The Indian Journal of Pediatrics

, Volume 85, Issue 7, pp 498–503 | Cite as

Cognitive Development of Toddlers: Does Parental Stimulation Matter?

  • Prahbhjot Malhi
  • Jagadeesh Menon
  • Bhavneet Bharti
  • Manjit Sidhu
Original Article



To examine the impact of quality of early stimulation on cognitive functioning of toddlers living in a developing country.


The developmental functioning of 150 toddlers in the age range of 12–30 mo (53% boys; Mean = 1.76 y, SD = 0.48) was assessed by the mental developmental index of the Developmental Assessment Scale for Indian Infants (DASII). The StimQ questionnaire- toddler version was used to measure cognitive stimulation at home. The questionnaire consists of four subscales including availability of learning materials (ALM), reading activities (READ), parent involvement in developmental activities (PIDA), and parent verbal responsivity (PVR). Multivariate regression analysis was used to predict cognitive scores using demographic (age of child), socio-economic status (SES) (income, parental education), and home environment (subscale scores of StimQ) as independent variables.


Mean Mental Development Index (MDI) score was 91.5 (SD = 13.41), nearly one-fifth (17.3%) of the toddlers had MDI scores less than 80 (cognitive delay). Children with cognitive delay, relative to typically developing (TD, MDI score ≥ 80) cohort of toddlers, had significantly lower scores on all the subscales of StimQ and the total StimQ score. Despite the overall paucity of learning materials available to toddlers, typical developing toddlers were significantly more likely to have access to symbolic toys (P = 0.004), art materials (P = 0.032), adaptive/fine motor toys (P = 0.018), and life size toys (P = 0.036). Multivariate regression analysis results indicated that controlling for confounding socio-economic status variables, higher parental involvement in developmental activities (PIDA score) and higher parental verbal responsivity (PVR score) emerged as significant predictors of higher MDI scores and explained 34% of variance in MDI scores (F = 23.66, P = 0.001).


Disparities in child development emerge fairly early and these differences are not all linked to economic disparities. There is a need to develop evidence-based parenting interventions for primary prevention of developmental problems, especially in resource poor countries.


Early stimulation Cognitive functioning Toddlers 


Several recently published articles in Lancet on child development have argued that millions of children growing up in low-income and middle-income countries (LMICs) are at significant risk of not reaching their developmental potential primarily due to adverse factors such as poverty, malnutrition, recurrent/chronic infectious diseases, inadequate nurturing care and cognitive stimulation [1, 2]. Indeed, prevalence of developmental disabilities is 4 to 7 times higher in children from LMICs than high income countries [3, 4, 5].

Available evidence indicates that adverse childhood factors have a cumulative impact and as risks accumulate, the likelihood of having one or more delay in development also increases exponentially [6]. Moreover, developmental problems, once established are highly resistant to change, and are likely to intensify over time, and growing up with poor nurturing care can have lifelong deleterious consequences including poor school readiness, decreased capacity to learn, and limited academic and career success [7, 8] resulting in what is known as “intergenerational transmission of poverty” [9].

Identifying the environmental determinants of children’s cognitive abilities is critical for remediating the increasing achievement gaps between children from disadvantaged and economically well-off families [10, 11]. Despite this, few studies from India have examined the quantity and quality of parental stimulation and home literacy and learning environments of toddlers. Material resources such as availability of books and toys may represent a means of encouraging verbal interactions among parent and child, and these have been documented to have sizeable impact on child developmental outcomes [12, 13]. Addressing early disparities in child development is a national priority and the present paper addresses this gap by examining the role of the early parental stimulating behaviors and availability of learning materials at home in predicting cognitive functioning of young Indian children. The authors hypothesized that parental stimulation would be related to cognitive outcomes over and above that of parental education and socio-economic status. Specifically, the objectives of the study were to examine the impact of quality of early stimulation on cognitive functioning of toddlers living in a developing country.

Material and Methods

A total of 150 toddlers in the age range of 12–30 mo (53% boys) (Mean age = 1.76 y, SD = 0.48) were recruited from child care centers and play schools of an urban centre in North India. Children with any prenatal, congenital, and chronic medical problems were excluded. The study was carried out in 2011–2013. Table 1 presents the descriptive statistics of socio-economic and demographic characteristics of the sample. Most of the parents had a high school or college degree and there was more or less equal representation of families from different socio-economic status. Majority of the mothers (74%) were not gainfully employed and were homemakers. The study was cleared by the Institute Ethics committee and informed written parental consent was taken.
Table 1

Characteristics of the study population



Mean Age (years)

1.76 (SD = 0.48)

Boys (%)

53.3 (80)

Mean Household Income (Rs. Monthly)


Education Mother % (n)

  < 10 Class

26.7 (40)

 High School

34.0 (51)

 Graduate and above

39.3 (59)

Education Father % (n)

  < 10 Class

25.3 (40)

 High School

37.3 (56)

 Graduate and above

37.3 (56)

Socioeconomic Status % (n)


19.3 (29)

 Upper Middle

30.0 (45)

 Lower Middle

30.0 (45)


20.7 (31)

SD/n given in parenthesis

The tools used were the StimQ Questionnaire (toddler version) [14] and Developmental Assessment Scales for Indian Infants (DASII) [15].

The StimQ Questionnaire (toddler version) [14]: The StimQ is a 39 items scale which assesses the kind of stimulation which the primary caregiver provides to the child. The StimQ has four subscales including availability of learning materials (ALM), READ scale, parental involvement in developmental advance (PIDA), and parental verbal responsivity (PVR). The ALM subscale assesses number of developmentally appropriate toys and learning materials that are available for child’s use including symbolic play, art materials, fine motor/adaptive, language stimulating toys, and life size toys. The READ subscale assesses number of children’s books available, shared reading activities such as frequency of reading, diversity of content of books shared; and whether caregiver points, names while reading to the child. The PIDA subscale assesses the frequency and quality of teaching activities parents engage in such as teaching letters, colors, counting, and body parts. The PVR subscale measures verbal interactions between parents and the child and engagement in interactive play and talk while performing daily activities like bathing and feeding. Total score of the StimQ ranges from 0 to 31. In the administration of the questionnaire, credit was given only for those activities that were provided by the primary caregiver and in case another person in the household was performing the activity, no credit was given.

The questionnaire was supplemented by a picture-booklet, assembled especially for the study, which depicted each of the learning materials in a pictorial form to ensure uniformity and easy comprehensibility by the caregiver. The internal consistency reliability of the questionnaire was high and the Cronbach alpha was found to be 0.93. Factor analysis of the scale was also done and four factors were identified where the Eigen value was more than 2 and these factors explained more than 50% of the variance, thereby showing that the scale identified similar components as the original scale. Therefore, the StimQ was found to be a reliable and valid questionnaire for use in India.

Developmental Assessment Scales for Indian Infants (DASII) [15]: The Mental Development Index (MDI) scale of the Developmental Assessment Scales for Indian Infants (DASII, Indian adaptation of Bayley Scales of Infant Development) was used to assess cognitive development of the toddler. The DASII assesses early vocalizations, language skills, memory, social and classification skills. The scale provides standard scores with a mean of 100 and a standard deviation of 15, and scores <80 are interpreted as delayed cognitive development.

SPSS version 20 was used for all analyses. One way analysis of variance and t test was used to compare the groups on continuous variables including StimQ subscale and total scores and MDI scores. Chi-square analysis was used for categorical variables analysis. Two stepwise multivariate regression analyses were performed to identify the predictors of total StimQ scores and MDI scores, respectively. To examine the potential predictors accounting for total StimQ score, age of child, birth order, household income, and parental education were used as predictor variables. Multivariate regression analysis to predict MDI scores used demographic (age of child), SES (income, parental education), and home cognitive environment (subscale scores of StimQ) as independent variables.


Mean MDI score was 91.5 (SD = 13.41); nearly one-fifth (17.3%) of the toddlers had cognitive delay (CD, scores less than 80). Overall, few toddlers were found to own any art materials such as coloring books (30%), chalkboards (27%), colourful clay (18%) and only half the toddlers had access to crayons. Toys to enhance language such as toy letters (28%), toy numbers (21%), and shape sorters (13%) were also not available in majority of the homes. Toddlers also had limited access to manipulative toys such as colourful plastic rings (28%), nesting toys (25%), blocks (14%), beads (11%), and wood puzzles (6%). Despite the overall paucity of learning materials available to toddlers, typical developing toddlers (TD, MDI scores ≥80) were significantly more likely to have access to symbolic toys (P = 0.004), art materials (P = 0.032), adaptive/fine motor toys (P = 0.018), and life size toys (P = 0.036) (Table 2).
Table 2

Mean number of learning materials available by delay status

ALM Subscales

Delayed M (SD)

Typical M (SD)

t value


Symbolic Toys

1.69 (2.21)

2.21 (0.78)




0.27 (0.45)

0.50 (0.50)




0.38 (0.57)

0.78 (0.80)




0.19 (0.40)

0.37 (0.49)



Life Size

0.35 (0.49)

0.57 (0.50)



M Mean; SD Standard deviation

Only half the toddlers had children’s books available to them and even among homes with book ownership, less than two-thirds (61%) parents read out aloud stories to their children regularly. Homes of TD children were 3.7 times more likely to own children’s books as compared to children with CD (χ2 = 15.07, P = 0.0001). Parents of typically developing toddlers were more involved in their development and were significantly more likely to teach them colors (χ2 = 3.72, P = 0.054), counting (χ2 = 4.41, P = 0.036), letters (χ2 = 7.12, P = 0.008), body parts (χ2 = 11.73, P = 0.001), make believe play (χ2 = 5.69, P = 0.017), show child how to use toys (χ2 = 8.43, P = 0.004), and point and name objects on the street and at home (χ2 = 16.45, P = 0.001).

The present results indicated that some parents talked and interacted more with their toddlers than others, and these differences in language input significantly impacted cognitive skills of their children. Specifically, mothers of TD, relative to delayed toddlers, were significantly more likely to provide language stimulation (χ2 = 8.65, P = 0.003), play social interactive games (χ2 = 8.06, P = 0.005), and play on one-to-one basis (χ2 = 6.82, P = 0.009). In fact, toddlers with sustained engagement, follow through, and verbal interactions with their parents had significantly higher MDI scores (F = 7.53, P = 0.001). Limited parental responsiveness resulted in an MDI score which was 11 points lower than toddlers whose mothers showed consistently higher responsiveness (Fig. 1).
Fig. 1

MDI score as a function of parental verbal responsivity

Children with CD, relative to typically developing cohort of toddlers, had significantly lower scores on all the subscales of StimQ and the total StimQ score (Table 3). Specifically, children with cognitive delay relative to typical developing children had significantly lower ALM (t = 3.35, P = 0.001), READ (t = 4.12, P = 0.001), PIDA (t = 4.10, P = 0.001), PVR (t = 4.94, P = 0.001), and total StimQ scores (t = 5.10, P = 0.001). Several demographic and socio-economic variables were positively related to StimQ total and subscale scores, including SES status score, maternal education, income, and age of the child. However, in order to identify the significant predictors of increased StimQ total score and higher MDI scores and their order of importance two multivariate regression analyses were performed. Results indicated that three predictors including higher maternal education level, higher family income, and higher age of the child together explained 50% of the variance in total StimQ scores (F = 50.7, P = 0.001). Sex of the child, paternal education level, and birth order were not associated with the Stim Q total scores. It is noteworthy that household income did not emerge as a significant predictor of total StimQ score. The second regression analysis results indicated that controlling for confounding socio-economic status variables, higher parental involvement in developmental activities (PIDA score) and higher parental verbal responsivity (PVR score) emerged as significant predictors of higher MDI scores and explained 34% of variance in MDI scores (F = 23.66, P = 0.001).
Table 3

StimQ subscale scores by delay status

StimQ Subscales

Delayed M (SD)

Typical M (SD)

t value



2.88 (2.14)

4.44 (2.15)




0.85 (2.11)

4.59 (4.52)




3.54 (2.73)

5.84 (2.57)




2.00 (0.98)

2.97 (0.89)



Total StimQ

9.27 (5.84)

17.83 (8.11)



M Mean; SD Standard deviation; ALM Availability of learning materials; READ Reading activities; PIDA Parent involvement in developmental activities; PVR Parent verbal responsivity


The present findings indicate that access to stimulating materials, reading to children, higher involvement in development enhancing activities and quantity and quality of language input significantly impacted cognitive skills of toddlers, over and above socioeconomic status and education level of parents. These findings add to the growing body of evidence that disparities in child development emerge fairly early and these differences are not all linked to economic disparities. Income differences may serve as a proxy for parenting and when parenting practices are added into the predictive equation, income effects on child outcomes are substantially reduced [11, 16, 17]. For instance, a longitudinal study, which utilized data from the UK Millennium Cohort Study, showed that positive parenting mitigated the negative impact of poverty and contributed to enhanced school achievement of children [17]. In similar vein, Rodriguez and Tamis-LeMonda assessed quality of mothers’ engagements with their children and the availability of learning materials among low-income children [11]. Large variations in the vocabulary and emergent literacy skills of young children were found, even among children from economically disadvantaged homes, and these differences were strongly predicted by children’s learning environment, such that children from the poorest literacy environment homes had scores more than 15 standard scores lower than children from the most stimulating homes.

Substantial variation in availability of resources and parenting language-related practices were found, and this appeared to have implications for understanding pathways through which home environments exert their influence on developmental trajectories. Since evidence indicates that inadequate home literacy environment can lead to disparities in reading at school entry, many Indian children appear to be at high risk for poor literacy outcomes. Parental involvement was found to significantly impact child development, and child-directed verbal engagement markedly influenced early intellectual development of the toddlers. Indeed, increased opportunities for reciprocal verbal interactions can reinforce cognitive processing skills that enhance cognitive development. Available evidence indicates that the amount of caregiver speech improves the early language environment of young children and is related to vocabulary development of children, especially from low socio-economic status homes [18, 19]. In a recent study, Weisleder and Fernald used audio recordings of parent infant language interaction to measure the home language environment of 29 toddlers and found that children who experienced more direct verbal interaction became more efficient learners and had larger vocabularies by the age of 24 mo [18].

It seems that interventions aimed at increasing positive parental verbal involvement with their children are especially critical for children at risk for poor development outcomes, and this holds promise to change their development trajectory. Home-based interventions which have been conducted to target cognitive deficits in young children at risk for poor cognitive development in developing countries have reported significant effects on cognition [20, 21, 22]. In fact, longitudinal studies have reported sustained positive intellectual and educational effect sizes in the range of 0.4–0.6 SD, persisting till adolescent years in a study from Jamaica [23]. Providing children toys, books and using videotaped interactions to promote early child development have also been found to promote child development in children from disadvantaged families in the short and long term [24]. In this context, it may be noted that research on early brain development underscores the effects of early experiences and secure relationships in generating and strengthening the neural connections that is the foundation of early learning. In fact, growing body of recent research evidence indicates that children develop in an environment of relationships and continuous back and forth interactions with adults can stimulate the growth of the child’s brain [25].

The present findings suggest the need to target parental responsiveness as an early intervention strategy for improving cognitive outcomes of infants and toddlers. In fact, several recent studies have reported that focused interventions on promoting positive responsiveness in young children improves their executive and cognitive functioning, enhances language development and literacy skills [26]. Integrating early childhood development activities and parent training into the primary health care services have been associated with some moderate benefits in intervention studies conducted in developing countries [22, 27, 28]. For instance, Chang et al., demonstrated the feasibility of implementing innovative parenting interventions in the Caribbean by community health workers on the development of 250 infants. The intervention involved showing short video clips on mothers’ responding, praising, comforting, and talking to their children. Mothers practiced these activities under the supervision of community health workers and were encouraged to do it on a daily basis at home. Results showed significant increase in parenting knowledge and positive gains for cognitive development of infants at 18 mo of age [28]. Indeed, psychosocial-stimulation intervention studies conducted in developing countries have been found to have significant impact on children’s cognitive and language development (effect size ranging 0.43 to 0.47) [29].

There are some limitations in this study. First, the results of the study do not demonstrate causality. Since children play an active role in their own experiences it is possible that those with higher cognitive skills are more responsive and elicit more verbal interactions and involvement from their parents. Secondly, since the measure of cognitive stimulation was a parent-report measure, possibly some social desirability bias may also be present. Although the StimQ has been found to have convergent validity with observational measures of parent and child behavior, a home visit and observation of parent-child interaction may have added to the strength of the study design. Additional work in this area is further warranted.

The present findings highlight the need for identifying the environmental determinants of children’s mental development for remediating the growing achievement gap which presents fairly early in life. Positive parenting interventions hold promise for primary prevention of developmental problems, especially in resource poor countries There is therefore a need to support early cognitive development of children by teaching parents consistent, responsive, interactive, and stimulating parenting to enhance the outcomes for at-risk children from the majority world.


Author’s Contributions

PM and BB conceptualized and designed the study and did the statistical analyses. JM collected the data, did the literature search, and assembled the pictorial booklet. MS led the training of the cognitive assessment of the toddlers and administration of the StimQ, and oversaw the data collection and helped in validating the StimQ. PM wrote the manuscript with critical inputs from all the authors and all the authors approved the final manuscript as submitted. BB will act as guarantor for this paper.

Compliance with Ethical Standards

Conflict of Interest



  1. 1.
    Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B. Developmental potential in the first 5 years for children in developing countries. Lancet. 2007;369:60–70.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Black MM, Walker SP, Fernald LC, et al, for the lancet early childhood development series steering Commitee. Early childhood development coming of age: science through the life course. Lancet. 2017;389:77-90.CrossRefPubMedGoogle Scholar
  3. 3.
    Singhi P, Kumar M, Malhi P, Kumar R. Utility of the WHO ten questions screen for disability detection in a rural community: the north-Indian experience. J Trop Pediatr. 2007;53:383–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Lu C, Black MM, Richter LM. Risk of poor development in young children in low-income and middle-income countries: an estimation and analysis at the global, regional, and country level. Lancet Glob Health. 2016;4:e916-22.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Aly Z, Taj F, Ibrahim S. Missed opportunities in surveillance and screening systems to detect developmental delay: a developing country perspective. Brain Dev. 2010;32:90–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Sidhu M, Malhi P, Jerath J. Multiple risks and early language development. Indian J Pediatr. 2010;77:391–5.CrossRefPubMedGoogle Scholar
  7. 7.
    Sidhu M, Malhi P, Jerath J. Early language development in Indian children: a population based pilot study. Ann Indian Acad Neurol. 2013;16:371–5.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Tamis-LeMonda CS, Luo R, McFadden KE, Bandel ET, Vallotton C. Early home learning environment predicts children’s 5th grade academic skills. Appl Dev Sci. 2017;
  9. 9.
    Harper C, Marcus R, Moore K. Enduring poverty and the conditions of childhood: life course and intergenerational poverty transmissions. World Dev. 2003;31:535–54.CrossRefGoogle Scholar
  10. 10.
    Landry SH, Smith KE, Swank PR, Guttentag CA. Responsive parenting intervention: the optimal timing across early childhood for impacting maternal behaviors and child outcomes. Dev Psychol. 2008;44:1335–53.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Rodriguez ET, Tamis-LeMonda CS. Trajectories of the home learning environment across the first 5 years: associations with children’s vocabulary and literacy skills at prekindergarten. Child Dev. 2011;82:1058–75.CrossRefPubMedGoogle Scholar
  12. 12.
    Tomopoulos S, Dreyer BP, Tamis-LeMonda C, et al. Books, toys, parent-child interaction, and development in young latino children. Ambul Pediatr. 2006;6:72-8.CrossRefPubMedGoogle Scholar
  13. 13.
    Malhi P, Bharti B, Sidhu M. Reading achievement of Indian children: role of home literacy environment. J Indian Acad Appl Psychol. 2017;43:49–58.Google Scholar
  14. 14.
    Dreyer BP, Mendelsohn AL, Tamis-Lemonda CS. StimQ- The Cognitive Home Environment. 2009. Available at: Accessed on 18 July 2017.
  15. 15.
    Misra N, Phatak P. Developmental assessments scales for Indian infants. Baroda: MS University of Baroda; 1996.Google Scholar
  16. 16.
    Dooley M, Stewart J. Family income, parenting styles and child behavioural- emotional outcomes. Health Econ. 2007;16:145–62.CrossRefPubMedGoogle Scholar
  17. 17.
    Kiernan KE, Mensah FK. Poverty, family resources and children’s early educational attainment: the mediating role of parenting. Br Educ Res J. 2011;37:317–36.CrossRefGoogle Scholar
  18. 18.
    Weisleder A, Fernald A. Talking to children matters: early language experience strengthens processing and builds vocabulary. Psychol Sci. 2013;24:2143–52.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Malhi P, Sidhu M, Bharti B. Early stimulation and language development of economically disadvantaged young children. Indian J Pediatr. 2014;81:333–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Nair MKC, Philip E, Jeyaseelan L, George B, Mathews S, Padma K. Effect of child development centre model early stimulation among at-risk babies—a randomized controlled trial. Indian Pediatr. 2009;46:S20–6.PubMedGoogle Scholar
  21. 21.
    Vazir S, Engle P, Balakrishna N, et al. Cluster-randomized trial on complementary and responsive feeding education to caregivers found improved dietary intake, growth and development among rural Indian toddlers. Matern Child Nutr. 2013;9:99–117.CrossRefPubMedGoogle Scholar
  22. 22.
    Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA. Effect of integrated responsive stimulation and nutrition interventions in the lady health worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. Lancet. 2014;384:1282–93.CrossRefPubMedGoogle Scholar
  23. 23.
    Walker SP, Chang SM, Younger N, Grantham-McGregor SM. The effect of psychosocial stimulation on cognition and behavior at 6 years in a cohort of term, low-birthweight Jamaican children. Dev Med Child Neurol. 2010;52:e148–54.CrossRefPubMedGoogle Scholar
  24. 24.
    Mendelsohn AL, Huberman HS, Berkule SB, Brockmeyer CA, Morrow LM, Dreyer BP. Primary care strategies for promoting parent-child interactions and school readiness in at-risk families: the Bellevue project for early language, literacy, and education success. Arch Pediatr Adolesc Med. 2011;165:33–41.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Reis HT, Collins WA, Berscheid E. Relationships in human behavior and development. Psychol Bull. 2000;126:844–72.CrossRefPubMedGoogle Scholar
  26. 26.
    Merz EC, Landry SH, Montroy JJ, Williams JM. Bidirectional associations between parental responsiveness and executive function during early childhood. Soc Dev. 2017;26:591–609.CrossRefPubMedGoogle Scholar
  27. 27.
    Hamadani JD, Nahar B, Huda SN, Tofail F. Integrating early child development programs into health and nutrition services in Bangladesh: benefits and challenges. Ann N Y Acad Sci. 2014;1308:192–203.CrossRefPubMedGoogle Scholar
  28. 28.
    Chang SM, Grantham-Mcgregor SM, Powell CA, et al. Integrating a parenting intervention with routine primary health care: a cluster randomised trial. Pediatrics. 2015;136:272–80.CrossRefPubMedGoogle Scholar
  29. 29.
    Aboud FE, Yousafzai AK. Global health and development in early childhood. Annu Rev Psychol. 2015;66:433–57.CrossRefPubMedGoogle Scholar

Copyright information

© Dr. K C Chaudhuri Foundation 2018

Authors and Affiliations

  • Prahbhjot Malhi
    • 1
  • Jagadeesh Menon
    • 2
  • Bhavneet Bharti
    • 1
  • Manjit Sidhu
    • 3
  1. 1.Department of PediatricsPost Graduate Institute of Medical Education and ResearchChandigarhIndia
  2. 2.Department of GastroenterologyPost Graduate Institute of Medical Education and ResearchChandigarhIndia
  3. 3.Department of PsychologyMCM DAV College for WomenChandigarhIndia

Personalised recommendations