Cognitive-linguistic Performance Research Articles

Optimising verbal fluency analysis in neurological patients with dysarthria: examples from Parkinson’s disease and hereditary ataxia

ABSTRACT Background Verbal fluency tests (VFTs) are widely used to assess cognitive-linguistic performance in neurological diseases. However, the influence of dysarthria on performance in tests requiring oral responses is unclear in ataxia and Parkinson’s disease. Objectives To determine the impact of dysarthria on VFT performance and evaluate the validity and reliability of alternative methods for analyzing VFT data. Method Trained raters evaluated dysarthria using VFT recordings in people with ataxia (N = 61) or Parkinson’s disease (PD; N = 69). Total Correct Items scores and qualitative parameters (intrusions, ambiguous verbalizations, perseverations, and interjections) were compared across semantic, phonemic, and alternating fluency tasks. Disease severity was considered as a covariate in the regression model. Results VFT dysarthria ratings correlated with the benchmark (ground truth) dysarthria scores derived from a monologue. Ambiguous responses resulting from unclear speech impeded the rater’s ability to determine if a response was correct. Regression analysis indicated that more severe dysarthria ratings predicted diminished scores in all three tasks (semantic fluency, phonemic fluency and alternating fluency) in the ataxia group. The contribution of disease severity to semantic, phonemic and alternating fluency was reduced substantially in the ataxia group after accounting for dysarthria severity in the model in both groups. Conclusions Dysarthria severity can be estimated based on speech samples derived from VFT. Dysarthria can lead to lower total correct items and is associated with more ambiguous verbalizations in VFT. Dysarthria severity should be considered when interpreting VFT performance in common movement disorders.

Association of cognitive-linguistic deficits to diffusion tensor imaging parameters in moderate to severe traumatic diffuse axonal injury

Cognitive-linguistic functions are an essential part of adequate communication competence. Cognitive-linguistic deficits are common after traumatic diffuse axonal injury (DAI). We aimed to examine the integrity of perisylvian white matter tracts known to be associated with linguistic functions in individuals with DAI and their eventual association with poor cognitive-linguistic outcomes. Diffusion tensor imaging (DTI) results of 44 adults with moderate-to-severe DAI were compared with those of 67 controls. Fractional anisotropy (FA) values of the superior longitudinal fasciculus (SLF), arcuate fasciculus (AF), SLF with frontal connections to the lower parietal cortex, and AF with temporal connections to the lower parietal cortex were measured using tractography. The associations between white matter integrity FA values and cognitive-linguistic deficits were studied in the DAI group. Cognitive-linguistic deficits were determined based on our earlier study using the novel KAT test. No previous studies have examined the associations between white matter integrity and cognitive-linguistic deficits determined using the KAT test. Patients with DAI showed lower FA values in all left-side tracts than the controls. Unexpectedly, the poor cognitive-linguistic outcome in the language comprehension and production domains was associated with high FA values of several tracts. After excluding five cases with the poorest cognitive-linguistic performance, but with the highest values in the DTI variables, no significant associations with DTI metrics were found. The association between white matter integrity and cognitive-linguistic functioning is complex in patients with DAI of traumatic origin, probably reflecting the heterogeneity of TBI.

Desempenho cognitivo-linguístico de pré-escolares em diferentes contextos educacionais

ABSTRACT Purpose: to investigate preschoolers’ cognitive-linguistic performance in different educational settings. Methods: thirty-nine children aged 4:0 to 5:11 years, enrolled in two private preschools from different Brazilian regions, were assessed with the Protocol for the Early Identification of Reading Problems, in the version adapted to preschool - which includes the following tests: alphabet knowledge; metaphonological skills; phonological working memory; rapid automatized naming; silent word reading; and hearing sentence comprehension based on figures. The groups were compared with the Mann-Whitney statistical test, and significant differences were set at p < 0.05. Results: as expected, data revealed different performances between preschoolers from the two schools. The worse results in both were related to rhyme production and rhyme identification, which reveals that phonological awareness is probably not being stimulated in these groups. Participants performed as expected or “under attention” in the other skills. Conclusion: the performances of preschoolers from both schools were identified and classified, revealing differences in cognitive-linguistic performances between the different educational settings. These results ratify the importance of a teaching approach that helps develop cognitive-linguistic skills, early in preschool.

Preschoolers’ cognitive-linguistic performance in different educational contexts

RESUMO Objetivo: investigar o desempenho cognitivo-linguístico de pré-escolares em diferentes contextos educacionais. Métodos: participaram do estudo 39 crianças, com idades entre 4:0 e 5:11 anos, matriculadas na pré-escola de duas escolas particulares, localizadas em diferentes regiões brasileiras. Os pré-escolares foram avaliados por meio do Protocolo de Identificação Precoce de Problemas de Leitura - IPPL, na versão adaptada para a Educação Infantil, que inclui provas de: conhecimento do alfabeto; habilidades metafonológicas; memória operacional fonológica; nomeação automática rápida; leitura silenciosa de palavras e compreensão auditiva de sentenças a partir de figuras. Os grupos foram comparados por meio do teste estatístico Mann-Whitney, considerando-se significativas diferenças com p<0,05. Resultados: como esperado, os dados revelaram diferenças de desempenho entre os pré-escolares das duas escolas. Verificou-se que os piores resultados, em ambas as escolas, foram relacionados às habilidades de produção de rima e identificação de rima, o que revela que a consciência fonológica não deve estar sendo estimulada nesses grupos. Nas demais habilidades os participantes apresentaram desempenhos dentro do esperado ou sob atenção. Conclusão: foi possível identificar e classificar o desempenho dos pré-escolares de ambas as escolas, havendo diferenças no desempenho cognitivo-linguístico em diferentes contextos educacionais. Tais resultados ratificam a importância de uma abordagem de ensino que promova o desenvolvimento de habilidades cognitivo-linguísticas desde a Educação Infantil.

The Relationship Between Cognitive-Linguistic Performance and Sleep Problems In Adults With Mild Traumatic Brain Injury

<h3>Research Objectives</h3> To determine the relationship between cognitive-linguistic performance and self-reported sleep problems. Hypothesis: Sleep problems, as assessed by global Pittsburgh Sleep Quality Assessment (PSQI) and measures of cognition (processing speed, memory, verbal fluency) will be significantly correlated and those with mTBI history will have reduced cognitive-linguistic performance compared to healthy controls. <h3>Design</h3> Retrospective, cross-sectional study. <h3>Setting</h3> Academic medical center. <h3>Participants</h3> Community-dwelling adults with (n=16) and without mTBI (n=23) were included in the sample. Inclusion criteria: age 18-55, native English speaker, normal to corrected vision and hearing. Exclusion criteria: history of neurological diseases (except mTBI), diagnosed speech or language disorder, presence of sleep disorders, and medications that may affect the brain. Individuals with mTBI were included if they met established clinical criteria for mTBI. <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Measures included the Pittsburgh Sleep Quality Index (PSQI), WAIS-IV Symbol Search/Coding Tasks, Control Oral Word Association Task (COWAT) and NIH Toolbox Cognition Battery. Demographic and injury information was collected via an intake form. Neurobehavioral symptoms were measured using the Neurobehavioral Symptom Inventory (NSI). <h3>Results</h3> An independent samples t-test revealed significantly different PQSI, t(37) = 2.011, p = 0.026. and NSI, t(20.665) = 2.634, p = 0.008 group differences. No significant differences in verbal fluency, processing speed, or NIH cognitive scores were observed. Sleep quality (global PSQI score) and processing speed performance were found to be moderately negatively correlated, r(39)= -.357, p< 0.05 (1-tailed). <h3>Conclusions</h3> Results of this study indicate that sleep quality is an important measure to consider in the clinical assessment and management of mTBI-related cognitive-communication disorders. Future research should include objective measures of sleep when examining cognitive-linguistic performance in individuals with mTBI. <h3>Author(s) Disclosures</h3> There are no conflicts of interest to disclose.

When words first fail: Predicting the emergence of primary progressive aphasia variants from unclassifiable anomic performance in early disease

ABSTRACT Background The majority of patients with primary progressive aphasia (PPA) can be distinguished into one of three variants: semantic, non-fluent/agrammatic, or logopenic. However, many do not meet criteria for any one variant. Aim To identify aspects of cognitive-linguistic performance that yield an early unclassifiable PPA designation that predicted the later emergence of a given variant. Methods & Procedures Of 256 individuals with PPA evaluated, 19 initially were unclassifiable and later met criteria for a variant. Receiver operating characteristic curves were used to evaluate the binary ability of a given task to predict eventual classification as a given variant. Tasks with a high area under the curve were examined using regression analyses to determine their ability to predict variant. Outcomes & Results High mean predictive value was observed for multiple naming assessments targeting nouns and verbs. The Boston Naming Test (BNT) was the only test that, in isolation, resulted in a significant model and high classification accuracy. Conclusions Although naming impairment is common across PPA variants, very low initial BNT scores emerged as a uniquely accurate basis for predicting eventual semantic variant, and normal BNT scores predicted eventual nonfluent/agrammatic variant. High performance on picture-verb verification was useful in identifying future lvPPA.

The Effect of Childhood Traumatic Brain Injury on Verbal Fluency Performance: A Systematic Review and Meta-Analysis.

Verbal fluency is a neuropsychological measure commonly used to examine cognitive-linguistic performance as reported in pediatric TBI literature. We synthesized the scholarly literature of verbal fluency performance in pediatric TBI and estimated the effects of TBI according to: (i) type of verbal fluency task (phonemic or semantic), (ii) severity of TBI, and (iii) time post-injury. Meta-analysis revealed that childhood TBI negatively impacted phonemic fluency and semantic fluency and that effect sizes were larger for children with more severe TBI. The negative effect of TBI was evident across time post injury within each level of severity. Verbal fluency tasks are efficient indicators of potential underlying impairments in lexical knowledge and executive functioning in children with TBI regardless of severity of injury or time post injury. Future research employing verbal fluency tasks are encouraged to explore if age at injury differentiates semantic versus phonemic fluency outcomes across severity levels.

Cognitive-Linguistic Difficulties in COVID-19: A Longitudinal Case Study

This case study examines a 44-year-old woman who contracted SARS-CoV-2 in early 2020 at the beginning of the COVID-19 pandemic in the UK. She was first examined by the author in January 2021. By that stage, it was apparent she had not made a complete recovery from her COVID infection and had gone on to develop the long COVID syndrome. Her predominant symptoms were fatigue and marked “brain fog”. As well as causing considerable distress, these symptoms were preventing her from resuming her occupational role as a community nurse working in a district nursing team. On assessment by the author, significant difficulties were evident in immediate and delayed verbal recall, the informativeness of spoken discourse, and verbal fluency. The author and woman communicated regularly between January and July 2021. Although some improvement in her condition was reported during this time, it was not sufficient for her to return to work and resume other daily activities. The author assessed her again at the end of July 2021 and reported a moderate improvement in her earlier cognitive-linguistic performance. This case study examines the onset and progression of this woman’s COVID illness, with particular focus on the cognitive-linguistic difficulties that remain her most persistent and troubling symptom. Keywords: Brain fog, COVID-19, long COVID, SARS-CoV-2, speech-language pathology. Read more →

Effects of language stimulation on cognition of institutionalized aged people: a preliminary case series study.

ABSTRACT.Cognitive stimulation programs for institutionalized elderly people show positive results, however few studies have investigated the effectiveness of language stimulation programs for the health of this population.Objectives:To characterize the cognitive-linguistic profile of institutionalized elderly and to compare their performance before and after a language stimulation program (LSP).Methods:An exploratory case series study was conducted with nine residents of a Home for the Aged. Elderly people aged 60 or over, of both sexes, without neurological or neuropsychiatric diseases, communication disorders, intellectual impairment or severe visual or hearing impairment were included. The participants were submitted to an initial assessment through the Montreal Cognitive Assessment (MoCA) and Montreal Toulouse Battery Language Assessment – Brazil to characterize the cognitive-linguistic profile of the studied group. Five elderly were selected to participate in the LSP, of wich only two participated effectively in the program, but all were reassessed after the program was completed.Results:on the initial assessment, of the nine participants, only one had adequate cognitive performance and all presented changes in macro and/or microlinguistics aspects of oral discourse, with oral comprehension preserved. On the reassessment carried out with five participants, only two participants who adhered effectively to the program obtained improvements in MoCa scores. In regarding language, three participants performed better in the oral emission measures. The performance of the participants in oral comprehension remained or declined.Conclusion:The speech-language therapy intervention through a LSP contributes to improving the cognitive-linguistic performance of institutionalized elderly.

Cognitive-linguistic performance of schoolchildren in the literacy cycle in the public school context: universal screening

ABSTRACT Objective: to characterize the linguistic-cognitive performance of schoolchildren in the literacy cycle, in order to identify children at risk for learning disorders in the public school context. Methods: this study involved 88 children, aged 6 to 8 years, enrolled in the first, second and third year of elementary education I, from two schools in the city of Recife, Pernambuco, Brazil. The procedure used was the Cognitive-Linguistic Skills Evaluation Protocol, which has collective and individual versions, both being applied. The analysis of the groups was performed through the statistical non-parametric Kruskal-Wallis test with p &lt;0.05. Results: all students were submitted to the individual version for presenting poor performance in the collective version of the protocol. Thus, the application of the collective version was not sufficient to identify children at risk for learning disorders, thus, the indication of the individual assessment. In the individual version, students from the 1st year showed a lower performance in most of the subtests that make up the instrument, whereas those from the 2nd and 3rd years had an average performance, which also deserves attention, according to the instrument of evaluation. These results, below the one expected for the age and school year, may be a consequence of poor learning opportunities within and outside school. There were also significant differences as a function of the schooling advance, revealing that the cognitive-linguistic skills, precursors of the reading and writing learning process, are only having a greater leap of development at the end of the literacy cycle, in the third year, which reveals a significant delay in terms of learning. Conclusion: the low performance observed in cognitive-linguistic abilities in schoolchildren hinders the early identification of children at risk for learning disorders and questions the quality of educational opportunities experienced by the students inside and outside the public school. Other factors, such as regional differences in language and linguistic context, need to be considered in the interpretation of tests that evaluate cognitive-linguistic abilities.

ERRATUM: Cognitive-linguistic performance of schoolchildren in the literacy cycle in the public school context: universal screening

ERRATUM: Cognitive-linguistic performance of schoolchildren in the literacy cycle in the public school context: universal screening

Reaction time and cognitive-linguistic performance in adults with mild traumatic brain injury

ABSTRACTObjective: The purpose of this study was to characterize cognitive-linguistic performance in adults with mild traumatic brain injury (mTBI) to advance assessment and treatment practices. We hypothesized that individuals with mTBI would demonstrate longer reaction times (RTs) and greater error rates when compared to an orthopedic injury (OI) group on a category-naming task.Method: Participants were age and education-matched adults with mTBI (n = 20; 12 females) and adults with OI (n = 21; 5 females) who were discharged to home after an Emergency Department visit. Our primary task was a category-naming task shown to be sensitive to language deficits after mTBI. The task was adapted and administered under speeded and unspeeded conditions.Results: There was a significant main effect of condition on RT (speeded faster than unspeeded) and accuracy (more errors in the speeded condition). There was a marginally significant effect of group on errors, with more errors in the mTBI group than the OI group. Naming RT and accuracy in both conditions were moderately correlated with injury variables and symptom burden.Conclusions: Our data showed a marginal effect of group on accuracy of performance. Correlations found between naming and neurobehavioural symptoms, including sleep quality, suggest that the latter should be considered in future research.

Cognitive-Linguistic Performance and Quality of Life in Healthy Aging

Background/Aims: This study investigated quality of life (QoL) in relation to cognitive-linguistic performance and demographic characteristics (age, education and gender) in a large cohort of cognitively healthy older adults. Method: A total of 578 Greek-Cypriots aged 60-91 years were recruited from the Neurocognitive Study on Aging. Of those, 395 healthy participants (171 males and 224 females) who met all study criteria were retained. They completed measures of executive functioning, working memory, receptive vocabulary and confrontational naming in addition to the WHOQOL-BREF (brief version of the WHO QoL questionnaire). Results: There were modest but significant relationships between executive functioning, working memory, vocabulary measures and the WHOQOL-BREF (p < 0.01). MANOVA yielded significant gender and education effects on QoL. Sequential stepwise regression confirmed that gender, depression scores and years of education made significant contributions to predicting the total score on WHOQOL-BREF and accounted for 31% of the variance (R² = 0.310). Conclusion: Self-reports of QoL remain stable in older adulthood. Demographic variables such as gender and years of education affected several domains of QoL, and, along with depression symptomatology, accounted for a significant part of the WHOQOL-BREF variance. Cognitive-linguistic measures correlated on the physical and psychological health domains of the WHOQOL-BREF in healthy older adults.

Avaliação de Alunos com Síndrome de Down: Aspectos Cognitivo-Linguísticos, Educacionais e Funcionais

The objective of this research was to establish a profile of four students with Down syndrome enrolled in the regular school system assessing the cognitive-linguistic potentialities, knowledge acquisition, and academic and functionality performance. For this, we confront the data obtained from the three types of assessments obtaining a profile of students. We note that, regardless of the ages and grades in which they were enrolled, no qualitative differences between assessments of intelligence, knowledge acquisition, academic content and functionality were observed. It is concluded that research, ongoing evaluation, analysis and recycling of educational resources and planning of educational activities must be in a constant search for improvement in meeting the needs of students with Down syndrome. Keywords: inclusive education; assessment; Down syndrome; cognition; functionality.

정상 노년층의 인지-언어 능력과 인지 보존능력 간 상관성에 관한 메타분석

인지 보존능력(CR)이란 보완적 뇌 연결망을 통해 인지적 수행력을 최적화 또는 극대화시키는 능력이다. CR은 노화에 따른 인지-언어 능력의 저하를 완화 또는 지연시키는 데 기여한다. CR 및 정상 노년층의 인지-언어 능력 간 상관성을 체계적으로 살펴본 국내 메타분석 연구는 거의 드문 편이다. 본 연구에서는 2000년 이후 게재된 국내외 문헌 중 총 32개 논문을 대상으로 메타분석을 실시하여 상관성을 체계적으로 검증하고자 하였다. 그 결과, CR의 유형은 교육수준과 인지자극 활동, 다중언어 사용, 직업 순으로 많았고, 인지-언어의 하위 영역 중에는 기억력, 전반적 인지능력, 언어능력이 대다수를 차지하였다. 또한, CR과 인지-언어 능력 간 상관성은 '중간' 정도였으며, 기억력, 언어능력 등이 여러 CR 유형과 유의한 상관성을 보였다. 본 연구는 CR이 정상 노년층의 인지-언어 능력에 미치는 효과성을 체계적으로 분석함으로써 증거 기반적 자료를 제공할 수 있다는 점에서 의의가 있다. Cognitive reserve(CR) is the ability to optimize or maximize performance through complementary brain networks. CR is relevant to normal aging in cognitive-linguistic abilities. There are few domestic systematic reviews or meta-analyses that analyze the relationships between multiple CR and cognitive-linguistic domains in healthy older people. This meta-analysis included 32 studies published since 2000. In result, education level topped the list, followed by the occupation, cognitively stimulating activities, and the multilingualism. Most studies were related to memory, global cognition, and language. CR had a modest positive association with cognitive-linguistic performance. Multiple domains including memory and language also showed the significant correlations across most measures of CR. This study provides evidence-based information to support cognitive-linguistic ability in normal aging.

The ins and outs of meaning: Behavioral and neuroanatomical dissociation of semantically-driven word retrieval and multimodal semantic recognition in aphasia

Theories about the architecture of language processing differ with regard to whether verbal and nonverbal comprehension share a functional and neural substrate and how meaning extraction in comprehension relates to the ability to use meaning to drive verbal production. We (re-)evaluate data from 17 cognitive-linguistic performance measures of 99 participants with chronic aphasia using factor analysis to establish functional components and support vector regression-based lesion-symptom mapping to determine the neural correlates of deficits on these functional components. The results are highly consistent with our previous findings: production of semantic errors is behaviorally and neuroanatomically distinct from verbal and nonverbal comprehension. Semantic errors were most strongly associated with left ATL damage whereas deficits on tests of verbal and non-verbal semantic recognition were most strongly associated with damage to deep white matter underlying the frontal lobe at the confluence of multiple tracts, including the inferior fronto-occipital fasciculus, the uncinate fasciculus, and the anterior thalamic radiations. These results suggest that traditional views based on grey matter hub(s) for semantic processing are incomplete and that the role of white matter in semantic cognition has been underappreciated.

Las destrezas narrativas en niños de 5 años: Propuesta de un instrumento de evaluación clínica del lenguaje

The skills involved in narrative competence allow us to predict the child’s further cognitive-linguistic performance. Thus, from a speech and language perspective, it is extremely important to have clinical tools to evaluate such aspect .The present manuscript addresses the design of a clinical instrument to assess the abilities involved in narrative competence. Such abilities comprise those related to the development of canonical narrative structure as well as those related to the expression of content. These abilities are analyzed through an activity of re-telling a store induced from an ad-hoc oral text accompanied with pictures .A form specifically created for systematic qualitative and quantitative analysis was used to collect the data. The materials used in and a preliminary psychometric analysis of a pilot study conducted in 22 normal-language development pre-school children coming from middle-class families in the city of Buenos Aires are discussed. The results show that the instrument is capable of determining which narrative skills are involved in pre-school children and the manner they should be assessed.

Habilidades cognitivo-linguísticas e sua relação com características respiratórias

OBJETIVO: relacionar características respiratórias com o desempenho em habilidades cognitivo-linguísticas de crianças de uma escola pública da grande Belo Horizonte. MÉTODO: estudo transversal, observacional e descritivo. Das 180 crianças recrutadas 131 atenderam aos critérios de inclusão e exclusão. Foram avaliadas 66 crianças da 4ª série e 65 da 3ª série do ensino fundamental, de ambos os gêneros, com idades entre nove e dez anos. Foi utilizado um questionário para investigação das características respiratórias e um protocolo previamente publicado e adaptado a população brasileira para avaliação das habilidades cognitivo-linguísticas. As informações coletadas foram analisadas por meio dos testes de Mann-Whitney e Kruskal Wallis, ao nível de significância de 1%. RESULTADOS: não foi observado valor de p&lt;0,01 na comparação entre as características respiratórias e as pontuações obtidas por cada série no teste das habilidades cognitivo-linguísticas. Observou-se que 59,1% dos alunos apresentaram escores no questionário de pesquisa das características respiratórias entre zero e quatro pontos, indicando pouco comprometimento respiratório. CONCLUSÃO: não foi encontrada relação significante entre o desempenho de habilidades cognitivo-linguísticas e a presença de características respiratórias em escolares de uma escola pública de Belo Horizonte, sendo que as crianças que apresentaram sinais e sintomas de alterações respiratórias não obtiveram desempenho abaixo daquelas sem estas alterações nas habilidades avaliadas.

Nomeação rápida, leitura e compreensão em escolares com dificuldades de aprendizagem

To compare and correlate the performance of students with learning difficulties in rapid naming, reading and comprehension. Participants were 32 students from 4th grade of elementary school of both genders, with ages between 11 years and 4 months and 12 years and 7 months. The first and second oral reading of a text selected based on the indication of 4th grade teachers were conducted, as well as the first and second reading comprehension task composed by four questions presented right after the reading, to which students should answered orally, and the rapid naming task from the Test of Cognitive-Linguistic Performance, individual version. Differences were found between the first and the second comprehension scores, and between rapid naming, first and second reading. There was a strong correlation between comprehension and reading, suggesting that the performance in the first reading significantly influenced the performance in the second reading, which also occurred for comprehension. The delay in the activities of naming, reading and comprehension in the first evaluation provoked failures in the phoneme-grapheme conversion that may be enough to cause learning difficulties in reading.

Differential susceptibility to long-term effects of quality of child care on externalizing behavior in adolescence?

Much research on the quality of child care reveals it —in the case of low-quality child care—to be related to poorer child functioning, net of confounding factors, perhaps especially in the case of cognitive-linguistic performance. Recent work using data from the National Institute of Child Health and Human Development (NICHD) Study of Early Child Care and Youth Development (USA) makes clear that when children’s early negative emotionality/difficult temperament is taken into account, it also predicts externalizing problems reported by teachers through the primary school years. More negatively emotional infants are more affected—for better and for worse—by child care quality than less difficult ones, such that the latter appear unaffected by it but the former benefit from good quality care and are adversely affected by poor quality care. Here we determine whether the same is true when children are restudied in adolescence and the focus is their own reports of externalizing problems, impulsivity and risk taking. Results prove more consistent with a diathesis-stress model of environmental action than a differential-susceptibility-related one, in that 15-year-olds who were highly negative as infants report more externalizing behavior (but not risk taking or impulsivity) if they experienced low-quality child care, but not fewer problems if they experienced high-quality care relative to their counterparts with less difficult temperaments in infancy. Results are discussed in relation to physiological stress, with possible explanations offered as to why the predictive nature of child care experience might change over time.