Objectives: The US needs to be proactive in developing a comprehensive follow up strategy for high-risk children. There must be a reevaluation of the weaknesses of each child, which exacerbate competency outcomes and the strengths of each child based on an assessment of protective factors in the environment. This study incorporates research directions established by NINR and Healthy People 2010 to develop nursing knowledge in health promotion for high-risk children. The objective of the longitudinal project is to (1) investigate birth weight and a cumulative medical risk index in assessing childhood developmental outcomes; (2)to estimate the direct relationship of proximal and distal protective processes not explained by medical risk in childhood developmental outcomes. The biological insult experienced by preterm children in concert with complex contexts place some children at increased risk for cognitive, academic, and socioemotional difficulties. Design: This is a prospective longitudinal study of children from birth through school age grouped by birth weight with a wide range of neonatal morbidity, and stratified by socioeconomic status. An examination of cumulative medical risk is compelling because over the period of childhood it has had the strongest explanatory power in explaining child competence. Rutter (1987) has indicated the difference between risk factors which may exacerbate disorder and protective processes which ameliorate outcomes are linked because of the protective processes relation to risk. We are testing Luthar’s (1993) main effect model which asks, “among high-risk children what distinguishes those that do well from those that do poorly?” An a priori condition of risk must be present before protective processes are examined. Population, Sample, Setting, Years: One hundred eighty eight infants, 151 who were preterm, were recruited from the NICU between 1985-1989. The full term infants were recruited simultaneously from the same medical center. The inclusion/exclusion criteria were representative of NICU admissions for that time. Variables Studied Together: To generate a medical risk index, the methodological approach was to aggregate risk as ‘high risk’ and ‘low risk’ from birth to age 4 from a neonatal morbidity risk scale, occurrence of chronic lung disease, intraventricular hemorrhage, as well as neurological and physical exam scores from age 4. There were 2 putative protective processes indexes. A distal protective set consists of personal and ecological family measures. A proximal protective set of measures of maternal personality and interaction style. Child outcomes were cognition (WISC-R), academic achievement (WRAT 3), academic, motor (Bruininks-Oseretsky), visual perceptual skills (TVPS), attention problems and school success. Methods: Data were gathered at birth and throughout childhood. At ages 4 and 8, children and their mothers came to the hospital laboratory where assessments were videotaped, the physical and neurological exams were conducted, and questionnaires including risk index data (age 4) and protective processes (age 8) were completed. Home and school visits were also done. Power analysis was completed for all statistical tests indicating adequate power (> .80) to detect medium effects at .05. Findings: The low birth weight group earned significantly better scores than the very low birth weight and extremely low birth weight on cognition, academic and motor outcomes. In the hierarchical regression models, the explained variance of birth weight was small (3-6%). The cumulative medical risk was significant for all outcomes, more than doubling the explained variance of birth weight. Trend analysis examined the relationship between the medical risk index and cognition/academic outcomes showing a sharp decline in verbal and performance scores when cumulative medical risk is considered. The 10-20 point score decline is both clinically and statistically significant. For all outcomes, there were main effects for distal and proximal protective processes after accounting for cumulative risk (R2 .09-.33). Conclusions: The best explanation for understanding school age outcomes of preterm children is the assessment of both cumulative medical risk and protective processes. The magnitude of the impact of cumulative risk actors showed a 1-2 fold increase in our understanding of outcomes. A process is called protective when there is sustained functioning in the face of risk. Any characteristic that may promote competence is likely to be part of a multiple processes involving adversity and individual adjustment, including processes that alter the characteristic itself. Implications: Identifying processes that might exacerbate or ameliorate these children against the effects of risk is of great health policy importance. The study supports that the a priori condition of risk must be present in order to evaluate the protective processes operating in the child’s environment. The findings detangle the complex conditions of risk and protection among our smallest most vulnerable citizens.
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