Influence of risk factors on language development and contributions of early stimulation: an integrative literature review

ABSTRACT

This study aimed to identify evidence in the literature regarding the influence of risk factors on child language development and point out the contributions of early stimulation. In this integrative literature review, the databases Lilacs, PubMed and SciELO and the descriptors Child language; Risk factors; Premature; Postterm child; Apgar score; Early intervention were used. From the findings, the following data were extracted: author, year of publication; objective and study design; participants and inclusion criteria; studied variables; main findings. For the organization and analysis of the studies, we used the thematic content analysis technique. We identified 1,421 articles; 29 met the inclusion criteria of this study. The studies were categorized by similar results. Most of the articles reveal the effect of prematurity on language development. Four studies investigated the association between risk factors in general and problems in language development. One study evaluated school-age children and associated Apgar scores with SLI. The authors' recommendation was unanimous about the monitoring and early intervention. We conclude that the risk factors listed in the study negatively influence children's language development. We reinforce the recommendation of early and qualified care for these children, as it contributes to proper development, in order to avoid and / or minimize risks and future changes.

Keywords:
Child Language; Risk Factors; Premature; Apgar Score; Early Intervention (Education)

RESUMO

O objetivo do estudo foi identificar evidências na literatura a respeito da influência dos fatores de risco sobre o desenvolvimento da linguagem da criança e as contribuições da estimulação precoce. Trata-se de uma revisão integrativa, que utilizou as bases de dados Lilacs, PubMed e SciELO e os descritores: linguagem infantil, fatores de risco, prematuro, criança pós-termo, índice de Apgar, estimulação precoce. A partir dos achados, extraíram-se os seguintes dados: autores, ano de publicação, objetivo, desenho do estudo, participantes e critérios, variáveis estudadas, principais achados. Para a organização e análise foi utilizada a técnica de Análise de Conteúdo do tipo temática. Foram identificados 1.421 artigos, 29 atenderam os critérios de inclusão. Os estudos foram categorizados por resultados afins; A maioria dos artigos selecionados trata do efeito da prematuridade sobre o desenvolvimento da linguagem. Quatro estudos investigaram a associação entre fatores de risco e problemas no desenvolvimento da linguagem. Um dos estudos avaliou crianças em idade escolar e associou valores de Apgar com DEL. Foi unanime a recomendação acerca do acompanhamento e intervenção precoce. Conclui-se que os fatores de risco elencados influenciam negativamente no desenvolvimento da linguagem. Reforça-se a recomendação do atendimento precoce e qualificado dessas crianças, evitando e/ou minimizando alterações futuras.

Descritores:
Linguagem Infantil; Fatores de Risco; Prematuro; Índice de Apgar; Intervenção Precoce (Educação)

Introduction

The language process is complex and, due to its relevance, it has been widely studied. The first three years in a child’s life correspond to a development phase characterized by the acquisition of new functions and skills and by brain plasticity. In this phase, great advances take place in the motor, cognitive and social areas, as well as the acquisition and mastery of language, which are essential for the child’s global development and language¹.

Around the first year of life, children with normal language development start to practice their first words². Before reaching this verbal language form, however, they develop a range of more general communication skills at a non-verbal, pre-linguistic level, which are essential for the normal development of language. In this process, the child’s language evolves from the use of a single word to a well-structured grammatical form and becomes increasingly efficient³.

Like other (environmental and socioeconomic) risk factors, the biological risk factors play an important role in the child’s development and can impair the cognitive skills and normal language development⁴.

In this review, we focus on the pre, peri and post-natal risk factors, including: prematurity, postmaturity, Apgar score, low birth weight and complications during pregnancy and birth^5,6.

Children who fit into any of these situations at birth present a potential risk for language development problems, which can extend from birth until adolescence in the learning process^2,6,7.

The Apgar score (or scale) offers a rapid assessment of the infants’ responses immediately after birth, as well as of his/her adaptation to extra-uterine life. Infants with Apgar < 7 at 5 minutes are considered as high-risk. The items assessed help to detect problems that require special care⁸.

Preterm infants (PT) are characterized by a gestational age of less than 37 weeks and low birth weight (LW) by a weight of less than 2,000g. Both can be associated with gestational factors like smoking and quality of prenatal care⁸.

Despite all factors harmful to child development, many associated risks can be avoided or minimized, depending on the implementation of effective prevention programs^9,10. One of the most effective prevention measures is the early identification. In addition, specialized monitoring is also needed, which should take place as early as possible, implementing stimulation, based on planned neuro-evolutive techniques, with a view to acting on the nervous system, which is still plastic and moldable⁵.

Authors suggest developmental monitoring for these children and emphasize the importance of early intervention^11-13.

In view of the large number of children with risk factors at birth that can impair their development, especially their language development, the following question emerged: Do the risk factors at birth truly influence normal language development? Can the effects of these adverse conditions on the children’s development be minimized through early intervention?

Departing from these questions, the objective in this integrative review was to identify evidence in the literature about the influence of risk factors on child language development and point out the contributions of early interventions for these clients.

Methods

An integrative literature review was undertaken, which intended to analyze the literature and present the research results’ contributions to improve the care practice¹⁴ for high-risk children.

Initially, the procedures that, according to the literature were needed for the integrative review, were listed. The first step was the identification and formulation of the research question, followed by the location of studies that answer it, in predefined databases. Finally, data were collected from the selected studies. The data were analyzed and interpreted, being grouped based on the similarity among the studies and discussing the findings¹⁵.

The guiding question was: Do the factors considered as risk factors at birth truly influence normal language development? Can the effects of these adverse conditions on child development be minimized through early intervention?

To search the articles, the following electronic databases were used: LILACS (Literatura Latino Americana e do Caribe em Ciências Sociais e da Saúde), PubMed, digital archive produced by the National Library of Medicine and the electronic library Scientific Electronic Library Online (SciELO).

For the selection, the titles and abstracts were read; then, the material was fully read and the articles were selected for inclusion in the review. The exclusion criteria were: repeated articles, studies that did not address the guiding question, reviews and articles whose full version was not available. The selected key words used the Descritores em Ciências da Saúde (DeCS) and the Medical Subject Headings (MESH) for reference, in their different combinations: child language; risk factors; preterm; postterm child; Apgar score; early stimulation.

The following data were extracted from each article: authors; year of publication; objective and study design; participants and (inclusion and exclusion) criteria; research variables; main findings about the influence of the risk factors for language development and authors’ recommendations to minimize the possible effects.

To organize and analyze the data, the thematic Content Analysis technique was used, which consists in the pre-analysis, material exploration or coding (categorization) and treatment of the obtained results/interpretation. The first step (pre-analysis) comprises the skimming, formulation and reformulation of hypotheses or premises and, at the end, the return to the initial inquiries. Categorization is a process in which the text is reduced to significant words and expressions. Finally, the data are classified and combined, choosing the theoretical or empirical data responsible for the specification of the theme. Then, inferences and interpretations are developed¹⁶.

Results

By crossing the descriptors in the consulted databases, 1,421 articles were identified, eight (0.6%) of which in LILACS; 885 (62.6%) in PubMed and 520 (36.8%) in the virtual library SciELO. Based on the reading of the titles, 411 publications were selected; after verifying the abstracts, 78 publications were withheld; after reading the full articles, 29 articles were included in this review.

Information was extracted about the influence of the risk factors on the language development and the contributions of monitoring these children. Twelve (41.4%) studies were developed in Brazil, six (20.7%) in the United States, two (6.9%) in the Netherlands, two (6.9%) in Norway, two (6.9%) in China, one (3.4%) in Italy, one (3.4%) in Finland, one (3.4%) in the United Kingdom, one (3.4%) in Chile and one (3.4%) in South Africa.

The studies were categorized by related results; 11 studies (37.9%) discussed the “Influence of preterm birth on language development”, five (17.2%) investigated the “Influence of the association between preterm birth and low weight on language development”, four (13.8%) discussed the “Influence of risk factors (in general) on language development”, one (3.4%) verified the “Influence of the Apgar”, three (10.3%) the “Effect of preterm birth on learning” and five (17.2%) studied “Early intervention in high-risk infants”.

In Figure 1, the categorization of the articles by similar themes and their main characteristics are displayed.

Figure 1:
Main characteristics of the articles selected for this review.

Most of the articles selected discuss the effect of preterm birth on language development. All studies found delays or changes in the groups of preterm children in different areas that were assessed. Only two articles found no statistically significant results for the influence of preterm birth on development. Nevertheless, in the group of preterm infants, lower scores were found in the domains assessed.

The areas mentioned with a lag included expressive and receptive language, cognition, neuropsychological skills, visual-motor and spatial skills, short-term memory, fine and gross motor skills and behavioral aspects.

The authors observed the effect of preterm birth in early development, in the preverbal and language acquisition phases.

When associated with low weight, preterm birth was also related with worse results on standardized developmental assessments in children with this risk.

In four studies, the association between overall risk factors and language development problems was investigated, also presenting similar results. The authors evidenced the biological risk factors.

One of the studies assessed children of school age and associated Apgar scores withSLD (Specific Language Disorder).

Studies indicated the influence of preterm birth on children’s learning. Three studies assessed cognitive and reading and writing skills, comparing full-term and preterm children. The results evidence a lag in the skills assessed in the preterm children and highlight that the delays deriving from this risk factors are not only observed in the preverbal and language acquisition phases, but continue over the years and can compromise their learning.

The authors unanimously recommended monitoring and early intervention for these children who, at birth, presented any of the risks described above. Five articles studied early intervention in high-risk infants, all of which found benefits for the development of these children.

Discussion

The objective of this review was to study the influence of the risk factors on language development, particularly the biological risk factors. The findings evidence that the biological risk factors have an important influence on language development.

Authors¹⁷also sought to investigate the risk factors for the development, especially for language acquisition, and found that children who live with biological risks in the first years of life are more prone to developing problems, which can affect their development, in line with the findings of this review. The influence of the risk factors on the development are noticeable even in the preverbal phase of language development, when preterm children already present delays in the assessment of certain pre-linguistic skills^18-21. The birth condition affects the language development since the acquisition of preverbal skills. One example is the delay in the expression of stammering, which are the initial sounds the child produces around the age of four months¹⁸.

The articles that studied the influence of risk factors on language development reveal that the impairments deriving from these factors are present in the course of the children’s life and last until adolescence²². Preterm or low-weight children present delays at school age and throughout the learning process.

In comparison with full-term children, they present worse performance and deficits in terms of overall cognition, phonological awareness, working memory and other essential metalinguistic skills for the successful learning of reading and writing^23-26.

In a literature review, authors addressed the relation between prematurity, birth weight and language development in Brazilian children and found an association between prematurity, low birth weight and language development⁶.

In studies that compared preterm and full-term children, it was evidenced that the former performed worse on the language indicators. It was also observed that the children born with lower weight performed worse on the language assessments when compared to the children with higher weight and a gestational age closer to 37 weeks, in line with the findings of studies included in this review^27,28.

During standardized assessment, preterm children have scored lower on intelligence scales, visual perception test, visual-motor integration test, memory and attention, impairments that go beyond the actual language development, although they do exert influence^26,29.

Most of the selected studies recommend that the speech and language development of children with one or more risk factors be periodically monitored and, if necessary, forwarded for early intervention^12,20. They further highlight that this monitoring can minimize the effect of birth problems³⁰and that non-intervention can entail significant health costs, as these children will experience difficulties in the course of their development³¹.

Different authors have studied the contribution of early intervention to the development of high-risk infants^13,32,33. Early intervention programs are intended to monitor, guide and stimulate the development of high-risk infants. One of these studies on the theme highlights the importance of early multidisciplinary intervention and points out significant benefits for the infants’ development when compared to infants who did not receive the intervention¹¹. Other authors also highlight that the infants who received any early intervention therapy demonstrated better performance in terms of cognitive functions in comparison with the infants who did not^13,34.

In a literature review on the theme “early stimulation in premature infants”, positive and clinical significant effects of the intervention were found on several aspects involving the mothers and the premature infants. The authors also alert that these should include psychosocial and educational support for the parents and therapeutic interventions with a view to the children’s development³⁵.

The importance of the mother-infant relationship was also mentioned in the selected studies, considering that one of the principles of early stimulation is the parents’ orientation towards stimulating the child’s development. To verify the impact of mother-child interaction on the oral language development of preterm children, in one study, it was verified that the mothers considered it was more important to educate and control the children than to stimulate them and the children, in turn, performed below expectations on all language tests. In that sense, the authors concluded that these results below expectations can be attributed to the insufficient quantity and quality of the mother-child interaction³⁶.

In two of the studies selected for this review, it was concluded that preterm birth did not influence the psychomotor development and vocabulary acquisition of the study populations.

The first study was aimed at comparing the neuropsychomotor development of preterm infants (with corrected age) and full-term children between six and 12 months of age, as well as to investigate the associated factors. In the analysis of the results, the authors did not observe any significant difference between the development of preterm and full-term children; for expressive communication, however, they found lower development rates for the preterm group³⁷. Although the results were not statistically significant, worse performance was found on the tests involving preterm children, as verified in different studies, previously cited in this review.

The second study intended to investigate the risk factors associated with vocabulary acquisition in two-year-old children born at the gestational age of 28 weeks or less, and found no significant association between gestational age and vocabulary. The only clinical factors correlated with vocabulary acquisition problems at the age of two years were severe disabilities³⁸.

It should be highlighted that the authors of the above study analyzed but one language aspect (vocabulary), while other studies analyzed different aspects of premature children’s performance (cognition, receptive and expressive language, phonological processing, working memory, among others) which the preterm risk factor could affect³⁹. Therefore, the analysis of a single variable is regarded as a limitation of that study. If other variables had been studied, language development alterations or delays could have been observed, as verified in most studies included in this review.

Conclusion

The objective in this integrative review was to identify evidence in the literature concerning the influence of risk factors on child language development and point out the contributions of early intervention to this development.

Based on the analysis of the studies, it was seen that the risk factors weight at birth, gestational age and Apgar score negatively influenced child language development, and this influence can range from the preverbal skills to adolescence and create problems in school age and in overall learning.

Therefore, early and qualified care for these children is recommended, as it contributes to their appropriate development, which permits avoiding and/or minimizing risks and future alterations.

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Publication Dates

• Publication in this collection
  Feb 2017

History

• Received
  08 Nov 2016
• Accepted
  11 Jan 2017