Grant Support: Funding for this study was received from the US Department of Health and Human Services Administration on Children, Youth, and Families, Children's Bureau; the US Health Resources and Services Administration, Maternal and Child Health Bureau, Leadership Education in Neurodevelopmental Disabilities Program.

Children involved with the child welfare system have lower gross motor scores than population norms. The authors found several factors contribute to this finding; abuse/neglect, medical neglect, and parental substance abuse produced lower scores.

Results: GM scores, lower than population norms, were associated with growth parameters. Children in kinship care had significantly higher GM scores compared with children in foster care and those with in-home protective services when adjusted for differences in time in CW. Abuse/neglect, medical neglect, and parental substance abuse produced lower scores; referral for abandonment produced higher scores. Age was most strongly related to GM outcome, with multiple regression explaining 19% of GM variance.

Purpose: To determine whether young children involved with child welfare (CW) have gross motor (GM) delay; to examine relationships between GM skills and the influence of multiple factors on GM skills.

INTRODUCTION

Children who come to the attention of Child Protective Services (CPS) have experienced child abuse, neglect, or abandonment, and thus become involved with the child welfare (CW) system. Among this group of children, placement may be in out-of-home care, such as traditional foster care (FC) with a nonrelative caregiver, or in kinship care (KC) with a caregiver who is a relative, although much of the published literature about children in out-of-home care combines both groups within the category of “foster care” and may not distinguish between these 2 conditions. More than 423 000 children involved with CW in the United States live in out-of-home care.1 In addition, some children involved with CW continue to reside with their own parent(s) while the family receives “in-home” Child Protective Services (IHPS) and often are not included in studies pertaining to children in out-of-home care. This article will use the term CW to include children when all 3 conditions are combined (FC, KC, and in-home), and will specify FC or KC when possible.

Children involved with CW tend to have more developmental and health problems than age-matched peers, but the etiology of these problems is not well known. Depending on the study, between 35% and 92% of children involved with CW have medical problems2 – 5 and up to 61% have developmental delays,5 – 8 which have been documented in a variety of domains,3 , 4 , 8 – 12 including motor skills.4 , 8 , 11 , 12 The American Academy of Pediatrics acknowledges that the youngest children are at particularly high risk for developmental delay9 , 10 with 33% to 37% of children involved with CW younger than 5 years identified with developmental delays13 and up to 45% of those in FC found to be eligible for early intervention (EI) services under the Individuals with Disabilities Education Act.11 In comparison, estimates of developmental delay among children younger than 5 years in the general population are 10% to 16%.14

Few studies have examined motor development in young children involved with CW. Current estimates are that 24% to 49% of young children involved with CW have motor delay,4 , 8 , 11 , 12 compared with 16% in the general population,14 however, limited attention has been directed to this discrepancy. Whereas each of these 4 studies used different motor scales to assess motor delay, they all simply reported its incidence (2 report gross motor [GM],4 , 8 1 fine motor,8 and 2 report motor composites without distinguishing between fine or GM11 , 12). Of the 4 studies that report motor delay among children involved with CW, none examined factors correlated with motor deficits or explored why delay occurred at a higher rate. An understanding of such factors can help lead to early identification of motor deficits, which is important for young children to encourage prompt diagnostic work-ups and proper intervention and treatment.15 It can also provide timely support to families and may lead to prevention of academic and psychosocial problems associated with motor deficits.15 – 17

Delayed motor development among children involved with CW is a topic that warrants further investigation. This issue is more compelling because many children involved with CW do not receive adequate or timely health care,2 , 4 which is the gateway for most young children with delays to access EI and physical therapy services. In addition, current standards of care for children in FC call for comprehensive health and developmental assessments upon entering care, and at regular intervals thereafter.9 , 10 , 18 However, if these children are not accessing routine health care, it is unlikely that they are obtaining either physical therapy or EI services. A better understanding of factors that affect motor development in young children involved with CW can improve our efforts to identify and refer children for appropriate interventions to enhance their developmental outcomes.19 , 20

Young children involved with the CW system experience a variety of adverse risk factors that may affect their motor development. Maltreatment involving physical abuse can result in bone fractures and delayed or deferred medical care, with significant sequelae if the growth plates are damaged. Head trauma from blows to the head or shaken impact syndrome may result in a range of motor deficits from poor coordination to conditions like cerebral palsy.21 Neglect is the primary reason young children enter the CW system, and it can affect motor skills secondary to excessive confinement to infant equipment or malnutrition.21

The vast majority of children involved with CW are born into families struggling with poverty, with its profound affect on health and family functioning. Factors (eg, poverty, substance abuse, and domestic violence) that predispose a woman to deliver an infant who is premature also are associated with the involvement of CPS and foster placement.22 , 23 Children born premature with lower gestational age have been found to have poorer motor skills than children born full-term even when their chronological age is adjusted (on the basis of their length of gestation) to correct for prematurity.24 – 29

Studies examining the effect of prenatal cocaine exposure (PCE) on children's development have found that infants with PCE are far more likely to be placed in FC or KC than matched controls without cocaine exposure.30 – 33 A number of studies indicate that PCE affects motor functioning during infancy16 , 34 – 43; however, significant methodological limitations of some of these studies30 must be considered. Prenatal cocaine exposure generally occurs within the context of polydrug use, with exposures to legal teratogens, such as tobacco and alcohol.16 The findings are inconsistent even with studies that are well-designed and control for exposures to alcohol and tobacco, as illustrated by 2 prospective longitudinal birth cohort comparison studies of the effect of PCE on motor development.16 , 33 Singer et al33 found that prenatal tobacco exposure predicted lower motor scores, while prenatal exposure to cocaine affected cognitive development. Miller-Loncar et al16 found that infants with PCE demonstrated lower motor skills at 1 month of age but that these early differences were not sustained over time. It is noteworthy that numerous studies indicate that smoking and significant use of alcohol during pregnancy have more serious effects than that of PCE.44 , 45 Prenatal alcohol exposure has been associated with young children's orthopedic and motor abnormalities, motor delays, and balance deficits.46 – 48

Type of placement has been shown to influence developmental outcomes. As described earlier, children with CW involvement may be placed in FC, KC, or remain with their own parents and receive IHPS. Among children involved with CW, those in out-of-home placement (FC or KC) are more likely to receive primary health care and educational services than those who remain with their parents with in-home CW intervention.49

Type of placement is also associated with the prevalence of children with special health care needs. Children placed in FC are more likely to have special health care needs than those placed in KC or those with IHPS.7 Length of time in placement and the number of placements children experience also have been shown to affect developmental and behavioral outcomes.3 , 8 , 50 For example, Horwitz et al3 found that adaptive behavior functioning significantly improved over a 12-month period of FC placement, and that time in FC placement contributed to improved functioning in a multiple regression prediction model. Alternatively, in an earlier study, Horwitz et al51 found that when children entering FC had developmental, medical, or behavioral problems, they were more likely to remain in care longer than their peers. The number of placements a child experiences (placement stability) can affect development, as an increased number of placements is associated with decreased continuity of health care,52 increased emergency department use,53 and increased mental/behavioral health problems.50 , 54 , 55

Reasons for out-of-home placement in FC or KC have been found to be associated with various medical problems,5 the likelihood of having medical problems identified,11 and improvement in scores on the composite Vineland Adaptive Behavior Scale after placement.3 In addition, researchers have shown that children placed in FC due to neglect/abandonment or abuse have lower scores on developmental testing than children in the general population5 , 56; however, motor delay and reason for placement have not previously been studied.

The objective of this study was to determine whether a sample of children aged 2 to 34 months and involved with an urban CW system had a higher rate of GM delay than children in the general population. We examined the relationship between GM development and other variables affecting developmental outcomes: prenatal exposure to illicit drugs,16 , 34 – 43 , 57 weight-for-height ratio,29 , 56 , 58 – 62 head circumference,60 gestational age,24 , 25 , 27 – 29 and factors specific to CW involvement discussed earlier that have been implicated in developmental outcomes: placement type,7 , 49 , 52 , 63 number of placements,52 , 53 , 55 reason for placement,3 , 5 , 11 , 56 and length of time of CW involvement.3 , 8 Finally, we evaluated the interaction among these factors and their combined influence on GM development.

METHODS

This study is based on the information gathered through a demonstration project involving an interdisciplinary pediatric evaluation and follow-up clinic for infants and toddlers with open CW cases. The evaluations aimed to identify the children's health and developmental needs provide recommendations for health care and EI services based on the evaluation results, monitor adherence to these service recommendations, and identify barriers families encountered that compromised adherence. All children involved in the clinic received an interdisciplinary evaluation: medical evaluation, including a physical examination, measurement of growth parameters (weight, length, and head circumference), and evaluation with standardized, normative measures for gross-motor, cognitive, and speech-language development. Prior to evaluation, the team social worker conducted a structured interview to gather demographic information, and social and medical history from the child's caregiver (birth parent and/or foster parent) and CW caseworker. Information from the structured interview and results of the interdisciplinary evaluation (eg, health status, growth parameters, developmental tests results, and adherence information) were maintained in a deidentified clinical database. This study was approved by the Institutional Review Board of The Children's Hospital of Philadelphia.

Sample Characteristics

Participants were recruited at the inception of the model clinic, with a letter sent to 60 agencies that were part of a consortium of private, nonprofit CW-provider agencies. The letter described the evaluation format and eligibility requirements (children between 2 and 34 months of age who had open cases with the county CW authority for FC, KC, or IHPS). The letter described the clinic as an opportunity for the child to receive a pediatric interdisciplinary developmental evaluation, with an EI service coordinator present to initiate enrollment for EI services should the child's evaluation results warrant EI services. Between 2002 and 2004, 218 children were evaluated (Table 1). Data from this convenience sample were analyzed for the present study. Of the 218 children referred, 176 were included in the current analyses. Children who did not receive testing for the GM domains of the Peabody Developmental Motor Scales, 2nd edition (PDMS-2), were excluded.

Measures

Gross Motor Ability: PDMS-2

All subjects were evaluated on the GM subscales of the PDMS-264 to yield the GM quotient (GMQ). The PDMS-2 has been shown to be a valid, reliable measure of motor skills for children from birth to 72 months.* The entire test consists of 7 subtests, 4 of which make up the GM domains: reflexes, stationary, locomotion, and object manipulation. The administration of 2 of these subtests is age-determined, with reflexes used with children younger than 12 months and object manipulation used with children 12 months and older. The GMQ is then derived from a composite of the 3 administered GM subtests. When scored, the raw scores on the PDMS-2 subtests can be converted into age-equivalents, percentiles, and subtest standard scores. Subtest standard scores are combined to yield a GMQ, which is a standard score with a mean of 100 and a standard deviation of 15.

The PDMS-2 is considered one of the gold standards for GM assessment for children from birth to 72 months. The GMQ has good to high internal consistency (0.96),64 test-retest reliability (0.84–0.99),64 , 65 and inter-rater reliability (0.89–97).64 , 66 – 69 The PDMS-2 GMQ has variable concurrent validity with other GM tests (0.30–0.86)64 , 68 , 70 , 71 and fair to good convergent validity (0.71–0.76).72 Other studies have examined various aspects of reliability and validity of subtest scores, age equivalents, and previous editions of the PDMS.71 , 73 , 74 In total, the literature supports the PDMS-2 GMQ as a reliable and valid test to assess for GM delay in children ages from birth to 12 and 24 to 60 months, but there is limited research regarding its use in the 12- to 24-month age range.64 – 74 It has also been suggested that the original PDMS and the PDMS-2 may not be sensitive to cultural differences in various populations, including African American, Hispanic, Native American, and Indian children.75 – 77

Although other measures may be stronger in some age-related subsets of our sample for GM assessment, the PDMS-2 GMQ was chosen a priori as the best measure to use across the sample to capture GM ability for 2 reasons. The clinic included only 1 measure of GM ability to limit the testing burden on the infant who was also receiving developmental assessments of communication and cognitive development on other measures. In addition, the infants were part of a follow-up program and many returned for re-evaluations at planned intervals, thus use of a consistent measure of motor development was preferable for tracking their progress. In this study, we examine data only from participants' first evaluation. The PDMS-2 GM subscales were administered by a physical therapist.

Growth Parameters

A pediatrician measured growth parameters (height, weight, and head circumference), calculated weight for height ratios, and documented percentiles on the basis of gender and gestational age.78 Head circumference and weight are associated with developmental outcomes,60 and the age of achievement of motor milestones is associated with all growth variables that include weight.58

Chronological and Gestational Ages

Chronologic age (in months) was determined on the basis of the date of the child's evaluation. Gestational age was determined from birth hospital discharge records when available, or by birth parent's report, and reported in weeks. Scores for PDMS-2 were based on corrected age for all patients less than 24-months-old when prematurity was identified.

Collateral Information

The following information was gathered from the structured interview detailed earlier: (1) Placement type: (FC, KC, in-home protective services) represents type of CW placement at the time of evaluation. (2) Time with CW: (in months) represents the length of time since the child's case was originally opened with CPS. (3) Number of placements: we divided the subjects into 2 groups depending on placement stability: stable (indicating 2 or fewer placements) versus unstable (those with 3 or more placements). (4) Prenatal exposure: was coded yes/no/unknown and represented illicit drug use, such as cocaine and opiates. We did not have access to direct perinatal assessment of the actual exposures our sample experienced; because this was a convenience sample of children 2 months and older, we relied on CW agency documents for this information. Given the limitation of using CW documents, we were unable to document prenatal tobacco and alcohol exposures within this variable despite their known effect on motor development.33 , 46 – 48 , 79 (5) Reason for placement: physical abuse, sexual abuse, neglect, medical neglect, abandonment, housing problems, parental substance abuse, maternal mental illness, abuse of siblings, maternal incarceration, or other (Table 2). This variable refers to the reason for the child's involvement with the CW system and included children receiving in-home services as well as those in placement. In contrast to the prenatal exposure category, when the reason for placement was due to parental substance abuse, reason for placement-parental substance abuse included any type of illicit drug or alcohol abuse. In addition, children in our sample may have entered the CW system for multiple reasons, so some children fell into multiple groups. For purposes of data analysis, we compared the means of each group with the rest of the sample. We also created a category of children referred for any type of abuse or neglect. For this category, to prevent duplication of subjects, children referred for 2 types of abuse are only represented once.

Data Analysis

Data from 218 children who received evaluations were compiled from clinic visits. One hundred seventy-six subjects received assessments on the PDMS-2 GMQ. Data were analyzed using SPSS v.17.0.80 Missing values for independent variables were excluded list wise for all analyses. Descriptive statistics were computed for all variables. Spearman's ρ correlation coefficients were estimated for continuous variables (gestational age, chronologic age at the time of evaluation, weight-for-height percentile, head circumference percentile, time with CW). The independent t test for 2-group comparison (number of placements, prenatal exposure, and reason for CW involvement) and analysis of variance and covariance (ANCOVA) for 3-group comparisons (placement type) were used. In comparing GMQ among the placement types, time in CW and head circumference were used as covariates. Stepwise multiple regression analyses were used to predict GM scores for children involved with the CW system.

RESULTS

Data from the PDMS-2 for 176 children were included in our analyses. The mean GMQ was 94.83 ± 12.72 (range: 43–119), and 13.6% (n = 24) had GMQ less than 80 (1.5 standard deviation below reported mean), indicating GM delay.* The mean age was 15.38 ± 8.39 months, and the mean time with CW was 6.95 ± 7.24 months. The percentage of children in FC was 48.8; 27.8% were in KC; and 22.7% with IHPS. Ten percent had 3 or more placements. The percentage of children reportedly exposed to substances in utero was 45.5%. The most frequent reasons for CW involvement were abuse or neglect (46.6%) and parental substance abuse (43.2%). Of the sample, 83.5% was African American, whereas 8% was white. Data are also presented for each of the CW subgroups (FC, KC, and IHPS; Tables 1 and 2).

Table 3 reports Spearman correlation coefficients. A positive correlation was found between GM score and weight-for-height percentile (r 156 = 0.218; P < .05), where children with a higher percentile had higher GM scores. There was a negative correlation between GM score and age at the time of assessment (r 176 = −0.382; P < .001), indicating that younger children had higher GM scores. Head circumference percentile was negatively correlated with time with CW (r 153 = −0.200; P < .05), while positively related to gestational age (r 153 = 0.182; P < .05), and weight-for-height percentile (r 153 = 0.243; P < .01), which indicates that children with smaller head circumferences experienced greater time involved with CW, had lower gestational age, and had lower weight-for-height percentile. Age at the time of assessment was negatively correlated with weight-for-height percentile (r 156 = −0.237; P < .01), which indicates that older children tended to have lower weight-for-height percentiles.