- Top of page
It is well documented that children born preterm are at high risk for neurodevelopmental challenges, including cognitive, attention and self-regulation difficulties . These difficulties have also been shown to persist throughout childhood and are associated with an increased incidence of learning and attention difficulties as well as behavioural problems .
In the past several years, there has been an increased interest not only in identifying the neurodevelopmental outcomes faced by children born preterm but also in identifying what factors are associated with more optimal outcomes in order to target early intervention efforts . Parental behaviours and their associations with child outcomes have been a key focus within prevention strategies, particularly given the essential role parents play in intervention efforts.
One parenting behaviour that has gained recent interest, and has been shown to influence outcomes in at-risk children, is parental scaffolding . According to the sociocultural theory of development , scaffolding occurs when parents provide children with the support necessary for them to accomplish goals that otherwise would be beyond their ability. Through parents' scaffolding efforts, children gradually learn more developmentally advanced skills and become better able to solve problems independently.
Recent studies have focused on the role of verbal scaffolding, which comprises the verbal prompts parents provide children to help them solve problems or help them understand conceptual links between objects and/or activities . These studies have highlighted how important the content of parents' verbal input is for children's learning, showing that higher levels of verbal scaffolding during early childhood is predictive of better language [4, 7], non-verbal problem-solving , reading , cognitive  and executive functioning skills  during school years.
The purpose of this study was to examine and compare maternal verbal scaffolding in toddlers born preterm and full term. Of particular interest was whether there are differences in the level of verbal scaffolding (i.e. simple vs complex) used in these group and the relationship between each level of scaffolding and children's cognitive skills. In addition, this study sought to examine which socio-demographic and neonatal medical factors are associated with each type of verbal scaffolding for the preterm and full-term groups. We hypothesized that mother's of infants born preterm would use less verbal scaffolding and that mothers with higher education levels would use more scaffolding across both groups.
- Top of page
Our study highlights early differences in mother–child interactive styles of children born preterm compared with those born full term, specifically with regard to maternal scaffolding behaviours. We found that mothers of children born full term used significantly more complex scaffolding behaviours in contrast to mothers of preterm children. This difference may reflect a process by which mothers adjust their scaffolding based on their perception of their child's developmental level. Because the preterm group had significantly lower developmental levels compared with the full-term sample, as indexed by the Bayley scores, it is possible that in our sample the mothers of children born preterm were attuned to this difference and, hence, adjusted their scaffolding in order to be sensitive to their child's level of understanding. If this is the case, however, it is unclear whether using less complex scaffolding is helpful to the children born preterm.
Interestingly, a previous study by Donahue and Pearl  compared the verbal input provided by mothers of children born preterm and full term during problem-solving tasks. They found that similar to our findings, mothers of children born preterm used less complex verbal input, thereby providing less complex verbal scaffolding to their children. As there are few studies that have compared scaffolding in these populations, it will be important that future studies examine whether mothers of children born preterm are appropriately ‘fine-tuning’ their verbal input to be sensitive to their children's needs or whether this may be related to a type of prematurity stereotyping whereby mother's adjust their input solely based on their child's prematurity.
Our study also found that verbal scaffolding was related to cognitive skills for the children born full-term and the preterm children who were less ill (required less ventilation) during the neonatal period. The finding that scaffolding is related to higher functioning in a range of domains is not unexpected as this has been demonstrated in previous studies [4, 7, 8]. Landry and colleagues , for example, found that among mothers of 3-year-old children born preterm and full term, verbal scaffolding was associated with higher functioning in both verbal and non-verbal problem solving at 4 years as well as increased executive functioning at 6 years for both full-term and preterm born children.
Interestingly, a recent study by Hammond et al.  found that the relationship between scaffolding and early executive functioning depended on the child's age. In their study of healthy full-term children, scaffolding at 2 years of age was not related to early executive functioning skills at 3 years; however, scaffolding at 3 years of age was associated with executive functioning at 4 years of age. Although speculative, it is possible that scaffolding has a different relationship with cognition and early executive function at different ages for preterm and full-term born children. This may be particularly true given the difference in the developmental level of both groups, as children born preterm are known to have significantly lower cognitive and executive functioning skills [1, 18, 19]. Examining this association at different ages in both groups could help us better understand this relationship.
Although we expected to find a relationship between complex scaffolding and maternal education across both groups, we only found this relationship in the preterm group. Within the preterm group, mothers with higher education used more complex scaffolding and combined scaffolding. Although the relationship between scaffolding and education does not appear to have been previously assessed in preterm groups, studies examining this relationship in full-term samples have found an association between education and scaffolding . It is possible that in the full-term group, the relationship between scaffolding and maternal education was not found because these mothers were already using more complex scaffolding. In contrast, in the preterm group, the mothers with higher education may have been using more complex scaffolding as they were more aware of the importance of scaffolding for the optimal development of their children compared with mothers with less education. Studies examining the relationship between maternal education and play interactions support this by showing that mothers with higher education appear to be more knowledgeable about play styles that enhance learning .
Within the preterm group, mothers with higher education who had sicker preterm infants (i.e. high ventilation group) used significantly more complex scaffolding behaviour. This finding within the preterm children may highlight the increased need of these children. Mothers with higher education may be more aware of the need that their children have, particularly if they were considered more at risk of having neurodevelopmental difficulties. As a result, they may try to compensate by providing more scaffolding for their child to help their development. Although not assessed in this study, this potential process of compensation may be related to the perception of child vulnerability that the mother holds for her child, in that mothers who perceive their child as more vulnerable may be more prone to helping their child during interactions . Interestingly, within the child vulnerability literature, maternal education has often been found to be positively associated with child vulnerability perceptions, as scaffolding was in this study. The link between scaffolding and maternal education, within the more vulnerable children born preterm, is particularly important given that Koldewijn et al.  recently showed that maternal education is an important factor associated with improved cognitive outcomes among children born preterm receiving neurobehavioral intervention. Furthermore, they highlighted the particular importance of supportive intervention within the most vulnerable groups of children born preterm in that children born preterm, who were considered most vulnerable due to bronchopulmonary dysplasia, benefited most from intervention .
A limitation of this study was that it only measured maternal verbal scaffolding, and it may have been beneficial to also look at styles of non-verbal scaffolding that occur with mother–toddler interactions. It would have also been useful to assess toddler language skills in addition to cognition, as an association between maternal scaffolding and language skills has previously been found [24, 25]. Future studies using the BSID-III could include the language scales to further this line of enquiry. We also did not have information on the early intervention or preschool programmes children were enrolled in so could not look at the effect these programmes may have had. In addition, there may be other medical variables associated with use of maternal scaffolding and/or child cognition (intraventricular haemorrhage, retinopathy of prematurity), not included in the current study. Despite limitations, this study helps us better understand the maternal interaction styles that augment development, hence highlighting potential areas of intervention. This type of an intervention is easy to administer and not costly, but can have lasting effects on both the mother–child relationships and potentially early cognitive skills.
In conclusion, we found an association between mothers' verbal scaffolding during play and full-term toddlers' developmental level that could potentially be an effective way to enhance developmental skills of young toddlers born healthy at full term and preterm. Teaching a parent ways to play with their child that utilize early problem-solving skills can potentially enhance the child's development while simultaneously advancing the child's methods of exploration and play.