How do children develop language capabilities? How are children able to comprehend and also express themselves using language? How would language deve

Citation: Kipping, S.M.; Kiess, W.;

Ludwig, J.; Meigen, C.; Poulain, T. Are

the Results of the Bayley Scales of

Infant and Toddler Development

(Third Edition) Predictive for Later

Motor Skills and School Performance?

Children 2024, 11, 1486. https://

doi.org/10.3390/children11121486

Academic Editor: Matteo Alessio

Chiappedi

Received: 11 November 2024

Revised: 28 November 2024

Accepted: 4 December 2024

Published: 6 December 2024

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Article

Are the Results of the Bayley Scales of Infant and Toddler Development (Third Edition) Predictive for Later Motor Skills and School Performance? Sophia Maria Kipping 1,* , Wieland Kiess 1,2, Juliane Ludwig 1, Christof Meigen 1 and Tanja Poulain 1,2

1 LIFE Leipzig Research Center for Civilization Diseases, Leipzig University, Philipp-Rosenthal-Strasse 27, 04103 Leipzig, Germany; [email protected] (W.K.); [email protected] (J.L.); [email protected] (C.M.); [email protected] (T.P.)

2 Department of Women and Children’s Health, Hospital for Children and Adolescents and Center for Pediatric Research (CPL), Leipzig University, Liebigstrasse 20a, 04103 Leipzig, Germany

* Correspondence: [email protected]

Abstract: Background/Objectives: The first year of life represents a critical developmental stage in which the foundations for motor, cognitive, language, and social–emotional development are set. During this time, development occurs rapidly, making early detection of developmental disorders essential for timely intervention. The Bayley Scales of Infant and Toddler Development—Third Edition (Bayley-III) is an effective tool for assessing language, motor, and cognitive development in children aged 1 to 42 months. This study aimed to investigate whether or not the results of the Bayley-III in healthy one-year-old children are predictive for their later motor skills and school performance. Methods: This study had a prospective, longitudinal design. The study participants were healthy children having performed Bayley-III at 1 year with information on motor performance (n = 170) at age 5–10 and school grades (n = 69) at age 7–10. Linear or logistic regression analysis was performed for data analysis. Results: Below-average performance in the cognitive part of the Bayley-III at age 1 was significantly associated with poorer performance in balancing backwards (b = −0.45), sideways jumping (b = −0.42), standing long jump (b = −0.54), and forward bends (b = −0.59) at age 5–10 (all p < 0.05). Performance in other parts of the Bayley-III was not significantly associated with later motor skills. Furthermore, we did not observe any significant associations between performance in the Bayley-III and grades in school. The associations were not moderated by age, sex, or socioeconomic status (all p > 0.05). Conclusions: The cognitive scale of the Bayley-III may be used as a predictive tool for later motor skills. Regarding school performance, the Bayley-III cannot be considered predictive.

Keywords: Bayley-III; predictive validity; motor skills; cognitive skills

1. Introduction

Early childhood represents a critical developmental stage in which the foundations for motor, cognitive, language, and social–emotional development are set [1]. By the age of one, children begin to develop basic cognitive skills, such as grasping object permanence and recognizing familiar people and objects [2]. They also start to understand cause and effect [2]. In language development, they can follow simple commands, say their first words, and use gestures to communicate [2]. Motor development at one year of age includes milestones such as crawling, standing with support, and taking their first steps [2]. Children also begin to refine fine motor skills, such as the pincer grasp [2].

During the first years of life, developmental and learning processes progress at their fastest rates [1,3]. At the same time, delays observed at this early stage might be a sign of developmental disorders that can affect further development [1,3]. Therefore, early

Children 2024, 11, 1486. https://doi.org/10.3390/children11121486 https://www.mdpi.com/journal/children

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detection of developmental disorders is essential to provide affected children with early intervention, leading to the possibility of improved development and functioning [4,5]. To identify these children, the Bayley Scales of Infant and Toddler Development—Third Edition (Bayley-III) can be used [6]. This is a pediatric developmental assessment tool that evaluates the language (expressive and receptive), motor (fine and gross motor skills), and cognitive development of children aged 1 to 42 months [6,7].

There is currently only a limited number of studies on the predictive validity of Bayley- III test results for later motor and cognitive abilities, and the findings from these studies are partly contradictory. Moreover, most studies focus on premature infants. Therefore, further research is needed to assess the predictive validity of Bayley-III in healthy, full-term newborns. This allows for a comprehensive evaluation of early childhood development, contributing to an improved understanding of both typical and atypical developmental trajectories [8].

Klein-Radukic and Zmyj [9] found positive predictive relationships between cognitive performance in the Bayley-III (at first, second and third year of life) and later intelligence quotient (IQ) (at 4 years) in children born at term. Bode et al. [10] examined the predictive validity of the Bayley-III cognitive and language scores in 2-year-old children (former pre- mature infants and a socioeconomically matched control group) for the IQ of these children at preschool age (4 years) and found positive associations. In contrast, Spencer-Smith et al. [11] assessed the Bayley-III cognition and language scores in 2-year-old premature children and examined their predictive power for future developmental disorders (at the age of 4). They rated them as poor predictors. A study by Månsson et al. [8] assessed the relationship between Bayley-III test results (cognitive, language, and motor scales) at the age of 2.5 years and IQ at school age (6.5 years) in full-term newborns with high socioeconomic status (SES). In this study, the cognitive score of Bayley-III was the best predictor for IQ score variability, but at the individual level, Bayley-III was considered an insufficient predictor for later IQ at school age [8]. In a systemic review by Griffiths et al. [12], the Bayley-III demonstrated predictive validity for later gross motor performance, with the highest predictive validity at the age of 2 years. Burakevych et al. [13] rated the motor scores of Bayley-III as poor predictors for later motor skills (compared at 2 and 4.5 years). Similarly, Spittle et al. [14] demonstrated that the motor scores of Bayley-III as- sessed at 2 years of age underestimated later motor impairments (at 4 years) in prematurely born children.

The present study aimed to determine whether or not the Bayley-III results in one- year-old children born at term predict their later motor skills and school performance. Additionally, we explored the potential moderating effect of sociodemographic factors (age, sex, and SES) on these associations. We hypothesized that we would find a significant positive association between the Bayley-III test results and later school performance, as well as between the Bayley-III test results and subsequent motor performance. These relationships were expected to be more pronounced in vulnerable children (those with lower SES) compared to children with higher SES. We had no specific hypothesis regarding the moderating effect of sex.

2. Materials and Methods 2.1. Participants

Data were taken from the LIFE Child study, which has been conducted since 2011 as part of the Leipzig Research Center for Civilization diseases (LIFE) at Leipzig Univer- sity [15]. The LIFE Child study is a prospective, longitudinal cohort study examining child development from the prenatal period to early adulthood [14]. The study participants do not have any chronic, chromosomal, or syndromic conditions [16]. Most of them are from Leipzig or the surrounding area [16]. The study program includes clinical examinations, questionnaires, tests, and the collection of various biological materials at different time points [16].

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The LIFE Child study was designed in accordance with the declaration of Helsinki [17] and the study program was approved by the Ethics Committee of the University of Leipzig (Reg. No. 477/19-ek) [14]. The parents sign a fully informed and written consent at each study visit [15].

For the present study, all children who had completed the Bayley-III test at the age of 1 year (t1) and, additionally, participated in a motor skills test at age 5 to 10 years (sample 1) and/or provided information on school grades at age 7 to 10 years (sample 2) (t2) were eligible for analysis. In cases where children had participated in a motor skills test several times or had provided information on school grades at several time points, only the last visit was taken into account. Subjects with missing information on SES or week of pregnancy at birth were not considered. Furthermore, children born preterm (<37th week of pregnancy) or having a heart disease were excluded. The individual steps of data cleansing for both samples can be seen in the following flowchart (Figure 1).

Children 2024, 11, x FOR PEER REVIEW 3 of 12

questionnaires, tests, and the collection of various biological materials at different time points [16].

The LIFE Child study was designed in accordance with the declaration of Helsinki [17] and the study program was approved by the Ethics Committee of the University of Leipzig (Reg. No. 477/19-ek) [14]. The parents sign a fully informed and written consent at each study visit [15].

For the present study, all children who had completed the Bayley-III test at the age of 1 year (t1) and, additionally, participated in a motor skills test at age 5 to 10 years (sam- ple 1) and/or provided information on school grades at age 7 to 10 years (sample 2) (t2) were eligible for analysis. In cases where children had participated in a motor skills test several times or had provided information on school grades at several time points, only the last visit was taken into account. Subjects with missing information on SES or week of pregnancy at birth were not considered. Furthermore, children born preterm (<37th week of pregnancy) or having a heart disease were excluded. The individual steps of data cleansing for both samples can be seen in the following flowchart (Figure 1).

Figure 1. Flowchart of data cleansing for sample 1 (left) and sample 2 (right).

After data cleaning, sample 1 comprised 170 participants (55% male, mean age at t1 = 1.0, sd = 0.11; mean age at t2 = 6.4, sd = 0.64) and sample 2 included 69 participants (59% male, mean age at t1 = 1.0, sd = 0.13; mean age at t2 = 8.9 years, sd = 0.72).

2.2. Instruments 2.2.1. Bayley-III: Bayley Scales of Infant and Toddler Development (Third Edition)

The Bayley-III is a pediatric developmental testing procedure used for the early de- tection of developmental delays [18]. It is the internationally best established test for as- sessing the development of young children [19].

In the context of the LIFE Child study, the third edition of the test (Bayley-III) was used for data collection. It was released in 2006 in the United States. Norms for the German

Figure 1. Flowchart of data cleansing for sample 1 (left) and sample 2 (right).

After data cleaning, sample 1 comprised 170 participants (55% male, mean age at t1 = 1.0, sd = 0.11; mean age at t2 = 6.4, sd = 0.64) and sample 2 included 69 participants (59% male, mean age at t1 = 1.0, sd = 0.13; mean age at t2 = 8.9 years, sd = 0.72).

2.2. Instruments 2.2.1. Bayley-III: Bayley Scales of Infant and Toddler Development (Third Edition)

The Bayley-III is a pediatric developmental testing procedure used for the early detection of developmental delays [18]. It is the internationally best established test for assessing the development of young children [19].

In the context of the LIFE Child study, the third edition of the test (Bayley-III) was used for data collection. It was released in 2006 in the United States. Norms for the German version (released in 2014) were created in 2011 with the help of the LIFE Child study [16]. The German version of the Bayley-III was shown to be a valid and reliable instrument [2]. It includes scales for cognitive, language (expressive and receptive), and motor (fine and gross

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motor) development for children aged 1 to 42 months [7,18]. The scores are transferred to age-specific standard values (mean = 100, sd = 15). Based on these standard values, performance values in the different domains of the Bayley-III are categorized as either ‘normal to above average’ (cutoff > 85) or ‘below average’ (cutoff ≤ 85). Thus, ‘normal to above average’ was chosen as the reference level. Dichotomizing the Bayley-III results simplifies clinical interpretation by categorizing them into clear groups, aiding in clinical decision-making and interventions.

2.2.2. Motor Skills Tests

As part of the LIFE Child study, the motor skills of the children are measured using a standardized motor skills test [20,21]. The test consists of five parts: balancing backwards, sideways jumping, standing long jump, pushups, and forward bends, which measure children’s coordination, strength, and mobility [22].

In the balancing task, participants walk backward on beams with widths of 6 cm, 4.5 cm, and 3 cm. Each beam includes one test trial forward and one backward, followed by two scoring attempts. A maximum of 8 steps can be scored per attempt, and the trial ends if the participant loses balance or falls off the beam. The sideways jumping task involves the participant jumping with both feet across the centerline of the test area and back as many times as possible within 15 s. Two attempts are made, with a 1 min break between them. The long jump involves the participant jumping from a standing position with slightly bent knees, using arm swing for momentum. Both takeoff and landing must be with both feet. The test is performed twice. The pushup task begins with the participant lying on their stomach with their hands resting on their buttocks. After the start command, they push up to a standard position and return to the starting position. The participant has 40 s to complete as many pushups as possible. In the forward bend task, the participant stands barefoot on a wooden bench with a vertical scale, bending forward with straight knees and reaching as far as possible with outstretched arms. The maximum reach is held for two seconds, and the value is recorded, followed by a brief pause before repeating [22].

The performance in each part was transformed to standard deviation scores (SDSs) (mean = 0, sd = 1) based on sex- and age-specific percentiles assessed in a large repre- sentative German sample [23]. Results of Shapiro–Wilks tests showed that all SDSs (with the exception of sideways jumping) were normally distributed (p > 0.05). For sideways jumping, a histogram showed a distribution that was very close to a normal distribution.

2.2.3. School Performance

In the LIFE Child study, school performance is measured by grades in the subjects of Mathematics, German, and Physical Education [22]. The information is provided by the parents or self-reported by the children [22]. In Germany, grades vary between 1 (best) and 6 (worst). In the present data set, no participant reported grades 5 or 6. For the analyses, grades were dichotomized into ‘high performance’ (grade 1) and ‘low performance’ (grades 2, 3, and 4) to ensure that the group sizes would be comparable. Even if grade 2 does not indicate poor performance, the term ‘low performance’ was used in this context for better readability.

2.2.4. Socioeconomic Status (SES)

The socioeconomic status was determined as a multidimensional index (SES index) combining information on parental education, profession, and net equivalent income [24]. SES scores ranging from 3 to 21 were categorized as low, medium, and high, based on cut-offs defined after examining a representative German sample [24]. Due to the low percentage of children from families with a low SES (3% in sample 1 and 2), we combined the ‘low’ and ‘medium’ groups to ensure comparable group sizes; i.e., the SES was dichotomized into ‘low/medium’ (n = 97 (57%) in sample 1 and 37 (54%) in sample 2) and ‘high’ (n = 73 (43%) in sample 1 and 32 (46%) in sample 2).

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2.3. Statistical Analysis

Data were described in means ± standard deviations (for continuous variables) or numbers/percentages (for categorical variables).

Linear regression analysis was applied to assess associations between cognitive, lan- guage, and motor skills in early childhood and motor skills (sample 1) in later childhood. For analyzing the associations between cognitive, language, and motor skills in early child- hood and school performance (sample 2) in later childhood, logistic regression analysis was used.

Age in later childhood (at time of the motor skills test or assessment of school perfor- mance), sex (male/female), and family SES in early childhood were included as covariates. We also checked whether the associations between early development and later motor skills and school performance were moderated by these covariates. Strengths of associations were represented by non-standardized regression coefficients (sample 1) or odds ratios (sample 2). Interactions with the covariates (moderator analysis) were only presented if they were statistically significant (p < 0.05). For the statistical analysis, the program R was used (version R 4.2.2.) [25].

3. Results 3.1. Performance in Bayley-III, Motor Skills Test, and School Grades

Table 1 summarizes the descriptive statistics for categorical and numerical variables in both study samples. In sample 1, 150, 137, and 137 children had completed the cognitive, language, and motor part of the Bayley-III, respectively. Of these children, 78% (n = 117), 69% (n = 95), and 78% (n = 107) showed ‘normal to above average’ performance in the cognitive, language, or motor part, respectively. Consequently, 22% (n = 33), 31% (n = 42), and 22% (n = 30) showed ‘below average’ performance in the respective parts. The mean percentile rank ± sd for performance in the Bayley-III were 97.13 ± 14.81 for the cognitive part, 92.3 ± 17.42 for the language part, and 96.84 ± 14.03 for the motor part. The average SDSs for performance in the motor skills test were 0.05 ± 1.1 for balancing backwards, −0.35 ± 1.0 for sideways jumping, 0.03 ± 1.01 for standing long jump, −0.01 ± 1.04 for pushups, and −0.15 ± 1.22 for forward bends.

Table 1. Descriptive statistics of the study samples.

Sample 1 (n = 170) Sample 2 (n = 69)

Sociodemographic characteristics

Sex: Female n (%) 77 (45%) 28 (41%)

Sex: Male n (%) 93 (55%) 41 (59%)

SES: Low/medium n (%) 97 (57%) 37 (54%)

SES: High n (%) 73 (43%) 32 (46%)

Age at time t1 Mean (sd) 1.0 (0.11) 1.0 (0.13)

Age at time t2 Mean (sd) 6.4 (0.64) 8.9 (0.72)

Bayley-III

Cognition: Normal/above average n (%) 117 (78%) 52 (83%)

Cognition: Below average n (%) 33 (22%) 11 (17%)

Language: Normal/above average n (%) 95 (69%) 33 (60%)

Language: Below average n (%) 42 (31%) 22 (40%)

Motor: Normal/above average n (%) 107 (78%) 41 (82%)

Motor: Below average n (%) 30 (22%) 9 (18%)

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Table 1. Cont.

Sample 1 (n = 170) Sample 2 (n = 69)

Motor skills

Balancing backwards Mean (sd) 0.05 (1.1)

Sideways jumping Mean (sd) −0.35 (1.0)

Standing long jump Mean (sd) 0.03 (1.01)

Pushups Mean (sd) −0.01 (1.04)

Forward bends Mean (sd) −0.15 (1.22)

School grades

Math: High performance n (%) 28 (41%)

Math: Low performance n (%) 41 (59%)

German: High performance n (%) 20 (29%)

German: Low performance n (%) 49 (71%)

Physical Education: High performance n (%) 15 (22%)

Physical Education: Low performance n (%) 54 (78%) Abbreviations: Bayley-III, Bayley Scales of Infant and Toddler Development 3rd edition; SD, standard deviation; SES, socioeconomic status; t1, time of Bayley-III assessment; t2, time of performed motor skills test (sample1) or time of information on school grades provided (sample 2).

In sample 2, 63, 55, and 50 children had completed the cognitive, language, and motor part of the Bayley-III, respectively. Of these children, 83% (n = 52), 60% (n = 33), and 82% (n = 41) showed ‘normal to above average’ performance in the cognitive, language, or motor part, respectively. Consequently, 17% (n = 11), 40% (n = 22), and 18% (n = 9) showed ‘below average’ performance in the respective parts. The mean percentile rank ± sd for performance in the Bayley-III was 98.81 ± 13.25 for the cognitive part, 91 ± 17.01 for the language part, and 97.5 ± 14.59 for the motor part. Regarding school performance, 41% (n = 28) had a ‘high’ and 59% (n = 41) had a ‘low’ grade in Mathematics. For German, the distribution was 29% (n = 20) ‘high’ and 71% (n = 49) ‘low’. In Physical Education, 22% (n = 15) showed ‘high’ and 78% (n = 54) ‘low’ performance. The average SDSs for the school grades were 1.68 ± 0.65 for Mathematics, 1.82 ± 0.62 for German, and 1.56 ± 0.5 for Physical Education.

3.2. Associations Between Bayley-III Results and Later Motor Skills

A below-average performance in the cognitive part of the Bayley-III was significantly associated with poorer performance in balancing backwards (b = −0.45, p = 0.045), sideways jumping (b = −0.42, p = 0.033), standing long jump (b = −0.54, p = 0.010), and forward bends (b = −0.59, p = 0.012). In more detail, the motor skill performance of children who showed a below-average performance in the cognitive part of the Bayley-III at the age of one year was about half a standard deviation lower than the motor performance of children who showed an average or above-average performance. These associations are also illustrated in Figure 2. Performance in the other parts of the Bayley-III were not significantly associated with later motor skills (see Table 2). The moderator analysis showed that the associations were not significantly moderated by age, sex, or SES (all p > 0.05).

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Figure 2. Estimated mean performance (+95% confidence interval) in the different parts of the motor skills test at age 5–10 years in children who showed normal to above average or below average performance in the cognitive part of the Bayley-III at age 1 year. * p ≤ 0.05.

Table 2. Associations (non-standardized regression coefficient + 95% confidence interval) between Bayley-III results and motor skills.

Dependent Variable: Motor Skills Independent Variable:

Below-Average Performance in the Respective Part of the Bayley-III

Balancing Backwards

Sideways Jumping

Standing Long Jump Pushups

Forward Bends

Cognitive part b −0.45 −0.42 −0.54 −0.21 −0.59

95% CI (−0.9; −0.01) (−0.81; −0.04) (−0.95; −0.13) (−0.71; 0.28) (−1.05; −0.14) p 0.045 0.033 0.010 0.399 0.012

Language part b 0.04 0.13 0.13 −0.20 0.12

95% CI (−0.37; 0.45) (−0.23; 0.48) (−0.29; 0.55) (−0.66; 0.26) (−0.37; 0.61) p p = 0.860 p = 0.488 p = 0.527 p = 0.388 p = 0.624

Motor part b −0.38 −0.05 −0.12 −0.28 −0.05

95% CI (−0.83; 0.08) (−0.46; 0.36) (−0.57; 0.33) (−0.79; 0.24) (−0.58; 0.47) p 0.104 0.810 0.592 0.294 0.837

Abbreviations: b, non-standardized regression coefficient; 95% CI, 95% confidence interval. All as- sociations were adjusted for age, sex, and SES.

3.3. Associations Between Bayley-III Results and Later School Grades With respect to school performance, we did not observe any significant associations

between performance in the Bayley-III scales at one year of age and grades in school at age 7–10 (see Table 3). The moderator analysis showed that the associations were not sig- nificantly moderated by age, sex, or SES (all p > 0.05).

Figure 2. Estimated mean performance (+95% confidence interval) in the different parts of the motor skills test at age 5–10 years in children who showed normal to above average or below average performance in the cognitive part of the Bayley-III at age 1 year. * p ≤ 0.05.

Table 2. Associations (non-standardized regression coefficient + 95% confidence interval) between Bayley-III results and motor skills.

Dependent Variable: Motor Skills Independent Variable:

Below-Average Performance in the Respective Part of the Bayley-III

Balancing Backwards

Sideways Jumping

Standing Long Jump Pushups Forward Bends

Cognitive part b −0.45 −0.42 −0.54 −0.21 −0.59

95% CI (−0.9; −0.01) (−0.81; −0.04) (−0.95; −0.13) (−0.71; 0.28) (−1.05; −0.14) p 0.045 0.033 0.010 0.399 0.012

Language part b 0.04 0.13 0.13 −0.20 0.12

95% CI (−0.37; 0.45) (−0.23; 0.48) (−0.29; 0.55) (−0.66; 0.26) (−0.37; 0.61) p p = 0.860 p = 0.488 p = 0.527 p = 0.388 p = 0.624

Motor part b −0.38 −0.05 −0.12 −0.28 −0.05

95% CI (−0.83; 0.08) (−0.46; 0.36) (−0.57; 0.33) (−0.79; 0.24) (−0.58; 0.47) p 0.104 0.810 0.592 0.294 0.837

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