The main focus of this qualitative study was to review research on the link between preterm birth and language development in toddlers. Initially the purpose of the research was merely to establish links, but this morphed into a study of how researchers of language acquisition in toddlers were in agreement, where they differed in opinion and why. This allowed a broader analysis of researchers’ views on the impact of preterm birth on language development, affective factors and possible interventions.
As neonatal care steadily improves and preterm children have an increasingly greater survival rate, there is a greater need to assess outcomes for children born prematurely. Preterm birth is often associated with risks of difficulties later in childhood (Wood et al., 2000) and studies of preterm infants report cognitive, motor and communication difficulties and behavioural problems in early childhood and preschool years (de Waal et al., 2007). Studies have shown that children born preterm may be prone to delays in cognitive and language development compared to those children born full term and preterm birth has also been associated with longer term effects, such as poorer school performance and increased risk of ADHD (Bhutta, 2002). Children’s expressive vocabulary increases during their second year, reaching up to 2,000 words by the age of 3 (Dapretto, 2000) and as the toddler stage is such an important stage of language development, it was therefore chosen to be the focus age range for this study.
This study has been achieved by a qualitative analysis using metasynthesis, which combines research by several different studies to form general conclusions about the impact of preterm birth on the language ability of toddlers. Metasynthesis is a research method that can contribute to knowledge on this subject by ‘bringing together the detailed findings of several qualitative research studies offer a new interpretation of an existing research question’ (Sandelowski, Docherty, & Emden, 1997). This study utilizes the skills of another Psychology Masters graduate (Hannah Wilson) who participated in coding the data. Including another researcher on the problem greatly improved the validity and reliability of research as both researchers bring their own different ideas and preconceptions to the research.
My own daughter was born prematurely and is currently of toddler age, so I bring my own preconceptions to this study. My child was born into a bilingual household and she must learn to adapt to using several languages from birth. Although the impact of preterm birth on her language ability is as yet unknown, the innate and acquired language abilities that she will need to explore her world are of great personal interest to this researcher. As a teacher and Special Educational Needs Coordinator, this researcher is also interested in the interventions available to support children with speech and language difficulties and how children adapt to overcome language barriers.
The results of this study are mixed. Not all researchers agree being born preterm can have an impact on all areas of language development (for some children it has no impact) and while most researchers feel that being born preterm does have some impact on a children’s language abilities, some feel that eventually many children will be able to ‘catch up’ with their peers. Others disagree and feel that problems may extend all the way into adulthood. But despite the differences in results found between each body of research, this information should be of great interest to parents, educators and all other stakeholders involved in a child’s general development.
The initial question agreed between the researchers was ‘Is there a correlation between premature birth and language development in toddlers?’ There are different opinions on what forces shape language development that are worthy of our prior consideration. Nativists such as Noam Chomsky (1965), argue that language is a ‘unique human accomplishment, and can be attributed to evolution or neural organization grounded in physical law’. Chomsky says that all children have what is called an ‘innate language acquisition device’ (LAD). Theoretically, the LAD is an ‘area of the brain that has a set of universal syntactic rules for all languages’. This device provides children with the ability to ‘make sense of knowledge and construct novel sentences with minimal external input and little experience’ (Chomsky, 1965). This theory would suppose that the impact of preterm birth on language development is down to biological factors. The alternative empiricist view claims that children receive enough linguistic input from engaging with their environment so there is no need to assume an innate language acquisition device even exists. Empiricists believe that general brain processes are sufficient for language acquisition. For a child to learn a language the parent adopts a particular way of communicating with their child and this is called child-directed speech (CDS). Many more researchers embrace an interactionist perspective, consisting of social-interactionist theories of language development. In an interactionist approach, children ‘learn language in the interactive and communicative context, learning language forms for meaningful moves of communication’. These theories focus mainly on the ‘caregiver’s attitudes and attentiveness to their children in order to promote productive language habits’ (Poll, 2011).
In many ways this study supports the interactionist perspective that biological processes impact on a child’s development in the womb. But parents and caregivers can support healthy development and compensate for delay caused by the conditions of preterm birth and subsequent impact on language acquisition.
The SPIDER method was chosen to conduct the research and Qualitative Evidence Synthesis (Cooke et al., 2012). This method includes five steps that were helpful in narrowing down the field of study. Using the SPIDER tool, a systematic search was conducted to answer the research question (see Table 1. below). A full search was conducted on the Wolverhampton University Library databases, including the Psychology and the Behavioural Sciences Collection and PsycINFO (for psychology related research), the Wiley online library (for research on linguistics) and CINAHL and MEDLINE (for medical related research relating to Podiatry). Search terms were truncated where appropriate to guarantee all relevant articles were highlighted. Two researchers (Wilson, H. and Stones, E.) conducted searches independently, with results reviewed and refined by both researchers. The researchers then narrowed down the list of research articles to be coded to six (to improve validity). In terms of search criteria, journals were limited to those that had been peer reviewed (for reliability). For convenience this was narrowed to those that were available online and with open access. Again, to improve validity more current articles were sought, sorted by relevancy and published between the dates of 2010-2011. Particular attention was made to articles involving a study. Very few qualitative studies were found as studies in this field of research were found to be largely quantitative in nature. This was because the phenomenon lent itself to quantitative research (using standardized tests for IQ and language ability). However, during coding, the researchers looked at qualitative comments made by researchers, rather than the quantitative data that supported these comments. The researchers wanted to get a feel for researchers’ views on the phenomenon of interest and its causes (the link between preterm birth and language delay). From a total search of 30 full text articles, the researchers limited this field to 6 articles published in the last 11 years which the researchers felt most successfully linked language ability to preterm birth. This was largely determined by reading the articles and deciding how much emphasis was given to establishing the link.
Method of coding
Following the search using the SPIDER method, a thematic analysis was conducted to find information that would answer the research question. Thematic analysis is ‘a method for identifying, analysing and reporting patterns and themes within data’, as described by Braun & Clarke (2006). Following this model (see Table 2. An adapted 15 point checklist of criteria for good thematic analysis), the analysis was undertaken using the following steps:
- The first step was for the researchers to familiarize themselves with the data and to look for ‘patterns of meaning and issues of potential interest in the data’ (Braun & Clarke, 2006). This involved repeated reading, taking notes and highlighting sections of interest in the articles. From this an initial list was generated of ideas about what was in the data and what was interesting about it.
- The next stage involved generating initial codes from the the raw data, organising them into meaningful groups. Coding was theme driven, in order to answer specific questions. This was carried out manually using highlighters from printed versions of the texts, then by entering the highlighted sections into a simple table (See Appendices 1-7).
- The third phase involved searching for themes amongst the coded data. It emerged that not all the codes were really necessary and these were whittled down to make for a more concise report.
- Stages four and five involved reviewing and refining themes, then defining and naming them.
- The final stage involved producing the report and ‘tell the story ‘of the data (Braun & Clarke, 2006). This began when all the themes had been worked out. Extracts of the data were chosen to demonstrate the prevalence of the themes and narrative chosen to produce an argument in relation to the research question.
Table 2. An adapted 15 point checklist of criteria for good thematic analysis (Braun & Clarke, 2006).
The researchers used an adapted 15 point checklist of criteria for good thematic analysis, as proposed by Braun & Clarke (2006).
From the review of the literature and metasynthesis of the data, there does appear to be ample evidence to support a link between preterm birth and difficulties by toddlers in both receptive communication skills and expressive communication skills (See coding in Appendices 1-6).
Cattani et al. (2010) found preterm children had ‘smaller action/gesture repertoires at 12 and 15 months, but by 18 months this had disappeared’ (see Appendix 1.). Their research differed from other researchers in that they found that most children were able to counter the effects of preterm birth and catch up with their peers by the late toddler stage and that “…despite the significant biological risk that is engendered by premature birth, early communicative and linguistic development appears to proceed in a relatively robust fashion among preterm children”.
Mansson & Stjernqvist, 2014 (Appendix 2.) looked at extremely preterm children (born before 27 gestational weeks) and also found ‘significant lower cognitive, communicative and motor function levels at 2.5 years compared with children born at term’. Incidentally, they also found that even allowing for differences in ethnic groups, medical and psychosocial factors, language scores still differed. This might indicate that preterm children born into a bilingual household are perhaps at greater risk of language delay.
Sanchez et al., 2020 (Appendix 3.) also noticed a number of areas of specific deficit. They found that ‘children born 30 weeks differ from their term-born peers across a number of conversational language variables such as in pronouncing words and morphemes, sentence structures and number of different word roots’.
Loeb et al., (2020) (Appendix 4.) focussed on environmental reasons for delays in language development. Loeb points out that some children born preterm are not only ‘medically fragile; they are also apart from their families during a critical period of bonding’. According to psychiatrist and psychoanalyst John Bowlby, young children need to develop a relationship with at least one primary caregiver for normal social and emotional development (Cassidy J., 1999). Bowlby’s theories on attachment could also perhaps account for differences in language development. Loeb’s findings also support findings in other articles that not all children born preterm will have language, cognitive, and/or motor delays and good nurture can counter the effects of preterm birth.
Ross et al., (2018) (Appendix 5.) had mixed results. They found significant differences in expressive communication between preterm and full term but no difference in receptive communication. They did however find that girls performed better than boys in some areas of language development and concluded that motor control areas of the brain may be implicated in expressive language development of premature children. There may well be a neurological impact of being born preterm and this impact on language development may be greater in boys.
Brósch-Fohraheim et al. (2019) (Appendix 6.) found that German speaking children born preterm have a ‘15% smaller expressive vocabulary compared to children born full term’, highlighting that there are cross cultural similarities between language delays of preterm toddlers. The research differed in that there were significant differences in expressive communication but no difference in receptive communication. The researchers also included some useful information on interventions and also felt that providing timely and effective paternal or carer support for preterm might help them catch up on their expressive vocabulary acquisition as their findings indicated that there exists ‘a chance of catch up growth as far as expressive language is concerned’.
Overall, the analysis did achieve the aim of clarifying the link between preterm birth and early language development in toddlers. But it also allowed other factors to be considered, such as attachment, environmental factors and cultural differences, the effects of being born preterm on the neurological development of unborn babies, and the importance of assessing children’s abilities by their gestational age and not their chronological age. It also allowed the researchers (as educators) to consider what interventions might be necessary for developing the language of pre-school children and what long term effects they might have beyond the toddler stage.
This research is significant as there is much evidence from the researchers to suggest the strong link between language delay and being born preterm. The results also suggest that the negative effects of being born preterm can generally be reduced through careful parenting, but can sometimes be long lasting. Further research has indicated that many children ‘continue to have language, motor and cognitive difficulties throughout the school years’ (Joseph et al., 2016) and have a lower quality of life at adulthood (Baumann et al., 2016). Therefore those children born preterm will need additional support with their language development to prevent problems later on in life and knowledge of their preterm status can help inform a child’s eligibility for services (Loeb 2020)
Evidence supports the empiricist’s view that children born preterm are not only medically fragile, they are also apart from their families during a critical period of bonding, which could ‘impact on their ability to attach with their parents’ and ‘variables associated with preterm birth, rather than preterm birth itself, place preterm-born children at higher risk of poor language outcomes’ (Loeb, 2020).
Early identification of language difficulties is important ‘so that they receive appropriate speech and language therapy to develop expressive communication skills, crucial for normal special interactions and behaviour regulation’ (Ross et al., 2018)
The main problems found during coding were the ‘anything goes’ nature of this type of qualitative research and the ‘lack of clear and concise guidelines to coding’ (Antaki et al., 2003). The process is somewhat wasteful as lots of coding extracts end up on the cutting room floor. It was also difficult to maintain continuity as there were contradictions within the different articles. Also, there is a huge range of articles on the subject of language delay and preterm birth and the subject is well studied. The SPIDER method helped narrow down this large list and focus on a good sample of research articles. Working with a research partner who was generally in absentia was also challenging. However, the process did provide a great deal of flexibility and lead to insightful analysis of new areas of interest. Future research should focus on what interventions work and are available to resolve the challenges preterm toddlers have in language acquisition.
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