Obradovic 2018

Article type : Special Issue Article
Accepted Article
Early Executive Functioning in a Global Context:
Developmental Continuity and Family Protective Factors
Jelena Obradović
Stanford University
Jenna E. Finch
University of Nebraska-Lincoln
Ximena A. Portilla
MDRC
Muneera A. Rasheed
Aga Khan University
Nicole Tirado-Strayer
WestEd
Aisha K. Yousafzai
Harvard University
This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/desc.12795
This article is protected by copyright. All rights reserved.

Acknowledgments: This research was supported by a research grant from the Grand
Challenges Canada Saving Brains Initiative (Grant number 0061-03). The preparation of this
manuscript was supported by a Scholar’s award from the William T. Grant Foundation and
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the Jacobs Foundation Advanced Research Fellowship to Jelena Obradović, and by a grant
from the Institute of Education Sciences (IES), U.S. Department of Education
(R305B090016) to Ximena A. Portilla, Jenna E. Finch, and Nicole Tirado-Strayer. The
authors also thank the children and families who participated and made this research possible,
and the staff who helped collect and process the data. The findings, conclusions, and opinions
here are those of the authors and do not represent views of Grand Challenges Canada,
William T. Grant Foundation, IES, or the U.S. Department of Education.
Correspondence concerning this article should be addressed to Jelena Obradović, Stanford

University, 485 Lasuen Mall, Stanford, CA 94305. Telephone: 650-725-1250. Electronic
mail may be sent to jelena.obradovic@stanford.edu.
Research Highlights
 We measured emerging executive functions (EFs) in a large sample of disadvantaged
four-year-olds in rural Pakistan, using six culturally and developmentally appropriate
tasks.
 Cognitive skills at age two were longitudinally associated with EFs and mediated how
an early intervention, home stimulation, and maternal scaffolding were related with
EFs.
 Preschoolers’ EFs were independently predicted by observed maternal cognitive
scaffolding practices and directly assessed maternal cognitive capacities.
 The early parenting intervention, physical growth status at age two, and number of
older siblings uniquely predicted EFs in preschoolers, after controlling for child IQ.

Abstract
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This study extends the methodological and theoretical understanding of executive functions
(EFs) in preschoolers from low- and middle-income countries (LMIC). First, the authors
describe a rigorous process of adapting and evaluating six EF tasks to produce a culturally
and developmentally appropriate measure of emerging EFs in a large sample of at-risk
children in rural Pakistan. Next, the authors identify critical developmental and family factors
that relate to preschoolers’ EFs over the first four years of life. Direct assessment of
children’s general cognitive skills at age two showed developmental continuity with EFs at
age four, and these early cognitive skills mediated the effect of an antecedent parenting
intervention on EFs as well as associations of targeted individual and family factors with EFs.
Further, directly assessed maternal cognitive capacities and observed maternal scaffolding
uniquely predicted EFs in preschoolers. This study is also the first to demonstrate a
significant overlap between direct assessments of IQ and EFs in young children from LMIC.
Children's general intelligence mediated the associations of EFs with antecedent physical
growth and cognitive skills as well as concurrent family factors (maternal verbal intelligence,
maternal scaffolding, and home stimulation). After controlling for shared variance between
preschoolers’ general intelligence and EFs, three factors emerged as unique predictors of
EFs: exposure to an early parenting intervention, physical growth status at age two, and
number of older siblings. The findings have important implications for the design of
interventions that aim to improve EFs in young children in LMIC countries.
Keywords: Executive functions, low- and middle-income countries, adversity, parenting
intervention, cognitive development

Early Executive Functioning in A Global Context:
Developmental Continuity and Family Protective Factors

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Interest in the developmental trajectories, correlates, and applications of early
executive functions has grown immensely in the last decade. Extensive research has linked
executive function (EF) skills to a wide range of social-emotional and school outcomes (e.g.
Liew, 2012). Crucially, researchers have found that EF skills can be hindered by
environmental adversity but improved through positive parenting behaviors and diverse
intervention efforts (e.g. Diamond, 2013; Finch & Obradović, 2017). However, most of this
work is based on studies of children in high-income countries (HIC; defined by the World
Bank as having annual Gross National Income per capita > US$12,235). We know very little
about early EF development in low-and middle-income countries (LMIC) where children
face high levels of adversity, including infections, malnutrition, and inadequate stimulation
(Walker et al., 2011). Although EFs can be construed as universal skills that support any
goal-directed behavior, EF assessment and exposure to family factors may be culturally and
contextually dependent. This study extends methodological and conceptual understanding of
emerging EFs in highly disadvantaged children; in this case, a large birth-cohort of at-risk
children in rural Pakistan. Using a developmentally and culturally appropriate battery of
adapted EF tasks, we demonstrated how antecedent and concurrent measures of cognitive
skills relate to emergent EFs in preschoolers in a low-income, rural setting. Further, we
identified unique protective factors that directly and indirectly predict EFs, after controlling
for the overlap of EFs with general cognitive skills. Knowing which proximal and distal
experiences relate to emerging EFs in the context of extreme chronic adversity can inform
intervention efforts aimed at promoting healthy early child development in disadvantaged
rural LMIC contexts.

Executive Functions as a Culturally Universal Index of Early Development
EFs are higher-order cognitive skills that enable individuals to regulate their attention,
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behavior, and emotions. Strong EFs are associated with lower levels of behavioral and
emotional problems and greater social competence, school engagement, and emergent
academic skills (Diamond, 2013; Obradović, Portilla, & Boyce, 2012). Studies of at-risk
children in the United States reveal that these skills may be especially important for
promoting resilience in contexts of adversity (Obradović, 2010). Performance on EF tasks has
been linked to activation of specific brain regions (Bunge & Crone, 2009) and provides a
proxy measure of neurocognitive development when direct assessments of neurobiological
processes are not feasible. Given the broad implication of EFs for salient domains of adaptive
functioning, assessment of EF skills can be used as an index of overall early childhood
development. However, most studies have been conducted in HIC, which greatly limits the
generalizability of findings.
We propose that basic EF skills, which enable children to control their impulses,
ignore distracting stimuli, hold relevant information in the mind, and shift between competing
rules or attentional demands, can be construed as a culturally universal set of skills that
promote culturally dependent, goal-directed behaviors. Similar factors may hinder (e.g.,
poverty) or promote (e.g., positive parenting) EF development across different cultures
(Hackman, Gallop, Evans, & Farah, 2015; Hamadani et al., 2014), although children’s
exposure to these factors may differ. Likewise, neural structures that support EFs appear to be
culturally invariant (Tarullo et al., 2017), but the activation of these brain regions may vary as
a function of the contextual influences that shape the developmental trajectories of EFs
(Sheridan, Sarsour, Jutte, D’Esposito, & Boyce, 2012). Indeed, mean level differences in EFs

across cultural, racial, and ethnic groups do not seem to reflect fundamental discrepancies in
the underlying structure of EFs, but rather variability in contextual influences (Lan, Legare,
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Ponitz, Li, & Morrison, 2011; Li-Grining, 2012; Sulik et al., 2010).
Since LMIC children’s limited access to educational programming, media, and
modern technology can affect their comprehension of cognitive tests’ instructions, stimuli,
and concepts, it is critical that EF tasks’ surface-level characteristics are designed to
minimize such biases. Previous efforts to adapt EF assessments for use with preschool
children in LMIC exposed considerable challenges. For example, evaluation of five adapted
EF tasks used with preschoolers in Indonesia revealed that children’s reluctance to participate
in two tasks led to low scores and missing data, whereas a third task showed poor test-retest
reliability and no expected correlation with age (Prado et al., 2010). Fernald and colleagues
(2011) reported significant floor and ceiling effects on a locally adapted inhibitory control
task used with three- to six-year-olds in Madagascar, highlighting the need to identify EF
tasks that provide adequate variability in LMIC settings. Further, studies that resort to a
single EF task (Fernald et al., 2011; McCoy, Zuilkowski, & Fink, 2015; Patel et al., 2013)
may not yield a reliable and valid measure of EF skills due to task-specific sources of
measurement error (Willoughby, Pek, Blair, & Family Life Project Investigators, 2013). We
identified a clear need to develop a battery of play-based EF tasks for young children in
LMIC, who tend to be inhibited in novel testing situations and hesitant to interact with
strangers, because of their unfamiliarity with standardized testing procedures and materials as
well as a general lack of experiences outside of their homes. It is crucial that researchers do
not confound children’s reluctance to engage or their limited understanding of assessment
procedures with an actual lack of EF skills.

The development of EF skills during the preschool period, a time of heightened
sensitivity to environmental influences and preparation for the school transition, has been
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understudied in LMIC. We also lack studies that examine how commonly employed
measures of cognitive development relate to direct assessment of EFs. There is a need to
examine longitudinal continuity between early cognitive skills and preschoolers’ performance
of EF tasks. Furthermore, by investigating the overlap of emergent EF skills with concurrent
measures of general intelligence, we can identify factors that uniquely relate to emergent EFs.
Early Life Experience and Executive Functions
Despite the important role that EFs play in promoting resilient adaptation of at-risk
children (Lengua, Bush, Long, Kovacs, & Trancik, 2008; Obradović, 2010), young children
from disadvantaged socioeconomic backgrounds in the United States perform worse on EF
tasks when compared to their more advantaged peers (Lawson, Hook, Hackman, & Farah,
2014). For example, financial difficulties and chronic poverty have been linked to EF deficits
in 4-year-olds, over and above other family characteristics (Raver, Blair, & Willoughby,
2013). Similarly, family wealth and maternal education have been linked to EFs and related
cognitive skills in preschoolers from Ecuador (Schady, 2011), Madagascar (Fernald et al.,
2011), Indonesia (Prado et al., 2010) and Ghana (Wolf & McCoy, 2017). Less is known
about how proximal early life experiences uniquely relate to the development of emergent
EFs in rural LMIC settings, where young children and their parents lack basic resources, have
limited access to health services and education opportunities, and face extreme levels of
chronic adversity. As a result, these children experience higher levels of malnutrition, growth
retardation, infectious illnesses, maternal illiteracy and depression, inadequate housing
conditions, and cognitive stimulation than at-risk children growing up HIC (Black et al.,
2017; Grantham-McGregor et al., 2007).

Experiences of poverty in LMIC have been linked to high incidence of nutritional
deficiencies and infection, which can lead to early growth retardation and stunting in young
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children (Grantham-McGregor et al., 2007). Stunting during the first two years of a child’s
life represents a serious, longitudinal risk for cognitive development (Black et al., 2017;
Grantham-McGregor et al., 2007). Although recovery from early stunting is possible, benefits
of recovery for cognitive development are inconsistent. For example, micronutrient
supplementation during the prenatal period, but not during the preschool years, yielded higher
EFs in seven- to nine-year-olds in Nepal (Christian et al., 2010; Murray-Kolb et al., 2012).
On the other hand, change in linear growth from infancy to age eight and recovery from early
stunting were associated with improved cognitive achievement in children in Ethiopia, India,
Peru, and Vietnam (Crookston et al., 2013). Given the profound effects of early growth
retardation on brain development, it is important to test whether food security and children’s
early height-for-age, a proxy for healthy physical growth, are related to emerging EFs in
LMIC, independent from their association with global measures of antecedent and concurrent
general intelligence.
The quality of home stimulation and caregiving has been hypothesized as a second
key pathway by which poverty undermines child development outcomes in LMIC
(Grantham-McGregor et al., 2007). These proximal family processes have been shown to
promote early EFs (Fay-Stammbach, Hawes, & Meredith, 2014) and mediate the link
between socioeconomic risk and EFs in HIC studies (Hackman et al., 2015; Sarsour et al.,
2011). A few recent studies have extended this work to LMIC settings. In the present sample
of preschoolers living in rural Pakistan, Obradović, Yousafzai, Finch, and Rasheed (2016)
found that the quality of concurrent home stimulation as well as earlier and concurrent
observed measures of maternal scaffolding independently predicted EFs. Using a cross-
sectional study of Zambian six-year-olds, McCoy and colleagues (2015) found that

concurrent reading activities at home mediated the link between family wealth and children’s
EFs. In a relatively more advantaged sample of urban Argentinian preschoolers, exposure to

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literacy activities and computer resources in the home mediated the effect of more distal
family socioeconomic factors (Lipina et al., 2013; Segretin et al., 2014). In contrast, Wolf and
McCoy (2017) did not find a significant association between caregivers’ stimulation practices
and EFs of Ghanaian five-year-olds. Moreover, Patel and colleagues (2013) found that after
accounting for the schooling exposure of seven- to nine-year-olds in Nepal, the quality of
home stimulation was not related to children’s performance on an EF task, highlighting the
need to test the unique contribution of family processes before school entry.
Given the striking parallels in how family processes relate to both measures of EFs
and general intelligence in young children in LMIC (Hamadani et al., 2014; McCoy et al.,
2015; Obradović, Yousafzai, et al., 2016), there is a need to model rigorous HIC studies in
identifying unique family predictors of early EFs, after controlling for the shared variance
with related measures of general intelligence (Bernier, Carlson, Deschênes, & Matte-Gagné,
2012; Obradović, Portilla, & Ballard, 2016; Sarsour et al., 2011). Further, knowing whether
the associations of family enrichment processes with EFs are mediated by antecedent or
concurrent measures of broad cognitive skills can inform the design and timing of early
intervention programs specifically targeting early EFs in LMIC.
Recently, maternal cognitive and self-regulatory capacities have been linked to EFs in
children in HIC, both directly and indirectly through parenting behaviors (Cuevas et al.,
2014; Deater-Deckard & Sturge-Apple, 2017; Distefano, Galinsky, McClelland, Zelazo, &
Carlson, 2018). Understanding the role of directly assessed maternal cognitive capacities is
especially relevant in rural LMIC contexts where a majority of women have no formal
education. In the present sample of highly disadvantaged mothers in rural Pakistan, maternal
working memory, short-term memory, and verbal intelligence have been shown to uniquely

predict maternal scaffolding behaviors (Obradović et al., 2017). However, it is unknown
whether these maternal cognitive capacities are directly or indirectly related to preschoolers’
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EFs. Knowing whether maternal cognitive capacities and specific parenting skills are
independently linked to children’s emerging EFs can inform the design of two-generation
interventions that target self-regulation skills in both caregivers and their children.
Current Study
The current study was designed to address methodological and empirical gaps in the
research on early EF development in preschool children from disadvantaged, rural areas of
LMIC. First, we engaged in a rigorous process of: (1) selecting, adapting, and administering
individual EF tasks; (2) examining children’s understanding of and performance on these
tasks; and (3) evaluating psychometric properties of the EF composite. Second, we identified
salient child and family factors that uniquely contributed to preschoolers’ EFs across time.
We studied a large birth cohort of children in Pakistan, a primarily agricultural, lower-
middle-income country (defined by annual Gross National Income per capita between
US$1,006 and $3,955) with 21% of the population living below the international poverty line
of US$1.25 daily (UNDP, 2014). The experience of Pakistani children reflects many
challenges faced by children in LMIC, including high rates of infant and under-five mortality
(NIPS & ICF International, 2013), health and educational disparities across urban and rural
areas (Di Cesare et al., 2015; UNICEF, 2013), poor access to education, low school
attendance amplified by gender inequalities, and high prevalence of adult illiteracy (UNICEF,
2013). The low quality of early education, due to inadequate teacher training, infrastructure,
and school resources, heightens the role of family in fostering early cognitive development.

Children in the current study were recruited at birth to participate in the Pakistan
Early Child Development Scale-Up (PEDS) Trial, a community-based, cluster-randomized,

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controlled, two-year trial with a 2x2 factorial design that evaluated the impact of integrating
early responsive stimulation (RS) and enhanced nutrition (EN) interventions within
government health services to promote child development (Yousafzai, Rasheed, Rizvi,
Armstrong, & Bhutta, 2014). The RS intervention promoted sensitive and responsive
caregiving via individualized coaching, support, and feedback during monthly home visits
and community group meetings; whereas the EN intervention expanded on existing health,
hygiene, and basic nutrition education, and included delivery of micronutrient supplements
(see Yousafzai et al., 2014 for details).
The current study extends published research on the direct and indirect effects of the
RS intervention on children’s EFs at age four (Obradović, Yousafzai, et al., 2016; Yousafzai
et al., 2016) in three key ways. First, we examined developmental continuity by testing how
general cognitive skills at age two predicted emerging EFs in preschoolers, after controlling
for socioeconomic factors at birth, direct effects of the PEDS interventions, as well as
targeted family factors and children’s physical growth at age two. This model enabled us to
test the hypothesis that children’s cognitive skills at the completion of the intervention trial
would partially mediate the effects of the RS intervention and the targeted family factors at
age two on preschoolers’ EFs. Second, we examined whether maternal cognitive skills
(working memory, short-term memory, and verbal intelligence) directly contributed to
children EFs in LMIC. We hypothesized that these maternal cognitive skills, partially
reflecting differences in maternal capacities to plan and adapt caregiving behaviors, would
uniquely predict children’s EFs, over and above the published contribution of the concurrent
home stimulation and maternal scaffolding (Obradović, Yousafzai, et al., 2016). This model
enabled us to test whether home stimulation and maternal scaffolding would remain

significant family predictors of children EFs after the inclusion of maternal cognitive
capacities, which partially reflect family socioeconomic resources and shared mother-child
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genetic endowment. Third, we identified shared variance between emergent EFs and
concurrent measures of general intelligence. By accounting for the overlap between EFs and
intelligence, this study is the first to identify salient developmental factors from birth to age
four, including the exposure to the RS intervention, that are uniquely relevant for
development of early EFs in the context of extreme, chronic adversity.
Method
Participants
Participants included 1302 children (46% girls) and primary caregivers (99%
mothers) who were enrolled in the original PEDS Trial from birth to age two years and were
included in a longitudinal follow-up at age four. Attrition at the follow-up (N = 187, 12.56%)
was predominantly due to disabilities, deaths, and migration (see below for a more detailed
description of missing data). The attrited group had a significantly higher share of children
who received the EN intervention compared to the group of children who were retained in the
study (t(1487) = 3.029, p = .003), but otherwise the two groups did not differ in terms of RS
exposure or any study variables from the baseline, 18-month, and 24-month assessments. The
final analytic sample was limited to 1144 children who had a valid EF outcome score.
Participants resided in the predominantly agricultural Naushero Feroze District, in
Sindh Province, Pakistan, and were exposed to high levels of poverty. Monthly household
income averaged US$100 (SD = $140). Primary school attendance in the region is low, and in
this sample 68% of mothers and 31% of fathers were illiterate. At baseline, mothers were
28.20 years old (SD = 5.85, range = 15.12 – 59.46) and reported an average 2.19 years of
education (SD = 3.69; range = 0 – 16). At the end of the intervention, when children were 24

months old, approximately one third of families reported food insecurity (33%), and a
substantial proportion of children were underweight (43%), or exhibited stunting (61%) or

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wasting (27%).
Procedures
A birth-cohort of children, born between April 1, 2009, and March 31, 2010, was
invited to enroll in the PEDS trial with their primary caregivers. The current study employs
data collected during the PEDS Trial (when children were 0 to 2.5, 18, and 24 months old),
and at the 48-month follow-up. Most children were assessed within a month of their birthday
at each time point. The assessment team received extensive training on interacting with
children and families, understanding the evaluation constructs, administering measures, and
dealing with assessment barriers. Throughout the PEDS trial, data were collected during
home visits. At age four, data were collected during a three-hour center visit and a three-hour
home visit by the team that was masked to the original intervention assignment. Child and
maternal assessments were alternated in a predetermined sequence to give both participants
time to rest, and cognitive tests were administered at the beginning of the center visit to
ensure that children’s performance did not suffer from fatigue. In addition to the set rest
periods, the assessors were trained to identify when participants needed to take a break for
refreshments, nap, playing, or bathroom. All questionnaires and child assessments were
administered in the local language, Sindhi. A multidisciplinary team of experts and local staff
spent six months adapting all selected measures for administration in a new cultural context
with a highly disadvantaged population.

Measures
Executive function composite. Since there was no existing EF battery for

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preschoolers in rural LMIC, we completed an extensive process of task selection, adaptation,
and evaluation (see Appendix A). The final EF assessment consisted of six tasks that assessed
children’s inhibitory control (IC), working memory (WM) and cognitive flexibility (CF). For
all tasks, we increased the number of practice trials to improve task comprehension, since
many aspects of the testing procedure were novel to this population and children tended to be
reticent in this context. More information on the administration procedures for the EF tasks
can be found in Appendix B.
The Fruit Stroop (IC task) assessed the child’s ability to focus on a subdominant
perceptual feature of an image, rather than on a dominant feature (Carlson, 2005). Children
were shown three pictures, each depicting a small fruit embedded within a different larger
fruit (e.g., a small apple inside a large banana) and were asked to point to the small fruit,
which required suppressing the inclination to choose the large, more salient fruit. The total
score reflected the percent correct across 3 test trials (α = .65). The Knock-Tap Game (IC
task) assessed children’s ability to implement a set of rules and suppress an imitation of the
assessor’s actions (Molfese et al., 2010). Using their hand, children were asked to tap on the
table after the assessor knocked on it, and, conversely, to knock after the assessor tapped. The
total score reflected the percent correct across 16 test trials (α = .83). The Big/Little Game (IC
task, Carlson, 2005) assessed children’s ability to state a contradictory rather than a salient
perceptual feature of an image. Children were asked to say “little” when presented with a
picture of a big cat and to say “big” when presented with a picture of a little cat. The total
score reflected the percent correct across 16 test trials (α = .92). The Go/NoGo Game (IC
task) assessed children’s ability to perform an action following a frequent “go” stimulus and
to inhibit that same action following a less frequent “no-go” stimulus (Willoughby, Blair,

Wirth, Greenberg, & The Family Life Project Investigators, 2010). Children were asked to
press a desk bell when presented with an image of a cat and not to press the bell when
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presented with an image of a dog. The total score reflected the percentage of correct “no-go”
trials (α = .89) for children who demonstrated at least 76% accuracy on “go” trials. During
the Forward Word Span (WM task), children were asked to repeat verbally presented word
sequences of increasing length. The total score represented the longest span for which at least
two test trials were repeated correctly, plus 0.5 if one longer sequence was correctly repeated
at the next level (Noël, 2009). Children who could not repeat any words, or only one word,
were given a score of 1 (α = .93). The Separated Dimensional Change Card Sort (S-DCCS,
CF task, Carlson, 2005) measured children’s ability to switch attention between two different
dimensions, using a set of colored cards (green or yellow) featuring the black silhouette of a
common shape (star or truck). Children were asked to complete six color trials, and then,
after a rule switch, six shape trials. The total score reflected the percentage of correct post-
switch trials (α = .86).
Antecedent cognitive skills. Children’s cognitive and language skills at 24 months
were assessed using the Bayley Scales of Infant and Toddler Development, Third Edition
(BSID-III; Bayley, 2006). Raw scores for the cognitive, receptive communication, and
expressive communication subtests were calculated by summing the number of correct items.
The cognitive (M = 78.24, SD = 14.61) and language (M = 82.76, SD = 13.43) composite
scores were averaged to create a measure of general cognitive skills at 24 months (M = 80.50,
SD = 12.79, r = .66).
General intelligence. Children’s intelligence at 48 months was assessed using the
Wechsler Preschool and Primary Scale of Intelligence – III (WPPSI-III; Wechsler, 2002).
Items were culturally adapted by replacing unfamiliar words and pictures with alternates that
are more representative of the local community (see Rasheed et al., 2017 for adaptation

details). A full scale comprising the Block Design, Matrix Reasoning, Picture Concepts,
Information, Vocabulary, Word Reasoning, and Symbol Search scale scores was used as a
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composite measure of general intelligence at 48 months (M = 75.56, SD = 7.56, α = .91).
Socioeconomic factors at birth. Family wealth was assessed using 44 items that
reflect ownership of property, livestock, and household assets (e.g., television, bicycle, car),
dwelling characteristics (e.g., access to water, sanitation facilities, type of flooring material),
and number of bedrooms in the home. Principal components analysis was used to generate a
single standardized factor score that represents cumulative family wealth (M = .00, SD = .99).
Maternal education was obtained by maternal report of the number of years the mother
attended formal school (M = 2.19, SD = 3.69). Mothers reported on the number of siblings the
target child had at birth (M = 2.50, SD = 2.31).
Intervention exposure. Two binary variables were created to represent children’s
exposure to the RS intervention (1 = RS, 0 = no RS) and EN intervention (1 = EN, 0 = no
EN). Consistent with the 2x2 factorial design of the PEDS Trial and published evaluation
studies (Yousafzai et al., 2016, 2014), we employed two binary variables to control for the
main effects of the intervention exposure. The RS intervention was based on the adapted
United Nations Children’s Fund and World’s Health Organization’s Care for Child
Development curriculum (UNICEF & WHO, 2011) and was administered by trained
community health workers. Mothers received coaching, support, and feedback during
monthly home visits and community meetings on how to be responsive and sensitive while
engaging in developmentally appropriate play and communication activities (see Yousafzai et
al., 2014 for details).

Height-for-age and food insecurity. Trained assessors measured children’s height to
the nearest 0.1 cm in accordance with standardized guidelines (Cogill, 2003). Height was
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converted into a standardized height-for-age index (M = -2.33, SD = 1.12) using WHO
Anthro software V3.2.2. Further, we controlled for family food insecurity (Coates, Swindale,
& Bilinsky, 2007) at 24 months, which was assessed using a binary measure of whether the
family had access to safe and nutritionally adequate food (0 = food secure, 1 = food insecure;
32.74 % were food insecure).
Home stimulation quality. Home stimulation quality was measured using the
adapted Home Observation for Measurement of the Environment Inventory (HOME;
Caldwell & Bradley, 1984), which has been used widely in LMIC (Aboud & Yousafzai,
2015). Items representing six dimensions (responsivity, acceptance, organization, learning
materials, involvement, and variety) of the infant/toddler version and eight dimensions
(responsivity, acceptance, language stimulation, learning materials, physical environment,
academic stimulation, modeling, and variety) of the early childhood version were scored as
absent or present, based on mothers’ report of family living patterns and habits, observation
of spontaneous mother-child interactions, and orderliness and enrichment potential of the
physical home environment (see Obradović, Yousafzai, et al., 2016 for lists of all items and
adaptation procedures). A total HOME score was generated by summing all 45 items at 18
months (M = 30.81, SD = 5.44, α = .82) and 54 items at 48 months (M = 32.07, SD = 6.74, α
= .94).
Maternal scaffolding. Maternal scaffolding behaviors were observed during a five-
minute interaction in which mothers were instructed to play with their children using a
picture book. They were rated using the Observation of Mother and Child Interaction
protocol (see Rasheed & Yousafzai, 2015 for details). Scoring was based on the frequency of
the observed behavior, with a higher score denoting more frequent demonstration of

behaviors (0 = never, 1 = very few, one to two times, 2 = sometimes, three to four times, 3 =
often, five or more times). A maternal scaffolding at 24 months (M = 1.602, SD = 0.804, α =

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.86) score was created by averaging six ratings of maternal behaviors: (1) sensitivity and
contingent responding; (2) scaffolding by expanding on the child’s speech; (3) pointing and
naming objects in the book; (4) posing questions to the child; (5) responding to the child’s
questions or requests; and (6) helping the child maintain interest. Maternal scaffolding at 48
months (M = 1.408, SD = 0.745, α = .67) was created by averaging four ratings: (1)
sensitivity and contingent responding; (2) scaffolding by expanding on the child’s speech; (3)
posing simple and complex questions to the child; and (4) helping the child to focus and
maintain interest.
Maternal cognitive skills. The vocabulary subtest of the Wechsler Abbreviated
Scales of Intelligence (WASI-II; Wechsler, 2011) was used as a measure of maternal verbal
intelligence. The subtest was deemed culturally relevant after expert review and two rounds
of piloting. A raw score based on 31 items that measure word knowledge and verbal concept
formation through picture and verbal items was converted to a t-score. The Forward Word
Span task, which requires repeating a sequence of words delivered by the assessor in the
same order, was used as a measure of maternal short-term memory. The Backward Word
Span task, which requires repeating a sequence of words delivered by the assessor in reverse
order, was used as a measure of maternal working memory. For both span tasks, final scores
were calculated using the longest span for which at least two test trials were repeated
correctly, plus 0.5 if a sequence was correctly repeated at the next level (Noël, 2009).
Missing Data
The percentage of missing data was small, ranging from 0.00% to 7.68%, except for
the child EF composite (12.14%) and maternal working memory measure (19.43%), which

was largely due to an inability to understand task rules. Other reasons for missing data
included external disruptions that caused the assessment to be cut short (e.g., no electricity in
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the room), lack of permission from the head of household to stay for the full duration,
challenging behavior, and obvious disabilities (e.g., unable to walk or speak). Missing data on
all independent variables was multiply imputed using chained equations with 20 datasets.
Data Analytic Plan
Main analyses were conducted in Stata Version 13.1 (StataCorp, 2013). We examined
the underlying structure of the EF construct using confirmatory factor analyses that compared
nested one-factor and two-factor models. We analyzed how antecedent and concurrent child
and family factors related to EFs using a series of five hierarchical regression models of
increasing complexity. To account for clustering of children within the 80 Lady Health
Workers who administered the original intervention trial, we used robust clustered standard
errors.
We tested the significance of indirect effect pathways using Stata’s seemingly
unrelated regression (sureg) command, which estimates a series of nested regression models
and allows for cross-equation error correlation. Indirect effects and standard errors were
calculated using the product of the coefficients method (Baron & Kenny, 1986). When
indirect effects were found for pathways that had non-significant direct effects, we calculated
the power to detect significant direct and indirect effects with the R package PowMedR,
which uses the joint-significance approach as described in Kenny and Judd (2014).

Results
EF tasks. We created six binary filter variables that reflected children’s performance
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on the practice trials using task-specific comprehension criteria (0 = did not pass criteria; 1 =
passed criteria). If children did not pass comprehension criteria, we did not use their
performance score on that task to create the final EF composite score. This ensured that
performance on test trials more accurately measured EFs rather than children’s ability to
understand the task rules (i.e., general intelligence) or other task-specific factors. The rate of
comprehension ranged from 80.1% to 91.3% across EF tasks, with the exception that only
47% of children passed both the color/shape practice trials and the pre-switch test trials of the
S-DCCS task. Please see Appendix C for a detailed description and evaluation of
comprehension criteria and performance variables for each individual EF task as well as task-
level correlations.
EF composite. Recent research has shown that while a full EF battery is preferred,
data from a three-task battery provides an acceptable measure of children’s overall EF
performance when there are study constraints or data collection challenges (Willoughby et
al., 2013). To produce an inclusive, but still reliable measure of overall EF performance, we
calculated a composite score only for children (N = 1144) who had valid test scores on at
least three of the six tasks (see Appendix C for more information). Children with at least
three valid EF scores were from households with significantly more wealth at baseline
(t(1476) = -2.327, p = .020) compared to children who were enrolled in the PEDS trial and
did not have valid EF scores due to attrition or a lack of EF task comprehension. There were
no significant differences between those two groups on maternal education or number of
siblings at baseline.

We conducted a confirmatory factor analysis to ensure that performances on different
EF tasks represent the same underlying construct, as has been reported in preschoolers from
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HIC (Wiebe, Espy, & Charak, 2008), before creating a single composite score. The one-
factor solution showed good absolute model fit (CFI = 0.986, TLI = 0.976, RMSEA = 0.023).
All six tasks loaded onto one factor, with standardized loadings ranging from .40 to .56. The
relative fit of this factor solution was further tested against a two-factor model that separates
the four IC tasks from more developmentally advanced WM and CF tasks. The two-factor
model did not fit the data better than the single-factor model (Δχ2(1) = 0.20, p = .652). We
created a composite score by standardizing and averaging the six EF performance scores (α =
.61, M = -0.03, SD = 0.61). Our tasks had relatively low bivariate correlations (see Appendix
C, Table C3), and a significant vanishing tetrad test chi-square statistic (χ2(45) = 119.74, p =
.002) provided support for averaged composite that equally weights each task (Willoughby,
Holochwost, Blanton, & Blair, 2014). The EF composite had a relatively normal distribution
(skewness = 0.182, kurtosis = 2.773), which is graphically represented in the Appendix.
Bivariate correlations reveal expected associations of EFs with the child and family
factors (see Table 1). The correlation between the general cognitive skills at 24 and 48
months (r=.39, p <.001) was significantly higher (z = 3.56, p <.001) than the correlation
between cognitive skills at 24 months and EFs at 48 months (r =.29, p <.001).
Regression Analysis: Developmental Antecedents and Correlates of Preschoolers’ EFs
Regression results are presented in Table 2. Model 1 included the child’s gender,
socioeconomic factors at birth (family wealth, maternal education, number of siblings), RS
and EN intervention effects, targeted family factors assessed during the second year of the
child’s life (home stimulation and maternal scaffolding), as well as food insecurity and
height-for-age at 24 months. We conceived of this model as a baseline model reflecting

findings that have been published elsewhere (Obradović, Yousafzai, et al., 2016). Significant
predictors of preschool EFs included maternal education, number of siblings at baseline,

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maternal scaffolding behaviors at 24 months, children’s height-for-age at 24 months, and the
RS intervention.
Model 2 extended previous work by showing that children’s cognitive skills at 24
months emerged as a unique longitudinal predictor of EFs at 48 months (β = 0.179, p <.001),
explaining significant additional variance in EFs (ΔR2 = .018; F(1, 76.7) = 23.85, p < .001).
Inclusion of this predictor shed new light on mediating processes during the first two years of
life. First, cognitive skills at 24 months partially mediated the effect of the RS intervention
exposure on preschoolers’ EFs (indirect effect: B = 0.020, p =.001, 24.09% of the total
effect). Second, cognitive skills at 24 months mediated the association between height-for-
age at 24 months and EFs at 48 months (indirect effect: B = 0.039, p <.001, 21.93% of the
total effect) as well as the association between maternal scaffolding at 24 months and
preschoolers’ EFs (indirect effect: B = 0.069, p <.001, 65.69% of the total effect). Third,
cognitive skills at 24 months also mediated the association between home stimulation quality
at 18 months on preschoolers’ EFs (indirect effect: B = 0.022, p =.001), even though home
stimulation quality was not a significant predictor of EFs. We had low power to detect the
association of home stimulation quality at 18 months with EFs at 48 months (30.0% power, α
=.05) and high power to detect the indirect mediation pathway (99.0% power, α =.05; Kenny
& Judd, 2014). These indirect effects are presented graphically in Figure 1a.
Model 3 added concurrent measures of home stimulation quality and maternal
scaffolding at 48 months, which explained significant additional variance in EFs (ΔR2 = .014;
F(2, 77) = 9.25, p < .001). Consistent with previously published findings (Obradović,

Yousafzai, et al., 2016), both aspects of concurrent family enrichment uniquely contributed to
preschoolers’ EFs, even with the inclusion of an antecedent measure of cognitive skills at 24
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months. All indirect effects for Models 2 and 3 are presented in Appendix Table D1.
Model 4 extended previous work by showing how three maternal cognitive skills
(verbal intelligence, short-term memory, and working memory) relate to children’s EFs.
Maternal verbal intelligence and short-term memory emerged as unique predictors of
preschoolers’ EFs (β = 0.145, p < .001; β = 0.065, p = .026, respectively), explaining
significant additional variance in EFs (ΔR2 = .023; F(3, 74.6) = 11.70, p < .001). The relation
between maternal education and EFs was no longer significant, as it was fully mediated by
maternal verbal intelligence (indirect effect: B = 0.029, p <.001, 98.17% of the total effect).
Maternal verbal intelligence also mediated the association between wealth and EFs (B =
0.019, p = .006) and maternal scaffolding at 24 months and EFs (indirect effect: B = 0.015, p
= .020), even though wealth and maternal scaffolding at 24 months were not significant
predictors of EFs due to power issues (direct effect power: 21.2% for wealth; 6.8% for
scaffolding; indirect effect power: 98.6% for wealth, 91.9% for scaffolding; α =.05). The
association between concurrent home stimulation quality and EFs was mediated by maternal
verbal intelligence (indirect effect: B = .027, p = .001, 31.58% of the total effect) and
rendered non-significant. In contrast, the link between concurrent maternal scaffolding and
EFs continued to be significant, but it was reduced in magnitude (β = 0.077, p =.014) and
partially mediated by maternal verbal intelligence (indirect effect: B = 0.010, p =.045,
12.02% of the total effect). These indirect effects are presented graphically in Figure 1b.
Model 5 extended previous work by showing that a concurrent measure of children’s
general intelligence emerged as a strong unique predictor of EFs above and beyond all other
covariates (β = 0.464, p <.001), explaining significant additional variance in EFs (ΔR2 = .161;
F(1, 75.4) = 234.26, p < .001). After accounting for the significant overlap with general

intelligence (i.e., 30.25% of shared variance), the following variables remained significant
predictors of preschoolers’ EFs: number of older siblings (β = 0.065, p =.020), height-for-age

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at 24 months (β = 0.079, p =.005), and the RS intervention (β = 0.062, p =.014). The
significant association between height-for-age at 24 months and EFs at 48 months was also
partially mediated by general intelligence at 48 months (indirect effect: B = 0.053, p < .001).
The longitudinal association between children’s cognitive skills at 24 months and EFs at 48
months was mediated by children’s general intelligence at 48 months (indirect effect: B =
0.116, p <.001, 69.84% of the total effect). Children’s general intelligence at 48 months also
mediated three concurrent associations between (1) maternal scaffolding and EFs (indirect
effect: B = 0.027, p =.040, 35.75% of the total effect); (2) home stimulation quality and EFs
(indirect effect: B = 0.051, p =.001; direct effect power: 6.4%; indirect effect power: 96.0%;
α =.05); and (3) maternal verbal intelligence and EFs (indirect effect: B = 0.111, p <.001,
74.96% of the total effect). These indirect effects are presented graphically in Figure 1c. All
indirect effects for Models 4 and 5 are presented in Appendix Table D2.
Discussion
The goal of the current study was to advance knowledge of factors that relate to EF
development in highly disadvantaged preschoolers living in rural areas of LMIC. We adapted
and tested a battery of standard EF tasks that can be used in similar settings to conduct a
developmentally and culturally appropriate assessment of early EF skills that yields reliable
and valid EF measures. Our work provided unique insights about the comprehension of EF
tasks among disadvantaged LMIC preschoolers and revealed the unidimensional structure of
an EF construct as indexed by six individual tasks. This longitudinal study is the first to: (1)
demonstrate developmental continuity between general cognitive development at age two and

emergent EFs at age four in a LMIC context; and (2) identify antecedent and concurrent
family and maternal factors that predict preschoolers’ EFs in a LMIC context, after
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accounting for the significant contribution of related, yet distinct cognitive skills at ages two
and four. We demonstrated the unique importance of an early childhood parenting
intervention and children’s growth status at age two for preschoolers’ EFs, after controlling
for the contributions of children’s general cognition at ages two and four. Our findings also
revealed that maternal cognitive scaffolding behaviors and mothers’ own cognitive capacities
were independently associated with children’s EFs. Finally, our results highlight that older
siblings may play a unique role in promoting EFs in a LMIC context.
Assessment of Executive Functioning in LMIC context
Many challenges arise when researchers employ tests developed and validated with
children living in HIC to assess cognitive skills of children in LMIC (see Pitchford &
Outhwaite, 2016; Zuilkowski, McCoy, Serpell, Matafwali, & Fink, 2016). We want to
highlight three issues in conducting EF assessments with preschool children in rural LMIC
settings at scale. First, we found it essential to work with local experts and complete
additional rounds of pilot testing to produce culturally and developmentally appropriate tasks
for young children who have not been exposed to any educational programming. For
example, children in our sample struggled with fanciful colors and symbols (e.g., red rabbit)
that are typically understood by older members of their community or by preschoolers in
more advantaged settings. Second, we found it necessary to address administration
procedures that are typically not discussed as part of cross-cultural measurement adaptation.
While most EF studies in the U.S. context are conducted by a small number of highly trained
research assistants, field research teams in LMIC are often larger and more heterogeneous in

terms of their education, experience working with children, and familiarity with
psychological assessments. In order to maintain high-quality data collection across a large

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sample and large assessment team, we standardized (1) assessment protocols; (2) explicit
guidelines for dealing with assessment challenges (e.g., non-compliance, inaudible response);
and (3) assessors’ feedback across six EF tasks that were originally independently developed.
Third, we evaluated children’s comprehension of EF task instructions by examining
performance on practice trials. Although it is common to exclude children who appear not to
understand task rules, extant EF studies rarely report explicit exclusion or comprehension
criteria or how these assessment decisions affect their analytic sample and strategy. We hope
future studies follow our lead in using performance on practice trials to post hoc evaluate
children’s comprehension rather than rely on field assessors to make this complex decision
during the assessment.
Although no task can purely measure a single EF component, the majority of children
in our study understood the tasks designed to primarily assess motoric and verbal response
inhibition and suppression of visual interference. Performance on a task designed to assess a
developmentally more advanced EF skill of cognitive flexibility (Diamond, 2013) proved
more challenging. Our analyses confirmed that all six performance variables loaded on a
single latent factor. This is consistent with the EF structure observed in preschoolers from the
United States and the argument that the tasks designed to assess conceptually distinct EF
dimensions in early childhood actually measure a unitary cognitive ability despite their
superficial differences (Wiebe et al., 2008). In accordance with these results and following
recent methodological recommendations (Willoughby et al., 2014, 2013), we used an
aggregate index of EFs to measure overall EF more reliably than any individual EF task.
However, we advocate for continued investigation and report of comprehension and

performance on individual EF tasks as a way to improve the reliability and validity of EF
assessments in LMIC settings.

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Antecedent Cognitive Development and Preschoolers’ EFs in LMIC
Until recently, developmental researchers studying young children in LMIC have
primarily focused on measuring general cognitive skills (Aboud & Yousafzai, 2015). Given
the growing interest in directly assessing children’s EFs in LMIC (Obradović, Yousafzai, et
al., 2016; Oluwole, Noll, Winger, Akinyanju, & Novelli, 2016; Pitchford & Outhwaite, 2016;
Wolf & McCoy, 2017), it is important to understand how antecedent cognitive skills relate to
emergent EFs. Using the widely-employed Bayley Scales of Infant and Toddler
Development, we found that direct assessments of general cognitive skills at 24 months were
significantly related to children’s performance on EF tasks at 48 months. Further, we found
evidence of divergent validity: the association between general cognitive skills at ages two
and four was significantly stronger than the association between cognitive skills at age two
and EFs at age four.
Moreover, measures of cognitive development at age two explained how the
antecedent child and family factors were linked to EFs. The effect of the responsive
stimulation intervention on preschoolers’ EFs was partially mediated by children’s cognitive
skills at the completion of the PEDS Trial (Obradović, Yousafzai, et al., 2016). The
longitudinal associations of the factors that were targeted by the PEDS Trial (i.e., physical
linear growth, quality of home stimulation, and maternal scaffolding during the second year
of the child’s life) with preschoolers’ EF were also mediated by cognitive skills at age two.
These findings highlight the need to account for developmental continuity of cognitive skills
in order to identify how and when early parenting programs contribute to EF development in
LMIC contexts. Knowing that the targeted familial stimulation practices affected

preschoolers’ EFs by increasing general cognitive skills at the conclusion of the intervention
program can improve the design of future interventions and follow-up booster sessions aimed
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at fostering EFs. Many early childhood stimulation curricula in LMIC that focus on
increasing parental sensitivity and responsiveness through play and communication activities
in the first two years of life could be expanded to help parents adapt these skills to later stages
of development and to engage in activities that promote preschoolers’ learning and self-
regulation. Specifically, parents can be supported in engaging young children in routines,
chores, and games that require planning, setting goals, following rules, monitoring progress,
turn-taking, collaborating, or responding flexibly, as a way to scaffold children’s EFs.
Home Stimulation, Maternal Scaffolding, and Maternal Cognitive Skills
The current study identified proximal family-level processes that are uniquely related
to EFs in preschoolers living in highly disadvantaged, rural areas of LMIC, while accounting
for more commonly studied distal factors like family wealth and maternal education (Fernald
et al., 2011; Prado et al., 2010; Schady, 2011). We found that concurrent associations of the
home stimulation quality and maternal scaffolding with EFs at age four (Obradović,
Yousafzai, et al., 2016) were robust to controlling for antecedent cognitive skills at age two.
Exposure to higher levels of cognitive stimulation at home appears to play a critical role in
promoting cognitive development of preschool-age children who live in rural LMIC areas,
where access to formal early educational opportunities is limited and where the quality of
existing programs is low (UNICEF, 2013).
Next, we examined whether maternal cognitive skills are linked to children’s EFs in
LMIC, parallel to what has been recently shown in HIC samples (Cuevas et al., 2014; Deater-
Deckard & Sturge-Apple, 2017). Indeed, both maternal verbal intelligence and maternal
short-term memory independently predicted preschoolers’ EFs, controlling for children’s

antecedent cognitive skills and physical growth. Further, we found that maternal verbal
intelligence fully mediated the association of maternal education with children’s EFs,
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underscoring the importance of employing direct cognitive assessments when investigating
variability of cognitive capacities among poor women with very little or no formal education.
Programs designed to improve child development outcomes in rural LMIC areas should
explicitly support the growth of maternal cognitive and literacy skills.
As more researchers turn to identifying specific, modifiable parental behaviors that
are linked to children’s cognitive development in LMIC (McCoy et al., 2015; Obradović,
Yousafzai, et al., 2016), it is important to understand whether the associations between
parenting behaviors and EFs are significant controlling for parental cognitive capacities
(Crandall, Deater-Deckard, & Riley, 2015). For example, the relation between concurrent
home stimulation quality and EFs was fully mediated by maternal verbal intelligence,
whereas concurrent maternal scaffolding remained a significant predictor of EFs. We can
assume that maternal verbal intelligence partially captures shared mother-child genetic
endowment and socioeconomic resources (e.g., maternal verbal intelligence also explained
the link between family wealth at birth and preschooler’s EFs). Thus, the current study
provides additional evidence that targeting maternal scaffolding behaviors with parenting
interventions is an effective way to promote early cognitive development in LMIC children,
irrespective of maternal intelligence and family wealth. Future research should continue to
examine how different maternal cognitive skills may affect child development in LMIC vis-à-
vis parenting practices and uptake of intervention messages.
Shared Variance with IQ and Unique EF Predictors
As higher-order cognitive skills, EFs are linked to general cognitive capacities.
Indeed, among preschoolers living in rural areas of LMIC, we found that 30% of the variance

in EFs was shared with the concurrent measure of general intelligence, as indexed by a gold-
standard direct assessment that has been locally validated (Rasheed et al., 2017). This finding
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corroborates the notion that EF and IQ skills are related, yet distinct constructs in LMIC
preschoolers. As such, it is important to identify factors that relate to emerging EFs in LMIC
context, beyond their associations with children’s general intelligence. To extend recent
LMIC studies that have examined children’s EFs and cognition as separate outcomes (McCoy
et al., 2015; Obradović, Yousafzai, et al., 2016), we modeled general cognitive skills as a
predictor of EFs.
Not surprisingly, children’s intelligence at age four fully explained the longitudinal
association of antecedent cognitive skills at age two with preschoolers’ EFs; however, it only
partially explained the link between antecedent physical growth and EFs. Our study
demonstrated that children’s height-for-age at 24 months, an index of physical linear growth,
is an important unique predictor of preschooler’s EFs in rural LMIC settings. Physical growth
status at age two can reflect early malnutrition (i.e., a height-for-age score below 2SD marks
growth retardation, known as stunting, which can result from prenatal or postnatal chronic
undernutrition) that may be particularly relevant for healthy neurocognitive development
(Walker et al., 2011).
We also found that a measure of children’s general intelligence fully explained the
concurrent associations of preschoolers’ EFs with maternal verbal intelligence, the quality of
home stimulation, and maternal scaffolding. It is possible that these three variables reflect
shared genetic endowment and enrichment opportunities that promote general cognitive
development, and not specifically EFs. However, it is important to note that our observed
measure of maternal scaffolding primarily focused on language stimulation (e.g., naming
objects, expanding on the child’s speech, posing questions, and responding to the child’s
questions). It is possible that mothers engaged in other everyday parenting practices that

directly promoted children’s EFs, but were not captured by our measure of maternal
scaffolding.
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Indeed, participation in an early responsive stimulation intervention targeting
maternal knowledge and practices during the first two years of life was a unique predictor of
EFs at age four, despite the inclusion of many significant child- and family-level predictors
and mediators. Given the unique relevance of EFs for self-regulated behavior and learning
(Jones, Barnes, Bailey, & Doolittle, 2017), future parenting intervention studies should
identify and bolster specific components that uniquely promote preschoolers’ EFs (e.g.,
teaching children how to stay focused, control impulsive behaviors, and cope with negative
emotions during chores, routines, and play). At the same time, there is a need to develop
developmentally appropriate and culturally sensitive observational measures of parenting
behaviors that go beyond scaffolding of language and attention to capture parenting practices
and family routines that foster young children’s inhibitory control, working memory, and
cognitive scaffolding.
Interestingly, the number of older siblings was also a unique positive predictor of EFs
in this context. Relationship dynamics in larger families may demand greater self-regulation
in children and thus offer more opportunities to practice and apply EFs. On the other hand,
older siblings are known to provide additional caregiving support and may engage in dyadic
co-regulation with the younger child. Positive parent-child co-regulation, as indexed by
moment-to-moment changes in the child’s and parent’s regulation of attention and affect, has
been shown to predict young children’s self-regulation skills in HIC (Bardack, Herbers, &
Obradović, 2017). Scalable and pragmatic approaches to measuring dynamic aspects of
familial interactions will be crucial to understanding the roles that other caregivers play in
promoting children’s self-regulation in LMIC.

Limitations and Future Directions
Although this study advances knowledge of EFs in disadvantaged preschoolers in a

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LMIC setting, it has several limitations. First, while the sample is large and representative of
Pakistani children living in rural areas, the participants’ experiences may differ from other
LMIC children, particularly children in urban settings who often have greater exposure to
educational opportunities. Second, longitudinal EF measurement would have enabled us to
examine how proximal and distal factors contribute to growth and change in EF skills, a
critical question for future EF research in LMIC. Third, our battery of EF tasks could be
expanded to include more measures of working memory and cognitive flexibility, which
would enable a rigorous examination of underlying EF factor structure and its changes over
time in LMIC settings. Fourth, our choice of family processes was theory-driven, but it was
not an exhaustive selection. Future studies should investigate the role of fathers (e.g.,
Meuwissen & Carlson, 2015) and other significant caregivers for preschoolers’ EF
development in LMIC, in order to identify the most promising targets for intervention.
Finally, the current findings need to be extended by identifying the relative contribution of
EFs and other cognitive measures for subsequent developmental (e.g., prosocial behaviors,
peer relationships) and educational (e.g., school engagement, academic achievement)
outcomes of children in LMIC in order to more fully understand the importance of early EFs
for adaptation and resilience in this highly disadvantaged population of children.
Conclusion
The current study offers a play-based battery of EF tasks along with adaptation
guidelines that can be implemented in other LMIC. Increased consistency in assessment of
early EFs across LMIC studies will enable cross-cultural comparisons of EF development and
advance our understanding of how these skills contribute to the development of children

around the world. Using multi-method, multi-informant longitudinal data and a rigorous
research design, this study sheds new light on the developmental timing and independent
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contributions of child and family factors from birth to age four for preschoolers’ EFs in
LMIC. Although our findings echo research conducted with at-risk children in HIC, children
in LMIC face more extreme levels of chronic adversity and have poorer access to services
and programs that can ameliorate those risks. The modest amount of variance in EFs that is
explained by traditional child and family factors in our study reinforces the critical need to
identify other processes that shape development of early EFs in highly disadvantaged LMIC
contexts.
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Table 1
Descriptive Statistics and Zero-Order Correlations Between Predictor Variables

Accepted Article
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
1. Male ___
2. Wealth -
___
(b) .01
3. Mat educ .37**
___
(b) .02 *
- -
4. Num sib .12** .16** ___
(b) .00 * *
- -
5. Food ins .25** .22** .12** ___
(24m) .04 * * *
- -
6. HOME - .30** .28** .16** .24* ___
(18m) .03 * * * **
-
7. Scaff - .20** .20** .15* .37** ___
(24m) .01 * * -.05 ** *
- -
8. Height - .27** .23** .10** .17* .23** .16** ___
(24m) .02 * * * ** * *
.39** .30**
___
9. RS .03 .04 -.01 .02 -.07* * * -.04
-
- .14* .10** .13** ___
10. EN .05 -.01 .09** -.03 ** * * .03 -.01
- -
11. Cog .25** .21** .12** .22* .42** .52** .35** .28** ___
(24m) .01 * * * ** * * * * .09**
-
12. HOME - .31** .34** .24* .46** .31** .24** .13** .36** ___
(48m) .01 * * -.02 ** * * * .09** * *
-
13. Scaff .17** .29** .11* .28** .28** .12** .13** .22** .31** ___
(48m) .03 * * -.06* ** * * * * .03 * *
-
.32** .42** .21* .32** .28** .17** .13** .24** .39** .29** ___
14. Mat IQ .03 * * -.05 ** * * * * .05 * * *
- -
15. Mat - .19** .34** .10** .15* .18** .14** .15** .16** .21** .20** .32** ___
FWS .03 * * * ** * * * .04 .00 * * * *
-
16. Mat - .18** .41** .15* .20** .21** .13** .18** .18** .17** .29** .34** ___
BWS .02 * * -.06 ** * * * .10** .05 * * * * *
-
17. Child .21** .22** .16* .26** .24** .28** .11** .38** .32** .23** .39** .21** .19** ___
IQ .05 * * -.06* ** * * * * -.03 * * * * * *
- ___
18. Child - .14** .18** .12* .19** .20** .23** .13** .29** .23** .20** .28** .18** .17** .55**
EFs .01 * * .02 ** * * * * .01 * * * * * * *
-
54 - 30.81 - 80.50 32.07 22.49 - 0.02
Mean / % % 0.002 2.192 2.500 33% 1 1.602 2.333 51% 48% 0 1 1.408 7 3.608 2.393 0.027 7
12.79 0.61
SD 0.988 3.686 2.309 5.444 0.804 1.123 3 6.741 0.745 3.777 0.853 0.747 0.611 1
1,3 1,30 1,14
N 02 1,294 1,302 1,267 1 1,273 1,301 1,278 1,302 1,302 1,298 1,295 1,289 1,202 1,254 1,049 1,144 4
Notes. *p < .05, **p < .01. b = baseline, m = months, mat educ = maternal education, num sib= number of siblings, food
ins= food insecurity, HOME = home stimulation quality, scaff = maternal scaffolding, height = height-for-age, RS =
responsive stimulation intervention, EN = enhanced nutrition intervention, cog = child cognitive skills, mat IQ= maternal
intelligence, mat FWS = maternal Forward Word Span, mat BWS = maternal Backward Word span, IQ = intelligence, EFs =
executive functions

Table 2
Stepwise Regression Models Predicting EF Skills from Family Factors and Developmental
Correlates
Accepted Article
Model 1 Model 2 Model 3 Model 4 Model 5
β se β se β se β se β se
- - - - -
Male 0.0 0.01 0.01 0.02 0.03
10 (0.029) 4 (0.028) 8 (0.027) 1 (0.026) 0 (0.024)
- - - -
Wealth (b) 0.0 0.00 0.01 0.03 0.02
05 (0.031) 4 (0.031) 3 (0.030) 4 (0.031) 7 (0.027)
0.1 (0.033) 0.10 (0.033) 0.07 (0.034) 0.00 0.02
Maternal education (b)
08 ** 6 ** 1 * 3 (0.035) 3 (0.035)
0.0 (0.032) 0.07 (0.031) 0.06 (0.032) 0.06 (0.031) 0.06 (0.027)
Number of siblings (b)
70 * 7 * 7 * 3 * 5 *
- - - - -
Food insecurity (24m) 0.0 0.03 0.02 0.01 0.00
44 (0.026) 6 (0.025) 8 (0.025) 8 (0.025) 9 (0.022)
- - -
HOME quality (18m) 0.0 0.02 0.02 0.03 0.02
47 (0.040) 4 (0.039) 1 (0.041) 0 (0.042) 9 (0.036)
-
Maternal scaffolding
0.1 (0.027) 0.03 0.01 0.01 0.00
(24m)
05 *** 5 (0.029) 0 (0.029) 1 (0.029) 8 (0.027)
0.1 (0.031) 0.14 (0.032) 0.14 (0.032) 0.13 (0.032) 0.07 (0.027)
Height-for-age (24m)
82 *** 2 *** 2 *** 3 *** 9 **
Responsive 0.0 (0.027) 0.06 (0.027) 0.07 (0.028) 0.06 (0.027) 0.06 (0.025)
stimulation (RS) 84 ** 3 * 3 * 5 * 2 *
- - - -
Enhanced nutrition
0.0 0.02 0.03 0.03 0.00
(EN)
22 (0.027) 6 (0.027) 1 (0.027) 1 (0.026) 7 (0.023)
Child cognitive skills 0.17 (0.036) 0.16 (0.035) 0.16 (0.035) 0.05
(24m) 9 *** 5 *** 9 *** 2 (0.033)
0.08 (0.037) 0.06 0.00
HOME quality (48m)
9 * 0 (0.037) 9 (0.033)
Maternal scaffolding 0.09 (0.032) 0.07 (0.031) 0.05
(48m) 8 ** 9 * 2 (0.029)
0.14 (0.035) 0.03
Maternal verbal IQ
5 *** 4 (0.032)
Maternal Forward 0.06 (0.029) 0.04
Word Span 5 * 9 (0.026)
Maternal Backward 0.03 0.02
Word Span 9 (0.029) 2 (0.027)
0.46 (0.030)
Child IQ (48m)
4 ***
- - - - -
Constant 0.0 0.02 0.02 0.02 0.05 (0.022)
15 (0.027) 2 (0.026) 5 (0.026) 9 (0.025) 0 *
N 1,144 1,144 1,144 1,144 1,144
R2 .102 .120 .134 .157 .318
Notes. *p < .05, **p < .01, *** p < .001. All models use robust standard errors, clustered at the Lady
Health Worker level. b = baseline, m = months, HOME = home stimulation, EFs = executive
functions.

Figure Caption
Accepted Article
Figure 1. Significant indirect effects for (a) Model 2, (b) Model 4, and (c) Model 5. Note that
significant direct effects are not shown. In Model 2, maternal education and number of
siblings have significant direct effects on EFs. In Model 4, number of siblings, height-for-
age (24 months), the responsive stimulation intervention, and child cognitive skills (24
months) have direct effects on EFs. In Model 5, number of siblings and the responsive
stimulation intervention have direct effects on EFs.

Accepted Article

Appendices
To Accompany
Accepted Article
Obradović, J., Finch, J. E., Portilla, X., Rasheed, M., Memon, U., Tirado-Strayer, N., &
Yousafzai, A. Assessing early executive functioning in a global context: Family factors
and developmental correlates in rural Pakistan. Developmental Science.
Table of Contents
Appendix A Selection, Adaptation, and Evaluation of Executive Functioning Tasks............ 1
EF Task Selection .......................................................................................................................... 1
Table A1 Descriptions of Individual EF Tasks............................................................................... 2
EF Task Adaptation & Evaluation.............................................................................................. 4
First Pilot (11 tasks; N = 5). ............................................................................................................ 4
Second Pilot (9 tasks; N = 4). ......................................................................................................... 5
Third Pilot (9 tasks; N = 4). ............................................................................................................ 6
Fourth Pilot (9 tasks; N = 20). ........................................................................................................ 6
Table A2 Descriptive Statistics for Individual EF Tasks................................................................ 9
Summary of Lessons Learned. ........................................................................................................ 9
Table A3 Summary of Adaptation Steps from Initial to Final EF Tasks ...................................... 11
Final EF Tasks............................................................................................................................. 11
Fruit Stroop. .................................................................................................................................. 11
Knock/Tap..................................................................................................................................... 12
Big/Little Stroop ........................................................................................................................... 12
Forward Word Span ...................................................................................................................... 13
Go/NoGo ....................................................................................................................................... 14
Separated Dimensional Change Card Sort .................................................................................... 15
Appendix B Administration Procedures for Executive Functioning Tasks ......................... 17
Appendix C Performance on Individual Tasks and Executive Function Composite
Measure ........................................................................................................................................ 19
Table C1 Executive Functioning Comprehension Criteria and Task Descriptives ..................... 20
Table C2 Correlations among EF Comprehension Criteria and Predictor Variables ............... 22
Table C3 Correlations among EF Performance Variables ......................................................... 23
Table C4 Correlations among EF Performance and Predictor Variables .................................. 24

Confirmatory Factor Analysis and Creation of Final Composite Measure .......................... 24
Figure C1 Distributions of Child EF Composite ......................................................................... 26
Accepted Article
Appendix D Indirect Effects Coefficients and p-values ........................................................... 27
Table D1 Indirect Effects for Models 2 and 3............................................................................... 27
Table D2 Indirect Effects for Models 4 and 5............................................................................... 28
References .................................................................................................................................... 29
Appendix A
Selection, Adaptation, and Evaluation of Executive Functioning Tasks
EF Task Selection
Since there was no existing battery of executive function (EF) tasks for four-year-old children
in a disadvantaged, rural LMIC context, the process began with an extensive literature review
of frequently used child EF tasks. These criteria determined the initial selection: (1) tasks
were developmentally appropriate for both three- and four-year-olds; (2) tasks were widely
used and had well-established psychometric properties; (3) tasks included materials and
instructions that could be adapted to the local context and were not computerized; (4)
performance required minimal verbal response (e.g., two-word responses, pointing, tapping),
as children can be shy in the unfamiliar context of a standardized assessment; and (5)
administration was feasible both in terms of the community assessors’ skill level and the
length of the assessment session.
Descriptions of all tasks are presented in Table A1.

ccepted Articl
Table A1
Descriptions of Individual EF Tasks
Task EF Component Citation Description
The child is shown three pictures, each depicting a little fruit embedded within a
(Kochanska,
different larger fruit (e.g., a little apple embedded within a large banana). The
Fruit Stroop Inhibitory control Murray, & Harlan,
child is asked to suppress the inclination to choose the large fruit and instead
2000)
choose the little fruit (e.g., “Show me the little apple).
The child is required to knock with their knuckles on the table or tap with the flat
(Molfese et al.,
Knock/Tap Inhibitory control of their palm that is the opposite action to that of the assessor (e.g., child knocks
2010)
when the assessor taps).
The Zebra-Lion Game was adapted from the Bear-Dragon Game. Children are
Zebra/Lion asked to focus on and perform commands instructed by a nice Zebra puppet
(Reed, Pien, &
Inhibitory control using a nice, sweet voice (activation trials) but control the impulse to perform
(Bear/Dragon) Rothbart, 1984)
commands instructed by a mean Lion puppet using a gruff voice (inhibitory
trials).
The child must perform an action (press a bell) given a certain stimuli (Go trial)
(Durston et al.,
Go/NoGo Inhibitory control and inhibit that action (not press a bell) when presented with a different set of
2002)
stimuli (NoGo trial).
The Big/Little Stroop was adapted from the Day/Night Stroop. Children are
Big/Little Stroop (Gerstadt, Hong, & presented with a card that either has a picture of a big or a little cat on it. When
Inhibitory control
(Day/Night Stroop) Diamond, 1994) the children see a card with the big cat on it, they are asked to say “little.” When
the children see a card with the little cat on it, they are asked to say “big”.
(Kochanska,
Delay of Children are instructed to wait for the assessor to ring a bell before retrieving a
Murray, Jacques,
Snack Delay gratification snack for under a plastic cup. Halfway through the delay, the assessor lifts the
Koenig, &
(inhibitory control) bell but does not ring it.
Vandegeest, 1996)
Dimensional Cognitive flexibility (Diamond, Carlson, After learning to sort the cards according to one dimension in part 1 (e.g. color),

ccepted Articl
Change Card Sort
(DCCS)
& Beck, 2005) children are asked to sort the cards according to the other dimension in part 2
(e.g. shape). The cards in the Separated version depict a black silhouette shape
on a colored card (red or blue), such that the shape and color dimensions are
separated. The cards on the Integrated version depict a shape that is either red or
blue on a white card such that the shape and color dimensions are integrated.
Children are asked to repeat a sequence of words in the exact same order either
(Davis & Pratt, forwards or backwards. The child is given three sequences per level. If the child
Word Span Working memory
1995) performs well on one level, the child will advance to the next level which
increases the sequence length by one word.
Children are asked to repeat a block-tapping sequence in the exact same order
either forwards or backwards. The child is given three sequences per level. If the
Corsi Block Tap Working memory (Corsi, 1972)
child performs well on one level, the child will advance to the next level which
increases the sequence length by one block.
(Willoughby, Blair, Self-ordered pointing task where children are asked to pick each picture so that
Wirth, Greenberg, & all of the pictures “get a turn.” Children receive four trials with two pictures to
Pick the Picture Working memory The Family Life choose from, six trials with three pictures to choose from, and eight trials with
Project four pictures to choose from. Children have to remember which pictures they
Investigators, 2012) already selected for each set.

EF Task Adaptation & Evaluation
Before piloting, we: (1) prepared uniform manuals and scoring sheets across all tasks to
ensure consistency in training and administration; (2) modified stimuli and instructions for
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socio-cultural relevance and linguistic accuracy, based on discussions with psychologists,
teachers, and assessors familiar with the community; and (3) reviewed back-translations to
ensure the validity of tasks was not compromised. A team of experienced assessors trained
the supervisory staff on the initial EF battery. During this process, supervisory staff provided
feedback on the feasibility and appropriateness of initial protocols. Over a few months,
assessors conducted several rounds of pilot testing with a representative sample of children in
the target age range.
Throughout pilot testing, we conducted daily debriefings in the field office and held weekly
conference calls with international team members to discuss issues with task instructions,
materials, and scoring procedures. These conversations informed decisions about whether and
how to adapt tasks for the next round of pilot testing. The first three pilot rounds relied only
on qualitative feedback from assessors, while the final round also relied on quantitative
analysis of pilot data.
First Pilot (11 tasks; N = 5). After assessor training session, our team conducted an initial
pilot test of all 11 tasks with five children from the local community. The first pilot revealed
that we needed to further adapt the protocol so that instructions could be easily understood by
children in this context, as well to make the script more explicit and standardized across the
tasks. Further, the pilot revealed tasks that should be adapted or removed from consideration.
The inhibitory control task known as Day/Night Stroop (Gerstadt et al., 1994) was deemed
too complex, as children did not associate a picture of the sun with “day” and a picture of the
moon with “night.” This task requires that children make this high-level symbolic association
in order to advance to test trials in which they are asked to reverse the association (e.g., say
“day” when presented a stimulus card depicting the moon). We modified the task by asking
children to associate the sun with “sun” and the moon with “moon.” (This modification was
inspired by the related inhibitory control task Grass/Snow (Carlson & Moses, 2001), which
associates the color green with “grass” and white with “snow.”)
Further, two tasks were dropped: Backward Word Span and Pick the Picture. Pilot results on
Backward Word Span showed a strong floor effect, indicating that the task was too difficult
for children in this context. Meanwhile, on Pick the Picture, assessors determined that
children were advancing to test trials without comprehending the game. Children who did not
understand the rules pointed to the same location on each trial, but the layout of the flipbook
was such that this produced accidentally correct responses. Prompts were also deemed too
verbose, which lengthened the task and caused children to lose interest.

Second Pilot (9 tasks; N = 4). We conducted a second round of pilot testing with the
remaining nine EF tasks, testing tasks in groups of three across three days to allow time for
feedback and to minimize exhaustion effects that could interfere with results. Four children
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(two attending school; two not attending school) participated. The two school-going children
performed well on most tasks and could sustain attention across all nine tasks. The two
children who did not attend school did not perform as well. One displayed a good
understanding of instructions on some of tasks, whereas the other showed limited or no
understanding across all tasks.
This round revealed further problems with the revised Day/Night Stroop task, as all four
children did not understand the association of the words “sun” and “moon” to the picture
cards, because parents do not commonly teach these words to their children. As a result, we
redesigned the task as an opposites game with adjectives that children would be familiar with:
“big” and “little.” We selected a picture of a cat (a recognizable image previously tested with
children in this context) and adapted the stimuli cards to display big cats and little cats. A
follow-up pilot test with the same four children demonstrated that the task was adequately
adapted and the task was renamed the Big/Little Stroop task. We also made minor revisions
to the protocol for the Dimensional Change Card Sort and Forward Corsi Block Tap tasks to
clarify prompts and make the practice trials more explicit.
Third Pilot (9 tasks; N = 4). We conducted a third round of pilot testing with four new
children on the nine tasks (all four-year-old males: two attending school; two not attending
school). This round focused on testing the order of the battery and timing of the tasks. The
two school-going children performed well and could sustain attention throughout the entire
assessment. The children who did not attend school did not perform as well, though they did
demonstrate a good understanding of task rules. Results from this round determined the final
sequence of the battery and determined that no further adaptation of tasks was needed.
Fourth Pilot (9 tasks; N = 20). We conducted the fourth and largest round of pilot testing
after all protocols and scoring sheets were finalized, translated from English to Sindhi, back-
translated to English, and reviewed. This round included twenty children (10 females, 10
males: 7 attending school; 13 not attending school). Ages ranged from 48 to 50 months (M =
49.10; SD = .64). Descriptive data on children’s performance on individual EF tasks is
presented in Table A2.
During this round, we made minor revisions to the protocol script for four tasks: Fruit Stroop,
Knock/Tap, Big/Little Stroop, and Forward Word Span. For example, we switched the order
of correct answers on the practice trials in Fruit Stroop to eliminate the left-to-right pattern of
correct response. On the Knock/Tap task, we found it more effective if the assessor
physically guided the child’s hand through the correct motion during practice trials, rather
than just demonstrating visually.
This round also revealed a need for more extensive adjustment of two tasks. For the
Go/NoGo task, we decided to use one stimulus for all Go trials (i.e., cat) and one stimulus for
all NoGo trials (i.e., dog). Alternating between animals across the Go trials was confusing for
the children, and not essential to the task. For the Dimensional Change Card Sort, we
identified a need to associate the color depicted on the stimuli cards with objects children
recognized in the real world. The script was changed to refer to the color green as “grass-
colored” and the color yellow as “mango-colored.” These simplifications resulted in greater

understanding once we entered the field. Finally, analysis of children’s response patterns
revealed that 14 children did not comprehend the Integrated version of the DCCS; they
seemed to perseverate on sorting by shape, following the rules of the Separated version. This
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lead to much higher scores on the Integrated post-switch trials when compared to scores on
the Integrated pre-switch trials. Since only two out of 20 children trials scored higher than
chance on the Integrated pre-switch and post-switch trials, we decided to abbreviate this task
and proceed with only the Separated version.
The other three tasks were dropped from further consideration: Zebra/Lion, Forward Corsi
Block Tap, and Snack Delay. For the Zebra/Lion task, we found that children were unfamiliar
with following instructions from a puppet, and thus they remained motionless throughout the
task. This resulted in a very low activation score, and an artificially high inhibitory score.
Only three children performed above chance on activation and inhibition trials. The lack of
movement that rendered this task meaningless could be due to (1) greater levels of behavioral
inhibition (i.e., shyness and possible fear of task novelty) in an unfamiliar testing context, (2)
confusion in response to an atypical request to obey puppet-issued commands, or (3)
heightened attention and interest that made children inclined to observe a novel spectacle
rather than participate in it. It is important to note that adults in the community are not
typically reticent. This task was also challenging to administer as it required two assessors,
one to hold the puppets and the other to score the child’s performance, since we would be
unable to video-record sessions in the field. For the Forward Corsi Block Tap task, children
struggled to sustain attention. After extensive adaptation that improved comprehension of the
task rules, more than half of children did not score above a two-tap sequence. We were
concerned about sufficient variability in the full sample, and we dropped the task due to time
constraints so that the final battery would not be too taxing for this age group. Finally, we
found little variability in children’s performance on the Snack Delay task. Almost all children
waited the maximum allotted time and hit the ceiling.

Table A2
Descriptive Statistics for Individual EF Tasks
Task Score Mean SD Min Max
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Total sum score across 3 test trials
Fruit Stroop 0.95 0.89 0.00 3.00
(out of possible 3)
Percent correct on 16 test trials

Knock/Tap 0.60 0.34 0.06 1.00
Percent correct on 6 pre-switch (shape) trials 0.85 0.26 0.17 1.00

DCCS - Separated
Percent correct on 6 post-switch (color) trials 0.36 0.36 0.00 1.00
Percent correct on 6 pre-switch

0.54 0.35 0.00 1.00
DCCS - Integrated (color) trials
Percent correct on 6 post-switch (shape) trials 0.64 0.39 0.00 1.00

Activation score, total sum score on 6 Zebra test
6.35 6.59 0.00 16.00
trials (possible range 0-18)
Zebra/Lion
Inhibition score, total sum score on 6 Lion test
13.90 5.43 4.00 18.00
trials (possible range 0-18)
Percent correct on valid Go trials

0.60 0.36 0.00 1.00
Go/NoGo
Percent correct on valid No-Go trials
0.37 0.37 0.00 1.00
Percent correct on 16 test trials

Big/Little Stroop 0.57 0.39 0.00 1.00
Forward Word Total span (longest span plus .5 for any additional
2.03 0.95 1.00 3.50
Span correct item)
Forward Corsi Total span (longest span plus .5 for any additional
1.89 0.81 1.00 3.50
Block Tap correct item)
Total average score across 4 test trials (out of

9.36 0.73 7.25 10.00
possible 10)
Snack Delay
Percentage of children who waited full time across
0.95 0.10 0.75 1.00
4 test trials
Summary of Lessons Learned. Many lessons emerged during the adaptation phase. The task
stimuli must be modified to be socio-culturally relevant, locally familiar, and age-appropriate,
while maintaining functional equivalence. Task images that were not culturally appropriate
(e.g., pig) or locally familiar (e.g., cruise boat) were replaced. Although some stimuli

involved concepts familiar to the greater community, they were confusing to young children
with no schooling or media exposure. For example, the children struggled with identifying
colors that they do not reference in the real world, so we switched the colors in the sorting
task from red and blue to green and yellow, and the script referred to these colors as “grass-
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colored” and “mango-colored.” Similarly, children had difficulty associating a particular
color with an object if that combination did not exist in the real world (e.g., red rabbit), so we
changed stimuli to represent more plausible pairings (e.g., yellow star, green truck). Further,
children failed to identify visual representations of day and night and were unfamiliar with
the icons of the sun and moon. Overall, the tasks were modified to hold children’s attention
and ease comprehension; we chose more colorful pictures, lowered task demands (e.g.,
number of stimuli that needed to be processed), contextualized instructions by using familiar
narratives, and increased the number of practice trials.
The final selection of the EF battery was based on: (1) qualitative feedback from participants,
child assessors, supervisors, and experts; (2) quantitative analyses of pilot-test data; and (3)
the final, operational pilot that examined the length, sequence, and feasibility of the entire
assessment visit, taking into account the attention, comfort, and fatigue of children,
caregivers, and assessors. Five tasks out of an initial list of 11 tasks were dropped due to
limited comprehension of task rules or due to floor or ceiling effects. Adapted versions of the
six remaining EF tasks were deemed developmentally and culturally appropriate for use with
four-year-old children in rural Pakistan. Table A3 shows a summary of the adaptation steps
for all piloted tasks.
Table A3
Summary of Adaptation Steps from Initial to Final EF Tasks
Initial EF tasks Outcome from adaptation Final EF tasks
1. Fruit Stroop Kept; slight adaptation Fruit Stroop
to adjust script
2. Zebra/Lion Dropped; limited comprehension
3. Day/Night Stroop Kept; extensive adaptation to Big/Little Stroop
simplify concepts depicted on
stimuli cards
4. Knock/Tap Kept; slight adaptation Knock/Tap
to adjust script
5. Go/NoGo Game Kept; extensive adaptation Go/NoGo Game
of visual stimuli
6. Forward Word Span Kept; no modification Forward Word Span
7. Backward Word Span Dropped; limited comprehension

8. Forward Corsi Block Tap Dropped; limited comprehension
9. Pick the Picture Dropped; limited comprehension
10. Dimensional Change Card Kept only Separated version; Dimensional Change Card
Sort (Separated & Integrated extensive adaptation to script and Sort (Separated version)
versions) stimuli cards
11. Snack Delay Dropped; no variability

Final EF Tasks
Below is an expanded description of final tasks and a brief description of adaptations.
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Fruit Stroop. The Fruit Stroop is an inhibitory control task that assesses the child’s ability to
focus on a subdominant perceptual feature of an image, rather than on a dominant feature
(Carlson, 2005). The assessor introduced children to large and small pictures of three fruits.
During six practice trials, children were asked to identify three large and three small fruits,
with the opportunity to repeat each incorrect trial. Children who correctly identified at least
five (83%) practice trials across the first or second attempt were considered to understand the
task instructions. During the test, children were shown three new pictures, each depicting a
small fruit embedded within a different larger fruit (e.g., a small apple inside a large banana)
and were asked to point to the small fruit. The final score reflects the percent correct across
three test trials (α = .65).
Knock/Tap. The Knock/Tap Game is an inhibitory control task that assesses children’s
ability to implement a set of rules and suppress imitating the assessor’s actions (Molfese et
al., 2010). Using their hand, children were asked to tap on the table after the assessor knocked
on it, and, conversely, to knock after the assessor tapped. During a practice round, children
were asked to demonstrate knowledge of both rules; each trial was repeated if incorrect. If a
child had any incorrect responses on the first attempt, two more practice trials were presented
with the opportunity to repeat each incorrect trial. This gave ample practice time to the child
to increase the likelihood the child understood the task before advancing to the test trials.
Children who performed both rules correctly across the first or second attempt were
considered to understand the task instructions. During the test, children were presented with
16 randomly distributed “knock” and “tap” trials. We increased the number of trials from 15
to 16 to match the protocol of the Peg Tap and Pencil Tap tasks, which are widely used
inhibitory control tasks used with young children (Diamond & Taylor, 1996; Smith-Donald,
Raver, Hayes, & Richardson, 2007). The final score reflects the percent correct across all 16
test trials (α = .83).
Big/Little Stroop. The Big/Little Stroop (Carlson, 2005), is an inhibitory control task that
assesses children’s ability to verbally state a contradictory, rather than the salient, feature of
an image. This game was adapted from the Day/Night Stroop, because children did not
associate a sun and a moon with day and night, respectively. Instead, the task used the
concepts of big and little and an image of a cat was presented on the cards, which was a
recognizable image previously tested with children in this context. To introduce the task,
children were asked to say “little” when presented with a card of a big cat and to say “big”
when presented with a card of a little cat. Then, during a practice round, children were asked
to demonstrate knowledge of both rules twice (two practice trials per rule), with the
opportunity to repeat each practice trial if incorrect. We included four practice trials for all
children because the task was particularly challenging in that it required a verbal response.
Children who performed both rules correctly across the first or second attempt were
considered to understand the instructions. During the test, children were presented 16
randomly distributed “big” and “little” trials. The final score reflects the percent correct
across all 16 test trials (α = .92).

Forward Word Span. The Forward Word Span task was used to assess children’s working
memory (Carlson, 2005), since the Backward Word Span task was too challenging for this
population. Children were asked to repeat word sequences. Stimuli words were changed
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because direct translation of the words provided in English were not necessarily one or two
syllable words. Instead, simple, recognizable one or two syllable words in Sindhi were
chosen. During a practice round consisting of two-word sequences, children were presented
with two practice trials; each trial was repeated if incorrect. If a child had any incorrect
responses on the first attempt, two more practice trials were administered. Children who
completed at least two correct practice trials across the first or second attempt were
considered to understand the task rules.
There were three test trials at each level of difficulty, starting with two-word sequences and
increasing by one word at each level of difficulty. The task continued until children failed
two trials within a level. The final score represents the longest span for which at least two test
trials were repeated correctly, plus 0.5 if a sequence was correctly repeated at the next level
(Noël, 2009). Children who could repeat one or no words were given a score of 1 (α = .93).
Go/NoGo. The Go/NoGo Game is an inhibitory control task that assesses children’s ability to
perform an action following a frequent “Go” stimulus and to inhibit that same action
following a less frequent “NoGo” stimulus (Willoughby, Blair, Wirth, Greenberg, & The
Family Life Project Investigators, 2010). In our version of the task, children were asked to
press a desk bell when presented with an image of a cat and not to respond when presented
with an image of a dog. So that the stimuli would be familiar to the children, the cat and dog
images were changed to look more consistent with the animals they see in their village and
were culturally appropriate. The rules were contextualized through storytelling to make them
more salient (i.e., “press the bell to call the kitty over so she will come play!” or “this is a
mean dog that may bite, so we do not want to call the dog”).
The assessor began the task by asking children to identify each of the stimulus pictures (cat
and dog), introducing the bell, and demonstrating how to play the game using one practice
block (consisting of four “Go” and two “NoGo” trials). The children were unfamiliar with the
act of pressing a bell, so instructions to show them how to press a bell were added. During a
practice round, children were presented with one practice block, which was repeated if the
child had one or more incorrect trials. Children who completed the entire block correctly on
the first or second attempt were considered to understand the task rules. During the test,
children were presented with 24 trials (17 Go, 7 NoGo). Since the test trials did not include
any item prompts as the stimuli changes (e.g., “Here is a kitty. Should you press the bell and
call the kitty?”), an extra test trial was added at the start. This allowed for one additional
prompt from the assessor in the event that the child appeared confused: “Remember, I am not
going to say anything when I flip the page. You are going to play by yourself. Only press the
bell to call the kitty.” The percentage of correct Go trials was used as the chance variable to
determine whether the child understood the game. Thus, a composite score was calculated
only for children who were able to correctly respond to at least 76% of Go trials. The final
score reflects the percentage of correct NoGo trials (α = .89).
Separated Dimensional Change Card Sort. The Separated Dimensional Change Card Sort
(S-DCCS) is a cognitive flexibility task that measures children’s ability to switch attention
between two different dimensions, such as color and shape (Carlson, 2005). The task consists

of two parts. After learning to sort the cards on color, children are asked to sort the cards by
shape. The cards in the S-DCCS depict a black silhouette shape on a colored card (green or
yellow). Thus, the shape and color dimensions are separated. This is an easier version than
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the Integrated DCCS in which the shape and color are integrated on the stimuli card (e.g.,
green star and yellow boat on a white card). Since most children were not attending school
yet, many did not know the labels of colors. The stimuli cards were changed from the typical
red and blue colors to be colors that were associated with familiar objects: “grass-colored”
(green) and mango-colored (yellow). The cards were referred to this way in the protocol
instead of using the names of the colors.
During a practice round, children were asked to demonstrate knowledge of the shapes on four
shape practice trials, using neutral white cards with a “star” or “truck” silhouette. The word
“shape” was changed to “picture,” since children did not know what a shape was. They were
next asked to demonstrate knowledge of the colors, using four “grass-colored” and “mango-
colored” cards with a neutral black “boat” silhouette. Each practice card was repeated if the
response was incorrect. The practice trials were adapted to first allow for two trials where the
child is asked to point to the box where the cards would be sorted and two trials where the
child physically sorts the cards. Children who correctly sorted at least three practice cards
(75%) on the first or second attempt were considered to understand the task.
During the test trials, children were asked to complete six color trials, and then, after a rule
switch, to complete six shape trials. The percentage of correct pre-switch trials was used to
further evaluate comprehension. The composite score was calculated only for children who
were able to correctly sort at least 67% of pre-switch cards. The final score reflects the
percentage of correct post-switch trials (α = .86).
Appendix B
Administration Procedures for Executive Functioning Tasks
The final EF tasks were administered by Community-based Child Development Assessors
(CCDAs), who held master degrees in either psychology or sociology from local universities.
Half of the CCDAs also had three years of experience conducting child development
assessments in the original intervention trial (Yousafzai, Rasheed, Rizvi, Armstrong, &
Bhutta, 2014). CCDAs were trained by the supervisory team using video demonstrations, role
play, and direct practice with local children. We found that it was important to provide
explicit training on how to: (1) build rapport with various types of children and ensure their
comfort with the testing environment before commencing the EF assessment; (2) set a pace
appropriate to the child’s ability level and, if necessary, slow down to facilitate
comprehension of novel tasks; (3) be patient, gentle, and enthusiastic, and refrain from
expressing any outward verbal or non-verbal frustration or disappointment to the child or
mother; and (4) continuously monitor the child’s engagement and fatigue and use
encouragement and breaks effectively. Explicit guidelines were also provided for skipping
certain tasks, in the event that the assessment proved especially challenging or needed to be
cut short. All protocols and scripts were standardized across the six tasks to achieve
reliability among CCDAs, improve the ease of scoring, and deal with ambiguous responses.

EF assessments were conducted in designated testing rooms, which were rented from local
households to minimize exposure to outside noises and distraction, and to approximate a
familiar home setting. Children sat next to the CCDA at a table that enabled them to interact
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easily with the task materials, while caregivers sat aside and were asked not to interfere with
children’s assessment. After each day of data collection, supervisory staff conducted
briefings with the team to resolve any issues and maintain quality control and assurance.
Weekly reports documented strengths and weaknesses in administration performance.
Constructive feedback and additional targeted training were provided to ensure high-quality
data collection by a large team of CCDAs. Supervisory staff reviewed one videotaped session
per CCDA each month and double-coded 10% of children’s responses on the EF battery (ICC
range for six tasks: .960-.998).
Appendix C
Performance on Individual Tasks and Executive Function Composite Measure
To assess children’s comprehension of EF task instructions and rules, we created six binary
filter variables that reflected performance on the practice trials using task-specific
comprehension criteria (0 = did not pass criteria; 1 = passed criteria). If children did not pass
comprehension criteria, we did not use their performance score on that task to create the final
EF composite score. This ensured that performance on test trials more accurately measured
EF skills rather than children’s ability to understand the task rules (i.e., general intelligence)
or other task-specific factors. Two tasks required additional passing criteria during test trials;
children had to demonstrate adequate performance on the Go/NoGo task’s Go trials and the
S-DCCS’s pre-switch trials in order to receive valid scores on the NoGo trials and the post-
switch trials, respectively. Table C1 summarizes the following: (1) comprehension criteria for
each task; (2) the percentage of children who met these criteria; and (3) descriptive statistics
for the final performance variables. For each task, at least 80% of children passed the
comprehension criteria, with the exception of the S-DCCS task. On that task, 90% of children
passed the color and shape identification practice trials, but only 47% passed the pre-switch
test trials, which were a prerequisite for the analysis of the post-switch trials.

ccepted Articl
Table C1
Executive Functioning Comprehension Criteria and Task Descriptives
% Passing
Comprehension
Task N Comprehension Criteria Criteria EF Score M (SD)
Correctly identified 5/6 big and 80.1%
(1) Fruit Stroop 1,274 % correct on valid trials 0.52 (0.35)
small fruit items (N=1,021)
Correctly performed both 87.2%
(2) Knock/Tap 1,257 % correct on valid trails 0.48 (0.24)
“knock” and “tap” rules (N=1,096)
Correctly performed both “big” 81.2%
(3) Big/Little 1,302 % correct on valid trials 0.55 (0.30)
and “little” rules (N=1,057)
Correctly completed at least two 85.3%
(4) Forward Word Span 1,249 Total spanb 1.65 (0.66)
2-word practice trials (N=1,062)
Correctly completed 6-trial block 91.0%
1,267 % correct on NoGo trials 0.78 (0.27)
(4 Go, 2 NoGo) (N=1,153)
(5) Go/NoGoa
Correctly completed 13/17 Go 80.7% % correct on NoGo trials if
1,153 0.76 (0.28)
trials (N=930) passed 13/17 Go trials
Correctly identified 3/4 color and 91.3%
1,276 % correct on post-switch trials 0.65 (0.30)
shape items (N=1,165)
(6) S-DCCSa
Correctly completed 4/6 pre- 46.7% % correct on post-switch trials
1,165 0.60 (0.35)
switch trials (N=544) if passed 4/6 pre-switch trials
Note. a Final analysis variable includes additional comprehension criteria. b Range = 1 – 4. S-DCCS = Separated – Dimensional Change Card Sort.

Table C2 shows bivariate correlations between the binary filter variables and study variables
for all children who completed each EF task. For the Go/NoGo task, two binary filter
variables represent children who correctly completed the 6-trial practice block and who
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completed both the 6-trial block and correctly completed 13/17 Go trials (i.e. the children
who received Go/NoGo scores). For the S-DCCS task, two binary filter variables represent
children who correctly identified 3/4 color and shape items in the practice block and those
who both identified 3/4 color and shape items and correctly completed 4/6 pre-switch trials.
Across all six EF tasks, passing the comprehension criteria was significantly related to higher
levels of antecedent cognitive skills at 24 months and IQ at 48 months. Most EF
comprehension variables were also positively related to measures of: (1) baseline family
wealth; (2) maternal education; (3) food security at 24 months; (4) home stimulation quality
at 24 and 48 months; (5) height-for-age at 24 months; (6) maternal scaffolding at 48 months;
(7) maternal IQ and short term memory. The percentage of children who passed the
comprehension criteria did not vary by sex or number of siblings.
Table C2
Correlations among EF Comprehension Criteria and Predictor Variables
Fruit Knock/ Big/ Word GNG GNG S-DCCS S-DCCS
Stroop Tap Little Span Prac Prac+Go Prac Pract + Pre
Male .02 .02 .01 .01 -.01 .00 .01 -.03
Wealth (b) .11*** .09** .11*** .05 .02 .06* .08** .01
Mat educ (b) .12*** .10*** .10*** .01 .02 .08** .07* .01
Num sib (b) -.03 .00 -.02 -.03 -.04 -.06* .01 -.02
Food ins (24m) -.08** -.08** -.04 -.07* -.07** -.07* -.01 -.06*
HOME (18m) .09** .05 .05 .06* .07** .08** .09** .02
Mat scaff (18m) .07* .05 .03 .03 .04 .09*** .00 .04
HAZ (24m) .17*** .10*** .09** .08** .09*** .12*** .06* .06*
RS .01 -.06* .01 -.06* .02 -.01 .002 -.02
EN .08** -.01 -.06 .03 .02 -.01 .05 .02
Cog (24m) .15*** .12*** .09** .13*** .12*** .13*** .07* .05
HOME (48m) .13*** .12*** .10*** .05 .07** .09** .12*** .06*
Mat scaff (48m) .13*** .02 .03 .07* .09** .10*** .08** .08**
Mat IQ .13*** .12*** .09** .08* .08** .16*** .09** .13***
Mat ST mem .13*** .10*** .08** .10*** .08** .11*** .07* .09**
Mat WM .08** .05 .08* .00 .04 .07* .03 .01
Child IQ (48m) .29*** .25*** .24*** .23*** .22*** .28*** .16*** .23***
Child EFs (48m) .21*** .20*** .12*** .12*** .14*** .22*** .14*** .18***
Note. *p < .05, **p < .001, ***p < .001. b = baseline, m=months, mat educ = maternal education,
num sib = number of siblings, food ins = food insecurity, HOME = home environment quality, mat
scaff = maternal scaffolding, HAZ = height-for-age, RS = responsive stimulation intervention, EN =
enhanced nutrition intervention, cog = cognitive skills, mat = maternal, ST mem = short term
memory, WM = working memory, EFs = executive functions, GNG prac = 6-trial practice block, Go
= 13/17 Go trials correct, S-DCCS = Separated-Dimensional Change Card Sort, S-DCCS prac =

correctly identified 3/4 color and shape items in the practice block, pre = correctly completed 4/6 pre-
switch trials. Ns change for each column depending on the number of children who completed the EF
task (listed above in Table C1).
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Table C3 shows the correlations among all six EF performance variables for the sample of
children who have a valid EF composite measure (N = 1144). In general, variables showed
low, but significant, correlations with other EF performance variables. However, performance
on the Go/NoGo task was uncorrelated with performance on the Knock/Tap and Big/Little
tasks. As shown in Tables C2 and C3, the correlations among the individual EF tasks were
smaller than the correlations between the individual EF tasks and the WPPSI IQ measure.
This is likely because the WPPSI is a standardized measure with stronger psychometric
properties and less measurement error than the individual EF tasks, which can capture more
measurement error on their own.
Table C3
Correlations among EF Performance Variables
Fruit Stroop Knock/Tap Big/Little Word Span Go/NoGo
Fruit Stroop ____

Knock/Tap .22*** ____
Big/Little .21*** .27*** ____
Word Span .15*** .27*** .21*** ____
Go/NoGo .15*** .20*** .27*** .15*** ____
S-DCCS .24*** .24*** .17*** .20*** .16***
Notes. N = 1,144 children who had a valid EF composite score. *** p < .001.
As shown in Table C4, associations with individual and family factors were largely consistent
across the six EF performance variables for the sample of children who had a valid EF
composite (N = 1144), a handful of discrepancies were probably driven by task-specific
characteristics (e.g., additional passing criteria, number of items, response modality). All six
were also positively correlated with maternal education, maternal scaffolding at 24 months,
home stimulation quality at 48 months, height-for-age at 24 months, cognitive skills at 24 and
48 months, and maternal IQ and short-term memory. Further, most were positively correlated
with family wealth, food insecurity at 24 months, home stimulation quality at 24 months,
exposure to the responsive stimulation intervention, maternal scaffolding at 48 months, and
maternal working memory. The lack of significance between a few covariates and
performance on Go/No-Go and S-DCCS tasks could be driven by smaller sample sizes due
the two levels of comprehension criteria (see Table C1). Sex differences emerged for only

two tasks; girls had higher scores on the Forward Word Span and boys had higher scores on
S-DCCS task.
Accepted Article
Table C4
Correlations among EF Performance and Predictor Variables
Fruit Stroop Knock/Tap Big/Little Word Span Go/No-Go S-DCCS
EF Performance
Male .01 -.06* .03 -.06 -.03 .11**
Wealth (b) .09** .11*** .10*** .13*** .02 .01
Maternal education (b) .08* .12*** .14*** .14*** .08* .12**
Number of siblings (b) .02 -.05 .04 -.01 .09** -.03
Food insecurity (24m) -.06* -.10*** -.05 -.12*** .04 -.05
Home quality (18m) .11*** .15*** .14*** .15*** .08* .07
Mat scaffolding (18m) .12*** .13*** .15*** .14*** .09** .09*
Height-for-age (24m) .13*** .18*** .14*** .18*** .07* .09
Responsive stim .10** .05 .07* .13*** .11*** .03
Enhanced nutrition .03 -.02 .01 .01 .02 -.11**
Cognitive skills (24m) .16*** .18*** .21*** .23*** .14*** .10*
Home quality (48m) .19*** .18*** .12*** .11*** .11** .16***
Mat scaffolding (48m) .07* .15*** .15*** .19*** .09** .06
Mat IQ .21*** .23*** .14*** .19*** .12*** .18***
Mat short term memory .16*** .09** .07* .20*** .07* .11*
Mat working memory .09* .12*** .11** .16*** .08* .06
Child IQ (48m) .32*** .39*** .36*** .37*** .27*** .25***
Child EFs (48m) .59*** .65*** .64*** .60*** .58*** .57***
Notes. N = 1144. *p < .05, **p < .001, ***p < .001. Correlations for Go/No-Go and S-DCCS
comprehension criteria involve performance on the practice trials. b = baseline, m = months, mat =
maternal, EFs = executive functions, S-DCCS = Separated-Dimensional Change Card Sort.

Confirmatory Factor Analysis and Creation of Final Composite Measure
Recent research has shown that while a full EF battery is preferred, data from a three-task
battery provides an acceptable measure of children’s overall EF performance in light of study
Accepted Article
constraints or data collection challenges (Willoughby et al., 2013). To produce an inclusive,
but still reliable measure of overall EF performance, we calculated a composite score only for
children (N = 1144) who had valid test scores on at least three of the six tasks (see Appendix
C for more information). Accordingly, we omitted 158 children (12.14%) who had zero
(3.5%), one (2.5%), or two (6.1%) valid test scores. The analyses included 1,144 children in
total: 341 children (26.2%) who had six valid scores, 406 (31.2%) who had five valid scores,
251 (19.3%) who had four valid scores, and 146 (11.2%) who had three valid scores.
Children with at least three valid EF scores were from households with significantly more
wealth at baseline (t(1476) = -2.327, p = .020) compared to children who were enrolled in the
PEDS trial and did not have valid EF scores due either to attrition or lack of EF task
comprehension. There were no significant differences between those two groups on maternal
education or number of siblings at baseline.
We conducted a confirmatory factor analysis to ensure that performances on different EF task
represent the same underlying construct as has been reported in preschoolers from HIC
(Wiebe, Espy, & Charak, 2008) before creating a single composite score. The one-factor
solution showed good absolute model fit (CFI = 0.986, TLI = 0.976, RMSEA = 0.023). All
six tasks loaded onto one factor, with standardized loadings ranging from .40 to .56. The
relative fit of this factor solution was further tested against a two-factor model that separates
the four IC tasks from more developmentally advanced WM and CF tasks. The two-factor
model did not fit the data better than the single-factor model (Δχ2(1) = 0.20, p = .652).
We created a composite score by standardizing and averaging the six EF performance scores
(α = .61, M = -0.03, SD = 0.61). Our tasks had relatively low bivariate correlations (see
Appendix C, Table C3) and a significant vanishing tetrad test chi-square statistic (χ2(45) =
119.74, p = .002) provided support for averaged composite that equally weights each task
(Willoughby, Holochwost, Blanton, & Blair, 2014). As shown in Figure C1, the EF
composite had a relatively normal distribution (skewness = 0.182, kurtosis = 2.773).
Figure C1
Distributions of Child EF Composite

Bivariate correlations among EF composite and other study variables reveal expected
associations of child and family factors with emerging EF skills. Although, EFs were
significantly correlated with measures of children’s cognitive skills at 24 months and
Accepted Article
intelligence at 48 months, it is important to note that the correlation between the general
cognitive skills at 24 months and at 48 months was significantly higher than the correlation
between cognitive skills at 24 months and EFs at 48 months (z = 3.561, p <.001).
Appendix D
Indirect Effects Coefficients and p-values
Table D1
Indirect Effects for Models 2 and 3
Model 2 Model 3
Pathway B p-val Pathway B p-val
Male  CoglanEF 0.003 .518 Male  HOME (48m) EF 0.001 .678
Wealth  Coglan  EF 0.009 .071 Wealth  HOME (48m)  EF 0.008 .040
Mat ed  Coglan  EF 0.002 .651 Mat ed  HOME (48m)  EF 0.011 .022
Sib  Coglan  EF -0.007 .102 Sib  HOME (48m)  EF 0.010 .024
FI  Coglan  EF -0.009 .066 FI  HOME (48m)  EF -0.006 .061
HOME (18m)  Coglan  EF 0.022 .001 HOME (18m)  HOME (48m)  EF 0.029 .012
Scaff (24m)  Coglan  EF 0.069 <.001 Scaff (24m)  HOME (48m)  EF 0.006 .099
HAZ  Coglan  EF 0.039 <.001 HAZ  HOME (48m)  EF 0.001 .606
RS  Coglan  EF 0.020 .001 RS  HOME (48m)  EF -0.011 .025
EN  Coglan  EF 0.004 .299 EN  HOME (48m)  EF 0.008 .035
Coglan HOME (48m)  EF 0.012 .027
Male  Scaff (48m) EF 0.003 .315

Wealth  Scaff (48m)  EF -0.001 .754
Mat ed  Scaff (48m)  EF 0.017 .005
Sib  Scaff (48m)  EF -0.002 .477
FI  Scaff (48m)  EF 0.000 .947
HOME (18m)  Scaff (48m)  EF 0.009 .050
Scaff (24m)  Scaff (48m)  EF 0.015 .008
HAZ  Scaff (48m)  EF -0.001 .642
RS  Scaff (48m)  EF 0.003 .310
EN  Scaff (48m)  EF -0.004 .218
Coglan  Scaff (48m)  EF -0.001 .875

Table D2
Indirect Effects for Models 4 and 5
Model 4 Model 5
Accepted Article
Pathway B p-val Pathway B p-val
Male  Mat VIQEF 0.006 .130 Male  Child IQEF 0.009 .426
Wealth  Mat VIQ  EF 0.019 .006 Wealth  Child IQ  EF -0.007 .610
Mat ed  Mat VIQ  EF 0.029 .001 Mat ed  Child IQ  EF -0.020 .180
Sib  Mat VIQ  EF 0.003 .421 Sib  Child IQ  EF -0.002 .884

FI  Mat VIQ  EF -0.006 .145 FI  Child IQ  EF -0.009 .495
HOME (18m)  Mat VIQ  EF 0.006 .292 HOME (18m)  Child IQ  EF -0.001 .941
Scaff (24m)  Mat VIQ  EF 0.015 .020 Scaff (24m)  Child IQ  EF -0.019 .197
HAZ  Mat VIQ  EF 0.003 .462 HAZ  Child IQ  EF 0.053 <.001
RS  Mat VIQ  EF 0.005 .307 RS  Child IQ  EF 0.003 .853
EN  Mat VIQ  EF 0.003 .512 EN  Child IQ  EF -0.039 .002
Coglan Mat VIQ  EF -0.006 .234 Coglan  Child IQ  EF 0.116 <.001
HOME (48m)  Mat VIQ EF 0.027 .001 HOME (48m)  Child IQ EF 0.051 .001
Scaff (48m)  Mat VIQ  EF 0.010 .045 Scaff (48m)  Child IQ  EF 0.027 .040
Mat VIQ  Child IQ  EF 0.111 <.001
Male  Mat STM EF -0.001 .415 Mat STM  Child IQ EF 0.016 .240
Wealth  Mat STM  EF 0.001 .523 Mat WM  Child IQ  EF 0.017 .240

Mat ed  Mat STM  EF 0.009 .075
Sib  Mat STM  EF -0.002 .290
FI  Mat STM  EF 0.000 .811
HOME (18m)  Mat STM  EF 0.001 .765

Scaff (24m)  Mat STM  EF -0.001 .765
HAZ  Mat STM  EF 0.002 .274
RS  Mat STM  EF 0.000 .945
EN  Mat STM  EF -0.002 .383

Coglan  Mat STM  EF 0.00 .683
HOME (48m)  Mat STM EF 0.00 .684
Scaff (48m)  Mat STM  EF 0.004 .138
Male  Mat WMEF -0.001 .410

Wealth  Mat WM  EF -0.001 .650
Mat ed  Mat WM  EF 0.012 .345
Sib  Mat WM  EF 0.002 .345
Accepted Article
FI  Mat WM  EF -0.001 .410
HOME (18m)  Mat WM  EF 0.000 .831
Scaff (24m)  Mat WM  EF 0.003 .256
HAZ  Mat WM  EF 0.001 .544
RS  Mat WM  EF 0.002 .417
EN  Mat WM  EF -0.000 .857
Coglan  Mat WM  EF 0.001 .575
HOME (48m)  Mat WM EF -0.002 .410
Scaff (48m)  Mat WM  EF 0.000 .971

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Article type : Special Issue Article

Developmental Continuity and Family Protective Factors

Aga Khan University

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Correspondence concerning this article should be addressed to Jelena Obradović, Stanford

 We measured emerging executive functions (EFs) in a large sample of disadvantaged

four-year-olds in rural Pakistan, using six culturally and developmentally appropriate

 Preschoolers’ EFs were independently predicted by observed maternal cognitive

scaffolding practices and directly assessed maternal cognitive capacities.

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and developmentally appropriate measure of emerging EFs in a large sample of at-risk

interventions that aim to improve EFs in young children in LMIC countries.

Keywords: Executive functions, low- and middle-income countries, adversity, parenting

intervention, cognitive development

This article is protected by copyright. All rights reserved.

Developmental Continuity and Family Protective Factors

about early EF development in low-and middle-income countries (LMIC) where children

contextually dependent. This study extends methodological and conceptual understanding of

children in rural Pakistan. Using a developmentally and culturally appropriate battery of

adapted EF tasks, we demonstrated how antecedent and concurrent measures of cognitive

skills relate to emergent EFs in preschoolers in a low-income, rural setting. Further, we

intervention efforts aimed at promoting healthy early child development in disadvantaged

rural LMIC contexts.

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promoting resilience in contexts of adversity (Obradović, 2010). Performance on EF tasks has

proxy measure of neurocognitive development when direct assessments of neurobiological

functioning, assessment of EF skills can be used as an index of overall early childhood

poverty) or promote (e.g., positive parenting) EF development across different cultures

This article is protected by copyright. All rights reserved.

Since LMIC children’s limited access to educational programming, media, and

and concepts, it is critical that EF tasks’ surface-level characteristics are designed to

not confound children’s reluctance to engage or their limited understanding of assessment

procedures with an actual lack of EF skills.

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measures of cognitive development relate to direct assessment of EFs. There is a need to

of EF tasks. Furthermore, by investigating the overlap of emergent EF skills with concurrent

Early Life Experience and Executive Functions

from disadvantaged socioeconomic backgrounds in the United States perform worse on EF

retardation, infectious illnesses, maternal illiteracy and depression, inadequate housing

2017; Grantham-McGregor et al., 2007).

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of recovery for cognitive development are inconsistent. For example, micronutrient

key pathway by which poverty undermines child development outcomes in LMIC

observed measures of maternal scaffolding independently predicted EFs. Using a cross-

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EFs. In a relatively more advantaged sample of urban Argentinian preschoolers, exposure to

intervention programs specifically targeting early EFs in LMIC.

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research on early EF development in preschool children from disadvantaged, rural areas of

individual EF tasks; (2) examining children’s understanding of and performance on these

We studied a large birth cohort of children in Pakistan, a primarily agricultural, lower-

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Early Child Development Scale-Up (PEDS) Trial, a community-based, cluster-randomized,

government health services to promote child development (Yousafzai, Rasheed, Rizvi,

(see Yousafzai et al., 2014 for details).

(working memory, short-term memory, and verbal intelligence) directly contributed to

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development of early EFs in the context of extreme, chronic adversity.

Participants resided in the predominantly agricultural Naushero Feroze District, in

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substantial proportion of children were underweight (43%), or exhibited stunting (61%) or

maternal assessments were alternated in a predetermined sequence to give both participants

with a highly disadvantaged population.