Scandinavian Journal of Occupational Therapy. 2014; 21: 191–198

ORIGINAL ARTICLE

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Factors related to cognitive function among elementary school children

FIDAA ALMOMANI1, NAOMI JOSMAN2, MURAD O. AL-MOMANI3, SOMAYAH H. MALKAWI4, MOHAMMAD NAZZAL1, KHADER A. ALMAHDAWI1 & FATEN ALMOMANI5 1

Jordan University of Science and Technology, Faculty of Applied Medical Sciences, Department of Rehabilitation Sciences, Jordan, 2University of Haifa, Faculty of social welfare and health services, Department of occupational therapy, Israel, 3King Saud University, School of medicine, Saudi Arabia, 4University of Jordan, Rehabilitation Sciences Faculty, Amman, Jordan, and 5Yarmouk University, Irbid, Jordan

Abstract Objective: The purpose of this study was to investigate cognitive functioning among elementary school children in Jordan. Methods: A total of 468 children aged 6–12 years were recruited to participate in this study. Cognitive functioning was assessed using the LOTCA battery (Loewenstein Occupational Therapy Cognitive Assessment; Itzkovich et al., 2000). Information obtained from the parents included demographics, work and income data and child’s daily behavior and school achievement. Results: The results of this study showed that the cognitive functioning increased by 3.8 points for each increase in the child’s GPA and increased by 2.35 points when the child ate breakfast regularly. By contrast, living in rural areas and smoking by a parent decreased cognitive functioning. Conclusions: Understanding of the child’s cognitive abilities is critical to establishing intervention goals and to planning therapeutic activities. Screening of cognitive abilities and associated factors is essential for a comprehensive and accurate understanding of the child’s abilities and limitations. Further research is recommended to investigate other factors in different populations.

Key words: socio-demographic factors and school achievement, school based occupational therapy, Loewenstein Occupational Therapy Cognitive Assessment (LOTCA), cognitive performance

Introduction Cognitive abilities refer to the mental skills that are essential to everyday functioning, including work, play, and leisure activities, as well as daily self-care (1). These skills enable individuals to know, be aware, think, conceptualize, use abstractions, reason, criticize, and be creative, as well as acquire, interpret, organize, store, retrieve, and employ information (1–4). Moreover, cognitive abilities are associated with an individual’s capacity to adapt to environmental demands (5). These abilities develop in sequentially, meaning that as children grow their thinking processes continually advance (5).

A fundamental concept in psychological processing theory demonstrates that children vary in their underlying cognitive abilities to process and use information (6). These differences affect a child’s learning and academic performance (6). Indeed, the critical importance of the early childhood years to cognitive growth and later success is becoming increasingly evident (1). Not only does cognitive performance predict school readiness and success, but also some cognitive abilities (e.g. reading and mathematical skills) strengthen in school (1,2). Therefore, the assessment of children’s cognitive performance components may provide a more basic

Correspondence: Fidaa Almomani, PhD, Assistant Professor, Department of Rehabilitation Sciences, Faculty of Applied Medical Sciences, Jordan University of Science and Technology, Irbid 22110, Jordan. Tel: +962 2 7201000, Tel: ext. 23773. Fax: +962 2 7201087. E-mail: [email protected]; [email protected] (Received 5 August 2013; accepted 4 October 2013) ISSN 1103-8128 print/ISSN 1651-2014 online  2014 Informa Healthcare DOI: 10.3109/11038128.2013.853098

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understanding of their abilities and disabilities in school performance (7). Early detection of high-risk children and those with special needs makes it possible to provide appropriate intervention during early learning years (4). Early childhood intervention can effectively increase children’s cognitive abilities and improve their academic performance (1,2,4). Several factors such as age, gender, socioeconomic status, parents’ education level, school setting, area of residence, birth order, nicotine exposure, and culture can affect children’s cognitive abilities and their academic performance (8–10). Therefore, early diagnosis and detection of cognitive disabilities among schoolchildren, both those who are typically developed and those with special needs, is a necessary step for early intervention. With early identification and treatment, many conditions and problems can be addressed so as to enable children to live a better life (4,11–16). Generally, there are several assessments and screening instruments used by therapists and researchers in the area of cognitive abilities (2,17), including the Kaufman Assessment Battery for Children (18), the Behavior Rating Inventory of Executive Function (19), and the Woodcock-Johnson Tests of Cognitive Abilities (20). However, to our knowledge, these instruments have not been validated and examined for their suitability to the Jordanian population. The Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) battery is an example of a cognitive instrument that was developed in Israel and designed to be used by occupational therapists working in neurological rehabilitation (3). This instrument was first published in 1990, modified in 1996 and later adapted for use with children aged 6–12 years (3). The test has excellent intra-rater reliability (100%), and good inter-rater reliability (86%) as well as criterion validity (78%) (3). This LOTCA test was chosen because of its psychometric properties and primarily non-verbal nature, making it potentially more suitable for evaluating the cognitive abilities of individuals from non-Western and nonEnglish-speaking cultures. Several studies have been conducted using this instrument in both Western (3) and Arab populations (1,2). Material and methods Subjects Participants were 468 typically developed children aged 6–12 years, who were enrolled in either public or private schools. Recruitment was conducted via random distribution of 540 leaflets to schoolchildren the day before data collection and testing. The leaflets contained a description of the study, information regarding the child needed from the parents (e.g.

child’s date of birth, known disorders or disabilities, annual family income [low, middle, high, or very high], and whether the mother or father smokes [smokes more than 10 cigarettes inside the home for more than three years], or work [works outside home or does paid work]) and a parental consent form. Children with known developmental, learning, or neurological/sensory disabilities, as reported by the teacher and/or the parents, were excluded. Of the 548 leaflet recipients, only 50 families refused to participate and 30 children were found to be ineligible to participate. Procedure Approval for conducting this study was obtained from the Institution of Research Board (IRB) at King Abdullah University Hospital and the Deanship of Scientific Research at Jordan University of Science and Technology in Jordan. Written parental consent and approval from the educational authorities were received prior to carrying out the study. After receiving the signed parental consent, trained research assistants assessed the cognitive abilities of the children using the LOTCA. The research assistants (occupational therapists, hearing and speech therapists, and school counselors) were trained by the principal investigator on how to collect data as well as administer and score the LOTCA battery. In order to obtain inter-rater reliability between research assistants, the principal investigator and the research assistants assessed and scored the same group of 20 children (10 males and 10 females aged 6–12 years) until 98% compatibility of the results was achieved between all of them. All children were assessed in a quiet environment within the school. Parents were not present during testing. Assessments were conducted between 8 a.m. and 10 a.m. or 11 a.m. and 1 p.m. (i.e. before or after school recess). Assessments required between 45 and 90 minutes. Instrument The LOTCA consists of seven major domains divided into 26 subtests, with each subtest scored on a four- or five-point Likert scale. The separate categories and their composite scoring were as follows: (i) orientation to time and place (scores ranging from 1 to 8); (ii) visual perception, which includes six subtests for visual perception of shapes and objects, figure– ground perception, object constancy, spatial perception, and praxis (scores ranging from 6 to 24); (iii) spatial perception, which includes three subtests for directions on child’s body, spatial relations, and spatial relations on pictures (scores ranging from 3 to 12); (iv) motor praxis, which includes three

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Cognitive function in children subtests for motor imitations, utilization of objects, and symbolic actions (scores ranging from 3 to 12); (v) visuo-motor organization, which examines perceptual-motor integration with spatial components, including seven subtests for copying of geometric forms, reproduction of two- and threedimensional models, pegboard construction, colored and plain block design, reproduction of a puzzle, and drawing of a clock (scores ranging from 7 to 28); (vi) thinking operations, which examines categorization and sequencing, including seven subtests for pictorial classification, object classification – both structured and unstructured – pictorial sequencing, and geometrical sequencing (scores ranging from 7 to 35); and (vii) attention and concentration (scores ranging from 1 to 4). Results are presented as a profile along all subtests. A composite score for each domain was calculated by summing the scores of the relevant subtests. The LOTCA score was calculated by summing the scores of all subtests. The maximum score on the test is 123, and the minimum score is 27. A higher score indicates better cognitive performance. The mean LOTCA score for the study sample (n = 466) was 100.90, the median LOTCA score was 102.20, and the standard deviation was 12.29.

rural areas (48% urban), and public vs. private schools (49% in public schools). The majority (96.2%) of the subjects lived with both parents, and 46.4% of the parents had a yearly family income of less than JD 6 000 (low income). More than twothirds (69.4%) of the subjects reported that they ate breakfast before going to school, and about 90% had a GPA range of 80 to 100. As presented in Table II, the majority (64.7%) of the mothers were not employed outside the home and Table I. Socio-demographic and personal data for the study sample (n = 468). n (%)

256 (54.7)

6–9

212 (45.3)

10–12

9.16 ± 1.9

Table I shows the distribution of socio-demographic variables in the study sample. Of the 468 children enrolled in the study, the ages ranged from 6 to 12 years with a mean of 9 years and 2 months and a standard deviation (SD) of 1 year and 10 months. The sample was almost equally divided between males and females (52% males), urban vs.

Mean ± SD Gender:

243 (51.9) 225 (48.1)

Male Female Area of residence:

225 (48.1)

Urban

243 (51.9)

Rural School type:

231 (49.1)

Results

Variable Age (years):

Data processing and statistical analysis Statistical analysis was performed by SPSS 19. Frequency distributions for the demographic variables were calculated. Multivariate linear regression model analysis, analyzing the association between explanatory (predictor) and outcome variables, was performed to test the association of the outcomes (cognitive functioning) with the independent variables included in the model. These variables included: child’s age, birth order, child’s academic grade point average (GPA), area of residence, eating breakfast, number of hours of sleep, father’s smoking status, mother’s smoking status, mother’s occupation, father’s occupation, father’s education, and annual family income in Jordan Dinar (JD). Using the backward elimination method, all the possible variables were entered into the model.

193

237 (50.6)

Public Private Lives with both parents:

450 (96.2)

Yes

18 (3.8)

No GPA:

1 (0.2)

Factors related to cognitive function among elementary school children.

The purpose of this study was to investigate cognitive functioning among elementary school children in Jordan...
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