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Developing Relationships between Language and Behaviour in Preschool Children from the Early Language in Victoria Study: Implications for Intervention

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Title: Developing Relationships between Language and Behaviour in Preschool Children from the Early Language in Victoria Study: Implications for Intervention
Language: English
Authors: Bretherton, Lesley, Prior, Margot, Bavin, Edith, Cini, Eileen, Eadie, Patricia, Reilly, Sheena
Source: Emotional & Behavioural Difficulties. 2014 19(1):7-27.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 21
Publication Date: 2014
Document Type: Journal Articles
Reports - Research
Descriptors: Social Development, Emotional Development, Mothers, Parent Child Relationship, Child Language, Verbal Ability, Preschool Children, Foreign Countries, Educational Attainment, Vocabulary, Role, Gender Differences, Intelligence Quotient, Language Impairments, Behavior Problems, Correlation, Questionnaires, Emotional Disturbances, Socioeconomic Status, Longitudinal Studies, Epidemiology, Hyperactivity, Anxiety, At Risk Persons, Peer Relationship, Check Lists, Toddlers, Nonverbal Ability, Statistical Analysis, Expressive Language, Measures (Individuals), Language Skills
Geographic Terms: Australia
Assessment and Survey Identifiers: Communication and Symbolic Behavior Scales, Clinical Evaluation of Language Fundamentals, Strengths and Difficulties Questionnaire
DOI: 10.1080/13632752.2013.854956
ISSN: 1363-2752
Abstract: Following a biopsychosocial model, the study investigated the role of child factors (gender, IQ), maternal factors (psychological distress, maternal education and vocabulary, maternal distress) and environmental factors (SES) in the relationship between language impairment and behaviour problems in preschool children. Participants were drawn from the Early Language in Victoria Study (ELVS) a prospective, longitudinal study examining the epidemiology and natural history of language impairment. The study reports on 1257 participants from the ELVS who completed questionnaires at 2 and 4 years and also completed face-to-face assessments at 4 years of age. Information was collected on child language, non-verbal cognition and social-emotional development; maternal vocabulary, maternal psychological distress and parent--child interaction; and SES. This study showed that language impairment is specifically associated with hyperactivity and peer problems but not anxiety and conduct problems at the preschool stage. Children with language impairment were at a higher risk for clinical levels of 'abnormal' behaviour which could lead to a psychiatric diagnosis than typically developing children. An examination of biopsychosocial variables associated with language and behaviour revealed that although language ability was a predictor of behaviour at both 2 years and 4 years of age, maternal distress was a stronger predictor of behaviour, with the association stronger for boys than for girls. Early intervention directed to children, especially boys, with language impairment deserves further attention, especially during the preschool period, in order to ameliorate the impact of language impairment on peer relationships and disruptive behaviour in later school years.
Abstractor: As Provided
Number of References: 74
Entry Date: 2014
Accession Number: EJ1029094
Database: ERIC
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  Value: <anid>AN0093305042;grv01mar.14;2019Apr01.12:21;v2.2.500</anid> <title id="AN0093305042-1">Developing relationships between language and behaviour in preschool children from the Early Language in Victoria Study: implications for intervention. </title> <p>Following a biopsychosocial model, the study investigated the role of child factors (gender, IQ), maternal factors (psychological distress, maternal education and vocabulary, maternal distress) and environmental factors (SES) in the relationship between language impairment and behaviour problems in preschool children. Participants were drawn from the Early Language in Victoria Study (ELVS) a prospective, longitudinal study examining the epidemiology and natural history of language impairment. The study reports on 1257 participants from the ELVS who completed questionnaires at 2 and 4 years and also completed face-to-face assessments at 4 years of age. Information was collected on child language, non-verbal cognition and social-emotional development; maternal vocabulary, maternal psychological distress and parent–child interaction; and SES. This study showed that language impairment is specifically associated with hyperactivity and peer problems but not anxiety and conduct problems at the preschool stage. Children with language impairment were at a higher risk for clinical levels of 'abnormal' behaviour which could lead to a psychiatric diagnosis than typically developing children. An examination of biopsychosocial variables associated with language and behaviour revealed that although language ability was a predictor of behaviour at both 2 years and 4 years of age, maternal distress was a stronger predictor of behaviour, with the association stronger for boys than for girls. Early intervention directed to children, especially boys, with language impairment deserves further attention, especially during the preschool period, in order to ameliorate the impact of language impairment on peer relationships and disruptive behaviour in later school years.</p> <p>Keywords: behaviour problems; emotional problems; language development; longitudinal study; preschool children</p> <hd id="AN0093305042-2">Background</hd> <p>Children seem to be hardwired to acquire language in a rapid, developmentally defined sequence. There can be wide variability in the growth of young children's language in typically developing children. Most children achieve age-appropriate language proficiency within an expected time frame but a significant number of children continue to show persistent language delay (Bishop and Leonard [<reflink idref="bib1" id="ref1">1</reflink>]; Fenson et al. [<reflink idref="bib1" id="ref2">1</reflink>]). Language delay is most common in young children, with Whitehurst and Fischel ([<reflink idref="bib68" id="ref3">68</reflink>]) reporting a prevalence of 9–17% in 2-year-olds. The Early Language in Victoria Study (ELVS), a large community-based study, found that 17.2% of 4-year-olds met criteria for specific language impairment (SLI) (Reilly et al. [<reflink idref="bib1" id="ref4">1</reflink>]), while Tomblin and colleagues reported a prevalence of language impairment of 7.4% in 5-year-old children (Tomblin et al. [<reflink idref="bib68" id="ref5">68</reflink>]). Beitchman and colleagues report a prevalence of language impairment of around 3–6% in early adolescence (Beitchman et al. [<reflink idref="bib1" id="ref6">1</reflink>]). The higher prevalence in young children could be due to normal variations in early language development, or to the reduced reliability of language tests for the preschool age group, or a combination of both. For example, many late talkers go on to develop normal language (Bishop et al. [<reflink idref="bib1" id="ref7">1</reflink>]; Petruccelli, Bavin, and Bretherton [<reflink idref="bib1" id="ref8">1</reflink>]).</p> <p>Because language is an essential communicative tool, it plays a critical role in social, emotional and academic development (Beitchman et al. [<reflink idref="bib1" id="ref9">1</reflink>]; Records, Tomblin, and Freese [<reflink idref="bib1" id="ref10">1</reflink>]; Tomblin et al. [<reflink idref="bib68" id="ref11">68</reflink>]; Young et al. [<reflink idref="bib68" id="ref12">68</reflink>]). Successful development of language skills provides children with a symbolic means for managing their environment to meet their personal needs from infancy onwards. Young children with impaired or delayed language are, therefore, at risk of concurrent or later difficulties in engaging in successful social relationships and in regulating their behaviour and emotions (Beitchman [<reflink idref="bib1" id="ref13">1</reflink>]; Cohen [<reflink idref="bib1" id="ref14">1</reflink>]; Gallagher [<reflink idref="bib1" id="ref15">1</reflink>]).</p> <p>There is some evidence indicating that language impairment is associated with a higher risk of psychosocial morbidity in young children, adolescents and adults. Botting and Conti-Ramsden ([<reflink idref="bib1" id="ref16">1</reflink>]) recruited 242 children aged between 6;6 and 7;9 years from specialist units for language-impaired children and found co-morbidity between language impairments and behaviour difficulties as high as 53%. Others also report that young children with language impairment have elevated rates of ADHD (attention deficit hyperactivity disorder) and anxiety problems, as well as poorer social skills and peer relationships than children with speech articulation problems alone, or than children with typical language development (e.g. Baker and Cantwell [<reflink idref="bib1" id="ref17">1</reflink>]; Benasich, Curtiss, and Tallal [<reflink idref="bib1" id="ref18">1</reflink>]; Jerome et al. [<reflink idref="bib1" id="ref19">1</reflink>]; Lindsay, Dockrell, and Strand [<reflink idref="bib1" id="ref20">1</reflink>]). Conversely, research has also revealed that children who primarily present with disruptive behaviour, peer relationship problems, low self-esteem, and/or anxiety are at risk for higher levels of language impairment than typically developing children (Cohen et al. [<reflink idref="bib1" id="ref21">1</reflink>]; Nelson, Benner, and Cheney [<reflink idref="bib1" id="ref22">1</reflink>]; Ripley and Yuill [<reflink idref="bib1" id="ref23">1</reflink>]).</p> <p>In the preschool period, McCabe and Meller ([<reflink idref="bib1" id="ref24">1</reflink>]) and McCabe ([<reflink idref="bib1" id="ref25">1</reflink>]) report that speech- and language-impaired children (mean age 4 years) have more social and behavioural difficulties than their non-impaired peers, with effect sizes particularly strong on teacher-rated indices relating to task orientation, dependency, egotism and aggression, placing them at a disadvantage in terms of learning and consolidating socially competent behaviours. Stanton-Chapman et al. ([<reflink idref="bib1" id="ref26">1</reflink>]) compared 45 preschoolers with SLI (aged between 4 and 5 years) to 53 children with typically developing language and found that by parent rating, the language-impaired preschoolers were lower on ratings of self-control than typically developing children. The preschoolers with language impairment were also rated lower on cooperation, assertion and responsibility, suggesting that language impairment is strongly associated with social development (Stanton-Chapman et al. [<reflink idref="bib1" id="ref27">1</reflink>]). In terms of behaviour, Stanton-Chapman et al. ([<reflink idref="bib1" id="ref28">1</reflink>]) found higher rates of internalizing behaviours (withdrawal, inhibition and anxiety) in the language-impaired preschoolers but rates of externalizing behaviour problems (aggression) did not differ from those of typically developing children. Despite reports that preschool children with language impairment have more emotional and behavioural difficulties than children with typical language development, information on the specific contribution of language development on behavioural outcomes in the preschool age group is generally lacking.</p> <p>Dodge and Pettit's (2003) biopsychosocial model, which incorporates multiple layers of influence at the intrapersonal (e.g. gender, age, IQ), interpersonal (e.g. parenting, peer relationships) and environmental (e.g. SES) levels is a useful model when considering the association between language and behaviour in the preschool period. Empirical research in this area has identified specific within-child factors, interpersonal and environmental factors associated with the development of language and the persistence of behaviour and emotional problems. At the child level, clear gender differences in the rate and severity of behaviour problems emerge by around 4 years of age. Boys exhibit a higher proportion of externalizing behaviour problems than girls (Keenan and Shaw [<reflink idref="bib1" id="ref29">1</reflink>]; Loeber et al. [<reflink idref="bib1" id="ref30">1</reflink>]; Loeber and Hay [<reflink idref="bib1" id="ref31">1</reflink>]) and this proportion increases considerably by school entry (Offord et al. [<reflink idref="bib1" id="ref32">1</reflink>]). In contrast, the rate of internalizing problems remains constant across gender, at least to middle childhood. Male gender is also associated with language impairment; for example, Reilly et al. ([<reflink idref="bib1" id="ref33">1</reflink>]) reported that male gender was associated with delayed language at 2 years of age and impaired language at 4 years of age in ELVS children.</p> <p>At the interpersonal level, parenting ability and maternal stress as well as maternal education and vocabulary have all been implicated in language and behaviour development. The parent–child relationship is regarded as integral for later psychological adjustment and several aspects of parenting behaviour and stress, particularly in relation to mothers, have been linked with childhood behaviour and language development (Burt et al. [<reflink idref="bib1" id="ref34">1</reflink>]). A longitudinal population-based study of infants and preschoolers, designed to identify the early childhood aetiology of internalizing and externalizing behaviours found that up to 3 years of age, maternal stress and negative parenting consistently and cumulatively predicted both externalizing and internalizing problems (Bayer et al. [<reflink idref="bib1" id="ref35">1</reflink>]). Noel, Peterson, and Jesso ([<reflink idref="bib1" id="ref36">1</reflink>]) investigated the effect of parenting and temperament on language development in low socio-economic status (SES) preschoolers. Their study on children aged between 2 and 10 years showed that parenting stress and child temperament were associated with children's oral language skills: parenting stress was associated with children's receptive and expressive vocabulary, while children rated high on emotionality had poorer receptive vocabulary skills. Bayer et al.'s findings suggest that parenting stress and negative parenting may mediate parenting behaviour and thus the quality of parent–child interactions. There is also evidence that maternal depression is related to both externalizing and internalizing problems in children and adolescents (Beardslee, Versage, and Gladstone [<reflink idref="bib1" id="ref37">1</reflink>]; Frye and Garber [<reflink idref="bib1" id="ref38">1</reflink>]; Goodman et al. [<reflink idref="bib1" id="ref39">1</reflink>]). Stein, Malmberg, Sylva, Barnes, Leach, and the Families, Children and Child Care Study team (FCCC [<reflink idref="bib1" id="ref40">1</reflink>]) showed, through structural equation modelling, that maternal depression in the postnatal period, but not at 36 months, was associated with poorer child language development. However, this association was indirect via the negative effects of depression on the quality of caregiving. In addition, the adverse effects of depression on caregiving were greater for socio-economically disadvantaged families (Stein et al. [<reflink idref="bib1" id="ref41">1</reflink>]). In a study by Dollaghan et al. ([<reflink idref="bib1" id="ref42">1</reflink>]), significant trends between higher maternal education and better performance on four of five measures of spontaneous speech and language (performance on a consonant articulation task was not statistically significant) were evident in a sample of 240 3-year-old children.</p> <p>At the environmental level, family socio-economic status has been implicated as a risk factor in the development of emotional and behaviour difficulties, especially disruptive behaviours (Burke, Loeber, and Birmaher [<reflink idref="bib1" id="ref43">1</reflink>]; Feldman et al. [<reflink idref="bib1" id="ref44">1</reflink>]; McGee and Williams [<reflink idref="bib1" id="ref45">1</reflink>]). Keiley et al. ([<reflink idref="bib1" id="ref46">1</reflink>]) found kindergarten-aged children from a lower SES had higher levels of externalizing behaviour problems by parent and teacher report, and higher levels of internalizing problems by teacher report. It is likely that this association is also moderated by differences in parenting practices between higher and lower SES parents (Patterson, De Baryshe, and Ramsey [<reflink idref="bib1" id="ref47">1</reflink>]). SES is also a known predictor of language acquisition in childhood (Hoff [<reflink idref="bib1" id="ref48">1</reflink>]; Hoff and Tian [<reflink idref="bib1" id="ref49">1</reflink>]). Children from lower SES families have been shown to develop language more slowly and have lower rates of vocabulary acquisition during their first three years compared with children from higher SES families (Hoff [<reflink idref="bib1" id="ref50">1</reflink>]; Lacroix et al. [<reflink idref="bib1" id="ref51">1</reflink>]), although this association may be moderated by the amount of time parents spend talking with their children (Hart and Risley [<reflink idref="bib1" id="ref52">1</reflink>]).</p> <p>Given the importance of language, social skills and behavioural competence in relation to school readiness and for children's later successful psychosocial adjustment (Meisels [<reflink idref="bib1" id="ref53">1</reflink>]; Prior, Bavin, and Ong [<reflink idref="bib1" id="ref54">1</reflink>]; Stanton-Chapman et al. [<reflink idref="bib1" id="ref55">1</reflink>]), it is timely for research to focus on the specific contributions impaired language might make to social, emotional and behavioural characteristics of preschoolers. By simultaneously controlling for other factors known to influence this association, a clearer picture of the impact of language on behaviour outcomes can be obtained.</p> <p>The Early Language in Victoria Study provides a unique opportunity to concurrently examine the contributions of predictors of both language impairment and socio/emotional problems in a large community sample of preschool children. Following a biopsychosocial model, the study will investigate the role of child factors (gender, IQ), maternal factors (psychological distress, maternal education and vocabulary, maternal distress) and environmental factors (SES) in the relationship between language impairment and behaviour problems in preschool children.</p> <hd id="AN0093305042-3">Method</hd> <p></p> <hd id="AN0093305042-4">Participants</hd> <p>This study reports on 1257 participants from the ELVS. Primary caregivers completed questionnaires when their children were 2 and 4 years of age, and children completed face-to-face assessments at 4 years of age. At about the time of the child's fourth birthday, trained researchers conducted face-to-face assessments with each child, including administration of standardized tests for speech, language and non-verbal cognition. Only measures pertinent to the present study are reported here.</p> <p>Infants were recruited from six of Melbourne's metropolitan local government areas (LGAs), using the Socio-Economic Index for Areas (SEIFA). The SEIFA is a product developed by the Australian Bureau of statistics, which is based on a five-yearly census, and ranks areas in Australia according to relative socio-economic advantage and disadvantage (Australian Bureau of Statistics [<reflink idref="bib1" id="ref56">1</reflink>]). Thirty-one LGAs in Victoria, Australia, were stratified into three tiers and we then selected two non-contiguous LGAs from each tier to ensure we sampled from geographic areas across the spectrum of disadvantage–advantage. All children aged between 7.5 months and 10 months living in the 6 LGAs during the recruitment phase were targeted for the study, unless they had developmental delay, cerebral palsy or other serious disability, or if their parents did not speak and understand English well enough to participate. Between September 2003 and April 2004, study participants were recruited through the maternal and child health program provided by the Victorian government, which directly services approximately 98% of newborn infants and their families, with about 82% of families reporting in for check-ups at around eight months of age. More participants were recruited at eight-months hearing-screening sessions. Maternal and child health nurses were asked to approach parents of all infants attending for their eight-months visit. Following some publicity in local newspapers, interested parents were also able to directly contact the research team.</p> <p>Questionnaires used in the study were written at no more than a School Year Six reading level, and completion by telephone interview was available. The ethics committees of the Royal Children's Hospital (Melbourne) and La Trobe University approved the ELVS, and all parents provided written, informed consent before participation. Detailed information on recruitment, sampling and measures is outlined in Reilly et al. ([<reflink idref="bib1" id="ref57">1</reflink>], [<reflink idref="bib1" id="ref58">1</reflink>], [<reflink idref="bib1" id="ref59">1</reflink>]).</p> <hd id="AN0093305042-5">Child measures</hd> <p></p> <hd id="AN0093305042-6">Child behaviour problems scale at 2 years</hd> <p>Behaviour problems were assessed via parental ratings on an 8-point scale from 'none' (<reflink idref="bib1" id="ref60">1</reflink>) to 'severe' (<reflink idref="bib8" id="ref61">8</reflink>), of eight common problems for the infant/toddler age group (sleep problems, excessive crying, tantrums, excessive shyness, accident prone, underactive, overactive, mood swings) developed by the Australian Temperament Project (ATP). This measure has shown concurrent and predictive validity in studies of temperament and behavioural adjustment in young Australian children (Prior, Sanson, and Oberklaid [<reflink idref="bib1" id="ref62">1</reflink>]).</p> <hd id="AN0093305042-7">Strengths and difficulties questionnaire at 4 years</hd> <p>When the child was 4 years of age, parents completed the Strengths and Difficulties Questionnaire (SDQ; Goodman [<reflink idref="bib1" id="ref63">1</reflink>]) which is a brief, validated, 25-item behavioural screen comprising 5 composites: Emotional Symptoms, Conduct Problems, Hyperactivity, Peer Problems and Prosocial scales. Each item is scored from 0 to 2. A Total Difficulties score (possible range 0 to 40) is generated as the sum of the scores on the 20 items spanning the first 4 sub-scales. The SDQ Total Difficulties score can also be used to determine 'caseness' relating to the risk of diagnosis of a future psychological disorder. Subjects scoring 11 or less are categorized as 'normal', those scoring between 12 and 14 inclusive as 'borderline' and those scoring above 14 as 'abnormal' or at high risk of diagnosis according to the <emph>Diagnostic and Statistical Manual of Mental Disorders</emph>, fourth edition (<emph>DSM IV</emph>; American Psychiatric Association [APA] 1994). The SDQ has a sensitivity of 70–90% for conduct–oppositional disorders, hyperactivity disorders, depression, pervasive developmental disorders, and some anxiety disorders, and has been widely used internationally.</p> <hd id="AN0093305042-8">CSBS infant toddler checklist – gestures at 2 years</hd> <p>The Communication and Symbolic Behavior Scales Developmental Profile (CSBS DP), developed by Wetherby and Prizant ([<reflink idref="bib1" id="ref64">1</reflink>]) is designed to identify different aspects of development in infants and toddlers. The Gestures subscale was used in this analysis as both early ELVS results and a growing body of recent literature suggests that early gesture use is an important predictor of later language development (e.g. Iverson and Goldin-Meadow [<reflink idref="bib1" id="ref65">1</reflink>]; Rowe and Goldin-Meadow [<reflink idref="bib1" id="ref66">1</reflink>]).</p> <hd id="AN0093305042-9">Expressive vocabulary at 2 years</hd> <p>Parents completed the Words and Sentences version of the MacArthur-Bates Communicative Development Inventory (CDI) (Fenson et al. [<reflink idref="bib1" id="ref67">1</reflink>]) when the child was 2 years of age. The CDI Vocabulary Production raw score is a count of the number of words that the child can say (out of a possible 688 words included in the measure). To accommodate differences between American and Australian usage, we received permission (from the authors) to substitute 24 vocabulary items on the Words and Sentences inventory (e.g. 'footpath' for 'sidewalk'). The expressive vocabulary production scores were used in the current analyses as a continuous variable of parent-rated expressive vocabulary. Children were classified as having low expressive vocabulary if their scores were in <10th percentile on the basis of gender-specific normative values (<119 words for girls and <79 words for boys) (Fenson et al. [<reflink idref="bib1" id="ref68">1</reflink>]).</p> <hd id="AN0093305042-10">Language assessment at 4 four years</hd> <p>The Clinical Evaluation of Language Fundamentals – Preschool 2nd Edition – Australian Adaptation (CELF-P2; Wiig, Secord, and Semel [<reflink idref="bib1" id="ref69">1</reflink>]) was used to measure receptive, expressive and core language at 4 years. It consists of these subtests: Sentence Structure, Word Structure, Expressive Vocabulary, Concepts and Following Directions, Recalling Sentences and Basic Concepts. Raw scores and standard scores (Mean = 100; SD = 15) are available for receptive language and expressive language. Participants scoring more than 1.25 standard deviations below the mean (i.e. 81 or less) on expressive, receptive or core language were categorized as having impaired language.</p> <hd id="AN0093305042-11">Non-verbal intelligence at 4 years</hd> <p>The matrices subtest of the Kaufman Brief Intelligence Test-2nd Edition (KBIT-2; Kaufman and Kaufman [<reflink idref="bib1" id="ref70">1</reflink>]) administered during the 4-year-old face-to-face assessment was used to quantify non-verbal intelligence. Standard scores (Mean = 100; SD = 15) were used in the analyses. The internal consistency for the non-verbal scale for 4–19-year-olds is 0.86, while test-retest reliability for 4–12 year olds is 0.76.</p> <hd id="AN0093305042-12">Maternal measures</hd> <p></p> <hd id="AN0093305042-13">Maternal distress</hd> <p>Three scales (completed as part of the 2-year-old and 4-year-old parent questionnaire) were incorporated into a single factor as an index of overall <emph>Maternal Distress</emph> encompassing psychological distress, life stress and coping capacity. The Non-specific Psychological Distress Scale (Kessler-6; Kessler and Mroczek [<reflink idref="bib1" id="ref71">1</reflink>]), with a possible score ranging from 0 to 24, was used to measure maternal psychological health; a score of 4 or more indicated the presence of maternal psychological distress. The K-6 has established validity and reliability. Two additional 5-point Likert scale measures of mothers' psychosocial health at 24 months were included: <emph>self rating of current life stresses</emph> (points ranging from 'no problems/stresses' to 'too many problems/stresses') <emph>and self-rating of perceived coping capacities</emph> (points ranging from coping 'extremely well' to 'not at all') (Prior et al. [<reflink idref="bib1" id="ref72">1</reflink>]). The K-6 and two Likert scale items were combined into a single measure of Maternal Distress, by rescaling the K-6 score so the plausible values ranged from 1 to 5 and then summing with the current stresses and coping items. A mother's overall rating of the easiness/difficultness of her child compared to average children provided a measure of the mother's overall perception of her child's difficultness. This single rating using a 5-point scale from 'much easier than average' to 'much more difficult than average' has proved to be a significant predictor of child adjustment over many ATP studies in combination with temperament and behavioural variables (Sanson et al. [<reflink idref="bib1" id="ref73">1</reflink>]).</p> <hd id="AN0093305042-14">Maternal vocabulary</hd> <p>Maternal vocabulary was measured with the written 44-item multiple-choice modified version of the Mill Hill Vocabulary Scale (Raven, Raven, and Court [<reflink idref="bib1" id="ref74">1</reflink>]), with each correct answer tallied to provide a raw quantitative score out of the possible 44.</p> <hd id="AN0093305042-15">Maternal education</hd> <p>Mothers' education was categorized as either fewer than 12 years of formal schooling; 12 years of schooling (elementary and secondary school); or more than 12 years of formal schooling (post-school education).</p> <hd id="AN0093305042-16">Environmental measures</hd> <p></p> <hd id="AN0093305042-17">Socio-economic status</hd> <p>The Socio-Economic Indexes for Areas (SEIFA; Australian Bureau of Statistics [<reflink idref="bib1" id="ref75">1</reflink>]) is derived from the 2001 Census of Population and Housing. It provides scores on five indices, which summarize different socio-economic aspects for given geographic areas. For this study we have used postcode to define the geographic area. The Index of Relative Socio-Economic Disadvantage, reported in this paper, represents attributes such as low income, low educational attainment, high unemployment, and jobs in relatively unskilled occupations (Mean = 1000; SD = 100). A high score on this index indicates that the area is more advantaged compared to other areas.</p> <hd id="AN0093305042-18">Statistical analyses</hd> <p>All analyses are based on the participants who had no missing variables. The predictors and outcome SDQ total score are summarized using means and standard deviations for males and females separately, with effect sizes (Cohen's <emph>d</emph>) presented to quantify the size of the mean differences relative to the pooled standard deviation across gender groups. Maternal Distress is the saved score on the first factor after fitting a factor analysis model to the second and third items of the Australian Temperament Scale and the Kessler-6 score. The 'regression' method was used to derive the factor score with an overall sample mean of 0 and standard deviation of 1. Higher scores indicate higher levels of distress. Linear regression models were fitted to relate the outcome measure, SDQ total score at 4 years, to the predictors for all participants. The scores for the other predictors and the SDQ score at 4 years were standardized to have a mean of 0 and standard deviation of 1, so that the resulting regression coefficients are standardized and should be interpreted as the number of standard deviation units increase in the outcome for each standard deviation unit increase in the predictors. The regression coefficients are, therefore, basically (partial) correlation coefficients. The coefficient of determination (R squared) is reported for each model. All analyses were implemented using Stata 10.1 software (StataCorp. [<reflink idref="bib68" id="ref76">68</reflink>]).</p> <hd id="AN0093305042-19">Results</hd> <p>Table 1 presents a summary of the demographic variables and known predictors (means and standard deviations) of language and behaviour for boys and girls at 2 and 4 years of age.</p> <p>Table 1. Summary of baseline demographic and predictors for boys and girls (mean and standard deviation).</p> <p> <ephtml> <table><thead><tr><td /><td>Boys</td><td>Girls</td></tr><tr><td>Variables</td><td>(N = 640)</td><td>(N = 617)</td></tr></thead><tbody><tr><td>SEIFA disadvantage score</td><td>1040 (56)</td><td>1038 (57)</td></tr><tr><td>CDI at 2 years</td><td>243 (159)</td><td>289 (159)</td></tr><tr><td>Gestures at 2 years (CSBS)</td><td>8.4 (1.7)</td><td>8.8 (1.5)</td></tr><tr><td>Mother's vocabulary</td><td>28.2 (4.4)</td><td>28.0 (4.6)</td></tr><tr><td>Mother's education < year 12</td><td>18%</td><td>23%</td></tr><tr><td>Year 12</td><td>42%</td><td>39%</td></tr><tr><td>Degree/Postgrad</td><td>41%</td><td>38%</td></tr><tr><td>Child Behaviour Problems at 2 years</td><td>0.03 (1.0)</td><td>−0.035 (0.99)</td></tr><tr><td>Maternal Distress at 2 years</td><td>0.04 (0.99)</td><td>−0.04 (1.00)</td></tr><tr><td>K-BIT2 Non-verbal IQ SS at 4 years</td><td>103.8 (13.6)</td><td>105.7 (12.5)</td></tr><tr><td>CELF Expressive language SS at 4 years</td><td>99.8 (14.8)</td><td>101.6 (13.7)</td></tr><tr><td>CELF Receptive language SS at 4 years</td><td>96.3 (14.6)</td><td>99.5 (13.7)</td></tr><tr><td>CELF Core language SS at 4 years</td><td>100 (13.9)</td><td>102.1 (13.3)</td></tr><tr><td>SDQ total score at 4 years</td><td>8.3 (4.8)</td><td>7.1 (4.1)</td></tr><tr><td>Maternal Distress at 4 years</td><td>0.05 (0.98)</td><td>−0.05 (1.0)</td></tr></tbody></table> </ephtml> </p> <p>The correlation matrix of predictors and the outcome measure (SDQ) for all children is presented in Table 2.</p> <p>Table 2. Correlation matrix of predictors and outcome variables for all participants (N = 1257).</p> <p> <ephtml> <table><thead><tr><td /><td>SEIFA</td><td>CDI</td><td>CSBS</td><td>Mat Dis 2 yrs</td><td>BPS 2 yrs</td><td>Core</td><td>Rec Lang</td><td>Exp Lang</td><td>IQ</td><td>Mat Dis 4 yrs</td><td>SDQ</td></tr></thead><tbody><tr><td>SEIFA score</td><td>1</td><td /><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>CDI (2 yrs)</td><td>−.01</td><td>1</td><td /><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>CSBS gestures (2 yrs)</td><td>−.05</td><td>.23**</td><td>1</td><td /><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>Mat Dis (2 yrs)</td><td>−.06</td><td>−.09</td><td>−.10</td><td>1</td><td /><td /><td /><td /><td /><td /><td /></tr><tr><td>BPs (2 yrs)</td><td>−.17**</td><td>−.06</td><td>−.06</td><td>.26**</td><td>1</td><td /><td /><td /><td /><td /><td /></tr><tr><td>Core (4 yrs)</td><td>−.15**</td><td>.45**</td><td>.06</td><td>−.15</td><td>−.15**</td><td>1</td><td /><td /><td /><td /><td /></tr><tr><td>Receptive (4 yrs)</td><td>−.16**</td><td>.38**</td><td>.08</td><td>−.04</td><td>−.16**</td><td>.86**</td><td>1</td><td /><td /><td /><td /></tr><tr><td>Expressive (4 yrs)</td><td>.19**</td><td>.50**</td><td>.05</td><td>−.01</td><td>−.14**</td><td>.92**</td><td>.76**</td><td>1</td><td /><td /><td /></tr><tr><td>IQ (4 yrs)</td><td>.13**</td><td>.19**</td><td>.06</td><td>−.04</td><td>−.09*</td><td>.45**</td><td>.46**</td><td>.42**</td><td>1</td><td /><td /></tr><tr><td>Mat Dis (4 yrs)</td><td>−.02</td><td>−.05</td><td>−.07*</td><td>.53**</td><td>.14**</td><td>−.02</td><td>−.03</td><td>−.01</td><td>.01</td><td>1</td><td /></tr><tr><td>SDQ score at 4 yrs</td><td>−.10**</td><td>−.09</td><td>−.11*</td><td>.25**</td><td>.36**</td><td>−.20**</td><td>−.21**</td><td>.20**</td><td>.17**</td><td>.29**</td><td>1</td></tr></tbody></table> </ephtml> </p> <p>3 Notes: SEIFA Score = SES Index of Relative Socio-Economic Disadvantage; CDI = MacArthur-Bates Communicative Development Inventory; CSBS = Communication and Symbolic Behavior Scales – Gestures subscale; Mat Dis = Maternal Distress composite; BPS at 2y = Child Behaviour Problems Scale; Core, Receptive and Expressive = CELF P2 Language Subscales; IQ = K-BIT2 Matrices (Nonverbal IQ); SDQ = Strengths and Difficulties Questionnaire. *<emph>p</emph> = <. 01, **<emph>p</emph> = <. 001.</p> <p>There were strong correlations and large effect sizes (Cohen [<reflink idref="bib1" id="ref77">1</reflink>]) between core, receptive and expressive language standard scores, and between expressive vocabulary at (CDI) at 2 years of age and expressive language at 4 years of age. The association between core and receptive language also correlated with expressive vocabulary (CDI) at 2 years with a medium effect size, with small correlations and effect sizes between expressive vocabulary (CDI) and gestures (CSBS) at 2 years of age. There were medium effect sizes between language at 4 years and non-verbal intelligence at 4 years of age, and a medium effect size in the association between behaviour problems at 2 years and the SDQ total score at 4 years of age. The total difficulties score of the SDQ also correlated with the Maternal Distress composite measured at both 2 years and 4 years and with all language measures at 4 years of age, but the effect size was small.</p> <p>Table 3 is a summary of the SDQ subscale scores at 4 years by low expressive vocabulary (CDI) status at 2 years and language impairment status at 4 years. Low vocabulary status at 2 years of age is significantly associated with increased SDQ Total Difficulties and Peer Problems and reduced Prosocial behaviour at 4 years. After adjusting for the potential confounders (gender, SES, maternal distress, maternal education and maternal vocabulary) only the association between low vocabulary and Peer Problems remained significant. There was no significant association between expressive vocabulary status at 2 years and the other sub-scales of the SDQ measured at 4 years.</p> <p>Table 3. Summary of SDQ behaviour subscale scores at 4 years by low expressive vocabulary (CDI) status at 2 years and language impairment status at 4 years.</p> <p> <ephtml> <table><thead><tr><td /><td>Low exp. vocab./Impaired</td><td>Normal</td><td>Unadjusted</td><td>Adjusted</td></tr><tr><td>Behaviour outcome at 4 years</td><td>Mean (SD)</td><td>Mean (SD)</td><td>difference (95% CI)</td><td><italic>p</italic>-value</td><td>difference (95% CI)</td><td><italic>p</italic>-value</td></tr></thead><tbody><tr><td /><td><bold>by Expressive vocab status at 2 years</bold></td><td /><td /><td /><td /></tr><tr><td /><td>N = 300</td><td>N = 1240</td><td /><td /><td /><td /></tr><tr><td>Emotional Symptoms scale</td><td>1.6 (1.7)</td><td>1.4 (1.5)</td><td>0.2 (–0.03 to 0.4)</td><td>0.10</td><td>−0.003 (–0.2 to 0.2)</td><td>0.98</td></tr><tr><td>Conduct Problems scale</td><td>1.7 (1.5)</td><td>1.6 (1.5)</td><td>0.1 (–0.1 to 0.3)</td><td>0.18</td><td>−0.1 (–0.3 to 0.1)</td><td>0.50</td></tr><tr><td>Hyperactivity scale</td><td>3.4 (2.3)</td><td>3.3 (2.2)</td><td>0.1 (–0.2 to 0.4)</td><td>0.39</td><td>−0.3 (–0.6 to 0.03)</td><td>0.08</td></tr><tr><td>Peer Problems scale</td><td>1.8 (1.6)</td><td>1.3 (1.4)</td><td>0.5 (0.4 to 0.7)</td><td><0.001</td><td>0.4 (0.2 to 0.6)</td><td><0.001</td></tr><tr><td>Pro-Social scale</td><td>7.2 (2.0)</td><td>7.5 (1.8)</td><td>−0.3 (–0.5 to –0.1)</td><td>0.02</td><td>−0.1 (–0.3 to 0.2)</td><td>0.52</td></tr><tr><td>Total Difficulties scale</td><td>8.5 (4.9)</td><td>7.6 (4.5)</td><td>1.0 (0.4 to 1.5)</td><td>0.001</td><td>0.04 (–0.6 to 0.6)</td><td>0.90</td></tr><tr><td /><td><bold>by Receptive language status at 4 years</bold></td><td /><td /><td /><td /></tr><tr><td /><td>N = 231</td><td>N = 1251</td><td /><td /><td /><td /></tr><tr><td>Emotional Symptoms scale</td><td>1.5 (1.7)</td><td>1.4 (1.5)</td><td>0.1 (–0.1 to 0.3)</td><td>0.22</td><td>−0.1 (–0.3 to 0.2)</td><td>0.64</td></tr><tr><td>Conduct Problems scale</td><td>2.1 (1.7)</td><td>1.5 (1.4)</td><td>0.5 (0.3 to 0.7)</td><td><0.001</td><td>0.1 (–0.1 to 0.4)</td><td>0.27</td></tr><tr><td>Hyperactivity scale</td><td>4.1 (2.5)</td><td>3.2 (2.1)</td><td>0.9 (0.6 to 1.2)</td><td><0.001</td><td>0.4 (0.03 to 0.7)</td><td>0.03</td></tr><tr><td>Peer Problems scale</td><td>2.1 (1.8)</td><td>1.2 (1.4)</td><td>0.9 (0.7 to 1.1)</td><td><0.001</td><td>0.7 (0.5 to 0.9)</td><td><0.001</td></tr><tr><td>Pro-Social scale</td><td>7.1 (1.9)</td><td>7.5 (1.8)</td><td>−0.4 (–0.6 to –0.1)</td><td>0.003</td><td>−0.02 (–0.3 to 0.3)</td><td>0.87</td></tr><tr><td>Total Difficulties scale</td><td>9.8 (5.5)</td><td>7.4 (4.2)</td><td>2.4 (1.8 to 3.0)</td><td><0.001</td><td>1.1 (0.5 to 1.8)</td><td>0.001</td></tr><tr><td /><td><bold>by Expressive language status at 4 years</bold></td><td /><td /><td /><td /></tr><tr><td /><td>N = 177</td><td>N = 1273</td><td /><td /><td /><td /></tr><tr><td>Emotional Symptoms scale</td><td>1.5 (1.6)</td><td>1.4 (1.5)</td><td>0.1 (–0.1 to 0.4)</td><td>0.27</td><td>−0.02 (–0.3 to 0.2)</td><td>0.88</td></tr><tr><td>Conduct Problems scale</td><td>1.9 (1.5)</td><td>1.6 (1.5)</td><td>0.3 (0.1 to 0.6)</td><td>0.005</td><td>−0.06 (–0.3 to 0.2)</td><td>0.66</td></tr><tr><td>Hyperactivity scale</td><td>4.2 (2.4)</td><td>3.2 (2.2)</td><td>1.0 (0.6 to 1.3)</td><td><0.001</td><td>0.6 (0.2 to 1.0)</td><td>0.002</td></tr><tr><td>Peer Problems scale</td><td>2.1 (1.8)</td><td>1.3 (1.4)</td><td>0.8 (0.6 to 1.1)</td><td><0.001</td><td>0.7 (0.4 to 0.9)</td><td><0.001</td></tr><tr><td>Pro-Social scale</td><td>6.9 (2.0)</td><td>7.5 (1.8)</td><td>−0.6 (–0.9 to –0.3)</td><td><0.001</td><td>−0.4 (–0.7 to –0.1)</td><td>0.009</td></tr><tr><td>Total Difficulties scale</td><td>9.7 (5.2)</td><td>7.5 (4.4)</td><td>2.3 (1.6 to 3.0)</td><td><0.001</td><td>1.2 (0.5 to 1.9)</td><td>0.002</td></tr></tbody></table> </ephtml> </p> <p>There were significant concurrent associations between low expressive and receptive language status at 4 years and each of SDQ Total Difficulties, Conduct Problems, Hyperactivity, Peer Problems and Prosocial behaviour. After adjusting for potential confounders, low expressive and receptive language were no longer associated with Conduct Problems. However, the association with Total Difficulties, Hyperactivity and Peer Problems remained significant. The association between Prosocial behaviour and expressive language remained significant but Prosocial behaviour was no longer significantly associated with receptive language ability. SDQ Emotional Symptoms were not significantly associated with expressive language at either 2 or 4 years of age, or with receptive language at 4 years of age.</p> <hd id="AN0093305042-20">SDQ caseness</hd> <p>SDQ 'caseness' using the total symptom score of the SDQ was examined and the results are presented in Table 4. The SDQ Total Difficulties score was used to determine 'caseness', which relates to the risk of diagnosis of a future psychological disorder. Participants scoring 11 or fewer are categorized as 'normal' or at low risk of a future diagnosis, those scoring between 12 and 14 inclusive as 'borderline', and those scoring above 14 as 'abnormal' or at high risk of diagnosis according to <emph>DSM-IV</emph> (APA 1994).</p> <p>Table 4. Summary of behaviour 'caseness' at 4 years by low expressive language (CDI) at 2 years and language impairment status at 4 years.</p> <p> <ephtml> <table><thead><tr><td>Behaviour caseness outcomes at 4 years</td><td>Impaired language</td><td>Normal</td><td><italic>p</italic>-value</td></tr></thead><tbody><tr><td /><td><bold>by Expressive language status (CDI) at2 years</bold></td><td /></tr><tr><td /><td>N = 300</td><td>N = 1240</td><td /></tr><tr><td>Category on SDQ Total Difficulties scale</td><td /><td /><td>0.22</td></tr><tr><td>% Normal</td><td>78.7</td><td>83.0</td><td /></tr><tr><td>% Borderline</td><td>10.0</td><td>8.1</td><td /></tr><tr><td>% Abnormal</td><td>11.3</td><td>8.9</td><td /></tr><tr><td /><td><bold>by Receptive language status at 4 years</bold></td><td /></tr><tr><td /><td>N = 231</td><td>N = 1251</td><td /></tr><tr><td>Category on SDQ Total Difficulties scale</td><td /><td /><td><0.001</td></tr><tr><td>% Normal</td><td>68.4</td><td>85.1</td><td /></tr><tr><td>% Borderline</td><td>12.1</td><td>8.0</td><td /></tr><tr><td>% Abnormal</td><td>19.5</td><td>7.0</td><td /></tr><tr><td /><td><bold>by Expressive language status at 4 years</bold></td><td /></tr><tr><td /><td>N = 177</td><td>N = 1273</td><td /></tr><tr><td>Category on SDQ Total Difficulties scale</td><td /><td /><td><0.001</td></tr><tr><td>% Normal</td><td>69.5</td><td>84.1</td><td /></tr><tr><td>% Borderline</td><td>13.0</td><td>8.2</td><td /></tr><tr><td>% Abnormal</td><td>17.5</td><td>7.7</td><td /></tr></tbody></table> </ephtml> </p> <p>Table 4 shows that, using the Total Difficulties score to predict 'caseness', there was little evidence of a difference in risk for a diagnosis of clinically significant emotional or behavioural problems at 4 years between those with and without low vocabulary at 2 years. However, there was evidence in both the unadjusted (chi-square test) and adjusted analyses that the percentage of children classified as having borderline or abnormal behaviour differed between those with and without impaired language in both the expressive and receptive modalities at 4 years. Of those with low expressive language at 4 years, 17.5% were classified as having abnormal behaviour compared to 7.7% typically developing children. The corresponding percentages for those with and without low receptive language at 4 years were 19.5% and 7.0%, respectively.</p> <hd id="AN0093305042-21">Regression analyses</hd> <p>Linear regression models were fitted to relate the outcome, SDQ total score at 4 years, to the predictors for all participants. Table 5 presents the three models that were fitted.</p> <p>Table 5. Regression analyses of SDQ total score at 4 years (N = 1256). Model 1 includes demographic variables as predictors; Model 2 includes demographic and 2-year-old variables as predictors; Model 3 includes demographics and 4-year-old measures of core language and non-verbal IQ as predictors.</p> <p> <ephtml> <table><thead><tr><td /><td>Model 1</td><td>Model 2</td><td>Model 3</td></tr><tr><td>Predictor</td><td>Coeff.</td><td>95% CI</td><td><italic>p</italic>-value</td><td>Coeff.</td><td>95% CI</td><td><italic>p</italic>-value</td><td>Coeff.</td><td>95% CI</td><td><italic>p</italic>-value</td></tr></thead><tbody><tr><td>SEIFA score</td><td>−.068</td><td>−.13 to −.01</td><td>.019</td><td>−.03</td><td>−.08 to.02</td><td>.28</td><td>−.04</td><td>−.09 to −.02</td><td>.18</td></tr><tr><td>Mat Vocabulary</td><td>−.03</td><td>−.09 to.02</td><td>.24</td><td>−.03</td><td>−.08 to.03</td><td>.34</td><td>−.03</td><td>−.08 to.03</td><td>.32</td></tr><tr><td>Mat Education Year 12</td><td>.01</td><td>−.13 to.16</td><td>.89</td><td>.03</td><td>−.11 to.17</td><td>.65</td><td>−.000</td><td>−.14 to.14</td><td>1.00</td></tr><tr><td>Mat Education > Year 12</td><td>−.23</td><td>−.39 to −.08</td><td>.003</td><td>−.13</td><td>.27 to.02</td><td>.09</td><td>−.18</td><td>−.33 to −.03</td><td>.019</td></tr><tr><td>CDI 2 yrs</td><td /><td /><td /><td>−.04</td><td>−.09 to.01</td><td>.15</td><td /><td /><td /></tr><tr><td>CSBS Gesture</td><td /><td /><td /><td>−.07</td><td>−.12 to −.02</td><td>.01</td><td /><td /><td /></tr><tr><td>BPs 2 yrs</td><td /><td /><td /><td>.29</td><td>.24 to.35</td><td>.000</td><td /><td /><td /></tr><tr><td>Mat Dis 2 yrs</td><td /><td /><td /><td>.16</td><td>.11 to.21</td><td>.000</td><td /><td /><td /></tr><tr><td>IQ at 4 yrs</td><td /><td /><td /><td /><td /><td /><td>−.11</td><td>−.16 to −.05</td><td>.000</td></tr><tr><td>Core Lang. 4 yrs</td><td /><td /><td /><td /><td /><td /><td>−.11</td><td>−.17 to −.05</td><td>.000</td></tr><tr><td>Mat Dis 4 yrs</td><td /><td /><td /><td /><td /><td /><td>.29</td><td>.24 to.34</td><td>.000</td></tr><tr><td /><td /><td>R<sup>2</sup> = 2.7%</td><td /><td /><td>R<sup>2</sup> = 17.1%</td><td /><td /><td>R<sup>2</sup> = 14.4%</td><td /></tr></tbody></table> </ephtml> </p> <p>4 Notes: Models 1, 2 and 3 – All predictor variables and SDQ total score outcome are standardized so that the mean and standard deviation (SD) are 0 and 1, respectively. The regression coefficients are therefore standardized and represent the SD change in SDQ total score for each SD increase in the predictors. The regression coefficients may be interpreted as (unadjusted or adjusted) correlation coefficients. Model 1 – Test of interaction showed no strong evidence that the effect of SEIFA disadvantage score differed between gender groups (<emph>p</emph> = 0.12). Model 2 – Tests of interaction showed no strong evidence that the effects of SEIFA disadvantage score (<emph>p</emph> = 0.11), Expressive language at 2 years (<emph>p</emph> = 0.33), Gestures at 2 years (<emph>p</emph> = 0.73) and Mother's Malaise at 2 years (<emph>p</emph> = 0.51) differed between gender groups. Model 3 – Tests of interaction showed no strong evidence that the effects of SEIFA disadvantage score (<emph>p</emph> = 0.11), Non-verbal IQ (<emph>p</emph> = 0.57) and Expressive language at 4 years (<emph>p</emph> = 0.33) differed between gender groups. There was, however, evidence that the effect of Maternal Distress at 4 years differed between gender groups (<emph>p</emph> = 0.04). Model 3 – Sensitivity analysis, in which the Receptive and Core language at 4 years were used, in turn, in place of Expressive language at 4 years, provided almost identical results. SEIFA Score = SES Index of Relative Socio-Economic Disadvantage; CDI = MacArthur-Bates Communicative Development Inventory; CSBS = Communication and Symbolic Behavior Scales – Gestures subscale at age 2 years; Mat Dis = Maternal Distress composite at 2 and 4 years; Mat ed = Maternal education; BPS at 2 years = Child Behaviour Problems Scale; Core = CELF P2 Core Language Subscale; IQ = K-BIT2 Matrices (Nonverbal IQ); SDQ = Strengths and Difficulties Questionnaire.</p> <hd id="AN0093305042-22">Model 1</hd> <p>SES (SEIFA disadvantage), maternal vocabulary and maternal education were included in this model and these variables predicted a significant but small percentage of the variance (2.7%) in behaviour symptoms (SDQ Total Score) in children at 4 years of age, (F (<reflink idref="bib9" id="ref78">9</reflink>, 1252) = 8.54, <emph>p</emph> < 0.001). SES emerged as negatively and significantly related to the total behaviour score, indicating that a higher family SES predicted fewer behaviour difficulties at 4 years of age. Likewise, maternal education higher than a Year 12 level (average age 17 years) significantly predicted fewer behaviour difficulties at 4 years of age even after controlling for maternal vocabulary. A test of interaction showed no strong evidence that the effect of SEIFA disadvantage score differed between gender groups (<emph>p</emph> = 0.12).</p> <hd id="AN0093305042-23">Model 2</hd> <p>This model incorporated SES, maternal vocabulary and maternal education as well as the Model 1 variables measured when the child was 2 years old as predictors of behaviour difficulties at 4 years. A significant and moderate amount of variance (17.1%) of behaviour at 4 years of age was explained (F (<reflink idref="bib7" id="ref79">7</reflink>, 1249) = 30.02, <emph>p</emph> <0.001). SES and maternal education were no longer significant predictors of behaviour at 4 years, but gesture (non-verbal communication) use at 2 years of age was negatively associated with behaviour problems at 4 years of age, and behaviour problems at 2 years of age were associated with behaviour difficulties at 4 years of age. Maternal Distress was also significantly related to behaviour difficulties at 4 years, such that the greater the level of distress reported by the mother, the higher the SDQ Total Difficulties score at 4 years of age. Tests of interaction showed no evidence that the effects of SEIFA disadvantage score (<emph>p</emph> = 0.11), Expressive language at 2 years (<emph>p</emph> = 0.33), Gestures at 2 years (<emph>p</emph> = 0.73) and Maternal Distress at 2 years (<emph>p</emph> = 0.51) differed between gender groups.</p> <hd id="AN0093305042-24">Model 3</hd> <p>Non-verbal IQ, core language and Maternal Distress measured when the child was 4 years were added to the Model 1 variables. Once again a significant model emerged (F (<reflink idref="bib7" id="ref80">7</reflink>,1249) = 30.02, p<.0001), explaining 14.4% of the variance in Total Difficulties Score on the SDQ. The significant predictor variables in this model were mother's education (greater than Year 12), non-verbal IQ, core language and maternal distress. Under Model 3, sensitivity analyses were conducted with receptive language and expressive language at 4 years substituted separately for core language. The results provided by the two alternative versions were virtually identical to the main Model 3; hence only Model 3 using core language score as the predictor is presented in Table 5. Tests of interaction showed no evidence that the effects of SEIFA disadvantage score (<emph>p</emph> = 0.11), Non-verbal IQ (<emph>p</emph> = 0.57) and Expressive language at 4 years (<emph>p</emph> = 0.33) differed between gender groups. There was, however, evidence that the effect of Maternal Distress at 4 years differed between gender groups (<emph>p</emph> = 0.04). The level of reported distress was greater in the mothers of boys than in the mothers of girls.</p> <hd id="AN0093305042-25">Discussion</hd> <p>Our main point of interest in this study was to report on any specific associations between language and behaviour in a large community sample of preschoolers after biopsychosocial variables such as child gender and non-verbal IQ, maternal education, vocabulary and psychosocial distress and social disadvantage were accounted for in the analyses. This study clearly showed that language impairment was specifically associated with hyperactivity and peer problems but not emotional symptoms or conduct problems at the preschool stage. Our findings also showed that as young as 4 years of age, children with language impairment are at a higher risk for clinical levels of abnormal behaviour, as defined by the SDQ Total Difficulties score, than typically developing children. An examination of biopsychosocial variables associated with language and behaviour revealed that although language ability was a predictor of behaviour at both 2 years (gesture or non-verbal communication) and at 4 years of age (receptive, expressive and core language), Maternal Distress (encompassing maternal psychological distress, life stress and coping, as well as parenting stress) was also a significant predictor of behaviour difficulties, at both 2 years and 4 years of age; with the regression coefficients suggesting that this relationship was stronger at 4 years of age.</p> <hd id="AN0093305042-26">Relationships between language and behaviour</hd> <p>Detailed comparisons of the psychosocial functioning of preschoolers with either normally developing language or with expressive vocabulary delay measured at 2 years of age showed that expressive vocabulary delay was significantly associated with problems with peer relationships, such as a tendency to play alone, not being liked, being bullied by other children and having fewer friends by the time the children were 4 years of age. Not unexpectedly, delayed expressive vocabulary at 2 years was also negatively related to prosocial behaviours, such as sharing, being considerate and helpful, measured at 4 years of age. When we controlled for biopsychosocial variables known to be related to language development and child behaviour, the association between peer problems and delayed expressive vocabulary measured at 2 years of age remained significant, whereas the association between prosocial behaviour and expressive vocabulary was no longer evident. Thus difficulties with peer relationships were specifically related to expressive language ability regardless of SES, maternal factors, child gender and IQ, and were associated with the child's expressive vocabulary from as young as 2 years of age.</p> <p>Expressive and receptive language was assessed in detail when the children were 4 years old. At this stage, where the measured variables were concurrent in time, impaired language was found to be associated with increased conduct problems, hyperactivity and peer problems, and with low prosocial behaviour. McCabe and Meller ([<reflink idref="bib1" id="ref81">1</reflink>]) and McCabe ([<reflink idref="bib1" id="ref82">1</reflink>]) also reported more social and behaviour problems in 4-year-olds with language problems than in normally developing peers, but they did not control for other possible sources of variance. When we controlled for biopsychosocial variables known to be associated with language and behaviour, only hyperactivity and peer problems remained predictive of low language. Low levels of expressive language in 4-year-olds were still related to lower prosocial behaviour but this was not the case for preschoolers with low levels of receptive language.</p> <p>Our results are concordant with previous studies (e.g. Baker and Cantwell [<reflink idref="bib1" id="ref83">1</reflink>]; Beitchman et al. [<reflink idref="bib1" id="ref84">1</reflink>]; Lindsay, Dockrell, and Strand [<reflink idref="bib1" id="ref85">1</reflink>]; McCabe and Meller [<reflink idref="bib1" id="ref86">1</reflink>]; McCabe [<reflink idref="bib1" id="ref87">1</reflink>]) which also showed that children with impaired language were rated as having significantly more hyperactivity and significantly greater difficulty with peer relationships than children with typically developing language. There was no difference, however, between children with impaired language and typically developing children, for conduct problems, or emotional symptoms in this sample of children at this relatively early stage in their development.</p> <p>Unlike the findings in this study, previous research has reported an increased risk for anxiety in young language-impaired children (e.g. Cohen et al. [<reflink idref="bib1" id="ref88">1</reflink>]; Nelson, Benner, and Cheney [<reflink idref="bib1" id="ref89">1</reflink>], Stanton-Chapman et al. [<reflink idref="bib1" id="ref90">1</reflink>]). Stanton-Chapman et al. ([<reflink idref="bib1" id="ref91">1</reflink>]) compared preschoolers with specific language impairment (SLI) with children with typical language development, and found internalizing symptoms were increased in the children with SLI, but noted that these symptoms were confined to withdrawal. However, the SDQ Emotional Symptoms Scale used in this study pertains mainly to symptoms of emotional reactivity – for example, fears, worries and unhappiness – rather than to withdrawal or social isolation. In the same study, Stanton-Chapman et al. ([<reflink idref="bib1" id="ref92">1</reflink>]) also reported no difference in the level of externalizing behaviour symptoms between the children with SLI and their typically developing peers. This is in contrast to many reports of externalizing behaviour problems in school-aged children and adolescents with language impairment (e.g. Botting and Conti-Ramsden [<reflink idref="bib1" id="ref93">1</reflink>]; Cohen et al. [<reflink idref="bib1" id="ref94">1</reflink>]; Ripley and Yuill [<reflink idref="bib1" id="ref95">1</reflink>]). However, these studies generally report on school-aged children referred for behaviour difficulties or language problems rather than on a prospectively studied community sample of preschoolers. Hyperactive behaviour and peer problems, rather than conduct problems, were elevated in our community sample of preschoolers, and this is a common finding in older children and adolescents with impaired language (e.g. Beitchman et al. [<reflink idref="bib1" id="ref96">1</reflink>], [<reflink idref="bib1" id="ref97">1</reflink>]). If, as suggested by our results, these problems arise before school entry then it is critical that they are addressed early to prevent escalation and interference with language-impaired children's continuing psychological adjustment, peer relationships and academic achievement.</p> <hd id="AN0093305042-27">Comparison of SDQ 'caseness' in preschoolers with and without language impairment</hd> <p>SDQ scores can be used as continuous variables as above, or they can be used to roughly categorize scores as 'Normal', 'Borderline' and 'Abnormal' to identify children with a possible clinical diagnosis in line with <emph>DSM-IV</emph> diagnoses (Goodman [<reflink idref="bib1" id="ref98">1</reflink>]). We also used the SDQ data to examine the risk for clinically significant behaviour problems in children with impaired language compared to children with typically developing language. Beitchman et al.'s ([<reflink idref="bib1" id="ref99">1</reflink>]) 14-year follow-up of a community sample of Canadian children found that 43% of the sample with language impairment at age 5 years had a psychiatric diagnosis at age 19 years, suggesting that children with language impairment are at risk for later psychiatric disorders. When the Total Difficulties score on the SDQ for our sample was categorized according to the SDQ protocol, our results indicated little evidence that children with low expressive language at age 2 years are at higher risk of being diagnosed with clinically significant 'abnormal' behaviour (as defined by the Total Difficulties score on the SDQ) which could lead to a psychiatric diagnosis in line with <emph>DSM-IV</emph> than their typically developing peers when assessed at age 4 years, even though their vocabulary level at 2 years was predictive of Peer Problems at age 4. Given the 'late talking' literature which suggests that up to 60% of children who have delayed language at 2 years of age catch up to their peers by preschool, this is probably not an unexpected finding.</p> <p>By age 4, however, there was evidence that children with low levels of receptive or expressive language were at a much higher risk of a clinical diagnosis of behaviour problems than their typically developing peers. Eighteen percent of preschoolers with poor expressive language could be categorized as having behaviour symptoms within the 'abnormal' range compared with only 8% of their typically developing peers, while 20% of children with low receptive language were at risk of a clinically significant diagnosis compared with only 7% of their typically developing peers. Again these associations remained significant when biopsychosocial factors, which impact on language and behaviour, were controlled for in the analysis. Thus, children with impaired language even as young as 4 years of age have a higher risk for clinical levels of 'abnormal' behaviour which could lead to a psychiatric diagnosis, related specifically to their language development, than typically developing children, regardless of relevant risk or protective factors. Preschoolers with impaired language skills could therefore be in double jeopardy if they enter school without adequate support for both language and behaviour.</p> <hd id="AN0093305042-28">The role of child, maternal and environmental factors in the relationship between language im...</hd> <p>Three models were analysed to examine the role of child, maternal and environmental factors in the relationship between language impairment and behaviour. The first model showed that maternal demographic variables, including education level and to a lesser extent SES were predictors of 4-year-old behaviour. Children from a higher SES environment and those whose mothers had more than 12 years of education had lower scores on the Total Difficulties scale of the SDQ. SES was not as strong a predictor of behaviour as maternal education level at 4 years of age, but nevertheless the results are in accord with other studies which have also implicated SES as a risk factor in the development of higher levels of externalizing behaviour in preschoolers by parent report (e.g. Keiley et al. [<reflink idref="bib1" id="ref100">1</reflink>]) and in older children (e.g. Feldman et al. [<reflink idref="bib1" id="ref101">1</reflink>]; McGee and Williams [<reflink idref="bib1" id="ref102">1</reflink>]). Maternal education, a correlate of SES (Marks et al. [<reflink idref="bib1" id="ref103">1</reflink>]), was a stronger predictor of children's 4-year-old behaviour, with higher education associated with lower behaviour difficulties scores. Maternal education has been reported to influence child behaviour in other studies as well (e.g. Dollaghan et al. [<reflink idref="bib1" id="ref104">1</reflink>]). Vocabulary, however, which could be regarded as a specific aspect of maternal education – for example, women in a higher SES tend to have a higher level of education, and women with a higher level of education tend to talk to their children more (Hoff [<reflink idref="bib1" id="ref105">1</reflink>]) – did not predict behaviour at 4 years of age, independently of maternal education and SES in these preschoolers.</p> <p>The inclusion of child factors (behaviour problems, CDI vocabulary and gestures from the CSBS at 2 years) as well as our Maternal Distress composite significantly increased the power of the model to predict behaviour at 4 years of age, with 17% of the variance in behaviour accounted for by this model. Controlling for the additional variables of child behaviour, language and Maternal Distress moderated the effects of SES and maternal education such that they were no longer significant predictors of behaviour at 4 years.</p> <p>When child variables (Non-verbal IQ, CELF Core language) measured at 4 years and maternal variables (maternal education and maternal distress) at 4 years were included in the model, a higher level of maternal education was again a significant but relatively weak predictor of fewer behaviour difficulties. Interestingly, Model 3 indicates that Maternal Distress (a composite of maternal emotional distress, perceived maternal distress and coping, and perceived parenting ability) is a strong predictor of difficult child behaviour at 4 years of age, more so than social disadvantage, or other maternal factors (education and vocabulary). Child factors (non-verbal IQ and language development) had a minor influence on behaviour at the 4-year-old stage, with better language ability and higher intelligence related to fewer behaviour problems. It is likely that there is a reciprocal relationship between deteriorating behaviour and increasing maternal distress, with distressed mothers less able to effectively parent children with behaviour problems. The significant interaction effects between gender and maternal distress, with mothers of boys reporting higher maternal distress levels than mothers of girls, further suggests that this may be more problematic for mothers of boys.</p> <p>Non-verbal reasoning and language ability also predicted behaviour difficulties, with the areas of most concern being hyperactivity and difficulties with peer relationships. Relating well to a peer group is critical for psychological adjustment, with evidence indicating that children who are not well accepted by their peer group are more likely to develop externalizing symptoms (e.g. Keiley et al. [<reflink idref="bib1" id="ref106">1</reflink>]; Ladd [<reflink idref="bib1" id="ref107">1</reflink>]; Ladd and Troop-Gordon [<reflink idref="bib1" id="ref108">1</reflink>]). Hyperactivity has also been shown to increase over time in children with language impairment: for example, again from Beitchman et al.'s 7-year follow-up study (1996), children from the poor language group showed a significant increase in their level of teacher-rated ADHD symptoms at age 13, after their 5-year-old ADHD level was controlled for in the analysis.</p> <p>The limitations of the study are that the correlation and regression analyses do not allow the attribution of causation. The strength of this study is the ability to utilize a large community sample of preschoolers allowing the simultaneous examination of critical variables (child, environmental and family) in order to predict behaviour outcomes. The use of face-to-face language assessment at the age of 4 years also provided a more reliable measure of language than many studies which have used shorter screening evaluations or selected subtests of language or vocabulary. However, it should be noted that there was a strong correlation between expressive language at 4 years and expressive vocabulary (parent report on the CDI) measured at 2 years of age.</p> <p>This study has provided information to suggest that early intervention for preschoolers with impaired language development, particularly assistance with peer relationships and overactive behaviour, deserves further research in an effort to circumvent later psychiatric morbidity. Future studies between language and behaviour would be strengthened by the addition of parenting and family measures which can tease out the contribution of robust factors in child emotional, behaviour and language development.</p> <p>Overall, our study suggests that biopsychosocially based early intervention directed to children, especially boys, with language impairment (speech and language therapy and modification of child behaviour), parents (factors contributing to maternal stress and coping and parenting ability) and the environment (peer relationships) deserve further attention, especially during the preschool period, in order to ameliorate the impact of language impairment on social relationships and disruptive behaviour in later school years.</p> <hd id="AN0093305042-29">Acknowledgments</hd> <p>We would like to acknowledge the members of the ELVS team, the National Health and Medical Research Council for research funding, and the support from the Victorian Government's Operational Infrastructure Support Program.</p> <ref id="AN0093305042-30"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> American Psychiatric Association. 1994. 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  Data: Developing Relationships between Language and Behaviour in Preschool Children from the Early Language in Victoria Study: Implications for Intervention
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  Data: <searchLink fieldCode="SO" term="%22Emotional+%26+Behavioural+Difficulties%22"><i>Emotional & Behavioural Difficulties</i></searchLink>. 2014 19(1):7-27.
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  Data: Routledge. Available from: Taylor & Francis, Ltd. 325 Chestnut Street Suite 800, Philadelphia, PA 19106. Tel: 800-354-1420; Fax: 215-625-2940; Web site: http://www.tandf.co.uk/journals
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  Data: <searchLink fieldCode="DE" term="%22Social+Development%22">Social Development</searchLink><br /><searchLink fieldCode="DE" term="%22Emotional+Development%22">Emotional Development</searchLink><br /><searchLink fieldCode="DE" term="%22Mothers%22">Mothers</searchLink><br /><searchLink fieldCode="DE" term="%22Parent+Child+Relationship%22">Parent Child Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Language%22">Child Language</searchLink><br /><searchLink fieldCode="DE" term="%22Verbal+Ability%22">Verbal Ability</searchLink><br /><searchLink fieldCode="DE" term="%22Preschool+Children%22">Preschool Children</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Attainment%22">Educational Attainment</searchLink><br /><searchLink fieldCode="DE" term="%22Vocabulary%22">Vocabulary</searchLink><br /><searchLink fieldCode="DE" term="%22Role%22">Role</searchLink><br /><searchLink fieldCode="DE" term="%22Gender+Differences%22">Gender Differences</searchLink><br /><searchLink fieldCode="DE" term="%22Intelligence+Quotient%22">Intelligence Quotient</searchLink><br /><searchLink fieldCode="DE" term="%22Language+Impairments%22">Language Impairments</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Correlation%22">Correlation</searchLink><br /><searchLink fieldCode="DE" term="%22Questionnaires%22">Questionnaires</searchLink><br /><searchLink fieldCode="DE" term="%22Emotional+Disturbances%22">Emotional Disturbances</searchLink><br /><searchLink fieldCode="DE" term="%22Socioeconomic+Status%22">Socioeconomic Status</searchLink><br /><searchLink fieldCode="DE" term="%22Longitudinal+Studies%22">Longitudinal Studies</searchLink><br /><searchLink fieldCode="DE" term="%22Epidemiology%22">Epidemiology</searchLink><br /><searchLink fieldCode="DE" term="%22Hyperactivity%22">Hyperactivity</searchLink><br /><searchLink fieldCode="DE" term="%22Anxiety%22">Anxiety</searchLink><br /><searchLink fieldCode="DE" term="%22At+Risk+Persons%22">At Risk Persons</searchLink><br /><searchLink fieldCode="DE" term="%22Peer+Relationship%22">Peer Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Check+Lists%22">Check Lists</searchLink><br /><searchLink fieldCode="DE" term="%22Toddlers%22">Toddlers</searchLink><br /><searchLink fieldCode="DE" term="%22Nonverbal+Ability%22">Nonverbal Ability</searchLink><br /><searchLink fieldCode="DE" term="%22Statistical+Analysis%22">Statistical Analysis</searchLink><br /><searchLink fieldCode="DE" term="%22Expressive+Language%22">Expressive Language</searchLink><br /><searchLink fieldCode="DE" term="%22Measures+%28Individuals%29%22">Measures (Individuals)</searchLink><br /><searchLink fieldCode="DE" term="%22Language+Skills%22">Language Skills</searchLink>
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  Data: <searchLink fieldCode="DE" term="%22Australia%22">Australia</searchLink>
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  Data: <searchLink fieldCode="SU" term="%22Communication+and+Symbolic+Behavior+Scales%22">Communication and Symbolic Behavior Scales</searchLink><br /><searchLink fieldCode="SU" term="%22Clinical+Evaluation+of+Language+Fundamentals%22">Clinical Evaluation of Language Fundamentals</searchLink><br /><searchLink fieldCode="SU" term="%22Strengths+and+Difficulties+Questionnaire%22">Strengths and Difficulties Questionnaire</searchLink>
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  Data: 10.1080/13632752.2013.854956
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  Data: 1363-2752
– Name: Abstract
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  Data: Following a biopsychosocial model, the study investigated the role of child factors (gender, IQ), maternal factors (psychological distress, maternal education and vocabulary, maternal distress) and environmental factors (SES) in the relationship between language impairment and behaviour problems in preschool children. Participants were drawn from the Early Language in Victoria Study (ELVS) a prospective, longitudinal study examining the epidemiology and natural history of language impairment. The study reports on 1257 participants from the ELVS who completed questionnaires at 2 and 4 years and also completed face-to-face assessments at 4 years of age. Information was collected on child language, non-verbal cognition and social-emotional development; maternal vocabulary, maternal psychological distress and parent--child interaction; and SES. This study showed that language impairment is specifically associated with hyperactivity and peer problems but not anxiety and conduct problems at the preschool stage. Children with language impairment were at a higher risk for clinical levels of 'abnormal' behaviour which could lead to a psychiatric diagnosis than typically developing children. An examination of biopsychosocial variables associated with language and behaviour revealed that although language ability was a predictor of behaviour at both 2 years and 4 years of age, maternal distress was a stronger predictor of behaviour, with the association stronger for boys than for girls. Early intervention directed to children, especially boys, with language impairment deserves further attention, especially during the preschool period, in order to ameliorate the impact of language impairment on peer relationships and disruptive behaviour in later school years.
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  Data: 2014
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  Data: EJ1029094
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