Visual attention in the first half year of life and functional outcome at school age

Over the past decades there has been growing interest in the prediction of
outcome from early infancy to performance at school age, particularly in
infants at high risk of developmental deficits. It has been increasingly
recognized that around 50 percent of the infants born preterm develop
neurological problems later on, which comprise not only mild motor problems
(minor neurological dysfunction, "MND") but also specific cognitive deficits
and behavioural problems. One of the fundamental components for motor,
cognitive and behavioral development is visual attention.

Research on development of visual attention showed that, at the age of 6 weeks,
preterm infants had more gazing behaviour than infants born at term. However,
preterm infants shifted their gaze more quickly to a peripheral stimulus than
infants born at term. Although there is no clear evidence of a potentially
beneficial or harmful effect of early visual experience, preterm infants showed
a temporary abnormal development of disengagement until the age of 26 weeks.
How the early development of visual attention (in the first 6 months) is
associated with several domains of functional development at school age, and
whether this association is different between preterm and term born infants, is
unknown.

Primary objectives:
- to determine whether early visual attention is associated with visual
attention and perception at school age
- to determine whether early visual attention is associated with motor
performance, visual-motor skills, intelligence and behavioural problems
at school age

Secondary objective:
- to determine whether the association between early visual attention and
functional outcome differ between infants born preterm and at term

Children will be invited for follow-up at the age of 9-11 years. Follow-up
consists of the following tests:

Motor performance:
To assess the children*s motor outcome we will administer the Movement ABC, a
standardized test of motor skills for children. This test yields a score for
total movement performance based on separate scores for manual dexterity (fine
motor skills), ball skills, and static and dynamic balance (coordination). The
tasks composing the Movement ABC are representative of the motor skills that
are required of children attending elementary school and are adapted to the
child*s age.
Test administration time: 20-30 minutes.

Coordination:
Subtests of Touwen*s neurological examination will be performed to evaluate the
child*s neurological condition. This is a standardized and age-appropriate
neurological examination. The two components that will be tested are 1)
graphesthesia using tactile perception (tactile recognition of a figure in
palm) and 2) proprioception using the finger-nose test and the Romberg test.
Test administration time: 10 minutes.

Writing skills:
The motor aspect of writing will be assessed by using *De Beknopte
Handschrifttest voor Kinderen* (BHK).
Test administration time: 7 minutes.

Intelligence:
Total, verbal and performal intelligence will be assessed using a short form of
the Wechsler Intelligence Scale for Children, third version (WISC-III). We will
use two verbal subscales (Similarities, Vocabulary) and two Performance
subscales (Picture Arrangement, Block Design). Verbal (VIQ), Performance (PIQ)
and Total (TIQ) intelligence quotient scores will be calculated.
Test administration time: 30 minutes.

Visual attention:
We will measure selective attention and attentional control with the two
subtests *Map mission* and Opposite worlds* of the Test of Every day Attention
for Children (TEA-Ch). Selective attention refers to a child*s ability to
select target information from an array of distracters; attentional control
refers to the ability to change attentional focus flexibly and adaptively.
Test administration time:10 minutes.

Visual perception:
We will measure visual perception with the three subtests *Form Constancy*,
*Visual Closure* and *Form Discrimination* of the Test for Visual-Perceptual
Skills- third Edition (TVPS-3)(15).
Test administration time is about 15 minutes.
In addition to the TVPS-3, we will let the children perform five experimental
computer tasks, adapted for children and based on research by Chen et al.
(protocolpag 15) and previously used in the PINKELTJE study (Preterm Infants
Knowledge on Target Height and Outcome). This study was approved by the IRB /
IEC (see METC 2005/130 dated 08.07.2008). The tasks measure speed and accuracy
of visual perception mediated by ventral and dorsal visual processing in the
brain.
Test administration time: 20 minutes.

Visual-spatial information processing:
Visual-spatial information processing will be assessed using three subtests of
the NEPSY-2-NL, a neuropsychological battery for children. The three selected
subtests, Geometric Puzzles, Arrows and Route Finding measure concentration,
memory and visuospatial information processing / visual perception.
Test administration time: 30 minutes.

Visuomotor integration:
Visuomotor integration will be assessed by the subtest *Design copying* of the
NEPSY-2-NL, in which the child is asked to reproduce geometric forms of
increasing complexity. Visuomotor integration involves the integration of
visual information with finger-hand movements.
Test administration time: 10 minutes.

Vision:
Clinical assessment of vision by Donders* method and testing of stereoscopic
vision.
Test administration time: 10 minutes.

The total duration of the follow-up will be approximately 3 to 3,5 hours,
including breaks.

The parents will be asked to complete the following questionnaires:

Behaviour:
In order to obtain information on children*s competencies and
behavioural/emotional problems the parents are supposed to complete the Child
Behaviour Checklist (CBCL/6-18, Child Behaviour Checklist for Ages 6-18). The
CBCL is a questionnaire in which parents, other relatives or teachers answer
questions about skills and behaviour of a child. These include daily and school
activities, attention functioning, social and emotional behaviour. Parents can
indicate how frequently the child has shown a particular behaviour in the past
6 months.
Duration: 15-20 minutes

Executive functioning:
Information on executive functioning can be obtained by the Behaviour Rating
Inventory of Executive Function (BRIEF). The BRIEF assesses executive
functioning involved in well-organized, purposeful, goal-directed, and
problem-solving behaviour. Executive functions are important when performing a
new or difficult task that requires constant attention and effort. Examples of
executive functioning are the ability to inhibit competing actions of
attractive stimuli, the flexibility to shift problem-solving strategies if
necessary, and the ability to monitor and evaluate one*s behaviour.
Duration: 10 - 15 minutes.

Attention:
Parents will be asked to fill out an Attention Deficit/Hyperactivity Disorder
(ADHD) questionnaire that contains 18 items on inattention, hyperactivity, and
impulsivity.
Duration: 10 - 15 minutes

Coordination:
To screen for motor problems in daily life the Developmental Coordination
Disorder Questionnaire- Dutch version (DCDQ-NL) will be handed out. This
questionnaire contains 17 items about motor coordination in daily life. Parents
should indicate to what extent the coordination of their child matches that of
other children of similar age.
Duration: 10 - 15 minutes.

Overall, testing will take 3 to 3.5 hours, in one session in the morning or
afternoon. In between tests breaks will be held to prevent the child
experiencing physical and physiological discomfort, and to ensure that the
child is able to complete the full set of tests.
Most infants like to participate since all tests include elements of play.
To parents and their child will be emphasized that they could stop or pause the
testing procedure at any time for any reason, if they wish to do so without any
consequences. If possible, test administration will be continued another time.
When parents decide to withdraw consent during the testing procedure, test
administration will of course not be resumed. Data obtained before withdrawal
will be removed from the database and no longer used for this study.
Data from this study can not be obtained in another population, as the
intention of this study is to investigate the association between early
development of visual attention and functional outcome at school age. The
children of whose visual attention is previously investigated are now
considered to be 9-11 years old. The neuropsychological tests (mentioned in
methods) are standardized and designed for children in this specific age group,
and its results (standard scores) give an adequate representation of
functioning at school age.
The results from this study increase our knowledge about the predictive value
of early visual attention for functioning at school age. This may, as a
consequence, lead to accurate monitoring of children who present with visual
attention problems in their first half year of life.
In addition, this study provides us information about the longitudinal
development of visual attention and whether these developmental trajectories
differ between children born preterm and children born at term.