H. Gerry Taylor

School-age outcomes in children with birth weights under 750 g.

Background Since the mid-1980s, increasing numbers of children with birth weights under 750 g have survived to school age. Methods We matched a regional cohort of 68 surviving children born from 1982 through 1986 with birth weights under 750 g (mean, 670 g; gestational age, 25.7 weeks) with 65 children weighing 750 to 1499 g at birth and 61 children born at term. Growth, neurosensory status, and functioning at school age in the three groups were compared. Associations of biologic and social risk factors with major developmental outcomes were examined by means of logistic-regression analyses. Results Children with birth weights under 750 g were inferior to both comparison groups in cognitive ability, psychomotor skills, and academic achievement. They had poorer social skills and adaptive behavior and more behavioral and attention problems. The mean (±SD) Mental Processing Composite score for the cohort was 87 ±15, as compared with 93 ±14 for children with birth weights of 750 to 1499 g and 100 ±13 for chil...

Poor predictive validity of the Bayley Scales of Infant Development for cognitive function of extremely low birth weight children at school age.

Objective. The Bayley Scales of Infant Development, Second Edition (BSID II) are commonly used to assess outcomes of extremely low birth weight (ELBW) infants. We sought to assess the predictive validity of the BSID II Mental Developmental Index (MDI) for cognitive function at school age. Design/Methods. Of 330 ELBW infants admitted in 1992–1995, 238 (72%) survived to the age of 8 years, of whom 200 (84%) were tested at both 20 months’ corrected age (CA) and 8 years. Mean birth weight was 811 g, mean gestational age was 26.4 weeks, 41% were boys, and 60% were black. Measures included the BSID II at 20 months’ CA and the Kaufman Assessment Battery for Children (KABC) Mental Processing Composite (MPC) at 8 years’ postnatal age. BSID II MDI and MPC scores were compared and the predictive validity calculated for all 200 ELBW children and for the 154 ELBW neurosensory-intact subgroup. Predictors of stability or change in cognitive scores were examined via logistic regression adjusting for gender and sociodemographic status. Results. For all ELBW children, the mean MDI was 75.6 ± 16 versus a mean KABC of 87.8 ± 19. For the neurosensory-intact subgroup, the mean MDI was 79.3 ± 16 and the mean KABC was 92.3 ± 15. Rates of cognitive impairment, defined as an MDI or KABC of <70, dropped from 39% at 20 months’ CA to 16% at 8 years for the total ELBW population and from 29% to 7% for the neurosensory-intact subgroup. The positive predictive value of having an MPC of <70 given an MDI of <70 was 0.37 (95% confidence interval [CI]: 0.27, 0.49) for all ELBW infants, 0.20 (95% CI: 0.10, 0.35) for the neurosensory-intact subgroup, and 0.61 (95% CI: 0.42, 0.77) for the neurosensory-impaired subgroup. The negative predictive values were 0.98, 0.99, and 0.85 for the 3 groups, respectively. Neurosensory impairment at 20 months’ CA predicted lack of improvement of cognitive function (odds ratio: 6.9; 95% CI: 2.4, 20.2). Children whose cognitive scores improved between 20 months and 8 years had significantly better school performance than those whose scores stayed at <70, but they did less well than those whose scores were persistently >70. Conclusions. The predictive validity of a subnormal MDI for cognitive function at school age is poor but better for ELBW children who have neurosensory impairments. We are concerned that decisions to provide intensive care for ELBW infants in the delivery room might be biased by reported high rates of cognitive impairments based on the use and presumptive validity of the BSID II MDI.

A randomized trial of adenotonsillectomy for childhood sleep apnea.

BACKGROUND Adenotonsillectomy is commonly performed in children with the obstructive sleep apnea syndrome, yet its usefulness in reducing symptoms and improving cognition, behavior, quality of life, and polysomnographic findings has not been rigorously evaluated. We hypothesized that, in children with the obstructive sleep apnea syndrome without prolonged oxyhemoglobin desaturation, early adenotonsillectomy, as compared with watchful waiting with supportive care, would result in improved outcomes. METHODS We randomly assigned 464 children, 5 to 9 years of age, with the obstructive sleep apnea syndrome to early adenotonsillectomy or a strategy of watchful waiting. Polysomnographic, cognitive, behavioral, and health outcomes were assessed at baseline and at 7 months. RESULTS The average baseline value for the primary outcome, the attention and executive-function score on the Developmental Neuropsychological Assessment (with scores ranging from 50 to 150 and higher scores indicating better functioning), was close to the population mean of 100, and the change from baseline to follow-up did not differ significantly according to study group (mean [±SD] improvement, 7.1±13.9 in the early-adenotonsillectomy group and 5.1±13.4 in the watchful-waiting group; P=0.16). In contrast, there were significantly greater improvements in behavioral, quality-of-life, and polysomnographic findings and significantly greater reduction in symptoms in the early-adenotonsillectomy group than in the watchful-waiting group. Normalization of polysomnographic findings was observed in a larger proportion of children in the early-adenotonsillectomy group than in the watchful-waiting group (79% vs. 46%). CONCLUSIONS As compared with a strategy of watchful waiting, surgical treatment for the obstructive sleep apnea syndrome in school-age children did not significantly improve attention or executive function as measured by neuropsychological testing but did reduce symptoms and improve secondary outcomes of behavior, quality of life, and polysomnographic findings, thus providing evidence of beneficial effects of early adenotonsillectomy. (Funded by the National Institutes of Health; CHAT ClinicalTrials.gov number, NCT00560859.).

Behavioral outcomes and evidence of psychopathology among very low birth weight infants at age 20 years.

Objective. Information on the mental health of very low birth weight (VLBW; <1500 g) children in young adulthood is sparse. We thus sought to examine gender-specific behavioral outcomes and evidence of psychopathology in a cohort of VLBW young adults at 20 years of age. Methods. We compared a cohort of 241 survivors among VLBW infants who were born between 1977 and 1979 (mean birth weight: 1180 g; mean gestational age at birth: 29.7 weeks), 116 of whom were men and 125 of whom were women, with 233 control subjects from the same population in Cleveland who had normal birth weights (108 men and 124 women). Young adult behavior was assessed at 20 years of age with the Achenbach Young Adult Self-Report and the Young Adult Behavior Checklist for parents. In addition, the young adults and parents completed the ADHD Rating Scale for Adults. Gender-specific outcomes were adjusted for sociodemographic status. Results. VLBW men reported having significantly fewer delinquent behaviors than normal birth weight (NBW) control subjects, but there were no differences on the Internalizing, Externalizing, or Total Problem Behavior scales. Parents of VLBW men reported significantly more thought problems for their sons than did parents of control subjects. VLBW women reported significantly more withdrawn behaviors and fewer delinquent behavior problems than control subjects. Their rates of internalizing behaviors (which includes anxious/depressed and withdrawn behaviors) above the borderline clinical cutoff were 30% versus 16% (odds ratio: 2.2; 95% confidence interval [CI]: 1.2-4.1). Parents of VLBW women reported significantly higher scores for their daughters on the anxious/depressed, withdrawn, and attention problem subscales compared with control parents. The odds ratios for parent-reported rates above the borderline-clinical cutoff among women for the anxious/depressed subscale was 4.4 (95% CI: 1.4-13.5), for thought problems was 3.7 (95% CI: 1.2-11.6), and for attention problems was 2.4 (95% CI: 1.0-5.5). There were no differences in the young adult self-report of attention-deficit/hyperactivity disorder (ADHD). Parents of VLBW men reported higher mean scores on the attention subtype of ADHD but not higher rates of ADHD. Conclusion. The increase in psychopathology among VLBW survivors in young adulthood indicates a need for anticipatory guidance and early intervention that might help to prevent or ameliorate potential psychopathology.

A Prospective Study of Short- and Long-Term Outcomes After Traumatic Brain Injury in Children: Behavior and Achievement

Longitudinal behavior and achievement outcomes of traumatic brain injury (TBI) were investigated in 53 children with severe TBI, 56 children with moderate TBI, and 80 children with orthopedic injuries not involving brain insult. Measures of preinjury child and family status and of postinjury achievement skills were administered shortly after injury. Assessments were repeated 3 times across a mean follow-up interval of 4 years. Results from mixed model analysis revealed persisting sequelae of TBI. Recovery of math skills was observed in the severe TBI group but only for children from less stressed families. Social disadvantage in children with TBI predicted more adverse behavioral sequelae and less favorable changes in some outcome measures. The findings suggest that pediatric TBI has long-term effects on behavior and achievement but that postinjury progress is influenced by the family environment.

Short- and long-term social outcomes following pediatric traumatic brain injury.

The social outcomes of pediatric traumatic brain injury (TBI) were examined in a prospective, longitudinal study that included 53 children with severe TBI, 56 with moderate TBI, and 80 with orthopedic injuries, recruited between 6 and 12 years of age. Child and family functioning were assessed at baseline, at 6- and 12-month follow-ups, and at an extended follow-up a mean of 4 years post injury. Growth curve analyses revealed that pediatric TBI yields negative social outcomes that are exacerbated by family environments characterized by lower socioeconomic status, fewer family resources, and poorer family functioning. After controlling for group membership, age, race, socioeconomic status, and IQ, path analyses indicated that long-term social outcomes were accounted for in part by specific neurocognitive skills, including executive functions and pragmatic language, and by social problem-solving. Deficits in these domains among children with TBI are likely to reflect damage to a network of brain regions that have been implicated in social cognition.

Middle-School-Age Outcomes in Children with Very Low Birthweight

Most previous studies of children with birthweight <750 g have focused on early childhood sequelae. To evaluate later outcomes, a regional sample of 60 <750-g birthweight children was compared at middle school age (M = 11 years) to 55 children with birthweight 750-1,499 g and 49 term controls. The groups were matched on age, gender, and demographic variables at the time of an early-school-age assessment (mean age 7 years). The <750-g birthweight group fared less well at middle school age than the term group on measures of cognitive function, achievement, behavior, and academic performance. In many instances, outcomes were less favorable for the <750-g children than for the 750 to 1,499-g group. Children in the <750-g group who were free of neurosensory disorders and global cognitive impairment performed more poorly on several tests than their term counterparts. Group differences in this subsample on tests of motor skills, math, and the ability to copy and recall a complex drawing remained significant even after controlling for IQ. Disparities between the <750-g and term groups increased with age for some measures. Despite favorable outcomes for many children in the <750-g group, this population is at risk for long-term developmental problems.

Social Outcomes in Childhood Brain Disorder: A Heuristic Integration of Social Neuroscience and Developmental Psychology.

The authors propose a heuristic model of the social outcomes of childhood brain disorder that draws on models and methods from both the emerging field of social cognitive neuroscience and the study of social competence in developmental psychology/psychopathology. The heuristic model characterizes the relationships between social adjustment, peer interactions and relationships, social problem solving and communication, social-affective and cognitive-executive processes, and their neural substrates. The model is illustrated by research on a specific form of childhood brain disorder, traumatic brain injury. The heuristic model may promote research regarding the neural and cognitive-affective substrates of childrens social development. It also may engender more precise methods of measuring impairments and disabilities in children with brain disorder and suggest ways to promote their social adaptation.

Bidirectional child-family influences on outcomes of traumatic brain injury in children.

Child behavior problems, injury-related family burden, and parent psychological distress were assessed longitudinally over the first year post injury in 40 children with severe traumatic brain injury (TBI), 52 with moderate TBI, and 55 with orthopedic injuries not involving brain insult. Parents rated childrens preinjury behavior soon after injury. Postinjury child behavior and family outcomes were assessed at 6- and 12-month follow-ups. Findings from path analysis revealed both direct and indirect effects of TBI on child behavior and family outcomes, as well as cross-lagged child-family associations. Higher parent distress at 6 months predicted more child behavior problems at 12 months, controlling for earlier behavior problems; and more behavior problems at 6 months predicted poorer family outcomes at 12 months, controlling for earlier family outcomes. Support for bidirectional influences is tentative given that limited sample size precluded use of structural equation modeling. The findings nevertheless provide impetus for considering the influences of person-environment interactions on outcomes of TBI.

Learning Disabilities in Children with Very Low Birthweight Prevalence, Neuropsychological Correlates, and Educational Interventions

This study examined achievement, neuropsychological, and intervention outcomes at a mean age of 11 years in children with very low birthweight (VLBW, < 1,500 g) compared with a term-born control group. To assess the prevalence and correlates of specific learning disabilities (LD), the sample was limited to children without neurosensory disorders who had at least low average IQ. Participants included 31 children with < 750 g birthweight, 41 with 750—1,499 g birthweight, and 52 controls. The < 750 g group obtained lower scores in math, IQ, and perceptual—organizational skills than the term-born group. The < 750 g group also had higher rates of past and present LD than the controls. Despite these differences, the groups did not differ significantly in rates of special education or tutorial/remedial assistance. These findings suggest that children with extremely low birthweight without gross physical or intellectual impairments are at higher risk for LD and cognitive deficiencies than their term-born peers and that further efforts are needed to improve identification and treatment of these learning problems.