Bracken School Readiness Assessment Research Articles

Neurodevelopmental Outcomes of Preschoolers with Antenatal Zika Virus Exposure Born in the United States.

Neurodevelopmental outcomes for preschool-age children in the United States with in utero Zika virus (ZIKV) exposure have not yet been reported. We performed a case-control study to assess whether children exposed in utero to ZIKV have abnormal neurodevelopment at age 4-5 years compared to unexposed controls. Thirteen ZIKV-exposed cases that did not have microcephaly or other specific features of congenital Zika syndrome and 12 controls were evaluated between ages 4-5 years. Child neurodevelopment was assessed using the Pediatric Evaluation of Disability Inventory, Behavior Rating Inventory of Executive Function, Peabody Picture Vocabulary Test, Bracken School Readiness Assessment (BSRA), and Movement Assessment Battery for Children (MABC). Caregivers answered questions on the child's medical history and family demographics. Cases and controls were evaluated at mean (SD) ages 4.9 (0.3) and 4.8 (0.4) years, respectively. Caregivers reported more behavior and mood problems in cases than controls. MABC scores showed more gross and fine motor coordination difficulties among cases than controls. Controls trended towards higher performance on concepts underlying school readiness on BSRA. Three cases had a diagnosis of autism spectrum disorder or global developmental delay. Continued follow-up through school age for children with prenatal ZIKV exposure is needed to understand the impact of in utero ZIKV exposure on motor coordination, cognition, executive function, and academic achievement.

Child biological stress and maternal caregiving style are associated with school readiness

Low socioeconomic status (SES) is a risk factor for unpreparedness for formal school entry. However, it is unclear how specific SES domains or factors related to SES, such as maternal caregiving style or child biological stress regulation, uniquely contribute to a child's academic competency. We examined the relation between early biological stress, SES, and caregiving style with the academic competency domain of school readiness in a preschool-age sample (N = 91) using multidimensional measures of SES, measures of maternal behavior, child hair cortisol concentrations, and diurnal salivary cortisol. We also investigated which correlates uniquely contribute to academic competency as indexed by the Bracken School Readiness Assessment and the NIH Picture Vocabulary Test. Higher cumulative biological stress, indexed through hair cortisol concentrations, was related to lower scores on both measures. Poor biological stress regulation, indexed by a flatter diurnal cortisol slope, was related to lower receptive vocabulary. More sensitive maternal behaviors and measures indicating higher SES were related to better performance in both academic competency measures. Of these significant associations, maternal intrusion and parental education uniquely contributed to pre-academic skills beyond other measures, whereas maternal structuring and parental education uniquely contributed to receptive vocabulary. These results provide new evidence that biological stress is related to academic competency in early childhood and demonstrate the importance of structured, non-intrusive parenting when preparing children for long-term academic success.

Parasympathetic Nervous System Activity During Measures of Volitional Self‐regulation Predicts School Readiness

ABSTRACTSelf‐regulation is an essential component of school readiness. Although in educational contexts self‐regulation is typically defined in terms of volitional processes, it also encompasses the activity of neurophysiological systems, including the parasympathetic nervous system (PNS). In a prospective longitudinal study, 102 preschoolers (Mage = 4.82 years; 52% female) completed two measures of volitional self‐regulation (the gift‐wrap task and a battery of EF tasks) at the beginning of their final preschool year, and then completed the Bracken School Readiness Assessment (BSRA) at year's end. Larger increases in parasympathetic function (indexed by respiratory sinus arrythmia, or RSA) during both the gift‐wrap and EF tasks were correlated with better performance on the BSRA at levels approaching significance, and subsequent regression models that controlled for relevant covariates revealed robust associations between increases in RSA and improved BSRA performance (gift wrap: B = 5.49, p = .012; EF: B = 7.77, p = .001). We interpret these results in light of polyvagal theory and discuss their implications for incorporating measures of parasympathetic activity into future educational neuroscience research.

The impact of multiple language exposure on cognition during childhood: evidence from the UK Millennium Cohort Study.

Many studies argue that exposure to, and use of, multiple languages in childhood has beneficial effects beyond the linguistic domain, including on executive functions (EFs), although recent evidence remains controversial. EFs encompass abilities necessary for regulating goal-directed behaviours in everyday life and, in children, EFs strongly predict later academic achievement and wellbeing. One theoretical framework distinguishes "hot" EFs, which have a reward or affective component, from "cool" EFs that do not. How exposure to more than one language in early childhood modulates hot and cool EFs in later childhood, alongside other environmental and cognitive factors, remains poorly understood. We analysed data from the UK Millennium Cohort Study, a large-scale, nationally representative longitudinal cohort study, which provides information on perinatal and environmental factors (e.g., languages spoken in the home, maternal education) alongside cognitive measures assessed in English. At 3 years, we examined the effect of multiple language exposure on the Bracken school readiness assessment (knowledge of shapes, letters, etc.), and on naming vocabulary. At age 11, we examined the predictors of cool EF, measured with a spatial working memory task; hot EF, measured using a gambling task; and vocabulary, measured using a verbal reasoning task. Data from 16,134 children were analysed. At age 3, a negative effect of multiple language exposure on school readiness and vocabulary was observed, but the difference was smaller with higher maternal education. At age 11, there was also a negative effect on vocabulary, but smaller than that observed at age 3. There were no direct effects of language exposure on either spatial working memory or gambling scores. For hot EF, the multiple language exposure effects were indirect, mediated by early cognition, and the most significant predictor of gambling strategy was sex. For cool EF, school readiness and vocabulary at age 3 were the strongest predictors. Our findings, based on a UK population sample, highlight the importance of considering socioeconomic status and early-life abilities when interpreting the effects of language environments on hot and cool EFs.

2132. Placental histopathology and long-term outcomes of children with antenatal Zika virus exposure

Abstract Background It is unclear whether placental changes in ZIKV infection influence short- and long-term child outcomes. The objective of this study is to determine if placental histopathology findings in ZIKV correlate with offspring outcomes at birth and age 4-5 years for children with in utero ZIKV exposure without congenital Zika syndrome. Methods 24 placentas collected from pregnant women with symptomatic ZIKV infection enrolled in a prospective ZIKV study in Colombia were formalin fixed and reviewed by a placental pathologist, blinded to child outcome. Children had neuroimaging as newborns and were longitudinally evaluated to age 4-5 years with the Bracken School Readiness Assessment (BSRA) and Pediatric Evaluation of Disability Inventory (PEDI-CAT). Scores were compared by presence of placental findings of perivillous fibrin deposition, calcifications, and increased syncytial knotting. T-test, fisher exact, and one way ANOVA were used for analysis; significance, p< .05. Results All 24 placentas had at least one abnormal pathological finding (Table 1). 14 (58%) placentas had extensive ( >30% coverage) and 7 (29%) had mild-moderate perivillous fibrin deposition (Fig. 1a). Placental calcifications were many ( >10) in 10 (42%) cases, and mild in 7 (29%) cases (Fig. 1b). 14 (58%) placentas had increased syncytial knotting. Placentas stained positive with CD163 for Hofbauer macrophages (Fig. 1c). All infants were born at term with normal birth weight, height, and head circumference, and 22 had a normal ponderal index. There was no difference in measurements based on each placental finding. There was no relationship between placental findings and non-specific neuroimaging. 20 (83%) children with placentas were evaluated at age 4-5. Children without placental calcifications scored higher on BSRA than children with mild/severe calcifications (p = .031). Children with increased syncytial knotting had lower scores on PEDI-CAT social/cognitive ability (p = .024). Conclusion Placentas from ZIKV-infected pregnancies have pathological findings that indicate risk of impaired fetal perfusion, but these were not associated with preterm birth or growth. There may be associations between placental findings and long-term neurodevelopment in ZIKV-exposed children requiring additional studies. Disclosures All Authors: No reported disclosures.

Preschool neurodevelopment in Zika virus-exposed children without congenital Zika syndrome.

Children with in utero Zika virus (ZIKV) exposure without congenital Zika syndrome (CZS) are at risk for abnormal neurodevelopment. Preschool-age outcomes for children with antenatal ZIKV exposure have not yet been established. Children with in utero ZIKV exposure and non-exposed controls had neurodevelopmental evaluations at age 3-5 years in Sabanalarga, Colombia. Cases did not have CZS and were previously evaluated prenatally through age 18 months. Controls were born before ZIKV arrival to Colombia. Neurodevelopmental assessments included Pediatric Evaluation of Disability Inventory (PEDI-CAT), Behavior Rating Inventory of Executive Function (BRIEF-P), Bracken School Readiness Assessment (BSRA), and Movement Assessment Battery for Children (MABC). Family demographics and child medical history were recorded. Fifty-five ZIKV-exposed children were evaluated at mean age 3.6 years and 70 controls were evaluated at 5.2 years. Family demographics were similar between groups. BRIEF-P t-scores were higher for cases than controls in shift and flexibility domains. Cases had lower PEDI-CAT mobility t-scores compared to controls. There was no difference in MABC between groups. In 11% of cases and 1% of controls, parents reported child mood problems. Children with in utero ZIKV exposure without CZS may demonstrate emerging differences in executive function, mood, and adaptive mobility that require continued evaluation. Preschool neurodevelopmental outcome in children with in utero Zika virus exposure is not yet known, since the Zika virus epidemic occurred in 2015-2017 and these children are only now entering school age. This study finds that Colombian children with in utero Zika virus exposure without congenital Zika syndrome are overall developing well but may have emerging differences in executive function, behavior and mood, and adaptive mobility compared to children without in utero Zika virus exposure. Children with in utero Zika virus exposure require continued multi-domain longitudinal neurodevelopmental evaluation through school age.

The Relationship between Physical Activity, Self-Regulation and Cognitive School Readiness in Preschool Children.

(1) Background: Limited research exists on the pathways through which physical activity influences cognitive development in the early years. This study examined the direct and indirect relationships between physical activity, self-regulation, and cognitive school readiness in preschool children. (2) Method: Participants (n = 56) aged 3–5 years were recruited from the PLAYCE study, Perth, Western Australia. Physical activity was measured using 7-day accelerometry. Self-regulation was measured using the Head Toes Knees and Shoulders task and cognitive school readiness was assessed using the Bracken School Readiness Assessment. Baron and Kenny’s method was used for mediation analysis. (3) Results: After adjustment for socio-demographic factors, total physical activity was positively and significantly associated with cognitive school readiness (B = 0.16, SE = 0.07, p ≤ 0.05). Moderate-vigorous physical activity (MVPA) was positively and significantly associated with self-regulation (B = 0.3, SE = 0.13, p ≤ 0.05) and cognitive school readiness score (B = 0.20, SE = 0.09, p ≤ 0.05). Self-regulation was found to be a partial mediator of the relationship between MVPA and cognitive school readiness. (4) Conclusion: These findings highlight the direct and indirect association between preschool children’s physical activity, self-regulation, and cognitive school readiness. Further research is needed to determine the causal relationships between young children’s physical activity and cognitive development, over time.

Academic school readiness in children born very preterm and associated risk factors

Background and aimsAlthough the intelligence quotient (IQ) test is useful to assess general cognitive function, it may miss more specific and subtle deficits of learning, working memory, attention and executive function. This study aims to evaluate cognitive performance and academic school readiness (SR) concepts in preterm very low birth weight (PT/VLBW) children, compared to typically developing term controls and to evaluate factors affecting basic (SR) concepts in children with IQ>85. MethodsA prospective cohort study of 123 PT/VLBW survivors with birth weights ≤1250 g and 74 term controls born between 2007 and 2009 in Singapore were assessed for school readiness using Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III), Bracken School Readiness Assessment (BSRA-3) and Beery-Buktenica Developmental Test of Visual Motor Integration (VMI) at age 5.5 years. Social risk composite score (SRCS) was calculated based on ethnicity, parental education and family income and marital status. Uni- and multi-variable regressions were conducted to evaluate risk factors associated with poor academic SR in the entire cohort and in those with IQ >85. ResultsMean gestational age and birth weight of the 123 PT/VLBW children were 27.8 (2.3) weeks and 939 (194) grams while that of the 74 term controls were 38.8 (1.2) weeks and 3165 (402) grams.PT/VLBW survivors had statistically significant lower full composite scores on WPPSI-III (97.0 vs 114), BSRA-3 (98.5 vs 112.3) and VMI (107.2 vs 112.9) compared to controls. The differences remained significant in preterm and children with higher SRCS even after adjustment. ConclusionsPrematurity and high social composite risk scores were risk factors affecting academic SR and this difference persisted in PT/VLBW children with normal cognitive scores with IQ >85.

Psychometric properties and optimizing of the Bracken School Readiness Assessment

The Bracken School Readiness Assessment (BSRA) has been used in large studies such as the Millennium Cohort Study (MCS). Important conclusions might be done regarding its reliability for the prediction of children’s school readiness taking advantage of such large-scale evaluation. Although BSRA has being largely used, few are the studies at item-level under latent approach investigating its psychometric features. Using data from 14,899 2–3-year olds who participated in the MCS, we used Bayesian confirmatory factor analysis to examine multidimensionality of the subtests of the BSRA and their consistencies, specificities, and reliabilities. We found clear indications of multidimensionality. From the 88 items, 10 showed low reliability. Future research may consider excluding these low reliability items to improve the psychometric properties of the BSRA and its use as multidimensional measurement tool.

Is amblyopia associated with school readiness and cognitive performance during early schooling? Findings from the Millennium Cohort Study.

Amblyopia is a neurodevelopmental condition causing reduced vision, for which programmes of whole population child vision screening exist throughout the world. There is an ongoing debate about the value of screening due to the lack of evidence about meaningful functional impacts of amblyopia. Our objective was to determine whether amblyopia is associated with school readiness and early cognitive performance. Data from the prospective Millennium Cohort Study of children born in the United Kingdom in 2000-01 and followed-up to age 7 years (n = 13,967). Using parental self-report on eye conditions and treatment coded by clinical reviewers, participants were grouped into no eye conditions, strabismus alone, refractive amblyopia, or strabismic/mixed (refractive plus strabismic) amblyopia. The outcomes were poor school readiness using Bracken School Readiness Assessment <25th percentile (age 3); and cognitive tests and their age-related trajectories using British Ability Scale II Naming Vocabulary (ages 3/5) and Pattern Construction (ages 5/7). Multivariable analyses showed that compared to children without any eye conditions, only those with strabismic/mixed amblyopia had an increased risk of poor school readiness (OR = 2.04, 95%CI 1.09-3.82). Small differences in mean scores for NV and PC of children with amblyopia (all types) compared to those without any eye condition were not clinically significant (>10 points) irrespective of whether treatment had already started. The age-related cognitive trajectories of children with amblyopia did not differ from those without any eye conditions for either NV (p = 0.62) or PC (p = 0.51). These associations are at population rather than individual level, so it might be that some individuals with amblyopia did experience significant adverse outcomes that are not captured by summary statistics. Amblyopia is not significantly associated with adverse cognitive performance and trajectories in early schooling and there is no evidence that this is due to a mediating effect of treatment. Although amblyopia combined with strabismus is associated with poor school readiness, this is not translated into poor cognitive performance. These novel findings may explain the lack of association reported between amblyopia and educational outcomes in adult life and suggest that the impact of amblyopia on education is not of itself a justification for whole population child vision screening aimed at detecting this disorder.

Lack of association between hypothyroxinemia of prematurity and transient thyroid abnormalities with adverse long term neurodevelopmental outcome in very low birth weight infants.

IntroductionThe association between hypothyroxinemia of prematurity with neurodevelopment was controversial.ObjectivesTo compare 5 year neurodevelopmental outcomes of very low birth weight (VLBW) infants with hypothyroxinemia of prematurity against those without.MethodsRetrospective cohort study in a single tertiary neonatal centre of VLBW infants born between the year 2008 to 2011. Comparisons were made between all abnormal and normal thyroid function controls using cord thyroid function tests, thyroid function tests during admission and pre-discharge thyroid function test done at term equivalent age. At 2 years corrected age, Bayley scales of infant and toddler development–third edition and Vineland II adaptive behaviour scales (VABS) were collected. At 5 years, Wechsler Preschool and Primary Scale of Intelligence (WPPSI-III), Bracken School Readiness Assessment, VABS and Beery Test of Visual-Motor Integration were collected.Results110 subjects were studied at 2 years corrected age and 80 subjects at 5 years old. 29 infants had abnormal thyroid function test (10 infants with hypothyroxinemia of prematurity and 19 infants with transient thyroid abnormalities). There were no significant difference in the 2 years and 5 years developmental outcome between infants with and without hypothyroxinemia of prematurity (p-value>0.05); and between infants with and without transient thyroid abnormalities (p-value>0.05). There were no significant difference in neurological, visual and hearing impairment between infants with or without hypothyroxinemia of prematurity (p-value>0.05).ConclusionsHypothyroxinemia of prematurity or transient thyroid abnormalities in VLBW infants were not associated with poorer neurodevelopment and did not support the need for levothyroxine supplementation.

Development of a predictive risk model for school readiness at age 3 years using the UK Millennium Cohort Study

ObjectivesThe aim of this study is to develop a predictive risk model (PRM) for school readiness measured at age 3 years using perinatal and early infancy data.Design and participantsThis paper...

Outdoor and indoor air quality and cognitive ability in young children

BackgroundThis study examined outdoor and indoor air quality at ages 9 months and 3 years and their association with cognitive ability at age 3 in England and Wales. MethodData from 8198 Millennium Cohort Study children were analysed using multilevel regression. Outdoor air quality was assessed with mean annual estimates of nitrogen dioxide (NO2) levels within a standard small area (ward). Indoor air quality was measured with parent-reports of damp or condensation in the home and exposure to secondhand smoke in the home. Cognitive ability was assessed with the British Ability Scales Naming Vocabulary subscale and the Bracken School Readiness Assessment. ResultsIn adjusted models, consistent exposure to high levels of NO2 at age 9 months and age 3 years was associated with lower verbal ability at age 3 years. Damp/condensation and secondhand smoke in the home at either age or at both ages were correlated with lower school readiness at age 3 years. Exposures to damp/condensation at age 3 years or at both ages and secondhand smoke at either age or at both ages were associated with lower verbal ability at age 3 years. ConclusionYoung children's exposures to indoor damp or condensation and secondhand smoke are likely to be detrimental for their cognitive outcomes. However, there do not appear to be any short-term effects of NO2.

CONSTRUCT VALIDITY EVIDENCE FOR BRACKEN SCHOOL READINESS ASSESSMENT, THIRD EDITION, SPANISH FORM SCORES

Convergent and discriminant validity evidence was examined for scores on the Spanish Record Form of the Bracken School Readiness Assessment, Third Edition (BSRA‐3). Participants included a sample of 68 Hispanic, Spanish‐speaking children ages 4 to 5 years enrolled in preschool programs in Puerto Rico. Scores obtained from the BSRA‐3 Spanish Record Form were compared with scores from the Nonverbal Index of the Kaufman Assessment Battery for Children, Second Edition, and the Preschool and Kindergarten Behavior Scales, Second Edition. As expected, the correlation between school readiness scores and nonverbal intelligence was significant and moderate in the positive direction and the correlations between school readiness scores and behaviors were low. Discriminant validity evidence for BSRA‐3 scores was demonstrated using Steiger's Z test to compare correlations of similar and dissimilar constructs. As hypothesized, significant results emerged.

The Investigation of School Readiness Level of Six Years Old Preschool Children in Terms of Different Variables

The purpose of this study is evaluation of school readiness level of six years old preschool children within the framework of different variables. This study is a survey model and includes the steps on surveying the six years old children who attend pre- school in 2010-2011 academic year in Sakarya. In this survey, Demographic Information Form, Bracken School Readiness Assessment was as data collection tools. The gathered data were analyzed using SPSS 16 program. At the end of this research, At the end of the research, it was concluded that the level of parents education had a strong positive effect on the children's school readiness. The jobs and age levels of the parents had also impact the level of children's school readiness.

Gestational Age and Cognitive Ability in Early Childhood: a Population‐based Cohort Study

Recent studies suggest that children born at late preterm (34-36 weeks gestation) and early term (37-38 weeks) may have poorer developmental outcomes than children born at full term (39-41 weeks). We examined how gestational age is related to cognitive ability in early childhood using the U.K. Millennium Cohort Study. Cognitive development was assessed using Bracken School Readiness Assessment at age 3 years, British Ability Scales II at ages 3, 5 and 7 years and Progress in Mathematics at age 7 years. Sample size varied according to outcome between 12,163 and 14,027. Each gestational age group was compared with the full-term group using differences in z-scores and risk ratios for scoring more than -1 SD below the mean. Children born at <32 weeks gestation scored lower (P < 0.05) than the full-term group on all scales with unadjusted z-score differences ranging between -0.8 to -0.2 SD. In all groups, there was an increased risk (P < 0.05) of scoring less than -1 SD below the mean compared with the full-term group for some of the tests: those born at < 32 weeks had a 40-140% increased risk in seven tests, those born at 32-33 weeks had a 60-80% increased risk in three tests, those born at 34-36 weeks had a 30-40% increased risk in three tests, and those born at 37-38 weeks had a 20% increased risk in two tests. Cognitive ability is related to the entire range of gestational age, including children born at 34-36 and 37-38 weeks gestation.

Reliability of Bracken School Readiness Assessment, Third Edition Scores With Young Children in Mumbai, India

To effectively provide early interventions to children, identifying those who are in need of these interventions is essential. In India, several problems hinder the process of early identification, including a lack of standardized measures for assessment. This study investigates the utility of the Bracken School Readiness Assessment, Third Edition (BSRA-3; Bracken, 2007) with an urban sample of children ages 3 to 5 years (N = 254) attending school in Mumbai, India. Reliability of BSRA-3 scores was assessed using coefficient alpha and split-half coefficients. Potentially problematic or biased items were identified using item analysis indexes of difficulty and discrimination. The BSRA-3 test scores with the Indian (Mumbai) population were reliable, and raw score means and rank orders were comparable with those for the U.S. normative sample. None of the test items on the test function differently with the Mumbai, India sample, thus providing initial evidence of BSRA-3's applicability with the Indian population.

A population-based cohort study of gestational age and cognitive ability in early childhood

ObjectiveTo examine how cognitive ability is related to gestational age and the extent to which observed differences could be explained by socio-economic confounding.MethodsThe Millennium Cohort Study collected data on 18...

Characteristics of the first child predict the parents' probability of having another child.

In a sample of 7,695 families in the prospective, nationally representative British Millennium Cohort Study, this study examined whether characteristics of the 1st-born child predicted parents' timing and probability of having another child within 5 years after the 1st child's birth. Infant temperament was assessed with the Carey Infant Temperament Scale (Carey, 1972; Carey & McDevitt, 1978) at age 9 months, childhood socioemotional and behavioral characteristics with the Strengths and Difficulties Questionnaire (Goodman, 2001), and childhood cognitive ability with the Bracken School Readiness Assessment (Bracken, 2002) test at age 3 years. Survival analysis modeling indicated that the 1st child's low reactivity to novelty in infancy, high prosociality, low conduct problems, and high cognitive ability in childhood were associated with increased probability of parents having another child. Except for reactivity to novelty, these associations became stronger with time. High emotional symptoms were also positively associated with childbearing, but this was likely to reflect reverse causality-that is, the effect of sibling birth on the 1st child's adjustment. The results suggest that child effects, particularly those related to the child's cognitive ability, adaptability to novelty, and prosocial behavior, may be relevant to parents' future childbearing. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Risk Factors Affecting School Readiness in Premature Infants With Respiratory Distress Syndrome

With advances in neonatal care, more children born prematurely are successfully reaching school age. It is unknown how many will be ready for school and what factors affect school readiness. Our objective was to assess readiness of children born prematurely for entry into public school, and determine risk factors associated with lack of school readiness in this population. This was a single-center prospective cohort study. Follow- up data were collected for 135 of 167 (81%) surviving premature infants with RDS requiring surfactant-replacement therapy. The children were seen between July 2005 and September 2006 (average age: 5.7 +/- 1.0 years) and underwent standardized neurodevelopmental and health assessments and socioeconomic status classification. A 4-level school-readiness score was constructed by using each child's standardized scores on assessments of basic concepts (Bracken School-Readiness Assessment), perceptual skills (Visual-Motor Integration Test), receptive vocabulary (Peabody Picture Vocabulary Test, Third Edition), daily living functional skills (Pediatric Functional Independence Measure), and presence of sensory impairments or autism. Proportional odds models were used to identify risk factors predicting lower school-readiness levels. Mean birth weight was 1016 +/- 391 g, and mean gestational age was 27.5 +/- 2.6 weeks. Ninety-one (67%) children were school-ready. Using multivariate analysis, male gender, chronic lung disease, and severe intraventricular hemorrhage or periventricular leukomalacia were associated with lower school-readiness levels. However, the most powerful factor determining school-readiness level was low socioeconomic status. Interventions targeting neonatal morbidities may be much less effective at improving overall performance at school age compared with the effect of the impoverished social environment.