Special Article

Risk Factors Associated with Language Development

Problems in Childhood - A Literature Review
Bhunyabhadh Chaimay MPH*,
Bandit Thinkhamrop PhD*, Jadsada Thinkhamrop MD**

* Department of Biostatistics and Demography, Faculty of Public Health, Khon Kaen University, Khon Kaen
** Department of Obstetrics & gynecology, Faculty of Medicine, Khon Kaen University, Khon Kaen

Background: Children with language problems are found to have a higher risk for future academic difficulties
and learning disabilities. Conclusions from related literature were in many ways inconsistent.
Objective: To identify systematically, the existing literature, and factors that influence language development
in children.
Material and Method: Databases of scientific literature were screened through the internet for publications
that involved factors effecting language development in childhood. Hard copies of related scientific journals
were also sought for relevant topics by the authors, making use of reference lists of publications, and citation
search. Studies were included if they were published since 1984 and investigated factors that affect language
development in children. They were excluded if they were not original research articles.
Results: Fifteen studies were included for this review - a case-control study, a cross-sectional study, and
thirteen longitudinal studies. Most studies demonstrated that the following factors affect language develop-
ment - antenatal care, Apgar scores, birth weight, premature delivery, birth order, parental education,
environmental factors, gender of the children, and family history with specific language impairment.
Conclusion: Perinatal/postnatal and environmental factors influence language development. Such factors
should be taken into account as confounding factors in further language development studies.

Keywords: Language development, Child language development, Antenatal care, Apgar score, Birth weight,
Premature, Birth order, Parental education, Environmental factors, Gender and family history, Perinatal,
Postnatal, Social and Literature review

J Med Assoc Thai 2006; 89 (7): 1080-86

Full text. e-Journal: http://www.medassocthai.org/journal

Language development among children is a or behavioral problems(7-10). However, conclusions from

complex process and very important for communica- this literature were in many ways inconsistent. This
tion(1). Language impairments are common and well - paper reviews these studies in a systematic approach.
recognised as important neurodevelopmental childhood
disorders(2) defined as Specific Language Impairment Material and Method
(SLI). Children with sensory, neuromotor and cognitive Inclusion and exclusion criteria
deficits present an impairment of language development. Studies were included if they were published
The prevalence of SLI among preschool children has since 1984 and investigated factors that affect language
been estimated to be about 2% to 8%(3-5). Children with development in children. The studies were excluded if
language problems have been found to have a higher they were not original research articles, such as meta-
risk for future academic difficulties and learning dis- analysis or other types of review.
abilities(6), as well as for psychiatric, neurological, and/
Correspondence to : Chaimay B, Department of Biostatistics
Searching method
and Demography, Faculty of Public Health, Khon Kaen The authors searched relevant research
University, Khon Kaen 40002, Thailand. articles in PubMed database (www.ncb.nlm.nih.gov), a

1080 J Med Assoc Thai Vol. 89 No. 7 2006

reference database provided by the National Library Antenatal care (ANC)
of Medicine, USA. For searching titles, abstracts and As shown in Fig. 1, only one study investi-
keywords of papers the following terms had been used: gated the association between antenatal care and
“factors”, “language”, “development” and “children”. language development outcomes such SLI. From the
Initially the terms and combination of keywords or cross-sectional study by Stanton-Chapman et al(18) in
phrases have been applied such as “language develop- children age 6-7 years, there was a weak risk of SLI.
ment” and “child development”, and “factors and The children born to mothers enrolled for ANC at the
language development”. Additional search sessions 2nd, 3rd trimester showed a smaller risk compared to
used the keywords mentioned above in combination children born to mothers enrolled for ANC at the 1st
with the terms “factors”, “language”, “development” trimester.
and “children”. The MESH terms were used on these
for searching as well. Apgar scores
Another source of the articles was hard Apgar score is associated with child’s brain
copies of the leading journals of a given field and functional and neurological development. It is an indi-
identified relevant publications, especially those who cator of increased risk for specific language develop-
cross about narrow boundaries of a given topic of ment in school children. The study of Staton-Chapman
interest. The authors also followed references listed in et al(18) demonstrated that children who had Apgar
the relevant articles found by the searching methods scores of 0-3 at five minutes are more than two times
mentioned above. The authors did these until there likely to have SLI than those who had Apgar scores of
were no more articles left unidentified. seven or higher (Fig. 1).

Critical appraisal method Birth weight and premature birth

The authors focused their approach on the Four studies reported the association between
magnitude of effects for each factor using statistics birth weight and language outcome as shown in Fig. 1
that were presented in the papers. Mean differences and 2. The studies by Stanton-Chapman et al(18), Aram
were used if the outcome was measured on a continuous et al(11), and Weicdrich et al(21) clearly showed that birth
scale such as a score obtained by language develop- weight was a risk of unsatisfied language development
ment tools. In cases where the outcome was dichoto- outcome while the study by Rice et al(14) showed that
mous, Relative Risk (RR) or Odds Ratios (OR) were such evidence was not conclusive. Luoma et al(20) also
used as available. If such figures were not available in investigated language comprehension and production
the papers, existing numbers that allowed calculating in prematurely born children. This study found that
these were used STATA. The 95% confidence inter- there were lower scores in both language comprehen-
vals were calculated for each of the effects. To facili- sion and production.
tate interpretation, findings were presented as forest
plot. However, no attempt was made to combine such Breast feeding
results as this was not the aim of the presented paper. In Fig. 1, Tomblin et al(15) shows the signifi-
cant protective effect of breast feeding on SLI. That is,
Results breastfeeding can reduce the risk of SLI in about 50%
Twenty-five publications related were found and 60% in children that have been breast fed and had
but ten of these were excluded from the present review. breast feeding for more than nine months respectively.
The excluded studies were on unrelated language de- The risk effects were also reported to be about 1.5 times
velopment (four on mental and psychological develop- as likely for a child that had been breast fed for less
ment, one on adult language), not original research than three months, but were not significant. In addi-
articles (2), and inaccessible original papers (3). tion, a study by Vestergaard et al(24) found that the
Fifteen publications were included and longer the duration of Exclusive Breast Feeding (EBF),
were on case-control studies(11-15) (5), cross-sectional the better the polysyllable babblers.
studies(16-18) (3), cohort studies(1,19,20) (3), and longitu-
dinal studies(21-24) (4). Summary of the findings are Gender
shown in Fig. 1 and 2. The summary is presented in SLI is four times more prevalent in males than
forest plots. The studies were grouped according to females (4:1)(16). Mothers with SLI had seven times as
factors and described in detail. many boys and four times as many girls with SLI. A

J Med Assoc Thai Vol. 89 No. 7 2006 1081

Fig. 1 Summary the association of potential factors influencing language development in childhood. The magnitudes of
effects are presented as Odds Ratios (OR) and Relative Risks (RR) and 95% confidence intervals

1082 J Med Assoc Thai Vol. 89 No. 7 2006

Fig. 2 Summary the association of potential factors influencing language development in childhood. The magnitudes of
effects are presented as mean differences and 95% confidence intervals

J Med Assoc Thai Vol. 89 No. 7 2006 1083

recent study supported that children with a family his- original studies using a critical appraisal approach.
tory of SLI tend to be at greater risk for SLI than those This present review was scientifically concluded from
in families without SLI. This is true for both males and those studies to answer the purpose mentioned above.
females. In general, boys are at greater risk than girls(19) This implies that a number of potential risk factors
as shown in Fig. 1. influence language development in children, giving
details of those factors.
Birth order The literature suggests that factors that
Two studies demonstrate that the birth order significantly increase the risk of language impairment
effects children’s language development as shown in include antenatal care, Apgar scores, birth weight,
Figure 1. From the Horwitz et al study(17), the first born premature delivery, birth order, parental education,
children are two times more likely to gain benefits for environmental factors, gender of the children, number
language developmental skills than the later/single of siblings and family history with specific language
born child(17). Moreover, the results showed that later impairment. However, the roles of some factors are not
born children are 1.5 times more likely to have SLI than conclusive and need further investigation. These
children of first born order(18). include environmental factors such maternal age,
poverty, type of family. This review shows the clear
Parental education benefit of breast feeding on language development.
Three studies investigated parental education That is, the longer the duration of breast feeding, the
and children’s language development as shown in lower the risk of language impairment. While the studies
Fig. 1 and 2. Dollaghan et al(22) demonstrated that the have recently been completed, further research is
mean language score of mothers who completed less needed to determine the exact role of breast milk.
than high school was significantly lower than children
born to mothers who graduated from high school or References
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J Med Assoc Thai Vol. 89 No. 7 2006 1085

ปัจจัยทีม่ คี วามสัมพันธ์ตอ่ ความผิดปกติของพัฒนาการทางภาษาในเด็ก - การทบทวนวรรณกรรม

ปุญญพัฒน์ ไชยเมล์, บัณฑิต ถิน่ คำรพ, เจศฎา ถิน่ คำรพ

ที่มา: เด็กที่มีความผิดปกติทางด้านภาษาพบว่ามีความเสี่ยงและส่งผลต่อความผิดปกติทางด้านการเรียน และ

การเรียนรู้ในวัยที่สูงขึ้น จากบทสรุปวรรณกรรมที่เกี่ยวข้องให้ผลที่ไม่สอดคล้องกันในหลายประเด็น
วัตถุประสงค์: เพื่อที่จะศึกษาปัจจัยที่มีผลต่อการพัฒนาการทางด้านภาษาในเด็กจากการทบทวนวรรณกรรม
ที่เกี่ยวข้องอย่างเป็นระบบ
วัสดุและวิธีการ: การศึกษาครั้งนี้เป็นการทบทวนวรรณกรรมที่เกี่ยวข้องกับปัจจัยที่มีผลต่อพัฒนาการทางด้าน
ภาษาในเด็ก โดยทำการสืบค้นข้อมูลจากฐานข้อมูลทางอินเตอร์เน็ต วารสารวิชาการที่เกี่ยวข้อง การสืบค้นจาก
เอกสารอ้างอิงตามงานวิจัยที่ได้รับการตีพิมพ์ และฐานข้อมูลในเอกสารอ้างอิง โดยรวบรวมงานวิจัยที่ศึกษาถึง
ปัจจัยที่มีผลต่อพัฒนาการทางด้านภาษาในเด็กที่ได้รับการตีพิมพ์ตั้งแต่ปี พ.ศ. 2527 งานวิจัยถูกทำการคัดออก
ในกรณีที่ไม่ได้เป็นงานวิจัยต้นฉบับ
ผลการศึกษา: จากการทบทวนวรรณกรรมพบว่ามีงานวิจัยที่เกี่ยวข้องจำนวน 15 เรื่อง เป็นการศึกษาแบบ case -
control study จำนวน 1 เรือ่ ง, การศึกษาแบบ cross-sectional study จำนวน 1 เรือ่ ง และการศึกษาแบบ longitudi-
nal study จำนวน 13 เรือ่ ง ผลการศึกษาส่วนใหญ่แสดงให้เห็นว่ามีปจั จัยต่าง ๆ ทีม่ ผี ลต่อพัฒนาการทางภาษา ได้แก่
การฝากครรภ์, Apgar score, น้ำหนักทารกแรกคลอด, การคลอดก่อนกำหนด, ลำดับที่ของบุตร, การศึกษาของ
บิดามารดา, ปัจจัยทางสิ่งแวดล้อม, เพศ และประวัติครอบครัวที่มีผิดปกติทางด้านภาษา
สรุป: ปัจจัยก่อนและหลังตั้งครรภ์ และปัจจัยทางสิ่งแวดล้อมมีอิทธิพลต่อพัฒนาการทางภาษาในเด็ก ดังนั้น
ปัจจัยดังกล่าวควรได้รับการควบคุมในการศึกษาในรูปแบบของปัจจัยกวน (confounding factors) ในการศึกษา
ทางด้านพัฒนาการทางภาษาต่อไป

1086 J Med Assoc Thai Vol. 89 No. 7 2006