PREDlCTlNG LANGUAGE AND BEHAVIOURAL OUTCOMES FOR HlGH-RlSK CHILDREN AT ElGHT VEARS OF AGE

Christine R. Wasson

A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy

Department of Human Development and Applied Psychology Ontario lnstitute for Studies in Education of the

University of Toronto

O Copyright by Christine R. Wasson (2000)

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Predicting Langua e and Behaviour Outcomes for High-Risk C 71 ildren at 8 years of age.

Christine R. Wasson Doctor of Philosophy

Department of Human Development and Applied Psychology Ontario lnstitute for Studies in Education of the

University of Toronto 2000

Abstract

Seventy high-risk children, who were born prematurely and/or had experienced

medical complications during the neonatal period, were evaluated at 8 years to detemine the

prevalence of language and behaviour problems and to investigate whether a relationship

exists between language functioning and behaviour outcome. This study assessed the

accuracy of a system that consisted of a risk index scale and preschool language and

behaviour measures in predicting subsequent Ianguage and behaviour development, and

identifying children at nsk for language and behaviour problems.

The children were administered a variety of standardized language measures (e-g.,

Reynell Language Scales; Peabody-Picture Vocabulary Test-Revised) at 3, 4 and 8 years.

The Child Behavior CheckliW4-18 (CBCL) was administered at 4 and 8 years to evaluate

behaviour. Although most of the children's receptive and expressive language skills fell in the

average range at 3, 4, and 8 years, they performed significantly lower on the Expressive

Language Scale of the Reynell at 3 years, and the Grammatical Morphemes subtest of the

TACL-R at 8 years compared to the normative samples of these language measures.

Boys at 4 and 8 years did not differ significantly from the normative sarnple of the

CBCL on the lnternalizing or Extemalizing scales, but girls were rated as having significantly

fewer behaviour problems compared to the normative sample of the CBCL. Both boys and

girls did not differ significantly from the normative sample of the CBCL on the Total

Cornpetence, Activities, Social, or School cornpetence scales of the CBCL at 8 years of age.

In this sample of generally normal functioning children, expressive vocabulary at 3

years of age was found to predict language and Total Competence at 8 years, whereas as

Externalizing behaviour at 4 years predicted behaviour outcome on the lntemalizing and

Externalizing scales of the CBCL at 8 years.

Because of the small sample size and low prevalence rate of language and behaviour

problems found in this sample of children, it was not possible to determine how useful the

system consisting of a risk index scale and preschool measures was at predicting or

identifying delays/problems in language and behaviour outcome at 8 years.

The present findings are very encouraging for the devetopmentai outcome of high-risk

children with normal intelligence who were found to have average language skills and normal

behaviour. However, the development for these children must continue to be monitored given

that they performed significantly lower on the Expressive Language Scale of the Reynell

Language at 3 years, and the Grammatical Morphemes subtest of the TACL-R at 8 years

compared to the normative samples. It was also found that preschool expressive language

functioning was related to outcome on the Total Competence scale of the CBCL at 8 years.

primarily for the boys, rather than earfy behaviour problems (i.e., intemalizing and

extemalizing problems) being related to language outcome at 8 years. Although aspects of

language and competence involved in this relationship were not indicative of problems in the

present sample, this relationship should be monitored. Given this relationship, it is possible

that other features of early language ancilor later schooi and social competence are

problematic for some high-risk children, and that early language delays do predict later

competence difficulties.

... III

Acknowledgments

There are many people who have contributed to the completion of this research, and to

whom I wish to express my gratitude.

I would like to begin by thanking the members of my thesis committee. First, and foremost,

I wish to thank my thesis supervisor, Dr. Linda Siegel for her advice and comments throughout

the various stages of this research. Dr. Siegel's theoretical knowledge and clinicai expertise with

premature children were invaluable. I would aiso like to give special thanks to Dr. Tom Humphries

for his painstaking review of several versions of my thesis, and for his unfailing guidance and

support.

1 would like to thank Dr. Keith Stanovich and Dr. Michele Peterson-Badali for serving on

my thesis committee and providing direction, feedback, and important fresh insights. A special

thanks to Susan Elgie for al1 her helpful pointers, statistical advice, and aid in statistical crises.

I also wish to express my gratitude to the many individuals involved in assisting with the

actual mechanics of this project, with regard to data collection, test scoring, and data entry, in

particular to Tony Ash and Dr. Margaret Lesperance.

1 also wish to thank al1 the children who participated in this study, as well as their parents,

who gave generously of their time.

Lastly, 1 would like to thank my family and friends. Without their support, this work would

not have been possible. I wish to thank Catherine Graham, Dr. Valerie Barsky, and Dr. Alexandra

Gottardo for their friendship, encouragement, and frequent reminders to keep things in

perspective. To rny husband Paul, 1 would like to thank him for his love, ongoing patience and

constant support. I dedicate this work to my father, Norman Wasson, and to the memory of my

mother, Anne Wasson. My parents have always encouraged and supported me throughout the

many years of my academic training, and although my mother is not here to share the celebration,

her love, energy and zest for life will always be a part of everything I do.

Table of Contents

Abstract .......................................................................................................... ii ............................................................................................................. Acknowledgments iv

Table of Contents ............................................................................................................ v List of Tables .................................................................................................................... vii ... List of Appendices ............................................................................................................ VIII

.................................................................................................................... List of Figures xi CHAPTER 1 ..................................................................................................................... 1

Introduction .......................................................................................................... -1 Rationale and Overview .......................................................................... 1 Literature Review

Long-Tem Outcome .................................................................... -2 Cognitive Development .......................................................................... -3 Academic Achievement ............................................................................. 5 Language Development .......................................................................... -7 Behavioural Development ................ ..... ............................................. -10 Relationship Between Language and Behaviour Outcome .................... -13 Biological and Environmental Factors ....................................................... 15

Biological Factors ................. ........,..... .... ............................ 1 5 Respiratory Distress Syndrome/Birth Asphyxia .............. 16 Duration of Mechanical Ventilation .................................... 17

.............................................. lntraventncular Hernorrhage 17 Birthweight and Gestational Age ...................................... 18 Small for Gestational Age ................................................. 19

Demographic Risk Factors .................... .. .................................. 20 Predicting Language and Behavioural Outcome ...................................... 22 The Present Study ................................................................................... 24 Questions and Hypotheses .................................................................... 25

Chapter 2 ............................ .... .................................................................................. 31 .................................................................................................................. Method 31

................................................................................................... Subjects 31 ......................................................................................... Sample 31 Inclusion Criteria .............................................................. -31

Sample Attrition ......................................................................................... 33 ........................................ ............................... Measu res .,. -34

Predictor Variables ..................................................................... 34 ................................................. Medical Records Data Coltection -35

Matemal Risk Index Variables .......................................... 35 Infant Risk Index Variables ............................................... 35

.......................... Severity of Illness Risk Index Variables 36 ........................... The Demographic Risk Index Variables 38

.......................................................................... f ests and Tasks 39 ......................................................... Cognitive Measures 43

The Stanford-Binet Intelligence Scale-4th ................................................................... Edition 43

The Wechsler lntelligence Scale for Children - 111 44 ........................................ Language Outcome Measures -46

Test of Auditory Language Comprehension . ................................................................ Revised 46

The Peabody Picture Vocabulary Test - ................................................................ Revised 47

.............................. Langua e Predictor Measures ....... ..... 47 yhe Reynell Developrnental Language Scales

.............................................................. (2nd rev.) 47 Vocabulary and Absurdities Subtests of the Stanford-Binet . Fourth Edition ............................. 48

Grammatic Closure Subtest of the Illinois Test of ....................................... Psycholinguistic Abilities 49

Behaviour Measure .......................................................... 50 The Child Behavior Checklistl4-18 ...................... 50

P roced u re ................... .. ............................................................................ -52 Assessmen t ................................................................................. -52

Data Analysis ........................................................................................... 52 CHAPTER 3 ..................................................................................................................... 55

............................................................................................................................. Results 55 Pattern of Performance .......................................................................................... 55 Preschool Tests as Predictors of Language and Behaviour Outcome at 8

.................................................................................................................... years 64 Preschool Language Measures Predicting Language Outcome at 8

....................................................................................................... Y ears -66 CBCL at 4 Years Predicting Behaviour Outcome on the CBCL at 8

....................................................................................................... Y ears -69 The Relationship Between Language and Behaviour/Competence Measures .. 72 Predicting Specific Language and Behaviour Outcomes .................................... -81

Hierarchical Regression Analyses ............................................................ 81 ..................................... Predicting Specific Language Outcornes -82

Predicting Specific Behaviour Outcornes ..................................... 83 ............................................................ Prediction of Below Average Performance 88

................................................................ Discriminant F unction Analyses 88 Identifying 8elow Average Performance

Significant Findings ....................................................................... 90 ..................................................................................................................... CHAPTER 4 93

........................................................................................................................ Discussion 93 .......................................................................................... Pattern of Performance 93

Language Functioning Receptive Language .................................................................... 93

............................................................................. Expressive Language 96 ............................................................... Behaviour-Competence Profile -97

Preschool Measures as Predictors of Outcome at 8 Years .................................. 100 Preschool Language Measures Predicting Language Outcome at 8

........................................................................................................ Years 100 ............. CBCL Scales at 4 Years Predicting CBCL Outcome at 8 Years 103

.... The Relationship Between Language and BehaviourICompetence Outcome 104 ..................................... Predicting Specific Language and Behaviour Outcornes 106

..................................................... Biological and Perinatal Risk Variabtes 107 ............................................................................. Environmental Factors -110

........ Early Measures of Development as Predictors of Later Functioning 111 ................................................. Identifying Below AverageIClinical Performance 112

References ................................................................................................................... 1 1 8

List of Tables

Table 2.1 Descriptive Characteristics of Children lncluded in the Study ................... 32

Table 2.2 Frequencies of Maternal and Infant Risk Index Variables of High-Risk Children lncluded in the Study (n=70) ................................... 37

Table 2.3 Frequencies of Severity of Illness and Demographic Risk lndex Variables of High-Risk Children lncluded in the Study (n=70) .................................................................................... 40

Table 3.1 Comparisons between the High-Risk Sample at 3,4, and 8 years of age and the Normative Sample of the Standardized Language Measures ............... .. ......................................... 56

Table 3.2 Comparisons between the Boys from the High-Risk Sample at 3, 4, and 8 years of age and the Normative Sample of the Standardized Language Measures .................................... 58

Table 3.3 Comparisons between the Girls from the High-Risk Sample at 3,4, and 8 years of age and the Normative Sample of the Standardized Language Measures .................................-.. 59

Table 3.4 Comparisons between the High-Risk Boys (4 8 8 years) and Boys (4-1 1 years) from the Normative Sample of the

........................................................................... Child Behavior Checklist 62

Table 3.5 Comparisons between the High-Risk Girls (4 & 8 years) and Girls (4-1 1 years) from the Normative Sample of the

.......................................................................... Child Behavior Checklist -63

Table 3.6 The Number of Children with scores In the Below Average/Clinical and Average/Nonnal Range on Language and Behaviour Measures

......................................................................... at 3, 4, and 8 Years of Age 67

Table 3.7 Pearson Correlations Between Language Measures at 3 and 4 years and Language Measures at 8 years ............................... 68

Table 3.8 Pearson Correlations Between CBCL Ratings ............................................................................... at 4 Years and 8 Years 70

Table3.9 AccuracyofCBCLScoresat4Yearsin Predicting Behaviour Outcorne on the CBCL at 8 Years ........................... 72

Table 3.1 0 Correlations Between Preschool Language Measures and Total Competence at 8 years Compared to Correlations Between Preschool Behaviour and Language Outcome

................................................................... at 8 years for High-Risk Boys 74

Table 3.1 1 Correlations Between Preschool Language Measures and Total Competence at 8 years Compared to Correiations Between Preschool Behaviour and Language Outcome at 8 years for High-Risk Girls ...................................................-................ 75

vii

Table 3.1 2 Pearson Correlations Between Language Measures a? 3.4. and 8 years and the CBCL Competence Scales at

....................................................... 8 years for High-Risk Boys and Girls 77

Table 3.1 3 Hierarchical Regressions for the Specific Language Measures at 8 Years ................................................................................ 85

Table 3.1 4 Hierarchical Regressions for the Specific CBCL Scales ................................................................................................. at 8 Years 87

Table 3.1 5 Accuracy of ldentifying Below Average/Clinical Performance on Language and CBCL Outcome ..................................... 91

viii

List of Appendices

Appendix A.

Appendix B.

Appendix C.

Appendix D.

Appendix E.

Table A l . Differences Between the Follow-Up Cases and the Attrition Group on Selected Demographic Characteristics and Cognitive, Language, and Behaviour Outcome Measures at 3 and 4 Years ............................... 143

Risk Index Variables Data Record Form ............................................. 146

Reliability and Validity of Standardized Test Measures ..................... 152

...................................................................... Parental Consent Form 158

Average Order of Acquistion of 14 Grammatical Morphemes ................................................................. Studied by Brown (1 973) 1 60

Figures 3.1

List of Figures

The Classification system used to relate 8 years outcomes to scores on preschool measures .............. .. ...........-........ 65

CHAPTER 1

Introduction

Rationale and Overview

The children in the present study are considered to be "high-risk" because of one or

more of the following reasons: low birthweight, prematurity, and/or the presence of serious

medical complications (Le., asphyxia, apnea, respiratory distress, and intraventricuiar

hemorrhage) with, or independent of, birth weight or prematurity. The majority of the children

participating in this study were low-birthweight (LBW) infants, as they had a birthweight of

below 2500 grams. Some of these LBW chifdren are refened to in the literature as being

very-low-birthweight (VLBW) which is typically defined as those children who have a

birthweight equal to 1,500 grams or less, and who are born prematurely with a gestational age

between 30 and 36 weeks. Earlier literature investigating the outcome of LBW and VLBW

infants focused primarily on their survival rate and neurological status. The more recent

research studies reviewed here have investigated the impact of subtle neurological

impairments that may be associated with low-birthweight and very-low-birthweight and that

may not be evident until the child begins school. Low-birthweight and VLBW children have

been found to be at a greater risk for a variety of developrnental deficits, such as lower

intelligence, increased leaming disabilities, poorer language functioning, and behaviour

problems (e.g., Aram, Hack, Hawkins, Weissman, & Borawski-Clark, 1991, Breslau, Aram,

Weissman, Klein, Borawski-Clark, 1992; Klebanov, Brooks-Gunn, & McCorrnick, 1994b;

Pharoah, Stevenson, Cooke, & Stevenson, 1994a; Robertson et al., 1990; Siegel, 1985a,

1985b, 1988). Most of the literature has iocused on comparing the LBW and VLBW infant's

developmental outcome with that of their full-terni, normal-birthweight (NBW) cohorts.

Although many researchers have examined the long term effects of low birthweight on

the child's later cognitive, language, academic, and to a lesser extent, behavioural

development (Le., Klein, Hack, & Breslau 1 989; Saigal, Szatmari, Rosenbaum, Campbell, &

King, 1991 a), few have attempted to determine what factors may have contibuted to these

specific outcomes. Some progress has been made in the development of systems that

enable the determination of which "high-risk" infants are likely to develop cognitive, leaming,

language, or behaviour problems (Barsky, 1992; Field, 1983; Molfese, 1989; Molfese &

DiLalla, 1995; Molfese, DiLalla, & Lovelace, 1 996, Molfese, Dilalla, & Bunce, 1997; Siegel,

Saigal, Rosenbaum, Morton, Young, Berenbaum, & Stoskopf, 1 982; Siegel, l982a; 1 982b,

1983, 1985a, 1985b, 1985c; Largo, Molinari, Cornenale Pinto, Weber, & Duc, 1986). Siegel

(1 982a; Siegel et al., 1982) has developed a simple, effective system of risk index variables

that can predict developmental outcome, as well as detect developmental delays in VLBW

infants. Both biological/medical variables (Le., birthweight, asphyxia) and environmental

variables (Le., socioeconomic status & materna1 education) were incorporated into this system

of risk indices. This type of system of risk indices is important as it enables professionals

working with these high-risk children to identify developmental delays and to implement

appropriate remediation early in development.

The present study sought to expand on Siegel's (1982a. Siegel et al., 1982, 1985c)

work by determining whether a system consisting of a risk index, and preschool language and

behaviour measures would accurately predict language and behavioural outcome, as well as

identify subsequent delays or difficulties in these areas of development for a sample of low-

birthweight, high-risk infants at eight years of age.

Literature Review: Long-Term Outcome

The literature on the outcome of low-birthweight, preterrn low-birthweight, or very-low-

birthweight infants is extensive and encompasses a wide age range (birth to school age) and

examines various developmental outcomes: physical growth, neurodevelopment, intellectual

functioning, language acquisition, visuomotor performance, academic achievement, and

behavioural performance. For the purposes of this study, the literature review is limited to the

discussion of cognitive, academic achievement, language and behavioural performance

outcome. The various biological and environmental factors that can render LBW and VLBW

children at risk for developmental delays will also be discussed.

Cognitive Development

Based on standardized measures of cognitive abilities such as the Wechsler

Intelligence Scale for Children-Revised, the McCarthy Scales of Children's Abilities, and the

Kaufman Assessment Battery for Children, many studies have found that preschool and

school age children (4 to 13 years of age) born low-birthweight (LBW) or very-low-

birthweight (VLBW), obtain significantly lower scores on cognitive measures compared to full-

term, normal-birthweight (NBW) children (Abel Smith & Knight-Jones, 1990; Hack, Breslau,

Ararn, Weissman, Klein, Borawski-Clark, 1992; Hunt, Cooper, 8 Tooley, 1988; Kitchen, Ryan,

Rickards, McDougall, Billson, Keir, 8 Naylor, 1980; Klein, et al., 1989; Lagerstrom, Bremrne,

Eneroth, & Janson, 1991 ; Pharoah, Stevenson, Cooke, & Stevenson, 1994; Ross, Lipper, &

Auld, 1 99 1 ; Saigal, et al., 1991 ; Siegel, l985a, 1 985b; Thompson, Gustafson, Oehler, Catlett,

Brazy, & Goldstein, 1997). Extremely-low-birthweight children (ELBW; birthweight c 750

grams), a subgroup of the very-low-birthweight (VLBW) population, also score significantly

lower on cognitive tests compared to the full-term group (Collin, Halsey, & Anderson, 1991 ;

Saigal et al, 1991 ) and compared to the VLBW group (weighing 750-1499 grams) (Hack,

Taylor, Klein, Eiben, Schatschneider, Mercuri-Minich, 1994), even when analyses had been

restricted to children who were neurologically normal and had average 10 scores. It is

important to note that despite obtaining significantly lower lnteiligence Quotients (IQ scores)

compared to their full-term peers, several studies have found that LBW and VLBW children

IQ scores fell within the normal range of ability (Breslau, Klein, & Allen, 1988; Grigoroiu-

Serbanescu, 1984; Hack et al., 1992; Hunt et al., 1988; Michelsson, Lindahl, Parre, &

Helenius, 1984; Rieck, Arad, & Netzer, 1996; Roussounis, Hubley, & Dear, 1993: Saigal et

al., 1991 ; Siegel, 1985a; Sansavini, Riuardi, Alessandroni, & Giovanelli, 1996; Vohr, Garcia

Coll, Flanagan, & Oh, 1992).

Furthermore, some researchers have found that by the time LBW or VLBW children

reached 7 or 8 years of age they no longer show significant delays in cognitive functioning

compared to normal-birthweight children. Lee and Stevenson Barratt (1 993) found that the

LBW children's intelligence scores did not differ significantiy from those of the NBW children at

6, 7, or 8 years, while VLBW children showed significantly lower IQ scores until the age of 6

years, but not at 7 or 8 yearç. Similarly, a sarnple of healthy premature children's intelligence

scores did not differ significantly from their full-term counterparts at eight years of age (Kalmar,

1996). Vohr and Garcia Col1 (1 985) found that neurologically intact, VLBW children perforrned

consistently better than VLBW children identified with neurological impairrnents on

standardized testing at 3 to 7 years, and by 7 years the neurologically intact VLBW children's

cognitive scores were within the normal range. These findings underscore the importance of

assessing LBW and VLBW children's cognitive development at different ages.

In addition, McDonaId, Sigman, and Ungerer (1 989) found that while there was no

significant difference in the Full Scale IQ scores between VLBW and full-term cohorts at five

years of age, VLBW children showed significant delays relative to full-terni children on the

Performance IQ but not Verbal IQ. Breslau et al. (1988) found that VLBW children scored

significantly lower than the controls on both the Full-Scale IQ and Performance IQ, but not on

Verbal IQ. Other studies, however, have found that VLBW children who were neurologically

intact perforrned significantly more poorly on the Full Scale, Performance, and Verbal IQ

compared to their full-terni cohorts (Aram, Hack, Hawkins, Weissman. & Borawski-Clark, 1991 ;

Siegel, 1985a). Studies have also revealed that while school aged LBW and VLBW children

may have average intelligence, they continue to perform less well on tests of language,

acadernic achievement, memory, visuomotor, and fine motor performance (Hack et al., 1992;

Hunt et al., 1988, Rieck et al., 1996). Hunt et al (1988) found that VLBW children at 8 years of

age demonstrated poorer functioning in visual-motor integration (21.3%), performance abilities

(1 2OA), and language abilities (1 2%), despite the fact that the rnajority (81 -5%) of these

children had IQ scores in the average or above average range. Barsky (1 992) found that

while 83 percent of the VLBW children at 3 years performed within the average range of

cognitive capabilities, approximately 51 percent of them perforrned within the below average

range on 2 or more specific cognitive and language measures. These studies illustrate the

possible problems of just using a global IQ score. Siegel (1989) has expressed concerns

about the use of global intelligence scores as measures of outcome as they do not

necessarily detect delays or difficulties in specific areas of cognitive processing or more subtle

leaming difficulties for which this group of children appear to be at risk. Therefore, when

assessing children for possible leaming difficulties specific tests of achievement (Le., reading)

and cognitive abilities (Le., language) should be administered.

Academic Achievement

Although the rnajority of the LBW and VLBW children have achieved intelligence

scores in the average range by the time they are school aged (6-9 years), studies have

found that these children still have significantly lower achievement scores and a higher

incidence of learning disabilities compared to their NBW peers (Calame, Fawer, Claeys,

Arrazola, Ducret, & Jaunin, 1986; Cohen, Parmelee, Sigman, Beckwith, 1988; Grigoroiu-

Serbanescu, 1984; Hunt et al., 1988; Klein et al., 1989; Michelsson et al., 1984; Rieck et al,

1 996; Robertson, Etches, & Kyle, 1990; Ross et al, 1991 ; Siegel 1983, 1 985a, 1 985c, 1988,

Vohr & Garcia Coll, 1985). Lagerstrom et al. (1991) found that LBW children had significantly

lower school marks than NBW children at 13 years of age. The reported percentage of LBW

and VLBW children classified as leaming disabled ranges from 16.7% to 37% (Cohen et al.,

1988; Hunt et al., 1988; Ross, Lipper, & Auld, 1996). This is higher than the estimated 10%

of learning disabled children found in the general school population. In regard to specific

academic deficits, studies have reported that LBW and VLBW children perforrned significantly

lower than full-terni children in one or more of the following areas: mathematics, word

recognition, reading comprehension, spelling, and mernory tasks (Klein et al., 1989; Pharoah,

Stevenson, Cooke, & Stevenson, 1994a; Rieck et al., 1996; Robertson et al, 1990; Ross et

al., 1996; Siegel, 1985a, 1985b; Vohr et ai., 1988). Hack et al. (1 992) found that their entire

sample of VLBW children scored significantly lower than NBW children on reading,

mathematics, and spelling tests. Marlow, Roberts, and Cooke (1 993) reported that 45% of

VLBW children were having difficulty with one or more school subjects (reading, mathematics,

or spelling) cornpared with 19OA of full-terni children, and that 26OA of VLBW children had

difficulty in two or more areas, compared with only 5OA of the full-tenn group. Studies have

also shown that VLBW children had significantly lower scores than full-terms on visual-

motor/perceptual measures (Hack et al., 1992; Lindgren, Harper, & Blackman, 1986; Hunt et

al., 1988; Siegel, 1983, 1 985b, 1985~). Furthemore, other studies have found that premature

children's visual-rnotor/perceptual skills were quite delayed at ages five, six, seven, and nine

years (Michelsson et al., 1 984; Siegel, 1 983, 1 985b, 1 985c).

Similar findings have been found for ELBW children, referring to children who had

birthweights below 750 grams. Hack et al. (1 994) reported that ELBW children had

significantly lower scores on academic achievement compared to VLBW and full-term children

at 6-7 years. Klebanov, Brooks-Gunn, 8 McCormick (1994a) also found that even among

children with ICI scores in the average range (> 85), ELBW children obtained significantly

lower math scores than NBW children. Saigal, Rosenbaum, Szatmari, and Campbell (1 991 b)

reported that while the prevalence of leaming difficulties in ELBW children (26%) was not

significantly different from that of NBW children (1 9%) in their sample, ELBW children did less

well in schooI and utilized more special resources according to teacher (31 % ELBW vs. 1 6%

NBW) and parent report (37% ELBW vs. 16% NBW)- Of note, the ELBW children in Hack

et a1.k (1 994) and Saigal et al.'s (1 991 b) studies had no neurological irnpairments and had

normal IQ scores (2 85).

Studies have also reported that LBW and VLBW children were also at a greater risk

for school failure than their NBW peers. Calame et al. (1 986) reported that the overall

incidence of school failure in VLBW children and full-tarm children at 8 years of age was 22.9%

and 2.4% respectively. Klein et al. (1 989) found that 40% of the VLBW children had

repeated a grade by the age of 9 while only 11 Oh of the NBW children had. Even when

children with below average IQ scores were excluded, 30% of the VLBW children still had

repeated a grade, compared with only 7% from the cornparison group (Klein et al., 1989).

Researchers have also reported that LBW and VLBW children were more likely to require

special education or remedial hetp than NBW children, with percentages ranging frorn 22% to

48% (Eilers, Desai, Wilson, & Cunningham, 1986; Michelsson et al., 1984; Ross et al., 1991;

Vohr & Garcia Coil, 1985; Vohr et al., 1989).

Language Development

Another body of research that has attracted increasing attention in the literature is the

investigation of language outcomes in LBW and VLBW children. Some investigators have

stressed that early language delays of any sort should not be taken lightiy as they may be

precursors of later intellectual and academic problems, particularly reading disabilities (e-g.,

Silva, McGee, 8 Williams, 1983; Vohr et al., 1989). Similarly, Ross, Lipper, and Auld (1 996)

have suggested that verbal deficits underlie learning disabiiities (Le., reading and spetling) in

premature children. For the toddler years (1 -3 years), studies have reported that LBW and

VLBW children experienced problems in one or more of the following areas compared to NBW

children: poorer comprehension, weaker receptive vocabuIary, decreased use of

vocalizations and gestures for procuring adult assistance, smaller vocabulary, shorter mean

length of utterances, and poorer verbal fluency (Byrne, Ellsworth, Bowering, & Vincer, 1993;

Crnic, Ragozin, Greenberg, Robinson, & Basliam, 1983; Field et al., 1983; Hubatch,

Johnson, Kistler, Burns, & Moneka, 1985; Landry, Schmidt, & Richardson, 1989; Scottish

Low Birthweight Study Group, 1992; Siegel, 1982a; Siegel, Cooper, Fitzhardinge, & Ash,

1995; Vohr et al., 1989). Furthemore, a higher percentage of LBW toddlers required speech

therapy compared to the full-terni toddlers (Vohr et al, 1989). However, some discrepancies

have been reported in the literature. For instance, Greenberg and Cmic (1988) found no

difference in receptive language or speech between VLBW and NBW children at 2 years.

Craig , Evan, Meisels, and Plunkett (1 991 ) reported that while auditory comprehension was

not problematic for LBW children, overall linguistic expression (expressive syntax) was

weaker for these children.

f o r the school aged population (5-1 1 years), studies have used a variety of speech

and language measures, which are believed to be sensitive to subtle deficits in specific areas

of language, such as syntactic comprehension, syntactic production, word retrieval, word

knowledge, receptive vocabulary, expressive organization, verbal reasoning, and speech

production (Achenbach et al., 1993; Aram, Hack, Hawkins, Weissman, & Borawski-Clark,

1 991 ; Hack et al., 1 992; Hunt et al., 1988; Robertson et al., 1 990; Siegef , 1 983; Vohr et al.,

1988). Although a variety of language skills have been examined, very few studies (Ararn et

al., 1991 ; Hack et al., 1992) have used more than one or two language rneasures at a tirne.

Generally, language skills have been studied in isolation to each one.

In spite of this limitation, studies have shown that school aged LBW and VLBW

children perfonned significantly more poorly on language tests than NBW children. Hunt et al.

(1 988) found that 12O/0 of the VLBW children who had average or above average IQ scores

still obtained significantly lower language scores than their NBW peers. Furthemore,

researchers have also reported that significantly more VLBW children (Le., 14%-17%) were

receiving speech and language therapy compared with none of the NBW children by the age

of 7-9 years (Aram et al, 1 991 ; Michelsson et al., 1984; Vohr 8 Garcia Coll, 1985)- Low-

birthweight and VLBW children were found to be at greater risk for having language problems

in one or more of the following areas: expressive languagenanguage production, language

comprehension, verbal ability, auditory memory, articulation, and syntax (Aram et al., 1991 ;

Barsky, 1 992; Byrne, Ellsworth, Bowering & Vincer, 1993; Beke & Gosy, 1997; Calame et

al., 1986; Field, Dempsey, & Shuman, 1983; Hack et al., 1992; Hack et al., 1994; Hunt et al.,

1988; Klebanov et al., 1994a; Largo, Molinari, Comenale Pinto, Weber, Duc, 1986; Lindgren et

al. 1986; Michelsson et al., 1984; Ross et al., 1991 ; Siegel, 1983, 1985~). Some studies have

reported difficulties with receptive vocabulary and receptive language (Hack et al., 1992;

Kentworthy, Bess, Stahlrnan, & Lindstrom, l987), while other studies have not (Achenbach

et al., 1993; Klein et al., 1985; Barsky, 1992; Robertson et al., 1990; Siegel, 1983, 1985b;

Vohr, Garcia-Coli, Oh, 1 989).

Extremely-low-birthweight children were found to be at greater risk for language

delays than other birthweight groups (LBW or VLBW). Studies have shown that ELBW

children scored significantly iower on language measures, such as language processing,

cornplex expressive language, auditory memory, and verbal reasoning skills, than VLBW

children (Grunau, Kearney, & Whitfield, 1 990; Scottish Low Birthweight Study Group, 1 992).

Although researchers generally agree that LBW and VLBW children are at greater risk

for experiencing specific language deficits, there is some discrepancy in the Iiterature to as

whether these children are also at greater risk of experiencing global speech or language

disorders. Calame et al. (1986) found that language disorders were more common among the

VLBW than the NBW group. Aram et al. (1 991) found, however, that VLBW children were no

more likely to experience general speech or language irnpairments than NBW children.

There is evidence that some language delays decrease as LBW and VLBW children

age, whiie other Ianguage delays or deficits are more persistent. Sansavini, Riuardi,

Alessandroni, and Giovanelli (1 996) found that LBW and VLBW children exhibited speech

delays until the age of 2 years but not thereafter. Vohr et al. (1989) reported that 280k of the

VLBW children had language delays at 2 years, but none of the children did at 3 years.

Similarly, Casiro, Moddemann, Stanwick, and Cheang (1991) found that language test scores

increased significantly overtime in the absence of any formal language intervention. Thirty-

nine percent of the VLBW children showed language delays at 1 year while only 15%

showed ianguage delays at 3 years (Casiro et al., 1991). These findings are consistent with

those of Craig, Evan, Meisels, and Plunkett (1 991) who found that 13% of the LBW children

demonstrated language problems at 3 years. However, Byrne et al. (1 993) reported that

LBW children experienced increased delays in both receptive and expressive language frorn

1 to 2 years of age. Kentworthy, Bess, Stahlman, and Lindstrom (1 987) found that the

percentage of receptive vocabulary delays for VLBW children varied from preschool to school

age: 28% at 3 years, 31% at 4 years; 14% at 8 years; 35% at 11 years. Largo, Molinari,

Comenale Pinto, Weber, & Duc (1986) noted that most stages of language developrnent

were fairly consistent but occurred at a slightly later stage among neurologically unimpaired

LBW children (1 -5 years) than among those bom at terrn.

Behavioural Development

Given that a higher incidence of behaviour difficulties has been reported among

children with learning disabilities than children without learning problems, one wouid predict

that since LBW and VLBW children are at a greater risk for experiencing learning difficulties,

they would also be more likely to exhibit behavioural problems. However, few studies have

investigated the behavioural outcorne of school aged LBW and VLBW children. Some

studies have found that pretemi children who were experiencing leaming difficulties were no

more likely to have behaviour problems than their full-terni peers (Cohen et al., 1988;

McDonald et al., 1989; Roussounis et al., 1993). In fact, McOonald et al. (1989) found that the

full-term group were rated by their parents as having more behaviour problems than the

preterm children.

The percentage of LBW and VLBW children with behaviour problems varies from

study to study. Goldberg, Corter, Lajkasek, and Minde (1990) reported that 46 percent of

their sample of 4-year-old VLBW children were identified as experiencing problematic

behaviour. The Scottish Low Birthweight Study Group (1 992) also reported that 47% of

LBW children had poorer attention and were rated by their parents as having more behaviour

problems than their siblings at 4 years. Pharoah et al. (1 994b) found that the percentage of

VLBW children rated by their parents and teachers as having a behavioural disorder was

36OA and 275% respectively, while the percentages for the NBW children, according to parent

and teacher report, were 22% and 12% at 8-9 years of age.

Studies that have identified behavioural differences between LBWNLBW children

and full-term children have not indicated whether the LBWNLBW children were learning

disabled. Low-birthweight children at 2 years of age were rated by their parents as having

sig nificantly decreased attention and increased restlessness (Field et al., 1 983). Vohr et al.

(1 989) found a similar pattern of behaviour difficulties (decreased attention and increased

inhibition and distractibiIity/hyperactivity) for LBW children at 3 years compared to NBW

children, but these differences were not significant. The majority of the studies that have

investigated the behavioural outcome of LBW and VLBW children between the ages of 6 and

12 years have found that while these children did not have overall behavioural difficulties,

they were rated by their parents (Hack et al., 1 992; Lindgren et al., 1986; Pharoah,

Stevenson, Cooke, & Stevenson, 1994b; Ross, Lipper, & Auld, 1990), teachers (Grigoroiu-

Serbanescu, 1984; Klebanov, Brooks-Gunn & McCormick, 1994b; Pharoah et al., 1994b;

Tessier, Nadeau, Boivin, & Tremblay, 1997), peers (Hoy, Sykes, Bill, Halliday, McClure, &

Reid, 1992; Tessier et al., 1997), and even by themselves (Hoy et al., 1992), as having

specific behavioural/emotiona1 problems. Studies have shown that LBW and VLBW children

were significantly more hyperactive, distractible, inattentive, and had poorer social skilis and

lower peer acceptance than their full-terrn cohorts (Field et al., 1983; Hack et al., 1992; Hack et

al., 1994; Hoy et al., 1992; Klebanov et al., 1994b; Robertson et al., 1990). Other

researchers have found that LBW and VLBW children were rated by their parents, teachers,

and peers as having increased internalizing behaviour problems (Le., socially withdrawn),

and lower social competence and school competence scores compared to their NBW peers

(Hack et al., 1992; Hoy et al., 1992; Klebanov et al., 1994b; Lindgren et al., 1986; Ross et al.,

1990; Tessier et al., 1997). Some studies have found the LBWNLBW child's 10 was not

associated with behavioural disturbances (Breslau et al., 1988), while others have found a

relationship (Pharoah et al., 1994b).

For the few studies which have used more than one informant to rate the LBWNLBW

child's behaviour, the inforrnants' ratings were usually consistent, but occasionally

discrepancies were found. Marlow et al. (1 993) found that parents of VLBW children reported

a similar frequency of behavioural problems as did parents of NBW children, but teachers

identified characte nstics typical of emotional problems (Le., fussiness, worries) and

overactivity (fidgety, inattention, restlessness) more frequently arnong the VLBW group than

the NBW cohort.

Studies have shown that ELBW children appear to be at greater risk for behaviour

difficulties than either VLBW or LBW children. Extremely-low-birthweight children were rated

by their parents and teachers as having significantly poorer attention and social skills and

increased behaviour problems as well as lower social competence, scholastic, and athletic

ability than were LBW, VLBW or NBW children (Hack et al., 1994; Klebanov et al., 1994b).

Gender differences have been noted in the behavioural outcome for LBW and VLBW

children. Breslau, Klein, and Allen (1 988) found that for their sample of VLBW 9-year-old

children, behavioural problems varied by sex. Parents' and teachers' ratings on the

behavioural questionnaires revealed that VLBW boys manifested significantly more

psychiatric symptoms and lower social adjustment than matched controls, whereas VLBW

girls were indistinguishable from their matched controls (Breslau et al., 1988). The VL6W

boys had behaviour problems in a wide range of areas, including both internalizing

(depressive-anxious) and externalizing (conduct problems) problems, and a higher proportion

of VLBW boys scored in the "clinical range" compared to NBW boys (Total Behavior Problem

in clinical range: VLBVI=44% vs. NBW=230h) (Breslau et al., 1988). Other studies found

that LBW and VLBW boys had significantly poorer social relations (i.e., the number of friends,

how well they get along with others), significantly more behaviour problems associated with

conduct disorders (Le., aggression, and delinquency), and were rated higher on measures of

hyperactivity and day dreaming and lower on attention compared to NBW boys (Calame et

al., 1 986; Grigoroiu-Serbanescu, 1984; Pharoah et al., 1 994b; Ross, Lipper, & Auld, 1989).

Low-birthweight and VLBW girls, however, had fewer behavioural or social problems

compared to NBW girls (Grigoroiu-Serbanescu, 1984; Klebanov et al., 1994b). Tessier et al.

(1 997) found that boys, whether they were from the LBW or the NBW group, tended to be

more aggressive than the girls from their respective groups.

Relationship Between Language and Behaviour Outcome

The roles of developing language facility and social competence in children are

considered to be pervasive and interdependent (Gallagher, 1993). Language not only plays

a critical role in communication, but also in social interaction as it is through language that the

child internalizes social rules of conduct, regulates hidher own behaviour, expresses feelings

and emotions, and influences the behaviour of others (Brinton & Fujiki, 1993; Gallagher, 1993;

Gordon, 1991 ). A child with subtle language problems may have difficulty with one or more

aspects of social behaviour, such as not having the language to resolve conflicts in any other

way other than fighting. Furthemore, language impairment and social difficulties rnay

compound each other as a child with pwr social competence skills is more likely to be rejected

by his/her peers thereby limiting the opportunities to practice and refine social interaction skills

(Brinton & Fujiki, 1 993; Gallagher, 1 993).

Although studies reviewed above have investigated the language and behaviour

outcome of LBW and VLBW children (Breslau et al., 1988; Klebanov et al., 1994b; Lindgren et

al., 1986; Hack et al., 1992; Hack et al., 1994), and several of them have demonstrated that

these children were more likely to exhibit language delays (Le., Aram et al., 1991; Michelsson

et al., 1984; Hunt et al., 1988) and behaviour problems (Hoy et al., 1992; Ross et al., 1990;

Tessier et al., 1997) compared to full-term peers, very few studies have examined the

interaction between language and behavioural outcome. Behaviour, however, has been

found to be related to both cognitive and language performance (Vohr et al, 1989). In addition,

preterm and full-terni children who were classified as having behaviour problems at 5 years

were more Iikely to have delays in symbolic and communication skills at 13 1/2 and 22 months

of age (McDonald et al., 1989). The lack of research investigating the relationship between

Ianguage and behaviour is rather surprising given that a number of studies based on ctinical

populations (Le., speech-language impaired, 8 psychiatric disorders) have demonstrated that

speech and language delays and behavioral/emotional problems appear to be moderately to

highly correlated with one another (Baker, Cantwell, & Mattison, 1980; Baker & Cantwell,

1987; Beitchman, Nair, Clegg, Ferguson, & Patel, 1986; Camarata, Hughes, 8 Ruhf, 1988;

Cantwell, Baker, & Mattison, 1979; 1980; Gualtieri, Koriath, Van Bourgondien, & Saleeby,

1983; Mack 8 Warr-Leeper, 1992). Studies have shown that children with speech and

language impairment were also at risk for psychiatric disorders such as hyperactivity, conduct

disorder, and withdrawn behaviour (Baker & Cantwell, 1987; Beitchman et al., 1986;

Mattison, Cantwell, & Baker, 1980). Sirnilarly, researchers have reported that chifdren with

mild to moderate behaviour disorders, as well as bcys with chronic behaviour disorders were

at greater nsk for speech and ianguage problems (Camarata et al., 1988; Gualtieri et al., 1983;

Mack & Warr-Leeper, 1992). For instance, Gualtieri et al (1 983) found that 50 percent of the

children referred for psychiatric services had moderate to severe developmental language

disorders. This is consistent with Cantwell & Baker's (1 980) findings that approximately 53

percent of the children with speech and language disorders were also identified as having

some type of psychiatric disorder. Chitdren with language problems rather than speech

difficulties were more Iikely to experience psychiatric disorders (Baker & Cantwell, 1987).

Furthermore, children with speech and language disorders were also found to have more

severe and more frequent behavioral abnorrnatities, particularly hyperactive behaviour (e.g.,

restlessness, short attention span) and developrnental problems (e.g., cry easily, cling to

parents) (Baker et al., 1980).

Similar findings pertaining to the relationship between speech and language

disabilities and psychiatric illness were also observed in a group of children selected from the

general cornmunity. Beitchman, Nair, Clegg, Ferguson, and Patel's (1 986) sample consisted

of 5-year-old children enrolled in various kindergarten classes from the same community. Their

results showed that the kindergarten children who were identified as having speech and

language impairments were also more Iikely to show behaviour disturbances, according to

mother and teacher reports, compared to children who had no speech and language difficulties

(Beitchrnan et al., 1986). Interestingly, Beitchman and his associates found, in their 7 year

follow-up study of the same sample of children seen at 5 years, that the children who were

identified with speech and language delays at 5 years of age continued to be more likely to

display psychiatric problems at 12 1/2 years of age (Beitchman, Brownlie, Inglis, Wild,

Ferguson, Schachter, Lancee, Wilson, & Mathews, 1996).

Although most VLBW studies have not examined the relationship between language

and behaviour, findings suggest that such a relationship exists. Calame et al. (1 986)

reported that VLBW children were not only more at risk for language delays but were aiso

more hyperactive. In addition, VLBW children with behaviour problems were also found to

have difficulty verbally expressing their ideas (Schraeder, Heverly, & Rappaport, 1990).

Biological and Environmental Factors

There are many rnedical complications (i.e., birth asphyxia, intraventricular

hemorrhage, respiratory distress) that can occur during the neonatal period that place a child at

risk for later developmental delays. Many of these complications are often associated with

low birth weight and prematurity. Various demographic factors have also been found to be

significant in deterrnining later outcome for a particular child. The biological and environmental

risk factors are presented in the following sections.

Biological Factors

A variety of biological factors have been found to be significant in determining the

outcome for a particular infant, such as the child's birth order and gender, materna1 age,

intrauterine growth retardation, arnount of matemal smoking during pregnancy, and the number

of previous spontaneous abortions. In this study the following biological and environmental

risk variables will be discussed in detail as they have been found to be among the better

predictors of developmental outcome: respiratory distress syndrome (RDS), birth asphyxia,

intraventricular hemorrhage (IVH), birthweight, and gestational age (Barsky et al., 1992;

Bendersky & Lewis, 1990; Field, 1983; Hack et al., 1992; Kalmar, 1996; Landry et al., 1989;

Siegel, 1982a; 1985a, 1985b; Siegel et al., 1982).

Respiratory Distress SvndromeIBirth As~hvxia

Respiratory distress syndrome (RDS) is a breathing disorder experienced by many

premature infants. It is caused by the infant's inability to produce surfactant, the fatty

substance that coats the lung's tiny air sacs (the alveoli) and prevents them from collapsing.

The more premature the infant the greater the likelihood he or she will develop RDS. In infants

less than 30 weeks gestation respiratory distress is not only the result of a lack of surfactant

but also due to an immaturity of the lung structure. Respiratory distress syndrome is treated

with oxygen, ventilation, and surfactant. Asphyxia is the lack of proper oxygen and blood

flow which is commonly associated with RDS. "The [infant] with RDS has difficulty making

the [transition] from the fetal pattern of circulation to the mature pattern, since the pressure in

[the infant's] poorly expanded lungs forces the blood away from the lungs and back through

the fetal blood vessel, the ductus arteriosus. Non-oxygenated blood then circulates to the

body, and the [infant's] tissues become oxygen-deprived" (Harrison 8 Kositsky, 1983, p.

57). Asphyxia results from the lack of proper oxygen and blood flow which leads to the

accumulation of biochemical waste products such as carbon dioxide and lactic acid that are

toxic and can contribute to neurological problems (Spreen, Risser, & Edgell, 1995).

Subsequent changes in the blood flow can cause intracranial pressure to build, which in turn

may lead to intraventricular hemorrhage.

Low-birthweight and VLBW children with RDS and asphyxia have been found to

perform less well on different measures of outcome than healthy NBW children. Low-

birthweight toddlers with RDS had weaker expressive communication skills (i-e., speech acts,

social exchange) (Landry, Schmidt, and Richardson (1 989), language production delays (i.e.,

verbosity) (Field et al., 1983; Hubatch et al., 1985), and poorer receptive language skills

(Hubatch et al., 1985). Respiratory distress syndrome has also been one of the perinatal risk

factors associated with neurological impairment (Michelsson et al., t 984), lower intellectuai

scores (Breitmayer 8 Ramey, 1986; Field et al., 1983), and increased behaviour problems

(Le., hyperactivity, shorter attention span) (Field et al., 1983) at 4-5 years. In addition, Ross,

Lipper, & Auld (1 996) found that the severity of RDS was one of the variables that

discriminated between children with and without learning disabilities at 7-8 years. The

presence of birth asphyxia has also been related to slight delays in expressive and

receptive language functioning (Janowsky & Nass, 1987) and leaming disabilities (Ross et

al., 1996).

Duration of Mechanical Ventilation

Infants with respiratory illnesses frequently require mechanical ventilation. However,

long durations of mechanical ventilation (Le., greater than 28 days) may cause damage to the

lungs and bronchioles resulting in a disease known as bronchopulamonary dysplasia (BPD)

or chronic lung disease (CLD) (Harrison & Kositsky, 1983). Longer duration of mechanical

ventilation and corresponding BPD have been found to be associated with poorer

neurodevelopmental outcomes for VLBW chiidren (Goldson, 1984; Meisels, Plunkett, Roloff,

Pasick, & Stiefel, 1986).

lntraventricular Hemorrhacle

lntraventricular hemorrhage (IVH) is bleeding within the ventricles of the brain. As with

most tissue in the premature infant's body, the walls of the tiny blood vessels in the

premature infant's brain are very fragile and are susceptible to abrupt fluctuations in the

infant's blood pressure which may cause these delicate vessels to rupture and bleed into the

bain (Harrsion & Kositsky, 1983). Premature infants have increased vulnerability in the area

around the ventricles, the spaces in the brain where cerebrospinal fluid is produced. Bleeding

into or near the ventricles occurs in different grades or levels of severity with a grade I bleed

being the least severe to a grade IV being the most severe. Infants with grades 1, II, and III

bleeds have a sornewhat optirnistic prognosis, while infants with a grade IV bleed generally

have serious ongoing neurological problems (Harrsion & Kositsky, 1983).

Studies have found a relationship between increasing severity of intraventricular

hemorrhage and greater neurological ancilor cognitive impairment (Ford, Steichen Asch,

Babcock, & Fogelson, 1989; Leonard, Clyman, Piecuch, Juster, Ballard, & Booth Behle, 1990;

Vohr et al., 1989; Vohr, Garcia Coll, Flanagan, & Oh, 1992). Studies have also demonstrated

that the presence and severity of IVH appeared to adversely influence language outcome.

Intraventricular hemorrhage has been found to be associated with lcwer expressive language

skills (Bendersky & Lewis, 1990; Janowsky & Nass, 1987; Landry, Schmidt, & Richardson,

1989; Vohr et a!., 1989), and poorer language outcome (Grunau et al, 1990) at 12 months and

24 months. Casiro et al. (1990) found both receptive and expressive language scores were

inversely associated with the severity of IVH at 12 months.

With the recent advances in medicine a new medication called indomethacin, a

synthetic indole derivative, has been shown to decrease the incidence of IVH when a low

dose was administered to premature infants 6 to 12 hours after their birth (Ment, Vohr, Oh,

Scott, AH, Westerveld, Duncan, Ehrenkranz, Katz, Schneider, 8 Makuch, 1996). Preliminary

findings indicate that indomethacin does not result in adverse cognitive or motor deficits at 3

years (Ment et al., 1996). This is very encouraging as preventing the occurrence of IVH rnay

also prevent the long lasting neurological impairments associated with severe intraventricular

bleeds.

Birthweiaht and Gestational Aae

Children with lower birthweight and shorter gestations perform less well on measures

of developmental outcome than children with higher birthweight and longer gestations. Lower

birthweight has been associated with decreased IQ scores (Breslau, DelDotto, Brown,

Kumar, Ezhuthachan, Hufnagle, & Peterson, 1994; Kitchen et al., 1980; Largo et al., 1986;

Largo et al., 1989), slower language development (Largo et al., 1989; Lee 8 Stevenson

Barratt, 1993), increased learning problems (Marfow et al., 1993; Lee & Stevenson Barratt,

1993); global developrnental delays (Collin, Halsey, 8 Anderson, 1991), and increased need

for special services (Schraeder, Heverly, O'Brien, & McEvoy-Shields, 1992). Birthweight

also appeared to affect the effectiveness of intervention for LBW infants. The lighter LBW

children (< 2000 g) were less able to benefit from early intervention than were heavier LBW

children ( Brooks-Gunn, Gross, Kraemer, Spiker, & Shapiro, 1992).

Shorter gestation has also been found to be related to lower intellectual scores and

neurological functioning (Kitchen et al., 1980; Largo et al., 1989), poorer schwl achievement

(Grigoroiu-Serbanescu, l984), and to slower language development (Casiro et al., 1990;

Largo et al., 1 989; Lee 8 Stevenson Barratt, 1 993; Vohr, Garcia Cofl, & Oh, 1 988, 1 989).

Some investigators have found that severe prernaturity was associated with cognitive delays

until the age of 4 years, but not thereafter (Kalmar, 1996). There is sorne consensus among

studies that infants with a gestational age of over 30 weeks have more favorable neurological

and intellectual outcomes than those born before 30 weeks (Kitchen et al., 1980; Largo et al.,

1 989).

Small for Gestational Aae

In the literature, studies have examined the development of LBWNLBW children

whose birthweight was appropriate-for-gestational-age (AGA) separately from LBWNLBW

children whose birthweight was small-for-gestational-age (SGA). The SGA group refers to

those infants whose birthweight was 2 standard deviations or more below the mean weight

for their gestational age based on regional noms, such as the Usher-McLean curves for a

Canadian sample (Usher & McLean, 1969).

Studies compteted in the 1970's, as cited by Rossetti (1 986). reported a rather

pessimistic future for premature SGA infants as these children were found to be more

susceptible to severe neurological impainnents and lower intelligence scores than premature

AGA infants. The findings from recent studies, however, are inconclusive in regards to the

long-term outcome of SGA children. Findings from some studies supported the hypothesis

that being bom small-for-gestational age has long-term adverse consequences, such as

having lower intelligence scores even up to 8 years of age (Collin, et al., 1991 ; Kalmar, 1996;

Sansavini et al., 1996), poorer academic performance and increased need for special

instruction (Eilers et al., 1986; Parkinson, Wallis, & Harvey, 1981), weaker language skifls

(Molteno, Woods, & Hollingshead, 1995). and increased behaviour problems (Le., poor

attention, problems in communicating with teacher and classmates) (Parkinson et al., 1981).

Other studies, however, reported that SGA children show similar outcomes to AGA

children in terms of their neurological status and intelligence (Abel Smith and Knight-Jones,

1990; Kitchen et al., 1980; Molteno et al., 1995), academic achievement (Robertson et al.,

1990), and language development (Vohr et al., 1989). A few studies found more favorable

outcomes for the SGA infants than the AGA infants. For instance, Siegel et al. (1 982) found

that when they corrected test scores for prematurity the SGA group did significantly better on

motor skills than the AGA group at 2 years of age. Similarly, Vohr et al. (1 989) found that

LBW SGA children had fewer cognitive deficits compared to LBW AGA children at 3 years.

Demographic Risk Factors

The demographic category includes socioeconomic status (SES) and materna1 level of

education, which are both considered to be environmental factors. Overall, studies have

shown that "high-risk" infants (i.e., LBW, VLBW) who corne from a higher socioeconomic

status andor have mothers who have attained a higher level of education (Le., high school or

above) often have higher scores on intelligence tests and language measures (Cohen &

Parmelee, 1983; Fawer, Besnier, Forcada, Buclin, & Calame, 1995; Greenberg & Crnic, 1988;

Grunau et al., 1990; Kitchen et al., 1980; Largo et al., 1986, 1989; Saigal et al., 1991 ; Siegel,

1982, 1983; Siegel et al., 1982; Thompson, Gustafson, Oehler, Catlett, Brazy, 8 Goldstein,

1997; Vohr, Garcia Coli, and Oh, 1988, 1989). There is also supporting evidence in the

literature that a relationship exits between matemal education and socioeconomic status and

later acadernic outcome (Siegel, 1989). O'Brien Caughy (1 996) found that matemal education

had a strong positive association with performance in mathematics and reading recognition.

Camp, Broman, Nichols, and Leff (1 998) reported that low socioeconomic status and mothefs

education of less than 9 years were the two risk factors that contributed most to later

developmental delays. Low maternai education has also been found to be one of the factors

independently associated with children who repeated kindergarten or first grade (Byrd &

Weitzman, 1994).

The present study has only examined two components of the child's environment,

socioeconomic status and maternai education, however, other aspects have also been found

to be important to the child's development, such as caregiver-child interaction, disciplinary

techniques, caregiver responsiveness, and quality of relationships and amount of support

among family members (Bee, Barnard, Eyres, Gray, Hammond, Spietz, Snyder, & Clark,

1982; Feingold, 1994; Greenberg & Crnic, 1988, Siegel, 1983, Wallace, 1988). For instance

the type of interaction and amount of stimulation given by a rnother to her child were

specifically related to language development (Lee & Stevenson Barratt; Siegel, 1984; 1989).

Environmental factors have been identified as assuming increasing importance over

time for cognitive and language outcome particularly for high-risk infants (McGaughey,

Starfield, Alexander, & Ensminger, 1992; Largo et al., 1986). Furthemore, there is evidence

that LBW and VLBW children were more strongly influenced by their environment on cognitive

and Ianguage measures than were NBW children (Greenberg 8 Crnic, 1988; Grunau et al.,

1990; Siegel, 1984). Interactions between biological and environment risk factors have been

reported in the literature. Specifically, environment factors act in conjunction with biological

factors to maximize or minimize the potentially adverse effects of pennatal difficulties in

cognitive development and academic achievement (Breitmayer & Ramey, 1986; Camp et al.,

1 998; Hunt et al, 1 988; Koller, Lawson, Rose, Wallace, & McCarton, 1 997; Ross et al., 1991 ;

Sameroff & Chandler, 1975; Sansavini et al., 1996; Spreen, Risser, & Edgell, 1995). For

instance, VLBW children who had a consistent pattern of very low cognitive scores from 1 to

6 years of age were more likely to have a higher incidence of perinatal complications and

mothers with lower educational levels (Koller et ai., 1997). Similady, an interaction between

increased prernaturity and lower SES levels was associated with lower intelligence, poorer

academic achievement, and shorter attention for VLBW children at 7 and 8 years (Ross et al.,

1 991 ). Bee et al. (1 982) suggested that vulnerable children (i.e., VLBW) were susceptible to

high-risk environments because their parents were less able 30 adapt to the changing

demands of the child, and to create or use helpful support systems for themselves" (p. 1 152).

Predicting Language and Behavioural Outcome

Studies using correlational analyses have demonstrated that biologicaf risk factors

(i.e., birthweight), infant tests, preschool measures, and quality of home environment are

related to neurological, intellectual, and language development (Beke & Gosy, 1997; Kalmar,

1996; Largo et al., 1989; McDonald et al., 1989; Michelsson et al., 1984; Miller & Siegel, 1989).

Recently, using a system or combination of variables, such as perinatal, demographic,

environmental, and infant and preschool tests to predict language, academic, and behaviour

outcorne as well as delays has become more common in the LBW and VLBW research (e.g.,

Grunau et al., 1990; Klebanov et al., 1994b; Molfese, 1995: Robertson et al., 1990; Ross,

Lipper, & AuId, 1996; Siegel, 1 982a, 198%). The specific variables or the particular

combination of variables found to account for most of the variance depend on the outcome

being measured. Molfese et al. (1 996) recommended that a variety of perinatal and social-

environmental variables be used when predicting developrnental outcome.

Siegel (1 982a, 1985~) has developed a relatively simple system of risk index

variables to determine which factors might be associated with language outcome as well as

other specific cognitive processes (Le., attention, visual spatial) in preschool and school age

VLBW children. Siegel's (1 982a) multivariate model incorporated 10 perinatal and

reproductive variables and 2 demographic variables. The perinatal variables were

birthweight, 1 -minute and 5-minute Apgar scores, gestational age, severity of respiratory

distress, birth asphyxia and apnea. The reproductive variables were birth order, amount of

matemal smoking during pregnancy, and number of spontaneous abortions. The

demographic variables were SES, gender, and matemal and paternal education levels.

Siegel's risk index system is particularly relevant to the present study as it has been used

across a broad age range of children who share many of the perinatal complications (Le., low-

birthweight; prematurity), and who were at risk for similar developmental deficits as the

present sample of "high-nsk" children.

Using stepwise linear multiple regression analyses, Siegel (1 982a, 1985c) found that

a combination of SES, maternal education, matemal smoking, respiratory distress, birth order,

number of previous spontaneous abortions, and degree of maturity, as well as the presence

of apnea and asphyxia were al1 variables that related to cognitive, language, and motor

development. Siegel (1 982a, 1985c) noted that the particular combination of flsk index

variables depended on the outcome being measured. For instance, Siegel (1 982a) found that

the combination of maternal smoking, birthweight, SES, RDS, and number of previous

abortions correlated with language comprehension outcome, while the combination of birth

order, SES, maternal smoking, apnea, 5-minute Apgar, and gender variables correlated with

expressive language outcome for a group of VLBW 3-year-old children.

After determining which risk index variables contributed to specific outcornes for the

VLBW infants, Siegel (1 982, 1982a, 1985~; Siegel et al., 1982) used discriminate function

ana!yses to determine the accuracy of the risk index at identifying or classifying those children

at risk for befow average performance. Again, the particular risk index variables used were

the ones that contributed significantly to the discriminate function which varied depending on

the outcome being measured (Le., language, cognitive, motor) (Siegel, 1982a). Overall,

Siegel has demonstrated that her system of risk index variables was reasonably accurate at

predicting various outcome scores (cognitive, language, achievement) for a number of ages

(2, 3, 5, 6, & 7 years), and at identifying developrnental delays in VLBW children (Siegel et

al., 1982; Siegel, 1982a, 1982b, 1983a, 1985b, 198%; 1988, 1989a).

Barsky (1 992) developed a system of risk index variables based on Siegel's (1 982a)

multivariate model to determine what factors predicted 3-year-old VLBW children's cognitive

and Ianguage performance, as well as detected developmental delay. Her study differed from

Siegel's (1 982a) in that only extremely prernature, very-low-birthweight, appropriate-for-

gestational age infants were included. In addition, Barsky (1 992) incorporated different risk

index variables. For instance, the measure of socioeconomic status used in Barsky's study

was based on Canadian norms instead of U S norms. Respiratory distress was measured

by duration of mechanical ventilation rather than the presence or type of assisted ventilation.

Barsky (1 992) also included intraventricular hemorrhage as a risk index variable. Overall,

Barsky's (1 992) systern of risk index variables was able to predict specific cognitive and

language outcomes and detect subsequent below average performances. She found that

SES, gender, materna1 age, and gestation were the best overall predictors. Other risk index

variables also found to contribute significantly towards specific outcomes were birth order,

amount of matemal smoking, number of previous spontaneous abortions and duration of

mechanical ventilation (Barsky, 1992). The presence of intraventricular hemorrhage was

associated with poorer performance on an expressive language measure (Barsky, 1992). As

with Siegel's (1 982a) model, Barsky (1 992) found that various combinations of risk index

variables (gestation, mâtemal age, birthweight, gender, SES & duration of mechanical

ventilation) were able to identify below average performance on two or more specific

cognitive and language outcome measures.

The Present Study

In the present study, a system consisting of a composite risk index score (Barsky,

1992; Siegel, 1982), and preschool language and behaviour measures was used to determine

what factors predict 8-year-old high-risk children's language and behavioural outcome as well

as identify developmental delay. This study is unique in several ways. First, a nurnber of

language measures have been used to assess various aspects of Ianguage, such as

receptive vocabulary, receptive language, expressive language, and expressive

vocabulary. Secondly, this study is one of the few studies to examine the relative

contributions of a biomedicaVenvironmental risk index score and preschool measures to the

prediction of behavioural outcome, and to the identifiction of behaviour difficulties in high-risk

children at 8 years of age. Thirdly, the relationship between performance on preschool

language and behaviour/competence measures and performance on language and

behaviour/competence measures at 8 years was investigated. Finally, this is one of the few

studies to investigate whether a relationship exists between language difficulties and

behaviour problems or poor competence for this group of high-risk children. By examining the

language and behaviour/cornpetence outcome of 8-year-old high-risk children, we can gain a

better understanding of the impact of these two factors on one another as well as on the

children's overall development.

Questions and Hypotheses

The present study addressed the following questions and hypotheses:

Question 1 : What is the pattern of performance on language and behaviour measures for this

sample of high-risk children?

H ypotheses:

a) High-nsk children's performance on the receptive language measures (Le., Reynell

Verbal Comprehension Scale, TACL-R Word Classes, Grammatical Morphemes, and

Elaborated Sentences subtests) will be similar to that of the normative sample on the

standardized language rneasures at 3.4, and 8 years.

Studies have reported that VLBW children (between 3 to 11 years) have relatively

intact receptive vocabulary and receptive language skills (Achenbach et al., 1993; Barsky,

1 992; Klein et al., 1 985; Robertson et al., 1 990; Siegel, 1 983, 1 985c, Vohr et al., 1 989).

b) High-risk children will have significantly lower scores on the Stanford-Binet

Vocabulary and Absurdities subtests, Reynell Expressive Language Scale, ITPA Grammatic

Closure, and the WISC-III Vocabulary and Similarities subtests compared to the normative

samples on these standardized language measures.

The language measures mentioned above assess the child's expressive language,

expressive syntax, and abstract reasoning skills. Previous studies have found that LBW

and VLBW children to be at greater risk for having problems in the areas of expressive

language, verbal ability, and syntactic production (Aram et al., 1991; Hack et al., 1992; Largo

et al., 1986; Lindgren et al., 1986; Michelsson et al., 1984; Siegel, 1985~).

c) High-risk boys will have significantly more lnternalizing and Externalizing problems

(Le., more socially withdrawn, inattentive, aggressive, and delinquent) on the CBCL

compared to the normative sample of boys from the CBCL, whereas high-risk girls will not

differ from the normative sample of girls from the CBCL at either 4 or 8 years of age.

Gender differences have been identified in the behavioural outcorne on the CBCL for

i S W and VLBW children. Low-birthweight and VLBW boys have been found to have

significantly poorer social relationships and more behaviour problems (Le., withdrawn,

aggression, delinquency, hyperactivity) compared to NBW peers, whereas LBW and VLBW

girls did not exhibit significantly more behavioural problems compared to NBW girls (Breslau

et al., 1 998; Ross et al., 1989; Tessier et al, 1 997).

d) High-risk children will have significantly lower scores on the Total Competence,

Activities, Social, and School competence scales of the CBCL at 8 years compared to the

normative sample from the CBCL. A lower score on the Competence scales reflects

decreased involvement and ability in participating in sports/hobbies, school, and social

interactions.

Studies have shown that premature school aged boys and girls had significantly

lower Total Competence and School Competence scores compared to their full-term peers

(Breslau et al., 1988; Ross et al., 1989).

Question 2:

(a) How well do individual language measures at 3 and 4 years predict language functioning

at 8 years?

Hypothesis: Preschool language measures will be related to language outcome at 8 years.

Studies have reported signifiant correlations between Ianguage measures

adrninistered at the same age, and at different ages, such as when testing was done 1 or 2

yeârs apart (Molfese et al., 1993; Siegel, 1982b, Siegel et al., 1995). Siegel (1 985b. 1995)

also found that early language rneasures (Le., 18 months, 2 - 4 years) were significantly

correlated with language measures (PPVT, WISC-R Vocabulary subtest) at 5 and 8 years.

(b) How well do the lnternalizing and Externalizing scales from the CBCL at 4 years predict

the Internalizing, Extemalizing and Total Competence Scale of the CBCL at 8 years?

Hypothesis:

lnternalizing and Externalizing scales of the CBCL at 4 years will be related to

lnternalizing and Externalizing scales of the CBCL at 8 years as these tests are testing the

same constructs (behaviour problems) at both ages. It is not known how well the

lnternalizing and Externalizing problems scales at 4 years will correlate with the Total

Competence scale at 8 years given that the Total Cornpetence measures the child's level of

functioning in different situations (sports, scho~l) rather than being a measure of the child's

behaviour problerns.

Achenbach, Phares, Howell, Rauh, and Nurcombe (1 990) found that there was

significant stability in mothers' ratings of their children's behaviour over a 2 year period on the

Internalizing, Externalizing, and Total Competence scales of the CBCL.

Question 4: Is there a relationship between language and behzdiour/cornpetence outcome

for this group of high-risk children?

Hypotheses: lt is not know whether a relationship will exist between the language measures

and the Internatizing, Externalizing scales of the CBCL at 4 and 8 years, or the Total

Competence scale at 8 years, for this group of high-risk children as none of the LBW and

VLSW studies reviewed have examined the interaction between language and behaviour

outcome, or language and competence outcome across different ages or at the same age.

However, studies based on clinical populations (Le., speech-language impaired or psychiatric

disorders) have found that language delays and behavioural/emotional problems are

moderately to highly correlated with one another (Baker et al., 1980; Baker & Cantwell, 1987;

Beitchman et al., 1986; Guâltieri et al., 1992). Beitchman et al. (1 996) also found that children

who were identified with speech and Ianguage delays at 5 years were more likely to display

psychiatric problems at 12 1/2 years.

Question 5:

a) Does a system consisting of a summary risk index score, and preschool language

and behaviour measures predict specific language and behavioural outcome for this sample of

high-risk children at 8 years?

b) Does the system of a risk index, and preschool Ianguage and behaviour measures

accurately identify below average performance for the individual high-risk children on specific

language and behaviour/competence outcome measures at 8 years?

Hypotheses:

The risk index scale and preschool language measures will account for a significant

amount of variance, as well as identify below average performance on the receptive and

expressive language measures (Le., WISC-III Similarities, TACL-R Grammatical Morphemes

subtest) at 8 years. The behaviour measure at 4 years will not account for a significant

amount of variance, or identify below average performance on language functioning at 8

years.

The behaviour measure at 4 years will account for a significant amount of the variance

in predicting outcome as well as identifying clinicat performance on the Internalizing,

Externalizing, and Total Competence scales of the CBCL at 8 years. In contrast, the risk

index score will not account for a significant amount of the variance or identify clinical

performance on the Internalizing, Extemalizing, and Total Competence scales of the CBCL at

8 years.

Molfese and Ditalla (1995) also used a system of factors that included a composite

risk index which consisted of seven cf Siegel's risk index variables. Molfese and DiLalla

(1 995) found that the composite risk index combined with the other factors in their system

correctiy identified children as delayed at 4 through 7 years of age. Furthemore, the

composite risk index score alone significantly discriminated functions for 10 and Verbal scores

at 7 years of age.

Most of the studies in the literature that have examined language functioning in

premature children have focused on using biomedical risk index variables and environmental

measures (Le., SES, home environment) to predict language outcome. Very few have

included preschool language measures in the list predictor variable to predict later language

outcome or delays. Siegel (1 983) found that 2- and 3- year language measures discriminated

between the delayed and nondelayed children on a receptive vocabulary measuie at 5

years. Miller and Siegel (1 989) found that infant measures of early language accurately

classified children with receptive and expressive language difficulties at 8 yean.

Very few of the studies that have studied behaviour outcome in LBW and VLBW

children have examined how early biomedical factors predict later behavioural outcome or

identify children's later tanguage delays. Mitchell et al. (1 985) found that for children at 8 years

of age, perintal and infant risk status variables were not significant discriminators of children

with behavioural problems and those without. None of the studies reviewed have used early

behaviour measures in a system of variables to predict later language and behaviour

outcome, or to identify subsequent delays or problems in the area of language or behaviour

functioning.

Chapter 2

Method

Subjects

Sam~le

The children in this sample were treated in a neonatal intensive care unit at a large

metropolitan hospital in Toronto, Canada between April, 1984 and June, 1986. These

children were participating in a prospective longitudinal study investigating the relationship

between brainstern electrical response audiometry, perinatal events and psychological and

educational outcorne of high nsk infants.

Inclusion Criteria

The children were considered to be high-risk as they al1 experienced neonatal

complications that required thern k i n g placed in a neonatal intensive care nursery.

Information has been collected for this group of high-risk children since they were 18 months of

age following professional guidelines of ethical conduct. This study, however, only presented

the data on language and behavioural outcome for children who were tested at three and eight

years and/or four and eight years of age. Children with serious complications (Le., brain

damage) were excluded. In addition, only children with a WISC-III Full Scale IQ score of 80

or above at 8 years of age were included in this study. The arbitrary IQ cutoff of 80 permitted

the investigation of language and behaviour outcome in a group of high-risk children without

severe intellectual deficits at 8 years of age. Table 2.1 presents the characteristics of the

children included in the study.

Table 2.1

Descri~tive Characteristics of Children lncluded in the Studv

M - SD Range - N

Birthweight (g)

Gestation (wk) .

Premature (gestation ~37wks) ('/O)

Full-term (gestation 2 37 wks) ('IO)

SGAa (

AGA^ ( '10

LBW (birthweight 2500-1 501 g)

VLBW (birthweight 5 15009)

Days on ventilation

Materna] Age (Years)

Materna1 Education (Post Secondary) (O/.)

SESc (Blishen)

Marital Status (Married) (%)

Raced (~aucasian) ("/O)

WISC-Ill IQ at 8 years

Note. N reflects the number of chitdren for the measures or variables Iisted above. Categoricai data given as percentages. =SGA - Small for Gestational Age: infant's birthweight falls 2 standard deviations or more below the mean weight for gestational age. =AGA - Appropriate for Gestational Age: infant's birthweight is appropriate for gestational age. %ES, socioeconomic status - see text for reference. dRace, motheh racial origin. elWISC-II I IQ score mean4 00 s.d.=15.

Sample Attrition

As with most longitudinal studies, the drop-out rate for the present study was high

(44-50°h). At 3 years, 129 children and their families participated in the follow-up study, but

only 65 of the children who met the inclusion criteria were assessed at 8 years. Similarly, at 4

years 103 children and their families participated in the follow-up study, but only 58 children

who met the inclusion crÏteria participated in the study at 8 years. Most of the children who

were not available for testing at 8 years had moved outside of the area, could not be located,

or their parents no longer wished to participate in the study. In order to determine whether

there was a selective dropout, comparisons of selected matemal and infant factors,

socieconomic level (SES), and preschool cognitive and language test scores were made

between the groups of children for whom scores were available at 8 years of age (the follow-

up group) and those for whom scores were not available at 8 years (the attrition group).

Appendix A displays the results of a series of t-tests comparing the performance of the

follow-up cases to the attrition group. As can been seen from Appendix A, there were no

significant differences between those who remained in the study and those who dropped out

on socioeconomic status or infant factors (e-g., birthweight), but two significant differences in

materna1 factors were found between the groups. The mothers in the attrition group were

significantly younger than the mothers in the follow-up group. They also had a lower level of

education compared to the educational level of the mothers in the follow-up group. On the

preschool cognitive and language measures only one significant difference was found

between the follow-up group and the attrition group. Children in the attrition group had

significantly lower standard scores on the Stanford-Binet Vocabulary subtest than the children

from the follow-up group at 4 years of age.

The attrition and follow-up groups were also compared on their parents' behavioural

ratings on the Internalizing and Externalizing scales from the CBCL at 4 years of age. These

cornparisons (t-tests) are also shown in Appendix A. No differences between the attrition

and the follow-up groups were found on the Intemalizing and Extemalizing Tscores of the

CBCL.

Overall, the above compansons showed that the children in the attrition group and the

follow-up group did not differ significstntly from one another on the severity of illness risk index

and infant variables, or on the preschool language, cognitive and behaviour outcome

measures. However, the findings suggested that there was a selective dropout between the

Wo groups related to the materna1 variables. Mothers who continued to participate in the

present longitudinal study tended to be older and had achieved a higher level of education

than the mothers who dropped out of the study.

Measures

Predictor Variables

Siegel (1 982a, 1982b, 1983, 1985a; Siegel et al., 1982) developed a risk index for use

with premature and full-terni infants. The risk index consists of a number of individual

variables that have been classified into four categories: matemal, infant, severity of illness,

and demograptiidSES. Because of the large number of individual risk index variables and the

relatively small sample size of the present study, a similar procedure to that of Molfese et al.

(1 997) was used where Siegel's risk index variables were combined into one risk index score.

It is important to note that some of the risk index variables used by Barsky (1 992) were also

included in Siegel's risk index scale (i.e., intraventricular hemonhage). Each of the risk index

variables was assigned a 1 or a O depending on whether the variable was considered to

place a particular child "at risk for developmental difficulties. The composite risk index scale

had a maximum score of 16. The higher the score on the risk index the more "at risk" the child

was for experiencing developmental difficulties. The mean risk index score for this sample

was equal to 4.33 (s.d. 2.60; range=O-9). A detailed description of how each of the risk index

variables was scored is discussed in the following sections.

Medical Records Data Collection

The risk index variables were collected from the medical records at the cornmunity

hospital where the children had been patients. The principal investigators of longitudinal

prospective study supervised this data collection (see Appendix B for data record form).

Maternal Risk lndex Variables

The maternal risk index variables included maternal age at time of the infant's birth,

birth order (gravidity), maternal smoking during pregnancy, and previous spontaneous

abortions. Maternal smoking during pregnancy and previous spontaneous abortions were

rated as present (1) or absent (0). Matemal smoking has been found to be associated with

lower birthweight, increased incidence of mortality and morbidity, and impaired scholastic

ability ( Finnegan, 1 985). Maternal age of 20 years and over was scored "not at risk" (O),

whereas a maternal age of 19 years or younger was scored as "at risk" (1). Infants born to

teen-age mothers are thought to be "at risk" for developmental delays because their mothers

tend to have lower socioeconomic status and educational levels which are a consequence of

earl y child bearing . Furthermore, studies have provided evidence t haî a positive correlation

exists between cognitive outcome and maternal age at the time of the infant's birth (e.g.,

Rickards, Ryan, & Kitchen, 1988). Following the rating system used by Molfese et al. (1 997),

gravidity of 1.2, or 3 was scored as "not at risk (0); whereas a gravidity greater than 3 was

considered "at risk" (1) (Molfese et al., 1997). Studies have found that later born children

perform less well on cognitive and language outcome measures than first born children (Klein,

Hack, Gallagher, & Fanaroff, 1985; Largo et al., 1986; Siegel, l982a). Table 2.2 shows the

frequencies for each of the matemal risk index variables.

Infant Risù lndex Variables

The infant index variables were sex, gestational age, and birth weight. Gestational

age was determined from the date of the rnother's last menstrual period and confirmed by fetal

ultrasound during the first trimester. Like Molfese et al. (1997). boys in this study were rated

as 1 and girls were rated as O, as boys have been found in the Iiterature to be at increased

risk for experiencing outcorne problems (Le., behaviour difficulties). A gestational age of 30

weeks or less was scored as "at risk (l), whereas a gestational age of 31 weeks or greater

was scored C. Studies have found that infants with a gestational age of over 30 weeks have

more favorable cognitive outcornes than those bom before 30 weeks (Kitchen et al., 1980;

Largo et al., 1989). A birthweight of 1500 grams or less was scored "at risk" (1). whereas a

birthweight of 1 501 grams or above was scored a O. Lower birthweight has been associated

with decreased IQ scores, slower language development, and increased learning problems

(Breslau et al., 1994; Largo et al., 1989; Lee et al., 1993). The frequencies for the infant risk

index variables are shown in Table 2.2.

Severitv of lllness Risk Index Variables

The severity of illness risk index variables included intraventricular hemorrhage (grade

level 1 -4). 5-minute Apgar scores, presence of mechanical ventilation, du ration of mechanical

ventilation, birth asphyxia, and presence of apnea. Table 2.3 shows the frequencies for the

severity of illness risk index variables.

1 ntraventricular hemorrhage was measured by se rial computed tomography brain

scans beginning in the first week of life and graded at initial scan by degree of severity

(Burstein, 1979): Grade I isolated germinal rnatrix hemorrhage; Grade If intraventricular

extension of hemorrhage with normal ventricular size; Grade III intraventricular hemorrhage

with dilated ventricles; Grade IV intraventricular hemorrhage with dilated ventricles plus

extension of germinal matnx hemorrhage into adjacent bain parenchyma (Burstein, 1979). ln

the present study, one variable denoted the presence of intraventricular hemorrhage

(presenkl , absent=O), while another variable indicated the severity of the intraventricular

hemorrhage (grade 1 & grade ll=O; grade III and grade IV=l ).

Table 2.2

Freauencies of Maternal and Infant Risk lndex Variables of Hiah-Risk Children lncluded in

Variables - n - O/O

Maternal Risk lndex Variables Maternal Aae

20 - 42 68 97.1 17 - 19 2 2.9

Gravidity 1.2, or 3 4 or more

Matemal Smokinq Absent Present Unknown

Previous S~ontaneous Abortions Absent Present Un known

Infant Risk lndex Variables Gender

Fernaie Male

Gestational Aqe (weeks) 31 & above 25-30

Birthweiaht (arams) 1501 - 2480 580 - 1500

The 1 -minute and 5-minute Apgar scores were measured using the Apgar (Apgar,

1953; Apgar 8 James, 1962), a screening device used to assess a newborn's physical

condition (heart rate, breathing effort, muscle tone, reflex irritability, & colour) immediately

following birth. A child was considered to have had asphyxia ("at risk"; 1) if his/her 1 -minute

Apgar score was 5 or lower. Consistent with the scoring criteria used by Molfese et al.

(1997), 5-minute Apgar scores greater than 8 were scored as "normal" (O), whereas lower

Apgar scores were considered "at risk (1).

The presence of apnea was defined as the absence of breathing for more than 15 or

20 seconds ("at risk"; 1). Mechanical ventilation was represented by two variables. One

variable denoted whether mechanical ventilation was required (present=l , absent=O). On

the second variable, children who had received mechanical ventilation for more than 27 days

were scored as "at risk" (l), whereas children who did not require mechanical ventilation for

more than 27 days received a score of O.

The Demoara~hic Risk fndex Variables

The demographic risk index variables are highest maternai level of education attained

and socioeconomic status (SES) as defined by Blishen, Carroll, and Moore (1 987). Maternal

education was scored as "not at risk" (0) if the mothers had completed high school or better,

whereas matemal education was scored "at Flsk"(1) if mothers had completed grade 1 1 or l e s

(Hack et al., 1992). The individual SES index score reflected the parent's occupation ( e-g.,

28.33 for a labourer to 101 -32 for a physician). In this particular sample, the SES index score

was calculated on the basis of the prirnary wage earner's occupation. Blishen et al. (1 987)

reported a rnean of 42.74 with a standard score of 13.28 based on the labour force from 1981

Census of Canada data. The mean SES score for the present sample was equal to 52.9

(s.d. 1 6.1 4; range=23.00-101 BO). Molfese et al. (1 997) did not include SES in Siegel's risk

index scale, rather they examined it as a separate independent variable. This study did not

examine SES as a separate variable because Pearson correlation analyses revealed that

SES was not significantly correlated with any of the language or behaviour outcome

measures. The majority of the families participating in this study were from low-middie to

upper-middle class backgrounds. Even though SES alone may not be a factor, it may have

an influence in combination with other variables like those included in a risk index.

Socioeconomic status was scored as "not at risk" (0) if the SES score did not fall more than

one standard deviation below the mean (Blishen score 2 30); SES scores more than one

standard deviation beiow the mean (Blishen score of 129) were considered "at risk" (1). A

Blishen score of 29 or less would include unskilied labourers and families receiving social

assistance. Table 2.3 shows the frequencies for the demographic risk index variables-

Tests and Tasks

Chronological age was used as the basis for calculating the children's scores on the

various cognitive, Ianguage and behavioural rneasures. For children who were born

prematurely, before 37 weeks gestation, the corrected age was not used as one of the

purposes of this study was to examine how these high-risk children perform on language and

behavioural measures compared to their same age peers. Corrected age refers to calculating

a child's age based on when helshe was expected to be born (due date) rather than when

they were actually born (date of birth). By the time children reach the age of 3 years, the

norms for most standardized tests cover a two to three month age span, thereby eliminating

the necessity of using the child's expected date of birth rather than their actual date of birth.

In the context of a prospective longitudinal research program investigating the

relationship between perinatal events and psychological, linguistic and behavioural outcornes

of high-risk children, a variety of measures sampling skills and abilities related to the child's

developing language repertoire were administered. A detailed description of each measure is

provided later in this chapter. Measures that assessed the child's ability to reflect on the

meaning of words and word concepts were selected. For example, the Vocabulary and

Absurdities subtests from the Stanford-Binet-Fourth Edition (Thorndike, Hagen, & Sattler,

1986) were used at 3 and 4 years of age. The Vocabulary and Absurdities subtests from the

Stanford-Binet were used instead of similar subtests from the Wechsler Preschool and

Primary Scale of Intelligence (WPPSI) (Wechsler. 1967) because the WPPSI-R (Wechsler,

1989) had not been published at the time of testing. The Stanford-Binet was a better choice

over the WPPSI as the WPPSl had an inadequate flooring effect in that it did not clearly

differentiate abilities at the lower end of the scale. Furthemore, Sattler (1 990) noted that the

WPPSI may not provide precise IQ scores for children who are functioning 2 or more standard

Table 2.3

Freauencies of Severitv of lllness and Demoara~hic Risk Index Variables of Hiah-Risk

Children lncluded in Studv [n=701

Variables - n - O/*

Severity of lllness Risk lndex Variables Grade of lVHa

O is, II III & IV

5-Minute A~aar scores 8 - 10 6-7

Duration of Mechanical Ventilation (dava O

Asphvxia Absent Present

A ~ n e a Absent Present

Demographic Risk lndex Variables Maternai Education

High school - Post Secondary Grade 1 1 8 Below

SES - Blishen score 30 - 101 23 - 29

alVH Present, presence of intraventricular hemorhage. bBirth Asphyxia, presence of Asphyxia CApnea, presence of Apnea.

deviations below the mean of the scale. With regard to the 8 year follow-up, other measures

reflecting on word meaning and word concepts were used. More specifically, the Vocabulary

and Similarities subtests from the Wechsler Intelligence Scale for Children-Ill (WISC-III)

(Wechsler, 1991) were substituted for the Vocabulary and Absurdities subtests from the

Stanford-Binet. The WISC-III is widely acknowledged as being the instrument of choice for

children functioning in the low-average range or above with respect to general intelligence

(Sattler, 1990).

A general measure of language development was also selected. The Reynell

Developmental Language Scales (2nd rev., Reynell & Huntley, 1985) was administered at 3

years. The Reynell provided a measure of the child's expressive language and language

comprehension (Le., receptive language). The Reynell was chosen because it is a well

normed test designed for children between the ages of 1 and 7 years (Reynell 8 Huntley,

1985). and it has been used in a number of studies investigating the outcome of VLBW and

premature children (e.g., Barsky, 1992; Miller & Siegel, 1989; Siegel et al., 1994; Silva et al.

1983). In addition, specific measures of language development were administered at age 4

years. The Grammatic Closure subtest from the Illinois Test of Psycholinguistic Abilities

(ITPA) (Kirk, McCarthy, 8 Kirk, 1968) is a measure of expressive syntax, while the Sound

Mimicry subtest from the Goldman-Fristoe-Woodcock Auditory Skills Test Battery ( G W )

(Goldrnan, Fristoe, and Woodcock, 1974) is a measure of early phonological development.

The Grammatic Closure subtest from the ITPA was chosen because it did not require the child

to formulate a complex verbal response, while performance on the Sound Mimicry subtest

from the GFW was not dependent on comprehension. Other studies in the literature have

also administered selected subtests from the ITPA as measures of language outcome for

VLBW and premature children (e.g., Largo et al., 1986; Michelsson et al., 1984; Siegel, 1985b,

Silva et ai., 1983).

Measures of general language development were not administered at 8 years

because the Reynell norms do not extend to this age, and time constraints precluded the

administration of other measures (e.g., Clinical Evaluation of Language (CELF) ; Semel-Mintz

& Wiig, 1982). Specific measures of language comprehension were, however, administered

at age 8. For example, receptive vocabulary was measured by the Peabody Picture

Vocabulary Test-Revised (PPVT-R) ( Dunn & Dunn, 1981), a well normed test that is widely

used in the literature (e-g., Aram et al., 1991 ; Achenbach et al., 1993, Grunau et al., 1990;

Saigal et al., 1 991 ; Siegel, 1 985b; Vohr et al., 1 989). The type of words included in the

PPVT-R are content words, primarily nouns and verbs, which gradually increase in difficulty.

However, it only represents a global measure of one-word receptive vocabulary, a short-

coming if one wishes to explore various facets of a child's receptive language abilities. For

this reason, the Test of Auditory Language Cornprehension-Revised (TACL-R) (Carrow-

Woolfolk, 1985). was selected as it provided a measure of several key facets of receptive

language in addition to a global total score, unlike tests such as the Test of Receptive

Grammar Language (TROG) (Bishop, 1989) which only provide a global score. For

example, the TACL-R includes subtests which measure the comprehension of syntactic

complexity and morphological markers. In contrast to other measures of receptive language,

the format of the TACL-R (Le., the use of pictorial stimuli; multiple-choice test), avoided the

confound of significant memory requirements (e.g. Listening Comprehension subtest from the

WIAT). Furtherrnore, tests such as the Token Test for Children (Disirnoni, 1978) explore the

effect of increasing the stimulus length on comprehension performance, whereas tests such as

the TACL-R are primarily concemed with the comprehension of grammatical forms (Carrow-

Woolfolk, 1 985).

Measures of expressive language were considered at age 8 but were rejected

because there were very few well norm-referenced tests available (Seymour 8 Wyatt,

1992). One of the main problems cited with norm-referenced standardized language tests is

that the depth and extent of their sampling of language is "quite superficial and largely

confined to 'form' of language. A few tests examine limited aspects of 'content', and still fewer,

if any, examine 'use' (pragmatics)" (Seymour & Wyatt, 1992, p. 207). The Sound Mimicry

subtest from the GFW was not administered at 8 years because of the inadequate ceiling for

this sample. The Grammatic Closure subtest of the ITPA was also not administered at 8

years because of its lack of differentiation at this age. Obtaining a language sample was

considered but rejected because of the variety of paradigms that can used to elicit a language

sample (Le., interview, informal observation, ask child to describe picture), lack of

standardization, and complexity of developing coding schemes. Furthemore, very few

studies in the literature following the development of LBWNLBW or premature children have

used informal language sampling as a measure of speech and language.

A measure that evaluated the child's competence skills and behaviour problems was

administered at the age of 4 and 8 years. The Child Behavior ChecklisV4-18 (Achenbach,

1991 ) was selected because it measures some unique aspects of social-emotional and

behavioural status that differ from those found on the Conners Parent Rating Scale (Conners,

1985) and the Quay-Peterson Revised Behavior Problem Checklist (Quay & Peterson,

1983). The CBCL was also selected because it is commonly used in the literature of

premature and VLBW children (Breslau et al., 1988; Hack et al., 1992; Ross et al., 1990).

Behaviour was not assessed at 3 years because the majority of the behaviour rating scales

are not designed for very young children (i-e., 3 years) and the Child Behavior Checklistf2-3

(Achenbach, 1992), which is designed to obtain parents' ratings of the behavioral/emotional

problems of 2- and Syear-old children, had not been published at the time of testing.

The following section describes each of the measures listed in Table 2.5. A brief

summary of each test's reliability and validity can be found in Appendix C.

Cognitive Measures

The Stanford-Binet Intelliaence Scale-4th Edition

The Stanford-Binet Intelligence ScaleQth Edition (Thorndike, Hagen, & Sattler, 1986),

a standardized test designed to assess general cognitive abilities, was administered to the

children at 3 and 4 yean. The scale scores can be used to obtain an IQ score as well as

subscale scores for Verbal Reasoning, AbstracWisual Reasoning, Quantitative Reasoning,

and Short Term Memory. Although the entire Stanford-Binet was administered to the children,

only the Vocabulary and Absurdities scale scores are reported here. A detailed description of

the Vocabulary and Absurdities subtests can be found in the language section of this chapter.

A more detailed description of the Wechsler Intelligence Scale for Children-Ill is

provided here because this was the cognitive measure used to determine which of the

children assessed at 8 years would be included in the present study (Le., IQ scores 180).

The Wechsler Intelliaence Scale for Children - 111

The Wechsler Intelligence Scale for Children - III (WISC-III; Wechsler, 1 991 ) was

administered when the children were 8 years old and provides a measure of cognitive

functioning. An estirnated full scale Intellectual Quotient (IQ) score was obtained using the

Similarities, Vocabulary, Digit Span, Arithmetic, Picture Completion, Bock Design, Coding, and

Picture Arrangement subtests. The sum of the scaled scores in the Verbal domain and the

Performance domain were pro-rated according to the instructions described in the WISC-III

manual. An estimated Full Scale IQ score was derived by adding the prorated scores for the

Verbal and Performance areas. The prorated IQ for each of these three scales had a mean of

100 and a standard deviation of 15, while each subtest sa le score had a mean of 10 and a

standard deviation of 3.

For the Vocabulary subtest, the child was required to provide the meaning of words.

The words increase in difficulty and included common nouns, abstract nouns and verbs.

Examples were "What is a knife?"; "What is a nuisance?". The child was awarded a two, one

or zero score depending on the quality of his/her response.

In the Similarities subtest the child was asked to Say in what way two things were

alike. Examples were "In what way are an APPLE and a BANANA alike?"; "ln what way are

ANGER and JOY alike?". A response indicating an abstract classification received more credit

(Le., two points) than a response indicating a concrete classification (i.e., one point). For

example, if the child responded that "an apple and a banana are both fruit" hekhe would

have received two points, but if the child had said "you eat them both" then he/she would

have only received one point.

In the Anthmetic subtest the examiner read the questions to the child, and the child

was required to solve several different types of arithmetic problems involving addition,

subtraction, multiplication, division, and problems solving within a specified time limit without

the aid of pencil and paper. The first 18 items were scored 1 or O, while Items 19 to 24 were

scored 2, 1 , or O. A score of 2 included a 1 -point bonus for answering the item correctly within

the first 1 0 seconds.

The Digit Span subtest was divided into two parts, Digits Foward, which contained

nurnber series ranging in length from two to nine digits and Digits Backward, which contained

number senes ranging in length from two to eight digits. Two trials were presented for each

sequence length. In Digit Forwards the child had to repeat for verbatim the series of nurnbers

given by the examiner, while in Digits Backward the child had to Say the number sequences

in the reverse order to that given by the examiner. The child received two points if he/she got

both trials of digits for each sequence length, one point if only one trial was correct, and zero

points if neither were correct.

The Block Design subtest consisted of nine cubes, coloured red on two sides, white

on two sides, and red and white on two sides. On the first two items the child was required to

use the blocks to reproduce the block design constructed by the examiner. Eleven cards with

printed designs bound into a booklet, provided the stimuli to be matched for designs 3 through

1 1. It was a timed test, bonus points were awarded for fast and accurate execution of the

task.

The child's task on the Picture Completion subtest was to name or point to the

essential part missing in 30 drawings of common objects, anirnals, or people ( e.g., cat) within

the 20-second tirne limit. The pictures were shown one at a time.

For each item on the Picture Arrangement subtest individual cards, depicting a

particular scene in a situation (Le., a man and a woman going on a picnic), were placed in a

specified disarrange order and the child was asked to arrange the pictures in the "right" in order

to tell a story that made sense. The number of pictures per item ranged from three to six. The

child was given bonus points if he/she completed the task quickly.

The Coding subtest consists of two separate parts. Coding A is given to children

under 8 years of age, and Coding 6 is given to children 8 years of age and older. Coding B

was used in this study. In Coding 8, the key/template consisted of boxes containing

num bers 1 through 9 in the upper part and symbols in the Iower part. Each number was

paired a with a different symbol. The test stimuli consisted of boxes containing a number in

the upper part and an empty box in the lower part. The child was required to write in the

empty box the symbol that was paired with the number. The child was given 1-point for

each correct item that he or she completed within 120 seconds.

Language Outcome Measures

The Vocabulary and Similarities subtests from the WISC-III, described above, were

used as measures of expressive language outcome at 8 years. In addition, the Test of

Auditory Language Comprehension and the PPVT-R were used as measures of receptive

language outcome at 8 years.

Test of Auditory Lanauaae Com~rehension - Revised

The Test of Auditory Language Comprehension - Revised (TACL-R; Carrow-

Woolfolk, 1985) was administered at 8 years and provided a measure of auditory

comprehension. The TACL-R has three subtests; Word Classes and Relations, Grammatical

Morphemes, and Elaborated Sentences.

For al1 items the child was required to point to one of three black line drawings that best

represented the meaning of the word, phrase, or sentence spoken by the examiner. One of

the choices for each item illustrated the meaning of the word or morphological or syntactic

structure being tested. The foils illustrated two contrasting linguistic forrns. A Deviation

Quotient (DQs) score was cornputed for each of the three subtests and the total TACL-R

score, with a mean of 100 and a standard deviation of 15.

The Word Classes and Relations subtest measured the literal and most common

meanings of word classes such as nouns, verbs, adjectives, and adverbs (e-g., "a little bird

eating"), and basic word relations such as agent-action, attribution-object, and attribution-

agent-action (e-g., "a large red bal!"). The Grammatical Morphemes subtest consisted of

short, simple sentences that measured grammatical morphemes such as prepositions, noun

inflections, noun-verb agreement, and derivational suffixes (e-g., "She would have

skipped."). The Elaborate Sentences subtest measured the child's ability to comprehend

elaborated sentences that varied in terms of their construction, such as active versus passive

voice. and direct versus indirect objects (e.g., "The boy the girl pulled had on a baseball

cap.").

The Peabodv Picture Vocabuiarv Test - Revised

The Peabody Picture Vocabulary Test - Revised (Form-L) (PPVT-R; Dunn 8 Dunn,

1981) was administered when children were 8 years old. This test is a multiple-choice

measure of receptive vocabulary in which the child was required to identify which one of four

pictures best depicted the meaning of the word read by the examiner. The results were

reported as a standard score with a mean of 100 and a standard deviation of 15.

Language Predictor Measures

The Revnell Develo~mental Lanauaae - Scales (2nd rev.)

The Reynell Developmental Language Scales (RDLS; 2nd rev., Reynell 8 Huntley,

1985) was adrninistered when the children were 3 years old. It has two scales, the Verbal

Comprehension Scale (Form A) and the Expressive Language Scale, designed to measure

receptive and expressive language skills. Each scale has a standard score with a mean of O

and a standard deviation of 1.

The Verbal Comprehension Scale consists of ten sections, a total of 67 questions,

which follow the developmental sequence of receptive language skills. The child was

required to fo!low the examinets directions pertaining to models of familiar objects (Le., doll,

car, spoons, etc.) and representations of objects, people and animais (Le., toy miniatures).

Questions were arranged in order of increasing difficulty where the directions become more

abstract (e.g., "Who used to go to school but doesn't now?") and more complex (e-g., "Put ail

the pink pigs round the outside of the field.").

The Expressive language scale is divided into three sections: structure, vocabulary,

and content. In the Structure section, the examiner observed the child's ability to use words

and word combinations meaningfully, sentences to communicate his or her needs and wants,

and use of syntax (e-g., prepositions and pronouns).

For the Vocabulary section, the child was required to name familiar items (e-g., bail,

doII, cup) as well as label coloured pictures of objects (e.g., chair, window). The child was

also asked to describe familiar items or concepts (e-g., "What's an apple?; "What does

'hungry' mean?").

In the Content part, the chiid was shown four pictures, one at a time, each depicting a

family engaged in a familiar activity or task (e.g., setting the tabte). The child was asked to tell

the examiner about the picture.

Vocabulary and Absurdities Subtests of the Stanford-Binet - Fourth Edition

The Vocabulary and Absurdities subtests from the Stanford-Binet Intelligence Scaie:

Fourth Edition (Thorndike, Hagen, & Sattler, 1986) were administered to children at 3- and 4-

years of age. The Vocabulary subtest is divided into the picture vocabulary section and the

oral vocabulary section. For the picture vocabulary section, the child was asked to name the

pictures shown (Le., bridge), and for the oral vocabulary items, the child was asked to explain

orally the meaning of words (e.g., dollar).

The Absurdities subtest also consists of two sections for the preschool children. For

the first four items, the examiner asked the child to identify which one of three pictures looked

wrong or silly (e-g., horse, cat, duck with bunny ears). For the remaining items, the child was

required to verbally express what was incorrect in each picture in response to the examiner's

query, "What is wrong, what is silly about this picture?" (e-g., man drinking from a baby's

bottle, cat in bird cage).

For each item in the Vocabulary and the Absurdities subtest was scored 1 or O. The

raw scores were then converted into a standard age score for each subtest with a mean of 50

and a standard deviation of 8.

Grammatic Closure Subtest of the Illinois Test of Psvcholinauistic - Abilities

The Grammatic Closure subtest of the Illinois Test of Psycholinguistic Abilities (ITPA)

(Kirk, McCarthy, 8 Kirk, 1968) was administered when the children were 4 years old. The

examiner read to the child incomplete statements, one at a time, that were accompanied by

pictures which portrayed the content of the statement. The examiner stopped abruptly at the

point where the child was to supply the missing word to complete the sentence (e.g., Here is

a dog. Here are two "; "Here the thief is stealing the jewels. Here the jewels have been

"). According to the test's authors, the Grammatic Closure subtest "[measures] the

child's ability to make use of the redundancies of oral language in acquiring automatic habits for

handling syntax and grammatic inflections" (Kirk et al., 1968, p. 11 ). A scaled score based on

age was used for this test with a mean of 36 and a standard deviation of 6.

Sound Mimicrv Subtest of the Goldman-Fristoe-Woodcock Sound-Svmbol Test

The Sound Mimicry subtest from the Goldman-Fristoe-Woodcock Auditory Skills Test

Battery (Goldman, Fristoe, and Woodcock, 1974) measures the child's ability to imitate non-

words (e-g., 'ost', 'maf', 'plon') immediately after auditory presentation. Each item was scored

O or 1. Raw scores were converted to percentile ranks.

Behaviour Measure

The Child Behavior Checklistl4-18

The Child Behavior Checklist/4-18 (CBCL; Achenbach, 1991 ) is a standardized

questionnaire designed to rneasure each child's behaviour problems and social competence

as reported their parents. This test was given to parents, usually the mother, when the

children were assessed at 4 and 8 years of age. The CBCL consists of a series of child

behaviour profiles that are standardized separately for children of each sex at age 4 to 11 and

12 to 18 years. The checklist consists of 20 social competence questions and 11 8 behaviour

problems items. The competence scales are computed for children 6 years of age and older,

and consist of 3 subscales entitled Activities, Social and School. On the activity scale the

child was rated on the number of sports, hobbies/ games, and jobskhores helshe does

outside of school. The child was also rated on how often and how well helshe performs the

activity compared to other children his/her age. The social score reflected participation in

social organizations, number of friends, frequency of contacts with friends, and how well the

child related to his parents, siblings and peers, as well as how well the child occupies hidher

own time. The school score reflected the child's academic performance, special class

placement, grades repeated and schwl problems.

The 11 8 behaviour problem questions pertain to the child's typical behaviour in a

number of situations. Each item was rated by the parent according to a three point scale

(O=not true, 1= somewhat or sometimes true, 2 = very true or often true). Separate problem

scales/syndromes were developed on the basis of factor analysis. Each behavioural item

was then grouped into one or more of these problem scales: Withdrawn (e-g., "withdrawn,

doesn't get involved with other"), Somatic Complaints (e.g., "Physical problems without a

known medical cause"), Anxious/Depressed (e-g., "Feels worthtess or inferior"), Social

Problems (e-g., "Doesn't get along with other kids"), Thought Problems (e-g., Can't get hidher

mind off certain thoughts, obsessions"), Attention Problems (e-g., "Can't concentrate, can't

pay attention for long"), Delinquent Behavior (e-g., Doesn't seem to feel guilty after

misbehaving"), and Aggressive Behavior (e-g., "Argues a lot").

A Total Problern score is based on al1 of the behaviour problem scores, while setected

problem scales are grouped into either Intemalizing or Externalizing behaviour problems. The

Withdrawn, Somatic Complaints, and Anxious/Depressed syndromes are classified as

lnternalizing behaviour problems, while Delinquent and Aggressive behaviours are classified

as Externalizing behaviour problems.

T scores were assigned for the competence and behaviour problem scales, as well as

the Internalizing, Externalizing, and Total problem scores. On the behaviour problem scales

Achenbach truncated the assignment of T scores as a means to equalize the starting points of

al1 the syndrome scales. Thus, Achenbach assigned a T score of 50 to al! raw scores that

had a midpoint percentile score 5 50. Achenbach (1 991) discusses in the CBCL Manual how

he obtained the midpoint percentiles for the competence domains, syndromes, and the total

behaviour score as well as the internalizing and externalizing scores. Normal, borderline, and

clinical ranges were determined for each scale as foltows: on the Total Competence scale a T

score of above 41 was normal; a T score between 37 and 40 was borderline; and a T score

below 37 was in the clinical range. On the 3 individual competence scales a T score of 34 or

greater was considered normal; a T score between 30 and 33 fell within the borderline range,

and a T score of 33 or l e s fell within the clinical range. For the 8 individual behaviour problem

scales a T sccilre below 67 was considered within the normal range, a T score between 67 to

70 was in the borderline range, and a T score above 70 was considered to be in the clinical

range. On the Internalizing, Externalizing, and Total Behavior Problem scales a T score

below 60 was normal, a T score between 60-63 was borderline, and a T score above 63

was in the clinical range.

Procedure

Assessmen t

At three, four, and eight years of age each child was given a standardized cognitive

and language assessment !hat took approximately two to four hours to complete, depending

on the age of the child. Two 15 minute breaks were usually taken during the assessment,

however, some children required more frequent breaks depending on their attention span and

ability to concentrate.

Majority of the children were assessed at the Ontario lnstitute for Studies in Education

(OISE), but home assessments were arranged for those parents or legal guardians who were

interested in their child's continuing participation in the study but were unable to travel to the

testing site. Participation was on a voluntary basis and informed consent was obtained from

the child's parent or legal guardian at the time of testing (Refer to Appendix O consent forrn).

A small renumeration for travel and parking expenses was made available to those who

chose to accept it.

Verbal feedback was given to the parent(s) or legal guardian(s) regarding the child's

general performance shortly after the testing session. Written research assessment reports

were sent to the parent or legal guardian, and to other facilities when requested by the parent

or legal guardian. If necessary, referrals for further assessment or remediation were made by

the supervising psychologist.

Data Analysis

To test the hypothesis that high-risk children would have average receptive language

and below expressive language skills, their performance was compared to the normative

sampIe of standardized tests using one-sample t-tests. To test the hypothesis that high-risk

boys would have significantly more behaviour problems compared to the normative sample,

whereas as high-risk girls would have scores similar to those of the normative sample of the

CBCL, one-sample t-tests were used to compared the two groups performances. One-

sample t-tests were also performed to examine whether high-risk children had significantly

tower competence scores compared to the normative sample of the CBCL. Correlation

analyses were performed to examine the relationship between individual preschool language

measures and language functioning at 8 years, and to examine how the Internalizing and

Externalizing scales of the CBCL at 4 years relate to Internalizing, Externalizing, and Total

Cornpetence scale of the CBCL at 8 years. Next, contingency analyses were developed,

and either chi-square analyses corrected for continuity, or Fisher's Exact Tests were

performed to examine how well preschool language and behaviour measures predict

corresponding language and behaviour functioning at 8 years. Chi-square analyses,

corrected for continuity, are used when N is greater than 40, whereas as the Fisher's Exact

Test is used when N is between 20 and 40 and the smallest expected frequency is less than

5, or when N is less than 20 (Siegel, 1956). To examine the relationship between language

development and behaviour ratings correlational analyses were perforrned. To investigate

the predictive value of language and behaviour measures on each other, contingency tables

were developed. The results were used to ascertain the number of subjects who were

performing within a certain range (either below averageklinical range or averagehormal limits)

at the initial and subsequent assessments. Chi-square analyses. corrected for continuity, or

Fisher's Exact Tests were performed to determine whether there was an association between

language and behaviour measures. To examine the relative contributions of Siegel's risk

index scale and preschool language and behaviour measures to the prediction of language

and behavioral outcome at 8 years, hierarchical regressions were conducted. Finally,

hierarchical discriminant function analyses were used to determine how well a system

consisting of Siegel's risk index scale and preschool language and behaviour measures were

in identifying delays in language development and behavioural outcome for high-nsk children

at 8 years.

Because of the exploratory nature of this study the alpha level was set at .IO. In

considering the smal! sample size, a more lenient alpha level was chosen in order to offset the

increase in type II enor rate (Klein et al., 1983). The more lenient alpha level also permits the

identification of the possible trends and patterns for this sampte of high-risk children.

However, because of the large number of cornparisons made in this study there is the

increased chance of making a type I enor. Therefore, the Bonferroni corrections for multiple

tests within domains of function were made (Hack et al., 1992). A decision was made to make

corrections by domain as oppose to studywise. When a studywise alpha is set, significant

differences rnay not emerge for the individual dornains because the correction that is done for

cornparisons across al1 domains has obscured the findings. All data analyses were performed

using the SPSS program, version 10.0-

CHAPTER 3

Results

Pattern of Performance

L a n ~ u a ~ e Functioninq

Of the 70 eight-year-old children who met the inclusion criteria of having a full-scale

IQ score of 80 or greater, 65 of these children were assessed at 3 years of age and 58 were

assessed at 4 years of age. The discrepancy in the frequencies on the Vocabulary and

Absurdities subtests of the Stanford-Binet Intelligence Scale: Fourth Edition (see Table 3.1)

is a result of the fact that some of the children received raw scores of zero and a scale score

could not be computed. At 3 years of age, 9 percent of the children in the present sarnple

received a raw score of zero on the Absurdities subtest, white only 2 percent of the children

assessed at 4 years of age received a raw score of zero on the same subtest. According to

Thorndike et al. (1 986). by age 3 and 4 years the Stanford-Binet "adequately discriminates

among ail except the lowest 2 percent of the age group" (p. 8). Children receiving raw

scores of zero on the Absurdities subtest are Iikely to be experiencing significant delays.

This suggests that the pattern of performance exhibited by this sample may provide

evidence for language difficulties to be identifiable even as young as at 3 years of age for a

high-risk sample. The discrepancy in the sampte size between the language measures at 8

years occurred because some of the language measures were introduced part way through

the 8 year follow-up assessrnent battery.

The means and standard deviations of the Ianguage rneasures at 3, 4 years, and 8

years, as shown in Table 3.1, were al1 within the average range. One-sample t-tests were

performed to compare the mean scores of the high-risk sample and the normative sample

on the standardized language measures by age (see Table 3.1). The Bonferroni correction

factor was used, which indicated an alpha value of .O3 for significance on the language

measures at 3 and 4 years, and an alpha value of -01 for significance at 8 years.

Table 3.1

Com~arisons between the Hiah-Risk Samde at 3.4. and 8 vears of acie and the Normative Sam~le of the Standardized Lanauaae Measures

High-Risk Sample

Normative Sample

3 years Stanford-Binet

Vocabulary Absurdities

Revnell Verbal Comprehension Expressive tanguage

4 years Stanford-Binet

Vocabulary Absurdities

GFW Sound Mimicry

ITPA Grammatic Closure

8 years WISC-III

Vocabulary Similarities

TACL-R Word Classes Grammatical Morphemes Elaborated Sentences Total Score

PPVT-R

Note. The indicated for the standardized language measures reflects the number of children for the age level that corresponds to the present sample.

aThe GFW reports the number of children by age group as oppose to individual ages, so the number indicated reflects the number of children assessed for the age group of 3 to 8 years.

b ~ h e n for the ITPA reflects the entire standardization sample as the ITPA manual does not report the sample size by age.

At 3 and 4 years: 'pc.03. At 8 years: 'pc.01.

57

Although partial support for the hypothesized relatively intact receptive vocabulary

and language was found, exceptions were noted. As shown in Table 3.1, high-risk children

generally did not perform significantly different from the children in the normative samples on

standardized receptive vocabulary measures (i.e., PPVT-R; TACL-R Word Classes subtest)

or language comprehension measures (Le., Reynell Verbal Comprehension scale) at 3, 4, or

8 years of age. However, high-risk children had significantly lower scores on the TACL-R

Total and Grammatical Morphemes subtest than the normative sample of the TACL-R.

Interestingly, high-risk children performed significantly better on the GFVV Sound Mimicry

subtest at 4 years compared to the normative sample of the GFW.

Overall, the one-sample t-test results show that this sample of high-risk children

demonstrated average abilities for receptive vocabulary and basic language comprehension

at 3, 4, and 8 years. They also show that these children's comprehension of grammatical

morphemes was significantly poorer compared to the normative sarnple of the TACL-R.

As Table 3.1 shows, high-risk children typically did not obtain significantly lower

scores on the expressive language measures compared to the normative sample of the

standardized language measures, with the exception of the Expressive Language Scale of

the Reynell Expressive at 3 years. Table 3.1 shows that high-risk children were found to

have significantly higher scores on the Stanford-Binet Vocabulary and Absurdities subtests

as well as the ITPA Grammatic Closure subtest at 4 years.

Separate one-sample t-tests were also performed to compare the mean scores of

high-risk boys and girls and the normative sample on the standardized language measures

by age (see Tables 3.2 and 3.3). The standardized language measures used in this study

do not report separate norms for boys and girls, therefore, the boys and girls from this study

were compared to the whole normative samples. Bonferroni corrections were made. The

alpha value was set at -03 for significance on the language measures at 3 and 4 years, and

at .O1 at 8 years. The findings were generally consistent with those found for the combined

sample. As can be seen from Tables 3.2. and 3.3, the boys and the girls in this sample

Table 3.2

Com~arisons between the Bovs from the Hiah-Risk Sam~le at 3.4. and 8 vears of aae and the Normative Sample of the Standardized lanauaae Measures

-

High-Risk Normative Boys Sarnple

M - SD r! M n t(df)

3 years Stanford-Binet

Vocabulary Absurdities

Re~nell Verbal Cornprehension Expressive Language

4 vears Sfanford- ine et

Vocabulary Absurdities

GFW Sound Mimicry

1TPA Grammatic Closure

8 years WISC-III

Vocabulary Similarities

TACL-R Word Classes Grammatical Morphemes Elaborated Sentences Total Score

PPVT-R

Note. The n indicated for the standardized language measures reflects the number of children for the age level that corresponds to the present sample.

=The GFW reports the number of children by age group as oppose to individual ages, so the number indicated reflects the number of children assessed for the age group of 3 to 8 years.

bThe g for the ITPA reflects the entire standardization sample as the ITPA manual does not report the sample size by age.

At 3 and 4 years: 'pc03. At 8 years: 'p.01.

Table 3.3

Com~arisons between the Girls from the Hiah-Risk Sam~le at 3.4. and 8 vears of aae and - the Normative Sam~le of the Standardized Lanauaae Measures

High-Risk Girls

Normative Sam ple

3 years Stanford-Binet

Vocabulary Absurdities

Revnell Verbal Comprehension Expressive Language

4 years Stanford-Binet

Vocabulary Absurdities

GFW Sound Mimicry

ITPA Grammatic Closure

8 years WISC-III

Vocabulary Similarities

TACL-R Word Classes Grammatical Morphemes Elaborated Sentences Total Score

PPVT-R

Note. The fi indicated for the standardized language measures reflects the nurnber of children for the age level that corresponds to the present sample.

aThe GFW reports the number of chiidren by age group as oppose to individual ages, so the number indicated reflects the number of children assessed for the age group of 3 to 8 years.

bThe 11 for the ITPA reflects the entire standardization sample as the ITPA manual does not report the sample size by age.

At 3 and 4 years: *p=.03. At 8 years: 'pc.01.

60

generally did not perfom significantly different from the children in the normative samples on

standardized receptive or expressive language measures at 3, 4, or 8 years of age.

However, consistent with the findings for the combined sample, high-risk boys and girls had

significantly lower scores on the TACL-R Grammatical Morphemes subtest than the

normative sample of the TACL-R. At 4 years of age, high-risk boys performed significantly

better on the Stanford-Binet Absurdities subtest and the GFW Sound Mimicry subtest

compared to the normative sample of these standardized measures. High-risk girls also

performed significantly better on the receptive and expressive language measures at 4

years of age compared to the normative sample of these standardized language measures.

Because the PPVT-R and the TACL-R Word Classes subtest were both used to

measure receptive language at 8 years using a sirnilar test format, the PPVT-R was not be

included in any further analyses as it did not provide any additional informational that was

not already provided by the TACL-R Word Classes subtest.

Behaviour-Competence Profile

The means and standard deviations of the CBCL Competence scales, the five

problems scales, as well as the lnternalizing and Externalizing scales for boys and girls at 4

and 8 years of age are shown in Tables 3.4 and 3.5. The mean T scores for ail the CBCL

scales at 4 and 8 years were within the normal range. The discrepancy in the number of

high-risk boys assessed on the Total Competence, Activities, Social, and School scales of

the CBCL at 8 years of age found in Table 3.4 is because some parents did not answer al1

the items for the Activities, Social, and School scales which resulted in the Total

Competence Scale not being calculated. Two children do not have scores on the CBCL as

their parents did not cornplete the forms. Only five of the eight problem scales were

presented here because these five scales represent the areas of behavioural difficulty

(withdrawn, social problems, inattention, aggressive behaviour) that have been found in

other high-risk populations (i-e., VLBW) (Breslau et al., 1 988; Ross et al ., 1 989; Tessier et

61

al., 1997). A series of one-sample t-tests were perforrned to compare the mean T scores of

the high-risk children and the normative sample of the CBCL by sex on each of the

competence, problem, and behavior scales (see Tables 3.4 & 3.5). Bonferroni corrections

were made. The alpha level was set at -01 for the cornparisons at 4 years. and.009 at 8

years. As Table 3.4 shows, support for the hypothesis that high-risk boys would have

significantly more Internalizing (Le., withdrawn) and Externalizing problems ( inattentive,

delinquent , aggressive) on the CBCL compared to boys of the CBCL was not found. High-

risk boys did not differ significantly from the normative sample of the CBCL at 4 or 8 years of

age.

Table 3.5 shows the results of the one-sample t-tests comparing the performances of

high-risk girls and girls from the normative sarnpie of the CBCL. As predicted high-risk girls

at 4 years of age did not differ significantly from the normative sample of girls of the CBCL

on four of the five individual problem scales or on the Internalizing or Externalizing scales.

However, at 4 years they had significantly lower scores on the Social Problems scale

compared to girls from the normative sample of the CBCL. A lower score on the CBCL

problem scales and Extemalizing and Internalizing scales is indicative of fewer behaviour

problems. At 8 years of age, high-risk girls had significantly lower scores on the Withdrawn,

Social Problern, Aggressive, and Delinquent problem scales as well as significantly Iower

scores on the Internalizing and Externalizing scales from the CBCL compared to girls from

the normative sample of the CBCL.

Tables 3.4 and 3.5 show the results of the one-sample t-tests comparing the T

scores of the high-risk group and the normative group by sex on the Competence measures

at 8 years. As Tables 3.4 and 3.5 show, support for the hypothesis that high-risk children

would have significantly lower scores on the Total Cornpetence scale as well as significantly

lower scores on the 3 individual competence scales was not found. A lower score on the

Competence scales indicates that the child is rated by the parent as being less competent in

terrnç of the child's ability to function in difterént situations (i-e., alone, school). Neither the

Table 3.4

Normative Sample of the Child Behavior Checklist (CRCL)

High-Risk CBCL Normative SampIe Boys Boys 4-1 1

4 yearsa Problem Scales

Withdrawn Social Prob lems Attention Problems Delinquent Behavior Aggressive Behavior

l nternalizing Externalizing

8 vearsb Total Competence (n=25)

Activities Social (n=26) School (n=27)

Problem Scales Withdrawn Social Problerns Attention Problems Delinquent Behavior Aggressive Behavior

Internalizing Externalizing

Note. The means and standard deviations are based on T scores.

A higher score on the Child Behavior Checklist (CBCL) problem scales is indicative of behaviour problems, while a lower score on the Competence scales reflects difficulties. The Total Competence Scale is not calculated if any of the items from the Activities, Social, or School scale are not answered.

=n=21. bn=28 unless othenvise indicated. =n=581.

Table 3.5

Com~arisons between Hiah-Risk Girls (4 and 8 vears) and Girls (4-1 1 vearsl from the

Normative Sam~le of the Child Behavior Checklist (CBCL)

High-Risk CBCL Normative Sample Girls Girls 4-1 1

M - - SD - M - SD t(df)

4 vearsa Problem Scales

Withdrawn 53.54 4.74 54.0 5.7 .57(34) Social Problems 52.11 3.74 54.0 5.9 2.98(34)' Attention Problems 53.22 4.88 54.1 5.9 1.06(34) Delinquent Behaviot 52.86 4.03 53.8 5 -7 1.38(34) Aggressive Behavior 53.68 5.48 54.0 5.8 .34(34)

Internalizing 46.40 7.99 50.1 9.7 2.74 (34) Externalizing 50.14 8.80 50.0 9.6 - 1 O(34)

8 vearsb Total Competence Scale

~ctivities Social School

Problem Scales Withdrawn Social Problems Attention Problems Delinquent Behavior Aggressive Behavior

Internalizing Externalizing

Note. The means and standard deviations are based on T scores-

A higher score on the Child Behavior Checklist (CBCL) problem scales is indicative of behaviout probiems, while a lower score on the Competence scales reflects difficulties.

At 4 years: 'e<.01. At 8 years: *g<.009.

high-risk boys nor the high-risk girls differed significantly from the normative sample of the

CBCL on any of the competence scales at 8 years of age.

In summary, behavioural difficulties were not identified for either the high-risk boys or

girls as indicated by the low scores on the 5 individual problem scales and on the

lnternalizing and Externalizing scales from the CBCL. High-risk boys at 4 years and 8 years

were rated similar to the boys from the normative sample of the CBCL. High-risk girls were

either rated as having similar behaviours or significantly fewer behavioural difficulties

compared to girls from the normative sample of the CBCL at 4 and 8 years. High-risk boys

and girls did not differ significantly from the normative sarnple of the CBCL on any of the

Cornpetence scales from the CBCL at 8 years.

Preschool Tests as Predictors of Language and Behaviour Outcome at 8 years

It was predicted that language measures at 3 and 4 years would be related to the

language measures at 8 years, and that lnternalizing and Externalizing scales of the CBCL

at 4 years would be related to these same CBCL scales at 8 years.

Pearson product correlations were used to determine the relationship between

preschool measures and the respective measures at 8 years of age. In addition to

correlational analyses, contingency analyses were also developed to investigate the

predictive value of the preschool measures on outcomes at 8 years. Contingency anaiyses

were also used because while correlational analyses indicate the degree to which measures

relate to one another, they do not indicate in what range (Le., below average, average) an

individual child will subsequently function. Siegel (1 989) suggested "contingency" analyses

as an alternate approach to the use of correlations. It is a method of determining the

accuracy of prediction for the individual child (Refer to Figure 3.1).

Tests at 8 Years

Below average/ Above or within clinical range average/ normal

rame

Below average/ Preschool Measures cfinid range

Above or within average/ normal range

True Positive

Figure 3.1. The classification system used to relate 8 year outcomes to scores on preschwl measures.

False Positive

False Negative

This rnethod of analysis involved calculating true and false positives and true and

false negatives. Following the ctassification terminology of Sackett, Haynes, and Tugwell

(1 985). the 8-year-old high-risk child whose test score was below averagelclinical range was

classified as positive, while the high-risk child functioning within or above average/normal

range was classified as negative. The following classification systern was used: a) true

positives were children who were predicted to perfom in the below average/clinical range and

did, b) true negatives were the number of children who were predicted to perform in the

average/normal range and did, c) false positives were the number of children who were

predicted to be perforrning in the below average/cfinical range, but actually perfoned in the

averagehormal range, and d) false negatives were children who were predicted to perform in

the averagehormal range and who, in fact, perfoned in the below average/clinical range.

Chi-square analyses or Fisher's Exact Tests were perfoned to determine whether there was

an association between being identified as being delayed or average on initial testing, and

being identified as being delay or average on subsequent testing.

On the language measures, the below average category was defined as performance

that was more than one standard deviation below the mean (i.e., Stanford-Binet subtest age

score less than 42, Reynell scale scores less than -1 -00, ITPA Grammatic

True Negative

Closure scale score less than 30, GFW Sound Mimicry percentile score of less than 25.

WISC-1 1 I scale score less than 7, and TACL-R scale scores less than 85). The average

range category was defined as performance within one standard deviation below the mean

and above (i.e., Stanford-Binet subtest age score of 42 or greater, Reynell scale scores of

-1 -00 or greater, ITPA Grammatic Closure scaIe score of 30 or greater, GFW Sound Mimicry

percentile score of 25 or greater, WISC-III sa le score of 7 or greater, and TACL-R scale

scores of 85 or greater). For the CBCL scales, normal and clinical ranges were determined

as foIlows: on the Total Cornpetence scale a T score of 40 and below was considered

clinical, while a T score of 41 and above was normal: on the Internalizing and Externalizing

scales a T score below 60 was normal, while a T score of 60 and above was considered

Clinical. It is important to note that the definitions of what was considered "normal" and

"clinical" for the CBCL scales departed from those assigned by Achenbach (1 991 ) as the

borderline and clinical categories have been combined into one category (clinical) for this

study. The borderline and clinical categories were combined because of the small number

of children in this sample who were identified as falling in either category.

Table 3.6 shows the number of children with scores falling in the delayed and the

average range on the language measures at 3,4, and 8 years of age, as well as the number

of children with scores falling in the normal and clinical range on the CBCL at 4 and 8 years

of age.

Preschool Lanauaae Measures Predictina Lanauaae Outcome at 8 Years

Table 3.7 presents the results of the Pearson correlations between preschool

language measures and language tests at 8 years. Bonferroni corrections were made. The

alpha level was set at -005. As Table 3.7 shows the receptive and expressive language

measures at 3 years of age were significantly correlated with the Similarities subtest from

the WISC-III at 8 years. The Vocabulary subtest from the Stanford-Binet at 3 years was also

significantly correlated with the Grammatical Morpheme subtest of the TACL-R at 8 years.

Table 3.6

The Number of Children with scores in the Below Averaaefclinical and Averaae/Normal

Ranae on Lanaauae and Behaviour Measures at 3.4. and 8 Years of Aae

Measures Average/ Below Average/ Normal Clinical - n

3 years Stanford-Binet: Vocabulary

Absurdities Reynell: Comprehension

Expressive

4 years Stanford-Binet: Vocabulary

Absurdities GFW: Sound Mimicry ITPA: Grammatic Closure

Combined CBCL Score* lnternalizing Externalizing

CBCL Scores for Bovs lnternalizing Externalizing

CBCL Scores for Girls l nternalizing Externalizing

8 years WISC-II 1: Similarities

Vocabulary TACL-R: Word Classes

Elaborated Sent. Grammatical Morph.

Combined CBCL Scoresa Total Competence lnternalizing Externalizing

CBCL Scores for Bovs Total Competence 1 nternalizing Externalizing

CBCL Scores for Giris Total Competence Internalizing Externalizing

a The Cornbined CBCL scale scores were obtained by summing then averaging the scores for boys and girls on each scale.

Table 3.7

Pearson Correlations Between tanauaw Measures at 3 and 4 vears and Lanauaae Measures at 8

Years

L a n w a e Measures at 8 vears

TACL-R WISC-Ill Word Gramm. Elabor. Vocabulary Similarities Classes Morph. Sent.

Early Language Measures

3 years Stanford-Binet

Vocabulary

Absurdities

Revnell Comprehension

Expressive

4 years Stanford-Binet

Vocabulary

Absurdities

GFW

Sound Mimicry

lTPA Grammatical Closure

Note. as are indicated in the brackets.

ap.009. .Q<.005

Only one significant correlation was found between the language measures at 4 years and

the language measures at 8 years. The Sound Mimicry subtest from the GFW at 4 years

was significantly correlated with the Similarities subtest at 8 years of age.

Using the cut-off scores defined earlier in this section, contingency tables were

developed, and chi-square analyses or Fisher Exact Tests were performed to determine

whether there was an association between those chifdren perforrning within a certain range

(either below average or average/above) at the initial and subsequent testing. Bonferroni

corrections were made, setting the alpha level at .W5. None of the Fisher's Exact Tests were

significant indicating that a statistically significant association was not found between being

identified as below average or average on the preschool language measures and being

identified as below average or average on the language measures at 8 years.

CBCL at 4 Years Predictina Behaviour Outcome on the CBCL at 8 Years

Table 3.8 presents the results of the Pearson correlations between the CBCL scales

at 4 and 8 years. The alpha level was set at -02. Table 3.8 shows that the Intemalizing and

Externalizing scales of the CBCL at 4 years for the combined group were significantly

correlated with the cornbined lntemalizing and Extemalizing scales from the CBCL at 8 years,

with the exception of the lntemalizing scale at 4 years and the Externalizing scale at 8 years

of age. The combined lntemalizing and Extemalizing CBCL scales at 4 years showed

rnoderate to low correlations with the lntemalizing and Externalizing CBCL scales at 8 years

(range: 1s = -33 to .56).

Pearson correlations were also perfomed to detemine whether a significant

relationship existed between the lntemalizing and Externalizing scales of the CBCL at 4

years and the Total Cornpetence scale of the CBCL at 8 years (See Table 3.8). Table 3.8

shows that a relationship was not found between the CBCL Intemalizing, and Externalizing

Table 3.8

Pearson Correlations Between CBCL Ratinas at 4 vears and 8 Years

CBCL Scale at 4 years

CBCL Scales at 8 vears

Total Competence Intemalizing Externalizing

Combined Scalesa l nternalizing

Externalizing

Note. The Combined CBCL Total Competence, Total Problem, Intemalizing, and Externalizing T scores for boys and girls were summed and then averaged to obtained a combined Tscore for each scale. a, = 55. The numbers in the brackets are the CS that differ from those indicated here. t

p c -02,

scales at 4 years and the CBCL Total Competence scale at 8 years for this group of high-risk

children as none of the correlations were statistically significant.

The accuracy of the CBCL at 4 years in predicting the outcome of the CBCL at 8

years was also examined using the contingency analyses which involved calculating the

number of cases that were identified as falling within the same functional range (normal or

clinical) at each tirne of testing. Fisher's Exact Tests were performed to determine whether

there was an association between performance on the Intemalizing and Externalizing scales

of the CBCL at 4 years and the CBCL scales at 8 years. The alpha level was set at -02.

Only statistically significant findings are reported. Table 3.9 shows that there was a

significant association between being identified as falling in the average or clinical range on the

Internalizing scale of the CBCL at 4 years and being identified as falling in the average or

clinical range on the lnternalizing and Externalizing scales at 8 years. Table 3.9 also shows

that there was a significant association to being identified as falling in the average or clinical

range on the Externalizing scale of the CBCL at 4 years and falling in the average or

71

clinical range on the Externalizing scale at 8 years. The nurnber of cases in each category

and the percentage of cases accurately predicted by the lnternalizing and Externalizing

scales of the CBCL at 4 years are shown in Table 3.9. The CBCL scales at 4 years were

found to predict functioning on the CBCL Internalizing, and Externalizing scales at 8 years

with an accuracy rate of 870h or greater. A significant association was not found between

the level of functioning on the Internalizing and Externalizing scales of the CBCL at 4 years

and the Total Cornpetence scale of the CBCL at 8 years.

In surnmary, the results from the correlational analyses indicate that there was sorne

relationship between preschool language mesaures and language functioning at 8 years. All

of the language mesures at 3 years were significantly related to the Similarities subtest of

the WISC-III at 8 years. The Vocabulary subtest of the Stanford-Binet at 3 years was also

significantly related to the TACL-R Grammatical Morphemes subtest at 8 years. Only one of

the four language measures at 4 years was found to be significantly related to the language

measures at 8 years of age. The GFW Sound Mimicry subtest at 4 years was significantly

correlated to the WISC-III Similarities subtest at 8 years. The contingency analyses were

not found to be a useful method of predicting language outcome as Fishefs Exact Tests

showed that the range of functioning (average or below average) on language measures at

3 or 4 years had no significant association with the range of functioning (average or below

average) on language measures at 8 years.

There was continuity in behaviour functioning as the CBCL lnternalizing and

ExternaIizing scaies at 4 years were reflective of the performance on the CBCL lnternalizing

and Externalizing scales at S years. The findings from the contingency analyses also

indicated that lnternalizing and Externalizing measures were generally accurate at predicting

lnternalizing and Externalizing functioning at 8 years. The Fishefs Exact Test indicated that

an average or clinical performance on the Internalizing scale of the CBCL at 4 years was

predictive of an average or clinical performance on the lnternalizing and Externalizing scales

Table 3.9

Accuracv of CBCL Scores at 4 vears in Predictina Behaviour Outcome on the CBCL at 8

years

4 Year Tnie Fat se True False0/o Correct CBCL Neaative Neaative Positive Positive Prediction

Combined 8 year CBCL Internalizing Score

Combined Scoresa lnternalizing 47 3

Combined 8 year CBCL Externalizing Score

Combined Scores lntemalizing 46 4 3 2 89.1 Extemalizing 44 3 4 4 87.3

&: Numbers represent individual cases. a ~ h e Combined CBCL scale scores were oùtained by summing then averaging the scores for boys and girls on each scale. ~c -02. Fishets Exact Test.

of the CBCL at 8 years. Performance on the Externalizing scale of the C8CL at 4 years was

also found to be significantly associated to performance on the Externalizing scale of the

CBCL at 8 years. Neither the lntemalizing or the Externalizing s a l e on the CBCL at 4 years

was significantly correlated to or associated with the performance on the Total Competence

scale of the CBCL at 8 years.

The Relationship Between Language and Behaviour/Competence Measures

For the total high-risk group, Pearson product correlations were conducted to determine

whether a relationship existed beniveen: 1) preschool language measures and the CBCL

lnternalizing and Externalizing scales at 4 years, 2) preschool language measures and the

Internalizing, Externalizing, and Total Competence scale of the CBCL at 8 years, 3)

the Internalizing and Extemaking scales of the CBCL at 4 years and language functioning at

8 years, and 4) language measures at 8 years and the Total Competence, Internalizing, and

Externalizing scales of the CBCL at 8 years. Based on the Pearson product correlations

using a Bonferroni correction with alpha level set at -01 for preschool language and behaviour,

at .O08 for preschool language and behaviour at 8 years, and at .O07 for fanguage and

behaviour at 8 years, the following significant relationships between language and behaviour

were found. The Vocabulary subtest of the Stanford-Binet at 3 years was found to be

moderately correlated with the CBCL Total Competence scale at 8 years (_! = -49, p < .008,

n=61). The Reynell Expressive Language Scale at 3 years was also found to be -

significantly correlated with the Tctal Competence scale of the CBCL at 8 years (r= .39, Q c

.008, ~=61) . None of the other correlations were statistically significant.

Because the sarne relationships between language measures and behaviour and

competence scores were examined by gender, it was important to determine whether boys

and girls perforrn differently on any of the language measures or CBCL scales. A series of t-

tests comparing the performance of boys and girls found no significant differences between

the genders on any of the language measures or CBCL scales at ages 3,4, or 8 years. The

Pearson product correlations, using a Bonferroni correction with alpha level set at .O1 for

preschool language and behaviour, at .O08 for preschool language and behaviour at 8 years,

and at .O07 for language and behaviour at 8 years, indicated significant correlations between

the Vocabulary subtest of the Stanford-Binet at 3 years and the Total Competence scale of

the CBCL at 8 years (E = .63, pc.008, -23), and between the Reynell Expressive

Language Scale at 3 years and the Total Competence scale of the CBCL at 8 years (1 = -60,

Q < .008, n=23) for boys . For the girls, none of the correlations between the language

rneasures at 3, 4, or 8 years and the Internalizing, Externalizing, or Total Competence scales

at 4 or 8 years were statistically significant.

To further highlight the pattern of relationships between early ianguage and later

competence, and early behaviour and later language, relevant correlations are presented in

Tables 3.1 0 and 3.1 1. For girls, the extracted comparisons show no significant relationship

between the different combinations of early and later variables. For boys,early expressive

language ability stands out as a predictor of later competence.

Because significant correlational findings were reported between some of the language

measures at 3 years and the Total Competence scale of the CBCL at 8 years for the

combined high-risk group, separate correlation analyses were also conducted, using

Bonferroni corrections with alpha set at .O08 at 3 and 4 years, and at .006 at 8 years, to

detenine whether there was a relationship between the language measures at 3, 4, and 8

years and the three separate CBCL cornpetency scales (Activities, Social, & School) at 8

years for high-risk boys and giris. As can be seen from Table 3.12, a different pattern in the

relationship between the language measures and the 3 Competence scales at 8 years

emerges for boys and girls. For the boys, the expressive language measures at 3 and 4

years were found to be significantly correlated with the Activities scale of the CBCL at 8

years. The significant correlations were high ranging from .63 to -72. The findings suggest

that high-risk boys who had higher expressive Ianguage scores at 3 and 4 years were rated

by their parents as being more competent in terrns of the number of activities they

participated in as well as how wetl they were perceived by their parents at performing these

activities. As Table 3.12 shows, preschool language measures were not found be

significantly related to either the Social or School scale from the CBCL at 8 years.

Furthemore, none of the correlations between the language measures at 8 years and the

Activities, Social, and School Competence scales of the CBCL at 8 years were found to be

statistically significant for high-risk boys.

R Table 3.10

Correlations Between Preschool Lanamae Measures and Total Competence at 8 vears Compared to Correlations Between Preschool

Behaviour Measutes and Lanauaae Outcome at 8 years for Hiah-Risk Bovs

CBCL Total Cornpetence at 8 yrs

S-B Vocabulary at 3 .63" yrs.

CBCL Total Cornpetence at 8 yrs

Reynell Expressive .60* Language at 3 yrs.

CBCL Total Cornpetence at 8 yrs

Reynell Language Comprehension at .46 3 yrs.

CBCL Total Cornpetence at 8 yrs

S-B Absurdities at 4 .31 yrs.

CBCL Total Competence at 8 yrs

ITPA Grammatic .46 Closure at 4 yrs.

Bonferroni corrections made.

CBCL lnternalizing at 4 yrs.

CBCL lnternalizing at 4 yrs,

CBCL lnternalizing at 4 yrs.

CBCL lnternalizing at 4 yrs.

CBCL lnternalizing

WISC-III Vocabulary at 8 yrs

.12

WISC-III Sirnilarities at 8 yrs

.31

TACL-R Word Class. at 8 yrs.

WISC-III Similarities at 8 yrs

.31

TACL-R Gramm. Morphernes at 8 yrs.

- . I O at 4 yrs.

WISC-III Vocabulary at 8 yrs

CBCL Externalizing at .28 4 yrs.

WISC-III Sirnilarities at 8 yrs

CBCL Externalizing at .12 4 yrs.

TACL-R Word Classes at 8 yrs.

CBCL Externalizing at 4 yrs. .18

WISC-III Similarities at 8 yrs

CBCL Externalizing at ,12 4 yrs.

TACL-R Gramm. Morphernes at 8 yrs.

C8Cl Externalizing at -.25

'e c ,008 for preschool language and Total Cornpetence at 8 years, **g < .O1 for language at 8 years and lnternalizing and Externalizing behaviour at 4 years,

Table 3.1 1

Correlations Between Preschool Lanauaae Measures and Total Com~etence at 8 vears Com~ared to Correlations Between Preschool

Behaviour Measures and Lanauaae Outcome at 6 vears for Hiah-Risk Girls

CBCL total Competence at 8 yrs

S-B Vocabulary at 3 ,40 yrs.

CBCL Total Cornpetence at 8 yrs

Reynelt Expressive .26 Language at 3 yrs.

CBCL Total Competence at 8 yrs

Reynell Lariguage Cornprehension at .O4 3 yrs.

CBCL Total Competence at 8 yrs

S-B Absurdities at 4 .25 yrs.

CBCL Total Competence at 8 yrs

ITPA Grammatic .22 Closure at 4 yrs.

Bonfer i.mi corrections made.

CBCL lnternalizing at 4 yrç.

CBCL lnternalizing at 4 yrs.

CBCL lnternalizing at 4 yrs.

CBCL lnternalizing at 4 yrs.

CBCL lnternalizing

Vocabulary at 8 yrs -12

WISCJII Similarities al 8 yrs

.32

TACL-R Word Classes at 8 yrs.

WISC-III Similarities at 8 yrs

.32

TACL-R Gramrn. Morphemes at 8 yrs.

.O5 - at 4 yrs.

WISC-III Vocabulary at 8 yrs

CBCL Externalizing at -.O0 4 yrs.

WISC-III Similarities at 8 yrs

CBCL Externalizing at .36 4 yrs.

TACL-Fi Word Classes at 8 yrs.

CBCL Externalizing at 4 yrs. .16

WISC-III Sirnilarities at 8 yrs

CBCL Externalizing at .36 4 yrs.

TACL-R Gramrn. Morphernes at 8 yrs.

CBCL Externalizing at .21 4 yrs.

Note. None of the correlations reported in the table were statistically significant.

Table 3.12

Pearson Correlations BetweenLanauaae Measures and the CBCL Cornoetence Scales for Hiah-Riçk Bovs and Girls

- -

Bovs' CBCL Scales at 8 vears Girls' CBCL Scales at 8 vears

Activities Social School Activities Social School - n Measures

3 years Stanford-Binet

Vocabulary

Absurdities

Revnell Comorehension

Expressive

4 years Stanford-Binet

Vocabulary

Absurdities

GFW Sound Mimicrv

ITPA - Grammatical Closure

Note. Numbers in the brackets are the ns LBW boys. Bonferroni Corrections made. 'p < ,008.

Table 3.10 Cont'd.

Pearson Correlations Between Language Measures and the CBCL Scales for Hiah-Risk Bovs and Girls

Boys' CBCL Scales at 8 years Girls' CBCL Scales at 8 vears

Activities Social School - n Activities Social School - n Measures

8 years m. Similanties

Vocabularv

TACL-R Word Classes Elaborated Sentences ,20 -.19 .1 O 14 Grammatical Morphemes .42 -.O3 .O7 14

Note. Nurnbers in the brackets are the gs that differ from those which have been otherwise indicated. Bonferroni Corrections made. 'e < . 0 7 .

For high-risk girls only one significant relationship was found between the preschool

language measures and the 3 Competence scales of the CBCL at 8 years. The Reynell

Expressive Language scale at 3 years was significantly correlated with the Activities scale of

the CBCL at 8 years (L = .48, p < .008). Table 3.12 shows that a significant relationship was

found between the WISC-III Simiiarities subtest at 8 years and the Activities and the School

scales of the CBCL at 8 years. The WISC-III Vocabulary subtest at 8 years was also found

to be significantiy correlated with the School Competence scale of the CBCL at 8 years for

girls. The significant correlations were considered moderate ranging from -45 to 57. The giris

from the high-risk sample who obtained higher scores on the expressive language measures

at 8 years were rated by their parents as being more competent in t e n s of their activities and

school performance.

The relationship between language functioning and behaviour outcome was also

examined using contingency analyses that used cut-off scores defined earlier in this section.

Chi-square analyses or Fisher Exact Tests were perforrned to determine whether there was

an association between those children perforrning within a certain range (either below average

or averagelabove} on language measures, 3.4, and 8 years and the C8CL scales at 4 and 8

years. Bonferroni corrections were made, setting alpha at .W5. None of the Fisher's Exact

Tests were significant indicating that a statistically significant association was not found

between being identified below average or average on the language measures at 3,4, and 8

years and being in the clinical or normal range on the Intemalizing, Extemalizing, and Total

Competence scales of the CBCL at 8 years.

In summary, the findings from the correlational analyses suggest that there is not a

significant relationship between the language measures at 3, 4, and 8 years and the

Internalizing, and Extemalizing scales from the CBCL for this group of high-risk children at 4 or

8 years. Significant findings were found between the Stanford-Binet Vocabulary subtest at 3

years and the Total Competence scale of the CBCL at 8 years, and between the Reynell

Expressive Language Scale at 3 years and the Total Competence scale of the

80

CBCL at 8 years for the total combined high-risk group and for boys. When the correlations

between the preschool language measures and the CBCL Total Competence scale at 8

years were examined in relation to the correlations of the CBCL Internalizing and

Externalizing scales at 4 years and language outcome at 8 years, high-risk boys early

Ianguage difficulties were related to poorer overall competence at 8 years, but internalizing

and externalizing behaviour at 4 years was not related to language outcome at 8 years.

Furthermore, separate correlations for boys and girls also showed a different pattern

in the relationship between language measures at 3, 4, and 8 years and the CBCL Activities,

Social, and School Competence scales at 8 years. For the high-risk boys a strong

relationship existed between the expressive language measures at 3 and 4 yeas and the

CBCL Activities Competence scale at 8 years, but none of the language measures at 8

years were found to be significantly related to the performance on the three CBCL

competence scales at 8 years. For the high-risk girls, the Reynell Expressive Language

scale at 3 years was the only preschool language measure found to be significantly reiated

to the Activities scale of the CBCL at 8 years. However, unlike high-risk boys, girls'

performance on the WISC-III Vocabulary subtest at 8 years was related to outcome on the

School Competence scale of the CBCL at 8 years, and the WISC-III Similarities subtest at 8

years was significantly related to outcome on bath the Activities and School Competence

scales at 8 years of age.

The contingency analyses were not found to be a useful method of predicting

behaviour or language outcome as Fisher's Exact Tests showed that the range of

functioning (average or below average) on preschool language measures had no significant

association with the range of functioning (average or below average) on the Internalizing,

Externalizing, and Total Competence scales of the CBCL s at 8 years, nor was a significant

association found between the CBCL scales at 4 years and language measures at 8 years.

Predicting Specific Language and Behaviour Outcornes

The results up to this point have discussed whether individual preschool variables

would be related to or predict outcome at 8 years. Hierarchical regressions were conducted

to determine whether using a multivariate model consisting of Siegel's risk index scale and

preschool measures would predict specific language and behavioural outcornes at 8 years.

Here each predictor variable was considered not by itself but in combination with the other

variables in the model to determine which of the variables used in the system accounted for

a significant proportion of the variance at predicting the specific language and behavioural

outcome measures for this sample of 8-year-old high-risk children.

Hierarch ical Rearession Analvses

Some of the predictors entered into the regression equation were chosen based on

theory presented in the Iiterature review, and other predictors were chosen based on the

results of the correlational analyses discussed earlier in this chapter. The predictors were

entered into the regression equation in the following order: 1) Siegei's Risk lndex scale, 3)

Stanford-Binet Vocabulary subtest at 3 years, and 4) the combined CBCL Externalizing

scale at 4 years. Siegel's Risk lndex scale, represented by a single score (0-1 6) and not its

individual variables, was entered first as a covariate on al1 the hierarchical regressions

because other sets of biomedical variables or risk index scales, whether they were used

alone or in a system of other variables, have been found to be related to later language and

developrnental outcome (Bendersky 8 Lewis, 1990; Molfese & DiLalla, 1995). Preschool

language functioning was entered next into the regression equation. The Vocabulary

subtest from the Stanford-Binet at 3 years was used as a measure of preschool language

functioning as it was found to be significantly correlated to two of the language measures at

8 years and the Total Cornpetence scale of the CBCL at 8 years. The Vocabulary subtest of

the Stanford-Binet was entered before the Externalizing scale of the CBCL at 4 years

because researchers have suggested that it is through language that a child regulates

his/her own behaviour and expresses feelings (Brinton & Fujiki, 1993; Gordon, 1991). The

Externalizing scale from the CBCL at 4 years was entered into the regression equation last.

The CBCL Externalizing scaie of the CBCL at 4 years was selected as it was found to be

significantly correlated to the lnternalizing and Externalizing scales of the CBCL at 8 years.

Although the Externalizing scale of the CBCL at 4 years was not found to be significantly

correlated to the language measures at 8 years, there was an interest in this study in

determining whether such behaviour would be related to the outcome on any of the

language measures once Siegel's Risk lndex scale and the Stanford-Binet Vocabulary

subtest at 3 years had been entered into the hierarchical regression.

Tables 3.1 3 and 3.1 4 display the R, R2. R2 Change, and F Change after the entry of

each predictor for the language measures and the CBCL scales at 8 years. Also presented

are the standardized regression coefficients (Final O) which are determine after the entry of

al1 three predictors. Table 3.1 3 presents the results of the hierarchical regression analyses

for each of the language measures at 8 years, whereas Table 3.14 presents the findings for

the lnternalizing and Externalzing scale of the CBCL at 8 years.

Predictina Specific Lanauaae Outcomes

As Table 3.1 3 shows, the overall multiple correlations range from .ll (TACL-R Word

Classes subtest) to .56 (WISC-III Sirniiarities subtest). The proportion of variance

accounted for by the preschool measures ranged from 11 to 32%. The proportion of

variance accounted for by Siegel's Risk lndex scale ranged from 1 to 4%.

Siegel's Risk lndex scale was entered first into the regression equation. As Table

3.1 3 indicates, Siegel's Risk lndex scale was not a significant predictor on any of the

language measures at 8 years of age. The final beta indicates that the risk index scale was

not related to the outcome on any of the language measures at 8 years when the Stanford-

83

Binet Vocabulary subtest at 3 years and the CBCL Externalizing scale at 4 years had been

entered into the regression.

The Stanford-Binet Vocabulary subtest was the second predictor variable entered

into the regression equation. As Table 3.13 the Stanford-Binet Vocabulary subtest at 3

years was predictive of performance on the WISC-111 Similarities and Vocabulary subtests

(additional variance explained = -1 4 and = -1 1, Q < .02, respectively), the TACL-R

Grammatical Morphemes and Word Classes subtests (additional variance explained = .27,

c .O1 and = -20, p < -02, respectively). The final beta indicates that the Stanford-Binet

Vocabulary subtest at 3 years of age was also related to the outcorne on the WISC-III

Vocabulary subtest and the TACL-R Word Classes and Grammatical Morphemes subtests

when Siegel's Risk lndex scale and the CBCL Externalizing scale at 4 years had been

entered into the regression. The Stanford-Binet Vocabulary subtest at 3 years. however, did

not contribute significantly to the prediction of the TACL-R Elaborated Sentences subtest.

Finally, the combined CBCL Externalizing scale at 4 years was entered last in the

hierarchical regression equations for the language measures at 8 years. As Table 3.1 3

shows, the CBCL Externalizing scale did not contribute significantly to the prediction of any

of the language measures at 8 years.

Predictina S~ecific Behaviour Outcornes

Table 3.1 4 presents the results of the hierarchical regression analyses for the

Internalizing, Externalizing, and Total Cornpetence scales of the CBCL scales at 8 years.

As Table 3.14 shows, the overall multiple correlations range from -22 (CBCL lnternalizing

Scale) to -60 (CBCL Externalizing scale). The proportion of variance accounted for by the

predictor variables ranged from 5 to 36%.

Siegel's Risk lndex scale was entered first into the regression equation. As Table

3.14 indicates, Siegel's Risk lndex scale was not a significant predictor on any of the CBCL

scales at 8 years. The final beta also indicates that the risk index scale was not related to

84

the outcome on the Total Competence, Internalizing, or Externalizing scales of the CBCL

when the Stanford-Binet Vocabulary subtest at 3 years and the CBCL Externalizing scale at

4 years had been entered into the regression.

The Stanford-Binet Vocabulary subtest was the second predictor variable entered

into the regression equation. As Table 3.14 shows the Stanford-Binet Vocabulary subtest at

3 years was predictive of performance on the combined Total Cornpetence scale of the

CBCL at 8 years (additional variance explained = -19 and = -1 1, Q < .001). The final beta

indicates that the Stanford-Binet Vocabulary subtest at 3 years of age was also related to

the outcome on the Total Cornpetence scale of the CBCL even when Siegel's Risk Index

scale and the CBCL Externalizing scale at 4 years had been entered into the regression.

The Stanford-Binet Vocabulary subtest at 3 years, however, did not contribute significantly

to the prediction of the combined lnternalizing and Extemalizing scales of the CBCL at 8

years of age.

The combined C8CL Externalizing scale at 4 years was entered last in the

hierarchical regression equations. The CBCL Externalizing scale contributed a significant

amount of unique variance to the prediction of the CBCL lnternalizing and Externalizing

scale outcome at 8 years (additional variance explained = -1 5 and = -28, g < .006,

respectively), even when Siegel's Risk Index scale and the Stanford-Binet Vocabulary

subtest at 3 years were entered before it in the regression. The CBCL Externalizing scale at

4 years did not contribute to the prediction of the CBCL Total Competence outcome at 8

years.

Overall, this multivariate model of a. risk index scale and preschool measures was

not an efficient method of predicting subsequent language or behaviour outcome. Only one

of the predictor variables was used in the regressions to predict outcome on the language

and behaviour measures at 8 years. For instance, the Stanford-Binet Vocabulary subtest at

3 years was used to predict language and CBCL Total Competence outcome at 8 years,

Table 3.1 3

Hierarchical Rearessions for the S~ecif ic Lanciuaae Measures at 8 vears

Forced Variables Multiple R Mult R2 R2 Change F Change Final O Entry

WISC-III Similarities Subtest @ = 50)

1 . Siegel's Risk Index -1 2 .O2 .O2 -76 -.O7

2. S-B Vocabulary at 3 yrs. -39 -1 5 -14 7.7' .32

3. CBCL Externalizing -44 -1 9 .O4 2.2 .20 Scale at 4 yrs.

WISC-III Vocabulav Subtest @ = 50)

1. Siegel's Risk Index -1 6 .O3 .O3 1 -32 -.O9

2. S-6 Vocabulary at 3 yrs. -37 -14 -1 1 6.37' -35'

3. CBCL Externalizing .38 -1 4 .O0 .O0 -.O3 Scale at 4 yrs

TACL-Fi Word Classes Subtest (g = 28)

1 Siegel's Risk Index -1 1 .O 1 .O 1 .31 .20

2. S-8 Vocabulary at 3 yrs. -46 .2 1 -20 6.64' .45*

3. CBCL Externalizing .47 .22 .O 1 3 -2 .10 Scale at 4 yrs

TACL-R Grammatical Momhemes @ = 28)

1. Siegel Risk Index .2 1 .O4 .O4 1.23 -.IO

3. S-B Vocabulary at 3 yrs. -56 -31 -27 10.26' -54'

4. CBCL Externalizing .56 .32 .O0 Scale at 4 yrs

Note. The CBCL Externalizing scale T scores for boys and girls were summed and then averaged to obtained a combined T score. aSiegel's Risk lndex (0-16) - each of Siegel's biomedical and environmental variables were assigned a 1 i f the variable placed the child at risk for experiencing developmental difficulties. A higher score placed a child at greater risk. ' p < .02.

Table 3.13 Cont'd

Hierarchical Rearessions for the S~ecific Lanauaae Measures at 8 vears

Forced Variables Multiple R Mult R2 Fi* Change F Change Final O Entry

TACL-R Elaborated Sentences Subtest @ = 28)

1 . Siegel's Risk Index -20 .O4 .O4 1.11 -.13

2. S-B Vocabulary at 3 yrs. .33 -1 1 .O7 2.09 -26

3. CBCL Externalizing -43 -18 .O7 2 .27 -27 Scale at 4 yrs

Note. The CBCL Externalizing scale T scores for boys and girls were summed and then averaged to obtained a combined T score. aSiegel's Risk lndex (0-1 6) - each of Siegel's biomedical and environmental variables were assigned a 1 if the variable piaced the chiid at risk for experiencing developmental difficulties. A higher score placed a child at greater risk. -Q < -02.

Table 3.1 4

Hierarchical Rearessions for the S~ecific CBCL Scates at 8 vears

Forced Variables Multiple Fi Mult R2 R2 Change F Change Final O Entry

Combined CBCL Total Comptence Scale (n = 48)

1. Siegel's Risk Index -28 .O8 .O8 4.0 -.tg

2. S-8 Vocabulary at 3 yrs. -51 -26 .19 1 1.70' -43'

3. CBCL Externalizing -52 .27 .O0 -24 .O6 Scale at 4 yrs

Combined CBCL lnternalizina Scale (n = 49)

1. Siegel's Risk Index .22 .O5 .O5 2.3 -16

2. S-B Vocabulary at 3 yrs. .22 .O5 .O0 -1 2 -.16

3. CBCL Externalizing -44 -1 9 -15 8.32' -40' Scale at 4 yrs

1. Siegel's Risk Index .28 .O8 .O8 3.96 -21

2. S-6 Vocabulary at 3 yrs. .28 .O8 .O0 .O 1 -.16

3. CBCL Externalizing -60 -36 .28 20.05' -55' Scale at 4 yrs

Note. The CBCL Externalizing scale T scores for boys and girls were sumrned and then averaged to obtained a combined T score.

aSiegel's Risk Index (0-1 6) - each of Siegel's biomedical and environmental variables were assigned a 1 i f the variable placed the child at risk for experiencing developmental difficuities- A higher score placed a child at greater risk.

whereas the CBCL Externalizing scale at 4 years was predictive of outcome on the

Internalizing and Externalizing scales of the C8CL at 8 years.

Prediction of Below Average Performance

Discriminant Function Analvses

To determine the accuracy of a multivariate model consisting of a risk index scale,

based on Siegel's risk index variables, and preschool mesures at identifying which high-risk

children will be at risk for language and behaviour problems at 8 years, hierarchical or

sequentiat discriminant function analyses were conducted. It is acknowledged that this

procedure would likely be vulnerable to chance due to the ratio of a sample size to a

relatively large number of predictor variables, and a categorical outcome variable rather than

a continuous outcome variable. However, the utiiity of the systems of risk index and

preschool rneasures would not be fully realized without the information provided. The need

for cross-validation on an independent sample of generalized applicability is necessary, but

not within the scope of the present study.

The following classification system was used: a) true positives were children who

were predicted to perform in the below average/clinical range and did, b) true negatives

were the number of chiidren who were predicted to perfom in the averagelnormal range and

did, c) false positives were the number of children who were predicted to be performing in

the below averagelclinical range, but actually performed in the averagehormal range, and d)

false negatives were children who were predicted to perfom in the averagehormal range

and who, in fact, performed in the below average/clinical range. The cut-off scores used to

define the below average/clinical and averagehormal categories have been described

earlier in this chapter.

To help answer the question of how well does a system consisting of a risk index

scale and preschool measures predict developmental delays or problems, a set of technical

terms defined by Sackett et al. (1985) have been adapted to suit the present study.

89

Sensitivity refers to the proportion of children with below average/clinical performance who

were correctly identified by the system of risk index and preschool variables. It is calculated

by (true positives/(true positive + false negatives)) X 100%. Specificity refers to the portion

of children with averagehormal performance who were correctly identified by the

cornbination of risk index and preschool variables. It is calculated by (true negative/(true

negative + false positive)) X 100%. Prevalence refers to the number of children in the

present sample identified by the combination of risk index and preschool variables who are

performing in the below average/clinical range. It is calculated by (true positives and false

negatives)/(total sample size) X 10O0/0. Finally, overall accuracy for screening refers to the

nurnber of true positives and true negatives out of the total sample that were correctly

identified.

Based on the previous patterns of performance found in the present study, it was

known that the classification of scores into below averageklinical and averagehormal

categories would not result in equal sarnple sizes for the two groups on each of the

language rneasures and the combined CBCL scales. For example, on the WISC-III

Vocabulary subtest 7% of the children were in the below average range of performance,

white on the TACL-R Grammatical Morpheme subtest 35OA of the children were in the below

average range of performance. The probability with which a case was assigned to a group

should, therefore, reflect whether the group itself was more or less probable in the sample

(Tabachnick & Fidell, 1 996). Tabachnick and Fidell (1 996) described how to modify

classification procedures by adding to each classification equation a term that adjusts for

group size. In order to modify the classification procedures a priori probabilities of

assignments to groups can be specified in the SPSS 10.0 program so that the observed

group sizes in the sample determine the probabilities of group membership. Therefore, a

priori probabilities for each discriminant function analysis were specified to reflect the

different prevalence rates for the specific language measures and combined CBCL scales.

Identifyina Below Averaae Performance: Sianificant Findinas

The results of the discriminant function analyses are shown in Table 3.15. The

variables are Iisted in the order in which they were entered in the discriminant function

analyses. It is important to note that Siegel's Risk Index scale and preschool measures did

not load into the discriminant function analyses for the TACL-R Elaborated Sentences

subtest or the CBCL Internaking scale. As Table 3.1 5 shows the discriminant function

analyses did not have significant discriminating power, despite having an overall accuracy

that ranged from 72.2% on the TACL-R Grammatical Morphemes subtest to 94.1% on the

WISC-III Vocabulary subtest.

Table 3.1 5 shows that the ability of the system of nsk index scale and preschool

measures to accurately identîfy average performance on the language measures and the

CBCL Total Cornpetence scale (i.e., specificity) was high. It ranged from 78% on the TACL-

R Grammatical Morphemes and Word Classes subtests to 100% on the Extemalizing scale

of the CBCL at 8 years. However, this high specificity occurs at the expense of adequate

sensitivity. For example, no children were identified as performing in the below average

range on the W ISC-III Vocabulary subtest, although the specificity was 100%. The below

average range for this measure was defined as a scale score of 6 or less. Sensitivity for the

other outcome measures ranged from OoA on the WISC-III Sirnilarities subtest to 61 -5'10 on

the TACL-R Grammatical Morphemes subtest.

Table 3.15

Accuracv of Identifvina Below Averaae/Clinical Performance on Lanauaue and CBCL Outcome

Risk Index True False Fafse True Overall Prevalence Variables Positive Positive Negative Negat ive Accu racy

W [SC-III Similarities Subtest

( s s d = below average) Siegel's Risk Index O 6 O 59 90.8% 0% 3 yr Stanford-Binet Voc. OO/oa 9.2% 0% 90.80hb 4 yr CBCL Externalizing

x2 (1 ) = 3.99. Q c -05

Siegel's Risk Index O 5 O 60 92 -3% 0% 3 yr Stanford-Binet Voc. OOha 7.7% O0/0 92.30hb 4 yr CBCL Externalizing

X* (1) = 5.08. p c .O5

TACL-R Grammatical Momhemes

Siegel's Risk Index 8 5 5 18 72 -2% 72.2% 3 yr Stanford-Binet Voc. 61 .50/oa 21 -7% 38.S0/0 78.30hb 4 yr CBCL Externalizing

x2 (1) = 8.41. p c .O1

TACL-R Word Classes

Siegel's Risk Index 1 7 3 25 72.2% 1 1 - 1 % 3 yr Stanford-Binet Voc. 250ha 21.9% 75% 78.1 %b 4 yr CBCL Externalizing

x2 (1) = 3-70, Q c .10

- -

Note. Numbers represënt individual cases.

Siegel's Risk lndex (0-16) - each of Siegel's biomedical and environmental variables were assigned a 1 if the variable placed the child at risk for experiencing developmental difficulties.

Table 3.1 5 Cont'd Accuracv of Identifvina - Below AveraaeIClinical Performance on Lanauaae and CBCL Outcome

Risk Index True False False True Overall Prevalence Variables Positive Positive Negative Negative Accuracy

Combined CBCL Total Com~etence Scale

Siegel's Risk Index 6 4 9 46 80.0% 23.1 O/o

3 yr Stanford-Binet Voc. 40°ha 6.70h 60.0% 92.o0/ob 4 yr CBCL Externalizing

X* (1 ) = 13-90. Q c .O01

Combined CBCL Externalizing Sçale

Siegel's Risk Index 1 O 6 48 89.0% 12.7% 3 yr Stanford-Binet Voc. 14.30ha 0% 85.7% 1 OO.OO/O~ 4 yr CBCL Externalizing

x2 (1) = 6.62. g =z .O1

Note. Numbers represent individual cases. The combined CBCL Total Cornpetence scale was obtained by summing then averaging the Tscores for boys and girls.

Siegel's Risk lndex (0-1 6) - each of Siegel's biomedical and environmental variables were assigned a 1 if the variable placed the child at risk for experiencing developmental difficulties.

CHAPTER 4

Discussion

The present study addressed the following questions: 1) What is the pattern of

performance on language and behaviour measures for this sample of high-risk children?, 2)

How well do preschool language measures predict language functioning at 8 years?; 3) How

well does behaviour functioning at 4 years predict behaviour outcome at 8 years?, 4) 1s there

a relationship between Ianguage and behaviour functioning as well as between language and

cornpetence?, 5) (a) Does the system consisting of a risk index scale and preschool

measures predict specific language and behaviourat outcome for 8-year-old high-risk

children?, and (b) Does this system of risk index scale and preschool measures accurately

identify which children are at risk for below average performance on language and behaviour

measures at 8 years?

Pattern of Performance

Lanauaae Functionina: Rece~tive Lanauaae

A total of Tt high-risk children were assessed at 3 and 8 years andor assessed at 4

and 8 years. The majority of these children (91 O h ) had IQ scores that fell within the average

range (FSIQ 2 80) at 8 years of age. Nine percent of the children were excluded from the

study because they had IQs that fell below the average range (FSIQ 5 80) at 8 years. The

percentage of children in this study who had IQ scores below 80 is comparable to the

estimated 9 percent of children found to have IQ scores below 80 in the general school

population. Although the children included in the study were found to have language scores

in the average range at 3 and 8 years, some difficulties were noted at 3 and 8 years. At 4

years of age this sample of children were found to perfom significantly higher on a number of

the language measures compared to the normative sample of the standardized language

measures. As hypothesized, this sample of high-risk children demonstrated average ability

for receptive vocabulary and basic language comprehension (e-g., Reynell Comprehension;

TACL-R Word Classes & Elaborated Sentences; PPVT-R), and the children generally did not

perform significantly differently from the children in the normative samples of these

standardized receptive language measures at 3 or 8 years. However, the children in this

sarnple did have significantly lower scores on the Grammatical Morphemes subtests of the

TACL-R at 8 years compared to the normative sarnple of the TACL-R.

The present findings are consistent with other research studies which have found that

premature children of normal intelligence did not differ significantly from full-term peers on

receptive vocabulary and basic auditory comprehension measures at 3, 5, or 6 years (Craig

et al., 1991 ; Klein et al., 1985; Vohr et al.. 1 989, Siegel, 1983, 1 985b).

Although studies investigating the language functioning of LBW and VLBW children

have assessed a variety of language areas such as syntactic comprehension and receptive

vocabulary, research examining rnorphological knowledge in LBWNLBW samples has not

been done. I t was, therefore, necessary to review some of literature on how grammatical

morphemes develop in speech impaired populations in order to gain a better understanding of

why the high-risk children might be experiencing difficulties in understanding grammatical

morphemes. Brown (1 973) studied the developrnent of a subset of 14 English grammatical

rnorphemes (refer to Appendix E, modification of Gleason, 1993), and found that the

acquisition of these 14 grammatical morphernes for children without language delays is gradual

and lengthy. Some grammatical rnorphemes are not used on a consistent basis until the child

enters school (e.g., "went"), rather the child continues to add new morphological and syntactic

structures as well as expands and refines existing ones (Owen, 1984). Because the

acquisition of rnorphological knowledge is a lengthy and gradual developmental process, it

rnaybe more sensitive to individual differences among children.

Studies of children with speech-Ianguage impairments (SLI) report that children with

SLI often show mild to moderate deficits in a range of language areas and a more serious

deficit in the use of morphology (Leonard, 1 989; Leonard, McGregor, & Allen, 1 992).

Johnston and Schery (1976) reported that children with SLI do not differ from children with no

language impairment in the structural aspects of grammatical morphology as they learned the

same forms in much the same order. However, children with SLI do differ from non-language

ddayed children in "the rate at which they move from the first use of a morphological rule to its

consistent general application" (Johnston & Schery, 1976, p. 257). Furthermore, literature on

the use of grammatical morphemes of children with SLI who are acquinng English and other

languages such as Geman (Clahsen, 1989) reveal that these children do not find ail

grammatical morphemes equally troublesome. English speaking children with SLI often show

significantly lower percentages of use of particular grammatical morphemes like the English

past tense and third person singular inflections "-su, and function words such as the articles

'la8' and "the" and auxiliaries, and are more limited in the use of both subject case marking and

verb morphology (Bishop, 1994; Johnston & Schery, 1976; Leob 8 Leonard, 1991 ; Leonard,

1 989; Leonard et al., 1 992).

The majority of the studies discussed so far have dealt with the use of grammatical

morphemes in speech. Very Iittle was found in the literature that focused on comprehension of

grammatical morphemes. Bishop (1 979) reported that most children with expressive

grammatical disorders were also impaired on a test of grammatical comprehension. Bishop

(1 979) also noted that children's grammatical morpheme deficits may not be obvious in casual

conversation where they can rely on context and redundancy to facilitate the comprehension

of language. Derwing and Baker (1 986) found that both semantic and phonetic similarity

among selected word pairs played a role in morpheme recognition, but that the semantic

connection was the more critical of the two as it was the one most readily identified as having

a morphological relationship. In addition, they found evidence that variables other than

semantic and phonetic similarity, such as orthographic similarity, influence judgements in

morpheme recognition tasks (Dewing & Baker, 1986).

The findings from the present study suggest that it is important to assess specific

areas of receptive language development (Le., syntax, grammatical rnorphemes) rather than

only global Ianguage outcorne for high-risk children. Future research should detemine whether

high-risk children show similar grammatical morpheme limitations in both their comprehension

and production. Furthemore, given the literature on children with SLI, future research should

examine whether high-risk children, in a manner similar to children with SLI, have particular

difficulty comprehending and/or using specific types of grammatical morphemes, such as

derivational suffixes (e.g., "Here is the pianist"). Future research should also determine

whether there is an association between comprehension of grammatical morphology and

reading and spelling functioning. Bryant, Nune, and Bindman (1 998) found that children's

reading experiences had a strong effect on the development of their explicit knowledge of

grammatical distinctions, and their ability to leam to spell patterns that had a grammatical

basis. Cohen et al. (1 988) found that although preterm children were not considered to be

language impaired as their performance fell in the average range, preterm children with learning

disabilities at 8 years had lower language comprehension scores at 2 years of age.

Ex~ressive Lanauaae

lt was predicted that high-risk children would have significantly lower scores on the

Stanford-Binet Vocabulary and Absurdities subtests at 3 and 4 years, the Expressive

Language scale from the Reynell at 3 years, and the WISC-III Vocabulary and Similarities

subtests at 8 years compared to the normative samples of these standardized expressive

language measures. However, the high-risk children did not obtain significantly lower scores

on the expressive language measures at 3,4, or 8 years compared to the normative sampfes,

with the exception of the Expressive Language Scale of the Reynell at 3 years. It is

important to note that the test examiner s had questioned the accuracy of the results for eight

of the children (12%) on the Expressive Language scale because of behavioural issues,

such as aoncompliance, fatigue, inattention, and shyness. Therefore, the performance on the

Reynell Expressive Language Scale for these 8 children may be an underestimate of their

language ability at 3 years, thereby decreasing the mean score for the high-risk group. An

unexpected finding was that high-risk children performed significantly better on the al1

expressive language measures at 4 years of age compared to the normative sample.

Previous research has shown that despite the finding that the majority (i.e., 81.5 to

83%) of the VLBW children, ranging in ages from 3 to 9 years, had IQ scores in the average

or above average range, they still experienced expressive ianguage and syntactic production

deficits (Barsky, 1 992; Hack et al., 1992; Hunt et al., 1 988; Siegel, 1 985). Siegel (1 98Sb)

found that preterm children performed significantly lower on the WISC-R Vocabulary,

Similarities, and Comprehension subtests at 6 years compared to full-terni children. In the

present sample, high-risk children did not demonstrate the same extensive expressive

language or syntax production difficulties as found with VLBW children. However, their

expressive vocabulary skills at 3 years were predictive of language and Total Cornpetence

outcome at 8 years. This will be discussed in more detail later in this chapter.

It is not known why the high-risk children in this sample at 4 years obtained

significantly higher scores than the normative samples on the Stanford-Binet Vocabulary and

Absurdities subtests and on the ITPA Grammatic Closure subtest. The range of scores on

the Stanford-Binet Vocabulary and Absurdities subtests at 3 years were similar to the range

of scores on the Stanford-Binet Vocabulary and Absurdities subtests at 4 years of age. One

possible explanation may be that the test items from the language measures at 4 years were

less difficult than were the language items at 3 and 8 years.

Behaviour-Cornpetence Profile

In the present study boys at 4 years and 8 years were not found to be significantly

more socially withdrawn, inattentive, aggressive, delinquent, or to have significantly more

lnternalizing and Externalizing problerns compared to the normative sample of the CBCL.

This is in contradiction to previous research studies that have found that LBW and VLBW

children were significantly more hyperactive, distractible, inattentive, and had poorer social

skills and increased internalizing behaviour problems (i.e., socially withdrawn) than their full-

term cohorts (Field et al-, 1983; Hack et al., 1 992; Hack et al., 1 994; Hoy et al., 1 992;

Klebanov et al., 1994b; Robertson et al., 1990, Tessier et al., 1997). For instance, Breslau et

al. (1 988) and Ross et al. (1 990), who used an older version of the CBCL than the one used

in this study (Child Behavior Checklist-Revised Child Behavior Profile: Achenbach &

Edelbrock, 1983), found that VLBW boys (7 to 9 years) had significantly higher scores

(indicating more problems) on the Social Withdrawal, Hyperactive, Aggressive, Delinquent,

lnternalizing and Extemalizing scales of the CBCL compared to the control group. It is

important to note that the control group in the Ross et al. (1990) study was the normative

sarnple of the CBCL. Studies using the more current version of the CSCL were not found in

the premature literature, One explanation for why the boys in the present study were not

found to have more behaviour problems compared to the normative sample of the CBCL, as

was found for VLBW boys in Ross et al. (1990), may be that boys in the present study

were less premature and had higher birthweights.

Consistent with previous research findings, the girls in the present study, in a manner

similar to VLBW girls, did not demonstrate behavioural problems, rather they exhibited fewer

behavioural problems compared to the normative sampfe of the CBCL. Specifically, high-risk

girls at 4 years were rated as having fewer lnternalizing problems. At 8 years, high-risk girls

had significantly lower scores (i.e., fewer problems) on the Social Problerns, Delinquent or

Aggressive scales of the CBCL as well as lower scores on the lnternalizing and Externalizing

scales. It was not expected that the girls frorn the present study would be rated as having

significantly fewer behaviour problems compared to the normative sarnple of the CBCL, as

studies have reported that VLBW girls dId not differ significantly on any of the behaviour

scales from the controls (Breslau et al., 1988; Ross et al., 1990).

Achenbach (1 991) stated that raw scores of 2 or 3 on the Total Problem scale were

low enough to be questionable as "such low scores suggest that the respondent has not

understood the CBCL, is poorly informed about the child, or is not being candid" (p. 235).

Therefore, extremely low behaviour scores was one possible explanation for why high-risk

girls obtained significantly lower behaviour scores compared to the normative sample of the

CBCL. However this explanation was not substantiated as the high-risk girls (8S0lO) were

no more likely to have extremely low Total Problem scores on the CBCL than were the high-

risk boys (6% at 8 years.

Another explanation for why girls were rated as having fewer behaviour problems

compared to girls from the normative sample of the CBCL rnay be because of parents

perceptions of what beiiaviours are problematic for girls and boys. Parents were the only

Înformants to rate their children's behaviour which raises the issue of how having a high-risk

child has biased parents' perceptions of their child's functioning. Parents' beliefs have been

found to influence whether they rate their child's behaviour as problematic or not. For

instance, Mills and Rubin (1 990) found that mothers and fathers were more Iikely to react to

and were less tolerant of problematic social behaviours in their daughters than in their sons.

This suggests that parents rnay accept deviation in behaviour less, and intervene to correct it

more, in daughters than in sons. Therefore, parents in the present study rnay have under-

rated certain behaviours (Le., aggression, noncompliance) as these behaviours rnay have

been perceived by them as being negative and they did not want their daughters to be

perceived as "bad". This explanation, however, is only speculative.

ln addition, the hypothesis that behavioural difficulties identified within a group of high-

risk children would be different for boys and girls was not supported. The boys and girts did

not differ significantly on the Internalizing, Externalizing, or the Total Competence scales of the

CBCL at 4 and 8 years. Tessier et al. (1 997) found that boys, whether they were low-

birthweight or normal-birthweight tended, to be more aggressive than the girls from the

respective groups. The parents in the present study rnay not have only under-rated

behaviour problems in their daughter, they rnay have also done so for their sons.

Neither high-risk boys or girls were found to differ significantly from the normative

sample of the CBCL on the Activities, School, Social, or Total Competence scales of the

CBCL at 8 years. These findings are consistent with Hack et al. (1992) who reported that

VLBW children with normal IQ scores (>85) did not differ significantly on the Social or School

Competence scales of the CBCL. However, Ross et al. (1 990) and Breslau et al. (1 988)

found that VLBW boys had significantly lower scores on the Social and School Competence

scales as well as on the Total Competence scale. A lower score indicates poorer

cornpetence. Their findings for the girls were somewhat mixed. Breslau et al. (1 988) found

that VLBW girls had a significantly lower score (indicating problems) on the Activities scale of

the CBCL compared to the controls. Ross et al. (1990), however, found that VLBW girls had

significantly lower scores on the CBCL School Competence and Total Competence scales

compared to the normative sample of the CBCL.

Preschool Measures as Predictors of Outcorne at 8 Years

Preschool Lanauaae Measures Predictina Lanauaae Outcome at 8 Years

A significant relationship was found between the receptive and expressive language

measures at 3 years and the Similarities subtest of the WISC-III at 8 years of age. The GFW

Sound Mimicry subtest at 4 years was also significantly related to the WISC-III Similarities

subtest at 8 years. The Stanford-Binet Vocabulary subtest at 3 years was found to be

significant correlated with the TACL-R Grammatical Morphemes subtest at 8 years. As

indicated, some of the preschool language measures were found to be significantly correlated

with a couple of the language measures at 8 years, but the number of significant findings was

smaller than expected. It was expected that the preschool language measures would be

significantly related to more of the language measures at 8 years.

It is difficult to comment on whether the present correlational findings are consistent

with other studies, as the ages at which the children are tested and the language measures

used elsewhere generally differ from those reported in this study. Siegel (1 992) found that

receptive language items from the Bayley at 18 and 24 months of age, and expressive

language items from the Bayley at 24 months correlated significantly with the WISC-R

Vocabulary subtest at 8 years. In the present study none of the language measures at 3 or 4

years were found to be significantly correlated with the WISC-III Vocabulary subtest at 8

years. Siegel (1 985b) found significant correlations between the Reynell Language Scales

measures at 2.3, and 4 years and the PPVT, a measure of receptive vocabulary, at 6 years

of age. However based on the alpha levels used in the present study, the Language

Comprehension and the Expressive Language scales of the Reynell at 3 years were not

found to be significantly related to any of the receptive language measures at 8 years of age.

The Vocabulary and Similarities subtests of the Stanford-Binet at 3 and 4 years were also not

found to be significantly related to language comprehension at 8 years, with the exception of

the Vocabulary subtest of the Stanford-Binet at 3 years and the Grammatical Morphemes

subtest of the TACL-R at 8 years. The measures used to measure receptive language at 8

years, the Word Classes, Elaborated Sentences and Grammatical Morphemes subtests of

the TACL-R, require the child to understand fairly complex language. One possible reason

for why preschool language measures in the present study were generally not found to be

significantly related to language comprehension at 8 years, is that the level of language

comprehension required at 3 and 4 years is less complex and not as subtle as what is

required at 8 years.

Other studies that have reported significant correlations among language measures

tend to compare the same Ianguage measure at different times, correlate different language

measures used at one age, or have correlated different language rneasures a few years apart.

For instance, Siegel (1 982b) reported a relationship between a child's performance on the

Reynell Language Scales at 2, 3, and 4 years of age. Molfese et al. (1 993) found that the

PPVT was significantly correlated with the Vocabulary, Cornprehension, and Absurdities

subtests of the Stanford-Binet at 3 years of age. Siegel et al. (1 995) found that for a group of

2-year-old LBW children, expressive language skills from the Bayley Developmental Scale

were significantly correlated with the Reynell Language Scales. Siegel (1 983) found that the

Reynell Languye Scale at 2, 3, and 4 years was significantly correlated with the receptive

vocabulary measure at 5 years of age, but the maximum amount of time between the first and

last age tested was only 3 years.

The relationship between preschool language measures and language measures at 8

years was also examined using contingency analyses which involved calculating the number

of cases that were identified as falling in the average or below average range at each time of

testing. However, none of the Fishefs Exact Tests were significant indicating that a

statistically significant association was not found between being identified as average or

below average on the preschool language measures and being identified as average or

below average on the language measures at 8 years. One of the limitations of the

contingency analyses was that the majority of the children perforrned in the average range on

preschool measures (85% - 93%) and on language rneasures at 8 years (89%-93%). On

the TAGL-R Word Classes and Grammatical Morphemes subtests at 8 years 76% and 65 O h

of the children, respectively, were identified as falling in the average range. Because the

majority of the children were identified as performing in the average range at the initial and

subsequent testing, there was not much opportunity to explore the association of the status

of the children who were identified as being below average.

Miller and Siegel (1 989) and Siegel (1992) successfully used contingency/chi-square

analyses to predict language outcome at 3 and 8 years of age using infant language items

from the Bayiey. It is important to note that in both studies there were well over one hundred

children used in each of the contingency/chi-square analyses. In the present study the

number of children varied (range 21 to 60) depending on the two language measures used in

the contingency analyses. The higher the nurnber of cases observed in each of the cells in

the contingency analyses, particularly the cell representing the children who were identified as

being detayed at both times, the more opportunity there was to explore the association for

those children who have been identified as being below average at initial and subsequent

testing. The poor sensitivity found here is attributed to the low prevalence rates of delays for

the majority of language measures in the present study. Because the prevalence of language

difficutties was low in the present sample, it was mathematically impossible to have high

sensitivity. Sackett et al. (1 985) noted that sensitivity decreases as prevalence decreases,

and that the most is gained frorn a "clinical sign, symptom, or laboratory test ... when the

prevalence of disease is 40% to 60%" (p. 81).

Although significant associations were not found between performance on preschool

language measures and language measures at 8 years, a small number of children were still

identified as having specific language problems. Silva, McGee, and Wiliiams (1 983) followed

a group of normal, healthy children between the ages of 3 and 7 years and found that 3 out of

4 children with language delay were affected at only one age. Silva et al. (1 983) also

recommended that children's language should be assessed at different ages given that they

found that language delay of any type at any age was associated with lower IQ and reading

difficul ties.

CBCL Scales at 4 Years Predictina CBCL Outcome at 8 Years

In the present study the Child Behavior Checklist Internalizing and Externaking

scales at 4 years were significantly correlated with the CBCL lnternalizing and Externalizing

scales at 8 years. Despite a small number of children being identified as having behaviour

problems at age 8 years, just as was found for their language problems, the contingency

analyses showed that the Internalizing and Externalizing scales of the CBCL at 4 years were

accurate at predicting behaviour outcorne on the CBCL at 8 years for high-risk children. In a

longitudinal study that included low birthweight and normal birthweight children, Achenbach et

al. (1 990) reported there was considerable stability in the mothers' ratings of their children's

behaviour over a 2 year period on the lnternalizing and Externalizing scales of the CBCL.

The correlation and the contingency analyses also showed that there was not a

significant relationship between the lnternalizing and Externalizing scales of the CBCL at 4

years and the Total Cornpetence scale of the CBCL at 8 years. This is understandable

given that there are two different constructs being measured. Rather than behaviour, the

Total Competence sa le asks parents to rate how active their child is and how skilled helshe

is at cornpleting various activities (e.g., sports, school) he/she is involved in as part of hislher

daily life.

Although there are studies which have reported the behavioural outcomes for LBW or

VLBW children, these studies have not detennined whether a relationship exists between

level of behavioural functioning at one age and behavioural functioning at a later age, rather

they have only examined the behavioural outcome at one point in time (Breslau et al., 1988;

Hack et al., 1992; Ross et al., 1990; Tessier, 1997).

The Relationship Between Language and Behaviour/Competence Outcome

None of the language measures at 3 , 4 or 8 years were found to be significantly

related the to lnternalizing and Externaking scales of the CBCL at 4 or 8 years. In the

lite rature on clinical populations, moderate to high correlations have been found between

language delays and behavioural/emotionaI problems (i.e., speech-language impaired or

conduct disorders)(Baker et al., 1980; Baker 8 Cantwell, 1 987; Beitchman et a!., 1 987;

Cantwell & Baker, 1987), but sirnilar correlational findings were not found for this high-nsk

group who were generally normal in their behaviour and language functioning. Some studies

have also reported significant relationships between behaviour and language development

for normal, healthy children. Mitchell et al. (1985) found that behaviour problems at 8 years of

age were associated with previous language development and delayed rnotor development

at 12 months of age. Bee et al (1 982) reported that while behaviour problems at 3 years

correlated with receptive and expressive language problems at 3 years of age, behaviour

problems at 4 years did not. Bee et al. (1 982) did not report the number of children in their

sample who were experiencing language detays at 3 years. It may be that more children in

the Bee et al. (1 982) study had language difficulties at 3 years than were found in the present

study (1 20h to 23%. Another explanation for why similar findings were not found in the

present study was that different behavioural and language measures were used than those

used in other research (Bee et al., 1982; Mitchell et al., 1985).

Expressive language skills at 3 years were found to be significantly related to the

Total Cornpetence scale of the CBCL at 8 years for this sample of high-risk children. To the

extent that the Total Competence scale includes items that could involve academic

functioning, this relationship between eady language skills and later competence seems to be

consistent with the literature (Cohen et a., 1992; Ross et al., 1996; Scarborough, 1990) that

indicates the importance of preschool language skills in the acquisition of later academic skills.

The relationship between the language measures and the C8CL competence scales

(Total Competence, Activities, Social, Schwl), differed for the boys and girls. For high-risk

boys, two of the three expressive language measures at 3 years (Stanford-Binet Vocabulary

subtest 8 Reynell Expressive Language Scale) were positively correlated with the Total

Cornpetence scale of the CBCL at 8 years, whereas a number of the expressive language

measures at 3 and 4 years were positively correlated with the Activities Competence scale of

the CBCL at 8 years. None of the language measures at 8 years were significantiy

correlated with the competency scales at 8 years for the boys. This suggests that for boys

early language and later competence were related, but were not indicative of problems in the

present sample. Given this relationship, it is possible that other features of early language

andor later school and social competence are problematic for some high-risk boys and that

early language delays do predict later competence diificulties.

For the high-risk girls a significant positive relationship was found between the

expressive language measures at 8 years and the Activities and School Competence scales

at 8 years of age. Although aspects of later language and later competence involved in this

relationship were not indicative of problems in the present sample of girls, this relationship

should be monitored. Given this relationship, it is possible that other features of later

language and/or later activities and school competence are problematic for some high-risk girls,

and that later language delays do predict later competence difficulties.

When the correlations between the preschwl language measures and the CBCL

Total Competence sa le at 8 years were examined in relation to the correlations between the

CBCL lnternalizing and Externalizing scales at 4 years and language outcome at 8 years,

findings differed for boys and girls. As already indicated a strong relationship was found for

boys between the preschool language measures and the Total competence at 8 years for

high-risk boys, while intemalizing and externalizing problems at 4 years were not refated

language outcome at 8 years. for the high-risk girls preschwl language rneasure were not

related to Total Competence at 8 years. Thus it seems that particularly for boys early

language may play a role in later competence. Although the boys in this study did not have

competence problems, this is a relationship that should be monitored in boys.

When the relationship between language and behaviour measures was examined

using contingency analyses, none of the Fisher's Exact Tests were significant indicating that

there was not a statistically significant association between being identified as below average

or average on the Ianguage measures 3,4 or 8 years and being in the Clinical range on the

CBCL Scales at 4 or 8 years. In the present study the majority of the children perfomed in

the averagehormal range on language and behaviour measures. For instance, 85% to 88%

of the children at 3 years, and 88% to 95% at four years demonstrated average language

functioning. The percentage of children falling in the normal range ranged between 86% and

91 O/O on the lnternalizing and Externalizing scales of the CBCL at 4 and 8 years. The

percentage of children classified as falling in the borderline/clinical range of the lntemalizing and

Externalizing scale of the CBCL at 4 years was 8% (n=5) and 14% (-8) respectively. At 8

years. 11 Oh @=7) of the children in this study had lntemalizing and Externalizing problems.

Predicting Specific Language and Behaviour Outcomes

Of the 3 variables entered into the regression (Siegel's risk index scale, Stanford-

Binet Vocabulary subtest at 3 years, and Externalizing behaviour at 4 years), the expressive

vocabularj measure at 3 years significantly predicted language and Total Competence at 8

years. A possible explanation for why expressive vocabulary at 3 years was found to

predict outcome on the Total Cornpetence scale of the CBCL at 8 years, is that the Total

Competence scale may be an indirect measure of acadernic functioning as several of the items

included this scale relate to school performance. Studies have found that a relationship exists

between preschool language performance and later academic outcome (Gathercole, Willis,

Emslie, & Baddeley, 1 992, Scarborough, 1990). Gathercole et al. (1 992) found that the

expressive vocabulary before the age of 5 years predicted later reading skills.

Bioloaical and Perinatal Risk Variables

In the present study Siegel's risk index scale was not found to predict language

outcome at 8 years. This finding is inconsistent with a number of studies. Siegel (1982a)

found that the combination of materna1 smoking, birthweight, SES, RDS, and number of

previous spontaneous abortions correlated with language comprehension outcome, while the

combination of birth order, SES, matemal smoking, apnea, 5-minute Apgar, and gender

variables correlated with expressive language outcome for a group of VLBW 3-year-old.

Other researchers have also found that various biomedical and environmental factors

were significantly related to language outcome for premature and LBW children ranging in ages

from 16 months to 5 years (e.g., Bendersky & Lewis, 1990, 1994; Hack et al., 1992; Kalmar,

1996; Largo et al., 1986; Vohr et al., 1989). For instance, Bendersky and Lewis (1 990) found

that a system of IVH, medical complications, and SES accounted for 45% of the variance of

language outcome at 2 years.

A direct cornparison with the samples from the above studies was not possible

because of the heterogeneous nature of the present sample. The children in the previous

research had younger gestational ages and lower birthweight. The studies also differ in terms

of the populations studied (Le., LBW, VLBW, or ELBW), and the measures used to assess

language and behaviour outcorne. For instance, Siegel's (1982a) sample was a cohort of

preterm VLBW infants born between 1975 and 1976 to younger mothers of iower SES than

those in the present sample. The present sample was a relatively recent cohort of high-risk

infants born between 1984 and 1986 to older mothers of higher SES and educational levels.

A possible explanation for why Siegel's risk index did not predict later language and

behaviour outcome in this study may be because the sample was not exclusively preterm.

Grigoroiu-Serbanescu (1984) stated that in cornbined groups of preterm and full-term children

the biological variables lose their predictive value because of increased inter- and intra-

individual variability. Similarly, Aylward and Kenny (1 979) found that the predictive value of

biological variables on later outcome was poor in heterogeneous groups or in groups of

normal children, while much better in groups of children with significant devetopmental delays.

These differences in cohorts may serve to illustrate the reason why it may not be possible to

create a specific system of risk index variables that will be clinically useful for al1 populations

unless the populations are similar in characteristics to one another.

Molfese and her colleagues have used Siegel's risk index variables in a number

studies (Molfese & DiLalla, 1995; Molfese et al., 1996; 1997). The number of Siegel's risk

index variables used (ranging from 6 to 11) to predict cognitive and verbal abilities varied as

did the ages at which the children were assessed (3 to 8 years). The subjects that

participated in Molfese's studies were considered to be healthy children who had not

experienced severe perinatal complications (e-g., intraventricular hemorrhage). When Siegel's

risk index variables were part of a model that included SES, infant cognitive measures at 1

year, and a measure of home environment (HOME), the model accounted for a significant

amount of the variance on Intelligence and Verbal Reasoning (Molfese et al., 1996).

However, when Molfese et al. (1 997) combined 6 of Siegel's risk index variables into a single

score (mean=4.53, sd=1.23), Siegel's risk index scale contributed little to cognitive outcome at

3 through 8 years. Similarly, in the present study Siegel's risk index scale, based on 16

variables with a possible total score of 16, was found to have a small mean and narrow

distribution of scores (mean=4.33, sd=2.6). A possible explanation for why Siegel's risk

index scale was not found to predict outcome in Molfese et a l 3 (1997) study or in the present

study may be that although the children in the two studies had some biomedical difficulties,

the number of difficulties was relatively low.

The present findings were consistent, however, with other studies that have not

found biological or perinatal variables commonly associated with prematurity to predict later

outcorne whether it be cognitive, academic, or language (Aram et al., 1991 ; Bee et al., 1982;

Byrne et al., 1993; Greenberg 8 Crnic, 1988; Klein, 1985; Kato Klebanov et al., 1994b; Lee &

Stevenson, 1993; Marlow et al., 1993). Others suggest that the influence of perinatal factors

(Le., IVH) on later developmental outcome (Le., language) decreases over time (Casiro et al.,

1991 ; Largo et al., 1993). Molfese, Holcomb, and Helwig (1 994) found that biomedical factors

were strongly related to cognitive and language development at 1 year, but not at 2 or 3

years of age. While very-low birthweight children were not exclusively followed in this study

the average birthweight (mean birthweight =1406 grams) and gestational age (mean

gestational age = 32 weeks) was similar to that of the samples followed in many of the

studies investigating the outcome of very-low-birthweight children (birthweight approximately

1200 grams; gestational age approximately 30 weeks) (e-g., Aram et al., 1991 ; Byrne et al.,

1993). The group of children followed by Byrne et al. (1 993) had complicated neonatal

histories very similar to those of the children in the present study. For instance, the

percentage of children in the Byme at al. (1 993) study with the following complications was:

340h had an IVH, 25% were SGA, and 47OA had asphyxia. The following percentages were

found for the present study: 23% had an IVH, 46% were SGA, and 33% had asphyxia. It is

important to note that the studies following children who experienced a relatively uneventful

neonatal period also did not find that biological or perinatal variables predict later outcome

(e.g., Bee et al., 1982).

In the present study Siegel's risk index scale was not found to predict Total

Cornpetence, Internalizing or Externaking outcome at 8 years. The few studies that have

examined whether risk index variables predict outcome on behaviour and competence scores

have only found that certain risk index variables were related to specific areas of behavioural

development. For instance, prematurity and RDS were found to be related to hyperactivity

and social cornpetence (Field, 1983; Ross et al., 1990).

Environmental Factors

In this study socioeconornic status (SES) was included as part of the risk index scale

and not entered in the regression as a independent variable because it did not significantly

correlate with the language and behaviour/cornpetence outcome at 8 years. This is contrary

to the findings in the literature. Several studies have shown that SES were related to later

cognitive, language, and behaviour outcome of LBW and VLBW infants (Cohen 8 Parmelee,

1983; Fawer et al., 1995; Greenberg & Crnic, 1988; Grunau et al., 1990; Kitchen et al., 1980;

Largo et al., 1 986, 1 989; Ross et al., 1989; Saigal et al., 1991 ; Siegel, 1 982a, 1983; 1 985b;

Siegel et al., 1982; Thompson et al., 1997; Vohr et al., 1988, 1989). One reason why SES

was not found to be significantly related to language development at 8 years may be

because of the restricted range of SES scores in this sample, thereby reducing the range in

the distribution of scores which can result in lower correlational findings. The majority of the

children in the present study came from middle class backgrounds. Another explanation may

be that SES is not be the best indicator of home environment.

Socioeconomic status (SES) and maternal education are commonly used in studies as

measures of environmental quality. Other environmental variables, however, have also been

found to be important to the child's development, such as caregiver-child interaction,

disciplinary techniques, caregiver responsitivity, and quality of relationships and amount of

support arnong famiiy members (Bee et al., 1982; Feingold, 1994; Greenberg & Crnic, 1988,

Siegel, 1983, Wallace, 1988). For instance, the type of interaction and amount of stimulation

given by a mother to her child were specifically related to language development (Lee &

Stevenson Barrett, 1993; Siegel, 1984; 1989). Bendersky and Lewis (1 994) argue that SES

and maternal education are not sufficient markers of environment quality as they are only

partially related to many of the other environmental variables found to be important in affecting

outcorne (Le., social support). They found that two different environmental measures, family

risk (i.e., parent-child interaction, stressful events) and social class risk (Le., SES and parental

education), represented different aspects of the environment and should be considered

separately (Bendersky 8 Lewis, 1994). This study used only measures of SES and

materna1 education to represent the environment, but Bendersky and Lewis (1 994) found that

it was family risk rather than social class nsk that was related to the development of LBW

children. Molfese et al. (1 997) found that for children with or without neonatal complications

the home environment, as measured by the Home Observation for Measurement of the

Environment lnventory - HOME, was the single most important predictor of intelligence from 3

to 8 years. Siegel (1 982; 1985b) also reported that the HOME correlated significantly with

language measures at 4 to 6 years, as well as with language based academic subjects (i.e.,

reading) at 5 to 6 years.

Earlv Measures of Develo~ment as Predictors of Later Functioninq

In this study the Stanford-Binet Vocabulary subtest at 3 years was an excellent

predictor of language outcome at 8 years as well as predicted performance on the combined

CBCL Total Competence scale at 8 years. The CBCL Externalizing scale at 4 years

predicted the combined CBCL lnternalizing and Externalizing scale at 8 years. Consistent

with the correiational analyses, it was the Stanford-Binet Vocabulary subtest at 3 years, and

not the CBCL Externalizing scale at 4 years, that predicted the performance on the CBCL

Total Competence scale at 8 years. This provides support for the CBCL Total Competence

scales as having more of a relationship to language functioning than to behaviour problerns.

Overall these findings are consistent with other studies that have found early measures of

development to predict later cognitive, language, and academic outcome (Bee et al., 1982;

Cohen et al., 1988; Kitchen et al., 1991). Miller and Siegel (1 989) reported that early cognitive

and motor performance can predict receptive language at 3 years, while McDonald et al.

(1 989) found that early language measures predicted cognitive outcome.

Identifying Below Average/Clinical Performance

The discriminative power of the model consisting of Siegel's risk index scale and

preschool measures was too low to allow reasonably accurate identification of below

average/clinical performance of the individual high-risk child on language and behaviour

measures at 8 years. This may be attributed to the issues discussed above regarding the

heterogeneous nature of the present sarnple.

In addition, the clinical usefulness of the system of risk index and preschool measures

for identifying below average or clinical performance on specific language outcome was not

reasonably accurate given that the prevalence rates of children falling in the below average or

clinical range was very low (e-g., Ooh on the WISC-III Vocabulary subtest & 23.1% on the

combined CBCL f otal Competence scale). Although the overall accuracy for cfassification

ranged from 72% to 92% for specific language and behaviour/competence outcomes, the

sensitivity or identification of the children in the below averagelclinicai range was frequently

less than 50°/~. On the WISC-III Similarities and Vocabulary subtests none of the children

were correctly identified as k i n g below average, the True Positives. If there are no True

Positives it is mathematically impossible to calculate sensitivity.

In contrast to the present findings, Siegel (1 982a, 1985a, 1989, 1992) has found that

risk index variables were quite accurate at predicting language delays, learning difficulties, and

below average cognitive functioning for preterm and full-term children. Other researchers

have also been able to accurately identify cognitive delays in children between the ages of 3

and 7 years using a system of variables that included Siegel's risk index variables (Molfese

& DiLalla, 1995; Molfese et al., 1996). However, Molfese and DiLalla (1 995) found that when

only Siegel's risk index variables were used to predict cognitive and verbal reasoning delays

for children between the ages of 4 to 7 years, the discriminant function analyses were only

significant at 7 years, but at no other age.

Furthermore, the system consisting of a risk index scale and preschool measures (3

and 4 years) was not particularly accurate at identifying the children who were at-risk for

experiencing specific Ianguage difficulties. It may be that if the children were at high risk for

specific language impairrnents it may have identified those with delays, but in the present

study very few children had language delays. However, the system of risk index variables

and preschool measures did identify children who were not at risk (Le., performed within the

averagehormal range) for experiencing language and behaviour difficulties at 8 years with a

high degree of accuracy. For instance, the specificity ranged from 78% on the TACL-R

Grammatical Morphemes subtest to 100°h on the Externalizing scaie of the CBCL at 8 years.

Limitations of the Study

A number of variables in this study had missing data which is one problem with

longitudinal studies. Large numbers of subjects are required to study low prevalence

outcornes. Unfortunately, with longitudinal studies Iike this one, attrition rates tend to be high

(42% to 45%). Maintaining a high follow-up rate is difficult and differential dropout can lead to

systematic bias. In the present study such systematic bias was not found between children

in the attrition group and children in the follow-up group on most of the language, cognitive,

and behaviour measures at 3 and 4 years. However, mothers who continued to participate in

the present longitudinal study were older and had achieved a higher IeveI of education than

mothers who dropped out of the study. Furthermore, it is unclear what impact participating in

the longitudinal study has had on the subsequent development of these high-risk children.

Parents have been provided with research reports that not only summarized the child's test

findings but also provided suggestions and recommendations. It is not known whether

parents followed through on the recommendations. In addition, çome children have received

formal intervention such as speech and language therapy, however, this was not always

reported by parents on a consistent basis.

As already mentioned, a second limitation for most of the cornparisons that examined

outcome associated with earlier classification was that the majority of the children were

identified as being averagehormal at the initial and subsequent testing. This does not leave

much opportunity to explore the association that exists between the children who have been

identified as having problems at the two points of testing. This was particularly true if no True

Positives were identified.

In the present study socioeconomic status (SES) was not found to be significantly

related to language or behaviour outcorne. However, based on other studies, SES as a

measure of environmental factors may not have been the best measure to use. Other

environmental variables such as caregiver-child interaction, disciplinary techniques, caregiver

responsivity, and quality of relationships and amount of support among family members have

also been found to be important to the child's development (Bee et al., 1982; Feingold, 1994;

Greenberg & Crnic, 1988, Molfese et al.. 1997; Siegel, 1983, Wallace, 1988). Bendersky and

Lewis (1 994) referred to the latter variables as "famity risk" and the former variables as "social

class risk". There is growing evidence that family risk rather than social class risk plays a

crucial role in subsequent development (Bendersky & Lewis, 1994).

Although this study compared the results of the high-risk children to test norms, they

were not compared to same age, healthy p e r s from their community, therefore the results

cannot be generalized beyond the sample discussed here.

The use of only parents as inforrnants about their children's behaviour is another

limitation. We do not know whether the parents' perception of their child's behaviour is

consistent with or different from that of the child's teacher or peers. For instance, parents in

this s tudy rated their daughters as having fewer behavioural problems than the normative

sample of the CBCL. If teacher ratings had also been obtained this finding may have been

different.

Another limitation is the type of language measures used in the present study.

Overall, the findings showed that high-risk children did not demonstrate any deficits on the

expressive language and most of the receptive language measures at 3, 4, or 8 years, with

the exception for the TACL-R Grammatical Morpheme subtest at 8 years. However, al1 the

measures used here were at the word or sentence level, with no assessment of discourse in

eit her conversation or narration. Measures of reading, spelling, and written language also

were not reported. Had these aspects of language and language-based academic skills been

investigated, it is possible that other subtle language deficits may have been identified. As

Aram et al. (1991) state "it may be that by 8 years of age, aura1 language abilities have

normalized but more complex aspects of connected discourse or secondary language

systems, including reading and writing, evidence continued deficits (p. 1 178).

Future Research

Suggestions for future research are derived from the findings and limitations of the

present study. Future research should explore: a) the use of a variety of different Ianguage

measures as alternative outcome measures, b) children's language functioning should be

assessed at different ages, c) the use of a multi-informant (parent, teacher, peer) approach to

behaviour outcome, d) the development of a simple and effective systern of risk index

variables to predict specific language and behaviour outcome, e) the use of such an index

which infants in the perinatal period are likely to develop subsequent problerns in order to

institute infant stimulation for these infants early in development, f) the effect of intervention for

high-risk infants identified as being at-risk for subsequent delays, g) long-term follow-up

through adolescence and adulthood to determine whether high-risk children continue to exhibit

the same pattern of language and behaviour development such as poor comprehension of

grammatical morphemes and normal behaviour and cornpetence scores, h) how language-

based academics relate to the CBCL competency scales, particularly the Activities and

School Cornpetence scale, and i) the use of home environment measurements, other than

SES or maternai education, such as the Home Observation for Measurement of Environment

(HOME) lnventory which measures several dimensions of a child's environment (Caldwell 8

Bradley, 1984; Elardo, Bradley, & Caldwell, 1975) that have been found to be related to later

outcome (e-g., Kalmar, 1996; Lee & Stevenson Barrett, 1993; Molfese 8 DiLalla, 1995;

Molfese et al., 1996; Molfese et al., 1 997; Siegel, 1982a, 1982b, 1985b).

Implications and Conclusions

This exploratory study has generated many interesting findings as well as questions.

It was found that the majority of this relatively heterogeneous sample of 8-year-old high-risk

children (88%) were functioning within the average range of cognitive capabilities as

measured by the Wechsler Intelligence Scale for Children - III (Full Scale IQ 2 80). Although

the children in the present study performed in the average range on al1 the language measures

and in the normal range on the CSCL scales at 3,4, and 8 years, they performed significantly

lower on the Reynell Expressive Language scale at 3 years and the TACL-R Grammatical

Morphemes subtests at 8 years compared to the normative sample of these standardized

Ianguage tests. The corretation analyses show that a relationship exists between language

and Total Cornpetence at 8 years for this sample of children. Interestingly, the pattern of this

relationship was somewhat different for boys and girls. For the high-risk boys preschool

expressive language skills were significantly related to performance on the Total Cornpetence

and Activities competence scales of the CBCL at 8 years. For the girls, expressive language

skills at 8 years was related to performance on the Activities and School competence scales

at 8 years. This suggests that girls rely heavily on their language skills being age-

appropriate in order for them to be socially effective. Although aspects of language and

competence involved in this relationship were not indicative of problems in the present

sample, this relationship should be monitored. Given this relationship, it is possible that other

features of earîy language andior later school and social competence are problematic for some

high-risk children, and that eady language delays do predict later competence difficulties.

Whether a similar pattern ernerges for boys and girl from different populations remains to be

seen. Because of the small sample size and the Iow prevalence of language and behaviour

problems found in this group of children, it was not possible to determine how useful a

system consisting of a risk index scale and preschool measures was at predicting or

identifying delays/problems in language and behaviour outcome at 8 years. The concept of

using a system consisting of a risk index that includes demographic, environmental, and

perinatal variables is important as such a system can be used to identify children who will

require special services (e-g., speech therapy), thereby minimizing the effects of subsequent

delay. Furthemore, the findings from this study suggest that preschool measures be used in

any system that is predicting subsequent outcome for school age children.

This study has several implications for professionals working with high-risk children.

The findings suggest that while high-risk children may be of average intelligence, subtle

deficits may still exist. Therefore, professionals should focus on using specific versus global

measures when examining the high-risk child's level of functioning. Professionals should also

monitor preschool language skills carefully as they was found to be related to language

outcome at 8 years. If delays are noted at 3 years of age then early remediation/intervention

programs should be implemented. The findings also suggest that high-risk children may

experience specific receptive language deficits, especially in the comprehension of

grammatical morphemes.

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Appendix A

* Table Al

Differences Between the Follow-Up Cases and the Attrition Group on Selected Demoara~hic Characteristics and Coanitive. Lanauaae,

and Behaviour Outcorne Measures at 3 and 4 Y e a ~

Variable

Follow-Up Group At Eight Years Attrition Group

Gestational Age (rnonths) 31.91 4.59 70 31.22 5.15 67 Birthweight (grams) 1409.00 509.27 70 1 390.55 540.56 67 Presence of Asphyxias IVH Presenta Age of Mother (Years) Education of mother Blishen Score (SES)

Outcome Measures 3Years Stanford-Binet: Vocabulary (ss)b 50.85 7.31 65 49.79 6.50 56 .84(119) Absurdities (ss) 51 -54 7.37 59 49.33 6.75 49 l,62(lO6) IQ 102.82 11 -71 65 99.4 1 11.22 58 1,64(121)

Reynell: Verbal Comprehension(ss) .O6 .90 65 -.21 .75 57 1.82(120) Expressive Language (ss) -.37 1.07 65 -.46 1 .O1 57 .50( 1 20)

Note. A lower level of rnaternal education receives a numerically higher score.

aData coded as O = not present, & 1 = present. ~ S S = standard score. 'p < .Os. -B < .O1

m 2 Table A l Cont'd

Differences Between the Follow-Up Cases and the Attrition gr ou^ on Selected Dernoaraphic Characteristics and Coanitive. Languaae.

Variable

Follow-U Group At Eight ! ears Attrition Group

U Q a E Stanford-Binet: Vocabula ry (ss)* 53.52 7.08 58 50.42 6.25 43 2.28(99)' Absurdi ties(ss) 55.14 6.36 57 54.1 2 8.07 43 .71(98) IQ 104.28 12.63 58 100.44 9.86 43

ITPA: Grammatic Closure (ss) 42.57 9.68 58 40.51 10.09 43 1 .O4 99 GFW: Sound Mimicry (5%) 80.96 25.18 56 95.12 46.57 41

' *""1"3 .7 1 (95)

Girls CBCLb Ratings Internalizing (7)c Externalizing (7)

Boys CBCL Ratings lnternalizing ( 7) Externalizing (q

Combined CBCL Scores: Internalizing (7) 47.82 8.66 56 48.36 7.71 42 .32(96) Externalizing (7') 5 1.23 9.18 56 54.36 7.65 42 1.79(96)

Note, The combined CBCL Total, Internalizing, and Externalizing Tscores were obtained by summing and then averaging the Tscores for the boys and girls in the sarnple for each of the three scales.

ass = standard score. k h i l d Behavior Checklist. CT= Tscore. 'e c .05. I

Appendix 6

1. Subject No.

Baby's

Mother's MSH ID#

Addresx: Number Street Apt.*

City Province Postal Code

Telephone No. - Home

Business

Sex 1 = male 2 - femaie

D.O.B. &Y month year

Expected Date Corrected day month year

GestationaI Age ( w w

SGA = 1 (SrnaIl for gestational age) AGA

B irth

Head

MSH

= 2 (~ppropr&te for gestatikl age)

circumference (cm.) -

Nunesr level 1 = fevel 2 2 = Ievel 3 3 = Ievel 1

of Binh 1 = Singleton 2 - Twin 3 - Triplets 4 - More than 3

Asp hvxia 1 = yes 2 = no

a) 5 minute Apgar scorec6 b) intermittent positive pressure (IPPTj>2 minutes c) umbilical cord artery PHe7.20

Encephelopathv 1 = yes 2 - no

a) persistent abnormal muscle tone/posturing b) seinires c ) loss of coasciousness

Intracranial Hemorrhage if yes, specify: -

a) grade 1 - germinal - 3 b) grade 2 - intraventricular with dilation = 4 C) grade 3 - ventilation - 5 d) grade 4 - blecding = 6

not aplicabk - 7

Hvper bilirubinemia 1 = yes > 250 mol/l 2 = no

Sertam biLiru bin Peak level (342,257)

Specify micro moI/l

Profound Hypoxia 1 - yes 2 = no

Artcrial P0,<4û torr. on more than 1 reading Soecify

Mechan ical Ventilation 1-ye~ 2 = no

16a. Totd duration (no. of days)

17. Apnea 1 - yes 2 - no 18. Apneic spdls

1 = none 2 = single

3 - recurreat

19. Intubated more than 24 houn 1 - yes 2 = no

20. If yes, how many days

Sepsis

21. a) meningitis 1 - yes 2 = no 22, b) systemia 1 = yej 2 = no

c) etiology specify

23. Ototoxic Antibiatics 1 = yes 2 - no 24. If yes, rend problem 1 = yes 2 - no

25. Congenital or Perinatal Infection 1 - yes 2 - no

26. I f yes, 1 - Toxo 3 - C M V 5 = Syph 2 =Bube 4 - Herp 6 = Not Appl.

27. Lare FHR deceleration 1 - ycs 2 = no

28. Meconium at birth in amniotic fluid 1 = yes 2 = no

Apgar scores

29. 1 minute 30. 5 minutes

3 1 . Reproductive Variables

Material Age (Y=-)

32. ~ à t e r n a l smokinq

O = None 1 = haif smaii package/day (10 cigarettct) 2 = half reguîar package/day (10-20 cigarettes) 3 = long ttrm

O = Noue 2 = Incidential 3 = Long tenu

34. Sponraneous 35. Thera pe u tic

36. Medications taken during preflnancy 1 - yes

So=ify type Frequency

37. Use of recreational dntgs during pregnancy 1 = yes 2 - no

Frequency

1 - 1st trimester 2 = 2nd trimester 3 - 3rd trimester 4 * throughout

5 =. None

39. Type of Labor

1 = spontaneous 2 = induced

3 = no labor

40. Type of Delivery

1 = vaginal vertex 2 = outlet fo;ceps 3 = forceps rotation 4 = vacuum 5 = breech 6 = breech and forceps 7 = CS classicai 8 = CS-LS

B a h ordcr 1 - 1st 2 - 2nd 3 - 3rd 4 = 4th

Parentai Education - 1 = professional (MA., MS., M.Ed., MD., Ph.D.) 2 = four yr. allege g a d (B.A., B a . , B.M.) 3 = 1-3 yrs. coiiege ( a h Bus. schaob) 4 = high school gnd 5 = 10- 1 1 yrs. high school 6 = 6-9 yn. high school or less 7 = unknown

42. Mother - 43. Father - Occupation of Parents

44. Mother - 1- f dl- time Zmpart-time 3=unemployed 4runknown

45. Father - 1 J 1 =full- cime 2-part- time 3-unemployed 4-unkno wn

Socioeconomic class

46. Bluhen 8 - unknown 9 - missing 47. Hoiiings head4 factor

48. Current Maritai Status

1 = married 2 = single 3 = separated/divorced 4 3 widow 5 = common-law

49. Has there been a change in marital status sincc the birth of this baby?

I = yes 2 = no

50. If yes. what w ; ~ your marital s t a t u at the time of thk birth?

married single separated/divorced widow cornmon-law -- not applicabIe

Birthplace of Parents

1 = North America 2 = Europe 3 = Mediterranean 4 = West Indies/Caribbean 5 = Asia 6 = Other, specify

- . 51. Mother 52- Fa ther

Race of Parents

1 - White 2 = Btack 3 = Orientai 4 = Indian/Asian 5 - Other

Mother Father

55. Primary Language Spoken at Home

1 = English 2 = French 3 = Italian 4 = Other, specify

56. Secondary Language Spoken at Home

1 = English 2 = French 3 = Italian 4 = Other. specify 5 = None

57. Primary Caretaker of Child

1 = mother 2 = father 3 = both parents 4 - X l a M y 5 - other, family, specify

58. Attendance at Day Care 1 - yes 2 - no

59. If yes, at what age did he/she start? (mo.1

99 = missing 88 = aot applicable

Appendix C

Reliability and Validity

The Wechsler Intelliaence Scale for Children - 111

The average internal consistency reliability coefficients are -95 for the Verbal

Scale IQ, -91 for the Pedormance Scale IQ, and .96 for the Full Scale IQ. Interna1

consistensy reliabilities range from -77 to -87 for the verbal subtests and -69 to -87 for

the performance subtests. Overall, the Vocabulary and the Similarities subtests had

average internal consistency reliabilities of .87 and .81, while at 8 years the Vocabulary

and the Similarities subtests had intemal consistency reliabilities of .88 and -84

(Wechsler, 1991). The stability coefficient for the WISC-III, after an interval between 12

and 63 days, ranged from -92 to .95 for the Full Scale IQ, .90 to .94 for the Verbal Scale,

and from -83 to .87 for the Performance IQ. The average test-retest reliabilities for the

individual subtests ranged from -57 to .89. The test-retest reliabilities for the Vocabulary

and the Similarities subtests are -89 and .81.

The four concurrent validity studies reviewed in the WiSC-III manual (Wechsler,

1991) were used to ascertain the relationship between the WISC-III and other measures

of intelligence (e.g., WISC-R). In the first study, the average correlation between the

WISC-III and the WISC-R verbal, performance and full scale IQs were -90, .81 and -89,

respectively. In the second study, composed primarily of children with learning

difficulties, reading problems, or attention deficit hyperactive disorders, the WISC-III and

WISC-R had correlations of .86 for full scale IQ, .86 for verbal IQ, and -73 for

performance IQ. The correlations between the WISC-III and the WAIS-R verbal,

performance and full scale IQs were .90, .80, and .86. Average correlations between

WISC-I II and WPPSI-R verbal, performance and full scale IQs were -85, .73 and .85,

respectively (Wechsler, 1991).

T c

The split-half reliability coefficients, corrected using the Spearman-Brown

formula, ranged from -73 to -95 (mean=.94) for the Word Classes and Relations subtest,

from .82 to -95 (mean=.94) for the Grammatical Morphemes subtest, and from -86 to -96

(mean=.95) for the Elaborate Sentences subtest (Carrow-Woolfolk, 1985). The split-half

reliability coefficient for the total score ranged from -88 to -97 (mean=.97). The split-half

reliability coefficients for children at 8 years of age are -77 for the Word Classes and

Relations subtest, -84 for the Grammatical Morphemes subtest, -86 for the Elaborated

Sentences subtest, and .88 for the total score. Test-retest reliabilities, calculated from a

sample of 129 children reassessed after a three to four week interval, are -90 for Word

Classes and Relations, -91 for Grammatical Morphemes, -89 for Elaborated Sentences,

and .95 for the total score.

Concurrent validity was demonstrated by significant correlations between the

TACL-R and other language measures such as ITPA (range of .37 to .73), PPVT (-68).

and Sequenced Inventory of Communication Development (range of .73 and -76).

Revnell Develo~mental Lanauaae Scales-Revised

Split-half reliability coefficients, corrected using Spearman-Brown procedures, for

the ReyneII ranged from -45 to .97 on the Verbal Comprehension Scale (Form A) and -80

to -96 on the Expressive Language Scale. The Reyneli was administered when the

children were 3 years of age and the split-half reliability coefficient for the corresponding

age norms at 3 and 3 112 years for the Verbal Comprehension Scale are -96 and -92,

and .93 for the Expressive Language Scale.

Correlations between the Reynell at 5 years 5 months and the WfSC-R and

Neale Reading cornprehension score at 10 years 6 months ranged from .59 to -76

indicating adequate predictive validity (Reynell & Huntley, 1985).

Peabodv Picture Vocabulary-Revised

Split-half reliability coefficients on the PPVT (Form L) for children and youth (2 to

18 years) range from -67 to .88- The split-half reliability for children at 8 years of age is

.87. For the adult sarnple, Form L has a median split-half reliabiiity coefficient of -82.

Alternate-form reliabilities ranged from .74 to -89 with a rnedian reliability coefficient of

.81 (Sattler, 1990).

Dunn and Dunn (1997), the authors of the Peabody Picture Vocabulary Test -

Third Edition (PPVT-III), reviewed several research articles which investigated the

relationship of the PPVT-R with other vocabulary tests and with vocabufary subtests of

individual intelligence and psycholinguistic tests. These included the Bracken Basic

Concept Scale, the Vocabulary subtest of the WPPSI-R, and the Naming Vocabulary

subtest of the Differential Ability Scales. The correlations behrveen the PPVT-R scores

and the scores on the vocabulary tests ranged from -59 to .76. The highest correlation

(.76) is with the Bracken Basic Concept Scale (BBS; Bracken, 1984), a test that closely

resembles the PPVT-R. Correlations with vocabulary subtests of individual intelligence

and psycholinguistic tests ranged from .40 to .70. The lowest correlation (-40) is

between the PPVT-R and the Vocabulary subtest of the Wechsler Preschool and

Prirnary Scale of Intelligence- Revised (WPPSI-R; Wechsler, 1989). Dunn and Dunn

(1997) argued that the low correlation between these two tasks may be because of the

expressive language demands of the Vocabulary subtest from the WPPSI-R. Dunn and

Dunn (1 997) reported that the mean correlations were higher with tests where the child

had to respond with only a single word such as with the Naming Vocabulary subtest of

the Differential Ability Scales (r=.73; Elliott, 1990) and the Expressive One-Word Picture

Vocabulary Test (r=.62; Gardner, 1979).

Vocabulary and Absurdities Subtest of the Stanford-Binet Intelliaence Scale: 4th Edition

lnternal consistency reliabilities, as measured by the Kuder-Richardson formula

20 (KR-20) on the preschool sample, for the Vocabulary and the Absurdities subtests is

.82 and .87, respectively. The test-retest reliability coefficients for the Vocabulary and

the Absurdities subtests are -75 and .70 (Thorndike et al., 1986).

Grammatic Closure Subtest from the Illinois Test of Psvcholinciuistic Abilities

lnternal consistency reliabilities range from .80 to .89 across the eight age groups

for Grammatic Closure (Paraskevopoulos 8 Kirk, 1969). The internai consistency

reliability at 4 years is -87. Test-retest reliabilities range behiveen .72 and -87.

The ITPA was found to correlate welt with the Verbal Comprehension and the

Expressive Language Scales of the Reynell (Reynell8 Huntley, 1985). The median

correlation for the Verbal Comprehension is -544 and ,569 for the Expressive Language

Scale. The correlation between the Grammatic Closure subtest from the ITPA and the

Reyneil Verbal Comprehension and the Expressive Language subtest is .685 and -625,

respectively.

The Child Behavior ChecklisV4-18

Comparison of referred and non-referred boys and girls showed differences on al1

behaviour problem and social competence scores. Specifically, "al1 competence scales

were scored higher and al1 problem scales were scored lower for non-referred than

referred children at p <.O1 " (Achenbach, 1991, p.91). Seven day test-retest correlations

averaged -87 for the competence scales and -89 for the problem scales. The mean

correlations over a 1 -year period are .62 for competence scales and .75 for problems

scales, and mean correlations over a 2-year period are -56 for competence scales and

.71 for problem scales. Among the competence scales, the mean interparent correlation

ranged from -74 to .76 for the four sex/age groups, and the mean interparent correlations

the problem scales ranged -65 to .75 (Achenbach, 1991). The mean correlations for the

cornpetence scales for boys and girls aged 4-1 1 is -78 and -76, respectively, while on the

problem scales the mean correlations for boys and girls aged 4-1 1 is -75 and -65-

Achenbach (1 991) compared the CBCL scale scores with scores from the closest

counterpart scales on the Conners Parent Questionnaire (Conners, 1973) and the

Revised Behavior Problem Checklist (Quay-Peterson, 1983). The correlations between

the CBCL and Conners syndrome scales ranged from -59 to -86. The correlations

between the CBCL lnternalizing and Externalizing scores and the corresponding

Conners scales ranged from -56 to .86, and the correlation between the CBCL and the

Conners total probfem scores is -82. Similarly, the correlations between the CBCL

syndrome scales and corresponding subscales on the Revised Behavior Problem

Checklist ranged from .59 to .88. The correlation between the total problern scores for

the two measures is .81, while the correlations between the CBCL lnternalizing and

Externalizing score and the corresponding scales from the Revised Behavior Problem

Checklist ranged from -52 10 -88.

Appendix O

fbc O m t r r i o l a m t i h t s for S ~ r d i u ir W m u & & r -- K m - t &*dw pédrg~giqi- de - g r r i o -4- - Z 2 Blmr Strcct W. Tomnio. Ontario W S IV6 252. W BbOr 7" <OMtior& IV6

PRE-TERM AND LOW-BIRTH WElGHT INFANT LONGITUDINAL STUDY BACKGROUND SUMMARY

PARENTAL CONSENT FORM

I hereby agree to allow my child (h i les Mm)

to participate in the Eariy Identification Study at The Ontario Institute for Studies in Education.

I understand that the procedures do not involve any nsû to my child. The investigators have ensured me that al1 information will be kept strictly confidentid and that I may withdraw my diild from the study at any time.

SIGNATURE

D A T E .

EL. (416) 9236641 TELEX 06217720 FAX (416) 9264725 Affiliaitd with thc University of Toronio/Affilit à I'Univeni<é de Toronio

Appendix E

Appendix E.l

Averaae Order of Acauisition of 14 Grammatical Morphemes Studied bv Brown (1 973)

Grammatical Momheme

1. present progressive Z3. prepositions in/on

4. plural 5. irregular past tense 6. possessive 7. copula, uncontractible 8. articles a/the 9. regular past tense

10. third person present tense, regular 1 1. third person present tense, irregular 12. auxiliary, uncontractible 1 3. copula, contractible 14. auxiliary, contractible

-S he had 's this is it

he ta1 ked he talks he has I was talking I am happy or I'm happy I am talking or I'm talking

From A First Lanauaae [p. 2741 by R. Brown (1973) with modifications made by J. B. Gleason (1993) fr [p. 1711.