Demographic and clinical associations to employment status in older-age bipolar disorder: Analysis from the GAGE-BD database project.

OBJECTIVE: The current literature on employment in older adults with bipolar disorder (OABD) is limited. Using the Global Aging and Geriatric Experiments in Bipolar Disorder Database (GAGE-BD), we examined the relationship of occupational status in OABD to other demographic and clinical characteristics. METHODS: Seven hundred and thirty-eight participants from 11 international samples with data on educational level and occupational status were included. Employment status was dichotomized as employed versus unemployed. Generalized linear mixed models with random intercepts for the study cohort were used to examine the relationship between baseline characteristics and employment. Predictors in the models included baseline demographics, education, psychiatric symptom severity, psychiatric comorbidity, somatic comorbidity, and prior psychiatric hospitalizations. RESULTS: In the sample, 23.6% (n = 174) were employed, while 76.4% were unemployed (n = 564). In multivariable logistic regression models, less education, older age, a history of both anxiety and substance/alcohol use disorders, more prior psychiatric hospitalizations, and higher levels of BD depression severity were associated with greater odds of unemployment. In the subsample of individuals less than 65 years of age, findings were similar. No significant association between manic symptoms, gender, age of onset, or employment status was observed. CONCLUSION: Results suggest an association between educational level, age, psychiatric severity and comorbidity in relation to employment in OABD. Implications include the need for management of psychiatric symptoms and comorbidity across the lifespan, as well as improving educational access for people with BD and skills training or other support for those with work-life breaks to re-enter employment and optimize the overall outcome.

Depression in multiple sclerosis across the adult lifespan.

OBJECTIVES: The objective of this study is to examine the burden of depressive symptoms across the adult age span in people with multiple sclerosis (MS) and test if the relationship between depressive symptoms and MS characteristics vary across age groups. METHODS: In analyses of the MS Partners Advancing Technology and Health Solutions (MS PATHS) network of adults with MS, we compared the prevalence of depression in MS PATHS with non-MS controls across age and evaluated for effect modification by age in the association between depressive symptoms and clinical and neuroperformance measures via multivariable-adjusted regression models. RESULTS: In total, 13,821 individuals with MS were included. The prevalence of depression was higher in MS versus non-MS controls, but was similar between men/women across age. The association between depression and processing speed (PST; p for interaction = 0.009) or walking speed (p for interaction = 0.04) varied by age. For example, younger depressed individuals had 0.45 standard deviation (SD) (95% confidence interval (CI) = -0.62, -0.29) worse PST Z-scores versus non-depressed younger participants, whereas older depressed individuals had 0.20 SD (95% CI = -0.32, -0.08) worse PST Z-scores versus non-depressed older participants. CONCLUSION: Depressive symptoms and age should be considered when interpreting measures of walking speed and cognitive function; these findings may have implications for analyses of neuroperformance change.

Association of Depressive Symptoms With Postoperative Delirium and CSF Biomarkers for Alzheimer's Disease Among Hip Fracture Patients.

OBJECTIVES: While there is growing evidence of an association between depressive symptoms and postoperative delirium, the underlying pathophysiological mechanisms remain unknown. The goal of this study was to explore the association between depression and postoperative delirium in hip fracture patients, and to examine Alzheimer's disease (AD) pathology as a potential underlying mechanism linking depressive symptoms and delirium. METHODS: Patients 65 years old or older (N = 199) who were undergoing hip fracture repair and enrolled in the study "A Strategy to Reduce the Incidence of Postoperative Delirium in Elderly Patients" completed the 15-item Geriatric Depression Scale (GDS-15) preoperatively. Cerebrospinal fluid (CSF) was obtained during spinal anesthesia and assayed for amyloid-beta (Aß) 40, 42, total tau (t-tau), and phosphorylated tau (p-tau)181. RESULTS: For every one point increase in GDS-15, there was a 13% increase in odds of postoperative delirium, adjusted for baseline cognition (MMSE), age, sex, race, education and CSF AD biomarkers (OR = 1.13, 95%CI = 1.02-1.25). Both CSF Aß42/t-tau (ß = -1.52, 95%CI = -2.1 to -0.05) and Aß42/p-tau181 (ß = -0.29, 95%CI = -0.48 to -0.09) were inversely associated with higher GDS-15 scores, where lower ratios indicate greater AD pathology. In an analysis to identify the strongest predictors of delirium out of 18 variables, GDS-15 had the highest classification accuracy for postoperative delirium and was a stronger predictor of delirium than both cognition and AD biomarkers. CONCLUSIONS: In older adults undergoing hip fracture repair, depressive symptoms were associated with underlying AD pathology and postoperative delirium. Mild baseline depressive symptoms were the strongest predictor of postoperative delirium, and may represent a dementia prodrome.

Depressive symptoms in relation to clinical symptom onset of mild cognitive impairment.

ABSTRACTObjective:There is increasing evidence of an association between depressive symptoms and mild cognitive impairment (MCI) in cross-sectional studies, but the longitudinal association between depressive symptoms and risk of MCI onset is less clear. The authors investigated whether baseline symptom severity of depression was predictive of time to onset of symptoms of MCI. METHOD: These analyses included 300 participants from the BIOCARD study, a cohort of individuals who were cognitively normal at baseline (mean age = 57.4 years) and followed for up to 20 years (mean follow-up = 2.5 years). Depression symptom severity was measured using the Hamilton Depression Scale (HAM-D). The authors assessed the association between dichotomous and continuous HAM-D and time to onset of MCI within 7 years versus after 7 years from baseline (reflecting the mean time from baseline to onset of clinical symptoms in the cohort) using Cox regression models adjusted for gender, age, and education. RESULTS: At baseline, subjects had a mean HAM-D score of 2.2 (SD = 2.8). Higher baseline HAM-D scores were associated with an increased risk of progression from normal cognition to clinical symptom onset ≤ 7 years from baseline (p = 0.043), but not with progression > 7 years from baseline (p = 0.194). These findings remained significant after adjustment for baseline cognition. CONCLUSIONS: These results suggest that low levels of depressive symptoms may be predictive of clinical symptom onset within approximately 7 years among cognitively normal individuals and may be useful in identifying persons at risk for MCI due to Alzheimer's disease.

Referral Sources Across Racial and Ethnic Groups at Alzheimer's Disease Research Centers.

Background: Despite the need to increase engagement of underrepresented groups (URG) in Alzheimer's disease and related dementias (ADRD) studies, enrollment remains low. Objective: Compare referral sources across racial and ethnic groups among participants enrolled in ADRC studies. Methods: Data for this cross-sectional secondary analysis were extracted from the National Alzheimer's Coordinating Center Uniform Data Set. We performed mixed effects logistic regression models using generalized estimating equations for professional referral versus non-professional referral by racial and ethnic group, adjusted for age, gender, education, visit year, and Clinical Dementia Rating scale (CDR) with a random effect for study site. Results: Included in the analysis were 48,330 participants across 46 ADRCs (mean [SD] age, 71.3 [10.5] years; 20,767 female [57%]; 4,138 Hispanic [8.6%]; 1,392 non-Hispanic Asian [2.9%]; 6,766 non-Hispanic Black [14%] individuals; and 676 individuals [1.4%] of other races. Non-Hispanic Black and Asian participants had lower odds of being referred by a professional contact compared to non-Hispanic White participants (Black: adjusted OR = 0.61, 95% CI = 0.44-0.86, p = 0.005; Asian: adjusted OR = 0.65, 95% CI, p = 0.004). In participants who had completed an MRI, there was no significant difference in referral source across ethnic and racial groups. Conclusions: Further studies are needed to better understand the systemic and structural factors that contribute to differences in referral sources and disparities in recruitment of URG into ADRD studies.

Phonological awareness and oral language proficiency in learning to read English among Chinese kindergarten children in Hong Kong.

BACKGROUND: Learning to read is very challenging for Hong Kong children who learn English as a second language (ESL), as they must acquire two very different writing systems, beginning at the age of three. Few studies have examined the role of phonological awareness at the subsyllabic levels, oral language proficiency, and L1 tone awareness in L2 English reading among Hong Kong ESL kindergarteners. AIMS: This study aims to investigate L1 and L2 phonological awareness and oral language proficiency as predictors of English reading among children with Chinese as L1. SAMPLE: One hundred and sixty-one typically developing children with a mean age of 5.16 (SD=.35) selected from seven preschools in Hong Kong. METHOD: Participants were assessed for English reading, English and Chinese phonological awareness at different levels, English oral language skills, and letter naming ability. RESULTS: Hierarchical regression analyses indicated that both oral language proficiency and phonological awareness measures significantly predicted L2 word reading, when statistically controlled for age and general intelligence. Among various phonological awareness units, L2 phonemic awareness was the best predictor of L2 word reading. Cross-language transfer was shown with L1 phonological awareness at the tone level, uniquely predicting L2 word reading. CONCLUSIONS: The present findings show the important role of phonological awareness at the subsyllabic levels (rime and phoneme) and oral language proficiency in the course of L2 reading development in Chinese ESL learners. The significant contribution of L1 tone awareness to L2 reading suggests that phonological sensitivity is a general competence that ESL children need to acquire in early years. The findings have significant implications for understanding L2 reading development and curriculum development.

The Delirium Interview as a new reference standard in studies on delirium assessment tools.

BACKGROUND: The reference standard in studies on delirium assessment tools is usually based on the clinical judgment of only one delirium expert and may be concise, unstandardized, or not specified at all. This multicenter study investigated the performance of the Delirium Interview, a new reference standard for studies on delirium assessment tools allowing classification of delirium based on written reports. METHODS: We tested the diagnostic accuracy of our standardized Delirium Interview by comparing delirium assessments of the reported results with live assessments. Our reference, the live assessment, was performed by two delirium experts and one well-trained researcher who registered the results. Their delirium assessment was compared to the majority vote of three other independent delirium experts who judged the rapportage of the Delirium Interview. Our total pool consisted of 13 delirium experts with an average of 13 ± 8 years of experience. RESULTS: We included 98 patients (62% male, mean age 69 ± 12 years), of whom 56 (57%) intensive care units (ICUs) patients, 22 (39%) patients with a Richmond Agitation Sedation Scale (RASS) < 0 and 26 (27%) non-verbal assessments. The overall prevalence of delirium was 28%. The Delirium Interview had a sensitivity of 89% (95% confidence interval [CI]: 71%-98%) and specificity of 82% (95% CI: 71%-90%), compared to the diagnosis of an independent panel of two delirium experts and one researcher who examined the patients themselves. Negative and positive predictive values were 95% (95% CI: 86%-0.99%), respectively, 66% (95% CI: 49%-80%). Stratification into ICU and non-ICU patients yielded similar results. CONCLUSION: The Delirium Interview is a feasible reference method for large study cohorts evaluating delirium assessment tools since experts could assess delirium with high accuracy without seeing the patient at the bedside.

Cognitive and Mood Profiles Among Patients With Stiff Person Syndrome Spectrum Disorders.

An emerging body of evidence suggests that changes in cognitive and emotional function are common aspects of stiff person spectrum disorders (SPSD). We sought to examine the pattern of cognitive impairment and psychiatric symptoms in SPSD. Methods: A retrospective review of medical records was conducted for patients seen at the Johns Hopkins Stiff Person Syndrome (SPS) center from 1997 to January 1st, 2020. Individuals who had received formal cognitive testing as part of routine clinical care for patient-reported cognitive changes were included. Demographics, prevalence of cognitive impairment, psychoactive medication use, and clinically significant psychiatric symptoms were described. Results: Out of 205 patients screened, 20 completed cognitive testing (75% female, mean age 47.4 years). The most common domains of impairment were verbal learning and recall memory (n = 14, 70%), verbal fluency (n = 10, 50%), processing speed (n = 8, 40%), and attention (n = 8, 40%). 9/11 patients assessed for depression reported clinically significant symptoms, and 4/9 patients assessed for anxiety reported clinically significant symptoms. Conclusions: Screening for cognitive impairment in SPSD should utilize testing that assesses verbal learning and recall, phonemic verbal fluency, attention, and processing speed. Moreover, it is important to evaluate for co-existing depression and anxiety symptoms, as these are common in SPSD.

Association Between Late-Life Neuropsychiatric Symptoms and Cognitive Decline in Relation to White Matter Hyperintensities and Amyloid Burden.

BACKGROUND: Neuropsychiatric symptoms (NPS) among cognitively normal older adults are increasingly recognized as risk factors for cognitive decline and impairment. However, the underlying mechanisms remain unclear. OBJECTIVE: To examine whether biomarkers of Alzheimer's disease (amyloid burden) and cerebrovascular disease (white matter hyperintensity (WMH) volume) modify the association between NPS and cognitive decline among cognitively unimpaired older adults. METHODS: Analyses included 193 cognitively unimpaired participants (M age = 70 years) from the BIOCARD study, including 148 with PET amyloid and WMH biomarker data. NPS were measured with Neuropsychiatric Inventory and Geriatric Depression Scale scores. Linear mixed effects models were used to examine the association between baseline NPS and longitudinal cognitive trajectories (M follow-up = 3.05 years), using separate models for global, episodic memory, and executive function cognitive composite scores. In a subset of individuals with biomarker data, we evaluated whether WMH or cortical amyloid burden modified the relationship between NPS and cognitive change (as indicated by the NPS×biomarker×time interactions). RESULTS: Higher baseline NPS were associated with lower executive function scores, but not a faster rate of decline in executive function. NPS symptoms were unrelated to the global or episodic memory composite scores, and there was little evidence of a relationship between NPS symptoms and cognitive change over time. The associations between NPS and cognitive decline did not differ by amyloid or WMH burden, and NPS were unrelated to amyloid and WMH burden. CONCLUSION: These results suggest that the effect of neuropsychiatric symptoms on executive dysfunction may occur through mechanisms outside of amyloid and cerebrovascular disease.

Tai chi as an intervention to improve balance and reduce falls in older adults: A systematic and meta-analytical review.

OBJECTIVE: The evidence of tai chi for balance improvement and fall reduction in older adults was updated and reviewed. METHOD: A systematic review was carried out by two independent reviewers among nine electronic databases to identify randomized controlled trials (RCTs) that examined the effects of tai chi on balance improvement and fall reduction in older adults using such key words as tai chi, falls, balance, and randomized trial. RESULTS: The results based on 13 RCTs indicated that tai chi was effective in improving balance of older adults but may not necessarily be superior to other interventions. Results also showed that in the absence of other interventions, tai chi reduced falls in the nonfrail elderly. CONCLUSION: Tai chi is recommended as an alternative treatment for improving balance so as to reduce falls. Future research with improved research designs such as more consistent outcome measures on balance and fall reduction and longer postintervention follow-up should be conducted to unravel the efficacy of different types of tai chi.

Meta-analysis of ICU Delirium Biomarkers and Their Alignment With the NIA-AA Research Framework.

BACKGROUND: Between 30% and 80% of survivors of critical illness experience cognitive impairment, but the underlying mechanisms remain unknown. OBJECTIVE: To determine whether intensive care unit (ICU) delirium biomarkers align with the National Institute on Aging-Alzheimer's Association (NIA-AA) research framework for diagnostic biomarkers for Alzheimer disease and other related dementias (ADRD). METHODS: Ovid MEDLINE, PsycInfo, Embase, and the Cochrane Library were systematically searched for articles published between January 1, 2000, and February 20, 2020, on the relationship between delirium and biomarkers listed in the NIA-AA framework. Only studies that addressed delirium in the ICU setting and fluid biomarkers were included in these analyses. RESULTS: Of 61 256 records screened, 38 studies met inclusion criteria, 8 of which were suitable for meta-analysis. In pooled analysis, significant associations were found between ICU delirium and amyloid ß-peptide 1-40 (standard mean difference [SMD], 0.42; 95% CI, 0.09-0.75), interleukin (IL)-1 receptor antagonist (SMD, 0.58; 95% CI, 0.21-0.94), and IL-6 (SMD, 0.31; 95% CI, 0.06-0.56). No significant association was observed in pooled analyses between ICU delirium and the other biomarkers. Few studies have examined ICU delirium and pathologic tau or neurodegeneration biomarkers. CONCLUSIONS: Inflammatory biomarkers and amyloid ß are associated with ICU delirium and point to potential overlapping mechanisms between delirium and ADRD. Critical care providers should consider integrating diagnostic approaches used in ADRD in their assessment of post-ICU cognitive dysfunction.

Depressive symptoms and CSF Alzheimer's disease biomarkers in relation to clinical symptom onset of mild cognitive impairment.

INTRODUCTION: We sought to examine whether depressive symptoms and level of Alzheimer's disease (AD) pathology are independently or interactively associated with the risk of progression to mild cognitive impairment (MCI). METHODS: The study included a total of 216 participants from the Biomarkers for Older Controls at Risk for Alzheimer's Disease study, a cohort of individuals who were cognitively normal at baseline (mean age = 57) and followed for more than 20 years (mean = 12.7 years), who had baseline Hamilton Depression Scale (HAM-D) scores and cerebrospinal fluid (CSF) amyloid beta (Aß)1-42 , t-tau, and p-tau measures available. RESULTS: Cox regression demonstrated that baseline HAM-D and CSF AD biomarkers were both associated with time to onset of MCI. There was an interaction between HAM-D scores and markers of AD pathology, in which depression was associated with time of onset in participants with low levels of AD pathology (hazard ratio = 0.64; 95% confidence interval = 0.43-0.95; P= .026). DISCUSSION: The effect of depressive symptoms on progression to clinical symptoms of MCI may be most evident among individuals with low levels of AD pathology.

Folkbiology meets microbiology: a study of conceptual and behavioral change.

Health education can offer a valuable window onto conceptual and behavioral change. In Study 1, we mapped out 3rd-grade Chinese children's beliefs about causes of colds and flu and ways they can be prevented. We also explored older adults' beliefs as a possible source of the children's ideas. In Study 2, we gave 3rd- and 4th-grade Chinese children either a conventional cold/flu education program or an experimental "Think Biology" program that focused on a biological causal mechanism for cold/flu transmission. The "Think Biology" program led children to reason about cold/flu causation and prevention more scientifically than the conventional program, and their reasoning abilities dovetailed with their mastery of the causal mechanism. Study 3, a modified replication of Study 2, found useful behavioral change as well as conceptual change among children who received the "Think Biology" program and documented coherence among knowledge enrichment, conceptual change, and behavioral change.

Beliefs about learning, self-regulated strategies and text comprehension among Chinese children.

BACKGROUND: Most studies have investigated college and high school students' epistemological beliefs in Western contexts, with few studies examining how beliefs about learning are related to children's strategies and comprehension in the Chinese cultural context. AIMS: The present study investigated Chinese elementary school children's beliefs about learning and examined their relations with self-regulated learning strategies and text comprehension. SAMPLE: The participants were 417 Grade 5 (mean age=10.8 years) and 420 Grade 6 (mean age=11.9 years) elementary school children in Hong Kong. METHODS: A questionnaire assessing children's beliefs about learning was constructed; children were also asked to complete the Motivated Strategies for Learning Questionnaire and several text comprehension tasks assessing deep understanding. RESULTS: Factor analysis indicated two contrasting factors of constructivist and reproductive beliefs about learning. High achievers outperformed low achievers on beliefs, strategy and comprehension scores. Multiple regression indicated that constructivist beliefs contributed to text comprehension over and above the effects of grade and strategy. CONCLUSIONS: This study corroborates current research on the roles of beliefs and strategies in text comprehension and suggests that meta-cognitive beliefs and strategies examined in English reading can also be identified among Chinese children in text comprehension.

Language disturbance and functioning in first episode psychosis.

Language disturbance has a central role in the presentation of psychotic disorders however its relationship with functioning requires further clarification, particularly in first episode psychosis (FEP). Both language disturbance and functioning can be evaluated with clinician-rated and performance-based measures. We aimed to investigate the concurrent association between clinician-rated and performance-based measures of language disturbance and functioning in FEP. We assessed 108 individuals presenting to an Early Intervention in Psychosis Service in Ireland. Formal thought disorder (FTD) dimensions and bizarre idiosyncratic thinking (BIT) were rated with structured assessment tools. Functioning was evaluated with a performance-based instrument, a clinician-rated measure and indicators of real-world functioning. The disorganisation dimension of FTD was significantly associated with clinician-rated measures of occupational and social functioning (Beta=-0.19, P<0.05 and Beta=-0.31, P<0.01, respectively). BIT was significantly associated with the performance-based measure of functioning (Beta=-0.22, P<0.05). Language disturbance was of less value in predicting real-world measures of functioning. Clinician-rated and performance-based assessments of language disturbance are complementary and each has differential associations with functioning. Communication disorders should be considered as a potential target for intervention in FEP, although further evaluation of the longitudinal relationship between language disturbance and functioning should be undertaken.

Impact of Chronic Pain on Treatment Prognosis for Patients with Opioid Use Disorder: A Systematic Review and Meta-analysis.

BACKGROUND: While a number of pharmacological interventions exist for the treatment of opioid use disorder, evidence evaluating the effect of pain on substance use behavior, attrition rate, and physical or mental health among these therapies has not been well established. We aim to evaluate these effects using evidence gathered from a systematic review of studies evaluating chronic non-cancer pain (CNCP) in patients with opioid use disorder. METHODS: We searched the Medline, EMBASE, PubMed, PsycINFO, Web of Science, Cochrane Database of Systematic Reviews, ProQuest Dissertations and theses Database, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform Search Portal, and National Institutes for Health Clinical Trials Registry databases to identify articles evaluating the impact of pain on addiction treatment outcomes for patients maintained on opioid agonist therapy. RESULTS: Upon screening 3,540 articles, 14 studies with a combined sample of 3,128 patients fulfilled the review inclusion criteria. Results from the meta-analysis suggest that pain has no effect on illicit opioid consumption [pooled odds ratio (pOR): 0.70, 95%CI 0.41-1.17; I (2) = 0.0] but a protective effect for reducing illicit non-opioid substance use (pOR: 0.57, 95%CI 0.41-0.79; I (2) = 0.0). Studies evaluating illicit opioid consumption using other measures demonstrate pain to increase the risk for opioid abuse. Pain is significantly associated with the presence of psychiatric disorders (pOR: 2.18; 95%CI 1.6, 2.9; I (2) = 0.0%). CONCLUSION: CNCP may increase risk for continued opioid abuse and poor psychiatric functioning. Qualitative synthesis of the findings suggests that major methodological differences in the design and measurement of pain and treatment response outcomes are likely impacting the effect estimates.

A nonparametric item analysis of a selected item subset of the learning process questionnaire.

BACKGROUND: Although there have been numerous studies conducted on the psychometric properties of Biggs' Learning Process Questionnaire (LPQ), these have involved the use of traditional omnibus measures of scale quality such as corrected item total correlations, internal consistency estimates of reliability, and factor analysis. However, these omnibus measures of scale quality are sample dependent and fail to model item responses as a function of trait level. And since the item trait relationship is typically nonlinear, traditional factor analytic methods are inappropriate. AIMS: The purpose of this study was to identify a unidimensional subset of LPQ items and examine the effectiveness of these items and their options in discriminating between changes in the underlying trait level. In addition to assessing item quality, we were interested in assessing overall scale quality with non-sample dependent measures. METHOD: The sample was split into two nearly equal halves, and a undimensional subset of items was identified in one of these samples and cross-validated in the other. The nonlinear relationship between the probability of endorsing an item option and the underlying trait level was modelled using a nonparametric latent trait technique known as kernel smoothing and implemented with the program TestGraf. After item and scale quality were established, maximum likelihood estimates of participants' trait level were obtained and used to examine grade and gender differences. RESULTS: A undimensional subset of 16 deep and achieving items was identified. Slightly more than half of these items needed some of their options combined so that the probability of endorsing an item option as a function of increasing trait level corresponded to the ideal rank ordering of the item options. With this adjustment, scale quality as measured by the information function and standard error function was found to be good. However, no statistically significant gender differences were observed and, although statistically significant grade differences were observed, they were not substantively meaningful. CONCLUSIONS: The use of nonparametric kernel-smoothing techniques is advocated over parametric latent trait methods for the analysis of attitudinal and psychological measures involving polychotomous ordered-response categories. It is also suggested that latent trait methods are more appropriate than traditional test-based measures for studying differential item functioning both within and between cultures. Nonparametric kernel-smoothing techniques hold particular promise in identifying and understanding cross-cultural differences in student approaches to learning at both the item and scale level.

Effects of a phonological awareness program on English reading and spelling among Hong Kong Chinese ESL children.

This study investigated the effects of a 12-week language-enriched phonological awareness instruction on 76 Hong Kong young children who were learning English as a second language. The children were assigned randomly to receive the instruction on phonological awareness skills embedded in vocabulary learning activities or comparison instruction which consisted of vocabulary learning and writing tasks but no direct instruction in phonological awareness skills. They were tested on receptive and expressive vocabulary, phonological awareness at the syllable, rhyme and phoneme levels, reading, and spelling in English before and after the program implementation. The results indicated that children who received the phonological awareness instruction performed significantly better than the comparison group on English word reading, spelling, phonological awareness at all levels and expressive vocabulary on the posttest when age, general intelligence and the pretest scores were controlled statistically. The findings suggest that phonological awareness instruction embedded in vocabulary learning activities might be beneficial to kindergarteners learning English as a second language.