Maternal interaction and language development in children with and without speech-related anomalies

J. COMMUN. DISORD. 21 (1988), 319-331

MATERNAL INTERACTION AND LANGUAGE DEVELOPMENT IN CHILDREN WITH AND WITHOUT SPEECH-RELATED ANOMALIES GAIL A. WASSERMAN Columbia University and New York State Psychiatric Institute

RHIANON ALLEN LongIsland University L. ORIANA LINARES Mount Sinai School of Medicine

This study explores relationships among maternal behavior, child language, and location of congenital structural anomaly in three groups of 24month-old children: 21 with speechrelated anomalies (SRA), 13 with non-speech-related anomalies (NSRA), and 45 normal controls. In addition to standardized assessment of intelligence and language, children and mothers were observed in a half-hour videotaped play session, later coded for maternal and child interactive behavior. SRA children showed significantly poorer performance than controls on standardized tests. Mothers of SRA children showed significantly more Physical Teaching and Initiating relative to controls. Mothers of both SRA and NSRA children used significantly more Attenrion Management than did controls. The pattern of poorer child performance and maternal interactive compensations is largely confined to children whose structural disabilities are speech-related. Maternal interactive behavior is not global in its response to child disability; rather, it varies with the particular pattern of child disabilities found.

INTRODUCTION School-age children with a wide range of physical handicaps often also show language deficiencies. For example, language problems have been studied in children with facial anomalies (e.g., Elfenbein, Wasiri, and Morris, 1981; Ester and Morris, 1970; Fox, Lynch, and Brookshire, 1978; Lewis, 1971; Nation, 1970; Richman and Eliason, 1984; Ruess, 1965; Smith and McWilliams, 1968) and in thalidomide-exposed children (DeCarie, 1965). With few exceptions (e.g., Richman and Harper, 1978; Steinhausen, 1981, Steinhausen and Wefers, 1976), children with multiple Address correspondence to Dr. Gail A. Wasserman, Department of Child Psychiatry, College of Physicians and Surgeons, Columbia University, 722 West 168th Street, New York, NY 10032. 0 1988 by Elsevier Science Publishing Co., Inc. 52 Vanderbilt Ave., New York, NY 10017

319 0021~9924/88/$3.50

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anomalies do worse than those with isolated anomalies (Gall, Hayward, Harper, and Gam, 1972; Lewis, 1971; McWilliams and Matthews, 1979). The language acquisition of children with facial anomalies may be affected by a variety of factors including deviations in oral and articulator-y structures, hearing problems severe enough to interfere with communication processes, mental retardation, and environmental factors such as early mother-child interaction patterns. Speech-Hearing Problems Speech delays or impairments, such as hypemasality, are expected in children with cleft palates due to the functional or structural abnormalities of the speech production mechanisms (Moll, 1968). Structural problems may require that the child develop new adaptations to compensate for speech distortions (Nation and Aram, 1977). Additionally, cranial-facial anomalies are associated with an increased risk of hearing problems, although these are frequently only mild, transitory losses consequent to otitis media. Problems in Language Acquisition Beyond their increased risk for speech difficulties, children with facial anomalies may also develop general language problems, although the mechanism behind such an association is unclear. A few recent studies have addressed aspects of language acquisition in very young children with cleft lip and palate. While lZmonth-old cleft lip and palate children show no delay in early comprehension abilities and gestural communication (Long and Dalston, 1982, 1983), the subsequent emergence of oral language is delayed (Bzoch, Kemper, and Wood, 1984; Morris, 1962; Nation and Wetherbee, 1985; Richman, 1980; Wasserman, Allen, and Solomon, 1985). For example, in a recent paper (Seidman, Allen, and Wasserman, 1986), we studied structural and functional features of the productive language of 15 2-year-olds with either oral-facial or orthopedic anomalies. As a group, compared to nonhandicapped controls, these children had shorter mean length of utterances (MLU) and upper bound, and smaller vocabularies, including fewer verbs. Because of the small size of the sample, subgroup comparisons between children with orthopedic, as opposed to oral-facial, anomalies were not examined, but communication difficulties were noted in both groups. Enviroumental Influences Factors in the child’s environment, such as early interaction with parents, clearly affect language acquisition in normal samples (Nelson, 1973). Aspects of maternal responsivity and contingency, such as gaze following

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(Rocissano and Yatchmink, 1983), extensive verbal topic uptake (Snow, 1964), and specific verbal inputs (Nelson, Carskaddon, and Bonvillian, 1973) are associated with accelerated language acquisition in normal and premature children. However, maternal behaviors that are known to facilitate or inhibit the language acquisition of children have rarely been addressed in studies of children with structural anomalies, although they have been examined for other groups such as prematures (Goldberg, Brachfeld, and Divitto, 1980), the developmentally delayed (Snyder, 1984), the hearing impaired (Nienhuys, Cross, and Horsborough, 1984; Snyder, 1984; White and White, 1984) and otherwise normal but language delayed (Conti-Ramsden and Friel-Patti, 1984; Snyder, 1984). Consistent differences in interaction patterns between mothers and their physically handicapped young children may thus be assumed to differentially affect their emerging language. In a longitudinal study of infants with various nonretarding congenital anomalies through the second year (Wasserman et al., 1985), we documented group differences in patterns of mother-child interaction. Compared to mothers of controls, mothers of handicapped toddlers were more initiating and less responsive to infant play, were more likely to use nonverbal means to teach the child about the play materials, and invested more energy in focusing the infant’s attention-a pattern that the literature on normals and prematures suggests is unlikely to foster optimal language acquisition. In our earlier work (Wasserman et al., 1985), we suggested that maternal interactive behavior was, to a large extent, a response to the pattern of disabilities presented in the infant-at-risk. We do not know, however, if different patterns of interaction appear between mothers and infants with speech-related anomalies (where speech problems would be anticipated) as compared to those with non-speech-related handicaps.

Subgroups of Handicapped Children Few studies have addressed the early stages of language acquisition in well-defined subgroups of young children with physical anomalies. Examination of such subgroup differences is necessary if we want to study the differential impact of the location of the structural anomaly on language development. Investigation of subgroup differences in language acquisition might further allow the early identification of those children likely to experience speech and language di&ulties. Moreover, the presence of language problems in certain groups of children may put them at further risk for difficulties in establishing and maintaining social relationships, in problem solving, and in the developing of a healthy self-image (see Baker and Cantwell, 1987, and 1985, for a review). This study attempts to explore the relationships among maternal behavior, child language, and location of structural anomaly at an age when language is being acquired. By examining the interaction of mothers and

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of infants with and without speech-related anomalies, we hoped to be able to determine the degree to which specific maternal adaptations are associated with language-related child problems, rather than a more global response to child disability. METHOD

Subjects Subjects were 3 groups of 24-month-old children (ranging from 23 to 29 months), followed in a longitudinal study in our laboratory. Exclusion criteria were an IQ of < 70 on the Stanford-Binet or the Bayley Scales of Infant Development (Mental Scale: Bayley, 1969) and a documented hearing impairment beyond mild or transitory conductive loss. Seven children from an available pool of 86 were excluded based on these criteria. Groups were as follows: 1. The speech-related anomalies group (SRA) included 21 children with either cleft palate (N = 7), cleft lip (N = 6), cleft lip and palate (N = 7), or nasal obstruction (N = 1). 2. The non-speech-related anomaly group (NSRA) included 13 children with various peripheral or facial anomalies unrelated to the speech structures: Goldenhar’s syndrome (N = 2), Vater syndrome (N = 2), deformities of limbs/fingers (N = 5), torticollis (l), ear tags (I), arthrogryposis (l), cranial-facial synostosis (1). 3. The control group included 45 children with no congenital anomalies, recruited on an individual basis. There were no significant group differences in a series of variables known to affect the rate of language acquisition, such as socioeconomic status, age at testing, gender, and birth order (Table 1). All children were free from gross neurological impairment.

Procedure Children and their mothers were videotaped in a laboratory playroom. Sessions involved a half-hour series of unstructured and semistructured situations such as free play with mother, play with a stranger, and cleaning Table 1.

Sample Demographic Characteristics

SES (percenj white-collar) Age (months; days) Gender (percent males) Parity (percent firstborn)

Speech-related (N = 20)

Non-speech-related (N = 13)

Controls (N = 45)

55% 24; 9 50% 30%

53% 23; 25 38% 30%

77% 24; 01 62% 26%

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up the room under mother’s supervision. Interactive measures considered here are all from the free play segment. Following the play session, standardized language and intelligence tests were administered.

Measures Murernal. Minutes 2-7 of the IO-min free-play period of the session were coded using the Maternal Style Scale (Wasserman and Solomon, 1980). Maternal measures are based on internally consistent subscales, coded for each lo-set interval. Descriptions are presented in Table 2. These measures have been found to be stable and to show meaningful developmental and risk-group differences in our previous research (e.g., Wasserman et al., 1985). To determine interrater reliability for the sep-

Table 2.

Observational Child and Maternal Measures Description

Measure Child Representational

play

Distractibility

Object focus

Mother Attention management

Verbal teaching

Physical teaching

Control

Encouragement

Negatives Initiating Responsiveness

The number of intervals in which the child shows pretend play behaviors The proportion of instances in which the child began to carry out maternal initiative, but diverted to something else before completion A composite of number of intervals of continuous play and the number of different actions used on objects

Number of maternal actions that are aimed at directing (when the child is unoccupied) or maintaining the child’s focus (e.g., “Look at all the toys?“) Number of maternal behaviors aimed at communicating about objects, persons, or surroundings through verbal means (e.g., “It’s a blue one.“) Number of maternal behaviors aimed at communicating about objects, persons, or surroundings through nonverbal means (e.g., showing an object) Number of maternal behaviors requiring an action from the child or a redirection of the child’s attention when already focused (e.g., “Go get the dolly.“) Number of behaviors aimed at motivating the child to perform some action or describing the child in positive terms (e.g., “You did that just right”) Number of maternal behaviors indicating refusal or withdrawal from the child (e.g., ignoring child’s request) The number of IO-set intervals in which mother takes the lead in the interaction. The number of IO-set intervals in which mother responds contingently to baby’s bids and/or cues

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arate subscales, two coders independently rated 10 videotapes chosen at random; percent agreements ranged from 78.7% to 98.7%. As an index of nominal scale agreement for each measure, kappa was computed (Cohen, 1960). All kappas exceeded 0.430 except in the case of one lowfrequency subscale (Negatives, K = 0.233). When tested as recommended by Fleiss (1981), all K’s were highly significant (p’s < .OOl). indicating a good degree of interrater agreement beyond chance levels. Infant. In choosing infant measures for examination, we selected, from a larger set investigated in our earlier research (Wasserman, 1983; Wasserman et al., 1985) those with anticipated relevance to cognitive linguistic development. From the same 5-min play period, we coded the number of IO-see intervals in which the child engaged in Representational Play as an indicator of emerging mental representation (see Belsky and Most, 1981). As outlined in Table 2, we also examined Object Focus and Distractibility as measures of attentional capacity. Further details of the system for scoring maternal and infant behavior are available elsewhere (Wasserman, Green, and Allen, 1983; Wasserman et al., 1985). On 10 subject visits drawn at random, agreement on the entire set of child measures ranged between 80% and 90%, with kappas between .37 and .70 (all significant at p = .OOOl). For the single continuous variable, Object Focus, interrater correlation equaled .85. Language development was tested using the Zimmerman Preschool Language Scale verbal ability quotient (VAQ: Zimmerman, Steiner, and Pond, 1979), which provides a ratio quotient for expressive verbal ability.’ IQ was assessed by the Stanford-Binet (Form L-M, 1972 norms).2

Data Analysis Group differences were examined by means of one-way ANOVAs (SPSSX). Post-hoc tests (Sheffe’s) examined specific group contrasts where appropriate. Associations among the different sets of measures were assessed by Pearson correlations (SPSS-X), separately for the three groups.

’ Fifteen normal, 10 SRA, and 6 NSRA children were unavailable for standardized language testing, but child language transcripts and MLUs for these cases had been previously compiled from the videotape sessions (Seidman et al., 1986). For those cases only, we derived an expressive language score by converting MLV first into MLV Age, using a regression formula (Miller, Klee, Paul, and Chapman, 1981), then into an MLU Quotient bydividing MLV Age by chronological age. ’ Two normal children and 10 anomalies children lacked the prerequisite word combinations and were tested using the Bayley Scales of Infant Development (MD1 only).

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ANOMALIES

RESULTS Group DiBerences Table 3 presents the results of the group comparisons. While all three groups performed within normal range, there was a significant effect of risk group for both IQ and verbal ability. Post-hoc testing revealed that, for both measures, only SRA children showed significant cognitive and language delays relative to controls, and a tendency to engage in less Representational Play. No group differences appeared in Distractibility or in Object Focus. Mothers of both groups of handicapped children used significantly more Attention Management than did mothers of controls. In addition, mothers of SRA children showed significantly elevated scores for Physical Teaching and Initiating, while NSRA mothers did not. There were no significant group differences in Verbal Teaching, in Control, or in the other maternal measures. In summary, SRA children are more likely to show poorer cognitivelinguistic performance than normal age-mates. Children with other kinds Table 3. and Test

Means and Standard Deviations (in Parentheses) for Observational Results’ Speechrelated (N = 20)

Measures

Non-speechrelated (N = 13)

F

Controls (N = 45)

(Risk)

Scheffe

111.07 (20.19) 111.08 (01.62) 1.73 (2.55) .17 (.16) 19.41 (8.20)

4.43b 5.07d ns. n.s. n.s.

3.53’ 3.54’

6.32d n.s. 5.70d n.s. n.s. n.s. 3.11b n.s.

3.53’~’

Child measures

IQ vAQ Representational Distractibility Object focus Maternal

play

90.85 (15.47) 91.19 (13.48) .65 (1.04) .20 (.19) 16.78 (3.03)

101.83 (16.85) 101.83 (27.90) 1.92 (2.40) .21 (.16) 18.81 (4.04)

measures

Attention management Verbal teaching Physical teaching Control Encouragement Negatives Initiating Responsiveness

10.55 26.55 12.45 8.45 4.85 .65 19.41 4.10

(5.03) (9.86) (6.00) (5.70) (4.70) (1.22) (5.68) (3.20)

11.00 21.17 11.42 8.25 4.92 .50 18.00 4.58

(4.61) (11.08) (5.55) (5.56) (4.91) (1.00) (6.69) (4.57)

6.91 24.18 8.27 5.53 3.56 1.24 16.20 5.44

a As indicated in the text, not all data are available for all subjects. b p < .05. CSRAZC. dp < .Ol. ‘NSRA#C.

(4.48) (9.83) (4.20) (5.10) (2.58) (4.34) (5.77) (3.88)

3.53’

3.53’

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of anomalies do not differ from controls on the measures employed here, although generally their performance is somewhere in between that of controls and that of SRA children. Mothers of both groups of children with anomalies are more likely to work to manage their attention; in addition, SRA mothers employ more Physical Teaching and Initiating. Associitions

among Variables

Intelligence. IQ was significantly related to a range of child and maternal measures. With more intelligent children, control mothers used more Verbal Teaching (r (43) = .43, p = .002), and less Attention Management (r (43) = - .28, p = .03) and Initiating (r (43) = .28, p = .03); since there were 8 possible associations between maternal behavior and child IQ, this substantially exceeds the number of associations one might expect by chance. For both groups of at-risk children, fewer associations appeared between IQ and maternal behavior. With more intelligent children, SRA mothers used more Encouragement (r (18) = .58, p = .004). No significant correlations between IQ and maternal variables were found for the NSRA group. Two-year IQ was significantly correlated with expressive verbal ability in all three groups (r (14) = .58, p = .00!9; r (10) = .84, p = .OOO;r (35) = .54, p = .OOO,for SRA, NSRA, and controls, respectively). For the NSRA group, intelligence was also correlated with representational play (r (10) = .80, p = .OOl). Once again, given that there are four possible associations between child IQ and other aspects of child behavior for each group, these associations exceed what we might expect by chance. Verbal Ability. There were fewer significant associations between expressive verbal ability and either maternal or child behavior. Mothers of those SRA children with the best expressive skills used less Physical Teaching (r (14) = - .47, p = .03). Mothers of high verbal-ability controls used less Control (r (37) = - .3 1, p = .03). NSRA mothers behaved more like controls than like SRA mothers: the association between VAQ and Control for NSRA dyads, while not significant, was in the same direction and of similar magnitude to that for control dyads (r (10) = - .23, p > . 10). Neither control nor NSRA dyads, in contrast to SRA dyads, showed any substantial association between VAQ and Physical Teaching (both r’s < .15, p’s > .35).

DISCUSSION Results suggest that different patterns of maternal behavior may be related to both the type of congenital anomaly in a child and to any functional disabilities that child may display. Children in this study, in addition to

CHILDREN WITH SPEECH-RELATED ANOMALIES

manifesting a structural disability that involved either the oral apparatus or some other site, also displayed varying degrees of intellectual and linguistic facility. In almost all cases in which group differences were observed, children with speech-related anomalies and their mothers were significantly different from controls, with children with other anomalies (and their mothers) falling midway between these groups. As anticipated, 2-year-olds with speech-related physical anomalies show both language delay and related below-average intellectual functioning. In contrast, children whose anomalies do not involve the speech apparatus do not. Because of the substantial overlap at this age between intelligence measures and language measures, it is not clear whether these findings represent a global deficit for SRA children, or whether problems are confined to language functioning. Nonetheless, clear differences appear between groups in cognitive-linguistic functioning. How can we best understand these differences? The presence of cognitive-linguistic delay in one group of handicapped children, and its absence in another, suggests that the reported deficit is not a result of some general environmental response to handicap status in itself. This suggestion is further supported by the findings of differential maternal interactive behavior across infant risk groups. Thus, mothers of children with speech-related anomalies (whose children do, indeed, show language delays) are more likely to take charge of the flow of their free-play interactions with their children. That is, they are more initiating and make use of specific techniques that control the pacing and focus of the child’s attention (Physical Teaching and AttentionManagement). However, they do not increase their level of Verbal Teaching in an attempt to compensate for poorer child language performance. Even within the SRA group, children who have more language have mothers who use less Physical Teaching during free play but who do not show increased Verbal Teaching. Comparable findings of increased maternal structure and increased use of nonverbal, object-related interacting strategies during play have been reported previously in a wide range of studies of mothers and language-impaired young children (see Snyder, 1984, for a review). In contrast, mothers of children whose anomalies involve nonspeech locations do not appear to differ from mothers of intact children, except in their attempts to focus the child’s attention, in which they resemble SRA mothers. While the phenomenon of increased attention-management may thus be a component of a global pattern of interaction with a disabled child, other adaptations seem more closely related to aspects of child cognitive and language delay. Elsewhere we have argued that, in studying the interactions of mothers and handicapped children, it is most parsimonious to explain the direction

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of effects as proceeding from the child to the mother (cf. Bell, 1977). With such children, aspects of maternal interactive behavior seem best understood as responses to patterns of deficit noted in the child. Maternal interactive behavior appears to be well matched to specific quantitative and qualitative differences in the behavior of the child at risk (Wasserman et al., 1985; Wasserman, Shilansky, and Hahn, 1986). Similarly, in the present study, the differences in maternal behavior that occur with language-delayed SRA children seem best understood as a response to language delay. Moving the focus of the interaction to objects and working hard to keep the child engaged in toy play seem reasonable adaptations to employ if the child is less able to play symbolically, to understand the mother’s statements, or to produce language on his own. Finally, in the present study we have seen that maternal interactive behavior is not global in its response to child handicap. Parental behavior varies as a function of the particular pattern of child disabilities found, with maternal behavior a reaction to both location of a structural anomaly and the actual functional disability. Discussions of parental “reactions” to such children (e.g., Klaus and Kennel, 1976) have tended to oversimplify the nature of those responses by ignoring the specificity that exists. Preparation of this article was supported by grants to the senior author from the National Institute of Mental Health (MH-36492 and MH-39778), the National Foundation/March of Dimes, and the Easter Seals Research Foundation. Data analysis was made possible by a Mental Health Clinical Research Center Grant (MH-30906) from NIMH to NYSPI. The authors express appreciation to Delmina Price for preparing the manuscript, and to the Departments of Genetics and Plastic and Orthopedic Surgery at Columbia-Presbyterian, Montetiore, and New York University Medical Centers for assistance in subject recruitment.

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