Effect of parent interaction on language development in children

Introduction Language development among children is a complex process that is foundational to their communication skills, school readiness, and achievements. Parents are the primary people engaging and interacting with infants on a consistent basis; consequently, parents are seen as a child’s first teacher. Positive quality of parent–child interactions and increased verbal responsiveness are essential in shaping a child’s literacy environment and language development. The first 3 years are the most intensive, as this is when the brain rapidly develops and is able to learn new information. If this critical period passes without adequate interaction and opportunity for language development, it will become more challenging to accomplish the milestones as the child develops [1,2]. Parental perceptions are essential to the development of parent–child interactions. Understanding the ways in which parents perceive language development, diffi culties, and intervention would allow speech and language therapists to be more sensitive to the needs of the families with whom they work, and would reduce the likelihood of parents misconstruing the purposes and processes involved in therapy. Th is, in turn, may aff ect uptake of, attendance to, participation in, and satisfaction with therapy [3]. Crosscultural variations in child-rearing practices have been well documented. However, limited data are available with regard to the opinion of parents or speech and language therapists on the nature of language development, diffi culties, and interventions [4].


Introduction
Language development among children is a complex process that is foundational to their communication skills, school readiness, and achievements. Parents are the primary people engaging and interacting with infants on a consistent basis; consequently, parents are seen as a child's first teacher. Positive quality of parent-child interactions and increased verbal responsiveness are essential in shaping a child's literacy environment and language development. The first 3 years are the most intensive, as this is when the brain rapidly develops and is able to learn new information. If this critical period passes without adequate interaction and opportunity for language development, it will become more challenging to accomplish the milestones as the child develops [1,2].
Parental perceptions are essential to the development of parent-child interactions. Understanding the ways in which parents perceive language development, diffi culties, and intervention would allow speech and language therapists to be more sensitive to the needs of the families with whom they work, and would reduce the likelihood of parents misconstruing the purposes and processes involved in therapy. Th is, in turn, may aff ect uptake of, attendance to, participation in, and satisfaction with therapy [3]. Crosscultural variations in child-rearing practices have been well documented. However, limited data are available with regard to the opinion of parents or speech and language therapists on the nature of language development, diffi culties, and interventions [4].
Language and conceptual development involve many factors; socioeconomic status (SES) is considered

Effect of parent interaction on language development in children
Rasha Farouk Safwat, Aya R. Sheikhany

Background
Positive quality of parent-child interactions is essential for shaping a child's language development. Many individual factors have been found to be associated with language development, but their interaction with each other and their relation with language development is still less clear.

Objective
The aim of the study was to evaluate whether the quantity and quality of parent-child interactions contribute to language development and to detect the factors that would in uence this interaction in different socioeconomic standards to consider them while planning the therapy program.

Patients and methods
This study included 100 parents and their children; they were attendants at the Phoniatric Unit of Kasr Al Aini Hospital, complaining of delayed language development in their children. Parents included 60 women and 40 men; their ages ranged between 21 and 43 years, with a mean age of 32.7 ± 5.5 years. The age range of the children was 27-49 months, with a mean of 38 ± 5.7 months. The parents were asked to ll in a questionnaire, which was divided into two sections (A and B). Section A described the parents' communicative behavior and section B included basic information on the parents and their beliefs about causes and management of delayed language development. Socioeconomic status of the parents was assessed. Children included in the study were subjected to the protocol of language assessment.
was assessed according to the scale developed by El-Gilanny et al. [9], which measured six domains: a score was assigned for each item and the total score was calculated (Appendix 2). At the end of the interview, parents were instructed on how to interact with their child to facilitate language acquisition; they were then asked for their opinion on whether they would be able to implement those interactions.
Children included in the study were subjected to the protocol of language assessment applied at Kasr Al Aini [10] to confi rm the diagnosis, and they were selected if they had a Stanford-Binet test of intelligence score of 89 or higher. Children with a history of hearing impairment, those with psychiatric, neurological, or developmental disorders, and those with severe medical conditions were excluded from the study.

Statistical analysis
Data analysis was carried out usin g SPSS software program for Windows, version 21 (SPSS Inc., Chicago, Illinois, USA). Data were expressed as number and percentage for qualitative variables and mean and SD for quantitative variables. Cronbach's for reliability was calculated for questionnaire consistency. Pearson's or Spearman's correlation coeffi cients were calculated for the association of diff erent quantitative variables. Standard linear regression analysis was carried out to explore the signifi cant predictors of total language age. P-values less than 0.05 were considered signifi cant.

Results
Th is study included 100 parents and their children. Th e frequency distribution of parent-child interactions is shown in Table 1. Mean, SD, range, and interquartile range (IQR) for the total interaction % score are shown in Table 3. Interaction % score was classifi ed into insuffi cient (<50%) and suffi cient (³50%). Results show that 93 (93%) of the included parents had insuffi cient interactions and seven (7%) had suffi cient interactions. Table 2 shows parents knowledge about language development and intervention. Mean, SD, range, and IQR for the total knowledge % score are shown in Table 3. Total knowledge % score was classifi ed into inadequate (<50%), adequate (50-70%), and excellent (<70%). It was found that 18 (18%) of the included parents had inadequate knowledge, 78 (78%) had adequate knowledge, and four (4%) had excellent knowledge.
Mean, SD, range, and IQR for SES are shown in Table 3. Th e total SES score was 61; hence, the score of two cutoff points was selected to categorize SES into three levels (low, intermediate, a nd high SES). Th e two one of the many important factors linked to language development as it encapsulates diff erences in parental beliefs, attitudes, motivations, and behaviors. A vast body of research has been dedicated to understanding the social-contextual factors that support children's early language development and learning. Many individual factors have been found to be associated with language development, but their interaction with each other and their relationship with language development is still unclear [5][6][7][8].
It is hypothesized that diff erent parent-child interaction patterns could play a major role in holding back or facilitating a child's language development. To verify this hypothesis, an analysis of parent-child interactions was designed. Th e aim of the present study was to assess whether the quantity and quality of parent-child interactions contribute to language development and to detect the factors that would infl uence this interaction in diff erent socioeconomic standards, to consider them while planning the therapy program.

Patients and methods
Th is study included 100 parents and their children; they were attendants at the Phoniatric Unit of Kasr Al Aini Hospital, with complaints of delayed language development in their children. Th e parents included 60 women and 40 men; their ages ranged between 21 and 43 years, with a mean age of 32.7 ± 5.5 years. Th e age range of the children was 27-49 months, with a mean age of 38 ± 5.7 months. Th is study was conducted from March 2013 until January 2014. Among the included participants, 51 (51%) parents were consulting a physician for the fi rst time, 26 (26%) had consulted a clinician previously and had come for a second opinion for their child's problem, and 23 (23%) of the included children had undergone language stimulation sessions for a duration of 1-3 months, with a mean of 2.2 months.
Written consent was obtained from the parents before the study; parents were then asked to fi ll in a questionnaire, which was divided into two sections (A and B). Section A elicited the parents' communicative behavior (i.e. the quality and quantity of parental interactions with their children). Quality was detected in terms of the use of various strategies by parents that would enhance their child's language acquisition. Th e frequency of interactions was measured using a three-point scale (never, sometimes, most of the time). Section B included basic information on the parents and their opinions on the causes and management of delayed language development (Appendix 1). Th e socioeconomic status of the parents

Number of earning family members: (3)
One member Two members 3 members 1 2 3

Home sanitation domain
Crowing index: (number of family members divided by number of rooms): (1) 1 person per room >1 person per room 1 0

Income from all sources: (3)
In debt Just meet routine expenses Meet routine expenses and emergencies Able to save/invest money Family receives governmental support: (1) points were 20 and 40; accordingly, SES was classifi ed into three categories as follows: (1) 20 or lower (low SES)  Table 4 shows a signifi cant association between the knowledge % score, the interaction % score, and the language age.
Multivariate analysis was carried out to explore the variables aff ecting the total language age (SES, total interaction score, total knowledge score). SES was  found to be a signifi cant predictor of a child's language age (P = 0.002).

Discussion
The primary purpose of this study was to understand the relationship between parent-child interaction and language acquisition; a secondary intent was to determine the presence of any possible relationship between socioeconomic standard and the parents' communicative behavior. Results indicate that the majority of the included parents did not use effective methods to foster their child's language acquisition, although their knowledge about language development and intervention was adequate, and this was associated with the child's language outcome among the included socioeconomic standards.
Th e present fi ndings reveal that the quality and quantity of parent-child interactions in the majority of the studied sample (93%) were defective in providing an enriching and stimulating environment necessary for language acquisition, and this was refl ected in the signifi cant positive association between the interaction score % and a child' total language age (Table 4). Several studies found similar fi ndings [11][12][13][14][15]. It was evident   from the majority of parent reports that the parents failed to create an ideal setting while interacting with their child, and their communication style and responses to their children were poor. Mothers reported that their verbal interactions mainly included asking questions, corrections, and instructions. A large number of parents (60%) reported that they were not actively involved with their child, who was left to play alone or with other siblings; they were less likely to consider that children learn important things while playing and emphasized the role of direct teaching and imitating others. Sixty-fi ve percent of the included parents reported that they participated in routine activities with their children. Raikes et al. [16] reported that frequent and consistent participation in routine activities provides young children with a familiar structure for interpreting others' behavior and language, helps them anticipate the temporal sequencing of events, provides rich information about objects and events in the environment, and allows them to draw inferences from new experiences.
A possible explanation for the relationship between quality of interaction and language outcome was off ered by Umek et al. [17]; in their study, they found that the quality of verbal interactions between a parent and child during reading and play-time stimulates the child's language development, improves his/her vocabulary skills and reading comprehension, and increases his/her school readiness. Parents who contingently respond to their children's verbal initiatives tend to have children with advanced phonological awareness and story comprehension skills. Th e role of maternal interaction with their child was emphasized by several studies [18-20], they recommended frequent maternal labeling, expansion of child's utterances, speaking to the child in a grammatically correct fashion, and interactive story telling.
Th e present data provide evidence that parent interactions are associated with language outcome; however, it was not obvious whether the quality or quantity of parent interaction was a predictor of language development. Several studies emphasize that the quality of the interactions may be a better predictor of achievement scores than quantity [7,12,21,22]. Morales et al. [23] reported that following the child's lead and maintaining joint attention were more eff ective in increasing a child's vocabulary than high maternal vocabulary alone. Westerlund and Lagerberg [20] found that parents who were warm and accepting while interacting with their child had interactions that involved follow through (reciprocity) and sustained engagement (synchrony) on the part of the child.
An unexpected fi nding was that the majority of the included parents (78%) had adequate information about language development and intervention, and there was a strong positive association between parental knowledge and interaction scores and a weaker interaction with language scores (Table 4). It was noted from parental opinions about the possible cause of delay in their child's language development that 51% considered much of a child's language learning to be incidental and reported that the home environment had a powerful infl uence in enhancing or hindering language acquisition. Peacey [24] reported a similar fi nding. Others suggested that the problem was due to hereditary factors, diffi culties within the family, lack of time to spend with the child, inconsistency in the implementation of strategies that would facilitate language acquisition, and diffi culty in dealing with stubborn or noncompliant children. Few parents were uncertain or confused about the reasons for delayed language development, and others blamed themselves because they felt that these problems refl ected badly on their parenting abilities. Parental concerns were consistent with the fi nding of Ayoub et al. [25]; they suggested that children with lower language skills may be more stressful for parents to interact with.
In the current study, it was obvious that parents had diff erent views about the eff ectiveness of interventions; accordingly, their willingness to be involved in the therapy process varied. In this study many parents (61%) considered that the nursery would be the main solution to enhance their child's social and communication problem. Th irty-six percent suggested that watching television would be eff ective, as they believed that their children needed to 'see and hear more' than the immediate family surroundings to acquire new vocabulary. A minority (25%) thought that medication would help increase their child's concentration, whereas others took language development for granted and were waiting for spontaneous recovery given that their child had no organic abnormality. It was also evident that there were discrepancies in the evaluation of the child's problem by parents and clinicians. Few parents reported that their children had received therapy and counseling; however, they failed to make all the recommended linguistic adjustments and/or did not fi nd expected improvement. Th e results of this study added to previous research [26][27][28].
It emerged from some parents' accounts after completion of the questionnaire that they were surprised at the expectation that they would have to take part in treatment and reported that they would not be able to implement the interactions that would enhance their child's language acquisition. Several reasons were given: Some parents reported that they were not convinced that it would work, some claimed that they did not have the necessary skills to communicate eff ectively with their child as they were impatient and wanted a quick response, and some claimed that other family members were not helping. It also seemed that, although some parents were willing to be involved in their child's therapy, they believed that a therapist needed to be involved and to administer the bulk of the therapy. Th e variation in the extent of parental involvement might refl ect the fact that what may be eff ective for one family may be inappropriate for another.
With regard to the eff ect of SES, the present data revealed a strong positive association with total interaction score and to a lesser extent with knowledge score and child's language age; this highlights the impact of socioeconomic factors (Table 4). In agreement with this fi nding, other studies [29,30] found that middle-SES and high-SES parents were more likely to engage in long conversations language development, delay, and intervention. Th e study includes a relatively large sample of families with diff erent socioeconomic levels. It used reliable and valid measures (detailed interviews as well as questionnaires) of parental interaction quality with a verbal outcome measure, and examined the association between socioeconomic variables and outcome.

Limitations
Th e study did not include ratings from direct observation of parents with their children; in addition, it was not possible to identify the contributions solely from each parent interaction and diff erent language outcomes.

Conclusion
(1) Parent-child interaction is an important variable in language development of a child.
(2) Future research should focus on increasing the quality of these interactions; this would involve providing parents with education aimed at increasing the sophistication of their language skills. (3) Our study highlights the need to understand the constituents of an appropriate environment for a child. Phoniatricians should investigate and take into account socioeconomic variables to work more successfully with families from a wide range of backgroun ds.
with their children, verbalized more to their children, participated more actively in their child's play, were more didactic, responsive, and elaborative, and practiced fe wer penalizing behaviors during interaction.
In the current study, the diff erences between fi nancial status, level of parental education, occupation, and number of children in the included families might have contributed to the diff erent outcomes. A small association was found between poverty and diff erences in parent talk and language delay. It is assumed that parents who are preoccupied with the stress of everyday life may perceive the needs of their child as an additional and overwhelming stress and fail to establish a reciprocal or emotional relationship with their child. Poverty might infl uence the quality of environmental support, the availability of material resources, and the provision of age-appropriate earning materials, adequate nutrition, and medical care. Data on the aspect(s) of poverty that are causally related to language delay are incomplete [22,25,31]. Th e present data also show that parents' occupations and education were more signifi cantly associated with the outcome than their economic status (Table 4). Education permits diff erent life experiences, which might infl uence parental values and child-rearing practices, and this was evident in the signifi cant positive association between parents' access to health information and their knowledge and interaction scores. Several studies found similar results [6,14,15,30,32]. Ruhm [33] and Pancsofar et al. [34] suggested that maternal employment can negatively impact the quality of parenting interactions because of less time spent by the mothers with their children.
Th e present data reveal a signifi cant positive association between the home sanitation domain (measured by crowding index) and interaction scores. It was expected that a large number of siblings would act as a barrier to responsiveness of parents to their children. Evidence from previous studies suggests poor cognitive, language, social, and behavioral outcomes [3,35,36].
SES has been shown to be a signifi cant predictor of child language outcomes. However, it is possible that even in the presence of demographic-related barriers, a child's language skills can be improved if parenting behaviors are enhanced. As demographic characteristics are rather stable and present a challenge for change, parental behaviors appear to be a critical point of intervention for a child's language acquisition.

Strengths and limitations Strengths
Th e interpretation of parental accounts enriches our understanding of parents' perspectives about