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Fine motor skills of two- to three-year-old drug exposed children

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Fine motor skills of two- to three-year-old drug exposed children

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Content FINE MOTOR SKILLS
OF TWO-TO THREE-YEAR-OLD DRUG EXPOSED CHILDREN
by
Linda Ann Adintori
A Thesis Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF ARTS
(Occupational Therapy)
August 1995
Copyright 1995 Linda Ann Adintor
UNIVERSITY O F S O U T H E R N C A L IFO R N IA
THE GRADUATE SCHOOL
U NIVERSITY PARK
LO S A N Q ELES. CA LIFO R N IA SOOOT
This thesis, w ritten by
Li,nda _Ann AdI.ntori.....................
under the direction of Ae.r Thesis C o m m itte e ,
and a p p r o v e d by all its members, has been p r e
sented to and accepted by the D e a n of T h e
G raduate School, in partial fulfillm ent of the
requirements fo r the degree of
MASTER OF ARTS
D**m
THESIS COMMITTEE
Chairman
....
Fine Motor Skills
of Two-To Three-Year-Old Drug-Exposed Children
Abstract
The purpose of this study was to determine if fine motor
skills in two-to three-year-old children who have been
prenatally exposed to drugs differ from fine motor skills of
non-exposed children of the same age. The Fine Motor Scale of
the Peabody Developmental Motor Scales(PDMS) was used to
assess the fine motor abilities of a group of drug-
exposed(n=8) and non drug-exposed(n=8) children. Two groups
were matched closely for socio-economic status, gender, age,
and ethnicity. The results of this study indicated that
scores on the eye-hand coordination subtest were significantly
lower for the drug-exposed children (p<.05), suggesting that
this is an area that occupational therapists should address
when working with drug-exposed children.
Thesis Adviser: Diane L. Parham, PhD.,OTR
TABLE OF CONTENTS ii
CHAPTER I. STATEMENT OF THE PROBLEM.............. 1
Statement of the Problem...................... 1
Relevance to Occupational Therapy........... 1
Study Design.................................... 2
Hypothesis...................................... 4
Assumptions..................................... 4
Limitations..................................... 5
CHAPTER II. REVIEW OF THE LITERATURE............. 7
Review of the literature...................... 7
Fine Motor Development........................ 8
Differentiation of Hand Functions........... 9
Developmental Progression of FM Skills...... 11
FM Development of Drug-exposed Children 12
CHAPTER III. METHODOLOGY........................... 17
Instrumentation .......................... 17
Participants.................................... 21
Procedure........................................ 24
Data Analysis................................... 27
CHAPTER IV. RESULTS................................. 28
CHAPTER V. DISCUSSION.............................. 30
Interpretation.................................. 30
Limitations..................................... 32
Future Research................................. 32
REFERENCES............................................ 34
APPENDICES
A Parent Questionnaire........................... 37
B Consent Form..................................... 39
1
CHAPTER ONE: STATEMENT OF THE PROBLEM
Statement of the Problem
The purpose of this study was to determine if fine
motor skills in two-to three-year-old children who have been
prenatally exposed to drugs differ from fine motor skills of
non-exposed children of the same age. This was measured by
the Peabody Fine Motor Scales in the areas of grasping, hand
use, eye-hand coordination and manual dexterity. Very
little research has addressed fine motor skills in children
with prenatal drug exposure. Several studies have indicated
that drug exposed children between two and three years of
age scored within a normal range on the Psychomotor
Developmental Index (PDI) and the Mental Developmental Index
(MDI) of the Bayley Scales of Infant Development (Deren,
1986; Howard, 1986). These studies mentioned that delays in
fine motor coordination were observed even though PDI and
MDI scores were found to be within age expectations. Fine
motor differences were noted anecdotally. None of the
reviewed studies referred to using a standardized fine motor
assessment for the purpose of evaluating this area.
Relevance to Occupational Therapy
Occupational therapists are currently facing the
challenge of working with drug-exposed infants in nurseries,
2
day care centers, preschools, and center-based therapeutic
programs. The first part of the challenge involves
acquiring a base of knowledge about the development of
prenatally drug exposed children (Lane, 1992), which may
have implications for early intervention. A description of
fine motor skill development in drug exposed children may
assist in therapeutic programming for these children.
Immature or delayed fine motor skill development has
occupational implications for children in school, play, and
daily life. For example, a child with fine motor skill
deficits may need assistance in cutting with scissors or
shoe tying.
Study Design
The research design chosen for this study is expost
facto or causal-comparative. The purpose of a causal-
comparative study is "to investigate possible cause-and-
effect relationships by observing some existing consequence
and searching back through the data for plausible causal
factors" (Isaac & Michael, 1989, p.42). The consequence
investigated in this study was fine motor skills and the
hypothesized causal factor was drug exposure. However, this
is not a simple cause-effect relationship. Developmental
skills are variable at all ages and the maturation of these
skills is also dependent upon other variables such as age,
gender, and environment to mention a few.
3
Data on a total of thirty-six children were obtained:
nineteen drug-exposed children and seventeen non-exposed
children. Not all of these children were able to be
matched, and subsequently, the study was completed with a
total of 8 matched pairs. Participants were matched by
socio-economic status, ethnicity, gender, and age.
Age ranges for testing were chosen to coincide with
scheduling for testing of drug-exposed children in the Hope
Clinic at the University of California at Irvine in Orange,
California, where this researcher is currently employed.
This is the site where the drug-exposed group was tested.
Children are currently seen at 24, 30, and 36 months of age
and this researcher had access to these subjects. A sample
of eight drug-exposed children and eight non-exposed
children were tested,
A comparison group was matched on age, gender, socio
economic status and ethnicity. These participants were
obtained from several local nursery schools. Residential
areas were matched as closely as possible to those of the
children with drug exposure.
The Fine Motor Scales of the Peabody Developmental
Motor Scales (Folio & Fewell, 1983) were administered to all
children. The purpose of using this tool was to supply the
researcher with information regarding the degree of fine
motor skill development.
4
Gebhard, Ottenbacher & Lane (1994) studied the inter
rater reliability of the PDMS Fine Motor Scales and reported
coefficients ranging from 0.90 to 0.97 for the subcategories
of grasping, hand-use, eye-hand coordination, and manual
dexterity. Twenty-three children between the ages of 2 and
5 years with developmental disabilities were tested. These
researchers concluded that "The PDMS fine motor scale can be
used consistently to evaluate fine motor delays in this
population of young children"(Gebhard, Ottenbacher, & Lane,
1994, p. 976). Inter-rater reliability was not evaluated in
the present study due to time constraints.
Hypothesis
The hypothesis which was tested was that two to three
year old drug-exposed children would obtain lower scores on
the Fine Motor Scales of the Peabody Developmental Motor
Scales(PDMS) than non drug-exposed children. The PDMS
scores that were examined were grasping, hand-use, eye-hand
coordination, and manual dexterity.
Assumptions
Assumptions were made which should be considered in the
discussion of this study. It was assumed that the parent(s)
of the children in the comparison group would be honest with
the researcher when asked if their child had been exposed in
utero to any illicit drugs such as amphetamines or cocaine.
5
Furthermore, it was expected that they would accurately
recall whether alcohol or tobacco were used during the
pregnancy in order to eliminate the possibility of develop
mental delays due to the use of other intoxicating
substances. An additional assumption was that the Peabody
Fine Motor Scales would provide an accurate assessment of
fine motor skills.
Limitations
The settings which were available for evaluation of the
children may be a limitation of this study. The group of
drug-exposed children and the group of non-exposed children
were not tested in the same place. The drug-exposed children
were evaluated in a testing room in Hope clinic at the
University of California in Orange, California, whereas the
comparison children were evaluated in a separate room in
their respective pre-schools. However, each child was
tested in a location unfamiliar to him or her. It is hoped
that environmental differences in the testing location did
not significantly affect performance of either group.
Other factors which could not be controlled were the
parents’ marital status, parents' intelligence quotient, and
the home environment. The drug-abusing environment may have
an effect on the development of the child, according to
Zuckerman & Bresnahan (1991). The latter factor may
contribute to the type and amount of environmental
stimulation, including experience with fine motor
activities, that is provided for the child. Thus, any
differences that may be found between groups cannot be
solely attributed to prenatal drug exposure.
Another limitation is that the researcher conducted a
of the testing, and was aware of each child's history
related to drug exposure. This may have biased the result
Unfortunately, time constraints prevented an evaluation of
inter-rater reliability, which would be been helpful if a
second rater could be used who was blind to the study.
Inter-rater reliability of the PDMS with children with
developmental problems does, however, appear to be quite
high (Gebhard, Ottenbacher, & Lane, 1994).
7
CHAPTER TWO: REVIEW OF THE LITERATURE
Review of the Literature
Chasnoff, Burns, Burns, & Schnoll (1986) reported that
the drug-seeking environment and lack of an appropriate
model from which drug-abusing women may learn parenting
skills, compounded by neurobehavioral deficits in the
newborn, are indicators that these infants are at high risk
for later developmental and school problems. The authors
suggest that intervention should aim at teaching parenting
skills “necessary for proper infant stimulation and
subsequent development" (Chasnoff et al., 1986, p. 361).
Information regarding fine motor development in children
with drug exposure is necessary if parents are to be
provided with proper stimulation techniques and sequential
developmental suggestions for early intervention. However,
this area of development has not previously been studied
systematically in children with prenatal drug exposure.
A literature review on the topic of drug exposed
children between two and three years of age revealed general
motor and mental performance to be within a normal range, on
the average, in most studies (Chasnoff, Griffith, Freier, &
Murray, 1992; Deren, 1986; Giacolo, 1990; Wilson, 1979).
Fine motor problems were mentioned anecdotally as a part of
some studies even though overall motor and cognitive scores
were within normal ranges (Chasnoff et al., 1986; Howard,
Kropenske, & Tyler, 1986; Wilson, 1973; Wilson, 1979). Fine
8
motor skill development of drug exposed children has not
been adequately documented in research using reliable and
valid methods of measuring fine motor skills.
Howard et al. (1986) reported that children exposed to
phencyclidine hydrochloride (PCP) were found to demonstrate
fine motor scores in the low normal range in the fine motor
area on the Gesell Developmental Schedules. A global
description of fine motor control was discussed based on a
very small sample size of 12 infants. Five of the 12
infants were born prematurely between 33 to 36 weeks
gestation. A correction was made for gestational age when
scoring the evaluations of the preterm infants so that
infants were seen at approximately the same chronologically
corrected age(CCA). Eight of the 12 initially enrolled
infants were evaluated at 8.75 months(CCA) with
developmental quotients of 81 + 18.7. Only 5 of the
original 12 were evaluated at 17.75 months with fine motor
developmental quotients of 86 ± 12.9. Fine motor scores
were lower than scores of gross motor skills, adaptive
skills, language skills or personal-social skills.
According to Howard et al. (1986), these children had
abnormal fine motor movements characterized by a continued
palmar approach to objects with difficulty approximating a
digital-thumb grasp. It is possible that these immature
grasp patterns may affect later performance.
9
Fine Motor Development
The term fine motor skills must be defined in order to
understand fine motor development. Fine motor refers to
movements of the small muscles of the body (Folio & Fewell,
1983). Erhardt describes skills as being "sequences of
organized, goal-directed actions, which apply strategies
proceeding to a future goal" (Erhardt, 1992, p. 14).
Therefore, fine motor skills may be defined as sequences of
organized, goal-directed movements of the small muscles of
the body which produce an outcome.
The Peabody Fine Motor Scales specifically test fine
motor skills which may then be analyzed using four
subcategories. The following four subcategories comprise
the Fine motor Scale of the Peabody Developmental Motor
Scales: grasping, hand use, eye-hand coordination, and
manual dexterity (Folio & Fewell, 1983). Grasping involves
simply holding the object. Hand use involves goal directed
action of the hands as seen on a developmental continuum.
Eye-hand coordination involves a visual component with
action on the object, and manual dexterity involves
sequential manipulation of the digits and/or objects in the
hand (Folio & Fewell, 1983). For the purposes of this
study, the term fine motor will refer to the completion of
tasks in one or more of these subcategories to achieve an
ultimate functional goal. For example, stringing a bead
involves a sequence and chain of events beginning with reach
10
and grasp of the bead and the lace using a variety of grasp
patterns, and manipulations of the objects using the hands
in combination with visual sequencing in order to complete
the action.
Differentiation of Hand Functions
The progressive development of grasp has been related
to the interplay between stability and mobility functions of
the hand (Rosenbloom & Horton, 1971). Rosenbloom and Horton
(1971) described the progressive development of the tripod
grasp in stages with proximal fixation of the joints
allowing refinement of localized movement to occur. An
example of the stability and mobility functions is seen in a
child’s first attempts at writing. The child first
initiates writing with movement occurring at the shoulder.
As the shoulder stabilizes, the movement is then initiated
at the elbow which assists in further refining the grasp
pattern (Rosenbloom & Horton, 1971).
Extrinsic and intrinsic hand movements develop as part
of the functions of stability and mobility of the hand.
Extrinsic movements involve moving the entire hand by using
the upper limb and intrinsic movements involve movements of
the digits in a coordinated manner to move the object in the
hand itself (Elliot, 1979).
Elliot & Connolly (1984) suggested that there is a
distinction between palmar grips and digital patterns of
11
prehension. Palmar grips require that the upper trunk,
shoulder, upper limb, and wrist be used in order to mobilize
the object in the hand. "Degrees of freedom of movement"
(Elliot & Connolly, 1984, p. 283) are limited in the hand by
the digits when a palmar grip is used. Variety of movement
increases when the object is held between the digits and
manipulated within the hand. This manipulation
distinguishes palmar grips from digital manipulation, the
latter of which requires coordination of finger movements
and organization. Elliot (1979) defined these uses of the
hand as extrinsic hand movements and intrinsic hand
movements. This sequence of hand movements are observed
progressively during fine motor skill acquisition.
Developmental Progression of Fine Motor Skills
A steady rate of progress is generally seen in the
development of fine motor coordination between the ages of
two and three years. Gesell (1947) listed several
activities which children are developmentally capable of
performing 24, 30, and 36 months of age. For example, at 24
months a child is able to tower 6 cubes, at 30 months tower
8 cubes, and at 36 months 9-10 cubes (Gesell, 1947).
Stability and precision appear to increase along a continuum
with skill development. Object use is then influenced by
the quality of fine motor behavior (Kopp, 1974).
12
Early manipulative patterns as described by Knobloch &
Pasamanick (1974) are simple and clumsily executed. As
complexity increases in the precision of the manipulations,
coordination must also increace (Knobloch, 1974). If fine
manipulation is viewed on a sequential developmental
continuum then coordination must continue to increase as the
complexity of the skill increases with age (Case-Smith &
Pehoski, 1992). For example, a child is first able to
unbutton a button by pulling the button apart from the
closure using both hands. The child then ascends the
developmental continuum by developing the manipulation and
coordination necessary to allow him or her to button the
button. The maturation of these skills allows a child to
progress from completing the task using larger sized buttons
to smaller sized buttons (Folio & Fewell, 1983).
A child's manipulative prehension matures through
repetition of purposeful activities (Gilfoyle, Grady, &
Moore, 1981). Mobility and stability of the joints and
muscles continually refine as the child grows, allowing
precise movements to occur. These movements are repeated in
activities which further refine the skill and quality of
execution. Learning to write i6 an example of repeated
activity which is refined as the child grows. The
repetition of activities culminates in prehension patterns
"which are unique to the person but encompassing the
essential components of prehension" (Gilfoyle, 1981, p.
13
152). As the child continues to add skill to his or her
repertoire and simultaneously refines the quality of the
hand skill, he or she becomes more proficient at the task.
Fine Motor Development of Drug-Exposed Children
The lack of refinement of hand skills has been
mentioned briefly in some studies and has been observed by
this researcher in a clinic for drug exposed infants.
However, very few researchers have used objective
assessments to examine the status of fine motor development
in drug exposed children.
Wilson (1973) reported poor fine motor coordination in
14% of 14 children who were born to heroin-addicted mothers
and were followed between the ages of 12 to 34 months even
though age appropriate performance was achieved on the
Gesell Developmental Schedules. Discrepancies between gross
motor and fine motor skills were noted in ten children. In
nine out of these ten cases gross motor skills were more
advanced than fine motor skills with respect to age. Gross
and fine motor performance was measured by performance on
the Gesell Developmental Schedules. Even though this scale
views both gross and fine motor performance, it does not
break down the areas of fine motor functioning as does the
Peabody Fine Motor Scales.
Wilson (1979) compared psychometric test scores of 3 to
6 year old children of heroin-addicted mothers with three
14
groups of children matched for age, race, sex, birthweight,
and socio-economic status. Although test scores on the
McCarthy Scales of Children's Abilities were within normal
ranges in the heroin-exposed group, performance was found to
be significantly poorer than the comparison groups on the
cognitive index of the McCarthy Scales of Children's
Abilities in the areas of visual, tactile, and auditory
perception. Self adjustment, social adjustment, and
physical adjustment were areas of greater difficulty as
rated by parents. Physical adjustments included fine motor
and gross motor skill areas. Impulsivity, decreased self
confidence and aggressiveness are examples of items which
varied significantly in the heroin-exposed group. The
heroin-exposed group scored lower on subtests of the
McCarthy Scales of Children's Abilities which required the
use of organizational skills and focused attention.
Organizational skills and focused attention are qualities
that are required as the complexity of fine motor skills
increases on the developmental continuum (Case-Smith &
Pehoski, 1992). These qualities may impede performance in
fine motor areas, particularly as dexterity and manipulation
are required. A child who is impulsive may not complete
tasks and ultimately may avoid performing activities which
are tedious. The heroine-exposed group of children also
performed poorly on the test of rapid alternating motion of
15
the hand (Wilson, 1979), a task involving the use of
bilateral motor coordination.
Lane (1992) reported having used the Peabody
Developmental Motor Scales (PDMS) to assess motor
performance in children prenatally exposed to cocaine. Lane
(1992) reported that a limited number of 24 month old
children were tested using the PDMS as of the date of this
article. No specific numbers of children were indicated.
Global results were reported as being within low normal
ranges on all subscales in the fine motor skill areas of
cocaine exposed children aged 12, 18, and 24 months. It is
unclear whether or not a comparison group was studied for
each age.
Chasnoff (1992) studied three groups of infants and
reported two year follow-up outcomes. Group one was exposed
to cocaine and marijuana and/or alcohol. Group two was
exposed to only marijuana and/or alcohol and group three was
not exposed to any drugs during pregnancy. The mean scores
on the Bayley Scales of Infant Development between the drug
exposed groups and the non-exposed group did not vary
significantly. However, Chasnoff reported that an increased
proportion of scores were two standard deviations below the
mean in groups one and two as compared to the scores of the
non-exposed group of children. Exact percentages were not
documented in the study. The incidence of delays on the
Bayley Motor Scales (being one or more standard deviations
16
from the mean) was significantly higher in the
cocaine/polydrug exposed infants (Chasnoff, 1992). Testing
results were not broken down into specific areas of
difficulty or ages. The Bayley Scales of Infant Development
(Bayley, 1969) contain fine motor tasks on the motor
portions of the test, which may have lowered scores if the
precision of the skill was not evident. However, whether or
not fine motor items depressed Bayley scores was not noted
by the researchers.
In the review of the literature, fine motor skill was
mentioned as an area of difficulty for children who have
been exposed to drugs in utero, yet specific measures of
this skill have not been employed in the preschool aged,
drug-exposed population. Further research is necessary in
this area to aid the development of intervention strategies
which may be employed in clinical and school settings to
assist these children in attaining their functional goals.
In the event that fine motor skills are found to be
normal in the drug-exposed group of children, these skills
may be used to compensate for other possible areas of
deficit or weakness in school, leisure time activities, and
play. For example, if a child has difficulty with gross
motor coordination he/she may choose to further develop
his/her skill at computer games.
17
CHAPTER THREE: METHODOLOGY
It was the goal of this study to investigate whether
there are differences in fine motor skill performance
between prenatally drug-exposed and non drug-exposed two-to
three-year-old children. The specific research question
was: Are there any differences between the drug exposed and
the non-exposed comparison group in the areas of hand use,
grasp, fine motor coordination, and manual dexterity that
are measured by the Peabody Developmental Motor Scales
(PDMS)?
Instrumentation
The Fine Motor Scale of the Peabody Developmental Motor
Scales (Folio & Fewell, 1983) was administered to all
participants. This test assesses fine motor skill and has
been found to be highly correlated with chronological age,
even more so than the McCarthy Scales of Children's
Abilities or the Bayley Scales of Infant Development
(Campbell, 1988). The latter two scales have been used
frequently in studies of the development of children with
prenatal drug exposure. The Fine Motor Scale of the Peabody
Developmental Motor Scales is sensitive to the progression
of fine motor skills and is considered to be a valid test
instrument (Folio & Fewell, 1983; Palisano, 1986).
The Fine Motor Scale is divided into four skill
categories: grasping, hand use, eye-hand coordination, and
18
manual dexterity. The test contains 6 or 8 items at each
age level. Test items are scored 0, 1, or 2 with a score of
1 indicating partial success in completing the item and a 2
indicating complete success. The Fine Motor Scale may be
administered in 20 to 30 minutes. Results are presented as
a standardized developmental motor quotient (DMQ), age
equivalent, z score, T score, and percentile rank (Folio &
Fewell, 1983). These scores are available for each area of
skill as well as for the total fine motor ability.
Hinderer, Richardson, & Atwater (1989) discussed the
clinical implications of the Peabody Developmental Motor
Scales with regard to strengths and weaknesses of the test
construction, reliability, validity, content,
administration, and scoring. The reviewers raise cautionary
notes regarding use of percentile scores due to large
standard errors of measurement (SEMs) and unequal age
intervals in the percentile rank tables. The z scores were
used in reporting scores for this study in order to provide
a more accurate analysis of performance. The authors
concluded that the Peabody Developmental Motor Scales (PDMS)
provide the clinician with valid and reliable information
regarding fine motor skills and that the test also fills a
void in testing the 2.5 to 4.5 year old child (Hinderer et
al., 1989).
Test-retest reliability and inter-rater reliability
coefficients reported in the test manual for the Peabody
19
Fine Motor Scale were high when they were calculated for
total scores, with reliability coefficients of .99 and .99,
respectively (Folio & Fewell, 1983). Stokes, Deitz, & Crowe
(1990) studied inter-rater reliability between two raters on
the Fine Motor Scales of the PDMS. A total sample size of
32 children between four to five years of age were tested.
Sixteen of the children had developmental delays which were
previously identified. The correlation coefficients between
sets of data for the two raters using the pearson product-
moraent procedure were r=.78 for the delayed group of
children and r=.97 for the non-delayed group of children.
Intraclass correlation coefficients were .76 and .96 for the
delayed group and the non-delayed group, respectively. The
percentage of agreement was greater between the two raters
for the non-delayed group than for the delayed group of
children. The researchers concluded that "the Fine Motor
scale of the Peabody Scales includes enough items to
minimize the total score difference between two
raters'*( Stokes, Deitz & Crowe, 1990, p. 334).
Palisano (1986) studied concurrent and predictive
validity of the Motor Scale of the Bayley Scales of Infant
Development and the Peabody Developmental Motor Scales
(PDMS). According to Palisano, "concurrent validity is
concerned with the correspondence between a test's results
and the results obtained with a previously available test
that is considered reliable and valid" (Palisano, 1986, p.
20
1714). Both tests were administered to 23 full term and 21
healthy premature infants at 12, 15, & 18 months of age.
The study revealed a high correlation between the Gross
Motor Scale of the Peabody Developmental Motor Scales (PDMS)
and the Bayley Motor Scale, thus assisting in establishing
validity of the PDMS. The Fine Motor Scale of the PDMS did
not correlate with the Bayley Motor Scale; however, it was
noted that the Bayley Motor Scale did not contain any fine
motor items past the 8.9 month age level (Palisano, 1986).
This is one reason why use of a fine motor scale in this
study is so important.
Palisano{1986) indicated that the predictive validity
of the 18 month scores from the 15 month scores on the Fine
Motor Scale of the Peabody Developmental Motor Scales was
unacceptable. He suggested that the ability to predict
motor development at older ages was limited by the
variability in child development. It was recommended that
both the Bayley Scales of Infant Development and the Peabody
Developmental Motor Scales "be used only to provide current
information on the motor ability of an infant relative to
the performance of the normative group" (Palisano, 1986, p.
1718). This indicates that repeated assessment is necessary
at later ages in order to continue to accurately assess fine
motor development.
21
Participants
The drug-exposed group of children met the criteria for
services at Hope Clinic. Specifically, term infants born at
hospitals in Orange County, California, to mothers who
tested positively by a urine toxicology screen for cocaine
and/or amphetamines during the perinatal period were
followed in the clinic.
The non-drug exposed comparison children were obtained
with signed consent from three local nursery schools. a
confidential questionnaire was requested of the parent(s)
prior to the selection of their child. This questionnaire
contained questions regarding alcohol, tobacco or illicit
drug use by the mother during pregnancy. It was expected
that consent would not be obtained for those children who
were exposed to these substances in utero. A copy of the
questionnaire is in Appendix A. The parent(s) or legal
guardian(s) of children entered in the comparison group
responded "no" to a question regarding the use of illicit
during the child's gestation and thereafter. Birth records
were unavailable for the non-exposed group of children.
Children with known developmental disorders and sensory
impairments were excluded from both groups. Examples
include diagnoses of developmental delay, syndromes such as
Down syndrome, or visual perceptual dysfunction.
Eight comparison children and eight drug-exposed
children were matched for age, gender, and socio-economic
22
status as closely as possible. All of the children in the
study were Caucasian. A description of the matched children
may be seen in Table 1. This information was available in
the medical records of the drug-exposed children and was
obtained by a parent questionnaire for the comparison group.
A copy of the parent questionnaire may be found in appendix
A. The total pool of 16 children consisted of 10 Caucasian
males and six Caucasian females. Hoilingshead1s two-factor
index of social position (Hollingshead, 1958) was used to
assess socio-economic status. The index contains an
occupational scale and an educational scale. Scores were
calculated and weighted to obtain an index of social
position score. Scores were then classified by their range
into one of five social classes (Hollingshead, 1958)
The ages chosen for this study were 24 months, 30
months, and 36 months. These ages were consistent with the
schedule of appointments in the clinic for drug-exposed
infants. A sample of eight children between 24 to 37 months
were tested in each of the comparison and drug-exposed
groups. ANOVA was used to determine whether or not the two
groups differed by age. No significant differences were
revealed between the drug-exposed group and the non-exposed
comparison group (p=.88). Specific ages for each matched
group are reported in Table 1.
Socio-economic status was perfectly matched between the
two groups. Seven of the eight matched pairs were
Table 1
Characteristics of Matched Children and z Scores
Matched
Children Age Gender SES Grasping Hand Use
Eye-hand
Coord.
Manual
Dexterity Total
match 1
Drug-exp 24. 25 male 3 0.68 -0.44 -1.28 -0.68 1.18
non drug-exp 25. 25 male 3 0.68 -1.75 -1.56 -1.75 -2.33
match 2
Drug-exp 24. 25 male 3 0.68 -0.44 -2 . 05 -0.02 -1.75
non drug-exp 25. 00 male 3 0.68 -1.75 -1. 28 -1.08 -1.75
match 3
Drug-exp 27.00 male 3 0.68 -0.44 -1.56 -1.75 -1.75
non drug-exp 27. 75 male 3 0.68 -1. 18 -1.28 -0.02 -1.18
match 4
Drug-exp 24.00 male 3 0.00 -1.04 -2 . 05 -2.05 -2.33
non drug-exp 27.00 male 3 0.68 1.28 -0.02 0.61 0.47
match 5
Drug-exp 30.00 female 3 0.00 2.33 2.05 -0.33 -0.55
non drug-exp 29.00 female 3 0. 68 2 .33 0.84 0.84 0.95
match 6
Drug-exp 30.00 female 2 0.00 0 .64 -2.05 -0.08 -0.55
non drug-exp 30.50 female 2 0.00 -1.04 -2 .05 -1.23 -2.33
match 7
Drug-exp 29.50 male 3 -0.20 0.00 -1. 18 -1.75 -1.18
non drug-exp 28.00 male 3 0. 68 -1.18 -0.33 -0.68 -0.84
match 8
Drug-exp 37.00 female 3 2.33 2.33 -1. 75 -1.18 -1.48
non drug-exp 36.00 female 3 2.33 2.33 0. 00 -1.18 -0.20
H o ta . S k i l l a r* a s a r « d o cu m an tad b y z s c o r e s w hich i n d i c z t a th a d is t a n c e f r e e th a a u n o f z a r o i n s t a n d a r d d e v ia t io n u n i t s .
24
classified in a class III social class and one of the
matched pairs was classified in a class II social class
using Hollingshead's two-factor index of social position
(Hollingshead, 1958). Most families had either completed
high school or had some college education and were employed
in middle class jobs. Table 1 shows the social class for
each child in this study.
Geographical areas of residence of the children in the
two groups were similar. all of the children resided in
either North or South Orange County in California.
Procedure
A total of 36 children were administered the Fine Motor
Scale of the Peabody Developmental Motor Scales at scheduled
appointment times. This number was chosen to allow the
researcher time to complete data collection within six
months at a rate of two children per week. This number
allowed for scheduling conflicts on the part of the
participants and researcher. Eight drug-exposed and eight
non drug-exposed children were able to be matched from this
pool of participants.
Hope Clinic for drug-exposed infants and children is
located at the University of California at Irvine in Orange
County, California, and was the site used to obtain drug-
exposed subjects for this study. The clinic is currently
funded primarily by grants from the March of Dimes and the
25
National Institute of Health. There is no charge to the
family for this service. The director of the clinic, Lynn
Hunt, MD, agreed to be the UCI faculty and medical sponsor
for this study. The proposal for this study was submitted
to the Human Subjects Review Committee at UCI and accepted
on February 28, 1994.
The drug exposed children were tested in Hope clinic
during their regularly scheduled visits. The child's parent
or guardian was asked to sign a research consent form prior
to administration of the Fine Motor Scales of the Peabody
Developmental Motor Scales(PDMS). A copy of this form is in
appendix B. The Peabody Fine Motor Scale was administered
as an additional part of their regular testing which
consisted of the Bayley Scales of Infant Development. The
Peabody Fine Motor Scale was administered prior to other
testing during the child’s regularly scheduled visit.
Nineteen drug-exposed children were tested during a six
month period of time. Additional children were not tested
due to the limited number of children available at these
ages in Hope clinic and the time constraints on the
research.
Testing was conducted according to standard testing
procedures. Each child was seated at a table with the
examiner seated across from him or her. The parent or
guardian was present in the room and was most often seated
next to, or in back of, the child. The child was then asked
26
to complete each item on the Peabody Fine Motor Scale until
the child reached a ceiling age level. The ceiling age
level was identified as the age range on the test at which
the child scored 0 on all of the items or 1 on one of the
items and zero on the remainder (Folio & Fewell, 1983).
This procedure was also followed when testing the non drug-
exposed children.
The non drug-exposed children were tested at three
different preschools. A total of 17 non drug-exposed
children were tested. Each child was taken from his or her
classroom and tested in a separate room seated at a table
across from the examiner. A teacher's aide brought each
child to the testing room and stayed during a portion of the
testing to be sure that the child was comfortable with the
examiner. The Peabody Fine Motor Scale was administered in
the same manner as previously described with the drug-
exposed children. The drug-exposed group of children were
then matched with the non drug-exposed children for age,
gender, and socio-economic status.
The pool of participants was reviewed with a list of
ages for drug-exposed and non drug-exposed children.
Children were matched for age between the two groups and
eliminated if they did not match. Gender and socio-economic
status were then matched in the same way. This resulted in
a group of eight matched participants.
27
Data Analysis
This study addressed whether or not there is a
difference in fine motor skills in two to three year old
drug-exposed children as compared to non drug-exposed
children the same ages. Data were analyzed using BMDP
statistical programs. Normality was tested via the W or
Wilkes statistic. This computer generated statistical test
for normality always has a positive maximum value of 1.0.
Anything greater than 0.9 is considered to be insignificant
indicating that there is a normal distribution. It should
be noted that the Fine Motor Scale of the Peabody
Developmental Motor Scales(PDMS) is standardized on a normal
population with a normal distribution.
The Wilcoxon signed rank test was used to examine
whether or not there was a difference between groups on fine
motor skills (Rosner, 1990). This nonparametric test was
performed on each subcategory of the Peabody Fine Motor
Scale (grasping, hand use, eye-hand coordination, manual
dexterity) as well as the total fine motor score. An alpha
level of .05 was set to detect statistical significance.
This nonparametric statistic was chosen because scores were
not normally distributed for the grasping, and hand use
subtests of the Peabody Fine Motor Scale. Furthermore, the
large SEMs for all scales mandated a conservative approach
to data analysis.
28
CHAPTER IV; RESULTS
Results of the statistical analysis revealed that there
were no significant differences between the drug-exposed and
the non-drug exposed groups (p>.05) for grasping, hand use,
manual dexterity, or the total of group scores on the Fine
Motor Scales of the Peabody Developmental Motor ScaleB
(PDMS). The drug-exposed group scored lower than the non
drug exposed group on the Fine Motor Scale of the Peabody
Developmental Motor Scales (PDMS) for eye-hand coordination
(p<.05). Table 2 depicts these scores for each subcategory
with corresponding values for the Wilcoxon Signed Rank test
and probability levels.
Results of the study were calculated using the z scores
from the Fine Motor Scales of the Peabody Developmental
Motor Scales. The z score indicates the distance from the
mean of zero in standard deviation units in either a
positive or negative direction. Five of the scores in eye-
hand coordination were greater than two standard deviations
below the mean. Four of these scores were recorded in the
drug-exposed group and were evenly distributed between males
and females. The lowest mean score for the drug-exposed
group wae for eye-hand coordination. The range of scores in
eye-hand coordination as seen in Table 2, appears to be much
more limited for the non drug-exposed group.
Table 2
Differences Between Groups on Fine Motor Scores
Subtests
Drua Exposed
x ± SD
Non-drua ExDosed
x + SD
Wilcoxon
Value p Value
Grasping 0.52 + 0.82 0.80 + 0 . 66 0.00 0.25
Hand Use 0.37 + 1.30 -0.12 + 1 .79 6.00 0.41
Eye-hand
Coordination
-1.74 + 0.39 -0.70 + 0.99 1.50 0.05
Manual Dexterity -0.98 + 0.81 -0.56 + 0.94 7.50 0. 33
Total -1.35 + 0.61 -0.90 + 1.23 9 .00 0. 47
Note. The Wilcoxon Signed Rank Test was used to detect differences between groups.
CHAPTER V: DISCUSSION
Interpretation
The results of this study indicated that there was no
significant difference between the drug-exposed group of
children and the non-drug exposed group for any of the
subtests of grasping, hand use and manual dexterity or the
total scores of the Fine Motor Scale of the PDMS. Scores on
skill C, eye-hand coordination, were significantly lower for
the drug exposed children (p<.05) as seen in Table 2. This
skill appears to be an area of weakness in the drug-exposed
children.
Eye-hand coordination is the only subtest involved in
this study which, by definition, specifically involves a
visual component with action on the object (Folio & Fewell,
1983). The complexity of this skill may increase with age
and require greater attention to the task, precision, and
refinement of movement in order to be completed accurately.
As the complexity of the task increases, so does the
coordination required (Case-Smith & Pehoski, 1992). This
may explain why the other skill areas were found to be well
within acceptable limits.
Skill A, grasping, involves gross grasp of objects and
much of the skill required to complete this activity is
developed earlier than 2 years of age. In this study,
children were evaluated between 24 and 36 months of age at
which time gross grasping should be well developed.This also
31
holds true for skill B, hand use. Skill D, manual
dexterity, involves sequential manipulation of the digits. A
child may be able to manipulate their fingers to string a
bead but not have the coordination to cut on a line with
scissors, which places greater demands on visual guidance of
refined, complex hand movement.
Several of the non-drug exposed children scored below
one standard deviation below the mean on several of the
subtests. Several explanations may account for this
phenomenon. The limited number of items on the subtests and
questionable method of scoring items as zero, one, or two on
the Peabody Fine Motor Scale may have brought these scores
down. A second possibility is that variability in
performance of specific tasks between the ages of 24 to 36
months and on any given day may have affected the scoring.
Another possibility is that task completion may have been
affected by familiarity with the task presented. For
example, a child who had previously practiced buttoning may
have completed the task more precisely than a child for whom
the task was novel.
This study has implications for occupational therapy in
preschool settings. Fine motor skill acquisition may be
more difficult for children exposed prenatally to drugs. In
particular, complex activities involving eye-hand
coordination may be less optimal for the drug-exposed child.
The drug-exposed child may be less interested in
32
participating in activities involving these complex tasks.
This may also limit the child's attention span and
socialization during fine motor activities. The occupational
therapist may strive to incorporate eye-hand coordination
skills into other daily activities which build upon the
child's strengths. The role of the occupational therapist
may be to find the "occupation" which best suits the drug
exposed child’s ability to develop the fine motor skills
which are necessary building blocks for future learning.
Limitations
This study had several limitations. First, the sample
size which was obtained for this study was small. This
limits generalizability to the population of drug-exposed
preschoolers. However, it provides some specific data
regarding previous observations of fine motor skills in
these children.
The second limitation was that this researcher
administered all of the testing and was aware of the history
related to the drug-exposed group. This may have biased the
results. A blind rater would have been helpful to this
study in order to eliminate bias by the researcher.
Future Research
Several studies may be suggested for future research in
this area. A long term study with a larger sample size would
33
enhance this research. A replication of this study on a
larger group of children may provide us with more
information about the specific fine motor deficits in the
drug-exposed population. Results approached significance at
an alpha level of p=.05 for eye-hand coordination in the
small sample studied. A future study with larger groups of
children should be pursued to see if the differences in
performance of this skill vary significantly between the
drug-exposed children and comparison group of non drug-
exposed children. A rater who is blind to the study would
be helpful in eliminating future bias and limitations in the
research.
A study whicn utilizes the TIME (Test of In-Hand
Manipulation by Exner) and the Fine Motor Scales of the
Peabody Developmental Motor Scales might further specify
deficit areas by not only studying global fine motor skills
in the 4 areas of grasping, hand use, eye-hand coordination
and manual dexterity but by also adding in-hand manipulation
(Exner, 1992). In-hand manipulation may require more
precise muscle movements than eye-hand coordination tasks or
manual dexterity and provide us with a better understanding
of the needs of drug-exposed children.
34
REFERENCES
Bayley, N. (1969). Manual for the Bavlev Scales of
Infant Development. New York: Psychological corporation.
Campbell, S.K., Wilhelm, I.J., Phillips, W., & Slaton,
D.S. (1988). Comparative performance of infants on three
tests of gross motor development. Physical Therapy. 68.
818.
Case-Smith, J. & Pehoski, C. (1992). Development of
hand skills in the child. Rockville, MD: AOTA, Inc.
Chasnoff, I.J., Burns, K.A., Burns, W.J., & Schnoll,
S.H. (1986). Prenatal drug exposure: Effects on neonatal
and infant growth and development. Neurobehavioral
Toxicology and Teratology. 8. 357-362.
Corbetta, D., & Mounoud, P. (1990). Early development
of grasping and manipulation. In C. Bard, M. Fleury, & L.
Hay (Eds.) Development of eve-hand coordination across the
life span. (pp. 188-216).
Deren, S. (1986). Children of substance abusers: A
review of the literature. Journal of Substance Abuse
Treatment. 3. 77-94.
Elliot, J.M. (1979). Motor skills in theory and
practice. In D.M. Oborne, M.M. Grueberg, J.R. Eiser (Eds.)
Research in Psychology and Medicine, Vol. II. London:
Academic Press.
Elliot, J.M. & Connolly, K.J. (1984). A classification
of manipulative hand movements. Developmental Medicine &
Child Neurology. 26, 283-296.
Erhardt, R.P. (1992). Eye-hand coordination. In J.
Case-Smith & C. Pehoski, Development of hand skills in the
child, (pp. 13-27). Rockville, MD: The American
Occupational Therapy Association, Inc.
Exner, C.E. (1992). In-hand manipulation. In J. Case-
Smith & C. Pehoski, Development of Hand Skills in the Child,
(pp. 35-45). Rockville, MD: The American Occupational
Therapy Association, Inc.
Folio, M.R., & Fewell, R.R. (1983). Peabody
developmental motor scales and activity cards. Allen, TX:
DLM Teaching Resources.
35
Gebhard, A.R., Ottenbacher, K.J., & Lane, S.J. (1994).
Interrater reliability of the Peabody Developmental Motor
Scales: Fine Motor Scale. American Journal of
Occupational Therapy. 48(11). 976-981.
Gesell, A. & Amatruda, C.S. (1947). Developmental
diagnosis(2nd ed.). Hoeber Medical Division: Harper & Row.
Giacola, G.P. (1990). Cocaine in the cradle: A hidden
epidemic. Southern Medical Journal, 83f8). 947-951.
Gilfoyle,E., Grady, A., & Moore, J. (1981). Children
adapt. New Jersey: Charles B. Slack, Inc.
Hinderer, K.A., Richardson, P.K. & Atwater, S.W.
(1989).Clinical implications of the Peabody Developmental
Motor Scales: A constructive review. Physical &
Occupational Therapy in Pediatrics, 9 ( 2 ), 81-106.
Howard, J., Dropenske, V., & Tyler, R. (1986). The
long-term effects on neurodevelopment in infants exposed
prenatally to PCP. [monograph] Phencyclidine: An Update,
National Institute on Drug Abuse Research. 64. 237-251.
Isaac, S., & Michael, W.B. (1989). Handbook in
Research and Evaluation (2nd ed.). San Diego, CA: EDITS.
Kaltenbach, K., & Finnegan, L.P. (1984). Developmental
outcome of children born to methadone maintained women: A
review of longitudinal studies. Neurobehavioral Toxicology
and Teratology, 6, 271-275.
Knobloch, H., & Pasmanick, B. (Eds.). (1974). Gesell
and Amatruda's developmental diagnosis: The evaluation and
management of normal and abnormal neuropsvchologic
development in infancy and early childhood (3rd ed.).
Hagerstown, MD: Harper & Row.
Kopp, C. (1974). Fine motor abilities of infants.
Developmental Medicine and Child Neurology, 16, 629-636.
Lane, S.J. (1992). Prenatal cocaine exposure: A
role for occupational therapy. Developmental
Disabilities Special Interest Section Newsletter.
15(2), 1-3.
Palisano, R.J. (1986). Concurrent and predictive
validities of the Bayley Motor Scale and the Peabody
Developmental Motor Scales. Physical Therapy. 66(11). 1714-
1719.
36
Rosenbloom, L. & Horton, M.E. (1971). The maturation
of the prehension in young children. Developmental Medicine
and Child Neurology. 13, 3-8.
Rosner, B. (1990). Fundamentals of Biostatistics.
Boston: PWS-KENT.
Schneider, J.W. (1990). Infants exposed to cocaine in
utero: Role of the pediatric physical therapist. Topics in
Pediatrics: Lesson 6. 1-8 .
Stokes, A., Deitz, J.C., & Crowe, T.K. (1990). The
Peabody Developmental Fine Motor Scale: An interrater
reliability study. American Journal of Occupational
Therapy. 44(4), 334-340.
Wilson, G.S., McCreary, R., Kean, J. & Baxter, J.C.
(1979). The development of preschool children of heroin-
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141.
Zuckerman, B., & Bresnahan, K. (1991). Developmental
and behavioral consequences of prenatal drug and alcohol
exposure. Pediatric Clinics of North America. 38. 1387-
1406.
37
APPENDIX A
PARENT QUESTIONNAIRE
38
PARENT QUESTIONNAIRE
1. Name of child:
2. Date of Birth:
3. Ethnic background: (circle appropriate)
Caucasian Black Asian Hispanic Other
4. Were any drugs used by the mother during pregnancy
at anytime? Yes/No
If so, what drugs were used?
5. Did the mother of this child smoke cigarettes? Yes/No
If so, how many packs a day?
6. Did the mother of this child drink alcohol? Yes/No
If so, how much and how frequently?
7. Any known medical diagnosis: _________________________
8. Father’s occupation:______________________________________
Highest level of education: (circle one)
(7) completed grammar school (6th grade)
(6) junior high (7th-9th grade)
(5) partial high school (10th or 11th grade)
(4) high school graduate
(3) completed 1,2,3 years of college
(2) graduated from college (4 years)
(1) graduate degree completed
9. Mother's occupation: __________________________________
highest level of education: (circle one)
(7) completed grammar school (6th grade)
(6) junior high (7th-9th grade)
(5) partial high school (10th or 11th grade)
(4) high school graduate
(3) completed 1,2,3 years of college
(2) graduated from college (4 years)
(1) graduate degree completed
APPENDIX B
CONSENT FORM
UNIVERSITY O F CALIFORNIA, IRVINE
Consent to Act as a H um an Research Subject
"Fine Motor Skills of Two* to Three-Year-Olds
Drug Exposed Children"
Linda Adintori, OTR, BCI\ Trinciapl Investigator
Lynn Hunt, M.D., Faculty Sponsor
Department of Pediatrics
(714) 456-5623
Name of Subject:_______________________________________________________ __
PURPOSE OF STUDY:
I have been asked to participate in a research project designed to investigate
whether there are any differences in fine motor skills, such as those necessary to
button, use scissors, etc, between children who have been exposed to illicit drugs
prenatally (before birth) and children the same age who have not been exposed
to drugs. The information gathered from this study will assist parents and
professionals who care for children of preschool age (24-36 months) who have
been exposed prenatally to drugs.
If I agree to particpate, the following will occr: I will meet with this researcher
either at UCI Medical Center in the Pediatric Clinic or if inconvenient, at my
child's local preschool. My child will be administered the Peabody Fine M otor
Scales . This test will take approximately 20-30 minutes and involves tasks such
as buttoning, drawing, and twisting objects. I understand that there will be
approximately 40 subjects, ages 24-36 months, involved in the study.
RISKS:
I understand that attention spans vary in children between the ages of 24-36
months of age, and some children may find it difficult to sit and follow
directions. If the testing becomes frustrating and elicits negative responses such
as crying or resistance to completing tasks, it will be stopped.
BENEFITS:
I understand that participation in this study will provide occupational therapists,
as well as other heath care professionals, with useful infomraiton needed to help
identify children with fine motor diffculties involving the small muscles of the
hands If my child has difficulty coordinating both hands to perform activities or
tv.
"Fine Molor Skills of Two- to Three-Year Old Drug Hxposcd Children"
H u m an Subjects Consent Form
Page 2
manipulating small objects, I will be provided with suggestions to assist them in
achieving these skills at home.
COSTS/COMPENSATION:
1 understand that there is no charge for the administration of this test and that no
compensation will be provided. No reimbursements for travel expenses will be
provided to or from the test site.
ALTERNATIVE TREATMENTS:
There are no alternative treatments or procedures which will be provided at this
time. The only procedures in which I am participating are stated in the
procedures section above.
I have read the Experimental Subjects' Bill of Rights and have been given a copy
of it and this consent form to keep. I consent to participate.
Signature of Parent/Guardian Date
Signature of Witness Date
Signature of Investigator Date
‘I
CONSENT FORM ■ PART II
1. Participation in research is entirely voluntary. Vou may refuse to participate or w ith d raw from participation at any
time w ith o u t jeo p ard y to future m edical care, em ploym ent, student sta tu s or o th er entitlem ents The in v estig ato r
m ay w ithdraw you a t his/her professional discretion.
2. If, during th e c o u rse of the study, significant n ew information which has b e en developed b ecom es available,
w hich m ay relate to your w illingness to continue to participate, this inform ation will be provided to you by th e
investigator.
3. C onfidentiality will b e pro tected to th e ex ten t provided by law.
4. In stu d ies involving investigational drugs and dev ices, the U.S. Food and Drug A dm inistration m ay in sp ect your
medical re co rd s w h ich relate to your participation in this study. This m ay include copying of m edical reco rd s.
5. if at any tim e you hav e qu estio n s regarding the research or your participation, you should co n tact the in v estig ato r
w ho m u st a n sw e r all q u estions. A telephone num ber is' provided at the ta p of Part I of the co n sen t farm .
6. If at any tim e you have com m ents or com plaints relating to the conduct of th is research , q u estio n s ab o u t your
rights as a re se a rc h su bject, or if you feel you have suffered a research-related illness or injury, you should c o n ta c l
the UC Irvine R esearch C om m ittees' Office. The U niversity wilt provide m edical trea tm e n t reasonably n e ce ssa ry for
any injury or illness w hich a hum an su b ject su ffers a s a direct result of participation in a University approved re sea rc h
stu d y or reim burse a su b ject for su ch c o sts ex cep t w hen th e injury or illness is ■ c o n se q u en c e of a m edical re sea rc h
procedure w h ich is d esigned to benefit th e su b ject directly. The University d o e s n o t provide any o th er form of
co m p ensation, h o w ev er.
For additional inform ation regarding the item s above, you should telephone the R esearch C om m ittees' Office at (7 1 4 )
8 5 6 -7 1 1 4 .
EXPERIMENTAL SUBJECTS' BILL OF RIGHTS
Any perso n w h o is ask e d to c o n se n t to participate i s a hum an subject in a m edical investigation or w h o is ask ed
to co n sen t on beh alf of another, h as the follow ing rights:
1. To be told w h a t th e stu d y is trying to find out.
2. To be told w h a t will happen in th e study and w h eth er any of the procedures, d ru g s or devices is different from
w h at w ould be u se d in stan d ard m edical practice
3. To be told a b o u t th e risks, side effects or d isco m fo rts w hich may be ex p ected .
4. To be told if th e su b ject can e x p ect any benefit from participating and if so. w h a t th e benefit m ight be.
5. To be told of o th er ch o ices available and ho w th ey m ay be better or w o rse th an being in the study.
6. To be allow ed to ask any qu estio n s concerning th e study, both before agreeing to be involved and anytim e during
the co u rse of th e stu d y .
7. To be told of an y m edical trea tm e n t available if com plications arise
8. To refu se to particip ate at all, either before or after th e study has started. This decision will not sffe ci any right
to receive sta n d a rd m edical treatm ent.
9. To receive a sig n ed and dated copy of Parts I and II of the consent form and this Bill of Rights.
10. To be allow ed tim e to decide to co n sen t or no t to co nsent to participate w ith o u t any p ressu re being bro u g h t
by the in v estig ato rs or o thers.
S u b je c t's/P a ra n t's/G u a rd ia n 's in itials_______________ D a te (Rev. 4/91]
1 4 HSRC-Mediul/Applicalioo Materiah
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The application of Sarbin's theory of emotions as narrative emplotments to stories of two men diagnosed with cancer

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A Biosocial Model Of Sex-Atypicality In Female Employment Aspirations

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Coping Strategies Of Three Adolescents With Disabilities

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An examination of the health-related quality of life and functional skills as reported by the parents of young children with developmental delays

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Interrater reliability of the Evaluation of Sensory Processing (ESP)

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A study of a pilot sensory history questionnaire using contrasting groups

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Violent environments and their effects on children

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The relationship between fatty acid composition of subcutaneous adipose tissue and the risk of proliferateive benign breast disease and breast cancer

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A model for integrating occupational therapy procedures

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Rationalizing risk: sexual behavior of gay male couples

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An investigation of the relationship between measures of social, academic and global self-concept

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Predictors of pretend play in Korean-American and Anglo-American preschool children

Asset Metadata

Creator Adintori, Linda Ann (author)

Core Title Fine motor skills of two- to three-year-old drug exposed children

School Graduate School

Degree Master of Arts

Degree Program Occupational Therapy

Degree Conferral Date 1995-08

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag health sciences, obstetrics and gynecology,health sciences, occupational health and safety,OAI-PMH Harvest,psychology, clinical,psychology, developmental

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Parham, Linda Diane (committee chair), Hedricks, Cynthia A. (committee member), Zemke, Ruth (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c18-6770

Unique identifier UC11357827

Identifier 1378393.pdf (filename),usctheses-c18-6770 (legacy record id)

Legacy Identifier 1378393-0.pdf

Dmrecord 6770

Document Type Thesis

Rights Adintori, Linda Ann

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA