u rn a l o f P e d ia tric s, 76, 694-699. Zelazo. P.D., Muller, U., Frye, D., & Marcovitch, S. (2003). The development of executive function in eariy childhood. M o n o g ra p h s o f th e S o c ie ty f o r R e sea rc h in C h ild D e ve lo p m e n t, 68(3, Serial No. 274).
APPENDIX A NEUROLOGICAL ASSESSMENT ITEMS
Appendix A
Items scored:
0 = Normal 1 = Moderately Abnormal 2 = Severely Abnormal
Tone: 2 items 1) Passive motor activityUpper and lower extremities 2 ) Truncal toneChild sits, head control 3) Closure of hands/ fisted = abnormal 4) Scissoring 5) SymmetryPosture of Limbs 6) Spontaneous motor activity 7) Abnormal movements 8) Dvskinetic Movements Stiffening 2 items 2 items 9) Muscle mass 10) Strength
64 Reflexes 1) Biceps 2) Triceps 3) .Knee jerk 4) Ankle jerk 5) Ankle clonus 6) Plantar response 7) Lateral propping reaction
Coordination (combo or arm and leg items) 1) Walking 2) Broad jump 3) Stands on 1 foot 4) Throws ball 5) Threads shoelace 6) Holds crayon 7) Tower of cubes 8) Bridge cubes 9) DrawingCircle 10) StairsWithout holding
APPENDIX B CORRELATION MATRIX
Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission.
Correlations Among Predictor Variables
2 year Neuro
Tone Coordination Reflexes
Executi ve P rocessin g
3 Boxes 6 Boxes
M otor
Leg Arm Tone Coordi nation Reflexes
2 vr Neuro
Tone Coordination Reflexes 1.00 .77 .67 .77 1.00 .62 .67 .62 1.00 .36 .43 .36 .16 .32 .17 -.35 -.25 -.08 -.19 -.19 -.07 .86 .76 .65 .76 .71 .65 .72 .63 .51
E xecutive Processina
3 boxes 4 boxes .36 .16 .43 .32 .36 .17 1.00 .22 .22 1.00 -.10 -.11 -.15 -.15 .44 .15 .40 .20 25 .12
Motor S k ills
Leg Arm -.35 .19 -.25 -.19 -.08 -.07 -.10 -.15 -.11 -.15 1.00 .26 .26 1.00 -.27 -.20 -.39 -.22 -.14 -.10
3 vr Neuro
Tone .86 .76 .71 .63 .65 .54 .51 .44 .40 .25 .15 .20 .12 -.27 -.39 -.14 -.20 -.22 -.10 1.00 .73 .71 .73 1.00 .56 .70 .56 1.00
Coordi nation .75 Reflexes .72
Vi neland
6 year 8 year 10 year 12 year 51 .48 -.38 -.31 -.43 -.38 -.41 -.38 -.36 -.29 -.29 -.22 .23 .16 .27 .27 -.07 -.13 -.07 -.10 .26 .14 .17 .27 .24 .17 -.01 .01 .46 -.46 -.45 -.44 -.45 -.43 -.49 -.43 -.45 -.45 -.33 -.31
O' O'

The Extent To Which Neurological Status, Gross Motor, and Executive Processing Support Growth in Daily Living Skills Across Elementary School Ages For Children Who Vary in Biological Risk

Uploaded by

Copyright:

Available Formats

The Extent To Which Neurological Status, Gross Motor, and Executive Processing Support Growth in Daily Living Skills Across Elementary School Ages For Children Who Vary in Biological Risk

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

The Extent To Which Neurological Status, Gross Motor, and Executive Processing Support Growth in Daily Living Skills Across Elementary School Ages For Children Who Vary in Biological Risk

Uploaded by

Copyright:

Available Formats

THE EXTENT TO WHICH NEUROLOGICAL STATUS, GROSS MOTOR, AND EXECUTIVE PROCESSING SUPPORT GROWTH IN DAILY LIVING SKILLS

A Dissertation Presented to the Faculty of the College of Education University of Houston

In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy

by Isa Fernandez Frangente August, 2007

UMI Number: 3272585

A Dissertation for the Degree Doctor of Philosophy by Isa Fernandez Frangente

Approved by Dissertation Committee:

Dr. Stewart Pisecco, Chairperson

Dr. Consuelo Arbona, Committee Member

Anu# & hie ' U t f

Paul Swank, Committee Member

In Partial Fulfillment of the Requirements for the Degree

byIsa Fernandez Frangente August, 2007

LIST OF FIGURES Figure Page

1. Hypothesized model...................................................................................................20 2. Model including indicators used to form each construct........................................ 27

CHAPTER 1 INTRODUCTION AND REVIEW OF LITERATURE

Insert Figure 1 about here

Intercept Daily Living Skills

Figure 2. Proposed indicators for constructs in measurement model

3 Box S earch Task

110 Y ear V ineland j

6 Box S earch Task

Growth Daily Living Skills Neurological

Socioeconomic status Birthweight2 (g) Gestational age (wk) n

Coordination 1.06 (2.89) Reflex

Three Box Six Box

Leg Arm Months Years

34 Table 3. Exploratory Factor Analyses

Trends in Cognitive Sciences. 3, 3 3 7 - 3 4 4 .

APPENDIX A NEUROLOGICAL ASSESSMENT ITEMS

0 = Normal 1 = Moderately Abnormal 2 = Severely Abnormal

APPENDIX B CORRELATION MATRIX

Correlations Among Predictor Variables

Coordi nation .75 Reflexes .72

You might also like