Extreme prematurity and behavioral problems: When is it a problem?

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We know that children born extremely preterm (less than 27 weeks gestational age) are at risk for a whole host of developmental problems, including cognitive, language, motor, and feeding delays, but the relationship between these delays and behavior problems are not well studied…yet. In this study, authors tried to better understand the relationship between global development (using the Bayley Scales of Infant and Toddler Development – III) and behavior problems (using the Child Behaviors Checklist, CBCL) in more than one thousand toddlers born extremely preterm.

You probably won’t be shocked to learn that toddlers with a higher total behavior score (meaning more problems) were more likely to have lower cognitive, language, and motor scores. But some types of behavioral problems weren’t significant after researchers controlled for certain different factors.

Behaviors that were categorized as externalizing, anxiety, attention/hyperactivity, and oppositional defiant only had a statistically significant relationship with low cognitive and/or language scores before researchers adjusted for socio-economic factors. On the other hand, internalizing, affective, pervasive developmental, and total behavior scores were all correlated with lower cognitive, language and motor scores even after the researchers controlled for things like socio-economic factors, medical diagnoses and sex. 

That means if you’ve got a little one on your caseload that was born before 27 weeks gestation, these behavior categories (internalizing, affective, pervasive developmental, and total behaviors*) should set off red flags for you!

Now, the authors acknowledge that we still aren’t sure if these behavior issues cause developmental delays or the other way around (or maybe they both feed off of each other in a vicious cycle), but including a measure of behavior in your evaluations could help you describe behaviors more accurately, determine how at-risk a given toddler is and set goals that are truly impactful for the family. For more on assessing risk in preterm infants, see our previous reviews here, here, and here.

*If the names for behavior types from the CBCL are a bit confusing, it might help to know that they are aligned with DSM-5 criteria for corresponding diagnoses. Or you can get more information from the CBCL manual.

Lowe, J. R., Fuller, J. F., Do, B. T., Vohr, B. R., Das, A., Hintz, S. R., Watterberg, K. L., & Higgins, R. D. (2019). Behavioral problems are associated with cognitive and language scores in toddlers born extremely preterm. Early Human Development. doi:10.1016/j.earlhumdev.2018.11.007

Language delay and behavior problems: How can we help?

It’s not much of a surprise to EI SLPs that language problems and behavior problems can be pretty intertwined (e.g., here), and parenting style can be associated with both behavior and language outcomes. We also know that well-designed parent-implemented interventions can be wonderfully effective (they had better be if entire states are re-vamping their early intervention programs to promote the coaching model). So—can we support these things simultaneously?

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Garcia et al. implemented the Infant Behavior Program (IBP) with a group of mother–child pairs. The Infant Behavior Program was adapted from the Child-Directed Interaction (CDI) component of Parent-Child Interaction Therapy (PCIT). Programs like PCIT and Triple P- Positive Parenting Program have been shown to help children reduce negative behaviors, but no one has really studied what how (or if) those parent implemented behavior interventions affect language development. While PCIT training and certification is geared toward mental health professionals, the components of CDI and IBP will sound familiar to EI SLPs. The intervention guides parents to interact with their children using positive parenting skills, avoiding negative parenting skills, and ignoring unwanted behavior, and consisted of 5–7 weekly visits of 60–90 minutes. Parents were then asked to continue using the taught parenting skills in 5-minute increments throughout the day.

“Do” (Positive parenting skills)

  • Imitating

  • Describing

  • Reflecting

“Don’t” (Negative parenting skills)

  • Negative talk

  • Questions

  • Commands

Researchers found that change in parenting style was associated with an increase in the children’s total number of utterances. (Note: this effect was seen at six months after the intervention ended; the kids didn’t show a difference in total number of utterances at three months, or number of different utterances at either time they were tested). But the authors cautioned that presence of negative parenting skills did not change the toddlers’ number of utterances for better or for worse, so definitely don’t interpret this to mean we should throw out questions and commands.

So if an EI SLP is called in on a case where both language and behavior are concerns, but parent priority is behavior, maybe we start with those “positive” responsive techniques (labeling, imitating, and reflecting) before we jump in with questions and commands, because it looks like these positive behavior strategies can also help with language development!

 

Garcia, D., Hungerford, G. M., Hills, R. M., Barroso, N. E., & Bagner, D. M. (2019). Infant language production and parenting skills: A randomized controlled trial. Behavior Therapy. Advance online publication. doi:10.1016/j.beth.2018.09.003

And more...

  • Bilgin et al. found that infants with difficulties regulating their feeding, sleeping, and crying have an increased risk of attention problems later in childhood. And many adults who had regulatory problems as infants still demonstrated attentional difficulties throughout adulthood.

  • Bontinck et al. used observations in the home setting to compare interactions between 2-year-olds and their older sibling with ASD with interactions between 2-year-olds and their older, typically developing sibling. Findings suggested that the 2-year-olds whose sibling had ASD attempted to initiate social interactions less frequently, demonstrated fewer positive responses to their sibling’s attempt to communicate or interact, and attempted to imitate their older sibling with ASD less frequently. And, when the researchers looked at total interactions—both positive and negative—between the sibling pairs, they found that higher levels related to more parent-reported ASD characteristics. What does this mean? Well, it suggests that younger siblings of children with ASD might be learning positive and negative behaviors. And, given that siblings provide the earliest form of social interaction, paired with the fact that siblings of children with ASD are at high risk for receiving the same diagnosis, findings from this study suggest that examining social interactions between siblings may provide insight into the development of young children whose sibling has ASD.

  • Typical disfluencies (e.g. revisions, phrase repetitions, filled pauses) are a normal part of preschoolers’ speech, and “appear at times of rapid language growth”. Generally, while children are learning new words and new sentence structures, typical disfluency rates can increase (see article for review). So how would this play out for bilingual children? That’s unknown, and the aim of Brundage & Rowe. In this study, they examined young (30-month-old) simultaneous Spanish–English bilingual children (with roughly 50-50 exposure to English and Spanish at home). They found slightly lower disfluency rates in Spanish, and lower disfluency rates, overall, compared to similar studies. Because their data is a bit unexpected compared to similar research on monolinguals, it’s difficult to know how to interpret this data. But, maybe that’s exactly the point? That it’s different for bilinguals? Future research should help clarify that.

  • After English, Spanish is the most common language spoken in the homes of U.S. children who are deaf or hard of hearing (DHH). Yet, we know very little about language and, specifically, vocabulary outcomes for this population. de Diego-Lázaront et al. looked at a variety of demographic, hearing-, and intervention-related factors to determine which might have a relationship with Spanish expressive vocabulary skills in 8 to 36-month-olds who are DHH. Results suggested that degree of hearing loss, range of functional hearing, and chronological age and age of intervention separately and combined predicted Spanish expressive vocabulary development. And, more specifically, the researchers found that the children who began receiving therapy early—by 6 months of age—received significantly higher scores on expressive vocabulary measures in Spanish.

  • Donegan-Ritter & Van Meeteren coached Early Head Start teachers on language strategies using video self-reflection and focused feedback. Teachers were able to increase their use of questioning, back and forth exchanges, and parallel talk with both infants and toddlers. Practice-based coaching may be an effective method for training teachers to increase their use of language strategies.

  • Dowd et al. looked at how young toddlers responded when a parent or experimenter got “hurt” (e.g., adults faked injuries when playing with a toy or fiddling with a clipboard) and suggest that we can see signs of social impairments by about 15 months. While we usually consider social concepts like empathy and emotional thinking to be later developing skills, the study’s results show us that we can start to see impairment fairly early in development.

  • Within a child’s first few years, the total number of words he produces often reigns king with regards to assessing his language level. When a child comes to us with a small vocabulary, one of our primary goals is generally to increase the total vocabulary.  However, Galeote et al. explain that a more nuanced approach than “total number of words” is important for fully capturing a child’s language and creating meaningful intervention plans.  We need to make sure that we are considering the makeup of a child’s word classes so that we can understand the child’s strengths and weaknesses and plan our intervention appropriately. With that understanding, if a child’s vocabulary was made up almost entirely of nouns, we would know to target verbs more intensively in intervention.

  • Infants as young as six months old can adapt their communication behaviors to their social environments! Ganea et al. found that non-blind infants of blind parents interact differently with their blind parents compared to non-blind adults.

  • Greenslade et al. provide further data that decreased initiation of joint attention, expressive language, and social communication behaviors during the infant and toddler years can predict pragmatic communication difficulties in the school years, even if a child does not meet criteria for a diagnosis of ASD.

  • Noyes-Grosser et al. offer a program review of New York State’s Part C services, and more specifically how children with ASD and their families respond to services. We can’t apply the results of this review to all of our readers, because Part C is interpreted and services are delivered differently state-by-state and even county-by-county, but the article offers a great overview of why we do things some of the things we do (e.g., COS statements). The authors also over some good tools for program evaluation (see here for Record Review Protocol and here for an EI Family Survey). For SLPs working in Part C programs, you might want to keep this citation handy to offer to your EI coordinators and/or supervisors.

  • Severini et al. implemented the Stay-Play-Talk (SPT) routine with two children with Down Syndrome who used high-tech AAC as their primary mode of communication. They found when peers were trained to use SPT strategies during free play there was an increase in stay and play behaviors for both children. (Sound familiar? We’ve written about Stay–Play–Talk before for children with ASD who use AAC, here and here.)

  • The parent-implemented Early Start Denver Model (P-ESDM; Rogers et al., 2012a) is an intervention that combines principles from Applied Behavioral Analysis (ABA) with a developmental, socially-focused approach to increase parent interactions that promote positive developmental outcomes for young children with ASD. Vismara et al. looked at whether the P-ESDM might also be an effective intervention for young children with fragile X syndrome (FXS) with and without a combined diagnosis of ASD. The first author of the study provided coaching to promote the use of the P-ESDM with four 1 ½ to 4-year-old children and their parents either in person or via video-conferencing. The parent-related outcomes were encouraging: all of the parents improved in their ability to accurately and consistently implement the P-ESDM intervention goals, and they found the coaching experience to be generally positive. The child-related outcomes (e.g., spontaneous communication and initiated joint attention) were more variable, indicating the need for more studies that examine the use of the P-ESDM with children with FXS with and without ASD.  

Bilgin, A., Baumann, N., Jaekel, J., Breeman, L.D., Bartmann, P., Bäuml, J.G. … Wolke. D. (2018). Early crying, sleeping, and feeding probelsm and trajectories of attention problems from childhood to adulthood. Child Development. Advance online publication. doi: 10.1111/cdev.13155.

Bontinck, C., Warreyn, P., Demurie, E., Bruyneel, E., Boterberg, S., Roeyers, H. (2018). Social Interactions Between 24-Month-Old Children and Their Older Sibling with Autism Spectrum Disorder: Characteristics and Association with Social-Communicative Development. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-018-3660-4.

Brundage & Rowe (2018). Rates of Typical Disfluency in the Conversational Speech of 30-Month-Old Spanish–English Simultaneous Bilinguals. American Journal of Speech–Language Pathology, 27, 1287–1298.

De Diego-Lázaro, B., Restrepo, A., Sedey, A.L., Yoshinaga-Itano, C. (2018). Predictors of Vocabulary Outcomes in Children Who Are Deaf or Hard of Hearing From Spanish-Speaking Families. Language, Speech, and Hearing Services in Schools. Advance online publication. doi: 10.1044/2018_LSHSS-17-0148.

Donegan-Ritter, M., & Van Meeteren, B. (2018). Using practice-based coaching to increase use of language facilitation strategies in early head start and community partners. Infants & Young Children, 31(3), 215–230.

Dowd, A. C., Martinez, K., Davidson, B. C., Hixon, J. G., & Neal-Beevers, A. R. (2018). Response to distress varies by social impairment and familiarity in infants at risk for autism. Journal of Autism and Developmental Disorders, 48(11), 3885–3898.

Galeote, M., Checa, E., Sebastián, E., & Robles-Bello, M. A. (2018). The acquisition of different classes of words in Spanish children with Down syndrome. Journal of Communication Disorders, 75, 57–71.

Ganea, N., Hudry, K., Tucker, L., Charman, T., Johnson, M.H., & Senju, A. (2018). Development of adaptive communication skills in infants of blind parents. Developmental Psychology, 54(12), 2265–2273.

Greenslade, K. J., Utter, E. A., & Landa, R. J. (2018). Predictors of pragmatic communication in school-age siblings of children with ASD and low-risk controls. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s10803-018-3837-x

Noyes-Grosser, D. M., Elbaum, B., Wu, Y, Siegenthaler, K. M., Cavalari, R. S., Gillis, J. M., & Romanczyk, R. G. (2018). Early intervention outcomes for toddlers with autism spectrum disorder and their families. Infants & Young Children, 31(3), 177–199.

Severini, K.E., Ledford, J.R., Barton, E.E., & Osborne, K.C. (2018). Implementing stay-play-talk with children who use AAC. Topics in Early Childhood Special Education. Advance online publication. doi: 10.1177/0271121418776091.

Vismara, L.A., McCormick, C.E.B., Shields, R., & Hessl D. (2018). Extending the Parent-Delivered Early Start Denver Model to Young Children with Fragile X Syndrome. Journal of Autism and Developmental Disorders. Advance online publication. doi: 10.1007/s1

And more

  • Bavin et al. found that in children with cochlear implants, pre-implant early receptive communication skills and early gesture use were the strongest predictors of vocabulary one year post-implant. Targeting receptive language and use of gestures may be the way to go if you are working with toddlers with hearing loss, prior to receiving a cochlear implant.

  • Cunningham et al remind clinicians and researchers alike to consider growth in outcomes related to engagement and participation rather than just impairment, and discuss predictors of communication participation outcomes. This is actually a very large study, with some strong data to show that speech­–language services, in general, work to improve the outcomes in early intervention. They also have intensity data here. So if you need a study to show that what we do really matters, this is a good one to add to your stack!

  • Although the research base that focuses on decoding, fluency, and reading comprehension in older children with autism continues to expand, relatively less is known about the emergent literacy skills of young children with ASD. Fluery and Lease (2018) examined code- and meaning-focused emergent literacy skills of 3 to 5-year-olds with ASD as well as their parents’ beliefs about their early reading development. Findings from this study have important clinical applications: First, variability in the children’s emergent literacy skills suggests that reading interventions for young children with ASD should be tailored to meet the individual needs of each child. Second, results suggested that parents of children with stronger communication skills had a more positive outlook on their child’s ability to benefit from reading exposure and instruction. This finding suggests that we need to provide extra support and education to parents whose children with ASD have more complex communication needs.

  • Eye gaze and, specifically, gaze following serves as an important social and language-learning tool for infants. What is still unclear is specifically what motivates an infant to follow a caregiver’s gaze. Findings from Gredeback, Astor, and Fawcett’s (2018) recent study suggest that social, attention-grabbing events (e.g., something as simple as a head turn) may be just as a strong of a motivator for infants to follow a caregiver’s gaze as previously recognized perceived communicative intent.

  • Ibanez et al examined the efficacy of a web-based program for training parents of children with ASD to use behavioral strategies in day-to-day routines such as bath time and snack. Parents in the tutorial group reported that they used more strategies, felt they parented more efficiently and experienced less stress, and reported that their children engaged and communicated more during daily routines. The article directs readers to an example of the tutorial and menu of current tutorials.

  • Neuman et al. analyzed over 2000 scenes from language-focused educational media. Videos with attention-directing cues (basically zooming in on the target) were most successful in helping children learn new vocabulary. However, children with higher language scores were more likely to use these cues to learn vocabulary, so educational videos may not be as helpful for those with language delays.

  • Pearson, Oliver, and Waite surveyed parents of children with rare genetic syndromes to see what types of information these families felt they needed most to help their children. They found that concerns associated with Angelman syndrome included sleep, communication, and health, while parents of children with Cri du Chat syndrome were most concerned with health, behavior, and daily living skills, and parents of children with Cornelia de Lange syndrome often wanted information on behavior, health, and self-injury. The authors highlight the need for clinicians to be aware of and address parents’ perceptions and concerns about their children’s disorders.

  • Spinelli & Mesman found that both the prosody of infant-directed speech and caregiver sensitivity to infants’ social–emotional cues contribute together to infant social–emotional development. We can’t do “motherese” alone, we have to be able to read and respond to baby’s cues and interactive attempts. (Also, see here for more information on the effect of motherese on infant development).

  • We know that exposing young children to decontextualized language, or, abstract talk that’s removed from the here-and-now, can improve their later vocabulary, narrative skills, and reading comprehension. Uccelli et al.’s recent study provides a unique perspective by demonstrating a link between toddlers’ use of decontextualized talk and higher levels of academic language proficiency 10 years later.

 

Bavin, E.L., Sarant, J., Leigh, G., Prendergast, L., Busby, P., & Peterson, C. (2018). Children with cochlear implants in infancy: predictors of early vocabulary. International Journal of Language & Communication Disorders. Advance online publication. doi: 10.1111/1460-6984.12383

Cunningham, B. J., Hanna, S. E., Rosenbaum, P., Thomas-Stonell, N., & Oddson, B. (2018). Factors contributing to preschoolers’ communicative participation outcomes: Findings from a population-based longitudinal cohort study in Ontario, Canada. American Journal of Speech-Language Pathology, 27(2), 737-750. doi: 10.1044/2017_AJSLP-17-0079.

Fleury, V. P., & Lease, E. M. (2018). Early indication of reading difficulty? A descriptive analysis of emergent literacy skills in children with Autism Spectrum Disorder. Topics in Early Childhood Special Education, 0, 1 – 12.

Gredeback, G., Astor, K., & Fawcett, C. (2018). Gaze following is not dependent on ostensive cues: A critical test of natural pedagogy. Child Development. Advance online publication. doi: 10.1111/cdev.13026.

Ibanez, L. V., Kobak, K., Swanson, A., Wallace, L., Warren, Z., & Stone, W. L. (2018). Enhancing interactions during daily routines: A randomized controlled trial of a web-based tutorial for parents of young children with ASD. Autism Research, 11(2), 667–678. https://doi.org/10.1002/aur.1919

Neuman, S. B., Wong, K.M., Flynn, R., & Kaefer, T. (2018). Learning vocabulary from educational media: The role of pedagogical supports for low-income preschoolers. Journal of Educational Psychology. Advance online publication. doi: 10.1037/edu0000278

Spinelli, M. &b Mesman, J. (2018). The regulation of infant negative emotions: The role of maternal sensitivity and infant-directed speech prosody. Infancy, 23(4), 502–518.

Uccelli, P., Demir-Lira, O. E., Rowe, M. L., Levine, M., & Goldin-Meadow, S. (2018). Children’s early decontextualized talk predicts academic language proficiency in midadolescence. Child Development. Advance online publication. doi: doi.org/10.1111/cdev.13034

And more...

  • Bottema–Beutel et al. found that parents of children with ASD used more utterances that were related to the object or activity that the child was focusing on compared to parents of typically developing children. And these utterances (esp. comments, as opposed to directives) were particularly effective in establishing joint engagement with reciprocal turn-taking and imitation between the parent and child.

  • Gunderson, et al., found that parental praise (specifically process praise (“praise for effort and strategies”) from ages 1–3 years indirectly predicts math & reading performance seven years later, in 4th grade. Specifically, praise related to effort was found to influence the children’s beliefs that intelligence is malleable. Keep on praising that hard work!

  • Loy et al. considered parent and infant behaviors that have been shown to predict joint attention in previous research, and examined how these behaviors might relate to later language outcomes. Findings provide evidence to support the notion that attentive, responsive, interactive caregivers are the key ingredient when it comes to establishing joint attention with infants and toddlers.

Bottema-Beutel, K., Lloyd, B., Watson, L., & Yoder, P. (2018). Bidirectional influences of caregiver utterances and supported joint engagement in children with and without Autism Spectrum Disorder. Autism Research. Advance online publication. doi: 10.1002/aur.1928

Gunderson, E. A., Sorhagen, N. S., Gripshover, S. J., Dweck, C. S., Goldin-Meadow, S., & Levine, S. C. (2018). Parent praise to toddlers predicts fourth grade academic achievement via children’s incremental mindsets. Developmental Psychology, 54(3), 397–409.

Loy, M., Masur, E. F., & Olson, J. (2018). Developmental changes in infants’ and mothers’ pathways to achieving joint attention episodes. Infant Behavior and Development, 50, 264 – 273.