Revist a de Saúde Pública
I SSN 0034- 8910 versão im pressaRev Saúde Pública 2004; 38(1)
Observation of language, visual and hearing function development
in infants
Maria Cecília Marconi Pinheiro Limaa, Grasiela Conceição Barbarinib, Heloisa Gagheggi Ravanini Gardon
Gagliardoc, Magali Aparecida de Oliveira Arnaisd and Vanda Maria Gim enes Gonçalvesa
a
Faculdade de Ciências Médicas da Univer sidade Est adual de Cam pinas ( Unicam p) . Cam pinas, SP, Brasil. bPont íficia Universidade Cat ólica de Cam pinas. Cam pinas, SP, Brasil. cFaculdade de Ciências Biomé dicas da Unicam p. Cam pinas, SP, Brasil. dFaculdade de Educação da Unicam p. Cam pinas, SP, Brasil
ABSTRACT
Objective
To invest igat e language, visual and hearing funct ion developm ent am ong infant s in a d ay- car e cen t er based on educat or s’ assessm ent s.
Methods
m em bers of t he day - car e cen t er st af f . St at ist ical an alysis was carried out using Chi- squar e t est or Fischer ’s ex act t est at p< 0 . 0 5 .
Results
I nfant s show ed differ ent language dev elopm ent pat t er ns as for poly sy llabic babbling and pr oduct ion of fir st w or ds. For v isual funct ion, infant s show ed a differ ent pat t ern of im it at ion and init iat ion in gest ure gam es and following com m ands wit h gest ures.
Conclusions
Th e d ay - car e cent er set t ing is pr obably pr om ot ing a dist inct pat t er n of language, v isual and hear ing funct ion dev elopm ent . Pr ev ent ion in day - car e cen t er s sh ould aim at int egr at ing educat ion and healt h t o achiev e t he com m on pur pose of child w elfar e.
Keywords
Child developm ent . Language developm ent . Vision. Audit ory percept ion. Visual percept ion. Hearing. Child day- car e- cent ers. Nurseries. Healt h prom ot ion.
I N TROD U CTI ON
I nfant educat ion is t he fir st phase of basic educat ion and is dir ect ed t ow ar d childr en fr om zer o t o six y ear s of age. Day - car e for infant s is a necessit y , par t icular ly in lar ge ur ban cent er s. The peculiar it ies of t his age gr oup r equir e t hat educat ion should car r y out t w o indissociable and com plem ent ar y funct ions: t o car e for and educat e infant s and sm all childr en. Societ y has influenced par ent s t o place infant s in educat ional inst it ut io ns earlier on in life and for longer periods of t im e. Despit e t he fact t hat pr ecise infor m at ion is lack ing as t o t he pr opor t ion of infant s w hich go t o day- car e cent er s in t he count r y as a w hole, it is est im at ed t hat 40% of t hese infant s ar e at t ending educat ional inst it ut ions.3 , 1 4 The int egr at ed dev elopm ent of t he child depends upon bot h car e, w hich inv olv es t he em ot ional dim ension of gr ow t h, and biological aspect s of t he body , such as: t he qualit y of food and healt h car e and t he w ay in w hich t hese ar e offer ed t o t he child.
Few inst r um ent s for scr eening ear ly language and det ect ing dist ur bances am ong infant s ar e m ent ioned in t he lit er at ur e. I n cont r ast , t her e ar e a lar ge num ber of st udies t hat scr een childr en aged t hr ee and older , but alm ost none t hat st udy t he fir st y ear of life.
visual inform at ion” .4 Children’s difficult ies in acquiring language according t o norm al pat t erns is alm ost alw ay s an indicat ion of som e k ind of subj acent pr oblem w it h r espect t o dev elopm ent .
Language m ay occur by m eans of t w o channels: t he audit or y channel, including speech and it s com pr ehension and t he v isual channel, w hich is necessar y for r eading and w r it ing, for gest iculat ing and for Sign Language, ut ilized by deaf people. I nfant s w ho hear m ake use of vocalizat ion, hear ing com prehensio n and gest iculat ion in order t o com m unicat e w it h ot hers ( social visual com m unicat ion) . As t o v ision, it is ack now ledged t hat it cont r ibut es a gr eat deal t o child dev elopm ent , for it is a fact or w hich m ot iv at es guides and cont r ols m ov em ent s and act ions. Visual dev elopm ent , as w ell as t he dev elopm ent of ot her funct ions of t he or ganism , is per m eat ed by fact or s r elat ed t o neur ological m at ur at ion and lear ning. I t is det er m ined by genet ic fact or s and influenced by env ir onm ent al fact or s.6 The m ost im port ant m odif icat ions in child developm ent happen during t he first year of life, w hen pr ogr ess occur s in gr eat leaps w it hin shor t er per iods of t im e. Thus, in t heir r ecipr ocal r elat ionship wit hin developm ent , t he t ransform at ions in t he axial and appendicular m ot or abilit ies, w hich happen t hr oughout t he fir st y ear of life, cont r ibut e t ow ar d t he r efinem ent of v isual capabilit ies.5
The healt h pr ofessional fr equent ly ov er est im at es childr en’s capabilit ies in t he dev elopm ent of language. This fact becom es clear w hen w e t ak e int o considerat ion t he sm all num ber of children up t o 3 y ear s of age w hich ar e counseled t o seek language ev aluat ion. I t is est im at ed t hat appr ox im at ely 2 t o 3% of t he children in t his age group present som e kind of delay in language developm ent , excluding t hose w it h m ent al r et ar dat ion, cer ebr al palsy and deafness.4
Pr ev ent ion and ear ly det ect ion of alt er at ions in infant ile dev elopm ent ar e pr ocedur es t hat ar e r ar ely applied in Br azil. Consider ing sensor ial deficiencies in par t icular , concer n w it h r espect t o pr ev ent ion and ear ly det ect ion ar e j ust ified by t he possibilit y of ant icipat ing t he pr ocess of int er v ent ion t ow ar ds t he beginning of t he child’s life, guar ant eeing t he necessar y st im ulat ion in all aspect s fundam ent al t o it s global dev elopm ent . Wit hin t his ar ea, scr eening pr ocedur es ar e ut ilized for t hey ar e char act er ized as low cost inst r um ent s w hich ar e efficient and easy t o apply .
Ther efor e, t he obj ect iv e of t his st udy w as t o inv est igat e language, v isual and hear ing funct ion dev elopm ent am ong infant s at t ending at a day - car e cent er dur ing t heir fir st y ear of life.
METHODS
One hundr ed and fift een infant s at t ending a day - car e cent er for healt h car e pr ofessionals w or k ing at a univ er sit y in t he St at e of Sao Paulo, sons and daught er s of em ploy ees of t his univ er sit y w ho w or k ed in shift s in t he period bet w een 1998 and 2001 w ere evaluat ed.
The 115 infant s w er e div ided in t hr ee gr oups accor ding t o age gr oups: Gr oup 1: 43 infant s aged 3 m ont hs and 16 days t o 6 m ont hs and 15 days. Group 2: 46 infant s aged 6 m ont hs and 16 day s t o 9 m ont hs and 15 day s. Gr oup 3: 26 infant s aged 9 m ont hs and 16 days t o 12 m ont hs and 15 days.
The st andar dized t est s of language, v isual and hear ing funct ion dev elopm ent w it hin t he Pr ot ocol w er e select ed by Lim a8 fro m t he “ Ear ly Language Milest one Scale” w hile ot her s w er e select ed by Gagliar do6 fr om t he “ Bay ley Scales of I nfant Dev elopm ent ” .
Consider ing t hat it w as necessar y t o conduct t he ev aluat ion dur ing a per iod of t he day w hen t he child w as feeling at ease, engaged in daily, rout ine act ivit ies, am ong people who were fam iliar t o him , t he t each er s of t h e day - car e cent er r esponsible for car ing for t he infant s, w er e t r ained t o apply t he t est s and lear ned t o obser v e t he phases of dev elopm ent of each child.
Som e it em s of t he Pr ot ocol could be obser v ed dur ing infor m al int er act ion, w hile t he infant s w er e inv olv ed in act iv it ies car r ied out r egular ly in t he day - car e cen t er or cou ld be dir ect ly t est ed, as occu r r ed w it h t h e t est s u n der t ak en t o locat e t h e sou n d of a bell on on e of t he sides or in t he t est w hich called for st udent s t o im it at e gest ur e gam es.
The par ent s of t he infant s w ho w er e assessed signed a consent for m w hen t hey r egist er ed t heir childr en in t he day- care - cent er accor ding t o w hich t hey per m it t ed t heir childr en t o under go r out ine assessm ent s. Since t his pr oj ect has been incor por at ed int o t he infant s’ ev aluat ion sy st em , t her e w as no need for a specific I nfor m ed Consent For m for t his r esear ch.*
* Subm ission of t he Pr oj ect t o an Et hics Com m it t ee of t he I nst it ut ion w as not r e quired due t o t he f act t h at t h is r esear ch w as con du ct ed in a Day - Care- Cent er .
The t r aining pr ogr am , adm inist er ed t o educat or s of t he day - car e- cent er in or der t o pr epar e t hem t o apply t he Pr ot ocol, consist ed of fiv e phases:
Fir st Ph a se : I n 1998, a m eet ing w as held by one of t he aut hor s of t he Pr ot ocol, a speech t her apist , w it h t h e t eam of edu cat or s of t h e day - car e - cent er “ Ar ea de Saúde” [ Healt h Field] , in or der t o infor m and sensit ize t hem w it h r espect t o t he issues of language dist ur bances, audit ory and visual problem s. The significance of scr eening w as discussed as w ell as t he j ust ificat ion for under t ak ing t his pr ocedur e. A m em ber of t he day- car e - cent er st aff, a pedagogue w ho w as v er y fam iliar w it h t he t est s t hat w er e going t o be applied, w as chosen t o t each h er co- w or k er s how t o apply t he Pr ot ocol.
Se con d Ph a se : The Pr ot ocol w as dem onst r at ed t o t he abov e m ent ioned pedagogue. The best place in t he day- care - cent er t o apply t he Pr ot ocol w as t hen chosen.
Th ir d Ph a se : The pedagogue t r ained m em ber s of t h e d ay - car e st aff r esponsible for car ing for t he infant s t o adm inist er t he Pr ot ocol. Each t est in t he Pr ot ocol w as dem onst r at ed and t he day - car e w or ker s w er e advised on how t o apply each of t hem on infant s w it hin sever al age gr oups. Planning w as u n d er t ak en so as t o int egr at e t hese pr ev ent iv e m easur es int o t he educat ional pr ogr am of t he d ay - car e - cen t er .
The descr ipt iv e analy sis of t he dat a w as under t ak en ut ilizing t he “ Epidem iological I nfor m at ion 6.0” Program ( Epi I nfo) . Variables of int ere st w it hin t he st udy w er e com par e3d by m eans of t he Chi-Squar e or Ex act Fischer t est s, w hen necessar y adopt ing 5% lev el of significance.
RESULTS
I nfant educat or s of t he day- car e cent er assessed 115 infant s, subdiv ided in age gr oups r anging fr om t hr ee m ont hs and 15 day s t o 12 m ont hs and 15 day s. Despit e t he fact t hat t he Pr ot ocol is designed t o scr een infant s one m ont h old, in t he pr esent st udy only infant s m or e t han t hr ee m ont hs old w er e consider ed, for t his is t he age at w hich t hey begin t o go t o t he day- c are - cen t er .
Th e r esu lt s of t h e ELM4 Scale t est s for Gr oup 1 ar e pr esent ed in Table 1.
Table 1 - Tests from the Protocol based on the ELM Scale, infants from Group 1* who performed the tests,
frequency of successful performance and data reported by Lima.**
Tests from the Protocol Infants who performed
each test
Data reported by Lima8 Level of significance
N=43 % N=44 %
Bubbles 35 81.4 44 100.0 P=0.0023
Localizes bell to the right 43 100.0 44 100.0 P=0.495
Localizes bell to the left 42 97.7 44 100.0 P=1.000
Follows object, horizontally, vertically 43 100.0 44 100.0
Blinks to threat 43 100.0 44 100.0
ELM – “Early Language Milestone”
*Group 1 – Infants (N.43) from three months and 16 days to six months and 15 days
**Lima8 – Doctoral dissertation (See data listed in the References)
This gr oup w as also subm it t ed t o t est s fr om t he BAYLEY Scales: 2 lift s t he hand t ow ar ds t he obj ect , w hich w as accom plished by 41 ( 95.3% ) infant s and hold an obj ect in each hand, accom plished by 26 ( 60.5% ) infant s.
I n Group I I t he r esult s of t he ELM4 Scale t est s ar e pr esent ed in Table 2:
Table 2 - Tests from the Protocol based on the ELM Scale, infants from Group 2* who performed the tests,
frequency of successful performance and data reported by Lima.**
Tests from the Protocol Infants who performed each test Data reported by
Lima8
Level of significance
N=46 % N=44 %
Produces simple syllables 40 86.9 44 100.0 P=0.026
Produces the same syllable repeatedly 25 54.3 42 95.5 P=0.001
Locates bell below, indirect 45 97.8 44 100.0 P=1.000
Imitates gesture games 19 41.3 41 93.2 P<0.001
*Group 2 – Infants (N.46) from six months and 16 days to nine months and 15 days
**Lima8 – Doctoral dissertation (See data listed in the References)
I n addit ion, infant s w er e subm it t ed t o t he BAYLEY2 Scales t est , t r ansfer t he obj ect fr om one hand t o
t he ot her , w hich w as accom plished by 35 ( 85.4% ) of t hem .
Th e r esu lt s of t h e ELM4 Scale t est s for Gr oup 3 ar e pr esent ed in Table 3.
Table 3 – Tests from the Protocol, Children from Group 3* who performed the tests, frequency of successful performance and data reported by Lima.**
Tests from the Protocol Infants who performed
each test
Data reported by
Lima8
Level of significance
N=26 % N=44 %
Produces mama/papa 14 53.8 34 75.6 P=0.060
Localizing the Bell directly below them 26 100.0 44 100.0 -
Follows command with gestures 23 88.5 44 100.0 P=0.045
Initiates gesture games 15 57.7 44 100.0 P< 0.001
First Word 10 38.5 34 75.6 P=0.002
Points to desired objects 14 (53.84%) 16 (35.56%) P=0.133
*Group 3 – Infants (26) from nine months and 16 days to 12 months and 15 days
**Lima8 – Doctoral dissertation (See data listed in the References)
Th e BAYLEY2 Scales t est s t o w hich t he gr oup w as subm it t ed w er e: opposing t hum b and forefinger in a pincer gr ip and placing one cube on t op of anot her .
The pr ehension t hum b/ index finger t est w as accom plished by 10( 38.5% ) of t he infant s. The t est w hich inv olv ed placing one cube on t op of anot her one w as accom plished by 5 ( 19.2% ) of t he infant s. I n or der t o v er ify t he adm inist r at ion of t he t est s by t he day - car e educat or s, t he aut hor s r e- assesses a r andom sam ple of 5 infant s fr om subm it t ed t o scr eening each year bet w een 1998 and 2001. The assessm ent s cor r esponded in 100% of t he ev aluat ions under t ak en by t he educat or s.
D I SCUSSI ON
pr evious st udies, par t icular ly t hose of Lim a8 , 9 , 1 0 ( 1997) , Coplan4 ( 1983) , Azev edo1 ( 1995) and Gogliardo.6
A differ ent pat t er n of language dev elopm ent w as obser v ed am ong t he infant s w it h r espect t o t he product ion of poly sy llabic babbling and t he fir st w or ds.
Furt herm ore, a reduced num ber of children im it at ed ot hers and produced spont aneous gam es inv olv ing social gest iculat ion, w hich indicat es t hat , alt hough no ev idence w as found t hat t her e w as a m odificat ion in language developm ent ( or al and expr essive) , t he envir onm ent of t he day - car e- cen t er pr obably pr opit iat es condit ions for a differ ent pat t er n of dev elopm ent t han t hat descr ibed by ot her aut hor s5 , 8 , 1 0 , 1 2 w ho st udied infant s w hich spent m ost of t heir t im e w it h one car egiv er , usually t he m ot her in one t o one int er act ion. Anot her elem ent t hat should be t ak en int o consider at ion is t he quant it y of v isual and audit or y st im ulant s t hat ar e found in a collect iv e env ir onm ent , lik e a day car e -cent er . Per haps language dev elopm ent am ong infant s does not follow a univ er sal pat t er n.
Audit or y assessm ent , by t est ing infant s’ r esponse t o audit or y st im uli, det ect ed disabilit ies in t w o infant s, w hich w as confir m ed by t he pr esence of ot it is m edia.
I n Gr oup 1 ( see Table 1) w hen t he t est “ m aking bubbles” was adm inist ered at six m ont hs, a sm aller num ber of infant s w er e able t o do so w hen com par ed t o Lim a’s st udy8 in w hich all infant s t he sam e age w er e able t o m ake bubbles. Coplan4 found t hat m ost infant s in his st udy pr oduced lip v ibr at ions in t he m iddle of t heir fir st y ear of life.
As t o t he v isual funct ion t est s, “ v isual t r ack ing and blink s t o t hr eat ” , in Gr oup 1 t he r esponses obt ained cor r esponded t o findings in t he lit er at ur e 4 , 7 , 1 1, t hat is, t hese ar e behav ior s pr esent ed by t he m ajor it y of infant s st udied at 4 m ont hs.
The t est s w hich inv olv ed locat ing a bell placed at a lat er al posit ion, t o t he r ight and t o t he left w er e successfully per for m ed by all infant s, cor r esponding t o findings in t he lit er at ur e. Fr om t hr ee m ont hs on, r esponses em er ge, such as sear ching for t he sour ce of a sound and lat er al localizat ion on t he sam e plane as t he ear , w hich char act er ize an ev olut ion in r esponses as a r esult of t he dev elopm ent of t he Cent r al Ner vous Syst em . 1 , 4 , 1 2 One child did not localize t he bell t o her left w hich w as ex plained by t he pr esence of Ot it is Media, diagnosed by an ear , nose and t hr oat specialist t o w hom he/ she w as indicat ed by t he day - car e - cent er for ev aluat ion.
I n Gr oup 2, Table 2, t he infant s w ho w er e subm it t ed t o t est s associat ed t o language, t hat is, w hen t hey begin t o produce t he sim ple syllable ( m onosyllabic babbling) and t o repeat t he sam e syllables ( polysyllabic babbling) , perform ed below t he expect ed level for t heir chronological age.
How ever, by analyzing t he result s m ont h by m ont h, it w as obser v ed t hat fiv e infant s did not pr oduce sim ple m onosyllables at seven m ont hs, one infant at eight m ont hs and anot her one at nine m ont hs, being t hat t he lat t er w as a child pr esent ing r ecur r ent Ot it is Media. I t should be not ed t hat m onosy llabic babbling occur r ed, in fact , w it hin t he sam e age gr oup as t he gr oup st udied by Lim a, 8 , 1 0 for t he m aj orit y was babbling sim ple syllables at eight m ont hs. Coplan4 found t hat m onosy llabic
babbling w as pr oduced am ong infant s w ho w er e over eight m ont hs old.
As t o im it at es gest ur e gam es, 19 ( 41.3% ) of t he childr en in t he day- car e - cent er were perform ing t his t est unt il t hey w er e nine m ont hs old. On t he ot her hand, t he m aj or it y of t he infant s st udied by Lim a
8 , 1 0 w ere perform ing t his t est at nine m ont hs.
Bot h t he t est s m ent ioned in w hich t her e w er e significant differ ences bet w een t his and ot her st udies, product ion of polysyllabic babbling and im it at ion of gest ure gam es, depend upon st im ulat ion and per haps a gr eat er am ount of int er act ion bet w een an adult and t he baby. Rubino1 4 st at es t h at , fr om t he m om ent in w hich t he baby is capable of v ocalizing sounds w it h char act er ist ics sim ilar t o t hose of adult speech, t he m ot her begins t o r epeat t he sounds m ade by infant s. The m ot her r eflect s t he im age of his v ocal gest iculat ions back t o t he child. Fur t her m or e, she begins t o int er pr et t he child’s v ocal pr oduct ions. The fact t hat an adult is not per for m ing t his act iv it y w it h t he infant m ay lead t o t his differ ent iat ed dev elopm ent pr esent ed by infant s at t he day- car e- ce n t er, wit h a sm aller num ber of t hem perform ing polysyllabic babbling at nine m ont hs.
A sim ilar sit uat ion occur r ed w it h r espect t o gam es inv olv ing t he im it at ion of gest iculat ions. Pr obably t he fact t hat t he infant does not hav e an adult w ho is close t o him av ailable t o play gam es involving t he im it at ion of gest ur es such as clapping one’s hands and blow ing k isses leads t o t he em er gence of t his behav ior at a lat er per iod t han t hat found in pr ev ious st udies.4 , 8 , 9
The infant s pr esent ed consist ent r eplies w it h r espect t o audit or y st im uli, t hat is, locat ing a bell in an indir ect m anner , w hich is com pat ible w it h ot her r efer ences fr om t he lit er at ur e.1 , 1 2 At eight m ont hs all
t he childr en w er e capable of locat ing sounds sit uat ed below or abov e ear lev el, indir ect ly .1 One of t h e childr en did not r espond t o t he bell, but lat er it w as v er ified t hat she/ he had Ot it is. The r esponses t o t he t est “ becom es inhibit ed w hen confr ont ed w it h a ‘no’” , t hat is, init ial com pr ehension of a sim ple com m and, were com pat ible wit h Lim a’s,8 f indings, accor ding t o w hich, t he m aj or it y of infant s
inv est igat ed under st ood a “ no” at nine m ont hs.
I n gr oup t hr ee, it m ay be obser v ed ( see Table 3) t hat , as t o t he use of ex pr essiv e language, 14 ( 53.8% ) infant s w ere saying m am a/ papa and 10( 38.5% ) w ere saying t heir first w ord. Perform ance w it h r espect t o t his last t est w as w or se am ong t hese infant s t han am ong t hose in Lim a’s st udy , 75.6% of w ho w er e em it t ing t heir fir st w or d at 12 m ont hs. Am ong t he fiv e infant s w ho had com plet ed 12 m ont hs, none had y et em it t ed t heir fir st w or d. Coplan4 found t hat 70% of t he infant s em it t ing t heir fir st w or d at 12 m ont hs. I t w ould be ex pect ed t hat m or e t han half of t he infant s, ev en in a sit uat ion in w hich t hey ar e im it at ing t he w or d enunciat ed by an adult , w ould incor por at e par t of t his enunciat ion, w it h t he m odificat ions appr opr iat e for his ow n lev el of dev elopm ent .
I n t he t est s r elat ed t o sound r ecept ion, t hat is, locat ing t he bell dir ect ly below t hem , 100% of t he infant s w er e per for m ing t he t est , in confor m it y w it h dat a f r om ot her st udies.1 , 8
The t est , “ init iat es gam e inv olv ing gest iculat ions” w as per for m ed by 15 ( 57.7% ) infant s, a pr opor t ion t hat w as low er t han t hat r epor t ed by Coplan4 and Lim a,8 in which t he m aj orit y of infant s perform ed t his t est at 11 m ont hs.
Th e t est “ point s t o desir ed obj ect s” w as per for m ed by 14( 53.8% ) infant s, a pr opor t ion gr eat er t han t hat found by Lim a,8 , 9 w hich w as 35. 6% .
I n conclusion, a r educed num ber of childr en per for m ed cer t ain t est s r elat ed t o language developm ent . How ev er , no ev idence w as found of dev elopm ent al disabilit ies am ong t hese infant s. Most pr obably , t h e d ay - car e- cent er env ir onm ent is pr opit iat ing condit ions for a differ ent pat t er n of language dev elopm ent t hat does not follow t he univ er s al pat t er n .
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12. Nor t her n J, Dow ns M. Audição em cr ianças. São Paulo: Manole; 1989.
14. Rubino R. Represent ando o int erlocut or no período pré - lingüíst ico [ disser t ação de m est r ado] . São Paulo: Pont ifícia Univ er sidade Cat ólica de São Paulo; 1989.
Address to correspondence
Maria Cecília Marconi Pinheiro Lim a Rua Tarum ã, 412
13098 - 341 Cam pinas, SP, Brasil E- m ail: ceclim a@fcm .unicam p.br
Received on 14/ 8/ 2002. Reviewed on 23/ 6/ 2003. Approved on 13/ 8/ 2003.
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