Research in Developmental Disabilities 33 (2012) 19481956

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Research in Developmental Disabilities

Evaluating preterm infants with the Bayley-III: Patterns and correlates

of development
Michelle M. Greene a,b,*, Kousiki Patra a, Michael N. Nelson a,b, Jean M. Silvestri a
a
b

Department of Pediatrics, Rush University Medical Center, Chicago, IL, United States
Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL, United States

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 4 March 2012
Received in revised form 24 May 2012
Accepted 24 May 2012
Available online 26 June 2012

This study investigates the Third Edition of the Bayley Scales of Infant and Toddler
Development (Bayley-III) and: (1) early patterns of neurodevelopmental performance
among preterm infants 812 months of age; and (2) correlations between known risk
factors and neurodevelopmental outcome of preterm infants in this cohort. Mean
Language Index (LI; 91  15) and Motor Index (MI; 94  17) were signicantly lower than the
Cognitive Index (CI; 102  15, p < .01). For the majority (53%) of infants, language
development was their weakest domain; for another 39%, motor skills were the weakest
area of development. Almost one-quarter (22%) of this cohort had mildly delayed language
and motor skills, while 7% had signicantly delayed language and motor skills. Regression
models revealed severely abnormal head ultrasound signicantly predicted MI, LI, and CI.
Oxygen dependence at discharge predicted CI, LI, and race/ethnicity predicted LI, MI. Results
support the addition of the Language Index to the newly revised Bayley-III Scales. Prediction
models of developmental performance conrm known neonatal risk factors and reveal
sociodemographic risk factors that call for additional research.
2012 Elsevier Ltd. All rights reserved.

Keywords:
Bayley-III
Preterm infants
Follow-up
Development
Race/ethnicity

1. Introduction
Preterm infants (born before 37 weeks gestational age) are known to be at high risk for neurodevelopmental impairment
and delay (Stephens & Vohr, 2009). Developmental delay and differences in preterm infants as compared with full-term
infants are clearly seen within the rst year of life; preterm infants have signicantly less developed executive functioning,
smaller receptive and expressive language lexicons, and weaker motor skills as compared with their full-term peers
(Evensen, Skranes, Brubakk, & Vik, 2009; Stolt, Haataha, Lapinleimu, & Lehtonen, 2009; Sun, Mohay, & OCallaghan, 2009).
Preterm infants continue to have clinically signicant problems with cognitive, language, and motor skills, academic
functioning, and adaptive functioning that persist throughout childhood and result in disproportionately high rates of
cognitive impairment, motor impairment, learning disabilities, and special education placement (Aylward, 2002; Stephens &
Vohr, 2009). This trajectory of neurodevelopmental delay highlights the importance of preterm infant assessment for the
purposes of monitoring and enrollment in early intervention.
The Bayley Scales of Infant Development-II (BSID-II) have a history of being among the most frequently used,
standardized tools for the assessment of infant development and have played a major role in the assessment of cognitive and
motor function in preterm infants under 3 years of age (Bayley, 1993; Spittle, Doyle & Boyd, 2008). Recently, the BSID-II have

* Corresponding author at: 1653 West Congress Parkway, 1200 Kellogg Building, Chicago, IL 60612-3833, United States. Tel.: +1 3129426656;
fax: +1 3129428592.
E-mail address: Michelle_Greene@rush.edu (M.M. Greene).
0891-4222/$ see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ridd.2012.05.024

M.M. Greene et al. / Research in Developmental Disabilities 33 (2012) 19481956

1949

been revised and re-normed. The function of the Bayley-III remains consistent with that of the BSID-II; both versions aim to
identify and quantify neurodevelopmental delay and to guide intervention (Bayley, 2006a; Spittle et al., 2008). The structure
of the Bayley-III, however, is notably different from that of its predecessor. The BSID-II was comprised of cognitive and motor
indices (Bayley, 1993). The Bayley-III continues to provide cognitive and motor indices, but also includes a newly created
Language Index and ve new subscales (Bayley, 2006a).
Currently, relatively little is known about neurodevelopmental patterns of performance and neonatal and sociodemographic correlates of neurodevelopmental outcome among preterm infants as quantied by the Bayley-III (Anderson,
De Luca, Hutchinson, Robert, & Boyle, 2010; Duncan et al., 2012). Thus far, relevant Bayley-III literature has focused on
neurodevelopmental patterns and correlates in extremely low birth weight infants (ELBW; birth weight <1000 g, or, <2
pounds, 3 ounces) in the second year of life; investigation of developmental performance reveals that cognitive, language,
and motor neurodevelopment is delayed, respectively, in 13%, 21%, and 15% of ELBW infants in the second year of life
(Anderson et al., 2010), and, investigation of correlates of neurodevelopment reveals minority race/ethnicity relates to
poorer language development in the second year of life (Duncan et al., 2012). In contrast to the relatively sparse Bayley-III
literature, an extensive body of work investigating neonatal and socio-demographic risk variables and neurodevelopmental
outcome as quantied by the BSID-II reveals a number of neonatal risk factors such as severe head ultrasound abnormalities,
necrotizing enterocolitis, sepsis, and chronic lung disease, in addition to social risk factors such as minority racial status,
public health insurance, and lower maternal education (Gargus et al., 2009; Stephens & Vohr, 2009; Wilson-Costello,
Friedman, Minich, Fanaroff, & Hack, 2005). Additional research of use of the Bayley-III among preterm infants is warranted.
Despite the emerging research conducted on the Bayley-III in preterm infants in the second year of life, to date, no
published manuscripts have reported neurodevelopmental patterns of performance and neonatal and socio-demographic
correlates of neurodevelopmental outcome as quantied by the Bayley-III among preterm infants within the rst year of life.
The ability to monitor patterns of performance, rates of developmental delay, and the impact of neonatal and sociodemographic risk factors throughout the rst year of life permits understanding of trajectories of risk and potentially more
effective use of early intervention services, which have been shown to improve outcomes in preterm infants (Nordhov et al.,
2010).
The Bayley Scales have an extensive history in determining eligibility for early therapeutic intervention and quantifying
outcome and progress for high-risk infants. However, little is known about the neurodevelopmental patterns or correlates of
the newest edition of this important tool within the rst year of life for preterm infants. As such, the current study aims to
investigate patterns and correlates of neurodevelopmental performance among preterm infants at 812 months corrected
age using the Bayley-III.
2. Method
2.1. Participants
A retrospective cohort of 85 preterm infants born in 2008 and cared for in a Neonatal Intensive Care Unit (NICU) in a large
academic medical center in the Midwest were administered the Bayley-III at 812 months corrected age. Only infants who
completed the Bayley-III prior to November 1, 2008 were included in this study.
Medical center interpreters were used to facilitate assessment with non-English speaking families. Non-English speaking
families were included in analyses because minority race/ethnicity, which is associated with uency in languages other than
English, has been found to be an important socio-demographic risk factor for preterm infant development (Duncan et al.,
2012) and because the Bayley-III has yet to be standardized in other languages (such as Spanish). The practice of including
infants administered the Bayley-III through an interpreter is consistent with investigations that include race/ethnicity as a
socio-demographic predictor of neurodevelopmental outcome of preterm infants in the second year of life (Duncan et al.,
2012).
2.2. Medical chart review and instruments
Neonatal and socio-demographic data were collected from the medical records of the study population. Infant birth data
including birth weight, gestational age at birth, and postmenstrual age at NICU discharge were collected. Neonatal
morbidities and therapy information included: small for gestational age (birth weight <10th percentile), receipt of postnatal
steroids, diagnosis of chronic lung disease (oxygen dependence at 36 weeks postmenstrual age), need for oxygen therapy at
hospital discharge (discharge home on oxygen), sepsis (culture-proven bloodstream infection or meningitis), necrotizing
enterocolitis (NEC; Stage 23) and/or intestinal perforation, retinopathy of prematurity, and severely abnormal head
ultrasound (HUS) ndings dened as the presence of Grades III and/or IV intraventricular hemorrhage, periventricular
leukomalacia, and severe ventricular dilatation. Socio-demographic data included maternal race/ethnicity and health
insurance status.
2.2.1. Gestational age, postmenstrual age, and corrected age
As noted above, the terms gestational age at birth, postmenstrual age at discharge from NICU, and corrected age are used
throughout the present investigation.

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M.M. Greene et al. / Research in Developmental Disabilities 33 (2012) 19481956

Gestational age is dened as, the time elapsed between the rst day of the last menstrual period and the day of delivery
(Engle, 2004, p. 1363) and is centered around the assumption that full-term gestation in humans is roughly 40 weeks in
duration. In accordance with recommended practice for investigations of preterm infants (Engle, 2004), completed weeks of
gestational age at birth was calculated and is reported (Engle, 2004). Additionally, postmenstrual age, dened as,
gestational age plus chronological age, and reported in weeks (Engle, 2004, p. 1363), was calculated to determine infants
age at time of NICU discharge and is reported.
Corrected age (or adjusted age) is calculated by subtracting the number of weeks born before 40 weeks gestation from
the chronological age, and is reported in units of months (Engle, 2004, p. 1362). For example, a chronologically 12 month
infant born at 28 weeks gestational age would have a corrected age of 9 months. The calculation and use of corrected age in
growth, nutrition, and developmental assessment of preterm infants is very commonly reported in preterm outcome
literature and is endorsed by American Academy of Pediatrics (AAP; Bernbaum, Campbell, & Imaizumi, 2009). A recent
review of the practice of correcting age empirically supports the AAP recommendation and concludes that use of corrected
age in assessing global development of preterm infants allows for more accurate comparison to normative references and
full-term infants (DAgnostino, 2010). Additionally, use of corrected age in assessing motor development allowed for greater
specicity and better predictive value of later neurological functioning (DAgnostino, 2010).
2.2.2. Bayley Scales of Infant and Toddler Development-Third Edition
Bayley-III scores were obtained from outpatient medical records. Preterm infants enrolled in the Neonatal High Risk
Infant Follow-Up Clinic at this Midwestern academic medical center are administered the Bayley-III by trained licensed
clinical psychologists as part of standard outpatient follow-up protocol.
The Bayley-III assesses development through a series of standardized test items and behavioral interactions designed to
quantify cognitive, language, motor, and social/personal skills with infants and toddlers 142 months of age. The Bayley-III
typically takes between 50 and 90 min to administer (Albers & Grieve, 2006).
The Bayley-III provides three norm-referenced Index Scores: the Cognitive, Language, and Motor Indices (Mean = 100,
SD = 15), and ve norm-referenced subscale scores: the Cognitive, Expressive Language, Receptive Language, Fine Motor,
and Gross Motor Subscales (Mean = 10, SD = 3; Bayley, 2006a). While not used in the present study, the Bayley-III also
includes a SocialEmotional Scale (M = 100, SD = 15) and Adaptive Behavior Scale (M = 100, SD = 15) which are generated
from caregivers responses to two questionnaire measures. The Bayley-III normative data was generated from a
standardization sample of 1700 children aged 142 months. The standardization sample was stratied on: parent
education, race/ethnicity, and geographic region to represent the 2000 US Census data for US youth aged 142 months
(Bayley, 2006b). The Bayley-III Indices and Subscales have good internal consistency; coefcient alphas range from .86 for
the Fine Motor Subscale to .93 for the Language Index (Bayley, 2006b). Additionally, testretest reliability within the
Indices and Subscales is strong and ranges from .80 for the Fine Motor Subscale to .87 for the Expressive Language Subscale
and Language Index (Bayley, 2006b).
As previously mentioned, the Bayley-III differs from its predecessor, the widely used second edition of the Bayley. The
BSID-II generated two indices, the Mental Development Index (MDI; M = 100, SD = 15) and the Psychomotor Development
Index (PDI; M = 100, SD = 15). Of note, the MDI of the BSID-II combined both cognitive and language items. The Bayley-III
deleted, added, and modied BSID-II items and, more notably, added a Language Index and ve subscales. The Cognitive and
Language Index Scores of the Bayley-III strongly correlate with the Mental Development Index (MDI) from the BSID-II (r = .60,
r = .71, respectively; Bayley, 2006b). The Motor Composite Index from the Bayley-III also strongly correlates with the
Psychomotor Development Index (PDI) from the BSID-II (r = .60; Bayley, 2006b). Analysis of mean differences between BSIDII and Bayley-III Index Scores reveals that Index Scores from the Bayley-III are on average seven points higher than Index
Scores from the BSID-II (Bayley, 2006b). The Bayley-III manual states that the magnitude and direction of this mean
difference is comparable to differences seen in other revised infant assessment batteries (Bayley, 2006b).
2.3. Statistical analyses
2.3.1. Descriptive statistics
Frequency and central tendency descriptive statistics were calculated for infant birth data, neonatal, and social risk
factors, and neurodevelopmental outcomes.
2.3.2. Bayley-III patterns of neurodevelopmental performance
Within-subject Analysis of Variance (ANOVA) and Least Squared Differences (LSD) post hoc analyses were used to
compare mean index and subscale scores within each individual and generate a prole of performance. That is, individual
infants performance (dependent variable) on the CI, LI, and MI (independent variable) and on the ve subscale scores were
compared in order to identify patterns of performance.
In order to investigate rates of delay and patterns of this delay, frequency of mildly delayed (scores more than one
standard deviation below the mean; Index Score < 85, Subscale Score < 7) and signicantly delayed (scores more than two
standard deviations below the mean; Index Score < 70, Subscale Score < 4) Bayley-III scores were calculated. Patterns of
relative strengths and weaknesses, or the frequency of the infants with each Index as highest or lowest scores, also were
calculated.

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It is important to note what while frequencies of developmental delay (percentage of infants with Index Scores one and
two standard deviations below the mean) were calculated for the purposes of examining developmental patterns and
proles, in the bivariate and regression analyses (Sections 2.3.3 and 2.3.4), which investigated the relations between sociodemographic and neonatal risk factors and Bayley Index Scores, continuous Bayley Index Scores (Mean = 100, SD = 15) were
used.
2.3.3. Neonatal and socio-demographic correlates of Bayley-III neurodevelopmental outcome: bivariate relations
Pearson and point-biserial correlation coefcients (r) were used, respectively, to analyze bivariate relations between
continuous and dichotomous neonatal and socio-demographic risk factors (independent variables) and the Bayley-III
Cognitive, Language, and Motor Indices (dependent variables). One-way ANOVA (F) was used to analyze bivariate relations
between categorical variables with more than two groups (i.e., race/ethnicity; independent variable) and the Bayley-III
Cognitive, Language, and Motor Indices (dependent variables) post hoc moderation and meditation analyses, conducted
according to Baron and Kennys (1986) guidelines, were conducted to further investigate two bivariate relations.
2.3.4. Neonatal and socio-demographic correlates of Bayley-III neurodevelopmental outcome: multiple regression relations
Bayley-III correlates (independent variables) that emerged as signicant at p < .05 were entered into three individual
hierarchical linear regression analyses that, respectively, predicted Cognitive, Language, and Motor Indices (dependent
variables). Linear regression analyses generated multiple correlation coefcients (R2) and unstandardized multiple
regression coefcients (b) used to analyze adjusted relationships between Bayley Index Scores and socio-demographic and
neonatal risk factors.
Neonatal risk factors were entered into the rst step of the hierarchical regression model and socio-demographic
variables were entered into the second step of the model. Entering the most powerful, known risk factors (i.e., birth
data, neonatal morbidity, and therapy) in the rst step allows for greater statistical power (Cohen, Cohen, West, &
Aiken, 2003; Gargus et al., 2009). The second and last step in the hierarchical regression is statistically equivalent to a
simultaneous regression and provides information about which risk factors emerge as signicant predictors of
Bayley-III outcome when all neonatal/medical and socio-demographic variables are considered concurrently (Cohen
et al., 2003).
This study was approved by the Institutional Review Board at this large, Midwestern academic medical center.

3. Results
3.1. Descriptive statistics
Table 1 provides a detailed summary of descriptive statistics for infant birth data, socio-demographic data, and neonatal
morbidities and therapies. The cohort had a mean birth weight of 1107  298 g (2 pounds, 7.04 ounces  10.56 ounces) and
mean gestational age of 28.6  2.5 weeks. The racial breakdown of the cohort was 42% African-American black, 33% non-Hispanic
white, and 24% Hispanic white. The majority had public health insurance (64%). Severely abnormal head ultrasound ndings were
noted in 12% of participants. The presence of any abnormality on head ultrasound was noted in 34%. Although 53% of the cohort
had chronic lung disease, only 6% were dependent on oxygen at the time of discharge. Mean postmenstrual age at discharge from
the NICU was 38.9  3.3 weeks.
3.2. Bayley-III patterns of neurodevelopmental performance
Table 2 summarizes descriptive statistics for the three Bayley-III Index Scores and the ve Bayley-III Subscales
scores for this cohort. Within-subject ANOVA identied signicant mean differences within the three Index [F
(1.78) = 33.44, p < .001] and ve Subscale scores [F (3.30) = 30.24, p < .001]. The Cognitive Index was signicantly
higher than the Language [p < .001] and Motor Indices [p < .001]. Among the subscales, the Cognitive and Fine Motor
Subscales were signicantly higher than the other subscales and the Expressive Language and Gross Motor Subscales
were signicantly lower than the other subscales. Specically, the Cognitive Subscale was signicantly higher than
both language subscales [Receptive Language Subscale; p < .001; Expressive Language Subscale; p < .001] and the
Gross Motor Subscale [p < .001]. Similarly, the Fine Motor Subscale was signicantly higher than both language
subscales [Receptive Language Subscale; p < .05; Expressive Language Subscale; p < .001] and the Gross Motor
Subscale [p < .001]. The Receptive Language Subscale was signicantly higher than the Expressive Language Subscale
[p = .004] and the Gross Motor Subscale [p < .001].
Twenty-two (22%) of preterm infants had mildly delayed Language Index Scores and, consistently, 22% of preterm infants
had mildly delayed Motor Index Scores. Thirty-one percent (31%) of preterm infants had mildly delayed Expressive Language
Subscale scores and nearly half (47%) had mildly delayed Gross Motor Subscale scores. Signicantly delayed subscale scores
were found in 14% of the Expressive Language Subscale scores and 12% of the Gross Motor Subscale scores. Overall, the
Language Index was the lowest score in 53% of infants while the Motor Index was the lowest score in 39% of infants. The
Cognitive Index was the highest score for the majority (64%) of the infants.

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Table 1
Infant birth, socio-demographic and neonatal morbidity and therapy data.
Descriptive statistics N = 85
Infant birth data
Birth weight (g)
Gestational age (weeks)
Antenatal steroids
Caesarean section
Female gender
Small for gestational age
Multiple birth
Outborn
Socio-demographic data
Race/ethnicity
African-American Black
Non-Hispanic White
Hispanic
Public health insurance
Neonatal morbidity and therapies
Severely abnormal HUSa
Any abnormal HUS
Oxygen dependence at 36 weeks
Oxygen dependence at discharge
Postnatal dexamethasone use
Postnatal hydrocortisone use
Sepsis
NEC or intestinal perforation
Retinopathy of prematurity
Postmenstrual age at discharge (weeks)
a

M  SD [range]
1107  298 [5151775]
28.6  2.5 [23.934.7]
N (%)
68 (80)
61 (72)
43 (51)
16 (19)
26 (31)
13 (15)
36
28
20
54

(42)
(33)
(24)
(64)

10 (12)
29 (34)
45 (53)
5 (6)
2 (2)
17 (20)
10 (12)
10 (12)
10 (12)
38.9  3.3 [34.150.0]

Grades 34 IVH, PVL, ventricular dilatation.

3.3. Neonatal and socio-demographic correlates of Bayley-III neurodevelopmental outcome: bivariate relations
Bivariate analyses revealed that severely abnormal head ultrasound, public health insurance, oxygen dependence at
discharge, and older postmenstrual age at discharge were universally related to lower Cognitive, Language, and Motor Index
Scores on the Bayley-III (Table 3). Small for gestational age was related to lower Cognitive and Motor Indices. Race/ethnicity
was signicantly related to Language and Motor Indices.
Post hoc analysis for the effect of race/ethnicity revealed that infants of Hispanic white race/ethnicity had signicantly
lower Language [M = 82  15] and Motor Indices [M = 83  20] than African-American black [Language Index; 93  13, p = .008:
Motor Index; 97  16, p = .006] and non-Hispanic white infants [Language Index; 95  15, p = .002: Motor Index; 98  15,
p = .004]. Additional post hoc analyses were performed to determine if any other correlates of race/ethnicity signicantly
mediated, or explained, the relation between race/ethnicity and Language and Motor Index Scores. Race/ethnicity was
signicantly related to insurance status [x2 (3) = 21.81, w (82) = .51, p < .001]. Hispanic white infants had the greatest proportion
of families receiving public insurance (95%, compared with 32.1% and 72.2%, respectively, among non-Hispanic white and AfricanAmerican black infants); however, insurance did not signicantly mediate the effect of race/ethnicity on Language or Motor Index
(Baron & Kenny, 1986).
Table 2
Patterns of performance on Bayley-III.

Cognitive Index*
Language Index
Motor Index

Cognitive Subscale
Receptive Language Subscale
Expressive Language Subscale
Fine Motor Subscale*
Gross Motor Subscale
* p < .001.

Mean Index Score

Subnormal Index Scores

Mean  SD

N (%) < 85

N (%) < 70

102  15
91  15
94  17

5 (6)
19 (22)
19 (22)

4 (5)
6 (7)
6 (7)

Mean Subscale Scores

Subnormal Subscale Scores

Mean  SD

N (%) < 7

N (%) < 4

10.5  3
9  2.5
7.9  3.3
10.1  3.2
7.4  3.4

5
9
26
10
40

4
3
12
5
10

(6)
(11)
(31)
(12)
(47)

(5)
(4)
(14)
(6)
(12)

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1953

Table 3
Bivariate relations between neonatal and socio-demographic risk factors and Bayley-III Index Scores.
Neonatal and socio-demographic risk factors

Cognitive Index
r or F

Gestational age
Small for gestational age
Multiple birth
Public health insurance
Race/ethnicity
Severely abnormal HUS
Oxygen at discharge
Postmenstrual age at discharge
Dexamethasone
a
b

.33
.24
.09
.23
.21a
.32
.34
.24
.20

Language Index

Motor Index

p-Value

r or F

p-Value

r or F

p-Value

.002b
.03
.44
.03
.053
.003b
002b
.03
.06

.17
.12
.22
.26
5.81a
.33
.36
.22
.26

.12
.26
.046
.02
.007b
.002b
.001b
.047
.02

.20
.25
.20
.24
5.27a
.22
.26
.24
.19

.06
.02
.06
.02
.004
.04
.02
.02
.09

ANOVA statistics.
Remains signicant after multistep Bonferroni correction.

The nding that older gestational age at birth was related to lower Cognitive Index Scores was investigated further. The
presence of severely abnormal head ultrasound moderates (interaction term = 8.40, p = .001) the effect of gestational age on
Cognitive Index, such that, when a severely abnormal head ultrasound was present, the negative relation between
gestational age and Cognitive Index was exacerbated, and when no severely abnormal head ultrasound was present the
negative relation between gestational age and Cognitive Index was attenuated.
After multistage Bonferroni adjustments were calculated, continued oxygen dependence at discharge and severely
abnormal head ultrasound remained signicant correlates of the Language and Motor Indices, gestational age remained a
signicant correlate of the Cognitive Index, and race/ethnicity remained a signicant correlate of the Language Index.
3.4. Neonatal and socio-demographic correlates of Bayley-III neurodevelopmental outcome: multiple regression relations
Three separate multiple regressions revealed adjusted relations between socio-demographic data and neonatal risk
variables and Cognitive, Language and Motor Indices. In order to minimize experiment-wise error, multiple regressions
between risk variables and the ve subscale scores were not calculated. Table 4 summarizes the second and nal step of the
multiple hierarchical linear regression models.
Power analyses determined that assuming a medium effect size (R2 = 15, f2 = 17), multiple regression analyses calculated
with ve independent variables would be adequately powered (1 b = .80). Independent variables were chosen for inclusion
in models if signicantly related at p < .05 to Cognitive, Language or Motor Index in bivariate relations. Five or fewer
independent variables met these criteria for Cognitive and Motor Indices. However, seven variables of theoretical interest
were signicantly related to the Language Index in bivariate correlations. The ve with small-medium and medium effect
sizes (r > .26) were chosen for entry into the regression equation (Cohen et al., 2003). Postmenstrual age at discharge and
small for gestational age status were not entered as predictors in a multiple regression due to a risk for multicollinearity
(Cohen et al., 2003; Leviton, Kuban, Pagano, Allred, & Van Marter, 1993).
The overall models of all three hierarchical multiple regressions were signicant [Cognitive Index, F (4, 80) = 10.30,
p < .001, R2 = .34; Language Index, F (5, 78) = 7.62, p < .001, R2 = .33; Motor Index, F (5, 78) = 4.65, p = .001, R2 = .23]. Neonatal
risk factors accounted for almost one-third (32%) of the variance in the Cognitive Index [Step 1 F (3, 81) = 12.44, p < .001;
R2 = .32]. Insurance status did not signicantly relate to, or meaningfully contribute to, the prediction model of the Cognitive
Index. In the nal step, the Cognitive Index was signicantly predicted by three factors: gestational age at birth, severely
abnormal head ultrasound, and oxygen dependence at discharge.
Table 4
Multivariate relations between neonatal and socio-demographic risk factors and Bayley-III Scores.
Neonatal and socio-demographic risk factors

Cognitive Index
(95% CI)

B
Gestational age
Small for gestational age
Severely abnormal HUS
Dexamethasone
Oxygen at discharge
Race/ethnicity
Insurance

1.97

3.07,

Motor Index

(95% CI)

(95% CI)

.87**

15.52

24.07,

6.97**

17.28

29.18,

5.39*

5.03

Language Index

10.85, .80

14.49
9.80
15.29
5.03
3.73

23.10, 5.88**
29.09, 9.50
27.57, 3.01*
9.32, .74*
12.26, 4.80

8.75
13.84
8.39
5.43
3.49

18.37, .87t
24.66, 3.03*
24.58, 7.80
10.80, .07*
11.88, 4.90

Empty cells or absence of data indicates that the predictor was not entered into the corresponding hierarchical regression model given pre-requisite criteria
noted in Section 3.4.
t
p < .07.
* p < .05.
** p < .01.

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M.M. Greene et al. / Research in Developmental Disabilities 33 (2012) 19481956

Neonatal risk factors accounted for almost one-fourth (23%) of the variance in the Language Index [Step 1 F (3, 80) = 8.03,
p < .001; R2 = 23]. After adjusting for relevant neonatal risk factors, the inclusion of race/ethnicity and insurance status
explained an additional 10% of the variance of the Language Index [Step 2 F (2, 78) = 5.61, p = .005; DR2 = .10]; race/ethnicity,
but not insurance, remained a signicant individual predictor of the Language Index. In the nal step, Language Index was
signicantly predicted by severely abnormal head ultrasound, oxygen dependence at discharge and race/ethnicity.
Neonatal risk factors accounted for 15% of the variance in the Motor Index [Model 1 F (3, 80) = 4.61, p = .005; R2 = .15].
Consistent with the effect of socio-demographic variables on the Language Index, the inclusion of race/ethnicity and
insurance status explained an additional 8% of the variance of Motor Index after controlling neonatal risk factors [Step 2 F (2,
78) = 4.15, p = .019; DR2 = .08]. Again, race/ethnicity, but not insurance, remained a signicant individual predictor of the
Motor Index. In the nal step of the analysis, Motor Index was signicantly predicted by race/ethnicity and severely
abnormal head ultrasound.
4. Discussion
The present study examined patterns of performance and correlates of neurodevelopmental outcome as measured by the
Bayley-III in preterm infants at 812 months corrected age. To date, no investigation has been published that looks at
patterns and correlates of performance of the Bayley-III in a preterm infant population within the rst year of life.
Understanding neurodevelopmental patterns as quantied by the Bayley-III is necessary since previous research has
revealed that preterm infants demonstrate cognitive (Sun et al., 2009), language (Stolt et al., 2009), and motor delays
(Evensen et al., 2009) at 812 months corrected age which contribute to altered neurodevelopmental trajectories and
adolescent outcome (Asrbouse-Moen, Weisglas-Kuperus, van Goudeover, & Oosterlaan, 2009; Kieviet, Piek, AarnoudseMoens, & Oosterlaan, 2009; Luu et al., 2009; Stolt et al., 2009). Sensitive identication of cognitive, language and motor delay
is required for accurate enrollment in early intervention in addition to on-going monitoring and re-evaluation of the
effectiveness of therapeutic services.
Among the present cohort of preterm infants, language, and motor development, specically expressive language and
gross motor development, are signicantly slower than cognitive development in preterm infants in the rst year of life.
Language and motor skills score near the lower bounds of the average range of performance and are suppressed relative to
cognitive abilities, which score in the average range, very near the 50th percentile. Expressive language and gross motor
skills fell in the low average range of performance, and were suppressed relative to other areas of functioning, including
receptive language and ne motor development. Given that the subscales that comprise the larger Language Index and
Motor Index were signicantly discrepant, follow-up of preterm infants may benet from placing stronger emphasis on
Subscales than Indexes, particularly when referring infants for services.
Rates of delay as quantied by the present study are highly consistent with a previous investigation of Bayley-III patterns
of performance in ELBW infants in the second year of life (Anderson et al., 2010). Anderson et al. (2010) revealed that almost
one-quarter (21%) of ELBW infants had some degree of language delay (Index Score < 85), while 78% had moderate to
severe language and motor delays, respectively (Index Score < 70; Anderson et al., 2010). Similarly, almost one-quarter (21%)
of our preterm cohort had mildly delayed language and motor skills (Index Score < 85), while 7% had signicantly delayed
language and motor skills (Index Score < 70). In the present study, this pattern was further explained by analyses of the
subscales, which indicated that 31% of infants had mildly delayed expressive language and 47% had mildly delayed gross
motor skills. For 53% of infants, language development was their weakest domain; for another 39%, motor skills were the
weakest area of development.
Consistent with previous research on known neonatal and socio-demographic risk, bivariate relations revealed that
insurance status, severely abnormal head ultrasound, oxygen dependence at discharge, and corrected age at discharge
universally predicted lower Cognitive, Language and Motor Index Scores (Wilson-Costello et al., 2005). Older gestational age
related to lower Cognitive Index Score, small for gestational age related to lower Cognitive and Mental Indices, and Hispanic
white race/ethnicity was related to lower Language and Motor Index Scores. The relation between older gestational age and
poorer cognitive performance in this study was moderated by severely abnormal head ultrasound.
When these neonatal and socio-demographic risk variables were considered in multiple regression analyses, severely
abnormal head ultrasound, oxygen dependence at discharge and race/ethnicity were consistently related to
neurodevelopmental outcome. Severely abnormal head ultrasound signicantly predicted lower Cognitive, Language,
and Motor Index Scores. Oxygen dependence at discharge signicantly predicted lower Cognitive and Language Index Scores,
but not Motor Index Scores. Hispanic white race/ethnicity predicted lower Language and Motor Index Scores after adjusting
for severely abnormal head ultrasound, oxygen dependence and insurance status. While the present study maximized its
cross-sectional and retrospective data through employment of a method of hierarchical entry of birth, neonatal risk factors,
and maternal socio-demographic variables, that was designed to model the temporal sequence of risk factors as they are
experienced by preterm infants, future longitudinal investigations could greatly improve our understanding (Laptook,
OShea, Shankaran, Bhaskar, & NICHD Neonatal Network, 2005; Leviton et al., 1993). Longitudinal research that monitors
these adjusted risk factors to determine if these same variables remain signicant over longer time periods would allow for
more targeted early intervention, which may ultimately help to improve the effectiveness of intervention.
The relation between Hispanic white race/ethnicity and poorer language and motor performance was not mediated, or
explained by, insurance status, which can be considered a proxy variable for socioeconomic status. The present studys

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1955

nding is remarkably consistent with results from one of the few extant investigations of socio-demographic correlates of
developmental performance among preterm infants as measured by the Bayley-III (Duncan et al., 2012). Duncan et al. (2012)
found that among at two year of age, after adjusting for relevant medical and socio-demographic covariates Hispanic white
race/ethnicity infants had language scores that were signicantly lower than their white or African-American/black peers
(Duncan et al., 2012). It is possible that a measure of parental education or a more sophisticated measure of socioeconomic
status that accounts for family income and parental education would have provided more insight into these relations.
Previous investigations of very preterm (born at <32 weeks gestational age) or of very low birth weight (VLBW; birth weight
<1500 g or birth weight <3 pounds, 5 ounces) infants and children have revealed that maternal education predicts a
favorable cognitive and language outcome (Luu et al., 2009). This relation appears to be particularly powerful for language
outcome; maternal education along with race/ethnicity account for more variance in receptive language than history of
severe brain injury (Luu et al., 2009). An alternate possibility is that the relations may have been due, in part, to Spanish as a
primary language/test administration using an interpreter, or, parental bilingualism, which has been associated with slower
cognitive and ne motor development in VLBW infants at 6, 12, and 22 months corrected age (Walch, Chaudhary, Herold, &
Obladen, 2009). It is important to note that the present study did not systematically quantify parental bilingualism. Future
investigations of the impact of socio-demographic variables on neurodevelopmental outcome in preterm infants should
continue to investigate the role of race/ethnicity and would benet from inclusion of measures of parental education and
bilingualism.
4.1. Limitations
Limitations to the present study include a relatively small number of participants and proposed psychometric issues of
the Bayley-III in the preterm infant population despite strong general psychometric properties (Bayley, 2006b). Power
analyses indicated that the present study was able to detect medium effect sizes; however, the study may have failed to
detect more subtle, small effects. Future studies involving larger cohorts of preterm infants in the rst year of life will be
important for replication and extension of these results.
Thus far, studies that have administered the Bayley-III to VLBW and ELBW infants in the second year of life (followed at
1224 months of age) suggest that Bayley-III scores are higher than BSID-II scores and underidentify neurodevelopmental
delay (Anderson et al., 2010; Daily, Slaughter, Carter, & Carter, 2010; Peralta-Carcelen, Phillips, & Oakes, 2010). Bayley-III
scores for preterm infants have been shown to be almost three-fths of a standard deviation (e.g., nine points) higher than
BSID-II scores for preterm infants and produce rates of delay substantially below rates previously reported in the literature
with the BSID-II (Anderson et al., 2010; Daily et al., 2010; Peralta-Cercelen et al., 2010). These studies call for additional
research on the application of the Bayley-III with alternate cohorts and age bands (Anderson et al., 2010) and underscore the
importance of the present study, which provides information about the Bayley-III among preterm infants under 12 months
of age.
4.2. Conclusion
Documentation of patterns of delay and neurodevelopmental performance during the critical rst postnatal year allows
clinicians and researchers to evaluate the early impact of perinatal risk factors on neurodevelopment, and prescribe or
evaluate appropriate interventions that could be preventative in nature. The present study provides several important
considerations and recommendations for clinicians using the Bayley-III. The newly created Language Index appears to be an
important improvement to the revised Bayley Scales as this domain appears to be commonly delayed. Additionally,
discrepancies between Receptive and Expressive Language and Gross and Fine Motor Subscale scores suggest that when the
Bayley-III is used for identifying delays and treatment planning, subscale scores and not overall indexes, may be used more
effectively to qualify infants for services. Furthermore, presence of severely abnormal head ultrasound, oxygen dependence
at discharge, and Hispanic white race/ethnicity appear to be consistent risk factors for development. Follow-up
investigations that analyze the slower development of Hispanic white infants and elucidate the role of maternal education
and parental bilingualism would improve targeted intervention. The present study had small sample size and did not contain
a comparison group of full-term controls and, as such, is somewhat limited in generalizability. Further, a review of current
published studies using the Bayley-III indicates a need for additional studies of this measure among at-risk populations.
Nevertheless, the Bayley Scales have a long history as an important neurodevelopmental assessment tool used to monitor
outcome and guide therapy, and the Bayley-III provides additional subscale scores and indexes that can be very useful both
for understanding neurodevelopment and for planning appropriate interventions.
Conicts of interest
The authors declare no conicts of interest.
Funding
None.

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M.M. Greene et al. / Research in Developmental Disabilities 33 (2012) 19481956

Acknowledgments
The authors wish to thank the infants and families for their follow-up and participation, and the Sections of Pediatrics and
Behavioral Sciences for their support.
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