A comparison of executive function in very preterm and term infants at 8 months corrected age

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Abstract

Background

Executive function (EF) emerges in infancy and continues to develop throughout childhood. Executive dysfunction is believed to contribute to learning and attention problems in children at school age. Children born very preterm are more prone to these problems than their full-term peers.

Aim

To compare EF in very preterm and full-term infants at 8 months after expected date of delivery.

Subjects

37 very preterm infants without identified disabilities, and 74 gender and age matched healthy full-term infants. The very preterm infants were all ≤ 32 weeks gestation and < 1250 g birthweight.

Outcome measures

EF tasks which measured working memory, inhibition of distraction, and planning at 8 months after expected date of delivery.

Results

The very preterm infants performed significantly more poorly than the full-term infants on all measures of executive function. No significant differences were found between very preterm and full-term infants on any of potentially confounding variables of, infant temperament, maternal education, family income and maternal psychological wellbeing. Very preterm infants had significantly lower scores on the Mental Development Index (MDI) and Psychomotor Development Index (PDI) on the Bayley Scales of Infant Development (BSID II), however when this was partialled out the differences in EF scores remained. Medical complications, lower birthweight and lower gestation age were all found to adversely affect the performance of very preterm infants on executive function tasks.

Conclusion

Very preterm infants performed more poorly than full-term infants on measures of EF. Further follow up studies are required to investigate whether EF measures in infancy can predict learning and attention outcome at school age.

Introduction

Advances in medical technologies have resulted in the increased survival of infants of progressively lower birthweight and shorter gestation. Compared with full-term infants, those born early are at increased risk of subsequent difficulties, in behaviour and learning [1]. The risk of these adverse outcomes increases as gestation age and birthweight decrease [2].

Executive function (EF) deficits have been linked to a range of problems, including attention deficit disorder (ADD), learning difficulties, and autism [3], all of which are more prevalent in children born preterm [4]. EF encompasses goal directed behaviour that is deliberate, conscious, and purposeful [5]. While dependent upon basic cognitive processes, such as perception and memory, the behaviours and processes referred to as EF are associated with higher-order cognitive abilities, that require holding plans or programs in mind until executed (working memory), inhibiting irrelevant action (inhibition), and planning a sequence of actions (planning) [3], [6]. These components of EF have been identified in factor analytic studies e.g., [7], [8] as well as studies of patients with frontal lobe lesions (e.g., [9]).

Preschool and school aged children who were born preterm have been found to have poorer performance on various tasks measuring EF than their full-term peers [10], [11] with those preterm children who had medical complications in the perinatal period being more impaired on EF measures than other preterm children [12].

It is generally agreed that EF is primarily governed by the prefrontal cortex of the brain [13] and the emergence of EF abilities coincides with the development of this part of the brain [14]. However as the prefrontal cortex is late to mature and develops rapidly in infancy, it may be particularly vulnerable to disturbance in preterm infants. For example, disruption of pathways in the prefrontal lobe may occur because of damage to other neural circuits that connect to the frontal lobes and are therefore implicated in EF development [15].

During the first year of life, significant development of EF takes place. A study of working memory in infants from 8 to 12 months of age, showed that on the AB task (see description of the AB task below in Section 2.3) the time delay between hiding the object and allowing the infant to retrieve it could be significantly increased as the child got older without incurring increased errors [16]. At a similar age infants have also been shown to begin to inhibit irrelevant responses [17], to become planful, and to be able to carry out relatively complex sequences of goal directed behaviour [18]. It has been suggested that any deviation in the development of EF during this critical period may result in enduring learning, attention or behavioural problems [12], [19].

Most previous studies of cognitive development in preterm infants have relied upon either the use of standard developmental assessments [20] which are poor predictors of later learning and behaviour [4], or the use of sophisticated technology to assess perception, memory or attention [21], [22]. The present research used practical and simple measures of EF that could be applied easily in clinics or field settings. It has been argued that the AB task measures working memory and inhibition [23] and that tasks which require the execution of a series of steps to achieve a goal measure planning [24]. Therefore these were the assessment tools of choice for comparing the performance of very preterm infants (who are known to have a high risk for learning and attentional problems) and full-term infants (who have a much lower risk for these difficulties). It was hypothesised that differences on measures of EF would exist between the two groups, even when the influence of confounding variables was taken into account. If this is the case these measures of specific cognitive abilities, which are associated with behaviour and learning, may provide a means of identifying children at risk of school difficulties at an early age.

Section snippets

Subjects

Both very preterm and full-term infants enrolled in the study were healthy, had no diagnosed disabilities, lived within a 50-kilometre radius of the Mater Mothers' Hospital, and came from English speaking families. All the very preterm infants were born at the Mater Mothers' Hospital, Brisbane, between May 1998 and July 1999, with gestational ages of ≤ 32 weeks and birthweights of < 1250 g. They were recruited into the study by the clinic co-ordinator when they attended for their routine

Results

Table 2 shows the results of ANOVAs and Chi-squares to examine differences between preterm and full term infants on potential confounding variables.

Very preterm infants had significantly lower scores than full-term infants on the psychomotor development scale (PDI) of the BSID II but no significant differences were found between the groups on the mental development scale (MDI) or any of the other variables. Analysis of variance (ANOVA) (unadjusted model) was firstly used to compare very preterm

Discussion

The present study found that at 8 months corrected age the performance of very preterm infants was inferior to that of full-term infants on EF tasks of working memory, inhibition to distraction, and planning. These findings reinforce the call from a number of researchers for the measurement of more specific cognitive abilities when assessing the development of very preterm infants [36]. Furthermore as very preterm infants performed more poorly than full term infants on measures of EF and as

Acknowledgement

The first author received financial support from an Australian International Postgraduate Research Scholarship and from the School of Early Childhood at the Queensland University of Technology. The authors also wish to acknowledge the support of the Growth and Development team at the Mater Children's Hospital, Brisbane.

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