Physical & Occupational Therapy in Pediatrics, Early Online:1–14, 2015 C 2015 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/potp DOI: 10.3109/01942638.2015.1012319
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Attention in 3-Year-Old Children with VLBW and Relationships with Early School Outcomes Gijs Verkerk1 , Martine Jeukens-Visser1 , Bregje Houtzager2 , Aleid van Wassenaer-Leemhuis3 , Karen Koldewijn1 , Frans Nollet1 , & Joke Kok3 1
Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands, 2 Emma Children’s Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands, 3 Department of Neonatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
ABSTRACT. Aim: To compare attention skills of children with a very low birth weight (VLBW) with children with a normal birth weight (NBW) when entering primary school, and explore the association of attention skills with school career 2 years later. Methods: Participants were 151 children with VLBW and 41 with NBW. Attention was assessed at 3 years and 8 months of corrected age (CA) and school career at 5 12 years of CA. Children performed two tests, parents completed three questionnaires, and an assessor systematically observed children’s attention. Results: Children with VLBW had significantly lower mean scores on five of the six measures. Significantly more children with VLBW had scores in the clinical range on the Child Behavior Checklist completed by the parents (13% versus 0%) and scores representing dysfunction on assessor observations (19% versus 2%). At 5 12 years of age, 36% of the children with VLBW followed special education or had grade retention. Dysfunctional attention as observed by the assessor was most strongly associated with need for learning support at 5 12 years of age. Conclusions: At preschool age, children with VLBW have attention difficulties. Attentive behavior at preschool age is a predictor of school career 2 years later. KEYWORDS. Attention, behavior, children born preterm, educational provision, preterm infant, very low birth weight
Children with a very low birth weight (VLBW) and/or born very preterm, defined as born with a birth weight below 1500 g and/or with a gestation of less than 32 weeks, are at an increased risk of attention problems (Aarnoudse-Moens et al., 2009; Anderson, 2014; Mulder et al., 2009; Van de Weijer Bergsma et al., 2008). Occupational and physical therapists are often involved in the care of children born with VLBW or very preterm (in short: children born with VLBW) (Spittle et al., 2012) because of their motor difficulties (Spittle and Orton, 2014). However, domains do not develop independent of each other. Children’s motor Address correspondence to: Dr. Gijs Verkerk, Department of Rehabilitation, A-01–414, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (E-mail: [email protected]). (Received 2 July 2014; accepted 18 January 2015)
1
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Verkerk et al.
capacity contributes to attention and concentration. Research has shown that motor and attention problems are interrelated, with common neurophysiological substrates (McLeod et al., 2014). Attention is an important regulatory skill needed for information processing and learning (Bronson, 2000; Center on the Developing Child at Harvard University, 2011; Lezak, 2004; Polderman et al., 2010). Attention problems can interfere with performance at school (Center on the Developing Child at Harvard University, 2011; Deutscher and Fewell, 2005; Jaekel et al., 2012; Polderman et al., 2010; Rueda et al., 2010). Early identification of attention problems, therefore, is important to prevent or reduce potential school problems (Larroque et al., 2011). Attention is assessed in young children (3–4 years) by observing the child’s ability to orientate to, shift between, and maintain focus on events, objects, tasks, and problems in the external world (Van de Weijer-Bergsma et al., 2008). Methods used to assess attention of young children include performance-based tests (McGrath et al., 2005; Woodward et al., 2011), questionnaires completed by parents or caretakers (McGrath et al., 2005), and systematic professional observation (McGrath et al., 2005). Different attention assessments may yield different findings. In addition, it is not clear whether the results of attention measurements at preschool age relate to school outcome. The objective of this study was to compare the attention skills of children with VLBW with term born peers with a normal birth weight (NBW) at preschool age from three different viewpoints and analyze the association of attention skills with early school career 2 years later at the age of 5 12 years. We hypothesized that at preschool age, children with VLBW perform less well on attention than children with NBW and that attention skills are positively related to school career at the age of 5 12 years. METHOD Participants Participants were 151 children born with VLBW and 41 children with NBW, all assessed at 44 months corrected age (CA). This age was chosen to investigate the attention skills just before entering school. In the Netherlands, children born with VLBW enter school when they are 48 months old (uncorrected age). For readability, we use the term “3 12 years corrected age” instead of “44 months corrected age.” Children born with VLBW were recruited from a cohort of 176 children who participated in a multicenter randomized controlled trial (RCT) on the effect of an early neurobehavioral intervention (Koldewijn et al., 2009). Infants were recruited from seven hospitals in Amsterdam, the Netherlands from 2003–2006, just before being discharged to home. Eighty-six children received the intervention and 90 children received the standard care. The intervention aimed to support an infant’s selfregulatory competence and developmental functions via responsive parent–infant interactions. Specifically trained pediatric physical therapists provided the intervention at home during 6–8 visits between 0 and 6 months corrected age; see for details Koldewijn et al. (2009). Parents of all 176 children were invited to participate in the follow-up study at 3 12 years corrected age (Verkerk et al., 2011, 2012) and at 5 12 years corrected age (van Hus et al., 2013). Twenty-five children of the
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Attention Assessment in Children Born Very Preterm
3
original cohort (n = 176) dropped out of the study at 3 12 years of age. Reasons for dropping out of the study were death (n = 2), moving abroad (n = 6), lost to followup (n = 6), and parental withdrawal (n = 11). The perinatal characteristics did not differ significantly between the children with VLBW who participated and those who dropped out. However, children with a father born outside the Netherlands discontinued participation significantly more often (p = .002), and children who are first-born continued to participate significantly more frequently (p = .005). A control group of 40 healthy children born at term age and with NBW (in short: children with NBW) was recruited through Amsterdam’s Public Health Service by sending invitations to 200 parents. Inclusion criteria for the NBW group were: being born after ≥37 weeks of gestation and a birth weight of ≥2500 g. To avoid that, parents of children born at term age with developmental problems would like to participate in the study, e.g., as a second opinion, children who were referred to a psychologist, pediatrician, or physician because of developmental or health problems were excluded. Sample size calculation resulted in a group of 40 children born with NBW to be able to detect a difference of 0.5 standard deviation (SD) between the groups on most measurements at the age of 3 12 years with a significance level of .05. Half a SD of change is regarded as a threshold of discrimination for changes in most measurements (Norman et al., 2003). Fifty-seven parents of children born with NBW were willing to participate. Sixteen of these children from highly educated mothers who applied for participation were not invited to ensure a similar distribution with respect to maternal education in both groups. The VLBW and NBW groups (n = 41) had the same proportion of boys (51%), maternal education ≤10 years (36%), and mothers born abroad (39%). The mean age (SD) of the children with NBW (mean calendar age 44 months [0.4]) did not differ significantly from the mean (SD) corrected age of the VLBW group (44 months [0.5]). The Medical Ethics Committee of the Academic Medical Centre, Amsterdam approved this study. Parents provided written informed consent. The perinatal characteristics and the socio-demographic factors of the VLBW group are shown in Table 1. Measures Attention was assessed using two performance tests, three parental questionnaires, and a structured observation of behavior. Performance Tests The children performed the Visual Attention test (VAT) of the Developmental Neuropsychological Assessment (NEPSY) (Korkman et al., 1998) and the Gift Delay test (Kochanska et al., 1996). The VAT records the speed and accuracy with which a child is able to focus selectively on, and maintain attention to, visual targets. The total score was compared with the age-related norm of US children with a mean of 10 (SD = 3). A score below
Phys Occup Ther Pediatr Downloaded from informahealthcare.com by RMIT University on 08/17/15 For personal use only.
Attention in 3-Year-Old Children with VLBW and Relationships with Early School Outcomes Gijs Verkerk1 , Martine Jeukens-Visser1 , Bregje Houtzager2 , Aleid van Wassenaer-Leemhuis3 , Karen Koldewijn1 , Frans Nollet1 , & Joke Kok3 1
Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands, 2 Emma Children’s Hospital, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands, 3 Department of Neonatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
ABSTRACT. Aim: To compare attention skills of children with a very low birth weight (VLBW) with children with a normal birth weight (NBW) when entering primary school, and explore the association of attention skills with school career 2 years later. Methods: Participants were 151 children with VLBW and 41 with NBW. Attention was assessed at 3 years and 8 months of corrected age (CA) and school career at 5 12 years of CA. Children performed two tests, parents completed three questionnaires, and an assessor systematically observed children’s attention. Results: Children with VLBW had significantly lower mean scores on five of the six measures. Significantly more children with VLBW had scores in the clinical range on the Child Behavior Checklist completed by the parents (13% versus 0%) and scores representing dysfunction on assessor observations (19% versus 2%). At 5 12 years of age, 36% of the children with VLBW followed special education or had grade retention. Dysfunctional attention as observed by the assessor was most strongly associated with need for learning support at 5 12 years of age. Conclusions: At preschool age, children with VLBW have attention difficulties. Attentive behavior at preschool age is a predictor of school career 2 years later. KEYWORDS. Attention, behavior, children born preterm, educational provision, preterm infant, very low birth weight
Children with a very low birth weight (VLBW) and/or born very preterm, defined as born with a birth weight below 1500 g and/or with a gestation of less than 32 weeks, are at an increased risk of attention problems (Aarnoudse-Moens et al., 2009; Anderson, 2014; Mulder et al., 2009; Van de Weijer Bergsma et al., 2008). Occupational and physical therapists are often involved in the care of children born with VLBW or very preterm (in short: children born with VLBW) (Spittle et al., 2012) because of their motor difficulties (Spittle and Orton, 2014). However, domains do not develop independent of each other. Children’s motor Address correspondence to: Dr. Gijs Verkerk, Department of Rehabilitation, A-01–414, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands (E-mail: [email protected]). (Received 2 July 2014; accepted 18 January 2015)
1
Phys Occup Ther Pediatr Downloaded from informahealthcare.com by RMIT University on 08/17/15 For personal use only.
2
Verkerk et al.
capacity contributes to attention and concentration. Research has shown that motor and attention problems are interrelated, with common neurophysiological substrates (McLeod et al., 2014). Attention is an important regulatory skill needed for information processing and learning (Bronson, 2000; Center on the Developing Child at Harvard University, 2011; Lezak, 2004; Polderman et al., 2010). Attention problems can interfere with performance at school (Center on the Developing Child at Harvard University, 2011; Deutscher and Fewell, 2005; Jaekel et al., 2012; Polderman et al., 2010; Rueda et al., 2010). Early identification of attention problems, therefore, is important to prevent or reduce potential school problems (Larroque et al., 2011). Attention is assessed in young children (3–4 years) by observing the child’s ability to orientate to, shift between, and maintain focus on events, objects, tasks, and problems in the external world (Van de Weijer-Bergsma et al., 2008). Methods used to assess attention of young children include performance-based tests (McGrath et al., 2005; Woodward et al., 2011), questionnaires completed by parents or caretakers (McGrath et al., 2005), and systematic professional observation (McGrath et al., 2005). Different attention assessments may yield different findings. In addition, it is not clear whether the results of attention measurements at preschool age relate to school outcome. The objective of this study was to compare the attention skills of children with VLBW with term born peers with a normal birth weight (NBW) at preschool age from three different viewpoints and analyze the association of attention skills with early school career 2 years later at the age of 5 12 years. We hypothesized that at preschool age, children with VLBW perform less well on attention than children with NBW and that attention skills are positively related to school career at the age of 5 12 years. METHOD Participants Participants were 151 children born with VLBW and 41 children with NBW, all assessed at 44 months corrected age (CA). This age was chosen to investigate the attention skills just before entering school. In the Netherlands, children born with VLBW enter school when they are 48 months old (uncorrected age). For readability, we use the term “3 12 years corrected age” instead of “44 months corrected age.” Children born with VLBW were recruited from a cohort of 176 children who participated in a multicenter randomized controlled trial (RCT) on the effect of an early neurobehavioral intervention (Koldewijn et al., 2009). Infants were recruited from seven hospitals in Amsterdam, the Netherlands from 2003–2006, just before being discharged to home. Eighty-six children received the intervention and 90 children received the standard care. The intervention aimed to support an infant’s selfregulatory competence and developmental functions via responsive parent–infant interactions. Specifically trained pediatric physical therapists provided the intervention at home during 6–8 visits between 0 and 6 months corrected age; see for details Koldewijn et al. (2009). Parents of all 176 children were invited to participate in the follow-up study at 3 12 years corrected age (Verkerk et al., 2011, 2012) and at 5 12 years corrected age (van Hus et al., 2013). Twenty-five children of the
Phys Occup Ther Pediatr Downloaded from informahealthcare.com by RMIT University on 08/17/15 For personal use only.
Attention Assessment in Children Born Very Preterm
3
original cohort (n = 176) dropped out of the study at 3 12 years of age. Reasons for dropping out of the study were death (n = 2), moving abroad (n = 6), lost to followup (n = 6), and parental withdrawal (n = 11). The perinatal characteristics did not differ significantly between the children with VLBW who participated and those who dropped out. However, children with a father born outside the Netherlands discontinued participation significantly more often (p = .002), and children who are first-born continued to participate significantly more frequently (p = .005). A control group of 40 healthy children born at term age and with NBW (in short: children with NBW) was recruited through Amsterdam’s Public Health Service by sending invitations to 200 parents. Inclusion criteria for the NBW group were: being born after ≥37 weeks of gestation and a birth weight of ≥2500 g. To avoid that, parents of children born at term age with developmental problems would like to participate in the study, e.g., as a second opinion, children who were referred to a psychologist, pediatrician, or physician because of developmental or health problems were excluded. Sample size calculation resulted in a group of 40 children born with NBW to be able to detect a difference of 0.5 standard deviation (SD) between the groups on most measurements at the age of 3 12 years with a significance level of .05. Half a SD of change is regarded as a threshold of discrimination for changes in most measurements (Norman et al., 2003). Fifty-seven parents of children born with NBW were willing to participate. Sixteen of these children from highly educated mothers who applied for participation were not invited to ensure a similar distribution with respect to maternal education in both groups. The VLBW and NBW groups (n = 41) had the same proportion of boys (51%), maternal education ≤10 years (36%), and mothers born abroad (39%). The mean age (SD) of the children with NBW (mean calendar age 44 months [0.4]) did not differ significantly from the mean (SD) corrected age of the VLBW group (44 months [0.5]). The Medical Ethics Committee of the Academic Medical Centre, Amsterdam approved this study. Parents provided written informed consent. The perinatal characteristics and the socio-demographic factors of the VLBW group are shown in Table 1. Measures Attention was assessed using two performance tests, three parental questionnaires, and a structured observation of behavior. Performance Tests The children performed the Visual Attention test (VAT) of the Developmental Neuropsychological Assessment (NEPSY) (Korkman et al., 1998) and the Gift Delay test (Kochanska et al., 1996). The VAT records the speed and accuracy with which a child is able to focus selectively on, and maintain attention to, visual targets. The total score was compared with the age-related norm of US children with a mean of 10 (SD = 3). A score below
