Effectiveness of ENGAGE in reducing difficulties in everyday executive functions among Finnish preschoolers: a randomized controlled trial.

Effective interventions applicable for young preschool-age children are needed to reduce the risk of widespread and sustained adversities that are linked to early executive function (EF) difficulties. This randomized controlled trial (RCT) examined the effectiveness of the play-based ENGAGE intervention in improving behavioral outcomes related to EFs among Finnish preschool-age children with hyperactivity and/or inattention problems. 95 children between 4 and 5 years of age and their parents were randomly assigned to the ENGAGE intervention or a waitlist control group. Parents and early childhood education (ECE) teachers rated the children's EF difficulties and problem behaviors at pre-intervention, post-intervention, and 5-month follow-up. Repeated measures linear mixed modeling was used to examine the effect of ENGAGE on child outcomes. Those receiving ENGAGE exhibited significantly greater decreases in parent-rated attentional problems, hyperactivity/impulsivity, and acting out behaviors than the control group did, with mostly moderate effect sizes. No consistent improvements in the teacher ratings of children's EF related difficulties were found in either group. Low dropout (8%) from the intervention and high acceptability ratings indicated that ENGAGE is a palatable intervention for parents. The present study showed that findings from an earlier RCT on ENGAGE conducted in New Zealand could be generalized to a different cultural setting, as the intervention effectively reduced young Finnish children's EF difficulties in the home context. Extending ENGAGE and other play-based interventions into different everyday contexts of children, such as ECE, could further enhance the beneficial effects on children's EFs and behavior.

Latent class growth analysis identified different trajectories in cognitive development of extremely low birthweight children.

BACKGROUND: Recent longitudinal studies suggest stable cognitive development in preterm children, although with great individual variation. This prospective neurocognitive follow-up study of extremely low birthweight (ELBW, <1000 g) children aimed to characterise groups with different developmental trajectories from preschool to preteen age. METHODS: ELBW children (n=115) born in Finland in 1996-1997 participated in cognitive assessments at a median age of 5.0 years and 11.3 years. A standardised test of intelligence (Wechsler Preschool and Primary Scale of Intelligence-Revised or Wechsler Intelligence Scale for Children-third edition) was administered at both ages. RESULTS: Three ELBW groups with different developmental trajectories over time were identified with latent class growth analysis. Children with average (Full-Scale IQ (FSIQ): 85-115) and below average (FSIQ: <85) intelligence at 5 years of age had significant decreases in intelligence scores by 11 years of age (-11.7 points and -14.9 points, respectively, both p<0.001), while those with above average intelligence (FSIQ: >115) showed stable development (-3.2 points, p=0.250). Multiple linear regression showed that neonatal complications (intraventricular haemorrhage grade 3-4 and blood culture positive sepsis) and maternal education significantly predicted lower intelligence at the second assessment (F(3,106)=7.27, p<0.001, adjusted R2=0.147). CONCLUSIONS: ELBW children represent a heterogeneous patient population in which groups with different cognitive trajectories can be detected. Deterioration may occur particularly in children with initial average or below average cognitive performance at 5 years of age, with neonatal complications and lower maternal education presenting as risk factors. Catch-up in cognitive functions seems more uncommon in the ELBW population, which should be noted in clinical work.

Analysis of neurodevelopmental outcomes of preadolescents born with extremely low weight revealed impairments in multiple developmental domains despite absence of cognitive impairment.

BACKGROUND AND AIMS: Children with extremely low-birth weight (ELBW) have a high risk for cognitive, motor, and attention impairments and learning disabilities. Longitudinal follow-up studies to a later age are needed in order to increase understanding of the changes in neurodevelopmental trajectories in targeting timely intervention. The aims of this study were to investigate cognitive and motor outcomes, attention-deficit hyperactivity (ADHD) behaviour, school performance, and overall outcomes in a national cohort of ELBW children at preadolescence, and minor neuromotor impairments in a subpopulation of these children and to compare the results with those of full-term controls. The additional aim was to report the overall outcome in all ELBW infants born at 22 to 26 gestational weeks. METHODS: This longitudinal prospective national cohort study included all surviving ELBW (birth weight <1000 g) children born in Finland in 1996 to 1997. No children were excluded from the study. Perinatal, neonatal, and follow-up data up to the age of 5 years of these children were registered in the national birth register. According to birth register, the study population included all infants born at the age under 27 gestational weeks. At 11 years of age general cognitive ability was tested with the Wechsler Intelligence Scale for Children, ADHD behavior evaluated with a report from each child's own teacher (ADHD Rating Scale IV), and school performance with a parental questionnaire. An ELBW subpopulation consisting of a cohort representative children from the two university hospitals from two regions (n = 63) and the age-matched full-term born controls born in Helsinki university hospital (n = 30) underwent Movement Assessment Battery for Children and Touwen neurological examination comprising developmental coordination disorder (DCD) and minor neurological dysfunction (MND), respectively. RESULTS: Of 206 ELBW survivors 122 (73% of eligible) children and 30 (100%) full-term control children participated in assessments. ELBW children had lower full-scale intellectual quotient than controls (t-test, 90 vs 112, P < .001), elevated teacher- reported inattention scores (median = 4.0 vs 1.0, P = .021, r = .20) and needed more educational support (47% vs 17%, OR 4.5, 95% CI 1.6-12.4, P = .02). In the subpopulation, the incidences of DCD were 30% in ELBW and 7% in control children (P = .012, OR 6.0 CI 1.3-27.9), and complex MND 12.5% and 0%, (P = .052; RR 1.1 95% CI 1.04-1.25), respectively. Of survivors born in 24 to 26 gestational weeks, 29% had normal outcome. CONCLUSION: As the majority of the extremely preterm born children had some problems, long-term follow-up is warranted to identify those with special needs and to design individual multidisciplinary support programs.

Heterogeneity of executive functions among preschool children with psychiatric symptoms.

The aim of the present study was to investigate associations between internalizing and externalizing symptoms and deficits in executive functions (EF) as well as to examine the overall heterogeneity of EFs in a sample of preschool children attending a psychiatric clinic (n = 171). First, based on cut-off points signifying clinical levels of impairment on the parent-completed Child Behavior Checklist (CBCL), children were assigned into groups of internalizing, externalizing, combined or mild symptoms and compared to a reference group (n = 667) with regard to day care teacher ratings of EFs on the Attention and Executive Function Rating Inventory-Preschool (ATTEX-P). Second, latent profile analysis (LPA) was employed to identify distinct subgroups of children representing different EF profiles with unique strengths and weaknesses in EFs. The first set of analyses indicated that all symptom groups had more difficulties in EFs than the reference group did, and the internalizing group had less inhibition-related problems than the other symptom groups did. Using LPA, five EF profiles were identified: average, weak average, attentional problems, inhibitory problems, and overall problems. The EF profiles were significantly associated with gender, maternal education level, and psychiatric symptom type. Overall, the findings suggest that the comparison of means of internalizing and externalizing groups mainly captures the fairly obvious differences in inhibition-related domains among young psychiatric outpatient children, whereas the person-oriented approach, based on individual differences, identifies heterogeneity related to attentional functions, planning, and initiating one's action. The variability in EF difficulties suggests that a comprehensive evaluation of a child's EF profile is important regardless of the type of psychiatric symptoms the child presents with.

Impairments of executive function in young children referred to child psychiatric outpatient clinic.

Few studies have reported on the quantity and quality of executive function (EF) deficits in young children referred to child psychiatric outpatient clinic with multiple psychiatric symptoms. We evaluated the EF deficits with the Attention and Executive Function Rating Inventory-Preschool (ATTEX-P) filled out by day care teachers for 4- to 7-year-old clinical group ( n = 171) and reference group ( n = 709). Family background information was collected from all families by parent questionnaire. Diagnoses of the referred children were collected from medical records. Clinical group exhibited higher mean ranks across the ATTEX-P Total score and all nine subscales than reference group ( p < .001). Most of the children in the clinical group (58.5%) showed a significant amount of EF deficits (ATTEX-P Total score over clinical cut-off) including distractibility (55.6%) and impulsivity (53.8%) regardless of their diagnoses. In a multiple logistic regression model (controlling for age, gender and parental education), children in the clinical group had increased risk (odds ratio (OR)) = 10.6, 95% confidence interval (CI) = [6.88, 16.2], p < .001) for scoring over the clinical cut-off point on the ATTEX-P Total score. Assessment of EFs should be a routine part of the treatment plan in young children referred to child psychiatric outpatient clinic as it may guide the treatment choices.

Behavioral Executive Functions Among Adolescents With Mathematics Difficulties.

This study investigates behavioral executive functions (EFs) in the mathematics classroom context among adolescents with different mathematics performance levels. The EF problems were assessed by teachers using a behavioral rating inventory. Using cutoff scores on a standardized mathematics assessment, groups with mathematics difficulties (MD; n = 124), low mathematics performance (LA; n = 140), and average or higher scores (AC; n = 355) were identified. Results showed that the MD group had more problems with distractibility, directing attention, shifting attention, initiative, execution of action, planning, and evaluation than the LA group, whereas the differences in hyperactivity, impulsivity, and sustaining attention were not significant. Compared to the AC group, the MD group showed more problems with all behavioral EFs except hyperactivity and impulsivity, while the LA group showed more problems only with shifting attention. Male adolescents showed more behavioral EF problems than female adolescents, but this gender difference was negligible within the MD group. The practical implications of the results are discussed.

Sleep and psychiatric symptoms in young child psychiatric outpatients.

BACKGROUND: Sleep may underlie psychiatric symptoms in young children. However, not many studies have reported on sleep and its associations with symptoms in young child psychiatric patients. OBJECTIVES: To assess the amount and quality of sleep and how sleep associates with psychiatric symptoms in young child psychiatric patients. Furthermore, we evaluated how sleep and daytime somnolence differed in patients and their age- and gender-matched controls. METHOD: The sample consisted of 139 3- to 7-year-old child psychiatric outpatients and 139 age- and gender-matched controls from community. We evaluated sleep and daytime somnolence with the Sleep Disturbance Scale for Children in all children and psychiatric symptoms with Child Behaviour Checklist (CBCL) in the patient group. Family background information was collected from the patients. RESULTS: Of the patients, 31.6% had a significant sleep problem and 14.4% slept too little. The most typical sleep problems were restless sleep (31.7%), morning tiredness (21.6%) and difficulties getting to sleep at night (18.7%). All types of sleep problems were associated with CBCL total, internalising and externalising problems (all p-values < .01). We observed a strong association between all types of sleep problems and emotionally reactive subscale ( p-value < .001). Furthermore, parent-reported sleep problems increased significantly the risk of having high scores on total (odds ratio (OR) = 5.3, 95% confidence interval (CI) = [2.2, 12.6], p < .001), external (OR = 3.7, 95%, CI = [1.6, 8.5], p < .01) and internal (OR = 2.5, 95% CI = [1.1, 5.5], p < .05) scores after controlling for age, gender, family structure and parent's educational level. Even mild sleep disturbance increased the intensity of psychiatric symptoms. Compared to controls, patients slept less ( p < .001) and had significantly more frequent restless sleep, nightmares and morning and daytime somnolence. CONCLUSION: Sleep problems and too little sleep are prevalent in young child psychiatric patients, and they relate strongly to the intensity of psychiatric symptoms. Identification and treatment of sleep problems should be a routine part of the treatment plan for young child psychiatric patients. The results emphasise the need for assessing sleep in young child psychiatric patients, as treating the sleep problem may reduce psychiatric symptoms.

Teacher Ratings of Executive Function Difficulties in Finnish Children with Combined and Predominantly Inattentive Symptoms of ADHD.

School-age children with difficulties in executive functions (EFs) are at risk for substantial academic impairment and poorer developmental outcome. Although Attention Deficit Hyperactivity Disorder (ADHD) is generally associated with weaknesses in EFs, a relatively minimal amount is known about school-related EF difficulties and differences between ADHD subtypes. The present study examined teacher ratings of EF behaviors in 7- to 15-year-old Finnish children with combined symptoms of ADHD (ADHD-C; n = 189), predominantly inattentive symptoms (ADHD-I; n = 25), and no ADHD (n = 691). The teacher ratings showed that both ADHD groups had more EF difficulties than controls. Ratings also indicated specific EF profiles for the ADHD subtypes, students with ADHD-I having more wide-ranging EF difficulties in attention as well as initiation, planning, and execution of actions than children with ADHD-C. According to the present findings, the school-related EF difficulties of children with ADHD-I need to be specifically acknowledged. Teacher ratings seem to be sensitive indicators of EF difficulties and distinguish between different kinds of EF profiles. In clinical practice, rating scales with reliable psychometric properties and normative data relevant to the specific cultural environment should be employed.

Parents tend to underestimate cognitive deficits in 10- to 13-year-olds born with an extremely low birth weight.

AIM: This study determined the cognitive outcomes of Finnish children born with an extremely low birth weight (ELBW) and assessed the agreement between their neuropsychological assessment and how their parents evaluated their cognitive difficulties. METHODS: The study focused on 121 children from an ELBW cohort with a mean age of 11.6 years (range 10.3-13.8) and assessed them using a standardised test of intelligence, a neuropsychological test battery and a parental developmental questionnaire. The results were compared with the test norms. RESULTS: ELBW children exhibited global cognitive impairment compared to the test norms, with no differences between children who were small or appropriate for gestational age. Children with average intelligence displayed specific impairment in executive, sensorimotor and visuospatial functions. Corresponding functions in the parental evaluation and neuropsychological assessment were associated, but 16-26% of children scoring under the clinical cut-off value in the neuropsychological test domains were not detected by the parental evaluations. CONCLUSION: Children born with an ELBW faced a high risk of global cognitive impairment at a mean age of 11.6 years, and those with average intelligence were at risk of specific cognitive sequelae. Compared to the neuropsychological tests, up to one-fourth of the parents underestimated their child's cognitive problems.

Examining methodological variation in response inhibition: The effects of outcome measures and task characteristics on age-related differences.

This study addressed methodological issues common to developmental studies on response inhibition. Age-related differences were investigated using two Stroop-like tasks with different levels of complexity and comparing different outcome measures in a sample of 340 children and adolescents aged 7-15 years. First, speed and accuracy of task performance were examined; the results showing that improvement in speed continued until age 13 in both the basic naming task and the two inhibition tasks. Improvement in accuracy was less consistent and continued until age 9 or 13 years. Second, two different algorithms were employed to control for the effects of basic processes in inhibition tasks. The difference algorithm indicated age-related differences similar to those for speed. The ratio algorithm, however, suggested earlier deceleration of development of response inhibition at 9 or 11 years of age. Factors related to the cognitive requirements and presented stimuli also had an effect on the results. The present findings shed light on the inconsistencies in the developmental studies of response inhibition and demonstrated that the selection of outcome measures and task characteristics are critical because they affect the way development is depicted.

The Attention and Executive Function Rating Inventory (ATTEX): Psychometric properties and clinical utility in diagnosing ADHD subtypes.

This study presents a new inventory, the Attention and Executive Function Rating Inventory (ATTEX), and examines the psychometric properties and the clinical utility of ATTEX in identifying the attention deficit hyperactivity disorder combined type (ADHD-C) and the ADHD predominantly inattentive type (ADHD-I) in school environments. A normative sample of Finnish 7- to 15-year-old children and adolescents (N = 701) and a clinical sample consisting of children with ADHD-C (N = 190) and ADHD-I (N = 25) were examined with the ATTEX and the ADHD Rating Scale-IV. The ATTEX and its scales had good internal consistency reliability (0.67-0.98) and criterion validity (0.68-0.95). Normative data was provided for the total normative sample and for boys and girls separately. Gender differences were noted in the ATTEX scores, boys having consistently higher scores on all ATTEX scales. The effect of age was significant only for one of the ten scales, the Motor hyperactivity scale, 7-year-olds having more problems of hyperactivity than 14-year-olds. Lower parent education level and the child's learning difficulties were related to higher ratings of EF problems in ATTEX. When different cutoff scores for boys and girls were applied, ATTEX was sensitive in identifying children with attention deficit disorders. In addition, ATTEX was accurate in differentiating children with ADHD-I from children with ADHD-C. In this Finnish sample, ATTEX showed solid psychometric properties and could be used as a reliable tool in the diagnostic evaluation of ADHD-C and ADHD-I.