The impact of environmental factors on Egyptian children with delayed language development

Abstract

Background

The current study was aimed at constructing a questionnaire for evaluating the role of variant environmental factors on language acquisition in the three surrounding levels of communication that include familial level, preschool or nursery level, and surrounding social environmental level among children with delayed language development (DLD) due to environmental deprivation. The current study was a retrospective case–control study that was performed on 100 Egyptian Arabic-speaking children aged from 2 to 5 years. The study was carried out among preschool age children in the Mansoura governmental and private preschools (53 males and 47 females). They were divided into 2 groups: Group I (case group) consisted of 50 children with DLD due to environmental deprivation, and group II (control group) consisted of 50 typically developed children.

Results

The present study demonstrated several factors for prediction of DLD due to environmental deprivation. Univariable analysis revealed multiple factors as number of hours that parents present at home, time of the mother’s job, the relation between the child and the mother, the parents select certain time to talk and play with their child, joint attention of the mother, mother asking her child what he wants, long time using multimedia, divorce as a traumatic stress, bad social performance, and low socioeconomic status. Multivariate analysis revealed that longer time of the mother’s job and less time the mother select to talk and play with her child were the environmental deprivation factors which had the most precipitating effect on predicting DLD.

Conclusions

The constructed Arabic questionnaire was proved to be valid, reliable, and homogenous and is likely to produce consistent responses in evaluating the variant environmental factors on language development among children with DLD due to environmental deprivation in the three surrounding communications levels.

Background

Language development does not happen in a vacuum. Children acquire a sign system when they acquire language, which has significant relationships to their social and cognitive development. The potential for language is present at birth, but its development needs a dynamic interaction between the developing brain and a child’s environment. In most cases, a non-stimulating (socially, emotionally, and culturally) environment may be the main causative factor of delayed language development in perfectly healthy children [1].

Within a family structure, where parents moderate their children’s behaviors to help them adapt to the larger social system, environmental factors have an impact. Value systems and belief, attitudes, socialization objectives and methods for behaviors modeling, styles of communication, use of language at home, interpersonal relationships, experiences, problem-solving techniques, and stress coping techniques are examples of environmental factors [2]. This perspective shows the interaction between internal factors which represent psychological and biological domains and external factors that represent psychosocial domains and socioeconomic standard (SES) on language development among children with an average intelligence. These two principles (internal and external factors) are very beneficial for clarifying the dynamic interaction between psychosocial, biological factors, and SES that influences language acquisition. Therefore, a child’s specific external environment (such as their home and family setting or the culture of their school) will either positively or negatively stimulate the child’s genetic potential [3].

In clinical work, it was noticed that some delayed language development (DLD) children with an average mentality (after exclusion of cases of specific language impairment) showed different language abilities despite having the same chronological age as well as mental age. Furthermore, there were differences in the way their families accepted, understood, and handled the issues those children were facing. Thus, language development needs to be taken into account in relation to peers, the family, the school, and the community. Taking into account the psychosocial setting [4], Saleh and Baz [3] evaluated and correlated the role of psychosocial factors influencing language acquisition in children with mild mental retardation, while Safwat and Sheikhany [5] evaluated the language development that is influenced by both quantity and quality of child-parent interactions, and the factors that would influence these interactions in different socioeconomic standards should be considered while implementing the therapy program.

From this point of view, a semistructured questionnaire that applied to parents was developed by the authors to assess and correlate the role of variant environmental factors on language development among DLD children in the three surrounding levels of communication that include familial level, preschool or nursery school level, and surrounding social and environmental level.

Methods

This study was a retrospective case–control study that was carried out on 100 Egyptian Arabic-speaking children aged from 2 to 5 years. The study control group was conducted among preschool age children in the Mansoura governmental and private preschools, and case group was conducted among preschool age children attending outpatient clinic unit at Mansours University Hospital from October 2018 to November 2019. The studied preschool children were 53 males and 47 females and were divided into 2 groups: group I (case group) included 50 children with DLD due to environmental deprivation with no significant differences in chronological age, gender, mental age, or IQ, and group II (control group) included 50 typically developed children. Children with delayed language development due to other causes as intellectual disability, autism spectrum disorder (ASD), and attention deficit hyperactivity disorder (ADHD), children with sensory impairment or physical disability, and children with history of previous language therapy and neurological and psychiatric diseases were excluded from the study. All children underwent an evaluation protocol consisting of history taking and evaluating their language skills using the Preschool Language Scale, Fourth Arabic Edition [6], and psychometric evaluation using Stanford-Binet Intelligence Scale “4th Arabic version” [7] and using Vineland Social Maturity Scale [8]. The developed questionnaire (Additional file 1: Appendix) was developed taking in account the social culture and language abrupt to the Egyptian culture and society for each proposed item in the questionnaire. The questionnaire was first pilot tested with 20 Egyptian children, and their parents then amended according to their suggestions to make the phrases more clear. Three phoniatricians assessed the questionnaire twice: first prior to the test being given to the pilot study group and again following the changes recommended by the group. The study groups were shown the completed questionnaire form following the expert’s opinion.

A formal written consent from children’s parents was obtained. The Institutional Research Board (IRB) of Faculty of Medicine — Mansoura University accepted the study protocol (MS/16.08.45).

Parents were asked to fill in the questionnaire including the following:

• I. Familial level

  • (A) The sociodemographic characteristics of parents: Contain (age, duration of their presence at home, education and culture domain, duration of time they spend at work, marital status, and order of the child).

  • (B) Parent–child interaction: Was assessed according to the semistructured psychosocial sheet developed by Saleh and Baz [3] including the following:

    • • 1. Relation between parents and their child: Neglect, warmth, hostility, dependent, independent, or overprotection

      • 2. Select certain time to talk and play with their child: All the time, sometime, or never

      • 3. Methods used for correcting behavior: Nothing, praising, insulting, beating, or severe punishment

  • (C) Language intervention strategies between the child and his parents or caregiver (i.e., the quantity and quality of intervention with their children): Quality was identified in terms of the use of various strategies by parents or caregiver that would augment their child’s language development. These interventions were assessed according to an Arabic questionnaire developed by Safwat and Sheikhany [5] that was consisted of parent-directed 16 questions and was measured using a 3-point scale (never, sometimes, most of the time). They included use or practice parallel talk, vary tone while speaking, use simple short sentences, parents spend time during the weekend with child, wait for child to communicate, repeat daily routine activities, imitate child actions, use gestures to convey meaning, emphasize facial expressions, show the objects you are talking about, joint attention, model a certain behavior, use reinforcers, ask child about what he wants, correct child utterances., and expand child utterances.

  • (D) Exposure to multimedia: It was assessed according to the Arabic questionnaire developed by Safwat and Sheikhany [5].

    • • 1. Type of multimedia: (1 = TV, 2 = iPad, or 3 = mobile phone)

      • 2. Number of watching hours: (1 = less than 2 h, 2 = 2–6 h, or 3 = more than 6 h)

      • 3. Child watches multimedia: (1 = alone, 2 = with siblings, or 3 = with parents).

  • (E) Exposure to traumatic stresses.

  • (F) The socioeconomic status of the parents: Was evaluated based on the scale that is developed by El-Gilanny et al. [9] which measured six domains: a score was assigned for each item, and the total score was calculated: Class I (high social standard = 25–30), Class II (middle social standard = 20–25), Class III (low social standard = 15–20), and Class IV (very low social standard < 15).

• II. Preschool or nursery level

It was assessed according to the semistructured psychosocial sheet developed by Saleh and Baz [3], including the following:

• 1. Child attendance: Either regular or irregular

• 2. Child social performance: Either good or bad

• 3. Child behavior in the nursery: Either normal, submissive, isolated, or aggressive

• 4. Child adaptation to teachers: Either adapted or not adapted

• III. Social and environmental level

It was assessed according to the semistructured psychosocial sheet developed by Saleh and Baz [3], including the following:

• 1. .Child attendance to social events (either attendant or not attendant)

• 2. .Child social performance (either good or bad).

• 3. .Child behavior in social events (either normal, submissive, isolated, or aggressive).

• 4. .Child attitude towards same-age colleagues (either normal, submissive, isolated, or aggressive).

Statistical analysis

The Statistical Package for Social Science (IBM Corp., 2011) was used to edit, code, tabulate, and bring the gathered data into a PC. Armonk, NY: IBM Corp.; IBM SPSS Statistics for Windows, Version 20.0. Data was presented, and appropriate analysis was carried out based on the kind of data found for each parameter. Data was presented as mean standard deviation (± SD) for parametric numerical data plus frequency and percentage of nonnumerical data. Student T, chi-square test, Monte Carlo test, and Mann–Whitney U-test were used to assess the statistical significance and examine the relationship among two qualitative variables. To evaluate the strength of association between two quantitative variables, we use the correlation coefficient analysis to determine the strength and direction of the linear relationship between two variables. Logistic regression analysis was used for prediction of risk factors. Using the chi-squared test, deviations from the expectations of the Hardy–Weinberg equilibrium were found. A 95% confidence interval and odds ratio were computed. Significant (S) if p < 0.05.

Results

Descriptive and comparative statistics

This study was done on two groups of Arabic-speaking children aged from 2 to 5 years. They were divided into 2 groups: Group I (case group) consisted of 50 children with DLD due to environmental deprivation (mean mental age = 34.52 ± 7.79 months, mean social age = 33.62 ± 6.92 months, mean IQ = 97.64 ± 8.5, mean language age (LA) = 26.08 ± 8.48 months), and group II (control group) consisted of 50 typically developed children (mean mental age = 38.34 ± 12.95, mean social age = 45.34 ± 15.26 months, mean IQ = 99.50 ± 7.93, mean LA age = 45.42 ± 14.19 months) (Table 1).

Table 1 Demographic and phoniatric data between both groups

Demographic and communication data between both groups

There were statistically significant differences in social age and language age in group I when compared to group II, with no statistically significant differences in chronological age, gender, metal age, and IQ in both groups (Table 1).

Descriptive and comparative statistics of the applied questionnaire between both groups

I. At family level

• A Sociodemographic data of parents

Statistically significant differences were found between group I and group II as regard the following:

• ▪ In mother’s education level (illiterate, read and write, intermediate, university graduate, and post graduate degree) respectively and also in father’s education level (intermediate, university graduate, illiterate, read and write, and postgraduate degree) respectively

• ▪ In number of hours that both mother and father are present at home

• ▪ In the duration of time that the mother spends at work (full time, not working, and part-time) respectively while in the duration of time that the father spends at work (full time, part-time, and not working) respectively

• ▪ In the marital status (married parents, divorced parents, and dead father)

• ▪ Conversely, there were no statistically significant differences with order of the child birth (Table 2).

Table 2 Sociodemographic data of parents in both groups

• B Parent–child interaction: it was assessed with both mother and father separately

Statistically significant differences were found between group I and group II as regard the following:

• ▪ In the mother relation with her child (warmth, overprotection, hostility, neglect, dependent, and in dependent) respectively.

• ▪ Also in the parent’s assign certain time to talk and play with their child (never, sometimes, and all the time)

• ▪ In contrast, there were no statistically significant differences in the father’s relation with his child and in the methods parents used for correction of their child’s behavior (Table 3).

Table 3 Parent–child interaction in both groups

• III. Language intervention strategies between father, mother, or caregiver and children

Statistically significant differences were detected between group I and group II regarding most of the language intervention strategies between mother and caregiver and children except the following: vary tone while speaking, use gestures to convey meaning, and emphasize facial expression. Also, there were statistically significant differences of some language intervention strategies between the father and children only in the following items: use simple short sentence, spend time for weekend with his child, use joint attention, and use of reinforcers (Table 4).

Table 4 Language intervention strategies between father, mother, or caregiver and children

• IV. Exposure to multimedia

As regard kinds of multimedia that the child is exposed to which was mentioned in Table 5, it was found that the number of DLD children with exposure to iPad, mobile, and TV respectively is significantly higher when compared with control group. The duration that children spend on multimedia was discussed in Table 5 and revealed that most of them were above 6-h usage of multimedia. Most of children with DLD due to environmental deprivation used to sit alone during multimedia viewing with high significant difference in number of children in control group.

Table 5 Descriptive and comparative statistics about exposure to multimedia in both groups

• E Exposure to traumatic stresses

There were 74.0% of the children in group I which was exposed to traumatic stress. There were statistically significant differences in exposure to traumatic stresses (family and economic straggle) respectively (Table 6).

Table 6 Descriptive and comparative statistics about the exposure to traumatic stresses in both groups

• F Socioeconomic status of the parents

Statistically significant differences were found between group I and group II regarding the level of socioeconomic status (very low to low level, middle level, and high level) respectively (Table 7).

Table 7 Descriptive and comparative statistics of the socioeconomic status of the parents

II. At preschool or nursery level

The relation between the child and nursery environment

Statistically significant differences were found between group I and group II as regard one-third of the children who were attending irregularly to their nursery and had bad social performance and isolated behavior, and all of them were not adapting to teachers. Also, there were statistically significant differences regarding that the child’s behavior in the preschool may be normal, isolated, submissive, or aggressive, respectively (Table 8).

Table 8 The relation between the child and nursery environment

III. At social and environmental level

The relation between the child and the environmental social events

Statistically significant differences were found between group I and group II as regard almost of children who were irregularly attending to their nursery, have bad social performance, and have normal behavior in social events and attitude towards same-age colleagues. Also, there were statistically significant differences regarding that child behavior in social events may be normal, submissive isolated, or aggressive respectively and attitude towards same-age colleagues may be normal, submissive, isolated, or aggressive respectively (Table 9).

Table 9 The relation between the child and the environmental social events

Correlation analysis in case group

Correlation between language age and applied questionnaire

The sociodemographic data of the mother showed that there are significant positive correlations between the language age and duration of time that the mother spends at work, while there were significant positive correlations with language age and number of hours that both mother and father are present at home. Parent–child interactions showed that there are significant positive correlations with language age and both mother and father were assigning certain time to talk and play their child. There were positive significant correlations between language age and both marital status and socioeconomic status of the family (Table 10).

Table 10 Correlation between language age and applied questionnaire

The language intervention strategies between the mother and caregiver and children showed that there was a significant positive correlation with language age and all questions except the following: vary tone while speaking, use gestures to convey meaning, and emphasize facial expression. Also, some of language intervention strategies between the father and children showed that there was a significant positive correlation with language age and the following items: use simple short sentence, spend time for weekend with his child, use joint attention, and use reinforces (Table 11).

Table 11 Correlation between language age and language intervention strategies between (father, mother, or caregiver) and children

Regression analysis

Logistic regression analysis was conducted for prediction of DLD due to environmental deprivation. Univariable analysis revealed multiple factors as duration of the parents’ presence at home, the duration of time that the mother spends at work, the relation between the child and mother, the parents assign certain time to talk and play with their child, joint attention of the mother, mother asking her child what he wants, long time using multimedia, divorce as traumatic stress, bad social performance, and low socioeconomic status. Multivariate analysis was done after univariate analysis depending on significant risk factors from univariate analysis and revealed that the long duration that the mother spends at her work and the less time the mother assign to talk and play with her child were the environmental deprivation factors which had the most precipitating effect on prediction of DLD (Table 12).

Table 12 Logistic regression analysis

Validity and reliability of the questionnaire

• ▪ Validity: Content validity was employed to validate the Arabic questionnaire. All items were found to be fully relevant to their intended aim in terms of language and cultural appropriateness by three experienced and bilingual phoniatricians.

• ▪ Reliability: The reliability of the questionnaire was assessed. Cronbach’s alpha was measured across the questions. In Cronbach’s alpha (≥ 0.8– < 0.9), it was denoted to be satisfactory. Table 13 demonstrates the value of Cronbach’s alpha coefficient if the corresponding question was removed.

Table 13 Reliability assessment of applied questionnaire

Discussion

Children acquire language through interactions with parents, relatives, peers, and/or adults [10]. Children aged less than 3 years are catching what is called the sensitive period for language. Deprivation of external stimuli during this period will prevent normal development of neural circuit for the exact function [11]. Environmental deprivation is considered a major risk as it adversely affects numerous brain regions, and the sympathetic nervous system is strained due to its continual stimulation [12].

The aim of this work was to develop a questionnaire for evaluating the role of variant environmental factors on language acquisition in the three surrounding levels of communication that include familial level, preschool or nursery level, and surrounding social environmental level among children with delayed language development (DLD) due to environmental deprivation. The developed questionnaire was constructed taking in consideration social culture and language abrupt to the Egyptian culture and society for each proposed item in the questionnaire.

The present study revealed that statistically significant differences in parent’s education level. This is in agreement with Safwat and Sheikhany [5] who suggested that a strong positive correlation was found between parents’ access to health information and their knowledge and interaction scores. Education allows for a wider range of life experiences, which may have an impact on parenting styles and values. Statistically significant difference in number of hours that both parents were present at home and at their work and the language age of the child was found in the current study. Also, there were significant positive correlations with language age of the child and number of hours that both mother and father are present at home. This is in agreement with Glascoe and Leew [13] who supported the idea that the father plays a role in the child’s learning and increases the likelihood that the child will mature in line with his age, while Al-Fadhli and Al-Bunaian [14] found that language development is significantly correlated with the child’s time spent at home with their mother, but not with the father. This could be as mother–child interaction is more verbal and directed, while fathers when stay with their children they mostly play freely and physically more than talking.

A number of studies identify a link between parental divorce and lower academic achievement and poor behavioral outcomes, even at early ages. Children born to married parents who divorced have lower vocabulary and pre-reading skills and more aggressive behaviors at age 5 than children in stably married families [15, 16]. The present study revealed a statistically significant positive correlation with language delay and marital status. This is in agreement with the results of a study done by Fagan and Churchill [17] which revealed that the amount of warmth directed towards the children, affection, pride, stimulation of academic behavior, support of social maturity, and stimulation of language in divorced homes are reduced. Less financial and emotional support is provided to children of divorced families. Also, there was a statistically significant positive correlation between the language delay and the mother’s relation with her child and parent’s assignment of certain time to talk and play with his/her child. This result is in agreement with Al-Fadhli and Al-Bunaian [14] that supported the assertion that the time spent with a child should involve play and storytelling as well as providing for their bodily needs, such as food, clothing, and transportation.

The present study revealed that the language intervention strategies between the mother or caregiver and children showed that there were significant positive correlations with language age and most of language intervention strategies except vary tone while speaking, use gestures to convey meaning, and emphasize facial expression. According to Raikes et al. [18], regular and consistent engagement in routine activities gives young children a structured framework for interpreting the actions and words of others, aids in their ability to predict the chronological order of events, gives them rich information about the objects and activities in their environment, and enables them to make deductions from novel experiences. On the other hand, the language intervention strategies between the father and children showed that significant positive correlations with language age and the following items: use simple short sentence, the time spent for weekend with his child, use joint attention, and use reinforcers during the time a father spends with his children are important. Rosenberg and Wilcox [19] reported fathers’ play has a special function in a child’s development and teaching them things like how to control their urges towards aggression and how to explore the world. Fathers’ interaction with their children also has an important influence on a child’s emotional, social development, and joint attention. In addition, fathers frequently encourage their children to be independent and outwardly focused. Fathers often push achievement, while mothers stress nurturing, both of which are crucial for child’s proper development.

The present study showed a statistically significant positive correlation between DLD and very low to low level of socioeconomic status (SES). This is in agreement with a study done by Safwat and Sheikhany [5] which believed that parents who are overwhelmed by the stress of daily life can view their child’s needs as an extra source of stress and fail to build an emotional or reciprocal relationship with them. Also, Hoff [20] found that higher SES mothers talk more to their children than do lower SES mothers. The speech of higher SES mothers more frequently is uttered for the purpose of eliciting conversation, while the speech of lower SES mother more frequently is uttered for the purpose of directing their children’s behavior.

The present study also showed that there was a statistically significant difference regarding most of the relation between the child’s attitude and preschool or nursery environment. In agreement with Hoff [21] who found that young children interact with peers in play groups, in child care settings, and in preschool. Peer interaction may be a significant context for language acquisition. The present study also showed that there was a statistically significant difference regarding that most of the relation between the child’s attitude and environmental social events. These results are in line with Loeber and Stouthamer [22] who reported that the child’s social environment has a major impact on how child manage experiences in his/her different cognitive aptitudes. Furthermore, those children were lacking the social skills experience mainly because of their complete reliance on their parents in dealing with people and colleagues; as a result, they would be submissive or aggressive or isolated socially.

Logistic regression analysis was conducted for prediction of DLD due to environmental deprivation. Univariate analysis revealed multiple significant factors as number of hours that parents are present at home, the duration of time that the mother spends at work, the relation between the child and mother, the parents assign certain time to talk and play with their child, joint attention of the mother, mother asking her child what he/she wants, long time using multimedia, divorce as traumatic stress, bad social performance, and low socioeconomic status. Multivariate analysis was done and revealed that the long duration that the mother spends at her work and the less time the mother assign to talk and play with her child were the most precipitating factors on prediction of DLD due to environmental deprivation.

The current study’s findings demonstrated that the majority of the case group’s parent–child communicative interactions lacked the quality and quantity needed to create the stimulating and enriching environment required for language acquisition. This was evident in the interaction’s significant positive correlation with a child’s total language age. Topping et al. [23] found that it was evident from the majority of parent reports that the parents failed to create the perfect environment for their interactions with their children, and their communication style and responses to their children were poor.

Conclusion

The constructed Arabic questionnaire was proved to be valid, reliable, and homogenous and is likely to produce consistent responses in evaluating the variant environmental factors on language development among children with DLD due to environmental deprivation in the three surrounding communications levels.

Recommendations

The developed questionnaire should be used as a routine to minimize the existence of undiagnosed or misdiagnosed cases of DLD due to environmental deprivation and to consider environmental factors while planning the therapy program. Future research should focus on increasing the number of cases and study the effect of trained parents-child interaction on their child language development. Further researches are needed to assess the role of environmental factors on all causes of delayed language development.