Books, Toys, Parent-Child Interaction, and

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and toys in the home, parent-child interaction, and child devel- opment at 21 ... KEY WORDS: children's books; developmental outcomes; ...... ehsnewborns.pdf.
Books, Toys, Parent-Child Interaction, and Development in Young Latino Children Suzy Tomopoulos, MD; Benard P. Dreyer, MD; Catherine Tamis-LeMonda, PhD; Virginia Flynn, MS; Irene Rovira, PhD; Wendy Tineo, PhD; Alan L. Mendelsohn, MD Objective.—To describe the interrelationships between books and toys in the home, parent-child interaction, and child development at 21 months among low-income Latino children. Methods.—Latino mother-infant dyads enrolled in a level 1 nursery and infants were followed to 21 months. The subjects consisted of the control group of a larger intervention study. At 6 and 18 months, the number of books and toys in the home and the frequency of reading aloud were measured by the StimQ. At 21 months, child cognitive and language development and parent-child interaction were assessed by the Bayley Mental Development Index (MDI), the Preschool Language Scale-3 (PLS-3), and the Caregiver-Child Interaction Rating Scale, respectively. Eligibility for early intervention (EI) services was determined on the basis of the MDI and PLS-3. Results.—Data were obtained for 46 (63.0%) of 73 at 21 months.

In multiple regression analysis, books provided at 18 months predicted both cognition (semipartial correlation [sr] ⫽ .49, P⫽ .001) and receptive language (sr ⫽ .37, P⫽ .02), whereas toys provided at both 6 and 18 months predicted 21-month receptive language (sr ⫽ .40, P⫽ .01; sr ⫽ .32, P⫽ .047, respectively). Reading aloud by parents ⱖ4 days a week was associated with decreased EI eligibility (adjusted odds ratio ⫽ 0.16, 95% confidence interval 0.03– 0.99). Conclusions.—Reading aloud and provision of toys are associated with better child cognitive and language development as well as with decreased likelihood of EI eligibility.

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play has been linked to interactions and outcomes, data exploring the role of toys are more limited.11 Child-oriented resources in the home may play a particularly important role for poor children. Economically disadvantaged mothers are less likely to verbally interact with their children; this is partly the result of low levels of education and also of depression.8,12–14 If there are few toys and books, verbal interactions may be limited, placing the child at higher risk for adverse developmental outcomes. In addition, childoriented resources may represent an avenue for intervention by pediatricians. For example, in providing books to poor families, programs such as Reach Out and Read (ROR)15,16 can influence both parent-child interaction and child development.17–20 The American Academy of Pediatrics (AAP) has recommended that pediatricians provide guidance to families around appropriate choice of toys6 and incorporate literacy promotion into primary care.21 In this article, we perform an exploratory analysis of the interrelationships between books, toys, parent-child interaction, and development in a cohort of poor Latino families with children at risk for developmental delay on the basis of low maternal education. We hypothesized that books and toys in the home would be related to developmental outcomes and that parent-child verbal interaction would account for some of this relationship (Figure).

KEY WORDS: children’s books; developmental outcomes; early childhood; parenting; play Ambulatory Pediatrics 2006;6:72–78

he resources that parents provide for children, such as books and toys, represent an important part of the cognitive home environment. However, there has been little research demonstrating the role of books in children younger than 3 or the role of toys at any age. Studies linking reading aloud to language development have been principally conducted in older preschool children.1–3 Although studies that used the HOME Inventory4 have shown that toys in the aggregate predict developmental outcome,5 there have not been any studies documenting effects on development resulting from use of different categories of toys.6 Resources such as books and toys may represent a means of enhancing verbal interaction, which is known to have a substantial impact on child developmental outcomes.7–9 For example, when parents read aloud, they use more words and longer utterances compared with other activities.10 Although

From the New York University School of Medicine and Bellevue Hospital Center, Department of Pediatrics (Dr Tomopoulos, Dr Dreyer, Mr Flynn, Dr Rovira, Dr Tineo, and Dr Mendelsohn) and New York University Steinhardt School of Education, Department of Applied Psychology, Center for Research on Culture, Development, and Education (Dr Tamis-LeMonda), New York, NY. Presented in part at the annual meeting of the Pediatric Academic Societies, May 4, 2003, Seattle, Wash. Address correspondence to Suzy Tomopoulos, MD, New York University, School of Medicine, Department of Pediatrics, 550 First Avenue, New York, NY (e-mail: [email protected]). Received for publication October 20, 2004; accepted October 13, 2005.

AMBULATORY PEDIATRICS Copyright © 2006 by Ambulatory Pediatric Association

METHODS Study Design The study was a longitudinal cohort study, in which mother-infant dyads were followed from birth to 21

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Figure. Hypothesized relationships between resources in the home, parent-child verbal interaction, and child development.

months. Enrollment was undertaken between August 1999 and January 2002 during the immediate postpartum period at Bellevue Hospital Center. On enrollment days, we assessed consecutive Latino mother-newborn dyads for eligibility. The primary inclusion criterion for this study was that the mother had not graduated from high school, placing the child at increased risk for developmental delay. Additional inclusion criteria were created to define a relatively homogeneous population in which confounding was minimized and follow-up was likely. These criteria were planned primary care at our institution, normal birth history, singleton gestation, no significant medical complications, mother at least 18 years old, no plans for adoption or foster care, and no plans for enrollment in Early Head Start. The subjects were participants in a randomized, controlled trial (RCT) of an intervention around child development22; this analysis includes only the controls. All participants were exposed to ROR,15–16 a program that promotes parent-child reading aloud and that was routinely provided during the study period. Longer-term follow-up through age 6 years is presently in progress. Human subjects approval was obtained from New York University School of Medicine, Bellevue Hospital Center, and the New York City Health and Hospitals Corporation. Parents provided informed consent. Data Obtained Family Characteristics At birth, data were collected by parent interview and included the following: child’s sex, birth rank, birth weight and gestational age; mother’s age, country of origin, education, and occupation; and father’s education, occupation, and presence in the home. Family’s Hollingshead Four Factor Socioeconomic Status (SES) was calculated.23 At 6 months, maternal depressive symptoms were assessed by the Center for Epidemiological Studies-Depression Scale (CES-D), with 16 used to define a positive screen.24 Resources in the Home At 6 and 18 months, toys and books in the home were assessed by StimQ.25,26 StimQ, which is based on a structured interview with the child’s caregiver, is validated for use in low-SES populations in English and Spanish. It has good internal consistency (Cronbach ␣ ⫽ 0.88), test-retest

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reliability (intraclass correlation coefficient ⫽ 0.93), and criterion-related validity (correlation with HOME4: r ⫽ .55, P⬍ .001) and is sex neutral.25 StimQ assesses only what the primary caregiver provides to the child. The StimQ-READ subscale assesses books that the caregiver provides for the child in the home. It includes scaled scores based on reading activities in the home, including number of children’s books that the caregiver provides (scored as 0: no books; 1: 1–9 books; 2: 10 –24 books; 3: 25– 49 books; 4: 50⫹ books) and frequency of reading (scored as 0: never; 1: 2–3 days per week; 2: 4 –7 days per week). In addition, there is an overall READ score (range 0 –19 for the infant form used at 6 months, 0 –18 for the toddler form used at 18 months) that also includes scores for board books, bedtime stories, and different varieties of children’s books. The StimQ-ALM (Availability of Learning Materials) subscale assesses toys that the caregiver provides for the child in the home. For the infant form, there are 3 categories of toys: First Infant, Activity/Manipulation, and Imagination (scored 0 for 0 –1, 1 for 2– 4, and 2 for 5 or more toys). For the toddler form, there are 5 categories: Symbolic and Fine Motor/Adaptive (scored 0 –2 as with the infant subscales), and Art, Language, and Life-Size (scored 0 for 0 –1, and 1 for 2 or more toys). Assessment of Child Development At 21 months, child cognitive and language development were assessed. Each assessment was performed in the child’s preferred language. Cognitive development was assessed by the Bayley Scales of Infant Development, 2nd edition, Mental Development Index (MDI).27 Expressive and receptive language was assessed by the Preschool Language Scale-3 (PLS-3).28 Eligibility for early intervention (EI) services was determined based New York state criteria: cognition or language 2 standard deviations below the mean, or both 1.5 standard deviations below the mean. Assessment of Parent Child Verbal Interaction At 21 months, parent-child verbal interaction was measured by the CCIRS (Caregiver-Child Interaction Rating Scale, also known as the Caregiver-Child Affect, Responsivity and Engagement Scale [C-CARES]),29,30 and based in part on modifications to the Mother-Infant Interaction Rating Scale.31 The CCIRS is scored on the basis of a free play activity in which the mother and child are videotaped for 10 minutes with a standardized set of toys. Items are scored on the basis of a 5-point Likert scale reflecting either frequency or quality. Cronbach ␣ values ranged from 0.67 to 0.89. Validation of the scale has been demonstrated by its association with concurrent child outcomes, including Bayley MDI, expressive and receptive language, and symbolic play, with correlations ranging from 0.25 to 0.65. Two research assistants (graduate students in clinical psychology) coded these videotapes; interrater agreement on items was 0.80. Eight items related to parent-child verbal interaction were used in this analysis, 4 of which assessed maternal language input (quantity and quality of maternal language directed to the child), and 4 of which assessed mutual communication (mother-child

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Table 1. Characteristics of 73 Enrolled Families Characteristic

Value

Male sex, % Firstborn child, % Maternal education grade, years completed, mean (SD) Socioeconomic status Class 5 (least affluent), % Mother’s country of birth, % Mexico Ecuador United States Dominican Republic Other* Language spoken by the mother, % Mostly/only Spanish Both English and Spanish Mostly/only English Mothers screening positive for depression, % Father living in the home, %

63 37 7.3 (2.6) 95.1 57.5 15.1 11.0 9.6 6.9 84.9 6.8 8.2 20.5 89.1

*El Savador, Honduras, Nicaragua, Peru.

verbal responsivity). These items were chosen on the basis of conceptual considerations and empirical evidence linking language input and mutual communication to child developmental outcomes8,32 as well as precedent in the use of this scale.33 Statistical Analysis A 2-tailed P value of less than .05 was considered to be statistically significant. Differences between means were assessed by t tests for independent samples and paired t tests for related samples. Differences between proportions were assessed using either ␹2 or Fisher exact tests as appropriate. The association between resources, parentchild verbal interaction and developmental outcomes was assessed by both simple (Pearson correlation) and adjusted (multiple linear regression) analyses. Each of the sociodemographic variables related to resources in the home (sex, birth rank, father living in the home, mother’s country of origin, and maternal education) with P⬍ .10 were included as potential confounders in the regression analyses; maternal depression was also included because of its potential impact on developmental outcome. Hierarchical multiple regression analysis was used to determine the degree to which parent-child interaction (CCIRS) explained the variance in child developmental outcomes.34 Simple (point-biserial and Spearman rank correlations) and adjusted (multiple logistic regression) analyses were used to assess the relationship between resources and frequency with which children met criteria for EI services. Data were analyzed by SPSS v.11.5.35 RESULTS Study Sample A total of 164 families were identified who met eligibility criteria, of which 150 (91.5%) agreed to participate. Of these, 73 (48.7%) of 150 were randomized to a control group in which no interventions were performed and are included in this analysis (Table 1). StimQ was obtained for 61 (83.6%) of 73 families at 6

Table 2. StimQ-ALM (Infant Form) Subscales and Frequencies of Individual Toys at 6 Months (n ⫽ 61)* Toy First Infant Toys Rattle Toys on ring Soft squeeze toy Mirror Soft person/clown Sock rattle Black/white pattern Activity/Manipulative Pop-up toy Toy instrument Stacking toy Snap beads/links Blocks Push and spin toy Shape sorter Imagination Stuffed animal Bath rubber duck Word recognition toy Toy telephone Doll Small car/truck Toy radio Boat for bath

Percentage 95% 78% 52% 37% 17% 15% 12% 48% 27% 18% 15% 12% 10% 8% 68% 60% 38% 35% 28% 28% 20% 10%

*Each subscale was scored as 0 for 0 –1, 1 for 2– 4, and 2 for 5 or more toys.

months and 51 (69.9%) of 73 at 18 months. Assessments of development and parent-child interaction were obtained for 46 (63.0%) of 73 families at 21 months. Of these 46, all completed assessment of cognitive development (Bayley MDI). However, 2 of 46 children were unable to complete the PLS-3, and attempts to bring these children back were not successful, leaving 44 children for analysis. One of 46 videotapes was damaged, leaving 45 for the analysis of parent-child interaction. Families who missed assessments had either moved away or were no longer being followed at Bellevue Hospital Center. Families completing all assessments were more likely to have mothers who were not born in the United States (P⫽ .04), to have first-born children (P⫽ .03), and have the father living at home (P⬍ .001). Books and Toys in the Home The mean number of books that parents read with the child increased with age from 2.6 (SD 3.6) at 6 months to 7.9 (SD 10.0) at 18 months (P⬍ .001). Frequency of reading increased from 2.1 (SD 2.3) days per week at 6 months to 3.5 (SD 2.8) at 18 months (P⬍ .001). Predictors of increased READ score were: male sex of child (6 months: r ⫽ 0.33; P⫽ .03; 18 months: r ⫽ 0.30, P ⫽ .04), child not first born (6 months: r ⫽ 0.26, P ⫽ .08; 18 months: r ⫽ 0.37, P ⫽ .01), and mother born in the United States (18 months: r ⫽ 0.28, P ⫽ .06). Birth rank, maternal education, maternal depression, SES, and father’s presence in the home were not associated with reading aloud. Specific frequencies for each toy are shown in Table 2 and Table 3. Predictors of increased ALM score included

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Development in Young Latino Children

Table 3. StimQ-ALM (Toddler form) Subscales and Frequencies of Individual Toys at 18 Months (n ⫽ 51)* Toy

Percentage

Symbolic Play Small car/truck Doll/action figure Set of small animals Toy food Toy pot/pan/dishes School bus with people Puppet Housekeeping toy Play set (eg, barn) Costume Fine Motor/Adaptive Toy instrument Pop-up toy Stacking blocks Stacking rings Shape sorter Nesting/stacking Pail/shovel Interlocking blocks Beads for stringing Language Word recognition toy Child’s tapes/CDs Toy letters Child tape/CD player Toy numbers Match/name cards Art Coloring book Crayons Markers Chalkboard Finger paint Clay Life-Size Car/animal to ride Stroller/cart to push Tricycle Child-size table/chair Toy kitchen

84% 64% 56% 32% 30% 28% 26% 26% 16% 6% 62% 48% 40% 32% 28% 28% 28% 16% 10% 70% 42% 30% 28% 28% 22% 60% 46% 22% 18% 10% 2% 44% 38% 28% 26% 4%

*Symbolic play and fine motor/adaptive subscales were scored as 0 for 0 –1, 1 for 2– 4, and 2 for 5 or more toys. Language, art, and life-size subscales were scored as 0 for 0 –1, and 1 for 2 or more toys.

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male sex of child (6 months: r ⫽ 0.28, P ⫽ .03; 18 months: r ⫽ 0.46, P ⫽ .001), higher maternal education level (6 months: r ⫽ 0.25, P ⫽ .05; 18 months: r ⫽ 0.32, P ⫽ .02), and father living at home (6 months: r ⫽ 0.27, P ⫽ .04). Birth rank, maternal depression, SES, and mother’s immigrant status were not associated with toys. READ and ALM scores were correlated with each other at 6 months (r ⫽ 0.39, P ⫽ .007) and 18 months (r ⫽ 0.57, P⬍.001). Six-month READ scores predicted 18-month READ scores (r ⫽ 0.54, P⬍.001). Six-month ALM scores predicted 18-month ALM scores (r ⫽ 0.53, P⬍.001). Developmental Outcomes Mean (SD) Bayley MDI at 21 months was 73.02 (13.2). Mean Receptive and Expressive PLS scores at 21 months were 79.82 (8.6) and 79.16 (9.9), respectively. A total of 50% met criteria for EI eligibility on the basis of MDI and PLS-3. Association Between Resources and Development Books Six-month reading activities did not predict outcomes. In contrast, 18-month reading activities predicted 21month cognitive development, language development and EI eligibility (Table 4). The strongest correlations were seen for the book score, which predicted MDI (r ⫽ 0.36, P ⫽ .01) and PLS-Receptive language (r ⫽ 0.32, P ⫽ .04). After adjusting for potential confounders, this relationship persisted, as shown in Table 5 (MDI: semipartial correlation (sr) ⫽ 0.49, P ⫽ .001; PLS-Receptive: sr ⫽ 0.37; P ⫽ .02). Compared with children with a book score of 0 (0 –1 books), children with a book score of 1 (2–9 books) had a 7.4-point increase (95% confidence interval [CI] 2.4 –12.3) in MDI, and children with a book score of 2 or more (10 or more books) had a 14.8-point increase (95% CI 9.8 –19.8). In this high-risk sample, children whose parents had a reading frequency score of 0 (0 –1 days per week) had a 75% chance (9 in 12) of meeting EI eligibility, compared with a 46.7% chance (7 in 15) for those with a reading frequency score of 1 (2 or 3 days per week), and a 36.8% chance (7 in 19) among those with a reading

Table 4. Correlation Between Books and Toys at 18 Months and Developmental Outcomes at 21 Months* 18-Month StimQ (n ⫽ 46)

Bayley MDI† (n ⫽ 46)

PLS-Receptive† (n ⫽ 44)

PLS-Expressive† (n ⫽ 44)

Early Intervention Eligibility‡ (n ⫽ 46)

READ subscale Books Days/week ALM subscale Symbolic Fine motor/adaptive Art Language Life-size

0.29§ 0.36储 0.24 0.12 0.14 0.16 0.03 ⫺0.06 0.07

0.29§ 0.32§ 0.24 0.37储 0.34§ 0.38储 0.26 0.09 0.15

0.05 0.05 0.00 0.06 0.23 0.22 ⫺0.13 ⫺0.19 ⫺0.08

⫺0.31§ ⫺0.30§ ⫺0.30§ ⫺0.20 ⫺0.24 ⫺0.35§ ⫺0.04 0.09 0.00

*PLS indicates Preschool Language Scale; MDI, Mental Developmental Index. †Pearson correlation. ‡Spearman rank order correlation. §P ⬍ .05 储P ⬍ .01

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Table 5. Summary of Variance Explained by Regression Models Predicting 21-Month Developmental Outcomes* (n ⫽ 44) Books in the home at 18 months† Block 1 Covariates

Block 2a Add Books

Block 2b Add PCI

Model

R2

F

P

sr2 Books

F Change

P

sr2 PCI

P

sr2 Books§

P

F Change

P

MDI PLS-Receptive

.03 .07

.19 .48

.98 .82

.24 .14

12.28 6.25

.001 .02

.22 .09

⬍.001 .04

.10 .08

.01 .05

15.54 4.46

⬍.001 .04

Toys in the home at 18 months‡ Block 1 Covariates

Block 2a Add Toys

Block 2b Add PCI

Model

R2

F

P

sr2 Toys

F Change

P

sr2 PCI

P

sr2 Toys§

P

F Change

P

MDI PLS-Receptive

.03 .07

.19 .48

.98 .82

.02 .10

.77 4.26

.39 ⬍.05

.35 .12

⬍.001 .02

.01 .07

.58 .08

20.83 5.57

⬍.001 .02

*Covariates: child’s sex, birth rank, father living in the home, mother’s country of origin, maternal education, and maternal depression. MDI indicates Bayley Mental Developmental Index; PLS Receptive, Preschool Language Scale Receptive language score; and PCI, parent-child interaction. †Scaled number of books in the home based on StimQ-READ score. ‡Scaled number of toys in the home based on StimQ-ALM (Availability of Learning Materials) score. §Adjusted for PCI.

frequency score of 2 (4 or more days per week); Spearman r ⫽ ⫺0.30, P ⫽ .05. Adjusting for the potential confounders in a multiple logistic regression model, reading 4 or more days per week was associated with decreased risk of meeting EI criteria (adjusted odds ratio [aOR] ⫽ 0.16; 95% CI 0.03– 0.99; P⬍.05). Toys Of the 6-month toy categories, only First Infant Toys were significantly related to 21-month development. First Infant Toys score predicted receptive language (r ⫽ 0.41, P ⫽ .006) and total language (r ⫽ 0.35, P ⫽ .02). These associations were still significant after adjusting for potential confounders (sr ⫽ 0.40, P ⫽ .01 for PLS-Receptive; sr ⫽ 0.35; P ⫽ .03 for PLS-Total). No association was seen between First Infant Toys and cognition, expressive language, or EI eligibility at 21 months. As shown in Table 4, toys provided at 18 months were associated with 21-month outcomes. StimQ-ALM score predicted 21-month receptive language (r ⫽ 0.37, P ⫽ .01); this retained significance after adjusting for potential confounders as shown in Table 5 (sr ⫽ 0.32; P ⫽ .047). Of the 5 categories of toys assessed at 18 months, the Symbolic and Fine Motor/Adaptive toy scores each significantly predicted receptive language and total language score. In addition, the Fine Motor/Adaptive toy score significantly predicted decreased EI eligibility at 21 months (r ⫽ ⫺0.35, P ⫽ .02); this retained significance after adjusting for potential confounders (aOR ⫽ 0.12 for having 2 or more Fine Motor/Adaptive Toys; 95% CI 0.02– 0.68; P ⫽ .02). Significant associations were not seen between the other 3 categories (Art, Language, and Life-Size) and child outcomes. Associations Between Parent-Child Verbal Interaction, Resources, and Developmental Outcome Books and toys at 18 months were each associated with parent-child verbal interaction, primarily maternal lan-

guage input. Books were significantly associated with maternal language input (r ⫽ 0.30, P ⫽ .04), but not with mutual communication (r ⫽ 0.19, P ⫽ .21). Similarly, toys were related to maternal language input (r ⫽ 0.34, P ⫽ .02) but not to mutual communication (r ⫽ 0.00, P ⫽ .93). Interrelationships between resources, parent-child verbal interaction, and developmental outcomes were assessed by hierarchical multiple regression. As shown in Table 5, when parent-child verbal interactions were added in the third block to each of the regression models, the degree to which resources were related to developmental outcomes decreased. For example, before inclusion of verbal interaction, books in the home at 18 months explained 24.2% of the variance in Bayley MDI at 21 months (block 2a). After inclusion of verbal interaction, books in the home explained 9.9% of the variance in Bayley MDI, a reduction of 59.1% (block 2b). Similar interrelationships were seen for books and toys with parent-child interactions in predicting receptive language. DISCUSSION In this longitudinal cohort study, we found that books and toys provided by parents were associated with developmental outcome in low-SES Latino children. Eighteenmonth-old toddlers exposed to more reading had better cognitive and receptive language development and were at lower risk for meeting EI eligibility criteria. We found that toys in the home at 6 and 18 months were predictive of receptive language development, and were associated with decreased frequency of meeting EI eligibility criteria. Furthermore, we found evidence that some categories of toys were more related to developmental outcomes than others. At 6 months, only First Infant toys (such as toys with patterns and mirrors) predicted later language. At 18 months, the toys with the greatest impact were Fine Motor/ Adaptive toys and Symbolic Play toys. For both books and toys, inclusion of parent-child verbal interaction in regression models was associated with a decrease in the amount

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of variance in developmental outcome, suggesting that the relationship between books and toys with developmental outcome was in part related to enhanced parent-child verbal interaction. In linking resources to parent-child verbal interaction, these findings support the important role of parents in facilitating the impact of books and toys on their children’s development. A large existing body of literature documents the effects of reading aloud on short- and long-term outcomes. For example, Payne et al36 found that parent-child reading aloud accounted for 12% of variance in receptive language in a sample of economically disadvantaged 4- and 5-yearolds. In addition, books in the home have been found to be an important indicator of adult health literacy and therefore may be important for children’s health outcomes.37 However, there has been limited study of the impact of books and reading for young preschool children, and no study to our knowledge documenting an impact on EI eligibility. The literature documenting effects of toys is more limited. Studies that used the HOME Inventory have shown that the Provision of Appropriate Play Materials subscale (which includes an assessment of toys) predicted firstgrade language development (r ⫽ 0.53).38 No study to our knowledge has looked quantitatively at the impact of individual categories of toys. However, Katz39 noted that symbolic play toys (such as a set of small people and a bus) facilitated joint pretend play during videotaped play sessions. Interestingly, the associations between resources on language development were limited to receptive language. No association with expressive language was seen. This may have been due to toys and books affecting development through an effect on maternal language input rather than on responsivity to the child. This is consistent with data indicating that language input principally affects receptive language; verbal responsivity (eg, parental elaborations on child vocalizations and use of response-eliciting questions) is more likely to show effects on child expressive language.3,40,41 In addition, an association with later development was seen at 6 months for toys but not for reading. We hypothesize that a relationship was not seen at 6 months for reading as a result of limited variability in reading and also because parents were just beginning to read to their children as ROR only began at 6 months. Our assessment of reading activities at 6 months may have been too early to show an association with later outcomes. We believe that the 18-month assessment showed significant associations with development because it reflected reading activities that had taken place during the period in which the children were between 6 and 18 months old. In contrast to reading activities, playing with toys is a more common and frequent activity even in early infancy. We also note that although ROR could have played a role in affecting the number of books provided and the children’s developmental outcome, we cannot assess this because all families received ROR as part of their routine primary care. It also is possible that families whose children would have been more developmentally advanced for

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other reasons would have specifically sought out physicians most interested in ROR and promoting reading aloud. This could have had an impact on the relationship between provision of books and developmental outcomes; however, it would have been unlikely to affect the relationship with toys. There are some potential limitations in this study. Unmeasured confounders might have accounted for the relationships found. It is possible that parents who provide more books and toys have other characteristics that would make them more likely to be more verbally responsive to their children even in the absence of books and toys. Another source of confounding is the possibility that parents with more books may also have more toys and vice versa. In contrast, SES was relatively homogeneous and therefore unlikely to have been a source of confounding. Indeed, interrelationships between the two were noted, making it difficult to delineate independent effects of toys and books. In order to minimize confounding, we performed multiple regression analyses adjusting for potential confounders such as maternal education and maternal depression. We are limited in our ability to demonstrate causality. It is possible that parents having more verbal interactions with their children would provide more resources, and that these verbal interactions would be present even in the absence of resources. It is also possible that children with earlier onset of developmental milestones might be more likely to play with more developmentally advanced toys. However, we do not believe that this was the case because the StimQ assesses a wide range of toys with equal credit given regardless of the toy’s level of difficulty. Our measure of EI had limitations. Although it was based on criteria in use in our state, it is not necessarily reflective of the number of children who receive EI services because others may have been referred and been evaluated outside of our project, and because low-SES families may face barriers to participation.42 Also, depressive symptoms were only assessed at 6 months, and therefore, we would not have picked up mothers with depressive symptoms later on. Finally, attrition was close to 40%, which could have affected the pattern of associations and may limit generalizability. Long-term follow-up is presently in progress through ages 5 to 6 years to assess the relationship between resources and school readiness in this sample. We conclude that reading aloud and provision of toys were associated with better child cognitive and language development as well as with decreased likelihood of EI eligibility. Parent-child verbal interaction explained part of this relationship. Additional work in this area would be useful to pediatricians in the provision of anticipatory guidance addressing reading aloud and provision of toys. ACKNOWLEDGMENTS This study was supported in part by the Rhodebeck Charitable Trust, the Tiger Foundation, the New York Community Trust and Children of Bellevue Inc. The sponsors did not play any role in the design or conduct of this study, in the collection, analysis, and interpretation of the data, and in the preparation, review, or approval of the manuscript. We thank two

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medical students who participated in this project: Abigail F. Nixon and Omolara Thomas. Finally, we extend our thanks to the families who participated, without whom this study could not have been performed.

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