Children born prematurely are at risk for a variety of social, behavioral, and academic problems. Although some VLBW children have major disabilities resulting from their premature birth and/or subsequent medical complications, the majority of these children have milder forms of dysfunction (Hack et al., 2000; Halsey, Collin, & Anderson, 1996; Msall et al., 1991; Saigal, Szatmari, Rosenbaum, Campbell, & King, 1991; Teplin, Burchinal, Johnson-Martin, Humphry, & Kraybill, 1991). Typically, they demonstrate subtle problems such as inattentiveness, difficulty following directions, problems adjusting to school, and poor school performance, especially when compared to their normal birth weight peers (Botting, Powls, Cooke, & Marlow, 1997; Breslau et al., 1996; Breslau & Chilcoat, 2000; Davis, 2003; Hoy, Bill, & Sykes, 1988; Klein, 1988; Sykes et al., 1997; Teplin et al., 1991). Because of the subtle nature of these problems, they often go unrecognized until after the children enter school. Approximately half of very low birth weight (< 1500 g; VLBW) children receive special educational services even in the absence of major disability. Unfortunately, the delay in diagnosis and treatment often necessitates costly remedial educational services and can have a long-term effect on their cognitive, emotional, and behavioral development and on academic success (Halsey et al., 1996; Msall et al., 1991; Saigal et al., 1991; Whitfield, Grunau, & Holsti, 1997). It is clear that a better understanding of the underlying developmental processes that lead to poor outcomes, particularly those related to academic achievement, is needed in order to develop specific interventions to ensure that these high-risk children reach their full potential.
Most researchers and clinicians would agree that adverse outcomes are the result of complex interactions among child and environmental factors. However, much is still unknown about the specific causal factors and the way in which biological and environmental factors interact to produce less than optimal developmental outcomes.
One important child factor shown to relate to children's developmental and academic achievement outcomes is temperament (Rothbart & Jones, 1998). Recent conceptualizations of temperament describe it as individual differences in self-regulation and reactivity that occur during development as a result of the dynamic interaction between the individual and his/her environment (Chang & Burns, 2005; Eriksson & Pehrsson, 2003; Kochanska, Murray, & Harlan, 2000; Rothbart, Ahadi, Hershey, & Fisher, 2001; Rothbart & Jones, 1998). This approach to temperament has largely been pioneered by Rothbart and others who contend that early regulatory control of arousal, reactivity, state, and attention form the basis for theories of temperament (Derryberry & Rothbart, 1997; DiPietro, Costigan, & Pressman, 2002; Huffman et al., 1998). Temperament includes physiological, motor, state, and attentional regulatory systems that are present at birth (Als & Lawhon, 2004; Rothbart & Bates, 1998). Although temperament is biologically based and stable over time, it is modifiable by maturation and experience (Rothbart & Bates, 1998). The human infant has been described as having a constitutional predisposition to react to the environment by using approach and avoidance behaviors to regulate the amount and type of stimulation solicited from the environment (Als & Lawhon, 2004; Rothbart & Bates, 1998). Infants with greater self-regulatory capacities have greater control over the intake of stimulation from their environment (Langkamp & Pascoe, 2001; Rothbart, Derryberry, Reed, & Hershey, 2000).
Recently, some temperament researchers have suggested that new methods are needed to measure temperament because previous instruments did not consider the developmental nature of temperament throughout early childhood and because there was considerable overlap, conceptually, among the dimensions underlying temperament (Rothbart & Bates, 1998; Rothbart & Jones, 1998; Rothbart & Mauro, 1990). Rothbart's framework allows researchers to better explore temperament variability (Rothbart et al., 2001) and may be particularly important when studying children who are at risk for problems with attention regulation such as children born prematurely. Rothbart's (1996) Children's Behavior Questionnaire (CBQ) includes assessments of 16 dimensions (see Method). Using factor analysis Ruff and Rothbart (1996) identified 16 dimensions, which have been clustered into 3 factors consisting of Effortful Control, Extraversion, and Negative Affectivity.
The first factor, Effortful Control, includes regulatory functions such as inhibition and activation responses (Jones, Rothbart, & Posner, 2003; Rothbart, Ellis, Rueda, & Posner, 2003) and has often been described in relation to executive control of attentional and other cognitive processes (see Chang & Burns, 2005 and Eisenberg et al., 2004 for discussions of distinctions between effortful control and attention). The second factor, Extraversion, has been linked to positive emotionality (Rothbart & Bates, 1998; Rothbart et al., 2003). Negative Affect, the third factor, refers to negative emotionality (e.g., anger, frustration, fear, and sadness) (Rothbart et al., 2001).
Of the three factors, research has shown that effortful control is a key component to children's cognitive and academic outcomes in normally developing populations (Rothbart & Jones, 1998). Effortful control is a biologically based and stable behavioral style characterized by the ability to self-regulate reactivity in response to both internal and external stimuli (Rothbart et al., 2003). Children who are rated low in effortful control typically demonstrate poor attention skills and achievement outcomes. In addition, temperament, including effortful control, has been linked to social competency (Eisenberg & Fabes, 1992; Saylor, Boyce, & Price, 2003), behavior problems (Blair, Denham, Kochanoff, & Whipple, 2004; Caspi, Henry, McGee, Moffitt, & Silva, 1995; Eisenberg et al., 2004; Olson, Sameroff, Kerr, Lopez, & Wellman, 2005; Paterson & Sanson, 1999; Saylor et al., 2003), resiliency (Eisenberg et al., 2004), childhood adjustment (Blair et al., 2004; Eisenberg et al., 2004), cognitive and learning skills (Gartstein & Rothbart, 2003; Rothbart & Jones, 1998), motivation (Chang & Burns, 2005), disruptions in family functioning and parent-child interactions (Eriksson & Pehrsson, 2003; Gauvain & Fagot, 1995; Kochanska et al., 2000; Paterson & Sanson, 1999), and alterations in teacher-child interactions (Rothbart & Jones, 1998). Recent research has shown that structured environments can buffer the negative consequences associated with low effortful control (Gartstein & Fagot, 2003; Kochanska et al., 2000). So, although effortful control is biologically based, there are important intervention implications (Rothbart et al., 2001; Rothbart et al., 2003).
The utility of a temperament framework has yet to be fully explored in children born prematurely. From birth, delays in regulatory control may impact specific factors of temperament, such as effortful control, in children born prematurely. Given that stability in the infant's ability to maintain state matures at approximately 36 weeks gestation (DiPietro et al., 2002), these children may not be equipped to regulate their internal processes and, accordingly, cannot control the intake of external stimulation. Some have linked early regulatory failures with later social, motor, and cognitive developmental outcomes (Doussard-Roosevelt, McClenny, & Porges, 2001; Doussard-Roosevelt, Porges, Scanlon, Alemi, & Scanlon, 1997).
Additionally, the environmental stimulation experienced in neonatal intensive care units is foreign to the infant who is delivered at full-term. Ironically, premature infants, with their diminished capacities to block out stimulation, are often exposed to environments characterized by excessive and noxious stimuli for extended periods of time (Als et al., 1994, 2004; DiPietro et al., 2002; Doussard-Roosevelt et al., 2001). The interaction between early biological insults resulting from premature birth and adverse environmental conditions may negatively influence the development of temperament as well as other developmental and regulatory systems.
Studies have reported differences in temperament characteristics between children born prematurely and those born at full-term, but the results, overall, have been inconclusive (Nygaard, Smith, & Torgersen, 2002) and have not explored self-regulatory aspects of temperament. Furthermore, few have looked at these differences at or beyond preschool age (Nygaard et al., 2002). Methodological differences between the studies and failure to replicate findings make it difficult to interpret the results. In general, compared to children who were born at full-term, children born prematurely have been found to rate lower on persistence, reactivity, intensity, and orientation toward the environment; have a lower sensory threshold; and be less goal-directed as infants and toddlers (Langkamp & Pascoe, 2001; Sajaniemi et al., 2001). It has been suggested that these temperament characteristics relate to behavioral and learning problems in children born prematurely (Schraeder, Heverly, & Rappaport, 1990).
Conceptualizing temperament in terms of individual differences in reactivity and self-regulation provides a foundation for better understanding how temperament might affect long-term developmental outcomes in children, especially children who are at risk for developmental delays and disabilities. In both the early home environment and later in the academic setting, children's individual differences in reactivity and self-regulation influence their response to both positive and negative stimulation (Rothbart & Jones, 1998). Because of the dynamic nature of developmental systems, some temperament characteristics may have compounding effects on children's emotional, behavioral, and cognitive development. Temperament appears to impact the way in which children adapt to the demands of academic environments (Rothbart & Jones, 1998). For example, the way in which children approach new people, new experiences, and new environments contributes to their academic success and influences the way in which others relate to them.
Rothbart's approach to the study of temperament seems particularly promising in trying to understand why children born prematurely are in need of such discrepantly large degree of special education services even when the children have IQ scores in the average range. Early identification of and intervention for children who have specific temperamental characteristics may improve their longterm developmental and achievement trajectories (Blair, 2001, 2002a, 2002b; Rothbart & Bates, 1998; Rothbart & Jones, 1998).
Effortful control has been suggested to have important implications for school readiness and academic success (Blair, 2002b; Burns et al., in press; Chang & Burns, 2005; Harris, Robinson, Chang, & Burns, 2005). Studies of temperament in children born prematurely have not demonstrated clear and consistent differences between children born prematurely and those born at full-term (Nygaard et al., 2002). However, most previous studies of temperament in infants and children born prematurely do not examine the self-regulatory aspect of temperament.
As described above, children born prematurely have been described as being inattentive and having poorer school performance than their normal birth weight peers (Botting et al., 1997; Breslau et al., 1996; Breslau & Chilcoat, 2000; Davis, 2003; Hoy et al., 1988; Klein, 1988; Sykes et al., 1997; Teplin et al., 1991). In addition, researchers have suggested that children born prematurely may have overall failures in self-regulatory functioning (Davis & Burns, 2001; Sykes et al., 1997). These failures in self-regulatory functioning may, in part, reflect differences in effortful control. It is not clear whether children born prematurely would be expected to demonstrate differences in negative affect and/or extraversion, but they have been reported to have a disproportionate number of problems that might be associated with lower levels of effortful control.
The purpose of this study was to describe temperament characteristics, using Rothbart's framework, in a sample of children born with VLBW and to determine if Rothbart's three temperament factors emerge in this population. Comparisons were also made between children born of VLBW and children born with normal birth weights (NBW). These descriptive data are needed to provide a foundation for more complex studies of the relationships between temperament and developmental outcomes in this special population of children.
Participants were 97 children, 4 and 5 years of age, who had been born prematurely and had weighed < 1500 g at birth as well as a comparison group of children born at full-term (n = 56). As part of a larger study, low birth weight children were recruited through the high-risk neonatal follow-up programs at two large urban medical centers. All parents of surviving children who were admitted to the neonatal intensive care unit and who met the inclusion criteria were asked to participate. Only children who were free from major disabilities and whose birth weights had been appropriate for gestational age were included. In the recruitment letter and subsequent phone calls, parents were asked if their children were functioning at an age-appropriate level. Children with known disorders such as major congenital anomalies, Grade III and IV intraventricular hemorrhages, mental retardation, Down syndrome, and moderate to severe visual and/or hearing impairments were excluded. Children in the comparison group, who had been born with NBW, were recruited through a variety of community programs, schools, churches, and public agencies. They, too, were included only if free from major disability and functioning at an age-appropriate level. Children were also excluded from the comparison group if they had been born prior to 37 weeks gestation. The mean age of the children at testing was 61.6 months (SD = 6.2; range 48.7-72.0 months). The sample consisted of 56% females and 44% males with a racial composition as follows: 67% Caucasian, 25% African-American, and 8% of another race or biracial. Almost all of the parents had at least a high school education (97.4%). Demographic data are presented in Table 1.
Child temperament. Child temperament was measured using Rothbart's parent-report instrument entitled the Children's Behavior Questionnaire (CBQ; Rothbart, 1996). The CBQ was developed to measure temperament characteristics and is based on the theoretical view that the temperamental processes of arousal, emotion, and self-regulation are key components of human individuality (Derryberry & Rothbart, 1988). Because of the emergent nature of the CBQ, several versions have been reported. At the onset of the current study, the CBQ consisted of 194 items. However, because the original Attentional Focusing scale was not strong psychometrically, Rothbart had created Attentional Focusing and Attentional Shifting scales for a total of 206 items. These scales were still being tested, but we opted to use the 206-item version because of the importance of these two dimensions to the overall goals of the larger study. The 206 Likert- type items represent the following 16 dimensions of temperament: Activity Level, Anger/Frustration, Approach, Attentional Focusing, Attentional Shifting, Discomfort, Falling Reactivity/Soothability, Fear, High Intensity Pleasure, Impulsivity, Inhibitory Control, Low Intensity Pleasure, Perceptual Sensitivity, Sadness, Shyness, and Smiling and Laughter. Attention Shifting has been included on some versions of the CBQ and is included on the Early Childhood Behavior Questionnaire. These dimensions are consistent with others' conceptualization of temperament components reported in the literature. Each item is rated by the parent on a scale of 1 (extremely untrue of your child) to 7 (extremely true of your child) or "not applicable (NA)." After re-coding the reverse items, a dimension score is obtained by summing all numerical responses and dividing by the number of items in that scale. If an item is omitted or scored as "NA," the sum is divided by the number of completed items.
As previously stated, Rothbart and colleagues have extracted Effortful Control, Extraversion, and Negative Affect factors from the 16 dimensions. Effortful Control is made up of the dimensions of Attentional Focusing, Attentional Shifting, Inhibitory Control, Low Intensity Pleasure, and Perceptual Sensitivity. The second factor, Extraversion, is computed from the dimensions of Activity Level, Approach/Anticipation, High Intensity Pleasure, Impulsivity, Shyness (reverse coded), and Smiling and Laughter (Rothbart et al., 2003). Negative Affect, the third factor, is characterized by the dimensions of Anger/Frustration, Discomfort, Falling Reactivity and Soothability (reverse coded), Fear, and Sadness (Rothbart et al., 2001).
Rothbart and others have demonstrated agreement between CBQ parent reports and laboratory observational measures of child behavior in typically developing children (Kochanska, Murray, Jacques, Koenig, & Vandergeest, 1996; Rothbart et al., 2000; Rothbart et al., 2001). Others have reported similar agreement using other parent-report temperament measures (Matheny, Wilson, & Thoben, 1987).
Child cognitive ability. General cognitive ability was assessed using the IQ Composite score from Kaufman Brief Intelligence Test (K-BIT) (Kaufman & Kaufman, 1990). The K-BIT is a brief, individually administered measure of verbal and non-verbal intelligence that has been standardized for children and adults from 4-90 years of age. The test consists of two sub-scales, Vocabulary and Matrices, and an overall score known as the K-BITIQ Composite. Split-half reliability coefficients for the Vocabulary, Matrices, and IQ Composite scores for 5-year- old children were .92, .74, and .88, and test-retest reliabilities for children 512 years were .86, .83, and .92, respectively. In studies to establish construct validity in children age 4-6, K-BITIQ Composite scores were significantly correlated with the Mental Processing Composite (r = .58) and the Achievement test of the Kaufman Assessment Battery for Children (K-ABC) (r = .74). To establish concurrent validity, the K-BITIQ Composite was compared to another brief test of intelligence, the Slossen Intelligence Test (r = .76). Sampling techniques were employed to obtain a standardization sample representative of the U.S. population on gender, race, geographic region, and SES. In addition, items were eliminated if they demonstrated item bias when comparing scores between gender and race (Kaufman & Kaufman, 1990). These data do not reflect performance by children born prematurely, however, by 4-5 years correction for degree of prematurity is generally not done. Although there is ongoing debate regarding the issue of correcting the chronological age for the degree of prematurity (e.g., the number of weeks born prior to the expected date of birth), it is generally recommended that correction continue up until 3 years for the more immature children (Marlow, 2004), such as those born of very low birth weight.
Demographic data. A researcher-developed parent information questionnaire was used to obtain parent demographic information. Clinic records were used to obtain child demographic data such as birth weight and gestational age.
For the preterm children, letters were sent to the parents of children who met the inclusion criteria. The parents returned a postcard if they wished to participate and, if they did this, they were contacted to schedule an appointment. The parents of NBW children responded to a flyer that was posted or sent home with their children. Parents received a stipend and the children received a small gift for their participation. All procedures were approved by the University Institutional Review Board at each institution and completed only after obtaining written parental consent.
Upon completion of the informed consent process, the parents completed a Parent Information Form and the CBQ (Rothbart, 1996). The K-BIT was administered to the child in a separate room. Demographic data were obtained from the clinic's records with permission from the parent. Both the parent and the child completed other procedures relevant to the goals of the larger study that will not be reported here.
Preliminary descriptive and correlational methods of data analysis were employed to describe the sample characteristics and to identify covariates that needed to be statistically controlled for in subsequent analyses. In addition, preliminary analyses were done to determine if children with extremely low birth weights (ELBW) or those weighing < 1000 grams at birth differed from the children who weighed 1001-1500 grams at birth. Children born prematurely are described clinically and in the literature as being ELBW (< 1000 g), VLBW (< 1500 g), or LBW (< 2500 g) at birth. Adverse outcomes are generally considered to be greater with decreasing birth weight. Greater statistical power would be available if the low birth weight children are examined as a whole. However, preliminary analyses were done to determine if it was valid to include all of the low birth weight children in one group.
Following the preliminary analyses, children born with VLBW were compared to children born with normal birth weights (NBW) to determine if the two groups differed on the 16 dimensions and/or 3 factors extracted from the CBQ. An Analysis of Covariance (ANCOVA) was used with Bonferroni adjustments for multiple comparisons. Lastly, to evaluate the validity of using the CBQ to assess temperament in children born with VLBW, it was necessary to determine if the 16 dimensions of temperament described by Rothbart, using a sample of children born at full-term, cluster into similar factors in children born prematurely. Aprincipal component analysis of the item scores on the CBQ was employed.
First, analyses to determine if preterm children weighing < 1000 grams (ELBW) at birth differed from those weighing 1001-1500 grams on the three CBQ factors were done. Because the two birth weight groups differed on age, child age was entered as a covariate in the MANCOVA. The two low birth weight groups did not significantly differ from each other on Effortful Control, 96) = 0.78, Extraversion, 96) = 0.31, or Negative Affect, 96) = 1.57 (p > 0.05). Since the two low birth weight groups did not differ, data were condensed into one group of VLBW children.
The VLBW and NBW children differed on child's age and maternal education (p < .001), so these variables were controlled in all analyses (see Table 1). Although the two groups did not differ on IQ (p > .05), IQ related to Effortful Control (r = .257; p < .01) and was therefore controlled in all analyses.
Temperament Structure for VLBW Children Compared to Normative Sample
The only data available to date using the CBQ to examine temperament characteristics in children born with VLBW are from a sample of children in Norway (Nygaard et al., 2002). The following analyses will describe the temperament structure in the current sample of 4- and 5-year-old VLBW children from the U.S. compared to Rothbart's normalization sample of children with NBW who were the same age.
A principal component analysis of the item scores on the CBQ was used with the extracted factors being obliquely rotated using the Promax algorithm. Consistent with Rothbart's findings, three factors were extracted (see Table 2). The three factors explained 62.2% of the variance on the 16 temperament dimensions. The dimensions loaded onto the factors in a pattern similar to that in Rothbart et al.'s (2001) sample, with a few exceptions. Conceptually, Rothbart et al. include the dimension of Smiling and Laughter in the Extraversion factor even though the subscale loaded similarly on both the Extraversion factor (.74) and the Effortful Control factor (.76) in their sample of 4- and 5-year-olds. Similar to Rothbart et al.'s sample, the current sample of VLBW children had a primary loading for Smiling and Laughter on Effortful Control (.73) with a substantial, but smaller coefficient for Extraversion (.55). In the current sample of VLBW children, the primary loading for the dimension of Approach was on Negative Affect (.75). Approach loaded to a lesser degree on Extraversion (.33). Rothbart et al. reported the opposite to be true in the normative sample in that the dimension of Approach loaded primarily on Extraversion (.60) and to lesser degree on Negative Affect (.46). Overall, there were only minor differences between the temperament structure in this VLBW sample and that of the normative sample for the CBQ.
Because of the relatively small sample size in relation to the number of items on the CBQ, these data represent a "first step" in providing validation of the CBQ for use with VLBW children in the U.S. Further evidence that the factors remain stable will be needed before construct validity can be confirmed. In the next section, our findings will be compared to a similar evaluation study conducted with VLBW children in Norway.
Temperament Structure for VLBW Children in the U.S. Compared to Norway
The children in the current sample of VLBW children in the U.S. had a very similar temperament structure compared to the VLBW sample (n = 96) of children in Norway (Nygaard et al., 2002). The major difference was that the Norwegian sample had a primary factor loading for Falling Reactivity/Soothability on Effortful Control with a secondary loading on Negative Affect. The opposite was true in the current sample as well as in the normal sample.
Comparison between Groups on CBQ Dimensions and Factors
Table 3 presents the means and standard deviations on each of the 16 temperament dimensions for each birth weight group. The VLBW children were rated lower than the NBW children on Attentional Focusing and Inhibitory Control (p < .001) and they were rated higher on Sadness (p < .05). Bonferroni adjustments were made for multiple comparisons.
Lastly, a single MANCOVA was used to assess whether VLBW children differed from NBW on the three temperament factors (see Table 4). The VLBW children were rated lower on Effortful Control than the NBW children, F (1, 148) = 6.40, p < .05. The two groups did not differ on ratings of Extraversion or Negative Affect (p > .05).
Children born prematurely, with no major disabilities, have previously been shown to be at risk for numerous problems related to attention and self- regulation that could potentially lead to academic underachievement. In the current study, a comparison of young children's temperament using Rothbart's CBQ was conducted between VLBW and NBW children who were 4 and 5 years of age and who had no major medical problems. Temperament, as described within Rothbart's model, is comprised of 16 dimensions grouped into three factors. These factors have previously been shown to relate to attention and academic achievement in NBW children (Blair, 2002b; Chang & Burns, 2005; Harris et al., 2005; Rothbart et al., 2003; Rueda, Posner, & Rothbart, 2005). The goal of the study was to compare the factor structure of the CBQ in VLBW children from the United States and extend knowledge about differences in temperament between VLBW and NBW children at ages 4 and 5 years using Rothbart's conceptualization of temperament.
The findings demonstrated that understanding temperament is a promising approach to studying individual differences in VLBW children and that the CBQ may be an appropriate and sensitive instrument for studying temperament in VLBW children from the U.S. The factor structure of temperament in VLBW children from the U.S. supported a previous report by Nygaard et al. (2002) with VLBW children from Norway and was similar to the factor structure described by Rothbart et al. (2001). The comparison between the VLBW and NBW children revealed that the VLBW children differed from the NBW children on the temperament factor of Effortful Control, but they did not differ on Negative Affect or Extraversion. These differences in effortful control may have a particularly negative impact on children's development of self-regulation and attention skills. Again, in studies with NBW children, it has been shown that children high in effortful control appear to be able to optimize the intake of relevant information in a more purposeful and organized manner to take full advantage of the cognitive opportunities available within the environment (Gauvain & Fagot, 1995; Robinson et al., 2003).
A better understanding of temperament, especially effortful control, in children born prematurely has important implications for their long-term academic and developmental outcomes. It has been said that children born prematurely are at risk in every domain necessary to succeed in the classroom (Whitfield et al., 1997). Academic success does not occur simply as a result of cognitive ability. To be successful in school, children must be able to sit in their seats, direct their attention to salient information in their environment, refrain from responding to distracters, and appropriately interact with their peers and teachers. just to name a few skills. Effortful control is an over-arching construct that relates not only to regulation of cognitive processes, but also to behavioral, motivational, social, and emotional regulation. Children born prematurely have been said to differ from their NBW peers across multiple domains that have been associated with effortful control. Because temperament is modifiable, these findings have important implications for intervention in early childhood. Interventions aimed at teaching parents of VLBW children to recognize their children's individual characteristics and to identify ways in which they can structure the physical environment and learning activities to capitalize on their children's individual strengths may result in improved academic trajectories for children born prematurely.
These findings provide new information about temperament in VLBW children and provide the foundation for studies to examine more complex relationships between preschool temperament and long-term developmental outcomes in a population of children who are at high risk for developmental delays and deficits, especially those related to academic success. Studying temperament using Rothbart's framework in this high-risk population has important implications for school intervention and school readiness. In a recent review article examining neurobiological conceptions of school readiness, Blair (2002b) cited Rothbart's CBQ and argued that, when children are low in effortful control, exposure to poorly organized environments interferes with their development of regulatory functioning, which, in turn, has a negative impact on academic achievement. Children born with VLBW are at risk in every domain necessary to succeed in school (Whitfield et al., 1997). Since temperament has been shown to be related to social, behavioral, and cognitive development as well as academic achievement (Caspi et al., 1995; Eisenberg & Fabes, 1992; Eisenberg et al., 2004; Eriksson & Pehrsson, 2003; Gartstein & Rothbart, 2003; Gauvain & Fagot, 1995; Kochanska et al., 1996; Kochanska et al., 2000; Paterson & Sanson, 1999; Rothbart & Jones, 1998; Saylor et al., 2003), this would appear to be a very important area for intervention.
More research is needed to identify the specific components for intervention programs for this group of high-risk children. However, with our understanding of the dynamic and interactive nature of developmental systems, it is clear that both child characteristics, such as effortful control, and environmental factors must be considered. While recent interventions for preterm and other high-risk infants have focused on restructuring the NICU environment to improve developmental outcome, more research is needed to develop specific interventions to promote the long-term development of regulatory functioning beyond the NICU.
Because much early learning occurs in a social context within the home environment, there are important implications for parental education, anticipatory guidance, and support.
Als, H., Duffy, F. H., McAnulty, G. B., Rivkin, M. J., Vajapeyam, S., Mulkern, R. V., et al. (2004). Early experience alters brain function and structure. Pediatrics, 113, 846-857.
Als, H., Lawhorn, G., Duffy, F. H., McAnulty, G. B., Gibes-Grossman, R., & Blickman, J. G. (1994). Individualized developmental care for the very low-birth-weight preterm infant: Medical and neurofunctional effects. Journal of the American Medical Association, 272(11), 853-858.
Blair, C. (2001). The early identification of risk for grade retention among African American children at risk for school difficulty. Applied Developmental Science, 5(1), 37-50.
Blair, C. (2002a). Early intervention for low birth weight, preterm infants: The role of negative emotionality in the specification of effects. Development andPsychopathology, 14, 311-332.
Blair, C. (2002b). School readiness: Integrating cognition and emotion in a neurobiological conceptualization of children's functioning at school entry. American Psychologist, 57, 111-127.
Blair, K. A., Denham, S. A., Kochanoff, A., & Whipple, B. (2004). Playing it cool: Temperament, emotion regulation, and social behavior in preschoolers. Journal of School Psychology, 42, 419-443.
Botting, N., Powls, A., Cooke, R. W. I., & Marlow, N. (1997). Attention deficit hyperactivity disorders and other psychiatric outcomes in very low birthweight children at 12 years. Journal of Child Psychology and Psychiatry, 38(8), 931-941.
Breslau, N., Brown, G. G., DelDotto, J. E., Kumar, S., Ezhuthachan, S., Andreski, P., et al. (1996). Psychiatric sequelae of low birth weight at 6 years of age. Journal of Abnormal Child Psychology, 24(3), 385-400.
Breslau, N., & Chilcoat, H. D. (2000). Psychiatric sequelae of low birth weight at 11 years of age. Biological Psychiatry, 47, 1005-1011.
Burns, B. M., Chang, F., Snyder, E., Robinson, J., Davis, D. W., Weatherholt, T., et al. (in press). Self-regulation in children of poverty. In Child psychology: New research. New York: Nova Science Publishers, Inc.
Caspi, A., Henry, B., McGee, R. O., Moffitt, T. E., & Silva, P. A. (1995). Temperamental origins of child and adolescent behavior problems: From age three to age fifteen. Child Development, 66, 55-68.
Chang, F., & Burns, B. M. (2005). Temperament in preschoolers: Associations with effortful control and motivation. Child Development, 76, 247-263.
Davis, D. W. (2003). Cognitive outcomes in school-age children born prematurely. Neonatal Network: The Journal of Neonatal Nursing, 22, 27-38.
Derryberry, D., & Rothbart, M. K. (1988). Arousal, affect, and attention as components of temperament. Journal of Personality and Social Psychology, 55(6), 958-966.
Derryberry, D., & Rothbart, M. K. (1997). Reactive and effortful processes in the organization of temperament. Development and Psycholopathology, 9, 633-652.
DiPietro, J. A., Costigan, K. A., & Pressman, E. K. (2002). Fetal state concordance predicts infant state regulation. Early Human Development, 68, 113.
Doussard-Roosevelt, J. A., McClenny, B. D., & Porges, S. W. (2001). Neonatal cardiac vagal tone and school-age developmental outcome in very low birth weight infants. Development and Psychobiology, 38, 56-66.
Doussard-Roosevelt, J. A., Porges, S. W., Scanlon, J. W., Alemi, B., & Scanlon, K. B. (1997). Vagal regulation of heart rate in the prediction of developmental outcome for very low birth weight preterm infants. Child Development, 68(2), 173-186.
Eisenberg, N., & Fabes, R. A. (1992). Emotion, regulation, and the development of social competence. In M. S. Clark (Ed.), Emotion and social behavior (pp. 119-150). Thousand Oaks, CA: Sage.
Eisenberg, N., Spinrad, T. L., Fabes, R. A., Reiser, M., Cumberland, A., Shepard, S., et al. (2004). The relations of effortful control and impulsivity to children's resiliency and adjustment. Child Development, 75, 25-46.
Eriksson, B. S., & Pehrsson, G. (2003). Relationships between the family's way of functioning and children's temperament as rated by parents of preterm children. Journal of Child Health Care, 7, 89-100.
Gartstein, M. A., & Fagot, B. I. (2003). Parental depression, parenting and family adjustment, and child effortful control: Explaining externalizing behaviors for preschool children. Applied Developmental Psychology, 24, 143-177.
Gartstein, M. A., & Rothbart, M. K. (2003). Studying infant temperament via the revised Infant Behavior Questionnaire. Infant Behavior and Development, 26, 64-86.
Gauvain, M., & Fagot, B. I. (1995). Child temperament as a mediator of mothertoddler problem-solving. Social Development, 4(3), 257-276.
Hack, M., Wilson-Costello, D., Friedman, H., Taylor, G. H., Schluchter, M., & Fanaroff, A. A. (2000). Neurodevelopment and predictors of outcomes of children with birth weights of less than 1000 g: 1992-1995. Archives of Pediatric & Adolescent Medicine, 154(7), 725-731.
Halsey, C. L., Collin, M. F., & Anderson, C. L. (1996). Extremely low- birthweight children and their peers: A comparison of school-age outcomes. Archives of Pediatric & Adolescent Medicine, 150, 790-794.
Harris, R. C., Robinson, J. B., Chang, F., & Burns, B. M. (2005). Characterizing preschooler children's attention regulation in parent-child interactions: The role of effortful control and motivation. Manuscript submitted for publication.
Hoy, E. A., Bill, J. M., & Sykes, D. H. (1988). Very low birthweight: A long- term developmental impairment? International Journal of Behavioral Development, 11(1), 37-67.
Huffman, L. C., Bryan, Y. E., del Carmen, R., Pederson, F. A., Doussard- Roosevelt, J. A., & Porges, S. W. (1998). Infant temperament and cardiac vagal tone: Assessments at twelve weeks of age. Child Development, 69, 624-635.
Jones, L. B., Rothbart, M. K., & Posner, M. (2003). Development of executive attention in preschool children. Developmental Science, 6, 498-504.
Kaufman, A. S., & Kaufman, N. L. (1990). Kaufman Brief Intelligence Test manual. Circle Pines, MN: American Guidance Service, Inc.
Klein, N. K. (1988). Children who were very low birthweight: Cognitive abilities and classroom behavior at five years of age. Journal of Special Education, 22(1), 41-54.
Kochanska, G., Murray, K., Jacques, T. Y., Koenig, A. L., & Vandergeest, K. A. (1996). Inhibitory control in young children and its role in emerging internalization. Child Development, 67, 490-507.
Kochanska, G., Murray, K. T., & Harlan, E. T. (2000). Effortful control in early childhood: Continuity and change, antecedents, and implications for social development. Developmental Psychology, 36, 220-232.
Langkamp, D. L., & Pascoe, J. M. (2001). Temperament of pre-term infants at 9 months of age. Ambulatory Child Health, 7, 203-212.
Marlow, N. (2004). Neurocognitive outcome after very preterm birth. Archives of Disease in Childhood: Fetal and Neonatal Edition, 89, 224-228.
Matheny, A. P., Wilson, R. S., & Thoben, A. S. (1987). Home and mother: Relations with infant temperament. Developmental Pyschology, 23(3), 323-331.
Msall, M., Buck, G., Rogers, B., Merke, D., Catanzaro, N., & Zorn, W. (1991). Risk factors for major neurodevelopmental impairments and need for special education resources in extremely premature infants. Journal of Pediatrics, 119(4), 606-614, 838.
Nygaard, E., Smith, L., & Torgersen, A. M. (2002). Temperament in children with Down Syndrome and in prematurely born children. Scandinavian Journal of Psychology, 43, 61-71.
Olson, S. L., Sameroff, A. J., Kerr, D. C. R., Lopez, N. L., & Wellman, H. M. (2005). Developmental foundations of externalizing problems in young children: The role of effortful control. Development and Psychopathology, 17, 25-45.
Paterson, G., & Sanson, A. (1999). The association of behavioral adjustment to temperament, parenting and family characteristics among 5-year-old children. Social Development, 8, 293-309.
Robinson, J., Dossett, D., Chang, F., Snyder, E., Weatherholt, T., Davis, D. W., et al. (2003, April). Individual differences in attention regulation in children of poverty. Paper presented at the Biennial meeting of the Society for Research in Child Development, Tampa, FL.
Rothbart, M. K. (1996). Children's Behavior Questionnaire. Oregon: University of Oregon.
Rothbart, M. K., Ahadi, S. A., Hershey, K. L., & Fisher, P. (2001). Investigations of temperament at three to seven years: The Children's Behavior Questionnaire. Child Development, 72(5), 1394-1408.
Rothbart, M. K., & Bates, J. E. (1998). Temperament. In W. Damon (Ed.), Handbook of child psychology (5th ed., Vol. 3, pp. 105-176). New York: Wiley.
Rothbart, M. K., Derryberry, D., Reed, M. A., & Hershey, K. (2000). Stability of temperament in childhood: Laboratory infant assessment to parent report at seven years. In D. L. Molfese & V. J. Molfese (Eds.), Temperament and personality development across the life span (pp. 85119). Hillsdale: NJ: Erlbaum.
Rothbart, M. K., Ellis, L. K., Rueda, M. R., & Posner, M. (2003). Developing mechanisms of temperamental effortful control. Journal of Personality, 71, 1113-1143.
Rothbart, M. K., & Jones, L. B. (1998). Temperament, self-regulation, and education. School Psychology Review, 27(4), 479-491.
Rothbart, M. K., & Mauro, J. A. (1990). Questionnaire approaches to the study of infant temperament. In J. W. Fagen & J. Colombo (Eds.), Individual differences in infancy: Reliability, stability, and prediction (pp. 411-429). Hillsdale, NJ: Erlbaum.
Rueda, M. R., Posner, M. I., & Rothbart, M. K. (2005). The development of executive attention: Contributions of the emergence of self-regulation. Developmental Neuroscience, 28, 573-594.
Ruff, H. A., & Rothbart, M. K. (1996). Attention in early development: Themes and variations. New York: Oxford University Press.
Saigal, S., Szatmari, P., Rosenbaum, P., Campbell, D., & King, S. (1991). Cognitive abilities and school performance of extremely low birth weight children and matched term control children at age 8 years: A regional study. Journal of Pediatrics, 118(5), 751-760.
Sajaniemi, N., Hakamies-Blomqvist, L., Makela, J., Avellan, A., Rita, H., & von Wendt, L. (2001). Cognitive development, temperament and behavior at 2 years as indicative of language development at 4 years in pre-term infants. Child Psychiatry and Human Development, 31, 329-346.
Saylor, C. F., Boyce, G. C., & Price, C. (2003). Early predictors of school-age behavior problems and social skills in children with intraventricular hemorrhage (IVH) and/or extremely low birthweight (ELBW). Child Psychiatry and Human Development, 33, 175-192.
Schraeder, B., Heverly, M. A., & Rappaport, J. (1990). Temperament, behavior problems, and learning skills in very low birth weight preschoolers. Research in Nursing and Health, 13, 27-34.
Sykes, D. H., Hoy, E. A., Bill, J. M., McClure, B. G., Halliday, H. L., & Reid, M. M. (1997). Behavioral adjustment in school of very low birthweight children. Journal of Child Psychology and Psychiatry, 38(3), 315-325.
Teplin, S. W., Burchinal, M., Johnson-Martin, N., Humphry, R. A., & Kraybill, E. N. (1991). Neurodevelopmental, health, and growth status at age 6 years of children with birth weights less than 1001 grams. Journal of Pediatrics, 118(5), 768-777.
Whitfield, M. F., Grunau, R. V., & Holsti, L. (1997). Extremely premature (< 800 g) schoolchildren: Multiple areas of hidden disability. Archives of Diseases in Childhood, 77, F85-F90.
Support for this study was provided by the University Pediatrics Foundation, Inc., University of Louisville; the Neonatal Follow-up Programs at the University of Louisville and Cincinnati Children's Hospital Medical Center; and a grant to Dr. Davis from the National Institute for Nursing Research, NIH (5 K01 NR 156-2). Their generous support is greatly appreciated. The authors would also like to thank the parents and children who participated in the study and Drs. Joan Austin and Phyllis Dexter for their valuable critiques.
Deborah Winders Davis
Department of Pediatrics
University of Louisville
Frank Porter Graham Child Development Institute
University of North Carolina at Chapel Hill
Barbara M. Burns
Department of Psychological and Brain Sciences
University of Louisville
Address correspondence to: Dr. Deborah Winders Davis, Neonatal Follow-up Program, 601 S. Floyd Street, Suite 801, Louisville, Kentucky 40202; Electronic mail may be sent to: email@example.com.
Table 1: Demographic Data
Birth Weight Group
Variable VLBW NBW
n = 97 n = 56
Age (months) 63.27 (5.4) 58.6 (6.50) ***
Birth weight (grams) 1007.1 (261.4) N/A
Female 54.6% 57.1%
Male 45.4% 42.9%
IQ Composite Score 100.46 (11.52) 102.79 (14.38) ***
Completed Maternal Education
< 12th grade 4.1% 0.0%
High school 40.2% 14.3%
1 year college or training 20.6% 30.4%
College degree 23.7% 28.6%
Graduate/Professional 11.3% 25.0%
Caucasian 71.1% 58.9%
African-American 19.6% 33.9%
Other 9.3% 7.1%
*** p <.001
Table 2: CBQ Factor loadings for VLBW Children
Scale 1 2 3
(n = 97) Effortful Negative Extraversion
Activity level -.320 .620
Approach .752 .328
Attention focusing .607
Attention shifting .599
Discomfort .847 -.397
Falling reactivity and
soothability .418 -.539
Fear .726 -.368
High intensity pleasure .789
Inhibitory control .698 -.331
Low intensity pleasure .720
Pereptual sensitivity .865 .350
Smiling/laughter .729 .549
Table 3: Means and Standard Deviations on Child Behavior
Birth Weight Group
Variable VLBW NBW F (1, 146) *
Attention Focusing 4.25 (0.76) 4.83 (0.76) 14.01
Attention Shifting 4.36 (0.61) 4.32 (0.64)
Inhibitory Control 4.39 (0.99) 4.88 (0.92) 14.07
Low Intensity Pleasure 5.69 (0.58) 5.69 (0.56)
Perceptual Sensitivity 5.07 (0.76) 5.13 (0.81)
Activity Level 5.24 (0.81) 4.97 (0.89)
Approach 5.36 (0.61) 5.25 (0.72)
High Intensity Pleasure 5.21 (0.84) 5.04 (1.01)
Impulsivity 4.72 (0.78) 4.60 (0.95)
Shyness 3.48 (1.17) 3.41 (1.46)
Smiling/Laughter 6.02 (0.54) 5.98 (0.82)
Anger/Frustration 4.61 (0.96) 4.45 (0.94)
Discomfort 4.33 (0.94) 4.32 (0.93)
and Soothability 4.44 (0.87) 4.59 (0.75)
Fear 4.03 (1.09) 3.91 (0.96)
Sadness 4.04 (0.78) 3.77 (0.88) 4.88
Variable p **
Attention Focusing <0.001
Attention Shifting ns
Inhibitory Control <0.001
Low Intensity Pleasure ns
Perceptual Sensitivity ns
Activity Level ns
High Intensity Pleasure ns
and Soothability ns
* After controlling for child age and IQ and maternal
** Bonferroni adjustment for multiple comparisons
Table 4: Differences between Factors on Child Behavior Questionnaire
Birth Weight Group
Variable VLBW NBW F(1, 148)* p
M (SD) M (SD)
Effortful Control 4.76 (0.55) 4.97 (0.50) 6.40 <0.05
Extraversion 5.18 (0.51) 5.07 (0.76) 0.34 >0.05
Negative Affect 4.11 (0.72) 3.97 (0.69) 1.26 >0.05
* controlling for child age and IQ and maternal education.