ATHABASCA UNIVERSITY UNIVERSITY OF CALGARY UNIVERSITY …dtpr.lib.athabascau.ca/action/download.php?filename=caap/Raghida… · A brochure was created to provide a summary of: (1)

ATHABASCA UNIVERSITY

UNIVERSITY OF CALGARY

UNIVERSITY OF LETHBRIDGE

MEETING THE COGNITIVE, SOCIAL, AND EMOTIONAL NEEDS OF

PREMATURELY BORN STUDENTS ENTERING ONTARIO

ELEMENTARY SCHOOLS: GUIDELINES FOR EDUCATORS

BY

RAGHIDA MAZZAWI

A Final Project submitted to the

Campus Alberta Applied Psychology: Counselling Initiative

in partial fulfillment of the requirements for the degree of

MASTER OF COUNSELLING

Alberta

November, 2006

i

DEDICATION

To my son; Ameer: Your early arrival into my life showed me how strong I can be and how

much love in me I have to give. You taught me not to take anything for granted. This project

came about because of your struggles and challenges. My hope is that through this project we

will make things better for those prematurely born students who will follow in your foot

steps.

ii

CAMPUS ALBERTA APPLIED PSYCHOLOGY: COUNSELLING INITIATIVE

SUPERVISOR SIGNATURE PAGE

Faculty of Graduate Studies and Research

The undersigned certifies that she or he has read and recommends to the Faculty of Graduate Studies and Research for acceptance, a final project entitled MEETING THE COGNITIVE, SOCIAL, AND EMOTIONAL NEEDS OF PREMATURELY BORN STUDENTS ENTERING ONTARIO ELEMENTARY SCHOOLS: GUIDELINES FOR EDUCATORS submitted by RAGHIDA MAZZAWI in partial fulfillment of the requirements for the degree of Master of Counselling.

___________________________ Dr. Gina Wong-Wylie

Project Supervisor

__ January 6, 2007_________ Date

iii

iv

ABSTRACT

Researchers have reported a multitude of cognitive, behavioural, emotional, and social

difficulties in prematurely born students, some of which might not be evident when children

enter school. Potential outcomes of a premature birth at school age include difficulties in fine

and gross motor development, working memory deficits, slow information processing,

speech and language delays, attention and impulsivity challenges, a high incidence of

attention deficit hyperactivity disorder (ADHD), cerebral palsy, deafness, and blindness.

Because support services in Ontario are allocated on the basis of formal assessment, these

children may not receive the additional support that they need to be successful at school in a

timely manner. The goal in this project was to create a resource for Kindergarten teachers

that can be used to meet the needs of prematurely born students awaiting formal assessment

and identification. A brochure was created to provide a summary of: (1) facts about

prematurity, (2) potential childhood outcomes associated with prematurity, (3) possible

challenges in the school (4) strategies and recommendations, and (5) resources. Early

identification and intervention are believed to be the most suitable recommendations for

meeting the cognitive, emotional, and social needs of prematurely born students.

v

ACKNOWLEDGEMENTS

I would like to thank Dr. Gina Wong-Wylie and Heather Johnson for their constant support

and constructive feedback. Also, special thanks to my family for their understanding and

patience. Finally, I offer my gratitude to all individuals who gave their time and effort to

support, direct, and encourage me along the way.

vi

TABLE OF CONTENTS

CHAPTER I .............................................................................................................................. 1

Introduction............................................................................................................................... 1

Project Rationale................................................................................................................... 1

Problem Statement ................................................................................................................ 2

Project Overview .................................................................................................................. 3

CHAPTER II............................................................................................................................. 5

Literature Review...................................................................................................................... 5

Definition of Prematurity...................................................................................................... 5

Possible Outcomes of a Premature Birth from Literature and Research .............................. 6

Physical development ....................................................................................................... 6

Brain development ............................................................................................................ 8

Neurodevelopment............................................................................................................ 9

Sensory functioning ........................................................................................................ 10

Cognitive abilities ........................................................................................................... 12

Speech, language, memory, and learning abilities.......................................................... 14

Socio-emotional development ........................................................................................ 15

Differences from other Students with Special Needs ......................................................... 16

Needs of Prematurely Born Students during Elementary School Years............................. 18

Physical needs................................................................................................................. 18

Academic needs .............................................................................................................. 19

Socio-emotional needs .................................................................................................... 21

Behavioural needs........................................................................................................... 22

vii

A Closer Look at the Special Needs Education Policy in Ontario ..................................... 23

Current and New Intervention Strategies: Thinking outside the Box................................. 26

Possible Outcomes in Adulthood........................................................................................ 29

CHAPTER III ......................................................................................................................... 31

Guidelines for Educators......................................................................................................... 31

Possible Challenges in Elementary School......................................................................... 31

Personal and social development .................................................................................... 32

Language......................................................................................................................... 33

Mathematics.................................................................................................................... 34

Heath and physical activity............................................................................................. 35

Resources Available through the Community .................................................................... 36

Learning Disability Association of Ontario (LDAO) ..................................................... 36

McMaster Perinatal Association (McPERA).................................................................. 37

Ontario Brain Injury Association (OBIA) ...................................................................... 38

March of Dimes .............................................................................................................. 38

Offord Centre for Child Studies...................................................................................... 38

Recommendations............................................................................................................... 39

Incubators to Classrooms.................................................................................................... 41

Facts about Prematurity .................................................................................................. 42

Resources ........................................................................................................................ 43

Potential Childhood Outcomes Associated with Prematurity......................................... 43

Possible Challenges in the School .................................................................................. 44

Corresponding Strategies ................................................................................................ 44

viii

Recommendations and Guidelines for Intervention and Prevention .............................. 44

CHAPTER IV ......................................................................................................................... 45

Discussion and Summary........................................................................................................ 45

Recommendations............................................................................................................... 47

REFERENCES ....................................................................................................................... 49

APPENDIX A......................................................................................................................... 60

APPENDIX B ......................................................................................................................... 61

APPENDIX C ......................................................................................................................... 62

APPENDIX D......................................................................................................................... 63

1

CHAPTER I

Introduction

The survival of premature infants has become the norm rather than the exception

thanks to advances in medicine and technology. Between the year 1991 and the year 2004 the

rate of live preterm infants (less than 37 weeks gestation age [GA]) in Canada increased from

6.6 % to 7.9 % (Public Health Agency of Canada, 2003; Statistics Canada, 2006). Even the

smallest of these infants; some weighing less than 1500 grams are reported to thrive in

incubators and eventually go home. For example, in the year 2003, 90 out of 111 (81%)

infants born at less than 29 weeks GA in the region of central-west Ontario survived and

were eventually discharged from the neonatal unit at McMaster children’s hospital in

Hamilton, Ontario (S. Saigal, personal communication, September, 10, 2006). However, this

improvement in survival rates has not come without some cost to the children, their parents,

and society as a whole.

Project Rationale

Researchers have identified many challenges that prematurely born infants might face

as they develop. Some of these challenges include neurosensory delays and deficits;

cognitive delays and mental retardation; and neurobehavioural and neuropsychological

disorders (Buck, Msall, Schisterman, Lyon, & Rogers, 2000; Horwood, Mogridge, &

Darlow, 1998; Luciana, Lindeke, Georgieff, Mills, & Nelson, 1999; Saigal et al., 2003; for a

review also see Wrape, n.d.). Although not all prematurely born infants develop problems,

the earlier the GA and the lower the birth weight, the higher is the risk of facing future

challenges. It is worth noting that these challenges are not always connected to neurological

deficiencies (Hack & Taylor, 2000) and in many cases some of these challenges do not

become evident until later childhood when the child is at school age (Zubrick, Macartney, &

2

Stanley, 1988). The needs of premature children seem to shift from basic survival during

their time in the neonatal unit to being able to function adequately within their families,

communities, and societies as they grow. This concern becomes especially significant during

the school age years.

The different developmental challenges that prematurely born students might have

may interfere with their acquisition and processing of information. This in turn affects these

children’s ability to learn. McCain and Mustard (1999) concluded that brain development

during the period from conception to six years of age sets the foundation for learning,

behaviour, and health over the life span. Therefore, elementary school teachers and

counsellors need guidelines on how to support prematurely born students and meet their

cognitive, social, and emotional needs in Kindergarten to Grade 2, where children will be six

years of age, or younger.

Problem Statement

Ontario elementary educators follow specific guidelines for the provision of special

needs services with an emphasis being placed on early identification to provide meaningful

early school experiences that relate to the individual student’s strengths and needs (Ministry

of Education, 2000). However, according to the present special education policy, a child free

of medical diagnosis or ongoing behavioural or developmental issues who begins to struggle

once entering school must wait for a professional assessment to qualify for help (Ministry of

Education, 2006a). Furthermore, a single cognitive, behavioural, or emotional challenge is

not seen as diagnostic of a learning disability (Ministry of Education, 1982, memorandum

8:2a). This belief is based on the assumption that these challenges might be attributed to

developmental differences amongst children. Accordingly, a Kindergarten student who

3

exhibits signs of learning challenges might not be assessed by Board personnel until Grade 1,

and in some cases even later, with the hope that he or she will “catch up” to his or her peers.

In this respect, current procedures for early identification and intervention applied to

pre-term children not exhibiting signs of major neurosensory damage when entering Ontario

schools appear to create a gap between the needs of these children and the resources

available through the different school boards. At the present the allocation of financial as

well as human resources seems to be the obstacles that school personnel face in the early

identification process of prematurely born students. While these students wait formal

assessments, teachers need to know how to best meet their academic, emotional, and social

needs. To be able to do so teachers need: (1) To understand the challenges that their

premature Kindergarten and Grade 1 students might face at school, and (2) to learn specific

strategies that can be used in meeting the cognitive, social, and emotional needs of these

students. These needs will be addressed in this project. My hope is that educators can use the

information presented in this project to support prematurely born students awaiting formal

assessments.

Project Overview

Further to elucidating the problem and providing the rationale for this project focus in

this first Chapter, I will examine the affects of prematurity on development in the literature

review in Chapter 2. I will achieve this by exploring the areas of physical development, brain

development, neurodevelopment, sensory functioning, cognitive abilities, speech and

language, memory and learning abilities, and socio-emotional development. To narrow the

scope of this project, I will specifically focus on the developmental status of premature

4

children who were born at an early GA (< 29 weeks) with a very low birth weight (VLBW)

of less than 1500 grams as they enter Ontario elementary schools.

In identifying the developmental challenges that these children might have, I will also

address the associated school difficulties they could face. In addition, it is not sufficient to

know that these children differ from other students; it is also essential to know how these

differences affect premature children’s abilities and styles of learning. Therefore, I will

explore the literature and research findings regarding intervention methods and programs

presently used with premature children. I will address the implications of a premature birth to

the effectiveness of strategies used with prematurely born students and note the need for a

more tailored approach that is based on their individual and unique needs.

In Chapter 3, I will outline the specific challenges that premature children might face

when starting Ontario elementary schools. I will do this by examining the learning

expectations for the Kindergarten program as outlined by the Ontario Ministry of Education.

I will evaluate the compatibility of these expectations with the developmental status of

prematurely born children entering Kindergarten. Any discrepancies between the two will be

identified as challenges. This information, in addition to the information from the literature

review will be summarized in a brochure. I will also include specific strategies as well as

general guidelines that educators can use to meet the cognitive, emotional, and social needs

of these children. Within the brochure, I will include five sections: (1) facts about

prematurity, (2) potential childhood outcomes associated with prematurity, (3) possible

school challenges and corresponding strategies, (4) guidelines and recommendations, and (5)

resources. Finally, in Chapter 4, I will provide a summary section to present conclusions,

possible challenges, and recommendations for further future research.

5

CHAPTER II

Literature Review Definition of Prematurity

According to the Public Health Agency of Canada (2003), a full term pregnancy is 37

to 42 weeks of gestation. Infants who are born prior to 37 weeks gestation age are considered

premature. Although prematurely born infants are at a higher risk of immediate medical

complications and childhood developmental challenges than full term infants (D’Agostino,

1998), the GA and the birth weight play an important role. By understanding the risk factors

that are associated with a premature birth, educators will understand that premature children

are not a homogenous group with respect to the conditions surrounding their birth (Chapieski

& Evankovich, 1997). This heterogeneity may lead to individual differences in

developmental difficulties amongst prematurely born children (For a review see Cole et al.,

2002; Wolke, 1998). These individual differences in development can have implications for

learning difficulties at school age.

Gestational age is the number of weeks that an infant remains in his or her mother’s

womb. There are degrees of prematurity and each is associated with different types of

medical and later developmental risk factors. Infants who are born extremely prematurely at

less than 29 weeks GA usually are at a higher risk of having and developing breathing

problems, brain haemorrhage, and gastrointestinal problems while in the neonatal intensive

care unit (NICU) (D’Agostino, 1998; Stenzel, 2004) as well as later physical, cognitive,

emotional, and behavioural problems as they develop (Bennett, 2002; D’Agostino, 1998).

Birth weight also affects the prognosis for survival as well as later developmental

status. In the Statistics Canada 2004 Births Report, the following weight categories for

premature births have been identified: (1) Low birth weight (< 2,500 grams), (2) Very low

6

birth weight (< 1,500 grams), and (3) Extremely low birth weight (<1000 grams) (Statistics

Canada, 2006). The lower the birth weight and the earlier the gestation age, the higher is the

risk for early medical complications and neurological damage, thus the higher is the chance

for later developmental complications (Miceli et al., 2000; Perlman, 2001).

Possible Outcomes of a Premature Birth from Literature and Research

To understand the developmental status of premature children entering elementary

schools educators need to examine the different areas of development that can be impacted

by a premature birth. Development in each domain involves the emergence of certain skills

that are necessary for children’s abilities to learn and to function adequately and successfully

within the school environment. What follows is an exploration of the different domains of

development that researchers have identified as areas of concern for school age VLBW

prematurely born children.

Physical development. In addition to physical health that can be compromised by

ongoing medical complications such as asthma, chronic lung disease, and gastrointestinal

illnesses, VLBW prematurely born children tend to follow a slower physical developmental

pattern than their full term counterparts. Motor development of VLBW premature children

seems to have received considerable attention due to the finding that delayed motor

development can compromise later school performance (Sullivan & McGrath, 2003). For the

first 3 years of life, growth and development experts assess a premature child’s progress

based on corrected age by taking into consideration the number of weeks that the child has

missed in the womb. Even with this allowance for “catching up” with their full term

counterparts 4-year-old preterm children have been reported to differ significantly from full

term children on fine and gross motor performance.

7

Furthermore, Sullivan and McGrath (2003) found that premature children with mild

motor delays had lower academic achievement scores and higher rates of school service use

at age 8 years than children who did not have any motor delays. These difficulties are

possibly due to perinatal circumstances; such as brain bleeds, which may produce

disturbances in brain development, specifically in areas governing motor functioning

(Peterson et al., 2000). In support of this hypothesis Sullivan and McGrath found that

preterm children who had neurological or medical illnesses as infants had lower fine motor

scores at age four than those premature children who as infants were free of medical or

neurological complications.

While neurological impairments such as cerebral palsy, blindness, and deafness can

impact a child’s physical mobility, such impairments are not always the reasons for fine and

gross motor delays and deficiencies in VLBW premature children. Researchers conducting

follow up studies reported that by early school age VLBW premature children still exhibited

signs of gross motor difficulties even in the absence of major neurosensory impairments

(Shing Yan, Chun Bong, Pui Yee, Yuen Bing, & Chi Chiu, 2004). These authors found that

neurologically intact VLBW 5-7-year-olds had significantly lower scores than their full term

counterparts in the different skill categories of the Peabody Developmental Motor Scales.

The areas of challenge included: sitting, standing on one foot, tiptoeing, walking on a balance

beam, jumping up, push ups, and sitting or standing up from a lying position. These

differences were present despite the children’s participation in a developmental stimulation

program for the first 3 years after discharge from the NICU. The authors suggested that

VLBW premature children might not benefit from early intervention programs that target

gross motor skill development. It is not clear though whether the children’s gross motor skills

8

were compared to a control group at age 3 or not. It is possible that the early intervention

program could have been successful if occasional follow up interventions had been

implemented.

Brain development. Although the brain comprises only 2% of a person’s weight it is

directly and/or indirectly responsible for managing 98% of the individual’s physical,

cognitive, behavioural, and emotional functions (Bennett, Good, & Kumpf, 2003).

Researchers found that the brains of infants born prematurely are smaller, weigh less, and are

structurally different than the brains of full term infants (Inder et al., 1999; Maalouf et al.,

1999). In many cases, these differences continue to be observed in these children during early

childhood (Peterson et al., 2000). In addition, children who are born prematurely with

VLBW are at a high risk of brain injury caused by hypoxia; inadequate oxygen levels in the

body due to the premature infant’s immature nervous system, as well as bleeds in different

regions of the brain (Inder et al.).

Siegel (1999) argued that traumatic experiences at the beginning of life might have

profound effects on the deeper structures of the brain thus affecting information processing

abilities. In fact, children who suffer trauma to the brain have been found to process

information differently and in some instances to require specifically tailored learning

strategies that differ from those needed for students with learning disabilities who do not

have brain injuries (Bennett et al., 2003). More specifically, Miller (n.d.) suggested that brain

injury in the immature brain could impair later brain development thus affecting an

individual’s long term functioning abilities. Brain injury acquired during the period from

birth to 2 years of age can result in disruptions in communication, physical, social, and

emotional development as well as deficiencies in gross and fine motor skills (Bennett et al.).

9

The increased risk of brain injury experienced by VLBW premature infants increases the

probability that they will grow up to face physical, cognitive, behavioural, emotional, and

social challenges (Hack & Taylor, 2000) that can impede their functioning in those areas.

Neurodevelopment. There has been a growing concern about the neurodevelopment

of premature children especially those born at a very early GA, and a VLBW (Hack &

Taylor, 2000). Although researchers have identified many cognitive, behavioural, and

emotional challenges in school aged prematurely born children (Bennett, 2002), it was not

always possible to trace neurobehavioural and neuropsychological deficits back to

neurological damage or neurosensory deficiencies (Hack, Taylor, Klein, & Murcuri-Minich,

2000; Saigal et al., 2003).

Researchers found that even in the absence of major neurological damage signs at the

ages of 3 and 4 years, children born preterm achieved lower mean scores than their full term

counterparts on the Stanford-Binet intelligence scale, visual perception test, visual motor

integration test, memory for location test, sustained attention test, and the picture vocabulary

test (Caravale, Tozzi, Albino, & Vicari, 2005). Moreover, Saigal et al. (2003) reported that

while only 13% of a group of VLBW 8-11 years old children from Ontario had Cerebral

Palsy, 57% of these children needed special education and grade repetition due to a variety of

cognitive, behavioural, and emotional needs. Furthermore, Olse´n et al. (1998) found that

although 8-year-olds who were born prematurely had within normal range cognitive abilities,

compared to their full term counterparts, they performed poorly on spatial and visuo-

perceptual tasks. Premature participants with minor neurodevelopmental deficits had more

problems in the domain of attention than those who were clinically healthy or who had

cerebral palsy.

10

McCormick (1997) has questioned the ways in which neurodevelopmental outcomes

have been reported stating: “[they] provide little guidance to clinicians or policy makers

about the functional impact on the individual child or the need for additional services” (p.

869). In addition, she notes methodological flaws as one of the reasons for her questioning

concerning outcome research. In a meta-analysis, Bhutta, Cleves, Casey, Gradock, and

Anand (2002) addressed this specific concern by looking at studies of cognitive and

behavioural outcomes of school aged children who were born prematurely. They concluded

that this population of children is at an increased risk of low cognitive test scores as well as

higher incidence of attention deficit hyperactivity disorder (ADHD) and other problem

behaviours. Along the same lines, Cole et al. (2002) concluded that:

Surviving premature infants often sustain multi-organ system complications that may

persist beyond the first few years of life and frequently result in permanent

impairments. Complications of even a single organ system may have a profound

impact upon other organ systems. Biomedical determinants of disability in premature

infants are often compounded by adverse determinants of social and psychological

adaptation of these vulnerable children and their families. (p. vi)

Still, McCormick’s questioning should be considered as an invitation for educators,

clinicians, and researchers to look more closely at the unique and individual needs of

prematurely born students and to consider between, as well as within group, similarities and

difference.

Sensory functioning. Understanding sensory functioning is important to helping a

prematurely born child within the school system. There seems to be inconclusive evidence

with respect to the prevalence of sensory impairments amongst VLBW premature children.

11

While Nafstad, Sameulsen, Irgens, and Bjerkedal (2002) found an association between

VLBW and a higher incidence of hearing impairments in a Norwegian sample of children,

Ari-Even Roth et al. (2006) reported a low prevalence of hearing impairments amongst

VLBW infants from Israel with higher rates of conductive loss (surgically correctable) than

sensorineural loss (permanent). As for visual functioning, Crofts, King, and Johnson (1998)

reported that babies born weighing less than 1500 grams were 26 times more likely than

babies who weighed 2500-3499 grams at birth to have severe visual impairments at age 5.

Furthermore, Msall et al. (2000) found an association between neonatal retinopathy of

prematurity (ROP); a disorder of the retina due to insufficient oxygen in the blood, in VLBW

infants and later functional ability. The authors found that at age 5.5 years compared to

premature children with no ROP, VLBW premature children with ROP had higher

incidences of self-care disability (25.4% versus 76.8%), continence disability (4.5% versus

50.0%), motor disability (5.2% versus 42.7%), and communicative-social cognitive disability

(22.4% versus 65.9%).

Accordingly, sensory impairments for premature children can extend beyond visual

and auditory processing. Our senses work collaboratively to form a composite picture of who

we are physically, where we are at, and what is going on around us. The brain is responsible

for the production of this composite picture for our ongoing use through the crucial function

of sensory integration (Sensory Integration International, n.d.). In addition to an immature

brain, premature children enter the world with fragile, easily over stimulated nervous systems

and multiple medical complications (D’Agostino, 1998; Sensory Integration International).

Over stimulation of the central nervous system of the premature child can be detrimental by

interrupting or damaging the natural process of neural connections responsible for this

12

function. When the child is unable to appropriately process data incoming through the senses,

a number of problems in learning, development, or behaviour may become evident. Some of

the symptoms that a child with sensory integration dysfunction (SID) can exhibit include:

over sensitivity to touch, movement, sights, or sounds; under reactivity to touch, movement,

sights, or sounds; distractibility; social and/or emotional challenges; high or low activity

levels; physical clumsiness or apparent carelessness; impulsive or lacking in self control;

difficulty making transitions; inability to calm self; poor self concept; delays in speech,

language, or motor skills, and delays in academic achievement. Many children tend to

outgrow SID and learn how to overcome their challenges, but some do not. Due to their

vulnerable neurological system at birth (D’Agostino, 1998), VLBW premature children

might be at a higher risk of having difficulties in sensory integration.

Cognitive abilities. As neurodevelopmental outcome investigators indicated, VLBW

premature children can face a number of cognitive challenges that can range from mental

retardation to less severe deficits that can limit processing, speech, memory, and perception

(Luciana et al., 1999; Peterson et al., 2000; Wolke & Meyer, 1999). However, in a recent

report by Ment and colleagues (2003) the authors found that premature children who did not

have any major neurological deficits showed progressive and significant increases in their

cognitive scores when tested at their corrected ages of 3, 4.5, 6, and 8 years. Some children

who scored in the mental retardation range at 36 months had scores greater than 70 (cut-off

score for diagnosing mental retardation) at age 8. These results were welcomed with

enthusiasm and excitement by professionals in the medical and the educational field alike.

The thought that these children eventually reach a somewhat normal level of

cognitive development has great implications for the educational system that must be

13

considered with great care. While an IQ of above 70 can spare a child the stigmatization that

is associated with the label of mental retardation (Ment et al., 2003), it can also deny the

child much needed special education services. A premature student entering elementary

school with a borderline intelligence can manage through the first 2 or 3 years of school

unnoticed. This may result in these students receiving educational services that do not meet

their needs (D’Agostino, 1998).

Moreover, consistent with past findings (Pinto-Martin, Feldman, Whitaker,

VanRossem, & Paneth, 1999), Ment et al. (2003) found that biological and environmental

factors played a role in the outcomes that these children had. Increases in maternal education

and living in a two parent household were both associated with an increase in cognitive

scores. Most importantly, they found that the provision of special education services was

especially beneficial for children whose mothers had less education. Providing additional

support was also associated with over time improvements in verbal scores of VLBW

children.

As brain plasticity which permits alteration in brain function and structure due to

experience (Luciana, 2003) can be used to understand the developmental difficulties that

premature children might face it can also account for the improvements seen in VLBW

premature children’s cognitive abilities. Yet the role that plasticity plays can be dependant on

the combination of genetic, biological as well as sociodemographic characteristics of the

individual child. Interventions and special education policy makers and providers must take

this into consideration when addressing the cognitive needs of VLBW prematurely born

students.

14

Speech, language, memory, and learning abilities. The effects of prematurity on a

child’s language development are initially seen in the delayed onset of babbling in VLBW

pre-terms (Jennische & Sedin, 1999). The parents of premature children born at 23-27 weeks

GA reported an absence of babbling in infancy and a higher incidence of stuttering at age 6.5

years. In addition, preterm infants started to talk intelligibly and to use full sentences at a

later age than children in the control group. Other challenges that have been reported include

delayed receptive and expressive language at age 2 (Vohr, Garcia, & Oh, 1988), and the use

of less complex sentences at age 3 as compared to full term cohorts (Grunau, Kearney, &

Whitlfield, 1990 as cited in Jennische & Sedin, 1999).

As VLBW premature children increase in age, researchers of language development

tend to shift their focus to the areas of memory, comprehension, speech articulation, and

prereading skills (Luciana et al., 1999; Wolke, & Meyer, 1999). For educators it is important

to understand whether premature children process language differently due to actual

differences in neural processes in the brain or not. This knowledge can be utilized to uncover

the need for special teaching strategies that are geared towards the unique processing and

learning styles of these children. Using functional magnetic resonance imaging (MRI),

Peterson et al. (2002) compared brain activity associated with phonologic and semantic

processing of language between premature and full term children. These researchers found

that the pattern of brain activity identified in a semantic processing task in preterm children

indicated that these children do not fully engage normal semantic processing pathways in a

language comprehension task. Instead, premature participants utilized pathways that normal

term children used to process meaningless phonologic sounds.

15

Accordingly, timely language development in children is necessary for early

communication abilities, such as babbling and cooing, as well as later learning abilities, such

as processing. Language and speech development delays that preterm children might

experience can increase the risk of learning disabilities in the school years.

Socio-emotional development. Socio-emotional development is significant in a child’s

school life as it affects his or her ability to adjust to the requirements of school environment

(Ross, Lipper, & Auld, 1990). Researchers have looked for behavioural and social

competence patterns in premature children. VLBW children have been found to be at a high

risk of exhibiting challenges in both areas of social and emotional development.

Ross et al. (1990) studied social competence and behavioural problems in 7-8-year-

old prematurely born children with a birth weight of less than 1501 grams. The authors

reported that both premature girls and boys had significantly lower total social competence

scores as measured by the Child Behaviour Checklist (CBCL). On the other hand, there were

some differences between the genders in terms of behaviour problems. While premature girls

did not differ significantly from the normative sample, premature boys had significantly

higher scores on the Hyperactivity, Aggressive, and Delinquent factors as well as the

Externalizing factor of the CBCL. These findings have important implications for educators

of prematurely born boys. Behavioural problems may have a significant impact on these boys

in the classroom as they may interfere with the children’s achievement and interactions with

the teacher and their friends (Klebanov, Brook-Gunn, McCormick, 1994). On the other hand

it is also important to monitor prematurely born girls as it is easier to miss the needs of a

withdrawn child than the needs of an aggressive child.

16

In addition, participants in the Ross et al. (1990) study who had suspected but no

severe neurological injuries had significantly lower social competence scores and

significantly higher behavioural problems scores than children who were neurologically

normal. Learning disabilities amongst that group were also associated with the incidence of

low social competence and high behavioural problems. Finally, family stability and social

class were also correlated with both behaviours. In fact, premature children who came from a

stable home and an upper social class were reported to have less behavioural problems and to

be more socially competent.

As for the emotional development of prematures, the findings have been somewhat

inconsistent. For example, Hoy et al. (1992) reported significantly higher mean scores of

sadness and social withdrawal in VLBW premature children when compared to normal birth

weight (NBW) cohorts. Meanwhile, Ross et al. (1990) reported that VLBW premature

participants in their study did not differ from the normative sample on depression, anxiety

level or obsessive compulsiveness. On the other hand, researchers in both studies reported

significantly lower social skill and peer acceptance scores amongst these children. Once

again the outcomes of a premature birth in the socio-emotional domain are affected by

multiple factors that must be considered when assessing and intervening with VLBW

prematurely born students.

Differences from other Students with Special Needs

As evident from the above literature review VLBW premature children may have

sequelae of developmental challenges, deficits, and deficiencies that can have a profound

affect on their functional abilities as they grow and develop. The implications during the

school years are that while children with an identified learning disability might be

17

functioning at an appropriate developmental level in other areas of development, school age

premature children with VLBW have been reported to have multiple developmental

impairments (Bhutta et al., 2002; Buck et al., 2000; Perlman, 2001; Saigal et al., 2003; Sykes

et al., 1997).

During school age the impact of multiple challenges can take a toll on the child’s

ability to function adequately within the school environment. By the late 1970s due to

improvements in neonatal intensive care practices 70% to 90% of VLBW and ELBW

premature infants in America were reported to be without serious impairments during early

childhood (Hack & Klein, 2006). In many cases however VLBW premature children exhibit

symptoms that are not severe enough to meet diagnostic criteria, yet significantly limit their

daily functioning. These less severe impairments are often very difficult to assess or

diagnose. Researchers generally report combinations of neurological findings, sensorineural

deficits, and borderline IQ scores (McCormick, 1997). This adds to the challenge of teachers

trying to meet the needs of these children without the additional support of educational

assistants or school counsellors.

In addition, the impact of multiple disabilities in premature children does not limit

itself to the classroom and the school. Daily reminders of the affects of prematurity will

present themselves in all aspects of a premature child’s life. For example going to the store

can become a feat for the child and his or her parents due to social anxieties, behavioural

problems, and sensory integration deficiencies. Constant negative interactions with people

and the environment can negatively impact a child’s self esteem and self concept. This will

transfer into the classroom and the school by manifesting itself in a low self confidence

resulting in continued underachievement in academic, social, and emotional areas.

18

Needs of Prematurely Born Students during Elementary School Years

While researchers have reported motor skill challenges, learning problems, language

deficits, behavioural problems, and neurodevelopmental abnormalities in VLBW premature

children, some researchers reported that these challenges do not become evident until school

age in premature infants who survived early childhood without major disabilities (Zubrick et

al., 1988). This sleeper phenomenon can further complicate the process of identifying these

children’s needs. One explanation for these “hidden handicaps” is that perinatal brain injury

can damage areas of the brain that are responsible for skills and abilities that a premature

child does not need to utilize until the school years. Keeping that in mind, as well as the

aforementioned research findings, teachers and school counsellors are encouraged to

consider the following needs of prematurely born students at the Kindergarten to Grade 1

levels.

Physical needs. Premature children are at a higher risk of having ongoing medical

issues and/or chronic illnesses (D’Agostino, 1998). These children might need additional

physical support that can range from someone assisting the child in the administration of

medication to a more demanding task of accompanying a physically handicapped child

throughout the day.

Fine and gross motor delays can affect a child’s ability to colour, write, use the

scissors, eat, dress, undress, sit, stand, walk, run, and balance (Trister-Doge & Colker, 1992).

Difficulties in tasks requiring the use of large muscle groups can be seen more easily in the

play ground, while small muscle skills are observed more often in the classroom. Any signs

of delays in any of these areas must be taken seriously. In my opinion, the involvement of

physiotherapists and occupational therapists as early as possible is of utmost importance to

19

the amelioration and/or possibly prevention of motor delays or deficits. This is most pertinent

at the Kindergarten level when young children’s mode of learning is still active play and

movement. It is my own perspective and that of other authors (e.g. Royal Commission on

Learning, 1994; Trister-Dodge & Colker, 1992; Woolfolk, 1990) in the literature that young

students must be able to successfully engage in this active learning process otherwise they

will lose interest in learning and fall behind.

Academic needs. This area of school functioning can prove to be the most challenging

depending on the neurodevelopmental status of the student. As was discussed earlier

neurological status can influence neurobehavioural as well as neuropsychological

functioning, thus increasing the risk of learning disabilities (Luciana et al., 1999; Perlman,

2001; Wolke & Meyer, 1999). Cognitive delays or abnormalities will affect thinking skills,

learning styles, comprehension, problem-solving, reasoning abilities, and memory. This

implies there is a need for additional resources to be able to create a learning environment

that is supportive of the student.

Reading, writing, and math skills are considered the building blocks for later learning.

As suggested by the Royal Commission on Learning (1994) “such fundamental codes as the

alphabet, and number systems which are acquired through practise and application, are

building blocks for everything that follows” (p. 88). Prematurely born students can be at a

higher risk of difficulties in all three areas (Saigal et al., 2003). Therefore, it is imperative

that pre-reading and pre-writing skills are established as early as possible for these children.

Similar emphasis must be placed on early mathematical skills. If educators postpone the

identification of prematurely born students for special education services they risk the

premature student completing primary grades without a solid base of these preliminary skills.

20

Sensory integration dysfunction can affect a student’s information processing

abilities. As Dunn and Dunn (1978) suggested in their Comprehensive Learning Styles

Model, that lighting, level of noise, proximity to other students, colours, and room

temperature in the classroom may affect the process of learning (Cited in Griggs, 1991).

Prematurely born students might require special consideration regarding their processing

needs. An assessment of the student’s needs in this area as well as an assessment of the

classroom setup can uncover any incompatibilities that exist and that can be interfering with

the child’s learning.

Speech and language developmental status must also be considered when trying to

meet the academic needs of prematurely born students. Premature children might become

challenged in learning due to deficits in this area. For example, as suggested by Troia (2005)

intelligence test scores do not specifically predict how well students learn to read when

provided with adequate instruction. Rather, a better predictor is individual performance in

reading-related language skills such as phonological and orthographic processing (see Troia

for related literature).

I believe that educators and school personnel must show patience and understanding

when working with these students. Within the context of an ethical practice and respecting

the dignity of the students (Ontario College of Teachers, 2000), educators must respect

students’ needs to appropriately express their frustrations and to help them find alternative

ways to compensate for their language delays and deficits. From my own involvement in my

son’s special education program at school I became cognizant of the fact that some teachers

can become too enthusiastic about helping students believe “that they can do it, if they try

harder”. Instead, educators need to recognize and acknowledge the child’s unique way of

21

processing information and expressing language. They also need to validate the student’s

feelings of inadequacy and normalize them. Teachers must work with the student to figure

out ways that work more effectively for the student such as the use of different modes of

teaching to accommodate different learning styles (Nelson, 2006).

Socio-emotional needs. Through his psychosocial development theory, Erikson

described the relation of the individual’s emotional needs to the social environment

(Woolfolk, 1990). Erikson believed that between the ages of 2 and 6 years emotionally

healthy children need to feel good about themselves, people around them, and the world in-

order for them to develop initiative. Prematurely born students entering Kindergarten might

have been living in an environment that revolved around them and their needs. Once they

enter school, children need to become more independent, to learn social interaction skills,

and to develop learning skills.

From an Eriksonian perspective it follows that these children’s success at school is

dependent on their abilities to initiate tasks in each of those areas and to succeed.

Considering the nature of a premature birth and all the complications associated with it, my

experience has been that it is natural that many of these children are raised in a somewhat

overprotective manner. There might be an understandable emotional overdependence on the

parent. Social anxiety and incompetence can be side effects of such rough start in life.

Educators can become positive agents in these children’s socio-emotional development by

giving these children the sense that they are accepted for themselves (Woolfolk, 1990), by

honouring their strengths, and respecting their weaknesses.

Given my experience in counselling children with socio-emotional problems, I

applaud teachers who gently encourage these students to become more independent and help

22

them develop self confidence. This guidance is important for prematurely born students

because as they grow and develop many of them might overcome some of their early

challenges but there seems to always be a lingering affect of prematurity (Hack et al., 2004).

As they get older these children might become more self conscious about their differences.

Having the self confidence will enable these students to accept their differences and to find

ways in which they can adapt the environment to their special needs.

Finally, these students do not live in a vacuum within the schools. Other students and

school personnel who are not aware of their needs might unintentionally impede these

students’ socio-emotional development. Educational programs and knowledge exchanges

regarding the needs of prematurely born students can counteract the negative affects of less

than favourable interactions. This is where the role of the school counsellor or the child and

youth worker comes in. One on one counselling with the student, group social skills

programs, and collaboration with the parents are starting points for nourishing and guarding

prematurely born students’ socio-emotional development.

Behavioural needs. It is difficult to assess the behavioural needs of premature

children. While neurological injuries can explain some of these behaviours such as the ones

associated with ADHD (Voeller, 2004), it is possible that troubled behaviours are

manifestations of frustration due to the children’s inability to function adequately within their

classrooms and their schools. Cormier and Nurius (2003) emphasized the importance of

accurate assessment of clients presenting problems to the success of intervention strategies.

Accordingly, educators need to accurately assess these children’s behaviours. Depending on

the underlying causes of the behaviour, teachers and support staff need to explore various

23

methods of intervention. It is important that the methods of choice are compatible with the

underlying causes of the behaviour.

It is apparent that individual teachers will not be able to meet any of the needs

discussed above without the support of educational assistants, school counsellors, social

workers, and other professionals that specialize in the different special needs areas.

Ultimately, prematurely born students need the support of the ministry of education, the

school board, the schools, and the teachers. Collaboration between all the parties involved is

essential to meeting the needs of these students.

A Closer Look at the Special Needs Education Policy in Ontario

Special education standards in Ontario school boards are provided by the minister of

education. Each board must comply with these standards as they are intended to “support the

government’s goal of ensuring that exceptional students in Ontario receive the best-quality

education possible. System-wide implementation of these standards will make school boards

more accountable to students, parents, and taxpayers” (Ministry of Education, 2000, p.3).

For school personnel to be able to provide such services students with special

educational needs must be identified. The process of identification is complex and is time

consuming. There are many decisions to be made and many people to involve. A committee

must be formed called the Identification Placement and Review Committee (IPRC)

consisting of at least three persons one of whom must be the school principle, or a

supervisory officer of the board. By consulting with a special education teacher from the

board of education, IPRC members have to decide whether or not the student should be

identified as exceptional, and identify the areas of the student’s exceptionality, according to

24

the categories and definitions of exceptionalities provided by the Ministry of Education

(Ministry of Education, 2006b). The final decision is made by the board’s consultant.

Furthermore, through the special education standards educators are encouraged to

translate psychological, educational, and medical reports into instructional expectations and

strategies that will assist teachers to meet the needs of each student. (Ministry of Education,

1982, Memorandum#8 section 3). In addition, it is the responsibility of school boards to

ensure that classroom assistants have suitable skills and knowledge for the implementation of

their assignments with learning disabled students. Finally, teachers must consult with parents

to know each child as soon and as thoroughly as possible in order to provide learning

opportunities that will help each child (Ministry of Education, 1982, Memorandum #11

section 2).

To help Ontario school boards meet the high quality standards presented above the

minister of education offers funding for each school board. There are four levels of funding.

Special Education Per-Pupil Amount (SEPPA) is allocated on the basis of total enrolment.

This amount is intended for the provision of additional assistance to the majority of students

with special needs (Ministry of Education, 2006c). The second level of funding is called

High Needs Amount and is aimed at covering the costs associated with intensive staff

support needed for students with very high needs. As outlined in the Spring 2006/07 special

education funding guidelines, the third level of funding is called the Special Equipment

Amount (SEA) and is intended to meet the costs of equipment needed by students to be able

to fulfill curriculum requirements. Finally, the Special Incidence Portion (SIP) supports the

students with exceptionally high needs, requiring more than two full time staff to address

their health and safety needs. School Board personnel must provide official documentations

25

of the needs of each student as well as ensure that each student meets specific criteria that are

determined by the ministry of education in order for them to be identified as eligible for any

level of special education funding (Ministry of Education). The criteria are very specific and

there is an emphasis on explicit physical, cognitive and behavioural manifestations of

disabilities that must be confirmed by a qualified professional.

Despite the emphasis on early identification and prompt provision of services, special

education funding arrangements are geared towards students with explicit and obvious

disabilities. VLBW prematurely born students who enter Ontario schools might not always

meet the criteria of eligibility for special education funding. Meanwhile, researchers have

presented an impressive amount of evidence that this student population is at an increased

risk of developing learning disabilities that extend beyond the cognitive domain. While many

of their developmental challenges might not meet diagnostic criteria, they are significant

enough to cause relevant and in many cases profound impacts on their lives and specifically

on their abilities to function and thrive within the education system.

The importance of early intervention implies that educators and policy makers need to

be educated about the needs of these children in order for them to become skilled at creating

teaching strategies and special education policies that will benefit these students while

awaiting formal assessments for eligibility for special education services. I am suggesting

though that this will not be sufficient for long term benefits. Early identification procedures

and allocation of funds must be revised to fill the gap that presently exists between these

children’s needs and available resources.

26

Current and New Intervention Strategies: Thinking outside the Box

Researchers who addressed intervention strategies for prematurely born children have

focused on programs and recommendations to be implemented in infancy. These programs

where either aimed at decreasing the adverse affects of NICU experience (D’Agostino, 1998;

Nair, Gupta, & Jatana, 2003) or at ameliorating or preventing developmental delays and

deficiencies in infancy and early childhood (Achenbach, Phares, Howell, Rauh, & Nurcome,

1990; Bradley et al., 1994; Brooks-Gunn, Klebanov, Liaw, & Spiker, 1993; Shing Yan et al.,

2004).

Recommendations regarding NICU environment are based on the premise that

optimal physical, social, psychological, and ethical environments are crucial for guaranteeing

the best developmental outcome for neonates (Nair et al., 2003). Environmental factors such

as sounds and lights are seen as having a major effect on the developing immature brain. The

busy, noisy, and brightly lit NICU environment is exactly the opposite of the quiet, calm, and

dark environment of the mother’s womb. In addition, medical procedures, excessive

handling, and touching can be painful and significant sources of stress on the immature

infant’s central nervous system (D’Agostino, 1998). Moreover, prolonged separation from

parents can lead to interruptions in parent-child attachment, thus effecting long-term socio-

emotional development. Talmi & Harmon (2003) suggested that promoting the perinatal

infant-parent relationship in the NICU can protect the baby from risk and promote healthier

developmental outcomes.

Intervention programs that targeted the developmental outcomes in early childhood

are based on the assumption that through early interventions professionals will be able to

maximize the chance that premature children reach normal developmental levels. The focus

27

was placed on increasing the sensitivity of parents to the needs of their premature children by

educating them about these special needs so they can become more responsive to their

children. One such program is the Infant Heath and development Program (IHDP) in the

United States through which researchers targeted a group of low birth weight pre-term

infants living in poverty. Researchers reported that at age 3 a higher percentage (39%) of

infants in the intervention group than the control group (11%) were identified as functioning

within the normal range of cognitive, health and growth, and social/adaptive parameters

(Bradley et al., 1994). Protective factors that accounted for this difference included a more

responsive, accepting, stimulating, and organized care in the home. Similarly Brooks-Gunn

et al. (1993) reported that rates of behavioural problems in the intervention group were

significantly lower than those reported in the non-intervention group. Interestingly, the

authors noted that the positive differences in cognitive scores were seen at 24 and 36 months

but not at 12 months. Brooks-Gunn and colleagues discussed these findings in terms of

timing and targeting of services for low birth weight premature infants.

Although there are a limited number of studies through which researchers addressed

the needs of premature children at the school level, usually recommendations were based on

methods used with the general population of students with special needs. Chapieski and

Evankovich (1997) explored the evidence of social and behavioural problems in low birth

weight prematurely born children and suggested that there is no reason to believe that

premature children would not be responsive to therapeutic interventions that have been

successful with other clinical populations. It is important to note that there is scarce research

addressing comparative results of the effectiveness of interventions applied to premature

school-age children and their full term cohorts. Meanwhile, Eliasson, Roslad, and Hagger-

28

Ross (2003) aimed at improving the control of reaching movements in 6 year old pre-term

children with impaired coordination. The authors reported that while non specific

intervention methods had a positive impact on the children’s fine motor skill, a task-specific

approach to practise was important to the success of the intervention program. Contrary to

what Chapieski and Evankovich (1997) proposed, I believe that as special considerations

were needed for interventions in the perinatal and early childhood stages, specifically tailored

intervention strategies are needed for successful intervention programs that target

improvements in school outcomes for VLBW premature children.

An educator’s underlying assumptions about human development influence his or her

approach to assessment of student needs as well as choice of teaching and guiding methods.

The issues of critical period and plasticity in human development have been at the heart of

many debates regarding an individual’s success in acquiring certain skills or in developing

specific abilities. Critical period refers to the notion that some developments must take place

within a specific time frame (Broderick & Blewitt, 2003) otherwise the individual will either

never develop or become underdeveloped in that area. On the other hand, plasticity refers to

the belief that an individual is able to acquire any new skill at any time if provided with the

right opportunities. The importance of understanding the implications of the difference

between these views is amplified when considering the development of children who were

born prematurely. Intervention strategies that are proposed in this report are based on the

belief that opportunities for development and learning must be presented in ways that are

congruent with the developmental status of the child. Regardless of the child’s age, educators

are encouraged to consider the individual child’s developmental level in each area of

development within the context of a premature birth. Premature children will not benefit

29

from plasticity in brain development unless they were presented with opportunities that will

optimize the possible outcomes of this plasticity.

Possible Outcomes in Adulthood

There are only a few longitudinal studies that follow prematurely born children into

adulthood. The results seem to be inconclusive and contradictory in some cases. Hack et al.

(2004) reported overall increase in psychopathology among a group of VLBW 20 year old

men and women. However there were significant differences between the genders. While

VLBW men reported similar incidences of internalizing, externalizing or behavioural

problems to normal birth weight participants, women reported significantly more anxiety,

depression and withdrawal. Parents of both VLBW men and women reported significantly

higher rates of thought problems than the parents of the control group men and women. The

authors suggested the need for “anticipatory guidance and early intervention that might help

prevent or ameliorate potential psychopathology” (p. 932).

In looking at educational outcomes of VLBW premature children, several researchers

from different countries found that these ex-premature adults had inferior educational

outcomes at age 20 years. Fewer VLBW adults had graduated from high school and fewer

were involved in post secondary education (Cooke, 2004; Ericson & Kallen, 1998; Hack et

al., 2002). To the contrary, in a more recent study Saigal et al. (2006) found more

encouraging outcomes when measured transition into adulthood of ELBW ex-premature

adults. They reported no significant differences in the rates of high school graduation, current

educational achievement, enrolment in college, rates of permanent employment, independent

living or marital relationships when compared with normal birth weight controls. The

divergence between these results can be explained in terms of sample characteristics as well

30

as differences in health care system service provision (Hack & Klein, 2006). If anything,

these differences should be taken as an indication of the importance of contextual factors and

individual differences in the long term outcomes of a premature birth.

Despite advances in technology and neonatal care and an increase in the survival rate

of premature children, there still exist many concerns regarding the long term outlook for this

population. Presently researchers are focusing on school age children because there is a

growing body of evidence that a large percentage of these children need support in their

attempts to learn and to integrate into their families, communities, and societies. In some

instances, the current identification procedures for eligibility for special education in Ontario,

seems to be failing to meet the needs of these children in a timely manner. Until there are

shifts in identification and funding policies, educators would benefit from a resource about

the different needs of these children, the challenges that they might face as a result of those

needs, and guidelines on how to help these students overcome their challenges. In Chapter 3 I

will present such information which I will also summarize at the end of the chapter in a

brochure that can be used by educators. The brochure will be entitled “Incubators to

Classrooms: Meeting the Cognitive, Social, and Emotional Needs of Prematurely born

Children: Guidelines for Ontario Elementary Educators”.

31

CHAPTER III

Guidelines for Educators

Possible Challenges in Elementary School

As was presented in the last chapter, prematurity has been linked to many

developmental challenges and needs in children. Although, many researchers have explored

additional areas of difficulties that premature children can face, school challenges that are

presented in this chapter are based on the specific research findings that were discussed in

Chapter 2.

In this Chapter, I examine the curriculum for the Kindergarten program as outlined

by the Ontario Ministry of Education for the school year of 2006/07, to gain a better

understanding of the challenges that prematurely born children can face as a result of their

needs when entering elementary schools. The learning expectations that are placed on the

students will be evaluated based on their compatibility with the developmental status of

VLBW premature children as presented in this project. Any incompatibilities will be

identified as challenges that these students might face in those specific areas.

The Ontario Ministry of Education identifies six areas of learning which include:

Personal and social development; language; mathematics; science and technology; health and

physical activity, and the arts. Under each area there is several learning expectations that

students are expected to achieve by the end of the Kindergarten program. For the purpose of

developing the brochure, I will identify some of the challenges that may arise in four of the

above areas of learning when considering the physical, cognitive, behavioural and,

social/emotional developmental status of VLBW prematurely born students entering

elementary schools. These areas are: 1) personal and social development, 2) language, 3)

32

mathematics, and 4) health and physical activity (see Appendix, A, B, C, and D for a list of

learning expectations in each of these areas). Exploring the areas of science and technology,

and the arts requires an in-depth analysis that extends beyond the scope of this project.

Therefore, I will not include these two areas in my discussion of challenges within the

brochure. I acknowledge that these are important challenges to be addressed and may

develop a companion brochure once I have completed the final project.

Personal and social development. Premature children might find it difficult to

demonstrate either partial or total independence in certain areas, such as dressing themselves,

feeding themselves and going to the bathroom due to the physical challenges arising out of

the impact of prematurity on fine and gross motor skills. This challenge might present itself

mostly during transition times when the teacher is occupied and the child is expected to do

tasks on his or her own. Some specific examples are: drop off time, pick up time, snack time

and tidy up time.

Self regulation might be another area in which prematurely born children might

struggle. Although usually ADHD is not diagnosed in children at the Kindergarten level,

prematurely born children might exhibit excessive impulsivity, inattention, and a noticeable

lack of self control; all of which are associated with ADHD (American Psychiatric

Association, 1994). Challenges in sensory integration can also interfere with the child’s self

regulatory functions. Emotional outbursts might be another challenge that these children may

need help managing.

Finally due to motor coordination challenges prematurely born children might seem

“clumsy” and unaware of their position within the space that they are in. This can challenge

their ability to show respect for the personal space of other students. Circle time, story time

33

and snack time might become times during which the child will need extra support. Such

challenges, if persistent, may negatively impact the child’s self image and cause him or her to

develop a lack of confidence and “a lack of willingness to take responsibility in learning and

other [social] activities” (Ministry of Education, 2006d, p. 31).

Language. The expectations for this area of development are based on the premise

that listening, speaking, reading, and writing are all interconnected with development in one

area supporting development in all other areas. In addition, oral language is believed to be

the foundation of literacy development in Kindergarten (Ministry of Education, 2006d).

The emphasis that is placed on language, pre-writing and pre-reading skills can be

challenging to prematurely born students. Working memory problems, information

processing deficits and language delays might form barriers to the student’s ability to learn

the alphabet and to learn reading and writing. Other processing deficiencies or delays that

might impact development in this area include; visual-motor integration, auditory-motor

integration, and perceptual-motor planning. These functions refer to the child’s ability to

process and make sense of the information incoming through the senses and being able to

coordinate it with physical movements such as eye-hand coordination. While a premature

child’s intelligence might be intact, and in some cases above average, the neurological status

of the child might prevent him/her from utilizing his or her intelligence.

Show and tell time when the child is required to communicate ideas, thoughts, and

feelings can be a source of frustration if the child is unable to articulate properly, form clear

sentences, or is slow in processing questions and inquiries. Activities that require colouring,

tracing and outlining can also be seen as opportunities where the teacher is able to witness

the premature child’s need for support in this area. Reading and writing skills whether it is

34

fine motor or mental processing can also be challenging. For example, a child who is unable

to position the pencil correctly in his or her hand and unable to stay focused for more than 4

minutes may benefit from repetition, hand on hand guidance and a specific structure to

follow. Such needs can be difficult to receive from a teacher who lacks the financial and

human resources.

Mathematics. This area of learning encompasses a wide range of thought process

development. The children are expected to learn counting, to gain some numbers operational

sense, to become aware of measurement sense and relationships, to grasp the concept of

geometry and spatial sense, and to be able to organize data in terms of patterns. These

mathematical processes are considered essential to the effective study of mathematics and

children need to learn and apply them in every aspect of their exploration of mathematical

concepts (Ministry of Education, 2006d).

Premature children’s developmental delays in the visual-perceptual and visual motor

abilities can manifest themselves clearly in the process of mathematical learning. To be able

to understand and to apply some of the concepts and processes stated above, children need to

have intact visual-spatial processing. A premature child might not be able to easily

differentiate similar shapes, patterns and designs. Inattention and inability to focus can also

affect the child’s ability to attend to small details. Thus activities such as matching, ordering,

sorting, and organizing may become frustrating and at times overwhelming to a premature

student with visual-spatial deficits and cognitive processing delays.

Moreover, fine and gross motor deficits may interfere in this area of learning, as the

teacher may attempt to incorporate physical action; such as hopping or clapping to create

basic representation of simple mathematical ideas (Ministry of Education, 2006d). If a

35

premature student is unable to master some of the motor skills used, then he or she will be at

a disadvantage since this process of learning mathematics might require more effort on the

child’s part compared to other children of his or her age. Fine motor challenges can also

make tracing and printing numbers more difficult.

Finally, premature children’s attempts to communicate their understanding of

mathematical concepts can be hindered by their speech and language processing delays.

There may be a difference between what and how much the child actually knows and what

and how much he or she is able to show or tell. So a premature child with a working memory

problem might not be able to hold the information (numbers, shapes, patterns) long enough in

his or her memory to perform certain mathematical operation. According to the Ministry’s

guidelines, children need to be given learning experiences that are within the range of things

they can do with and without guidance. Premature children’s capacity to do certain

mathematical processes without guidance can differ significantly from those abilities of their

full term classmates. Concrete objects, prompting and repetition are important in assisting

prematurely born students with such difficulties. Introduction of mathematical concepts must

be presented in a manner that is appropriate to a premature child’s cognitive and motor

developmental level.

Heath and physical activity. The emphasis in this area of development is placed on

the ability to show fine and gross motor control in a variety of contexts within the school

environment. In addition, a child is expected to present this development by willingly

participating in a variety of activities that require the use of these muscles.

The curriculum is designed in a manner that builds on previous experience,

knowledge, and skills. The significance of this approach to the school experience of

36

premature children can be clearly seen in this area of learning. While the differential patterns

of motor development for full term children can consist of small delays and immaturities that

will diminish with appropriate support and time, premature children’s differential pattern of

development might not diminish as the child matures and grows. A differentiation must be

made between a delay and a deficit. Many premature children are diagnosed with

Developmental Coordination Disorder (DCD), which is a diagnosis that is descriptive of a

general motor delay or deficiency. As the name suggests, premature children with this

diagnosis, might have trouble coordinating movements needed for walking, balancing,

jumping, galloping, hopping, moving, and reaching. Their inability to successfully participate

in physical activities should not be viewed as a reflection of an unwillingness to participate.

Therefore, these children should not be made to feel that they are not trying hard enough or

that their efforts are not appreciated. Their challenges in meeting the expectations are due to

real physical limitations that without the appropriate intervention and support will continue to

limit these children’s physical development.

Resources Available through the Community

Learning Disability Association of Ontario (LDAO). This is a charitable non-profit

organization that offers many resources, services, information, venues, and products designed

to help people with Learning Disabilities (LDs) and ADHD. It is also a useful resource for

parents, teachers, and other professionals. LDAO is active in creating public awareness about

LD through different events to inform the public of the issues and challenges faced by people

with learning disabilities. More information is available at their website www.ldao.ca

LDAO has a resource library with books to borrow, journals to read, and videos to

view. You can request information online by following http://www.ldao.ca/infoRequest.php

37

Moreover, this association offers an online service for teachers called the Web Based

Teaching Tool (WBTT) to support the Ministry of Education’s early intervention and

screening program. Kindergarten to grade 2 teachers will be able to determine which students

in their classroom need additional support by identifying what areas they are struggling with,

and how their areas of need can be addressed within the classroom. This will help the teacher

identify students who are at risk of developing future school difficulties. In addition, this tool

provides an interventions database, which includes strategies for working with at-risk

students and strategies that can benefit all children in the class. The information compiled on

the WBTT can greatly assist teachers with instruction, tracking, assessing, and reporting.

This resource can be invaluable to teachers in trying to help prematurely born students who

are awaiting formal assessment. For more information on the different services available to

teachers, students, school counsellors and parents check the aforementioned website.

McMaster Perinatal Association (McPERA). Sometimes an educator will need to

direct the parents to appropriate individuals and agencies for help and support. McPERA is

geared towards supporting parents of premature children from the time their children are at

the NICU and beyond. A peer support group aims to help parents cope with the challenges of

having a premature baby. This group meets weekly in the NICU and provides new parents

the opportunity to hear educational presentations and get to know each other. This group is

open to other parents who had their premature children at hospitals other than McMaster. In

addition, McPERA offers yearly reunion picnics for McMaster Children’s Hospital, NICU

graduates. For contact information check out the following link:

http://www.inform.city.hamilton.on.ca/details.asp?RSN=29142&Number=3

38

Ontario Brain Injury Association (OBIA). This agency is committed to providing

support, information, advocacy, training, and education to persons living with the effects of

acquired brain injury, their families as well as other professional caregivers. This resource

can be useful in obtaining information regarding teaching and working with students whose

brain structure and function differs from the normal patterns of development. Due to the

effects that neonatal risk factors can have on the developing brain, educators might be faced

with obstacles when trying to implement strategies that were designed without taking into

account such risk factors to the premature student’s brain. Teachers will be able to obtain

many resources that are geared specifically to meet the needs of students who might have

memory, processing, attention, focus and regulation problems due to acquired brain injury.

Their resource book Educating Educators about ABI can be accessed at

www.abieducation.com

March of Dimes. In trying to achieve its two goals of raising awareness about

prematurity and reducing the incidence of prematurity, the March of Dimes campaign offers

research findings and educational information to help families raise healthier babies. Since

the focus of this campaign is on supporting research about prematurity, this resource can be

an important source of academic findings about the effects of prematurity on children as they

grow and develop. Teachers might be able to enhance their understanding about prematurity

and the role it plays in the challenges that their pre-term students are facing. More

information can be accessed at http://www.marchofdimes.com/prematurity/prematurity.asp

Offord Centre for Child Studies. The Offord centre is affiliated with McMaster

University and McMaster Children’s Hospital. This is a centre for research in healthy child

development whose researchers aim at studying solutions that enhance children’s emotional,

39

social, and cognitive development. They emphasize the importance of sharing this

knowledge with parents and policy makers to improve programs affecting young children.

Their magazine, promisingfutures can prove to be a valuable resource for information

regarding child development. More information can be found at www.offordcentre.com

Recommendations

After carefully reviewing the process of identification for eligibility for special

education services of VLBW prematurely born students who are free of explicit neurological

illnesses, I concluded that this process could take a minimum of one school year. The

assumption for the following recommendations is that the teacher does not have additional

help in the classroom and needs strategies and guidelines that he or she can implement

independently without additional resources. In addition, these recommendations are based on

the belief that the school must be a psychologically healthy environment for development;

designed in a manner to support children’s optimum adjustment and adaptation (Baker, Dilly,

Aupperlee, & Patil, 2003). Baker and colleagues suggested that for the above to materialize,

there needs to be “a good fit between the developmental needs of students and the affordance

[what it is able to provide] of the school environment” (p. 209). For educators to be able to

create that goodness of fit between premature student’s developmental needs and the learning

environment, they need to attain the skill and confidence to identify these needs and

understand their sources (Achenbach et al., 1990). Through this understanding teachers will

be able to optimize transactions between the students and the environment.

Finally, as stated in one of the guiding principles for early identification procedures

and intervention of the Hamilton Wentworth Catholic School Board (2005), there needs to be

“a recognition of the long term value of a preventive model of service delivery based on

40

proactive early and ongoing detection of students at risk along with early interventions to

meet the learning needs of those students (p. 12). Accordingly, these recommendations and

guidelines do not replace the need for the early identification of VLBW prematurely born

students. They are meant as a support for educators who lack the appropriate funding

resources to try and offer their students a learning environment that is congruent with the

students’ needs and that supports the students’ development and growth.

41

Incubators to Classrooms: Meeting the Cognitive, Emotional, and Social Needs of Prematurely Born Students Produced by: Raghida Mazzawi for a Master degree in Counselling Psychology final project at Campus Alberta Applied Psychology Program for Graduate Studies in Counselling For more information on this project follow this link: CAAP DTPR-link to Project provided here.

Copyright © 2006 Raghida Mazzawi

Incubators to Classrooms

Meeting the Cognitive, Emotional, and Social Needs of Prematurely Born Students

Guidelines for Educators in Ontario Elementary schools

42

Facts about Prematurity

The Public Health Agency of Canada defines a full term pregnancy as 37 to 42 weeks of gestation. Infants who are born prior to 37 weeks gestation age (GA) are considered premature.

The lower the birth weight and the earlier the gestation age,

the higher is the risk for early medical complications and neurological damage, thus the higher is the chance for later developmental complications.

Between the year 1991 and the year 2004 the rate of live

preterm infants (less than 37 weeks GA) in Canada increased from 6.6 % to 7.9 %.

Researches found up to 40-50% increased risk of a learning

disability manifesting itself by Grade 3 amongst very low birth weight premature children.

The implications for educators are the possible increase in

numbers of prematurely born students who will need a helping hand to support them in their education.

“The teacher who walks in the shadow of the temple, among his followers, gives not of his wisdom but rather of his faith and his

lovingness”. (Gibran Khalil Gibran, The Prophet)

43

Resources There will be a higher chance for learning success when working with prematurely born children, if educators work collaboratively with parents, educational assistants, school counsellors, and other specialists within the school and the community. These are the names of some associations and organizations that might be of benefit to teachers throughout the process of assessment, identification, and intervention.

Learning Disability Association of Ontario (LDAO). For information about their services log on to www.ldao.ca

Offord Centre for Child Studies. For more information about this centre’s

services log on to www.offordcentre.com

McMaster Perinatal Association (McPera). This association aims to offer help and support to parents of premature infants. As well as a resource for parents who have general questions about prematurity. Contact person: Karla Schwarzwer at (905) 521-2100 Ext 73210

March of Dimes. Offers an online resource library that can be accessed at 6

http://www.marchofdimes.com/prematurity/prematurity.asp Books

Bennett, S., Good, D., & Kumpf, J. (2003). Educating educators about ABI: Resource book. Ontario Brain Injury Association.

Expert Panel on Literacy and Numeracy Instructions for Students with

Special Education Needs, Kindergarten to Grade 6. (2005). Education for All. Ministry of Education. Queen’s Printer for Ontario.

Greene, R. W. (2005). The explosive child: A new approach for

understanding and parenting easily frustrated chronically inflexible children. New York: HarperCollins Publishers.

4

Potential Childhood Outcomes Associated with Prematurity

Prematurity can lead to injuries in a baby’s immature brain thus affecting its growth and later development. Growth of the brain outside the mother’s womb also increases the risk of medical and developmental complications. This risk is related to impairments in a child’s long term functioning abilities.

Physical Development

Fine and Gross motor delays and deficits Lower averages of height and weight Asthma and increased risks of respiratory infections Slower physical developmental pattern Sensory Integration Dysfunction Cerebral Palsy, blindness, and deafness

Cognitive Development

Lower scores on intelligence tests Working memory challenges Visual-motor integration problems Visual-perception integration problems Slower information processing Speech and language delays and deficits Inability to focus and pay attention

Behavioural and Socio-emotional Development

Lower social skills and competence Hyperactive and aggressive behaviour Lack of self control and impulsivity Lower peer acceptance Higher incidence of Attention Deficit Hyperactivity Disorder

1

44

Possible Challenges in the School

Corresponding Strategies

Recommendations and Guidelines for Intervention and Prevention

Teachers, school counsellors, and staff from the Board of Education are encouraged to consider the aforementioned strategies and the following suggestions to facilitate learning and development; to promote a positive self concept and confidence; and to foster a love for learning in premature children who are awaiting formal assessment and identification:

Offer respect, understanding, and acceptance Utilize the expertise and support of physiotherapists and

occupational therapists whenever possible Give special consideration to the room environment and setup

to accommodate their sensory needs Make available special writing equipment to accommodate

their fine motor challenges Be cognizant of the fact that these children might not be

developmentally ready to display certain skills. Consolidation of prerequisite skills is important to achieve prior to presenting new information from the next developmental level

Use developmentally appropriate assessment methods as well as teaching strategies

Consult expert staff members who are qualified to manage behavioural challenges in a manner that is supportive of the child

Seek early identification for eligibility for special education services

Engage the parents and the child in the planning process. Work collaboratively with all parties involved Utilize external resources for gathering information regarding

premature children and the unique needs of this student population

Consider alternative intervention strategies (Refer to books suggested in the resource section) in addition to those that are being successfully used with other students

Aim at increasing the number of positive interactions between the child and the environment. Set the child up for success

3

Difficulty in self help skills Inability to master pre-reading and pre-writing skills Challenges in understanding the concept of numeracy Difficulty adapting and adjusting to the structured school

environment Inability to conform to school policy regarding

behavioural expectations Inability to form friendships Separation anxiety from parents Feelings of incompetence and inadequacy Needing additional emotional and physical support

Encourage and praise the student for each and every attempt to apply his or her motor skills, regardless of their success or failure

Focus on introducing the child to a variety of reading and writing tools. Do not emphasize the importance of acquiring specific reading and writing expectations. Rather concentrate on the process of exploring books and simple ways to use writing tools

Use a lot of repetition and utilize concrete objects for representation

Show flexibility and offer reasonable accommodations Use strategies that will redirect the student’s attention in a

constructive manner. Rather than time out for constantly blurting out answers, request that the student show you the proper way to answer. Modeling appropriate behaviour is more affective than punishment

For emotional and social support assign to the student developmentally appropriate responsibilities to foster self esteem and confidence

2

45

CHAPTER IV

Discussion and Summary

Within this project, I focused on potential challenges faced by prematurely born

students, although I recognize that not all premature children will grow up to face difficulties

at school. For example, Luciana et al. (1999) proposed that it is not prematurity per se that

leads to negative outcomes, but the degree of neonatal illness associated with premature birth

that is predictive of later planning and working memory deficits. Since factors such as birth

weight and gestational age will impact the degree of risk for neonatal complications, each

premature student must be viewed within the context of the unique circumstances of his or

her birth.

When VLBW premature children enter elementary school, they can be faced with a

multitude of challenges and difficulties (Bennett, 2002) that can intensify if the appropriate

measures are not taken (McCain & Mustard, 1999). In their Early Years Study report,

McCain and Mustard proposed that if “Ontario wants to keep track of how its children are

doing; we will need to improve our capacity to monitor key measures of development in the

early years” (p. 9). I believe that this point is especially significant for prematurely born

children. While follow-up programs are offered through the hospitals for the first 3 years of

life, McCain and Mustard emphasized that critical periods of development in many areas

extend beyond the first 3 years of life. Risk factors that are associated with a pre-term birth

further increase this significance. Moreover, researchers have found that many VLBW

premature children who do not exhibit signs of neurological damage or serious impairments

during early childhood can still have developmental delays that may eventually lead to

learning disabilities and other behavioural and social problems at school age (Hack & Klein,

46

2006). These findings challenge the belief that prematurely born children eventually catch up

to their full term counterparts.

The present Ministry of Education policies for early identification and eligibility for

special education services in Ontario elementary schools are based on specific criteria that

many Ontario students do not meet to be identified as “exceptional pupils”, although they can

still exhibit disabilities that signify their need for special education programs and services

(Expert Panel on Literacy and Numeracy in Kindergarten to Grade 6, 2005). There is a gap

between the needs of VLBW children who do not meet eligibility criteria entering the

Kindergarten program and the resources available to meet those needs. Kindergarten teachers

and other educators at the school entry level are in need of a resource that they can consult

regarding the needs of premature children as well as strategies and guidelines for meeting

those needs.

It must be emphasized that such recommendations should not replace advocacy for

early identification. While it is not a teacher’s responsibility to formally identify a student as

“exceptional” it is his or her responsibility to make sure that the student’s learning as well as

developmental needs are being met within the classroom. Limited funding and human

resources can make the allocation of services and funds a challenge. Therefore, I see a need

for a change at the policy level, where policy makers acknowledge the scientific evidence

available regarding the developmental status of VLBW premature children as they enter

elementary schools and the higher risk that exists for these students developing learning

disabilities. It is also necessary that they recognize the need for early identification and early

intervention. While for the purpose of this project I investigated the special education

policies of the Ontario Ministry of Education, it would be prudent of Education Ministries of

47

other provinces in Canada to examine their policies and their effectiveness in meeting the

needs of prematurely born students in an appropriate and timely manner.

The information included in this final project may also be of use to other individuals.

Teachers of other elementary grades; especially Grades 1 and 2, school counsellors, special

education resource teachers, educational assistants, child and youth workers, social workers

and child therapists can utilize the information presented in this project to carry out informed

assessments and intervention strategies. As such, it is recommended that the Ministry of

Education, the School Boards, and the schools offer the brochure and information within this

project through their libraries and resource centres.

Recommendations

There is a need for further research about the status of prematurely born children at

school age. While there has been a consistent supply of studies that reported outcomes of a

premature birth at school age, there is a lack of attention given to effective teaching strategies

and intervention programs for this population of students with special needs. Due to the risk

of injury and insult to the brain associated with a premature birth (D’Agostino, 1998; Inder et

al., 1999) and the comorbidity of developmental, neurobehavioural, and neuropsychological

difficulties (Hack et al., 2000; Saigal et al., 2003) there is a reason to believe that prematurely

born students may need uniquely tailored teaching strategies and intervention techniques.

Another important area that needs addressing is that of teacher and child workers

training. If educators are to offer prematurely born students developmentally appropriate

teaching strategies and child and youth workers and counsellors are to utilize

developmentally appropriate intervention methods, individuals in both groups of

professionals need to possess the knowledge and expertise to identify the needs of these

48

students and to be able to address these needs in an appropriate and timely manner. Teacher

educators and training program designers are encouraged to consider this necessity in

planning and designing the curriculum for teachers and other educators.

My prematurely born son’s question at the tender age of 6: “God made me different,

why can’t you accept it?” made me stop in my tracks. What became clear to me was the

importance of acknowledging that premature children can have different needs from other

children, but what they need most of all is acceptance. Acknowledgement leads to

acceptance, and acceptance leads to understanding, which in turn facilitates cooperative

problem solving. Educators, child workers, and policy makers need to give prematurity the

attention it deserves and acknowledge the risk that prematurely born students face of

developing learning disabilities and other developmental difficulties that can profoundly

impact their school functioning. Through collaboration and constructive problem solving all

parties involved in a premature student’s education will become closer to empowering the

student and offering him or her a greater chance at successful learning and a better outlook

for a brighter future.

49

REFERENCES

Achenbach, T. M., Phares, V., Howell, C. T., Rauh, V. A., & Nurcombe, B. (1990). Seven-

year outcome of the Vermont early intervention program for low birth weight infants.

Child Development, 61, 1672-1681.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental

disorders (4th ed.). Washington, DC: Author. Retrieved from On October 20th, 2006

from http://www.psychologynet.org/dsm.html

Ari-Even Roth, D., Hildesheimer, M., Maayan-Metzger, A., Muchnik, C., Hamburger, A.,

Mazkeret, R., et al. (2006). Low prevalence of hearing impairment among very low

birthweight infants as detected by universal neonatal hearing screening. Archives of

Disease in Childhood - Fetal and Neonatal Edition, 91, 257-262.

Baker, J. A., Dilly, L. J., Aupperlee, J. L., & Patil, S. A. (2003). The developmental context

of school satisfaction: Schools as psychologically healthy environments. School

Psychology Quarterly, 18, 206-221.

Bennett, F. C. (2002). Low birth weight infants: Accomplishments, risks and interventions.

[Perspective]. Infants and Young Children, 15, 6-9.

Bennett, S., Good, D., & Kumpf, J. (2003). Educating educators about ABI: Resource book.

Ontario Brain Injury Association. Also available online at www.abieducation.com

Bhutta, A. T., Cleves, M. A., Casey, P. H., Gradock, M. M., & Anand, K. J. S. (2002).

JAMA, 288(6), 728-737. Retrieved on October 11, 2006 from www.jama.com

Bradley, R. H., Whiteside, L., Mundfrom, D. J., Casey, P. H., Kelleher, K. J., & Pope, S. K.

(1994). Contribution of early intervention and early caregiving experiences to

50

resilience in low-birthweight, premature children living in poverty. Journal of clinical

Child Psychology, 23, 425-434.

Broderick, P.C., & Blewitt, P. (2003). The life span: Human development for helping

professionals (2nd ed.). Columbus, Ohio: Pearson-Merrill Prentice Hall.

Brook-Gunn, J., Klebanov, P. K., Liaw, F.R., & Spiker, D. (1993). Enhancing the

development of low-brithweight, premature infants: Changes in cognitions and

behaviours over the first three years. Child Development, 64, 736-753.

Browne, J. V. (2003). New perspectives on premature infants and their parents. Zero to

Three, 24(2), 4-12.

Buck, G. M., Msall, M. E., Schisterman, E. F., Lyon, N. R., & Rogers, B. T. (2000). Extreme

prematurity and school outcomes. Paediatric and Perinatal Epidemiology, 14, 324-

331.

Caravale, B., Tozzi, C., Albino, G., & Vicari, S. (2005). Cognitive development in low risk

preterm infants at 3-4 years of life. Archives of Disease in Childhood. Fetal Neonatal

Edition, 90, 474-479. Retrieved on 19 June 2006 from

http://fn.bmjjournals.com/cgi/content/full/90/6/F474

Chapieski, M. L., & Evankovich, K. D. (1997). Behavioral effects of prematurity. Seminars

in Perinatology, 21, 221-239.

Cole, C., Hagadorn, J., Kim, C., et al. (2002). Criteria for determining disability in infants

and children: Low birth weight. Evidence report/technology assessment No. 70

(Prepared by Tufts New England Medical Center Evidence-based Practice Center

under Contract No. 290-97-0019).AHRQ Publication No. 03-E010. Rockville, MD:

51

Agency for Healthcare Research and Quality. Retrieved on October 16, 2006 from

www.ahrq.gov/downloads/pub/evidence/pdf/lbw/lbw.pdf

Cooke, R. W. I. (2004). Health, lifestyle, and quality of life for young adults born very

preterm. Archives of Disease in Childhood, 89, 201-206. Retrieved on October 30,

2006 from http://adc.bmjjournals.com

Cormier, S., & Nurius, P. (2003). Interviewing and change strategies for helpers:

Fundamental skills and cognitive behavioural interventions (5th ed.). CA:

Brooks/Cole-Thomas Learning.

Crofts, B. J., King, R., & Johnson, A. (1998).The contribution of low birth weight to severe

vision loss in a geographically defined population. British Journal of Ophthalmology,

82, 9-13.

D’Agostino, J. A. (1998). Neurodevelomental consequences associated with the premature

neonate. AACN Clinical Issues Advanced Practice in Acute and Critical Care, 9,

14pp. Retrieved on October 4, 2006 from

www.aacn.org/AACN/jrnlci.nsf/GetArticle/ArticleTwo91

Eliasson, A.C., Roslad, B., & Hagger-Ross, C. (2003). Control of reaching movements in 6-

year-old prematurely born children with motor problems-An intervention study.

Advances in Physiotherapy, 5, 33-48.

Ericson, A. Kallen, B. (1998). Very low birthweight boys at the age of 19. Archives of

Disease in Childhood. Fetal Neonatal Edition, 78(3), F171-F174. Retrieved on

November 1, 2006 from http://adc.bmjjournals.com

52

Expert Panel on Literacy and Numeracy Instructions for Students with Special Education

Needs, Kindergarten to Grade 6. (2005). Education for All. Ministry of Education.

Queen’s Printer for Ontario.

Griggs, S. A. (1991). Learning Styles Counselling. Retrieved on October 16, 2006 from

ERIC Digest database at http://ericae.net/edo/ED341890.htm

Hack, M., Flannery, D., Schluchter, M., Cartar, L., Borawsky, E. Klein, N. (2002). Outcomes

in young adulthood for very-low-birth-weight infants. The New England Journal of

Medicine, 346, 149-157.

Hack, M., & Klein, N. (2006). Young adult attainment of preterm infants. Journal of

American Medical Association, 295, 695-696. Retrieved on September 24, 2006 from

www.jama.com at University of Calgary.

Hack, M., & Taylor, H. G. (2000). Perinatal brain injury in preterm infants and later

neurobehavioral function. Journal of American Medical Association, 284, 1973-1974.

Hack, M., Taylor, H. G., Klein, N., & Mercuri-Minich, N. (2000). Functional limitations and

special health care needs of 10-to-14 year-old children weighing less than 750 grams

at birth. Pediatrics, 106, 554-560. Retrieved on June 19, 2006 from

www.pediatrics.org

Hack, M., Youngstorm, E. A., Cartar, L., Schluchter, M., Taylor, H. G., Flannery, D., et al.

(2004). Behavioural outcomes and evidence of psychopathology among very low

birth weight infants at age 20 years. Pediatrics, 114, 932-940.

Hamilton Wentworth Catholic District School Board. (2005). Student services; Special

education plan. Retrieved from on October 12, 2006 from

http://www.hwcdsb.edu.on.ca/departments/fs_d_intro.html

53

Horwood, L. J., Mogridhe, N., & Darlow, B. A. (1998). Cognitive educational, and

behavioural outcomes at 7 to 8 years in national very low birthweight cohort.

Archives of Disease in Childhood. Fetal Neonatal Edition, 79, 12-20.

Hoy, E. A., Sykes, D. H., Bill, J. M., Halliday, H. L., McClure, B. G., & Reid, M. M. (1992).

The social competence of very-low-birth weight children: teacher, peer, and self

perception. Journal of Abnormal Child Psychology, 20(2), 123-150. Abstract

obtained from Expanded Academic ASAP. Thomson Gail. University of Calgary on

October 13, 2006. Abstract Number A12336414.

Inder, T. E., Huppi, P. S., Warfield, S., Kikinis, R., Zientara, G. P., Barnes, P. D., et al.

(1999). Periventricular white matter injury in the premature infant is followed by

reduced cerebral cortical gray matter volume at term. Annals of Neurology, 46, 755-

760.

Jennische, M., & Sedin, G. (1999). Speech and language skills in children who required

neonatal intensive care: Evaluation at 6.5 y of age based on interviews with parents.

Acta Paediatrica, 88, 975-982.

Klebanov, P. K., Brook-Gunn, J., & McCormick, M. C. (1994). Classroom behaviour of very

low birth weight elementary school children. Pediatrics, 94, 700-708.

Luciana, M. (2003). Cognitive development in children born preterm: Implications for

theories of brain plasticity following early injury. Development and Psychopathology,

15, 1017-1047.

Luciana, M., Lindeke, L., Georgieff, M., Mills, M., & Nelson, C. A. (1999).

Neurobehavioural evidence for working memory deficits in school-aged children with

histories of prematurity. Developmental Medicine and Child Neurology, 41, 521-533.

54

Maalouf, E. F., Duggan, P.J., Rutherford, M. A., Counsell, S. J., Fletcher, A. M., Battin, M.,

et al. (1999). Magnetic resonance imaging of the brain in a cohort of extremely

preterm infants. The Journal of Pediatrics, 135, 351–357. Retrieved on October 10,

2006 from Science Direct Journals at

http://www.sciencedirect.com/science/journal/00223476

McCain, M. N., & Mustard, J. F. (1999). Reversing the real brain drain: The early years

study final report. Retrieved on August 17, 2006 from www.children.gov.on.ca

McCormick, M. C. (1997). The outcomes of very low birth weight infants: Are we asking the

right questions? Pediatrics, 99, 869-876. Retrieved on October 3, 2006 from

www.pediatrics.org.

Ment, L. R., Vohr, B., Allan, W., Katz, K. H., Schneider, K. C., Westerveld, M., et al.

(2003). Change in cognitive function over time in very low-birth-weight infants. The

Journal of the American Medical Association, 289, 705-711. Retrieved on September

24, 2006 from www.jama.com

Miceli, P. J., Goeke-Morey, M. C., Whitman, T. L., Sipes-Kolberg, K., Miller-Loncar, C., &

White, R. D. (2000). Brief report: Birth status, medical complications, and social

environment: Individual differences in development of preterm, very low birth weight

infants. Journal of Pediatric Psychology, 25, 353-358. Retrieved on October 1, 2006

from http://jpepsy.oxfordjournals.org/cgi/content/abstract/25/5/353

Miller, S. P. (n.d.). Abnormal brain development and injury in premature newborns. Child &

Family Research Institute. Retrieved on October 10, 2006 from

http://www.bcricwh.bc.ca/our_research/researchers/search_researchers/researcher_de

tail.asp?ID=94

55

Ministry of Education. (2006b). Education act. Ontario regulation 181/98. Retrieved on

October 5, 2006 from http://www.e-

laws.gov.on.ca/DBLaws/Regs/English/980181_e.htm#TOC

Ministry of Education. (1982). Policy/program memorandum no. 8. Retrieved on August 11,

2006 from http://www.edu.gov.on.ca/extra/eng/ppm/8.html

Ministry of Education. (2006a). Special education. Retrieved on August 15, 2006 from

http://www.edu.gov.on.ca/eng/parents/speced.html

Ministry of Education. (2006c). Special education funding guidelines: Special equipment

amount (SEA) and special incidence portion (SIP), 2006-07. Retrieved on October

15, 2006 from http://www.edu.gov.on.ca/eng/funding/0607/speced.pdf

Ministry of Education. (2000). Standards for school boards’ special education plans.

Retrieved on August 15, 2006 from http://www.edu.gov.on.ca

Ministry of Education. (2006d). The kindergarten program. (Revised). Retrieved on October

2, 2006 from http://www.edu.gov.on.ca.

Msall, M. E., Phelps, D. L., DiGaudio, K. M., Dobson, V., Tung, B., McClead, R. E., et al.

(2000). Severity of neonatal retinopathy of prematurity is predictive of

neurodevelopmental functional outcome at age 5.5 years. Pediatrics, 106, 998-1005.

Nafstad, P., Samuelsen, S. O., Irgens, L. M., & Bjerkedal, T. (2002). Birth weight and

hearing impairment in Norwegians born from 1967 to 1993. Pediatrics, 110(3), 30-

36. Retrieved on October 10, 2006 from www.pediatrics.org

Nair, M. G., Gupta, G., & Jatana, S. K., (2003). NICU environment: Can we be ignorant?

[Editorial]. Medical Journal Armed Forces India, 59, 93-95. Retrieved on August 24,

2006 from http://medind.nic.in/maa/t03/i2/maat03i2c.shtml

56

Nelson, G. D. (2006). Breaking the learning barrier for underachieving students: Practical

teaching strategies for dramatic results. Thousand Oaks, CA: Corwin Press.

Olsén, P., Vainionpää, L., Pääkkö, E., Korkman, M., Pyhtinen, J., & Järvelin, M. R. (1998).

Psychological findings in preterm children related to neurologic status and magnetic

resonance imaging. Pediatrics, 102, 329-336.

Ontario College of Teacher. (2000). Ethical standards for the teaching profession. Author.

Retrieved on October 17, 2006 from http://www.oct.ca/publications/pdf/ethics_e.pdf

Perlman, J. M. (2001). Neurobehavioural deficits in premature graduates of intensive care-

Potential medical and neonatal environmental risk factors. Pediatrics, 108, 1339-

1348. Retrieved on August, 24, 2006 from www.pediatrics.org

Peterson, B. S., Vohr, B., Kane, M. J., Whalen, D. H., Schneider, K. C., Katz, K. H., et al.

(2002). A functional magnetic resonance imaging study of language processing and

its cognitive correlates in prematurely born children. Pediatrics, 110, 1153-1162.

Peterson, B. S., Vohr, B., Staib, L. H., Cannistraci, C. J., Dolberg, A., Schneider, K. C., et al.

(2000). Regional brain volume abnormalities and long-term cognitive outcome in

preterm infants. Journal of American Medical Association, 284, 1939-1947.

Retrieved on September 26, 2006 from www.jama.com

Pinto-Martin, J., Feldman, J., Whitaker, A., VanRossem, R., & Paneth, N. (1999). Neonatal

cranial ultrasound abnormalities in non-disabled low birthweight children: I.

Relationship to cognitive and motor performance at ages 2, 6 and 9. Developmental

Medicine and Child Neurology, 41, 826-833.

57

Public Health Agency of Canada. (2003). Canadian perinatal health report. Author.

Retrieved on September 15, 2006 from http://www.phac-aspc.gc.ca/publicat/cphr-

rspc03/index.html

Ross, G., Lipper, E. G., & Auld, P. A. (1990). Social competence and behavioural problems

in premature children at school age. Pediatrics, 86, 391-397.

Royal Commission on Learning. (1994). For the love of learning. Queens Printer for Ontario.

Retrieved on October 16, 2006 from http://www.edu.gov.on.ca/eng/

Saigal, S., Ouden, L. D., Wolke, D., Hoult, L., Paneth, N., Streiner, D. L. (2003). School-age

outcomes in children who were extremely low birth weight from four international

population based cohorts. Pediatrics, 112, 943-950. Retrieved on August 10, 2006

from www.pediatrics.org

Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal

experience. New York: Guilford Press.

Sensory Integration International. (n.d). Answers to frequently asked questions. Retrieved on

October 5, 2006 from http://www.sensoryint.com/faq.html

Shing Yan, R. L., Chun Bong, C., Pui Yee, A., Yuen Bing, H., & Chi Chiu, S. (2004). Gross

motor skills of premature very low birth weight Chinese children. Annals of Tropical

Paediatrics, 24, 179-183.

Statistics Canada. (2006). Births: Live births 2004. Health Statistics Division, Catalogue no.

84F0210XIE, p.30. Retrieved on September, 19. 2006 from http://dsp-

psd.pwgsc.gc.ca/Collection/Statcan/84F0210X/84F0210XIE.html

Stenzel, J. (2004). A primer on preemies. Retrieved on September 30, 2006 from

http://www.kidshealth.org/parent/growth/growing/preemies.html

58

Sullivan, M. C., & McGrath, M. M. (2003). Perinatal morbidity, mild motor delay, and later

school outcomes. Developmental Medicine and Child Neurology, 45, 104-112.

Sykes, D. H., Hoy, E. A., Bill, J. M., McClure, B. G., Halliday, H. L., & Reid, M. C. (1997).

Behavioural adjustment in school of very low birthweight children. Journal of Child

Psychology and Psychiatry, 38, 315-325.

Talmi, A. & Harmon, R. J. (2003). Relationships between preterm infants and their parents:

Disruption and development. Zero to Three, 23(2), 13-20.

Trister, Doge, D., & Colker, L. (1992). The creative curriculum for early childhood (3rd ed.).

Washington, DC: Teaching Strategies Inc.

Troia, G. A. (2005). Responsiveness to intervention: Roles for speech language pathologists

in the prevention and identification of learning disabilities. Topics in language

Disorders, 25, 106-119.

Voeller, K. S. (2004). Attention deficit hyperactivity disorder (ADHD). Journal of Child

Neurology, 19, 798-814.

Vohr, B. R., Garcia-Coll, C., & Oh. W. (1988). Language development of low-birthweight

infants at two years. Developmental Medicine and Child Neurology, 30, 608-615.

Abstract obtained from National Centre for biotechnology Information: PubMed,

Abstract No. 3229558. http://www.ncbi.nlm.nih.gov/

Wolke, D., & Meyer, R. (1999). Cognitive status, language attainment, and prereading skills

of 6-year-old very preterm children and their peers: the Bavarian Longitudinal study.

Developmental Medicine and Child Neurology, 41, 94-109.

59

Wolke, D. (1998). Psychological development of prematurely born children. Archives of

Disease in Childhood, 78, 567-570. Retrieved on October 16, 2006 from

http://www.bmjjournals.com

Woolfolk, A. E. (1990). Educational Psychology (4th ed.). Englewood Cliffs, NJ: Prentice

Hall.

Wrape, P. (n.d.). Prematurity research disproves the theory that preemies catch up by age

three. Retrieved September 18, 2003, from

http://www.prematurity.org/research/notcatchingup2.html

Zubrick, S. R., Macartney, H., & Stanley, F. J. (1988). Hidden handicap in school-age

children who received neonatal intensive care. Developmental Medicine and Child

Neurology, 30, 145–152.

60

APPENDIX A

Overall Expectations for Personal and Social Development for Kindergarten Level

Adapted from: Ministry of Education. (2006). The Kindergarten Program (Revised).

1. demonstrate a sense of identity and a positive self-image 2. demonstrate a beginning understanding of the diversity in individuals, families,

schools, and the wider community 3. demonstrate independence, self regulation, and a willingness to take responsibility

in learning and other activities 4. demonstrate an ability to use problem solving skills in a variety of social contexts 5. identify and use social skills in play and other contexts 6. demonstrate an awareness of their surroundings

61

APPENDIX B

Overall Expectations for Language Development for Kindergarten Level

Adapted from: Ministry of Education. (2006). The Kindergarten Program (Revised).

1. communicate by talking and by listening and speaking to others for a variety of purposes and in a variety of contexts

2. demonstrate understanding and critical awareness of a variety of written materials that are read by and with the teacher

3. use reading strategies that are appropriate for beginning readers in order to make sense of a variety of written material

4. communicate in writing, using strategies that are appropriate for beginners 5. demonstrate a beginning understanding and critical awareness of media texts

62

APPENDIX C

Overall Expectations for Mathematical Skills Development for Kindergarten level

Adapted from: Ministry of Education. (2006). The Kindergarten Program (Revised).

1. demonstrate an understanding of numbers, using concrete materials to explore and investigate counting, quantity, and number relationships

2. measure and compare length, mass, capacity, area, temperature of objects/materials, and the passage of time, using non-standard units, through free exploration, focused exploration, and guided activity

3. describe, sort, classify, and compare two dimensional shapes and three dimensional figures, and describe the location and movement of objects through investigation.

4. explore, recognize, describe, and create patterns, using a variety of materials in different contexts

5. sort, classify, and display a variety of concrete objects, collect data, begin to read and describe displays of data and begin to explore the concept of probability in everyday contexts

63

APPENDIX D

Overall Expectations for Health and Physical Activity Development for Kindergarten level

Adapted from: Ministry of Education. (2006). The Kindergarten Program (Revised).

1. demonstrate an awareness of health and safety practices for themselves and others and a basic awareness of their own well-being

2. participate willingly in a variety of activities that require the use of both large and small muscles

3. develop control of large muscles (gross motor control) in a variety of contexts 4. develop control of small muscles (fine motor control) in a variety of contexts