Are They Associated with Early Word Production and Neurodevelopmental Abilities at the Preschool Age? Peter B

Early Human Development (2007) 83, 107—114

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Events at early development: Are they associated with early word production and neurodevelopmental abilities at the preschool age? Peter B. Marschik, Christa Einspieler *, Bettina Garzarolli, Heinz F.R. Prechtl

Institute of Physiology (Developmental Physiology and Developmental Neurology), Center for Physiological Medicine, Medical University of Graz, Harrachgasse 21, 8010 Graz, Austria

Accepted 18 May 2006

KEYWORDS Abstract Apgar score; Birth order; Background: Obstetrical and neonatal complications and/or an adverse parenting environment Cognition; are risk factors for language impairment, but little is known about their effects on early word Language; production (late talking). Late talker; Aims: To determine obstetrical and neonatal risk factors in children with delayed word Minor neurological dys- production; to assess the influence of the parenting environment on word production; to function (MND); determine whether the toddler’s vocabulary competence is related to his/her social Neonatal intensive care; competence; to document the neurodevelopmental outcome at the late preschool age. Obstetrics; Study design: Prospective follow-up study. Based on word production at 18 months, children Parental environment; were retrospectively classified into consistent or transient late talkers and controls. Perinatal optimality Subjects: Full-term infants, N =30 (mean GA 40.3F1.1 weeks, mean birth weight 3577F score; 267 g) were assessed at 18 and 24 months; and 5 years and 7 months. Social competence Methods: Austrian Communicative Development Inventories; Bayley Scales of Infant Development; Griffiths Developmental Scales. Outcome measures: Peabody Picture Vocabulary Test; Kaufman Assessment Battery for Children; Touwen’s neurological examination. Results and Conclusions: Lower Apgar scores and the need for neonatal intensive care were associated with delayed word production. The parents’ educational and vocational levels were lower in late talkers. Early vocabulary competence correlated with social competence. With regard to the prediction of lexical and cognitive outcomes, late talkers did not differ from controls. Minor neurological dysfunctions (MND) were seen in nearly half of the late talkers and indicate the necessity to follow these children into school age, when MND might become more obvious and literacy can be assessed. D 2006 Elsevier Ireland Ltd. All rights reserved.

* Corresponding author.x Fax: +43 316 380 9630. E-mail address: [email protected] (C. Einspieler).

1. Introduction competence was related to his/her social competence; and finally, to document the neurodevelopmental outcome at the Considering the immense complexity of language acquisi- late preschool age. tion, it is not surprising to note that the onset of word production is delayed in 10—14% of children [1,2]. As half of these children will catch up with their peers within a year or 2. Methods so [2], clinicians and researchers hesitate to use the term dlanguage impairedT in connection with these children. 2.1. Participants Instead, they are labelled dlate talkersT. At 24 months, late talkers speak some 50 words or even less and do not yet Sixty-two children were enrolled in an ongoing longitudinal combine them [3]. Usually, they are identified by scoring in study concerning various aspects of motor, cognitive and the lowest 10% [1,4] on the MacArthur—Bates Communicative language development. They were recruited at the Depart- Development Inventories (CDIs) [5], one of the most fre- ment of Obstetrics and Gynaecology of the Graz University quently used parental report forms to document early Hospital as well as at three private maternity clinics in Graz, vocabulary acquisition [6]. Around 7% of late talkers develop Austria. The inclusion criteria were as follows: singleton specific language impairments at the age of 5 years [2], and birth at term, an appropriate birth weight (Table 1), and are likely to develop reading, writing, behavioural, social, residing in or close to Graz. For the part of the project and schooling problems later on [7—10]. dealing with language development, we only included Neonatal complications may place children at risk for monolingual Austrian—German speaking families (N =58). delayed or even impaired language development [9,11—14]. At the age of 18 months, ten girls and five boys (N =15) Furthermore, smoking during pregnancy [15,16], low ma- spoke less than 25 words, which is below the 10th CDI ternal education, and/or a low household income may be percentile [5]. Seven of them consistently remained below indicators of an adverse parenting environment that affects the 10th CDI percentile until 24 months (Group A, late talkers; early language capacities [17—19]. ¶—… in Figs. 1 and 2). In addition, none of them had To our knowledge, only a few prospective studies have multiword combinations at 24 months. The remaining eight investigated the neurodevelopment of late talkers over a toddlers improved to normal language production at the longer period of time. Even after the vocabulary size had latest at 24 months (Group B, transient late talkers; ‹—‡ in moved into the normal range, many late talkers continued to Figs. 1 and 2). From the original study group, we randomly exhibit deficits [7], such as problems in short-term memory or selected 15 controls (Group C; o in Figs. 1 and 2) with an auditory processing of complex information [10], or other average vocabulary production (80—120 words) at 18 months, cognitive [20] or neurological impairments [21,22]. Our own individually matched for each case in Group A and B by gender prospective follow-up study concerning various aspects of and date of birth (F5 days). Thus, the final sample consisted development allowed us to retrospectively select 18-month- of 30 children. The children’s parents had given their written old toddlers whose CDI scores were below the 10th percen- informed consent to participate in the longitudinal study; the tile. Based on parental reports and direct observation at 24 study has been approved by the Austrian Ethics Committee. months, we divided the children into those with a consistent or a transient delay in word production. The aims of this study 2.2. Word production reported by parents and were fourfold: to determine obstetrical and neonatal risk observed directly factors in children with delayed word production; to assess the influence of the parenting environment on early language The Austrian CDIs [23] are age-related parental report forms production; to determine whether the toddler’s vocabulary for infants and toddlers adapted from the MacArthur—Bates

Table 1 Obstetrical, neonatal and socio-economic data Group A, N =7 Group B, N =8 Group C, N =15 p-value Girls/boys 4/3 6/2 10/5 Gestational age in weeks; mean (S.D.) 40.4 (1.3) 39.7 (0.5) 40.7 (1.2) n.s. Birth weight in grams; mean (S.D.) 3688 (475) 3553 (147) 3722 (382) n.s. Apgar score at 5 min; median (IQR) 8.9 (8—10) 8.7 (7.8—9.3) 10 (10—10) p b0.01 Neonatal intensive care 2 3 — p b0.05 Length of hospital stay in days; median (IQR) 5 (4—5) 4 (4—6) 4 (3—4) p b0.01 Perinatal optimality score; median (IQR) 50 (47—52) 48.5 (46—51) 50 (47—51) n.s. Birth order; median (IQR) 2 (2—3) 1 (1—2) 1 (1—2) p b0.01 First-borns — 6 11 p b0.01 Family size; median (IQR) 5 (4—5) 4 (3—4) 3 (3—4) p b0.01 Householder’s education and vocation; med. (IQR) 3 (3—4) 3 (1—4) 2 (2—3) p b0.05 Maternal education; median (IQR) 3 (3—3) 2 (1—3) 2 (2—3) p b0.05 Maternal smoking during pregnancy — 2 2 n.s. Maternal smoking after delivery — — 2 n.s. Paternal smoking 2 4 4 n.s. Events at early development 109

Figure 1 Developmental trajectories of word production (18 to 24 months), lexical knowledge (PPVT-III [28]), and cognitive abilities (K-ABC [29]) at the late preschool age of seven consistent late talkers (Group A, ¶ to …), eight transient late talkers (Group B, ‹ to ‡), and 15 matched controls (Group C, ). P, percentiles; m, months; Austrian-CDI, Austrian Communicative Development Inventory ([23]); PPVT-III, Peabody Picture and Vocabulary Test; K-ABC, Kaufman-Assessment Battery for Children; Sequential, K-ABC sequential processing scale; Simultaneous, K-ABC simultaneous processing scale.

CDIs [5] with the permission of the CDI advisory board. We [5] (extrapolated for the slightly divergent number of used the toddler CDI, which consists of a 698-item vocab- items), as no Austrian CDI standardisation exists. However, ulary checklist organised into 23 categories [23].The cross-linguistic analyses on quantitative aspects of early MacArthur—Bates CDI for toddlers [5] consists of 680 vocabulary development have demonstrated similarities vocabulary items, which is 18 items less than the adapted across languages [24]. Austrian version. The slightly divergent number of items is All subjects were tested with the Bayley Scales of Infant due to language- and culture-specific adaptations. The Development [25] and the German version of Griffiths parents filled the CDI every 2 months from the age of 18— Developmental Scales [26] at 18 and 24 months. For the 24 months. We had to use the MacArthur—Bates percentiles purpose of the present study, we selected the productive 110 P.B. Marschik et al.

Figure 2 Neurological performance at the late preschool age in respect to the children’s word production during their second year of life (consistent late talkers ¶ to …; transient late talkers ‹ to ‡; and controls, ). MND, Minor Neurological Dysfunction. language items: eight items from the Bayley mental scale, Lexical knowledge, i.e., the receptive single-word vo- two items from the Griffith subscale dpersonal—social cabulary in response to pictorial stimuli, was assessed using competenceT (B scale), and eleven items from the Griffith the third edition of the Peabody Picture Vocabulary test subscale dhearing and speechT (C scale). The two items (PPVT-III) [28]. To assess cognitive abilities we applied the shared by both scales were scored on a one-time basis. German version of the Kaufman Assessment Battery for Thus, a total of 19 items were scored: the child names one Children (K-ABC) [29]. The age-specific subtests dhand to four objects, one to five pictures, names different movementsT, dnumber recallT, and dword orderT were used edibles, says one to 20 words, uses words to make needs to assess sequential processing; the subtests dgestalt known, and talks about events. For statistical computation, closureT, dtrianglesT, dmatrix analogiesT, and dspatial mem- we used the number of items passed. The examiner (B.G.) oryT were applied to assess simultaneous processing. was not aware of the results of the parental checklists After a break of approximately 15 min, all participants (Austrian CDIs). underwent a Touwen’s neurological examination [30], which is a detailed age-specific assessment aimed at 2.3. Obstetrical, neonatal and socio-economic data detecting minor deviations in neural functions. Based on the data of the Groningen Perinatal Project, six clusters of The medical charts of infants and mothers were reviewed dysfunctional signs were defined [31]: dysfunctional mus- and the obstetrical and neonatal factors were listed for a cle tone regulation, reflex abnormalities, choreiform comparison between the three groups. Prechtl’s optimality dyskinesia, coordination problems, dysfunction in fine concept [27] was applied to a list of 57 items referring to manipulative abilities, and rarely occurring miscellaneous pregnancy, delivery and early postnatal history. Optimal disorders (such as an excessive amount of associated conditions were predefined. For each non-optimal item, one movements for age, or mild cranial nerve palsy). Had- point was subtracted from the maximum score of 57, ders-Algra [32] distinguished two forms of minor neurolog- resulting in a quantification of reduced optimality. ical dysfunction (MND): simple MND and complex MND. The Socio-economic data were ascertained by summarising criteria for these two forms are age-specific and based on the householder’s educational and vocational levels, developmental changes in the nervous system [30—32]. expressed on a scale from 1 (highest) to 5 (lowest). Maternal Between the age of 4 years and the onset of puberty, the educational level was rated on a scale from 1 (university distinction between simple and complex MND is based on degree) to 5 (compulsory education). the number of clusters of dysfunction. Simple MND is defined by one or two clusters of dysfunction, whereas 2.4. The toddler’s social competence children with complex MND exhibit three or more clusters of dysfunction [32]. The assessments were carried out at the Institute of In order to measure the level of independence in daily life Physiology of the Medical University of Graz. Data on word and general social competence, the subscale dpersonal— production from 18 to 24 months were not known to the social competenceT (B scale) of the Griffiths Developmental examiners (CE and HFRP). The neurological examination was Scales [26] was applied at 18 and 24 months. video-taped. Choreiform movements, the quality of fine manipulation, coordination of the extremities, and the 2.5. Neurodevelopmental assessments at the late occurrence of associated movements were analysed by CE preschool age from the video. In addition, all videotapes were viewed by HFRP, whose judgement coincided with that of CE (Kap- All assessments were performed within a 2-week window pa=0.94). when the children were 5 years and 7 months old. Typically, None of the participants experienced a severe medical Austrian children enter kindergarten at 3 years and elemen- condition, an accident, or a significant life event that might tary school at 6 years of age. We therefore refer to 5 years have influenced his/her language, cognitive or motor and 7 months as the dlate preschool ageT. development. Events at early development 111

2.6. Statistical analysis 3.3. Social competence

None of the data were normally distributed. Using SPSS Consistent late talkers scored significantly lower in the 13.0, the Kruskal—Wallis Test and the Mann—Whitney U- dpersonal—social competenceT scale than did transient late Test were applied to determine differences between the talkers and controls at 18 months (Kruskal—Wallis test, average ranks of the groups. Fisher’s Exact Test and p b0.01), and 24 months ( p b0.05; Table 2). In addition, Pearson’s Chi-Square Test were used in cross-tables. direct language assessment correlated significantly with Spearman-Rho Correlation Coefficient was applied to dpersonal social competenceT at 24 months (Pearson’s measure relationships between ordinal and metric scales. correlation coefficient r =0.81, p b0.001) but not at 18 Pearson’s Correlation Coefficient was used on metrical months (r =0.27, n.s.). Parental environmental data were data. A p-value less than 0.05 was considered significant. significantly associated with the child’s social competence (Table 2).

3. Results 3.4. Neurodevelopmental outcome at the late preschool age At 18 months, late talkers (Group A) passed a median of 5 productive language items (IQR: 4 to 7). Transient late 3.4.1. Lexical knowledge talkers (Group B) were similar (median: 7, IQR: 4 to 8). The The PPVT-III scores did not differ between the three groups median of the controls was significantly higher (10, IQR: 9 to (Kruskal—Wallis test, n.s.). Only one of the five preschool b 17; Kruskal—Wallis test, p 0.01). Six months later, transient children in the lowest quartile was a late talker (‚ in Fig. 1). late talkers caught up with controls, both with a median of On the other hand, none of the consistent late talkers scored 17 (IQR: 16 to 19), whereas late talkers scored significantly above P50 (Fig. 1). By and large, neonatal and socio- b lower (11, IQR: 10 to 14; Kruskal—Wallis test, p 0.01). economic data were not associated with lexical knowledge Pearson’s correlation coefficients between parental reports at the late preschool age (Mann—Whitney U test and b and direct observation were r =0.44 ( p 0.05) at 18 months Spearman-Rho correlation coefficient, n.s.). However, b and r =0.51 ( p 0.05) at 24 months. first-borns (N =17) scored significantly higher on the PPVT- III than did children who were not first-borns (Mann— 3.1. Obstetrical and neonatal history Whitney U test and Spearman-Rho correlation coefficient r = À0.67; p b0.001), irrespective of the group they Obstetrical variables, gestational age, and birth weight did belonged to. not account for slower language development. In addition, the perinatal optimality score was not related to the 3.4.2. Cognitive abilities development of word production (Kruskal—Wallis test and The mean ranks of the K-ABC standard scores did not differ Pearson’s correlation coefficient, n.s.; Table 1). Due to between the three groups (Kruskal—Wallis test, n.s.; Fig. 1). ‚ respiratory problems or hyperbilirubinaemia, five of the 30 Again, late talker remained in the lowest K-ABC quartile participants (”…ﬂ†) received neonatal intensive care; (Fig. 1). Neonatal and socio-economic data were not related all of them scored below the 10th CDI percentile at 18 to later cognitive abilities (Mann—Whitney U test and months (Fisher’s exact test, p b0.05; Table 1). The Apgar Spearman-Rho correlation coefficient, n.s.). score at 5 min was significantly lower for late talkers as compared to controls (Kruskal—Wallis test, p b0.01). Fur- 3.4.3. Neurological performance thermore, their postnatal hospital stay was longer (Kruskal— All controls were neurologically normal at the late preschool Wallis test, p b0.01; Table 1). The birth order for late talkers age. Seven late talkers, four of them consistent and three (Group A) was higher than that for transient late talkers and b controls (Kruskal—Wallis test, p 0.01). Moreover, none of Table 2 Median (IQR) of the subscale B of the Griffiths the late talkers (Group A) were first-borns (Fisher’s exact developmental scales (personal—social competence) [26]; b test, p 0.01; Table 1). Spearman-Rho correlation coefficient between this subscale and the socio-economic variables 3.2. Parenting environment Social competence With the exception of one control, all children grew up with At 18 months At 24 months both parents. The family size was largest in late talkers Group A 92 (88—102) 89 (86—98) (Kruskal—Wallis test, p b0.01; Table 1). The householder’s Group B 111 (102—115) 100 (98—105) educational and vocational level was lower in late talkers Group C 108 (105—117) 100 (96—110) (consistent and transient) than in controls (Kruskal—Wallis p-value p b0.01 p b0.05 test, p b0.05). Mothers of consistent late talkers had a lower Householder’s education r =À0.02 r =À0.43 education level (Kruskal—Wallis test, p b0.05; Table 1). and vocation n.s. p b0.05 However, these socio-economic data were not related to Maternal education r =À0.21 r =À0.47 lexical knowledge at the late preschool age (Spearman-Rho n.s. p b0.05 correlation coefficient, n.s.). Parental smoking was not Family size r =À0.48 r =À0.60 associated with a delay in word production (Chi-Square test, p b0.01 p b0.01 n.s.; Table 1). 112 P.B. Marschik et al. transient, had a neurological dysfunction in at least one CDI authors [5,6], namely, that the CDI norms may not be cluster (Fisher’s Exact test, p b0.01); case even in two applicable to children from low-education/low-income clusters (Fig. 2). All of them were girls. In accordance with families. Although none of the families participating in our Hadders-Algra’s definition [32], these children were classi- study was assigned the lowest score for income and/or fied as simple MND. The results of the neurological education, we are aware of the fact that parental checklists assessment were not related to lexical knowledge or do have certain limitations. Nothing can be said about cognitive abilities at the same age (Mann—Whitney U test, phonological development or about the frequency with n.s.). Three girls with simple MND required postnatal which children use particular vocabulary types. On the intensive care treatment. Apgar scores were significantly other hand, it is only the parents who are able to observe related to neurological performance at the late preschool their child in the natural surroundings, even without the age. Children with simple MND had a lower Apgar score at 5 child’s co-operation. Parental checklists correlated posi- min (median: 9, IQR: 7 to 9) than did neurologically normal tively with spontaneous speech analyses and with other children (median: 10, IQR: 8 to 10; Mann—Whitney U test, laboratory assessments, including the Bayley language p b0.05). scores [3,6,44,45]. Our moderate correlation between CDI and direct assessment of early vocabulary development suggested that both methods should supplement rather than 4. Discussion substitute each other. A number of studies reported a significant relation Every fifth child with specific language impairment had pre- between prenatal cigarette exposure and lower language and perinatal problems [13,14]. However, very little is scores from the second year of life [16] to the preschool age known about pre- and perinatal problems affecting early [15,46]. Only four children in our study had been exposed to word production. The majority of the studies on this subject nicotine prenatally. Two mothers stopped smoking after were carried out in low birth weight infants, usually born delivery. The remaining two belonged to the control group. preterm, or in twins, and revealed controversial results The incidence of paternal smoking was somewhat higher, but [12,33,34]. In our study, all obstetrical variables as well as equally distributed between the groups. Besides, the the perinatal optimality score, which is a composite smoking habits of our families were not related to income measure of perinatal factors, were not related to early or educational level. vocabulary competence. However, our children were born at Children with specific speech and language difficulties term and with an appropriate birth weight. Interestingly, a were reported to have a poorer social cognitive knowledge lower Apgar score at 5 min and the need for neonatal [47] and an impaired social relationship at home as well as intensive care were associated with late talking at 18 in school [48]. A few studies only focussed on the child’s months. In this regard, our findings compared well with social and verbal competence during the second year of the results of two Scandinavian studies [11,35]. Worthy of life, and found a delay in word production to be associated note is the fact that this association existed irrespective of with poor social competence [49,50]. We also observed that whether late talking remained consistent or whether the consistent late talkers scored lower on the personal—social children had caught up with their peers 6 months later. competence scale than did transient late talkers or As our study did not reveal an association between early controls. As late talking was associated with lower maternal word production and PPVT-III scores at the preschool age, education and family income (Table 1), the latter also we anticipated no effect of obstetrical or neonatal risk contributed to the social competence score of 2-year-olds. factors on preschool lexical knowledge. In fact, this was in The user’s manual of the Griffiths’ scales mentions no accordance with previous findings [36,37]. It was surprising effect of socio-economic status on its scores [26]. Despite to note that the first-borns’ vocabulary competence our controversial results, we fully agree with Brandt and exceeded that of children who were not first-borns during Sticker [51] in that it is the quality of parental care rather the second year of life and also before entering school. This than income or education that influences the child’s finding gives rise to another controversial discussion. Some development. Interestingly, children from smaller families authors reported that first-borns scored higher in verbal scored better in the personal—social competence scale than achievement [18,38],whereasothersdidnotprovide did children from larger families. In this regard, it should be evidence in support of a birth order effect in language noted that, particularly in the Griffiths subscale B, a development [39]. Bornstein et al. [40] emphasised that it number of items are scored by interrogating the mother was mainly the maternal report, and not the experimenter’s rather than by direct observation. This is important, as a assessment, that overestimated the vocabulary competence recent study showed that sensitivity, specificity, and the of first-borns. However, our data revealed a birth order negative predictive value of maternal opinion of child effect irrespective of age and the method used. development increased with maternal education and family Several studies showed a substantial effect of maternal income [52]. educational level and household income on language Although none of the consistent late talkers scored above development [17,18,41,42]. The majority of the studies the median of the PPVT-III at 5 years and 7 months, the were focused on children older than 3 years; some of them lexical knowledge at this age could not be predicted from also used the PPVT as an outcome measure [19,37]. We were language assessments during the second year of life. Apart unable to confirm such an effect for the preschooler’s from late talker ‚, two controls and two transient late lexical knowledge, but early word production was related to talkers scored in the lowest PPVT-III quartile (Fig. 1). The lower parental educational and vocational levels. Arriaga et two studies reporting a significant correlation between the al. [43] emphasised the precautionary statement issued by number of words spoken during the second year of life and Events at early development 113 lexical knowledge at the preschool age were carried out in References families with a low income [45] and mothers with a low education level [53]. It is interesting to note that the [1] Thal DJ, Bates E, Goodman J, Jahn-Samilo J. Continuity of parental environment of our participants did not affect the language abilities: an exploratory study of late- and early- PPVT-III scores, although such an effect did exist until 24 talking toddlers. Dev Neuropsychol 1997;13:239–73. months. The predictive validity from CDIs to the PPVT was [2] Hart H. Speech and language disorders and associated problems: meeting children’s needs. Dev Med Child Neurol reported to be stronger in the rural than in the urban 2004;46:435 [Editorial]. community [45]. All of our participants lived in an urban [3] Rescorla L. The language developmental survey: a screening environment. Finally, those studies [45,53] applied the PPVT tool for delayed language in toddlers. J Speech Lang Hear Res at the age of 3—4 years. 1989;54:587–99. Reasonable concurrent, and also predictive validity, was [4] Bates E, Dale PS, Thal D. Individual differences and their recently reported for more than 100 children scored on the implications for theories of language development. In: Fletcher CDI and tests of cognition at 2—3 years of age [54]. Our P, MacWhinney B, editors. Handbook of child language. Oxford7 cognitive measures at the late preschool age showed no Basil Blackwell; 1995. p. 1–32. evidence of subtle cognitive deficits in late talkers, but [5] Fenson L, Dale PS, Reznick JS, Thal D, Bates E, Hartung JP, et again, we assessed a different age group. al. MacArthur communicative development inventories. User’s guide and technical manual. San Diego, CA7 Singular Publishing; Rapid skilled movements and language have been 1993. hypothesised to share a common neural basis [55]. General [6] Fenson L, Dale PS, Reznick JS, Bates E, Thal DJ, Pethick SJ. difficulties in programming coordinated sequences of motor Variability in early communicative development. Monogr Soc movements have been found to co-exist with language Res Child Dev 1994;59:1–185. delays [13,20,55]. The motor deficits reported in these [7] Weismer SE, Murray-Branch J, Miller JF. A prospective longitu- children were, however, not necessarily restricted to tasks dinal study of language development in late talkers. J Speech involving rapid programming of sequential movements. Lang Hear Res 1994;37:852–67. Balancing on one leg proved to be one of the most [8] Bishop DVM. How does the brain learn language? Insights from discriminating measures between children with specific the study of children with and without language impairment. language impairment and controls [21]. In our study, all The 1999 Ronnie Mac Keith Lecture. Dev Med Child Neurol 2000;42:133–42. seven preschool children exhibiting dysfunctions in one or [9] Wolke D. Language problems in neonatal at risk children: two neurological clusters (simple MND [32]) were identified towards an understanding of developmental mechanisms. Acta aslatetalkersat18months(Fig. 2). Four of them Paediatr 1999;88:488–90. exhibited a 6-month consistent language delay. Although [10] Rescorla L. Age 13 language and reading outcomes in late- children with MND had a lower Apgar score than neurolog- talking toddlers. J Speech Lang Hear Res 2005;48:459–72. ically normal children, only case … had both, a lower Apgar [11] Jennische M, Sedin G. Speech and language skills in children score and a consistent delay in word production. Simple who required neonatal intensive care: evaluation at 6.5 y of MND is the most frequently encountered form of MND at age based on interviews with parents. Acta Paediatr 1999;88: preschool and school age, but is of limited clinical 975–82. significance. It reflects the presence of a normal, but [12] Cusson RM. Factors influencing language development in preterm infants. J Obstet Gynecol Neonatal Nurs 2003;32:402–9. non-optimally wired brain [32]. It has been suggested that [13] Selassie GR, Jennische M, Kyllerman M, Viggedal G, Hartelius L. motor and language problems share a common underlying Comorbidity in severe developmental language disorders: mechanism, such as cerebellar impairment [56,57]. The neuropediatric and psychological considerations. Acta Paediatr coordination difficulties of late talkers „, » and … are 2005;94:471–8. indicative of cerebellar dysfunction [30], whereas the [14] Nelson HD, Nygren P, Walker M, Panoscha R. Screening for choreiform movements of late talker ¶ could be attributed speech and language delay in preschool children: systematic to basal ganglia dysfunction [58]. evidence review for the US Preventive Services Task Force. As the frequency of MND is expected to increase with age Pediatr 2006;117:298–319. [31,32], we intend to follow our sample at school age and re- [15] Tomblin JB, Hammer CS, Zhang X. The association of investigate their neurological performance, as well as their parental tobacco use and SLI. Int J Lang Commun Disord 1998;33:357–68. reading and writing ability, as the latter is believed to be [16] Delaney-Black V, Covington C, Templin T, Kershaw T, Nord- more likely impaired in previously identified late talkers strom-Klee B, Ager J, et al. Expressive language development [8,10]. of children exposed to cocaine prenatally: literature review and report of a prospective cohort study. J Commun Disord 2000;33:463–80. Acknowledgements [17] McAllister L, Masel C, Tudehope D, O’allaghan M, Mohay H, Rogers Y. Speech and language outcomes 3 years after neonatal This study was supported by the Austrian Science Fund intensive care. Eur J Disord Commun 1993;28:369–82. (FWF), project number P16984-B02. We are grateful to Dr. [18] Stanton-Chapman TL, Chapman DA, Bainbridge NL, Scott KG. Ralf Vollmann, Institute of Linguistics, University of Graz, Identification of early risk factors for language impairment. Res Dev Disabil 2002;23:390–405. for his help in adapting the CDIs into Austrian German; to [19] To T, Guttman A, Dick PT, Rosenfield JD, Parkin PC, Tassoudji M, Professor Ulrike Willinger, University of Vienna, for providing et al. Risk markers for poor developmental attainment in young the German PPVT item list, and to Mrs. Sujata Wagner for children: results from a longitudinal national survey. Arch revision and editing. We are also highly indebted to the Pediatr Adolesc Med 2004;158:643–9. parents and children involved in the study for their [20] Bishop DV, Edmundson A. Specific language impairment as a cooperation. maturational lag: evidence from longitudinal data on lan- 114 P.B. Marschik et al.

guage and motor development. Dev Med Child Neurol 1987; [40] Bornstein MH, Leach DB, Haynes OM. Vocabulary competence 29:442–59. in first- and second-born siblings of the same chronological [21] Powell RP, Bishop DV. Clumsiness and perceptual problems in age. J Child Lang 2004;31:855–73. children with specific language impairment. Dev Med Child [41] Weindrich D, Jennen-Streinmetz C, Laucht M, Esser G, Schmidt Neurol 1992;34:755–65. MH. At risk for language disorders? Correlates and course of [22] Valtonen R, Ahonen T, Lyytinen P, Lyytinen H. Co-occurrence of language disorders in preschool children born at risk. Acta development delays in a screening study of 4-year-old Finnish Paediatr 1998;87:1288–94. children. Dev Med Child Neurol 2004;46:436–43. [42] Campbell TF, Dollaghan CA, Rockette HE, Paradise JL, Feldman [23] Marschik PB, Einspieler H, Vollmann R, Einspieler C. Lexiko- HM, Shriberg LD, et al. Risk factors for speech delay of unknown nerwerb im zweiten und dritten Lebensjahr: Wie viel erz7hlen origin in 3-year-old children. Child Dev 2003;74:346–57. uns die ersten Wfrter? LOGOS Interdiszip 2005;13:8–14. [43] Arriaga RI, Cronan T, Pethick SJ. Scores on the MacArthur [24] Bornstein MH, Cote LR, Maital S, Painter K, Park SY, Pascual L, Communicative Development Inventory of children from low- et al. Cross-linguistic analysis of vocabulary in young children: and middle-income families. Appl Psycholinguist 1998;19:209–23. Spanish, Dutch, French, Hebrew, Italian, Korean and American [44] Dyer Ring E, Fenson L. The correspondence between parent English. Child Dev 2004;75:1115–39. report and child performance for receptive and expressive [25] Bayley N. Bayley scales of infant development. San Antonio7 vocabulary beyond infancy. First Lang 2000;20:141–59. TX: The Psychological Corporation, Harcourt Brace; 1969. [45] Pan BA, Rowe ML, Spier E, Tamis-LeMonda C. Measuring [26] Brandt I. Griffiths Entwicklungsskalen (GES) zur Beurteilung productive vocabulary of toddlers in low-income families: der Entwicklung in den ersten beiden Lebensjahren. Weinheim, concurrent and predictive validity of three sources of data. Basel7 Beltz; 1983. J Child Lang 2004;31:587–608. [27] Prechtl HFR. The optimality concept. Early Hum Dev 1980; [46] Fried PA, O’Connell CM, Watkinson B. 60- and 72-month follow- 4:201–5. up of children prenatally exposed to marijuana, cigarettes, [28] Dunn LM, Dunn LM. PPVT-III, Peabody picture vocabulary test. and alcohol: cognitive and language assessment. J Dev Behav Examiner’s Manual. 3rd edition. Circle Pines, MA7 American Pediatr 1992;13:383–91. Guidance Service; 1997. [47] Marton K, Abramoff B, Rosenzweig S. Social cognition and [29] Melchers P, Preug U. K-ABC Kaufman assessment battery for language in children with specific language impairment (SLI). children. German version6th edition. Leiden7 PITS; 2003. J Commun Disord 2005;38:143–62. [30] Touwen BCL. Examination of the child with minor neurological [48] Lindsay G, Dockrell J. The behaviour and self-esteem of dysfunction. 2nd edition. Clin Dev Med, vol. 71. London7 children with specific speech and language difficulties. Br J Heinemann; 1979. Educ Psychol 2000;70:583–601. [31] Hadders-Algra M, Huisjes HJ, Touwen BCL. Perinatal corre- [49] Bornstein MH, Haynes OM. Vocabulary competence in early lates of major and minor neurological dysfunction at school childhood: measurement, latent construct, and predictive age: a multivariate analysis. Dev Med Child Neurol 1988; validity. Child Dev 1998;69:654–71. 30:472–81. [50] Horwitz SM, Irwin JR, Briggs-Gowan MJ, Bosson Heenan JM, [32] Hadders-Algra M. Two distinct forms of minor neurological Mendoza J, Carter AS. Language delay in a community cohort of dysfunction: perspectives emerging from a review of data of young children. J Am Acad Child Adolesc Psych 2003;42:932–40. the Groningen Perinatal Project. Dev Med Child Neurol 2002; [51] Brandt I, Sticker EJ. Griffiths Entwicklungsskalen zur Beurtei- 44:561–71. lung der Entwicklung in den ersten beiden Lebensjahren. [33]ByrneJ,EllsworthC,BoweringE,VincerM.Language Goettingen7 Beltz Test; 2001. development in low birth weight infants: the first two years [52] de Lourdes Drachler M, de Castro Aerts DG, de Souza RM, de of life. J Dev Behav Pediatr 1993;14:21–7. Carvalho Leite JC, Giugliani EJ, Marshall T. Social inequalities [34] Rutter M, Thorpe K, Greenwood R, Northstone K, Golding J. in maternal opinion of child development in southern Brazil. Twins as a natural experiment to study the causes of mild Acta Paediatr 2005;94:1137–9. language delay: I. Design; twin-singleton differences in lan- [53] Reese E, Read S. Predictive validity of the New Zealand guage, and obstetric risks. J Child Psychol Psychiatry 2003;44: MacArthur communicative development inventory: words and 326–41. sentences. J Child Lang 2000;27:255–66. [35] Jensen TS, Boggild-Andersen B, Schmidt J, Ankerhus J, Hansen [54] Feldman HM, Dale PS, Campbell TF, Colborn DK, Kurs-Lasky M, E. Perinatal risk factors and first-year vocalizations: influence Rockette HE, et al. Concurrent and predictive validity of on preschool language and motor performance. Dev Med Child parent reports of child language at ages 2 and 3 years. Child Neurol 1988;30:153–61. Dev 2005;76:856–68. [36] Wesley BD, van den Berg BJ, Reece EA. The effect of forceps [55] Preis S, Schittler P, Richter-Werkle, Sterzel U, Lenard HG. delivery on cognitive development. Am J Obstet Gynecol Typical pattern of the Kaufman-assessment battery in children 1993;169:1091–5. with developmental language disorder. Neuropediatr 1997; [37] O’Callaghan M, Williams GM, Andersen MJ, Bor W, Najman 28:328–32. JM. Social and biological risk factors for mild and [56] Diamond A. Close interrelation of motor development and borderline impairment of language comprehension in a cognitive development and of the cerebellum and prefrontal cohort of five-year-old children. Dev Med Child Neurol 1995; cortex. Child Dev 2000;71:44–56. 37:1051–61. [57] Viholainen H, Ahonen T, Cantell M, Lyytinen H. Development of [38] Breland HM. Birth order, family configuration, and verbal early motor skills and language in children at risk for familial achievement. Child Dev 1974;45:1011–9. dyslexia. Dev Med Child Neurol 2002;44:761–9. [39] Tomblin JB. The effect of birth order on the occurrence of [58] Prechtl HFR, Stemmer CJ. The choreiform syndrome in developmental language impairment. Br J Disord Commun children. Dev Med Child Neurol 1962;4:119–27. 1990;25:77–84.