Effect of Parents’ Involvement Interventions in Speech Language Delay among Late Talking Toddlers in Egypt: A Quasi-Experimental Study

Talking is one of the most important visible developmental achievements of early childhood [1]. Given that ability to make intelligible speech and language is an important correlate of child’s overall development and intellect, the diagnosis of speech delay is made when a child does not achieve this developmental milestone at the expected age [2,3]. Globally, the prevalence of speech and language delay in children ranges from 5-15% [4]. In the United States and Canada, 8-12% of pre-school and 12% of school-age children experienced speech delay [5]. In Egypt and many countries in the Gulf regions; paucity of data exists on the burden of this important early childhood disorder. Nevertheless, empirical evidence showed that the quality of language learning during these early years of life does not only impact significantly on the development of oral language skills, but also on later success in literacy [6,7]. Language problems may result from mental retardation, physical handicaps, hearing loss, neurological problems, or environmental deprivations [7]. It has serious sequelae that may persist into adulthood in terms of educational, social, and emotional development [8]. When children fail to develop normal speech at appropriate time, it is therefore not surprising that they develop Crimson Publishers Wings to the Research Research Article

Communication development in the early years is closely linked with and dependent upon the input and stimulation received from parents and primary caregivers. When interactions between a parent/caregiver and a child are deranged, this places the child at risk for a communication disorder [9]. Hence, parents and caregivers play an important role in the early identification of language disorders. Parents and care-givers of children experiencing language delay are more likely to be reluctant in seeking medical advice at early age [10]. Four language teaching strategies have been identified by experts to improve children's language abilities. These are: prelinguistic milieu teaching, which helps children make the transition from pre-intentional to intentional communication; milieu teaching which consists of specific techniques embedded within a child's ongoing activities and interactions; responsive interaction which involves teaching caregivers to be highly responsive to the child's communication attempts; and direct teaching characterized by prompting, reinforcing and giving immediate feedback on grammar or vocabulary within highly structured sessions [11]. Early parent involvement programmes have proved effective and have positive impact on children's language outcome [11]. Reliable data on parent involvement interventions in speech language problems and of communication disorders such as Delayed Language Development (DLD) are currently unknown in Egypt [12]. This study was designed to evaluate the effect of parent involvement in language development intervention programmes on a population of late talking toddlers whose families could not afford specialized consultations in private clinics, and where these services were not available in public hospitals in Egypt. We hypothesized that implementation of language training intervention would improve the children's language development.

Research design
This was a quasi-experimental study adopting a pre/post-test intervention design to evaluate speech intervention programmes among late talking toddlers recruited from six private local kindergarten schools in Alexandria city of Egypt.79 mother-child pairs were enrolled into the study and followed up over a six-week period. The study participants were randomly assigned into two groups: experimental group and control group. The experimental group enrolled 68 mothers of children with language delay who were exposed to the interventions, and the control group consisted of 11 mothers and children with language delay who were exposed to routine care according to the national policy on kindergartens education in Egypt [13,14].

Planned imbalances
Researchers intentionally recruited a greater number of participants in the experimental group than in the control group. The allocation of participants to intervention was predetermined rather than manipulated by the researchers. Reasons for the imbalance include inaccessibility to specialist care, financial cost of care and a relative lack of interest by parents of affected children:

Study population
The study children were selected randomly from various kindergarten schools operating in two municipal areas of AlMontaza District of Alexandria Governorate, northern Egypt. With a population of approximately 1.2 million people, AlMontaza district is the largest district of the governorate [15]. Public education system in Egypt consists of three levels: the basic education stage for 4-14 years old: kindergarten for two years followed by primary school for six years and preparatory school (ISCED Level 2) for three years. The Ministry of Education is responsible for making decisions about the education system with the support of three centers: the National Center of Curricula Development, the National Center for Education Research, and the National Center for Examinations and Educational Evaluation. Each center has its own focus in formulating education policies with other state level committees [14].

Study questionnaire
A semi-structured, pre-tested questionnaire was adapted by the researchers from Language Development Survey (LDS) [11,16]. LDS was a vocabulary checklist designed as a screening tool for the identification of language delay in toddler age children. The LDS consists of a one-page vocabulary checklist of about 309 words, and a question asking about combining two or more words into phrases. If a 2-year-old child has fewer than 50 words or no word combinations; the child is considered to have a language delay. This tool was translated to Arabic language by the first author (SF) who is a native speaker of Arabic language. The translated version was back-translated to English language to confirm that the original meaning of the contents of the document was retained.
The LDS formed the main instrument used during data collection and this checklist was used for first time in Egypt. The 309 different words included in the LDS are arranged in 14 semantic categories (191nominals and 118 non-nominals). The categories are 'food'(32 words), 'outdoors' (11 words), 'toys' (11 words),'animals' (21 words),'body parts' (21 words), 'places' (8 words), 'household'(31 words), 'personal' (14 words), 'people' (15 words), 'clothes' (17 words),'vehicles' (10 words), 'actions' (56 words), 'modifiers' (31 words) and 'other' (32 words). All words within these categories can be classified into five categories as nouns, people word, adjectives and modifiers, actions and closed-class words [17]. The LDS total scores of all words were calculated and classified according to language improvement into three categories: mild language delay, moderate language delay, and severe language delay. Two sections were added to complement the LDS questionnaire: the first section focused on the socio-demographic characteristics of care-giver/ parent including age, highest level of education attained, marital status of parent/caregiver, occupation, family history of language delay and socioeconomic status (total annual income) that was assessed by using a combination of socioeconomic status scales [18-

Validity and Reliability of Adapted LDS
Given that this was the first time LDS would be used in Egypt, face and content validity was conducted for the tool to assess its appearance regarding readability, clarity of words used, consistency of style and likelihood of the target study participants being able to answer the questions satisfactorily. The adapted LDS was reviewed by a panel of five experts who had experience in instrument validation, drawn from the pediatric nursing (Nursing Practices) department of Umm Al-Qura University, Makkah, Kingdom of Saudi Arabia. The experts confirmed the relevance and appropriateness of the adapted LDS to Arabian context. They also agreed unanimously that essential elements of speech language delay were addressed adequately in the tool.

Pilot study
A pilot study was carried out amongst a sub-set of the sample population. This represented 10% of the study sample (n=7 mothers and 7 children) to test the applicability, feasibility, clarity and time needed to complete the study tool. Findings from the pilot study were used to modify the adapted LDS. The mother-child pairs enrolled in the pilot study were excluded from the main study. Eligible parents and children who met the following criteria were included in the main study: parents of children aged between 18 and 30 months; children aged 18 and 30 months with normal nonverbal IQs (according to their medical records); children with no sensory, motor or social-emotional problems; children who had little or no expressive language, defined as having a vocabulary of 30 single words or less; children who have not been diagnosed with a general developmental delay; children who did not have any past history of otitis media; and children who had not received previous speech / language therapy. Data collection for this study was undertaken from April to May 2019. After the study purpose and procedures have been explained to the study mothers, each mother and child provided verbal consent that they voluntarily agreed to participate in the study along with their children. The study mothers were subsequently invited to attend an initial assessment and interview. With the support of a trained research assistant, each study mother was requested to mark on the list of words in the adapted LDS which her child said spontaneously, indicate if the child had language delay. Also, if the child used phrases and sentences, the study mother wrote down five of the child's best phrases, and completed the question items on parent and child's socio-demographic characteristics.

Intervention Group: Parental Training Procedures
The study mothers who were randomly assigned to the intervention arm attended group speech and language therapy training sessions twice a week, over a six weeks' period. Twelve sessions were held in total, with each session lasting about 45-60 minutes. In each session, specific language objectives were set for the mothers to work on at home. The mothers were asked to use daily routines with their children. Flexibility in approach to each language objective was encouraged during the sessions through the use of small group work. The main aim for the six weeks' period of the group sessions was to increase the child's linguistic ability from a single word level to the level of producing three-to-four word utterances. The study mothers were taught about language therapy application so that they could carry out the procedure and follow-up at home. Intervention effects were reported by nursery school nurses and the study mothers for a broad range of language measures, including vocabulary acquisition, development of multiword sentences, and speech sound development.

Control group
Study mothers assigned to control arm had routine care according to kindergartens policy in Egypt [13,14]. This consisted of a set of educational activities aimed at achieving the comprehensive development of the children and preparing them for school [14].

Ethical considerations
Ethical approval for this study was obtained from the Vice-Deanship of Postgraduate Studies and Scientific Research, Faculty of Nursing, Umm Al-Qura University. Written permission to conduct this study was also obtained from AlMontaza Education authorities, Alexandria. Given the low risk involved in this study, verbal consent was obtained from the study mothers after informing them about the purpose and procedures of the study. Voluntary participation, confidentiality, anonymity and rights to withdraw from the study at any time were explained to each mother before starting data collection.

Data analysis
Data were analysed using Statistical Package for the Social Sciences (SPSS) version 21.0 (ed. Chicago: SPSS Incorporation. 2016). Descriptive and inferential statistics were performed. Continuous variables were summarized and presented using the mean (±SD) for normally distributed variables. Categorical variables such as sex, age category, socio-economic status were summarized and presented using proportions and percentages, as applicable. The differences between mean (±SD) of continuous variables were compared using independent Student t-test or Analysis of variance (ANOVA). The differences between proportions and percentages of categorical variables were compared using the Pearson's chi-squared (χ2) test. The first step in the analysis was to divide the study children in each sample into six vocabulary size classes (<50 words, 50-99 words, 100-149 words, 150-199 words, 200-249 words and 250 words or more). Next, the words on the validated LDS were re-grouped into five basic word class categories (common nouns, people words, verbs, adjectives and closed-class words), drawing on definitions suggested by Bates E, et al. [21]. Comparison between the control and the experimental group's findings was done to evaluate the effect of parent-involvement in language intervention/speech therapy program on a sample of late talking toddlers. Statistical significance was established when probability value (p) was less than 0.05. The study children were classified into three phases of expressive language acquisition according to child age (22): first words for children at age of 12-<19 months; word combinations for children at age of 19-<30 months; sentences for children at age of 30-<48 months. The socio-demographic characteristics of the study parents were illustrated in Table 1. Less than two thirds of the mothers (63.2%) in the experimental group were in the age group (20-40 years). More than half of the mothers (52.9%) had basic educational level, and more than three quarter (77.9%) of mothers in experimental group were currently married. In addition, majority of the mothers (82.4%) were the biological mothers of the study children. Approximately two thirds of mothers (66.2%) were unemployed. Also, 70.6% of study mothers in the experimental group had an average annual income, according to the national socioeconomic status scale [20]. More than one quarter (27.9%) of the study mothers in the experimental group had family history of language delay. Approximately half (47.1%) of the mothers attended group speech/language therapy training sessions. The demographic characteristics of the study children were illustrated in Table 2. Of the 78 children enrolled into this study, 53 (67.9%) were boys. More than three quarter of the study children (79.4%) in the experimental group were within the age group of 19-<30 months. Regarding to birth order, approximately half (45.6%) of the children were in range of 2nd-4th birth order and about two thirds (65.9%) of them had 1-3 siblings. Less than half of children (42.6%) in the experimental group had history of ear infection. The mean values of each word category relative to all types of vocabulary expression categories in experimental and control groups pre and post-intervention, (according to the study mothers' reports),were illustrated in Table 3a. Post-intervention, the mean value (SD) of           Table 5 showed that comparing experimental and control groups across the six weeks' period, there was a statistically significant improvement (p=<0.001) in first words total score for study children aged 12-<19 months across six weeks in both groups In addition, towards combinations for study children aged 19-<30 months, a statistically significant improvement (p=<0.001) was observed in experimental group compared with no statistical significant improvement (p=0.557) in the control group. Among study children aged 30-<48 months, no statistical significant improvement was observed in the experimental and control groups.  Table 7 showed that when the parents and nurses' responses for the study children's language delay severity across the experimental and control groups were compared, approximately one third (30.9%) of the study children in the experimental group RPN.000592. 4(4).2020

Results
had severe language delay pre-intervention and this decreased to 16.2% of children, post-intervention(p=0.043) Figure 1. On the other hand, less than one quarter (18.2%) of the study children in the control group had severe language delay pre-intervention, this result increased to about half (54.5%) of children post-intervention (p=<0.043).

Discussion
To our knowledge, this is the first study reporting the effects of parents' involvement language intervention programmes on speech language delay in Egyptian toddlers. Of the 79 toddlers enrolled into the study, more than three quarter of the study children (79.4%) randomly assigned to the experimental group were within the age group of 19-<30 months. This is not surprising given that this is the peak age in which speech language delay has been widely reported in previous studies. [22,23,24] The mean scores for girls in all domains of LDS were greater than boys and reached statistical significance. Previous findings on the role of gender in speech language disorder has been inconclusive; while some studies reported association of gender, others reported no influence of gender on speech language delay in children. Our findings contrast with study conducted by Akbari and colleagues [25] who reported that the risk of developmental delay is higher in boys. Conversely, Kerstjens, et al. [26] reported about 2-5 higher increased risk in girls compared to boys while Piek, et al. [27] reported that gender had no influence on developmental delay, consistent with Kapci, et al. [28] who reported no significant differences between male and female children in their study. Despite these conflicting findings, experts have reported an increased tendency towards speech language delay in male children might be related to X-linked disorders more frequently seen in male children [29].
Our study showed that approximately two thirds of the study mothers (66.2%) were unemployed and in low socio-economic strata, with 70.6% of the mothers in the experimental group having an average annual income. This resonates with previous findings which reported association of low maternal education and socioeconomic level with speech language delay [23,30]. Plausible reason cited for this was the financial challenges posed by low educational and socio-economic status which limit the purchasing power of the mothers to provide necessary materials required to nurture and support child's speech development. Majority of the study mothers (63.2%) in the experimental group were in the age group of 20-40 years while more than one quarter (27.9%) had family history of language delay. This is consistent with findings which reported increased risk of development delay in children delivered by mothers at ages above 35 years [31,32]. Although, we found that about 40% of the study children in the experimental group had a history of ear infection compared to about 20% in the control group, this finding supports previous studies which reported similar observations [2,29] Our study has a couple of strengths and limitations. The quasiexperimental design of this study made it possible to demonstrate the effect of parents' involvement interventions in late talking toddlers. We also adapted and validated the LDS tool [11] to objectively assess the improvement of the study children following exposure to a battery of interventions that actively were facilitated by study mothers. This tool developed and used amongst ethnolinguistically diverse South African toddlers [11] was successfully adapted and validated cross-culturally to establish the relevance of the vocabulary of (LDS) in Egyptian late talking toddlers.
The relatively small sample size in our study is a major limitation in generalizing the findings to the population of Egyptian toddlers with speech delay. Also, inability to monitor the level of compliance of the study mothers and depending solely on their self-reports about the performance of the children may over or under-estimate the actual speech status of the children. Nevertheless, our study has contributed to the small but important body of knowledge on the relevance of parents' involvement intervention in late talking toddlers.

Conclusion
Our study has demonstrated that parents' reports provided some useful ideas about their involvement and its positive effect in terms of language development of their late-talking toddlers. We also found that parent involvement in language interventional/ speech therapy program is a viable model for promoting short-term developmental progress in late-talking toddlers. Further studies using randomized controlled design are needed for evaluation and long-term follow-up of this important strategy for children with speech language delay.