Research in Developmental Disabilities 35 (2014) 185–191
Contents lists available at ScienceDirect
Research in Developmental Disabilities
The relationship between multiple developmental difficulties in very low birth weight children at 3½ years of age and the need for learning support at 5 years of age Gijs Verkerk a,*, Martine Jeukens-Visser a, Aleid van Wassenaer-Leemhuis b, Joke Kok b, Frans Nollet a a b
Department of Rehabilitation, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands Department of Neonatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 August 2013 Received in revised form 2 October 2013 Accepted 2 October 2013 Available online 15 November 2013
This study investigated whether multiple developmental difficulties are more frequent in very low birth weight (VLBW) children than in those born full term. The association between multiple developmental difficulties assessed at 3½ years of age and educational provision for the child at 5½ years was also investigated, with ‘educational provision’ referring to the curriculum, school placement and the level of learning support. There were 143 VLBW children without cerebral palsy (CP) and 41 term-born peers assessed at 3½ years of age. The assessment included 6 measures of development: word comprehension, visual motor integration, visual perception, motor coordination, executive functioning and behaviour. Educational provision was determined at age 5½ years. A mildly abnormal score (score 1 difficulty score) in each child. This study showed that at 3½ years of age, the VLBW children had significantly more difficulty with motor coordination than their term-born peers. In addition, 27% of the VLBW children had multiple difficulties compared to 10% in the term-born group. Multiple logistic regression analyses showed that of the difficulties, impaired motor coordination was most strongly associated with the requirement for learning support two years later. Regression analyses showed that having multiple difficulties was significantly associated with the need for learning support (Odds Ratio of 3.4 (95% CI: 1.5–7.8). These results show that the presence of multiple difficulties in a VLBW child of preschool age, can impact the child’s educational provision two years later. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: VLBW Very preterm born Preschool Multiple developmental difficulties Learning support School Education
1. Introduction The number of very low birth weight (VLBW) children with severe neonatal morbidities is decreasing worldwide (Horbar et al., 2012). However, VLBW children are at risk of neurodevelopmental problems. Meta-analyses and reviews show that VLBW children, mainly those 4 years of age, do not perform as well as their term-born peers in domains such as word comprehension (Barre, Morgan, Doyle, & Anderson, 2011), visual motor integration (Geldof, van Wassenaer, de Kieviet,
* Corresponding author at: Department of Rehabilitation, A-01-414, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Tel.: +31 20 5667610; fax: +31 20 5669154. E-mail addresses: [email protected] (G. Verkerk), [email protected] (M. Jeukens-Visser), [email protected] (A. van Wassenaer-Leemhuis), [email protected] (J. Kok), [email protected] (F. Nollet). 0891-4222/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2013.10.007
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Kok, & Oosterlaan, 2012), visual perception (Geldof et al., 2012), motor coordination (De Kieviet, Piek, Aarnoudse-Moens, & Oosterlaan, 2009) and executive functioning (Aarnoudse-Moens, Weisglas-Kuperus, van Goudoever, & Oosterlaan, 2009). VLBW children also have more behavioural difficulties (Hayes & Sharif, 2009). Further, a number of studies show that VLBW children older than 4 years of age are at increased risk of difficulty in multiple developmental domains, with ‘difficulty’ defined as a score 59 (>1 SD) indicate a borderline clinical range (Achenbach & Rescola, 2000) and the presence of a behavioural or emotional functioning difficulty. 2.3.5. Educational provision at 5½ years CA At 5½ years CA, parents were asked about their child’s educational provision, i.e. whether their child was receiving learning support (including whether the child was repeating a school year) and if this was provided in a mainstream or nonmainstream setting (van Hus et al., 2013a). Educational provision was dichotomised in receiving learning support versus following mainstream education. 2.4. Statistical analysis Data were analysed using the Statistical Package for the Social Sciences (SPSS) 16.0 (SPSS Inc., Chicago, IL). Scores on the measures were calculated for the corrected age; age corrected for preterm birth. A score 1) were found significantly more often in VLBW children compared to their term-born peers: 39 (27%) versus 4 (10%), respectively, p = .019. 3.3. Associations with educational provision at 5½ years CA in the VLBW children Assessment data were available at both 3½ years CA and at 5½ years CA for 117 VLBW children. Of these, 77 (66%) participated in mainstream education without any need for learning support, while 40 (34%) received learning support. Of the 40 that received learning support, 31 were required to repeat a school year, and 9 were referred for non-mainstream provision. Table 1 Perinatal and sociodemographic characteristics of the very low birth weight sample (n = 143). Perinatal factors Weeks of gestation, mean (SD) Gestation 10 years, n (%) Maternal age in years, mean (SD) Paternal age in years, mean (SD) Mother born in the Netherlands, n (%) Father born in the Netherlands, n (%) Family status of 2 parents, n (%)
29.9 (2.1) 21 (15) 1284 (338) 36 (25) 25 (18) 39 68 70 35 102
(27) (48) (49) (25) (71)
53.0 (26) 5 (4) 73 (51)
55 (39) 88 (61) 32.2 (5.3) 35.9 (7.1) 86 (60) 86 (60) 122 (85)
a Abnormal ultra sound scan defined as; intra ventricular haemorrhage (IVH), and/or periventricular leukomalacia (PVL) and/or ventricular dilatation. IVH was defined according to Papile, Munsick-Bruno, and Schaefer (1983). PVL was defined according to de Vries, Eken, and Dubowitz (1992).
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Table 2 Number (%) of difficulties (defined as a score 1) developmental difficulties
39 (27)
4 (10)
.019a
(18) (13) (24) (26) (11) (13)
p value: VLBW group compared with term-born group. a Pearson’s chi-square test. b Fisher’s exact test.
Table 3 Association between difficulty (score 1) at 3½ years CA was also significantly associated with the need for learning support at 5½ years CA: OR 3.4 (95% CI: 1.5–7.8), p = .004; Nagelkerke R2, .09 (Table 3). 4. Discussion VLBW children without CP had significantly more impaired motor coordination than their term-born peers at 3½ years CA. Difficulty in the other domains was up to 6 times more frequent in VLBW children compared to their term-born peers, but this was not significant. In addition, 27% of the VLBW children exhibited multiple developmental difficulties across a number of the assessed domains. Having impaired motor coordination and multiple developmental difficulties at 3½
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years CA, before school entry, were each risk factors that could impact a child’s ability to reach his or her learning potential. 4.1. Developmental difficulties In the current study, 27% of the preschool-age VLBW children had multiple developmental difficulties. Previous studies compared VLBW children with their term-born peers with respect to multiple developmental difficulties at higher ages (Potharst et al., 2011; Roberts et al., 2011; van Baar et al., 2005; Woodward et al., 2009). In older children, neurodevelopment is more advanced; thus, difficulties become easier to detect with increasing age. These studies differed from the current study with respect to the gestational age and birth weight of the participants, the number of outcome measures (8), the venue of the assessment and the assessments themselves. Nevertheless, these studies also found that VLBW children significantly more often had multiple difficulties compared to their term-born peers. In the current study, 44% of the VLBW children had no difficulty in the assessed domains at 3½ years CA. At 4 years of age, 38% of assessed VLBW children had no difficulties (Woodward et al., 2009), while two studies reported that 25% (Potharst et al., 2011) and 28% (Roberts et al., 2011) had no difficulties at 5 years of age. These data indicate that in VLBW children, the number of difficulties can increase with increasing age. This was also found in the long-term follow-up of a cohort study of VLBW children assessed at 2, 5, 10 and 14 years of age (Walther et al., 2000). 4.2. Relationship of the presence of multiple difficulties to educational provision In the Netherlands, 2.6% of Dutch children of primary school age (4–12 years) received learning support in either a mainstream or non-mainstream school in 2011 (CBS, 2013). This 2.6% did not include children who repeated a school year. In our study, 7 (6%) of the 117 VLBW children with multiple difficulties required some level of learning support (not including repeating a school year). The need for learning support for VLBW children with multiple difficulties will almost certainly increase as they age (Walther et al., 2000) as the educational demands on a child increase. Coping with multiple difficulties therefore becomes more demanding with increasing age. The findings of the current study show that developmental difficulties can be detected as early as 3½ years CA. The findings also suggest that detection of multiple difficulties in a VLBW child should not rely solely on the assessment of one or two domains or on an extremely abnormal score; rather, it should involve assessment across a number of domains and the detection of several mildly abnormal scores. School readiness includes several areas: physical, cognitive and social competence as well as positive attitudes towards learning (NAEYC, 2009; Patrianakos-Hoobler et al., 2010). The current study assessed only limited aspects of physical competence and cognition. It did not assess social competence or attitudes towards learning. This may be the cause of the limited variance with regard to educational provision as explained by having multiple difficulties, i.e. 9%. In addition, this might also explain why 22 of the 40 (55%) VLBW children who received learning support did not have multiple developmental difficulties. Impaired motor coordination was the most common difficulty in VLBW children. In addition, impaired motor coordination was strongly associated with the need for learning support at 5½ years CA. The motor coordination assessment requires a child to accurately draw lines with pencil on a pre-printed form. This task demands several abilities: understanding the task, following instructions, maintaining a stable sitting posture, visual acuity for seeing the dots and borders on the form, the ability to hold and draw with a pencil, motor planning, sustained visual attention while drawing and persevering with a task even when it is difficult. The clear association between difficulty with motor coordination and the need for increased levels of learning support can be explained by the fact that 19% of the school curriculum for 5-year-old children requires the ability to take part in paper and pencil activities (Marr, Cermak, Cohn, & Henderson, 2003). 4.3. Relevance Our findings suggest that the early identification (at 3½ years CA) of multiple difficulties in VLBW children is important and allows appropriate arrangements to be made for effective school entry. The multiple developmental difficulties that were assessed in the current study are relevant to common preschool activities and to activities that parents may be particularly willing to do with their child (Haertl, 2010). Helping parents provide an environment/structure that supports their child’s development and mitigates behavioural problems during routine preschool activities will almost certainly help prepare a child for school entry. Specifically, impaired motor coordination can be addressed using play/exercise books that require the use of fine motor skills. However, more research is needed to clarify which interventions best support schoolreadiness in VLBW children with multiple developmental difficulties. 4.4. Limitations One limitation of this study is that the assessor was aware of whether a child was VLBW or term born prior to the home assessment. However, the assessment protocols were strictly adhered to. Another limitation is that there were no educational data for 27 VLBW children and for the term-born peers.
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5. Conclusions Compared to their term-born peers, significantly more VLBW children, not diagnosed with CP, had multiple developmental difficulties at 3½ years CA just before they started school. In addition, impaired motor coordination or the presence of multiple developmental difficulties could impact a child’s ability to reach his or her learning potential. Sources of support This study was supported by grants from Innovatiefonds Zorgverzekeraars (project number 576) and from the Netherlands Organisation for Health Research and Development; ZonMw project number 62200032. References Aarnoudse-Moens, C. S., Weisglas-Kuperus, N., van Goudoever, J. B., & Oosterlaan, J. (2009). Meta-analysis of neurobehavioral outcomes in very preterm and/or very low birth weight children. Pediatrics, 124, 717–728. Achenbach, T. M., & Rescorla, L. A. (2000). Manual for the ASEBA preschool forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. ASEBA. (2013). Achenbach System of Empirically Based Assessment. Available at: http://www.aseba.nl Accessed June 2013. Barre, N., Morgan, A., Doyle, L. W., & Anderson, P. J. (2011). Language abilities in children who were very preterm and/or very low birth weight: A meta-analysis. The Journal of Pediatrics, 158, 766–774. Bax, M., Goldstein, M., Rosenbaum, P., Leviton, A., Paneth, N., Dan, B., et al. (2005). Proposed definition and classification of cerebral palsy, April 2005. Developmental Medicine & Child Neurology, 47, 571–576. Beery, K. E., & Beery, N. A. (2006). The Beery-Buktenica developmental test of visual-motor integration, Beery VMI, with supplemental developmental tests of visual perception and motor coordination, administration, scoring and teaching manual (5th ed.). Minneapolis: Pearson Assessments. CBS. (2013). Centraal Bureau voor de Statistiek. Available at: http://www.cbs.nl Accessed June 2013. De Kieviet, J. F., Piek, J. P., Aarnoudse-Moens, C. S., & Oosterlaan, J. (2009). Motor development in very preterm and very low birth weight children from birth to adolescence: A meta-analysis. The Journal of the American Medical Association, 302, 2235–2242. de Vries, L. S., Eken, P., & Dubowitz, L. M. (1992). The spectrum of leukomalacia using cranial ultrasound. Behavioral Brain Research, 49, 1–6. Geldof, C. J. A., van Wassenaer, A. G., De Kieviet, J. F., Kok, J. H., & Oosterlaan, J. (2012). Visual perception and visual-motor integration in very pretem and or very low birth weight children: A meta-analysis. Research in Developmental Disabilities, 33, 726–736. Gioia, G. A., Espy, K. A., & Isquith, P. K. (2003). BRIEF-P Behavior Rating Inventory of executive function-preschool version. Lutz: PAR Psychological Assessment Resources Inc. Gioia, G. A., Espy, K. A., & Isquith, P. K. (2007). Dutch version of BRIEF-P Behavior Rating Inventory of executive function-preschool version. Dutch translation; Smidts, D. P. & Sergeant, J. A.. Lutz: PAR Psychological Assessment Resources Inc. Haertl, K. (2010). A frame of Reference to Enhance Childhood Occupations: SCOPE-IT. In P. Kramer & J. Hinojosa (Eds.), Frames of reference for pediatric occupational therapy (3rd ed., pp. 266–305). Baltimore: Lippincott Williams & Wilkins. Hayes, B., & Sharif, F. (2009). Behavioural and emotional outcome of very low birth weight infants-literature review. Journal of Maternal and Fetal Neonatalogy Medicine, 22, 849–856. Hedlund, R. (2013). The infant behavioral assessment and intervention program ß1998. Kansas, USA: Publication available from IBAIP International Training Center, R., Hedlund, Lawrence. Available at: http://www.ibaip.org Accessed June 2013. Horbar, J. D., Carpenter, J. H., Badger, G. J., Kenny, M. J., Soll, R. F., Morrow, K. A., et al. (2012). Mortality and neonatal morbidity among infants 501 to 1500 grams from 2000 to 2009. Pediatrics, 129, 1019–1026. Hornby, G., & Woodward, L. J. (2009). Educational needs of school-aged children born very and extremely preterm: A review. Educational Psychology Review, 21, 247–266. Koldewijn, K., Wolf, M. J., van Wassenaer, A., Meijssen, D., van Sonderen, L., van Baar, A., et al. (2009). The Infant Behavioral Assessment and Intervention Program for very low birth weight infants at 6 months corrected age. The Journal of Pediatrics, 154, 33–38. Koldewijn, K., van Wassenaer, A., Wolf, M. J., Meijssen, D., Houtzager, B., Beelen, A., et al. (2010). A neurobehavioral intervention and assessment program in very low birth weight infants: Outcome at 24 months. The Journal of Pediatrics, 156, 359–365. Marr, D., Cermak, C., Cohn, E., & Henderson, A. (2003). Fine motor activities in head start and kindergarten classrooms. The American Journal of Occupational Therapy, 57, 550–557. NAEYC. (2009). The National Association for the Education of Young Children. Where we stand on school readiness. Available at: www.naeyc.org/positionstatements/ school_readiness Accessed June 2013. Papile, L. A., Munsick-Bruno, G., & Schaefer, A. (1983). Relationship of cerebral intraventricular hemorrhage and early childhood neurologic handicaps. The Journal of Pediatrics, 103, 273–277. Patrianakos-Hoobler, A. L., Msall, M. E., Huo, D., Marks, J. D., Plesha-Troyke, S., & Schreiber, M. D. (2010). Predicting school readiness from neurodevelopmental assessments at age 2 years after respiratory distress syndrome in infants born preterm. Developmental Medicine & Child Neurology, 52, 379–385. Potharst, E. S., van Wassenaer, A. G., Houtzager, B. A., van Hus, J. W. P., Last, B. F., & Kok, J. H. (2011). High incidence of multi-domain disabilities in very preterm children at five years of age. The Journal of Pediatrics, 159, 79–85. Roberts, G., Lim, J., Doyle, L. W., & Anderson, P. J. (2011). High rates of school readiness difficulties in very preterm infants compared with term controls. Journal of Developmental & Behavioral Pediatrics, 32, 117–124. Schlichting, L. (2005). Peabody Picture Vocabulary Test-III-NL, Nederlandse versie. Amsterdam: Harcourt Test Publishers. van Baar, A. L., van Wassenaer, A. G., Brie¨t, J. M., Dekker, F. W., & Kok, J. H. (2005). Very preterm birth is associated with disabilities in multiple developmental domains. Journal of Pediatric Psychology, 30, 247–255. van Hus, J. W. P., Jeukens-Visser, M., Koldewijn, K., Geldof, C. J. A., Kok, J. H., Nollet, F., et al. (2013). Sustained developmental effects of the infant behavioral assessment and intervention program in very low birth weight infants at 5.5 years. The Journal of Pediatrics, 162, 1112–1119. van Hus, J. W. P., Jeukens-Visser, M., Koldewijn, K., van Sonderen, L., Kok, J. H., Nollet, F., et al. (2013). Comparing two motor assessment tools to evaluate neurobehavioral intervention effects in very low birth weight infants at 1 year. Physical Therapy June: (Epub ahead of print). Verkerk, G., Jeukens-Visser, M., Houtzager, B., Koldewijn, K., van Wassenaer, A., Nollet, F., et al. (2012). The infant behavioral assessment and intervention program in very low birth weight infants; outcome on executive functioning, behaviour and cognition at preschool age. Early Human Development, 88, 699–705. Walther, F. J., den Ouden, A. L., & Verloove-Vanhorick, S. P. (2000). Looking back in time: Outcome of a national cohort of very pretem infants born in the Netherlands in 1983. Early Human Development, 59, 175–191. Woodward, L. J., Moor, S., Hood, K. M., Champion, P. R., Foster-Cohen, S., Inder, T. E., et al. (2009). Very preterm children show impairments across multiple neurodevelopmental domains by age 4 years. Archives of Disease in Childhood. Fetal and Neonatal Edition, 94, F339–F344.
Contents lists available at ScienceDirect
Research in Developmental Disabilities
The relationship between multiple developmental difficulties in very low birth weight children at 3½ years of age and the need for learning support at 5 years of age Gijs Verkerk a,*, Martine Jeukens-Visser a, Aleid van Wassenaer-Leemhuis b, Joke Kok b, Frans Nollet a a b
Department of Rehabilitation, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands Department of Neonatology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
A R T I C L E I N F O
A B S T R A C T
Article history: Received 20 August 2013 Received in revised form 2 October 2013 Accepted 2 October 2013 Available online 15 November 2013
This study investigated whether multiple developmental difficulties are more frequent in very low birth weight (VLBW) children than in those born full term. The association between multiple developmental difficulties assessed at 3½ years of age and educational provision for the child at 5½ years was also investigated, with ‘educational provision’ referring to the curriculum, school placement and the level of learning support. There were 143 VLBW children without cerebral palsy (CP) and 41 term-born peers assessed at 3½ years of age. The assessment included 6 measures of development: word comprehension, visual motor integration, visual perception, motor coordination, executive functioning and behaviour. Educational provision was determined at age 5½ years. A mildly abnormal score (score 1 difficulty score) in each child. This study showed that at 3½ years of age, the VLBW children had significantly more difficulty with motor coordination than their term-born peers. In addition, 27% of the VLBW children had multiple difficulties compared to 10% in the term-born group. Multiple logistic regression analyses showed that of the difficulties, impaired motor coordination was most strongly associated with the requirement for learning support two years later. Regression analyses showed that having multiple difficulties was significantly associated with the need for learning support (Odds Ratio of 3.4 (95% CI: 1.5–7.8). These results show that the presence of multiple difficulties in a VLBW child of preschool age, can impact the child’s educational provision two years later. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: VLBW Very preterm born Preschool Multiple developmental difficulties Learning support School Education
1. Introduction The number of very low birth weight (VLBW) children with severe neonatal morbidities is decreasing worldwide (Horbar et al., 2012). However, VLBW children are at risk of neurodevelopmental problems. Meta-analyses and reviews show that VLBW children, mainly those 4 years of age, do not perform as well as their term-born peers in domains such as word comprehension (Barre, Morgan, Doyle, & Anderson, 2011), visual motor integration (Geldof, van Wassenaer, de Kieviet,
* Corresponding author at: Department of Rehabilitation, A-01-414, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands. Tel.: +31 20 5667610; fax: +31 20 5669154. E-mail addresses: [email protected] (G. Verkerk), [email protected] (M. Jeukens-Visser), [email protected] (A. van Wassenaer-Leemhuis), [email protected] (J. Kok), [email protected] (F. Nollet). 0891-4222/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ridd.2013.10.007
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Kok, & Oosterlaan, 2012), visual perception (Geldof et al., 2012), motor coordination (De Kieviet, Piek, Aarnoudse-Moens, & Oosterlaan, 2009) and executive functioning (Aarnoudse-Moens, Weisglas-Kuperus, van Goudoever, & Oosterlaan, 2009). VLBW children also have more behavioural difficulties (Hayes & Sharif, 2009). Further, a number of studies show that VLBW children older than 4 years of age are at increased risk of difficulty in multiple developmental domains, with ‘difficulty’ defined as a score 59 (>1 SD) indicate a borderline clinical range (Achenbach & Rescola, 2000) and the presence of a behavioural or emotional functioning difficulty. 2.3.5. Educational provision at 5½ years CA At 5½ years CA, parents were asked about their child’s educational provision, i.e. whether their child was receiving learning support (including whether the child was repeating a school year) and if this was provided in a mainstream or nonmainstream setting (van Hus et al., 2013a). Educational provision was dichotomised in receiving learning support versus following mainstream education. 2.4. Statistical analysis Data were analysed using the Statistical Package for the Social Sciences (SPSS) 16.0 (SPSS Inc., Chicago, IL). Scores on the measures were calculated for the corrected age; age corrected for preterm birth. A score 1) were found significantly more often in VLBW children compared to their term-born peers: 39 (27%) versus 4 (10%), respectively, p = .019. 3.3. Associations with educational provision at 5½ years CA in the VLBW children Assessment data were available at both 3½ years CA and at 5½ years CA for 117 VLBW children. Of these, 77 (66%) participated in mainstream education without any need for learning support, while 40 (34%) received learning support. Of the 40 that received learning support, 31 were required to repeat a school year, and 9 were referred for non-mainstream provision. Table 1 Perinatal and sociodemographic characteristics of the very low birth weight sample (n = 143). Perinatal factors Weeks of gestation, mean (SD) Gestation 10 years, n (%) Maternal age in years, mean (SD) Paternal age in years, mean (SD) Mother born in the Netherlands, n (%) Father born in the Netherlands, n (%) Family status of 2 parents, n (%)
29.9 (2.1) 21 (15) 1284 (338) 36 (25) 25 (18) 39 68 70 35 102
(27) (48) (49) (25) (71)
53.0 (26) 5 (4) 73 (51)
55 (39) 88 (61) 32.2 (5.3) 35.9 (7.1) 86 (60) 86 (60) 122 (85)
a Abnormal ultra sound scan defined as; intra ventricular haemorrhage (IVH), and/or periventricular leukomalacia (PVL) and/or ventricular dilatation. IVH was defined according to Papile, Munsick-Bruno, and Schaefer (1983). PVL was defined according to de Vries, Eken, and Dubowitz (1992).
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Table 2 Number (%) of difficulties (defined as a score 1) developmental difficulties
39 (27)
4 (10)
.019a
(18) (13) (24) (26) (11) (13)
p value: VLBW group compared with term-born group. a Pearson’s chi-square test. b Fisher’s exact test.
Table 3 Association between difficulty (score 1) at 3½ years CA was also significantly associated with the need for learning support at 5½ years CA: OR 3.4 (95% CI: 1.5–7.8), p = .004; Nagelkerke R2, .09 (Table 3). 4. Discussion VLBW children without CP had significantly more impaired motor coordination than their term-born peers at 3½ years CA. Difficulty in the other domains was up to 6 times more frequent in VLBW children compared to their term-born peers, but this was not significant. In addition, 27% of the VLBW children exhibited multiple developmental difficulties across a number of the assessed domains. Having impaired motor coordination and multiple developmental difficulties at 3½
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years CA, before school entry, were each risk factors that could impact a child’s ability to reach his or her learning potential. 4.1. Developmental difficulties In the current study, 27% of the preschool-age VLBW children had multiple developmental difficulties. Previous studies compared VLBW children with their term-born peers with respect to multiple developmental difficulties at higher ages (Potharst et al., 2011; Roberts et al., 2011; van Baar et al., 2005; Woodward et al., 2009). In older children, neurodevelopment is more advanced; thus, difficulties become easier to detect with increasing age. These studies differed from the current study with respect to the gestational age and birth weight of the participants, the number of outcome measures (8), the venue of the assessment and the assessments themselves. Nevertheless, these studies also found that VLBW children significantly more often had multiple difficulties compared to their term-born peers. In the current study, 44% of the VLBW children had no difficulty in the assessed domains at 3½ years CA. At 4 years of age, 38% of assessed VLBW children had no difficulties (Woodward et al., 2009), while two studies reported that 25% (Potharst et al., 2011) and 28% (Roberts et al., 2011) had no difficulties at 5 years of age. These data indicate that in VLBW children, the number of difficulties can increase with increasing age. This was also found in the long-term follow-up of a cohort study of VLBW children assessed at 2, 5, 10 and 14 years of age (Walther et al., 2000). 4.2. Relationship of the presence of multiple difficulties to educational provision In the Netherlands, 2.6% of Dutch children of primary school age (4–12 years) received learning support in either a mainstream or non-mainstream school in 2011 (CBS, 2013). This 2.6% did not include children who repeated a school year. In our study, 7 (6%) of the 117 VLBW children with multiple difficulties required some level of learning support (not including repeating a school year). The need for learning support for VLBW children with multiple difficulties will almost certainly increase as they age (Walther et al., 2000) as the educational demands on a child increase. Coping with multiple difficulties therefore becomes more demanding with increasing age. The findings of the current study show that developmental difficulties can be detected as early as 3½ years CA. The findings also suggest that detection of multiple difficulties in a VLBW child should not rely solely on the assessment of one or two domains or on an extremely abnormal score; rather, it should involve assessment across a number of domains and the detection of several mildly abnormal scores. School readiness includes several areas: physical, cognitive and social competence as well as positive attitudes towards learning (NAEYC, 2009; Patrianakos-Hoobler et al., 2010). The current study assessed only limited aspects of physical competence and cognition. It did not assess social competence or attitudes towards learning. This may be the cause of the limited variance with regard to educational provision as explained by having multiple difficulties, i.e. 9%. In addition, this might also explain why 22 of the 40 (55%) VLBW children who received learning support did not have multiple developmental difficulties. Impaired motor coordination was the most common difficulty in VLBW children. In addition, impaired motor coordination was strongly associated with the need for learning support at 5½ years CA. The motor coordination assessment requires a child to accurately draw lines with pencil on a pre-printed form. This task demands several abilities: understanding the task, following instructions, maintaining a stable sitting posture, visual acuity for seeing the dots and borders on the form, the ability to hold and draw with a pencil, motor planning, sustained visual attention while drawing and persevering with a task even when it is difficult. The clear association between difficulty with motor coordination and the need for increased levels of learning support can be explained by the fact that 19% of the school curriculum for 5-year-old children requires the ability to take part in paper and pencil activities (Marr, Cermak, Cohn, & Henderson, 2003). 4.3. Relevance Our findings suggest that the early identification (at 3½ years CA) of multiple difficulties in VLBW children is important and allows appropriate arrangements to be made for effective school entry. The multiple developmental difficulties that were assessed in the current study are relevant to common preschool activities and to activities that parents may be particularly willing to do with their child (Haertl, 2010). Helping parents provide an environment/structure that supports their child’s development and mitigates behavioural problems during routine preschool activities will almost certainly help prepare a child for school entry. Specifically, impaired motor coordination can be addressed using play/exercise books that require the use of fine motor skills. However, more research is needed to clarify which interventions best support schoolreadiness in VLBW children with multiple developmental difficulties. 4.4. Limitations One limitation of this study is that the assessor was aware of whether a child was VLBW or term born prior to the home assessment. However, the assessment protocols were strictly adhered to. Another limitation is that there were no educational data for 27 VLBW children and for the term-born peers.
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5. Conclusions Compared to their term-born peers, significantly more VLBW children, not diagnosed with CP, had multiple developmental difficulties at 3½ years CA just before they started school. In addition, impaired motor coordination or the presence of multiple developmental difficulties could impact a child’s ability to reach his or her learning potential. Sources of support This study was supported by grants from Innovatiefonds Zorgverzekeraars (project number 576) and from the Netherlands Organisation for Health Research and Development; ZonMw project number 62200032. References Aarnoudse-Moens, C. S., Weisglas-Kuperus, N., van Goudoever, J. B., & Oosterlaan, J. (2009). Meta-analysis of neurobehavioral outcomes in very preterm and/or very low birth weight children. Pediatrics, 124, 717–728. Achenbach, T. M., & Rescorla, L. A. (2000). Manual for the ASEBA preschool forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. ASEBA. 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