We Need to Talk About Social Inequalities in Language Development

The language skills developed by children during the early years contribute significantly to their health and well-being and their ability to satisfy needs, establish meaningful connections with others, and realize aspirations. Timely and smooth language development of all children should be considered an important public health goal. However, many children worldwide grow up in social environments that may limit the development of their full language and communication potential (Maggi et al., 2005). Speech-language pathologists (SLPs) are encouraged to partake in discussions and decisions aimed at supporting the language and communication skills of children in their local or regional public health arenas. To do so, developing knowledge of key concepts and theories drawn from public health and health promotion and gaining a more detailed understanding of how they relate to language development is important. This viewpoint article aims to take a step in this direction by exploring current knowledge about the social determinants of language and social inequalities in language development and by suggesting some implications of these concepts for interventions in speech-language pathology.

Social Determinants and Social Inequalities in Language Development

The World Health Organization (2021) defines social determinants of health as “the complex circumstances in which individuals are born and live that impact their health. They include intangible factors such as political, socioeconomic, and cultural constructs, as well as place-based conditions including accessible healthcare and education systems, safe environmental conditions, well-designed neighborhoods, and availability of healthful food.” These social determinants are the underlying causes of many disparities in health, functioning, and quality-of-life outcomes among individuals and social groups (Maggi et al., 2005).

The concept of social determinants in health can be expanded to child development (Maggi et al., 2005) and by extension to language development (Law et al., 2017) to refer to the “social determinants of language development (SDLs).” These SDLs thus refer to the environments and experiences that influence early language development. Our knowledge on SDLs has grown steadily since the influential study by Hart and Risley (1995), which provided striking evidence of the disparities in the amount of words that young children from varying socioeconomic backgrounds are exposed to during the early years (known as the “30 million word-gap”). This study paved the way to many more, confirming that engagement in responsive and rich verbal interactions with adults, over and above the sheer amount of words, is one of the most important SDLs (Hirsh-Pasek et al., 2015). These interactions are associated with broader SDLs such as income, social support network, levels of education of the parents, and access to high-quality early childhood education centers (Chang, 2017; Pace et al., 2017).

Decades of research have demonstrated the effects of unequal exposure to these SDLs among children: The prevalences of language difficulties are consistently higher in socially and economically disadvantaged communities than in the population as a whole (Law et al., 2017). What is perhaps less widely known is that these inequalities in language skills seem to follow a “social gradient,” a central concept in public health (Potvin et al., 2010). A social gradient means that health (or language) outcomes do not simply depend on a specific threshold resulting in a dichotomous classification of risk level, such as children living in poor versus affluent families (Potvin et al., 2010). What this means is that children growing up in families at the top of a social hierarchy are in better health (or present better language skills, for the purpose at hand) than those immediately under, who are themselves in better health than those following and so on until the very bottom of the social scale.

Law et al. (2017) offer a compelling example of the distribution of language difficulties across the social gradient. These researchers studied three cohorts of 5-year-old children at differing levels of social disadvantage across the whole population in the United Kingdom (Millenium Cohort Study), Scotland (Growing up in Scotland), and Australia (Early Language in Victoria Study) and divided each study sample into quintiles reflecting increasing levels of disadvantage. Results suggest a similar pattern across cohorts: Although differences are more pronounced in the lower quintiles, the median score of children on language measures systematically declined with increasing levels of disadvantage. In these cohorts, even slight gains in social and economic resources (e.g., moving from Quintile 1 to Quintile 2) resulted in commensurate gains in language skills among children, as well as a decrease in the prevalence of language difficulties. This suggests that there is a gradient relationship between social disadvantage and language skills.

We see these findings as having two main implications. First, many children (not only those who live in the most adverse life conditions) are faced with social inequalities in language development (Law et al., 2017). Using this term (social inequalities in language development) more frequently could help put children's developmental health (to which language contributes) on an equal footing with topics such as children's rights. Second, these social inequalities in language development are due to variations in living conditions and more specifically to disparities in SDLs. To support the language skills of children in a meaningful way, conducting actions targeting these determinants is a promising avenue. To guide such actions, it is imperative to become familiar with theoretical foundations that provide guidelines to understand the influences exerted by children's living environments on their developmental health. The Total Environment Assessment Model for Early Child Development (TEAM-ECD) framework has the potential to support SLPs in this endeavor.

The TEAM-ECD Framework to Understand the Social Determinants of Development

Developed for the World Health Organization's Commission on the Social Determinants of Health, the TEAM-ECD (Siddiqi et al., 2007) is borne out of the imperative of synthesizing the available evidence on the environments and experiences that influence early child development (ECD). Its evidentiary base is derived from three primary sources: peer-reviewed scientific literature; reports from governments, international agencies, and civil society groups; and international experts in the field of ECD. It offers one of the strongest means of understanding SDLs, as it builds on diverse literature and concepts, including bio-ecological models of child development, developmental psychology, biological embedding, social determinants of health, and social relations in human society and political economy.

This framework shows that there are opportunities to foster nurturing conditions for ECD at multiple levels of society (Siddiqi et al., 2007). Putting the child at the center of her or his surroundings, it features interacting and interdependent environments or spheres of influence that are instrumental for ECD: family environment, residential (i.e., neighborhoods) and relational communities (i.e., religious or other social bonds), programs and services, regional, national and global environments, and civil society.

For each sphere of influence, the TEAM-ECD identifies numerous evidence-based social determinants of ECD, all of which are also SDLs. For example, at the family level, social resources such as parenting skills; education and literacy; cultural practices and approaches; intrafamilial relations; the physical and mental health status of family members; and access to health and child care and economic resources such as wealth, occupational status, and living conditions are factors that can enable families to provide rich domestic language environments and make choices in the best interest of their child (Pace et al., 2017).

At the community level, evidence shows that access to high-quality services and resources, such as learning and recreation, childcare, medical, transportation, food markets, and opportunities for employment, often varies according to residential area. When applied to language development specifically, access to libraries and parks creates opportunities or constraints for play-based learning and exploration, both critical for language development (Pace et al., 2017). Because relations within the community contribute to information sharing about child-rearing practices and child development, they also offer opportunities for social participation and mutual support (social capital), which increase parents' ability to create nurturing environments for their child.

At more distal levels, inequalities in early language development can be reduced or eliminated through public investment in universal access to evidence-based programs and services that nurture children's language development. They can also be reduced by acting on physical, social, political, and economic factors at the regional (e.g., effective governance of ECD programs), national (e.g., employment policies and parental leave), or global (e.g., priority to children in social policy, monitoring child development in societies) environment level.

What Does This Mean for Speech-Language Pathology Interventions?

Language interventions, whether in individual or group modalities or even population-level interventions, typically include environment-focused actions, which target the linguistic environment of children, such as helping parents develop specific language stimulation skills (e.g., conversational recasts), in addition to child-focused actions, which directly target the language skills of children. The main insight of TEAM-ECD, when applied to language development, is the idea that many parents are confronted with personal, family, or social adversity that may prevent them from engaging in the responsive and supportive verbal interactions crucial to language development. The framework reminds us that language development is a collective responsibility, rather than a family one solely, and that many families cannot provide strong nurturant environments for their child without help from local, regional, national, and international resources and agencies (Irwin et al., 2012). Two main implications of this perspective on SLP interventions will be discussed.

Keeping an Eye on the Social Determinants of Language

To promote children's language development in an effective and holistic way, institutions offering speech and language therapy services and SLPs should be encouraged to conduct actions targeting SDLs, in addition to acting directly on children's language skills and fostering parental skills. Specific questions can provide guidance to identify appropriate actions: What measures could be put in place to support family-level SDLs such as parental levels of stress, mental health, and social support network? How could access to new environments, such as day care, the local library, or a community organization, be facilitated to provide children with supportive interactions and rich language models outside their home environment? How can relations between the children's environments (e.g., family, library, day care, and community organization) be created or strengthened in hopes of fostering more language learning opportunities for individual children, as well as children in the local community? The previously presented concept of “social gradient” of language skills reminds us that carrying out even one innovative action aimed at these SDLs in the context of speech-language pathology interventions has the potential to decrease levels of social disadvantage and, ultimately, foster early language development. Conducting such actions on SDLs implies reconceptualizing what language intervention “is.”

Language Interventions as Events in Systems

The focus of early language interventions should be on enhancing children's language skills and increasing the language learning opportunities available to them. As such, we propose to view speech-language pathology interventions as “intervention systems,” which include the broad set of actions conducted toward this aim. We borrow this idea from the “complex systems” approach to interventions in public health (Hawe et al., 2009). This approach considers any activity in a population-level intervention as an “event” within the complex systems that compose a person's environment through changing relationships, displacing entrenched practices, and redistributing and transforming resources. Through this lens, interventions conducted by SLPs might be better thought of as ongoing social processes (new routines, relationships, resources, power structures, and sets of values) rather than fixed and bounded entities (intervention strategies, techniques, materials, activities, processes, and agents).

Consider, as an example, a child from a migrant family, who may face a multitude of risks with regards to the social determinants of health, including difficulties or reluctance to access health care and social services, social exclusion and isolation, language barriers, experiences of trauma, and socioeconomic barriers such as access to employment and low income. All of these determinants are also likely to shape their child's language development. In this example, SLPs might work with other organizations to connect the family to mental health support resources and to community organizations, whose mandate often includes supporting social integration, access to employment, food security, and parenting. Because community organizations are also a meeting place for individuals from different cultural communities, they can also contribute to decrease isolation (thus increasing social capital and mental health) and positively influence parents' emotional availability to engage in quality interactions with their child. These actions combined might also help increase therapeutic alliance between SLPs and families, a key ingredient to the success of language interventions.

In summary, although they do not target language per se, these actions and the events that they create are language interventions. Thus, the effects of language interventions should not solely be measured by the progress in language skills but also in changes in resources, relationships, routines, practices, and knowledge within children's various environments. These events, which go beyond linguistic progress made by the child, must be considered as relevant intervention outcomes if our goal is to truly support the early language development of children.

Conclusions

Building on public health concepts and theories, the arguments provided in this article offer a fresh perspective on language interventions, which emphasizes the importance of addressing SDLs. This approach encourages SLPs and institutions to broaden the scope of actions that can be conducted to support the language development of children, especially those exposed to social inequalities in language development opportunities.

Author Notes