Associations between Caregiver Mental Health, Early Childhood Language Outcomes, and Caregiver Perception Bias: Evidence from Rural China

Associations between Caregiver Mental Health, Early Childhood Language Outcomes, and Caregiver Perception Bias: Evidence from Rural China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Associations between Caregiver Mental Health, Early Childhood Language Outcomes, and Caregiver Perception Bias: Evidence from Rural China Qi Jiang, Yiwei Qian, Tianli Feng, Hanwen Zhang, Evelyn Zhang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7661882/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2026 Read the published version in Scientific Reports → Version 1 posted 13 You are reading this latest preprint version Abstract Language development and the home language environment during early childhood are critical for long-term child outcomes. Caregiver mental health may influence early language outcomes directly, but it can also introduce perception bias, which refers to the discrepancies between caregiver self-assessments and the actual status of child language outcomes. This study examines the associations between caregivers mental health symptoms and (i) child language development and home language environment, and (ii) caregiver perception bias in self-report assessments of child language development and home language environment. The stduy recruited 137 rural Chinese households with children aged 16–24 months. Objective measures of child language development and the home language environment were collected using Language Environment Analysis (LENA) technology. Caregiver perception bias were measured by the descrepency between the objective and caregiver self-report measurements. Results show that caregiver anxiety and stress symptoms were linked to poor child language development, while symptoms of depression and anxiety symptoms were associated with less stimulating home language environment. Caregivers with depressive and anxiety symptoms tended to overestimate their children’s language development, and those with depressive symptoms also overestimated their own verbal inputs. These findings call for caution when implementing self-report assessments of early childhood development. Health sciences/Diseases Health sciences/Health care Biological sciences/Psychology Social science/Psychology early childhood language development early childhood language environment Language Environment Analysis (LENA) caregiver mental health rural China Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Language development during the first three years of life is a fundamental component of early childhood development that lays the groundwork for future language, cognitive, and learning outcomes. Delays in early language development can have lifelong consequences, such as low education attainment and diminished employment performance [ 1 – 3 ]. Unfortunately, many children in low- and middle-income countries (LMICs) are at risk of early language delays. In rural China, for example, a recent meta-analysis revealed that 46% of young children failed to reach their language development potential [ 4 ]. Growing evidence indicates that poor home language environments, characterized by insufficient verbal interactions between children and their caregivers, is a main predictor of early language developmental delay in LMICs [ 5 – 7 ]. Identifying the factors that hinder an interactive, stimulating home language environment is crucial for improving early language development in low-income regions. Caregiver mental health substantially influences child development outcomes, but its specific impact on language development remains unclear. One in five mothers in LMICs reported depressive symptoms in LMICs during the post-partum period [ 8 ]. A suvey of 2541 participants suggested that 39% of primary caregivers (mothers and grandmothers) of children under age three living in rural China reported depressive, anxiety, or stress symptoms [ 9 ]. A substantial body of research links caregiver depressive symptoms to impaired child cognitive, motor, and social-emotional development, as well as disturbances in early attachment and increased behavior problems [ 10 – 12 ]. A Lancet review suggests that depressive symptoms contribute to these developmental adversities by altering the early caregiving environment, particularly the caregiver’s parenting practices and interactions with the child [ 13 ]. However, the much smaller body of literature has focused on early childhood language development and other mental health symtpoms beyond depression. Research on caregiver mental health and early language development is further complicated by the perception bias associated with caregiver mental health symptoms. Perception bias, the discrepancies between caregiver self-assessments and the actual status of child language outcomes, occurs when caregivers experiencing mental health symptoms misinterpret or overlook their own and their children’s behaviors, making distorted assessments. When perception bias results in negative attributions, caregivers could misinterpret typical child behaviors as problematic or deliberately disobedient rather than situationally driven [ 14 , 15 ]. Caregiver mental health symptoms could also impair their capacity to pay attention to the child [ 16 ], thus reduce the accuracy of caregiver-reported measurements. Desipite most widely implemented measurements of child development rely on caregiver self report, few studies have tried to quantify whether caregiver mental health symptoms were associated with their perception bias in caregiver self-assessments of child language development and their home language environment [ 17 ]. Recent advances in the Language Environment Analysis (LENA) technology have enabled the recording and analysis of sounds in the child’s surrounding environment and those produced by the child, which allow for an objective measure of child language development and the verbal interactions that form the home language environment. Leveraging LENA data as benchmark objective measurements, the goals of the current study are to a.) investigate the association between caregiver mental health symptoms, child language development, and the home language environment; and b.) examine the association between those symptoms and perception bias in caregiver-reported assessments of child language development and their language home environment. Methods Study Location Data were collected from households in two distinct areas (a peri-urban district and two rural counties) in Sichuan Province, China. The peri-urban district is in the suburbs of Chengdu, the provincial capital, and has rapidly transitioned from an agricultural economy into one of the fast-developing areas in the province. Due to rapid urbanization, the district hosts a large population of a.) households with rural backgrounds, including rural migrants, that migrated from rural regions without access to urban public welfare benefits due to their rural rural household registration status, and b.) urbanized rural households, whose farmland in the area had been acquired by the government. In 2019, the average per capita disposable income of rural residents in this district was 30,405 RMB (4,403 USD), much lower than the average per capita income in the Chengdu’s central urban districts (49,193 RMB or 7,613 USD) [18]. The second sampling location was in two counties in a rural, prefecture-level city in Sichuan. The average per capita income for rural residents in this prefecture was 14,670 RMB (2,124 USD), less than half of the average per capita income of urban residents in Sichuan (36,153 RMB or 5,235 USD) [19]. Participants The participants in the study are children aged 18 to 24 months and their primary caregivers, within the households with rural backgrounds. We focus on toddlers aged 18 to 24 months due to the rapid language development that occurs during this period: Around 18 months of age, many children experience a “vocabulary burst” and start to acquire new words at a much faster rate than before (Goldfield & Reznick, 1990). By this age, they can also distinguish are grammatically correct or incorrect placement of familiar function words (Santelmann & Jusczyk, 1998). By 24 months, the speed and accuracy in spoken word understanding increase dramatically over the second year of life (Fernald et al., 1998). Therefore, any disparity in the home language environment at this stage is likely to have measurable impacts on the child’s language skills. Sampling protocol Due to the geographic and administrative differences between the rural and peri-urban communities, the research team separately sampled participants from the two study locations. To select the peri-urban sample, the research team followed a two-step protocol. First, the research team obtained a list of children between 18 and 24 months of age based on birth records from two local hospitals. Second, households were then randomly selected from the list and trained enumerators screened them for eligibility via phone calls. Households were invited to participate in a survey if their residency status met the legal criteria for rural migrants or urbanized farmers: A household was considered a rural migrant family if a.) the legal residence of either parent was in a rural area outside of Chengdu Municipality; and b.) one parent had lived in the sample district for at least 6 months. To be considered urbanized farmers, a.) the legal residence of either parent must be within the district; b.) all or part of the household’s farmland must have been reclaimed by the government; and c.) any remaining cultivated land owned by the household must be less than 200 square meters per adult family member on average. Following this protocol, a total of 109 households were enrolled in the survey. Of these, 81 consented to the collection of home language environment data (34 rural migrant households, 47 urbanized rural households). To select the rural sample, the research team followed a three-step protocol. First, all townships in the two sample counties were included in the study, except the townships that housed the county seat, which are typically wealthier and more urbanized than townships In the the rest of the county. This resulted in 11 townships. Second, we obtained a list of households with children aged between 18 and 24 months based on birth records from the township governments, which resulted in a total of 175 households across the 11 townships. Third, we excluded those that were not legally classified as rural residents and enrolled all remaining 109 eligible households in the study. Of these, 77 consented to the collection of home language environment data. Of the 158 households that completed home language environment data collection, we excluded 21 in which the primary caregiver was not the respondent of the household survey. The final analytic sample includes 137 households: 40 urbanized rural, 27 rural migrant, and 70 rural households. A balance test found no significant differences in demographic information between households that consented to LENA data collection and those that did not [See Apendix Table 1]. Data Collection The research team collected data on the home language environment, caregiver mental health, child language development, and demographic characteristics of the household young children and their households. Trained enumerators collected data from all sample households in the summer and fall of 2020 following a standardized four-day protocol. On the first day, enumerators surveyed the primary caregiver of each sample child at their home or the hospital. After the survey, caregivers were instructed on how to record home language environment data with LENA. Caregivers then recorded their home language environment during the second and third days. On the fourth day, enumerators retrieved the recording devices and conducted an exit interview to ensure compliance with the data collection protocol. Measures Caregiver mental health To measure caregiver mental health, enumerators administered the Depression, Anxiety, and Stress Scale-21 (DASS-21) to the primary caregiver of the child, identified by each household as the person primarily responsible for the child’s daily care. The DASS-21, a short-form version of the DASS-42 [20], is a self-report questionnaire with three subscales evaluating if the caregiver was at risk for the depression, anxiety, and stress, respectively (and the severity of the risk). Caregivers were asked to rank, on a scale of 0 to 3, how each of 21 statements (seven describing each mental health issue) applied to them in the past week. The score on each subscale is the sum of their ratings for the seven statements multiplied by two. Hence, the score for each subscale could range from 0 to 42, with higher scores indicating more severe symptoms. Following the DASS-21 scoring guidelines, participants were considered experiencing symptoms of mental health if they scored above 9 for depression, 8 for anxiety, and 14 for stress [20]. Notably, while the score cannot be used for clinical diagnosis, studies in multiple countries, including China, have demonstrated the validity of DASS-21 as a measurement of the severity of depression, anxiety, and stress symptoms [21, 22]. Home language environment The direct-assessment of children’s home language environment used the LENA system. LENA consists of a small recording device worn by the child and the corresponding software that records and analyzes all sounds in the child’s surrounding environment over the course of a day [23]. Previous research has shown LENA to be a valid and reliable measure of language environments in American English [24], Spanish [25], Dutch [26], Korean [27], Vietnamese [28], and Mandarin-speaking populations [29, 30]. Each sample household was given a LENA recording device, a specialized LENA shirt, and a LENA charger. Caregivers were instructed to record 16 hours per day over two days that were representative of what their child typically experienced at home. The recording device was placed in the chest pocket of the LENA shirt which the child wore throughout the day and was removed only when the child bathed or slept at night. Caregivers also was instructed to charge the LENA device overnight between the first and second days of recording. In this study, the home language environment is measured by two variables automatically generated by the LENA software: The first is the adult word count (AWC), defined as the number of words spoken to or near the child by adults in the recording. The second is conversational turn count (CTC), defined as the number of adult-child alternations in conversation in the recording. In addition, the caregiver-report home language environment was measured using the four items in the Family Care Indicators (FCI) scale. The FCI is a validated survey instrument developed by UNICEF to evaluate the quality of the home environment and quantify the different types of parenting practices [31]. Caregivers reported the time they spent with their child in the previous day on interactive reading, storytelling, singing, and playing. These four parenting practices were selected because they are the most commonly reported measures of stimulating parenting practices for language development in the literature on rural China [4]. Factor analysis also was used to generate a standard index for stimulating parenting practices for language development. Child language development The LENA-generated measure on child’s language development is the child vocalization count (CVC). CVC captures the frequency of child-produced utterances, including all sounds, words, vocalizations that are not vegetative noises, cries, or coughs. Notably, researchers have proposed that children’s vocalizations can indicate the quality of the home language environment (Ramírez-Esparza et al., 2014; Werwach et al., 2021) because they are driven by the children’s interactions with other social entities (Moeller et al., 2007) and, as auditory feedback models suggest, hearing one's own voice supports language development (Brainard & Doupe, 2000). Nevertheless, we focus on CVC as an indicator of children’s language development in this study because it has been widely used as a measure of language development (Ramírez-Esparza et al., 2014) and has been shown to be highly predictive of language skills later in life (Y. Wang et al., 2020; Werwach et al., 2021). The caregiver-report measure on child language skills is the Chinese version of the short-form MacArthur-Bates Communicative Development Inventory (CDI). The CDI measures expressive vocabulary of children aged 16 to 30 months [32], and the short-form CDI has been validated in Mandarin Chinese [33]. The primary caregiver was given an inventory of 113 words and asked to identify the words that their child could say. For words the child could say, caregivers were asked to give an example of the context in which the child said the word. The number of words the child could say were then summed to reach a final CDI score which could range between 0 and 113, following CDI scoring guidelines [33]. Caregiver perception bias Perception bias is measured as the discrepancy between the caregiver-report assessment and the LENA-generated measures of child language development and language environment. Since the LENA measures, CDI, and the parenting practices index are on different scales, direct comparisons between them are not feasible. To enable meaningful within-sample comparisons and account for increases in the raw scores with the child’s age, we internally standardize the scores by removing the effect of age (using the child’s age for child measures and caregiver’s age for caregiver measures) [34]. We compute internal z-scores based on age-specific averages and standard deviations, which are estimated through non-parametric regression. This method reduces sensitivity to outliers and small sample sizes, producing smooth, standardized scores with a mean of zero across all age groups. Then, we compute differences between the standardized scores to derive perception bias. Specifically, the perception bias in child language development is defined as the difference between the self-reported CDI score and the objectively collected CVC. The perception biases in child language environment are similarly defined as the difference between a parenting practices index computed from self-reported FCI items and AWC, as well as the difference between the parenting practices index and CTC. For the resulting bias scores, a positive score indicates an overestimation of the child’s language development or language environment relative to their LENA outcomes, while a negative score indicates underestimation. Statistical Analysis We standardized the LENA measurements, including AWC, CTC, and CVC. The two 16-hour recordings were standardized into 12-hour data to adjust for skewing that is common for count data. We used Chebyshev polynomials transformation to normalize the data: First, we used LASSO regression models to select the final Chebyshev polynomials model for transforming the data. We also predicted residuals with the final model. Then, we estimated the residualized count variables from the transformed data and rescaled them back to the original count metric. We used ordinary least squares (OLS) regression models to examine the associations between caregiver mental health, child language environment, and language development, as well as the association between caregiver mental health and perceptions bias. The models controlled for demographic information and sample strata fixed effects (urbanized rural, rural migrant, or rural), with cluster-robust standard errors estimated by the sample strata. Demographic information including child age, sex, whether mother was the primary caregiver, primary caregiver’s age and education level, family assets, and the number of adults stayed at home were collected through a questionnaire administered by trained enumerators to caregivers. To estimate family assets, caregivers reported whether they owned or had access to a series of household items like tap water, computer, internet, and a car. A family asset index was then calculated using polychromic principal component analysis [35]. Given the small sample size, we used bootstrap resampling with replacement (1,000 replications) to obtain more robust estimates [36]. Results Summary statistics The demographic characteristics of the participants are presented in Panel A, Table 1 . The average age of the children was over 21 months, 58% of them were male, and 58% were primarily cared for by their mothers. The average age of the primary caregivers was approximately 37 years, and 50% of them (n = 74) had completed high school. Households from the rural counties make up 51% of the sample (n = 70), while another 29% were urbanized rural households (n = 40), and the rest 20% were rural migrant households (n = 27). Of the sample caregivers, 17 (12%) reported depressive symptoms, 21 (15%) reported anxiety symptoms, and 11 (8%) reported stress symptoms (Panel B). The average CDI score was 45 words (out of 113), and the average CVC was 1,923 vocalizations (Panel C). The average AWC was 13,773 words and the mean CTC was 557 turns. On average, caregivers reported spending 5 minutes reading books, 5 minutes telling stories, 5 minutes singing songs, and 28 minutes playing with their child throughout the day prior to the survey (Panel D). [insert Table 1 here] Caregiver mental health symptoms and child language development The raw distributions of CVC were left-skewed for caregivers who reported depressive, anxiety or stress symptoms, compared to those who did not (Fig. 1 ), suggesting an unadjusted association between caregiver mental health symptoms and reduced CVC. After adjusting for demographic characteristics and sample status fixed effects (Table 2, Panel A), caregiver anxiety symptoms were significantly associated with lower CVC ( \(\:\beta\:\) = -0.44, 95% CI [-0.69, -0.18], p < 0.01), and caregiver stress symptoms were significantly associated with both lower CVC ( \(\:\beta\:\) = -0.75, 95% CI [-1.27, -0.24, p < 0.01) and lower CDI score ( \(\:\beta\:\) = -0.57, 95% CI [-1.00, -0.15], p < 0.01). [insert Fig. 1 here] [insert Table 2 here] Caregiver mental health symptoms and child language environment The raw distributions of both AWC and CTC were also left-skewed among caregivers who reported depressive, anxiety, or stress symptoms, compared to those who did not (Fig. 2 ), indicating that, without adjustment, caregiver mental health symptoms were linked to lower AWC and CTC. Controlling for demographic characteristics and sample status fixed effects (Table 2, Panel B), AWC was not significantly associated with any mental health symptoms. In contrast, lower CTC was significantly associated with caregiver depressive symptoms ( \(\:\beta\:\) = -0.51, 95% CI [-0.91, -0.12], p = 0.011) and anxiety symptoms ( \(\:\beta\:\) = -0.54, 95% CI [-0.76, -0.31], p < 0.01). [insert Fig. 2 here] Caregiver mental health symptoms and perception bias in child language development The mean of the distributions of caregiver perception bias in child language development were right of zeros for caregivers with depressive and anxiety stymptoms (Fig. 3 ). After controlling for confounders (Table 2, Panel C), there is a marginally significant association between caregiver depressive symptoms and a positive bias ( \(\:\beta\:\) = 0.26, 95% CI [-0.02, 0.54], p = 0.064). Caregiver anxiety symptoms were also significantly associated with a positive bias ( \(\:\beta\:\) = 0.44, 95% CI [0.10, 0.77], p = 0.012). These findings suggest that caregivers experiencing depressive and anxiety symptoms were more likely to overestimate their children’s language development. [insert Fig. 3 here] Caregiver mental health symptoms and perception bias in child language environment The mean of perception bias in child language environment among caregivers were right or zeros for caregivers with depressive, anxiety, or symptoms, suggesting a tendency of overestimation linked to those symptoms (Fig. 4 ). After adjusting for demographic characteristics and sample status fixed effects (Panel D, Table 2), depressive symptoms were significantly associated with a stronger positive bias using CTC ( \(\:\beta\:\) = 0.66, 95% CI [0.40, 0.93], p < 0.01), suggesting that caregivers with depressive symptoms were more likely to overestimate their home language environment. No significant associations were observed between anxiety or stress symptoms and perception bias in child home language environment. [insert Fig. 4 here] Discussion Drawing on novel Language Environment Analysis (LENA) data collected from low-resource households with rural backgrounds in China, this study examines the associations between caregiver mental health, the home language environment, and children’s language development. The paper also investigates whether mental health symptoms are associated with the perception bias of caregivers in those outcomes. As measured by LENA, we found that caregiver anxiety and stress symptoms were significantly associated with lower levels of child language development. Additionally, caregivers with depressive or anxiety symptoms engaged in fewer verbal interactions with their children. These findings align with prior studies using caregiver-report meausres, which have shown that maternal mental health symptoms affect children’s language development in both high-income countries [ 37 – 39 ] and LMICs [ 40 ]. Caregiver mental health symptoms are associated with reduced engagement in interactive parenting, including numerous studies in rural China [ 41 – 43 ]. Our results also support recent studies from high-income countries using LENA, which suggests that caregiver depression and anxiety symptoms were associated with adverse home language environment [ 39 , 44 ]. Caregiver mental health symptoms were also associated with perception biases in their assessments of their children’s language development and the home language environment. Specifically, caregivers with depressive symptoms were more likely to overestimate their children’s language development. Depressive symptoms often manifest as persistent negative thoughts and cognitions [ 45 ], causing caregivers to adopt a more pessimistical view of their children’s language skills and undervalue the developmental milestones they reach. Additionally, the fatigue and low energy associated with depression may reduce caregiver’s awareness of their children’s day-to-day behaviors [ 16 ] and lead them to overlook developmental achievements. These factors suggest a tendency toward underestimation—making the observed overestimation unexpected. These results highlight the need for furture research to explore why caregiver depression may be linked overestimation of child langauge development. Caregivers with depressive and anxiety symptoms also tended to overestimate how many verbal interactions they had with their children. While existing studies have documented a general tendency for caregivers to overreport verbal interactions [ 46 ], our result suggests that this bias could be more pronounced among those experiencing depressive or anxiety symptoms. One possible explanation is that verbal interactions may demand greater physical, cognitive, and emotional effort for individuals experiencing depression, making the interactions more salient to them and thus more likely to be overestimated [ 47 ]. In addition, anxiety symptoms have been linked to heightened concerns on social evaluation and a greater susceptibility of social desirability bias [ 48 ], suggesting that caregivers with anxiety symptoms may overreport their children’s language milestones to present the household in a more favorable light. Furthermore, anxiety symptoms are often associated with maintaining positive illusions that lead to overly optimistic assessments of oneself and the world [ 49 ]. In this context, caregivers may exaggerate their children’s language skills to mitigate distress about their children’s development. The perception bias associated with caregiver mental health symptoms are concerning, as most assessments of child development and parenting practices rely on caregiver self-reports [ 17 ]. In LMICs, where caregiver mental health symptoms are common, such bias may compromise the accuracy of these measures. Relying on caregiver reports in surveys may introduce bias in estimation of intervention impacts on child development if caregiver mental health changes differentially between treatment and control groups over time. Similarly, using caregiver-reported assessments to screen for developmental delays may fail to identify vulnerable children, particularly those whose caregivers experience depression or anxiety symptoms. These findings highlight the need for caution when using and interpreting self-report tools in early childhood development research. Whenever possible, researchers should employ direct-assessment tools to measure child outcomes. When self-reports are unavoidable, studies should account for caregiver mental health status during both data collection and analysis periods. Additionally, developing benchmarks that adjust for caregiver mental health symptoms may improve the accuracy of caregiver-reported assessments. We acknowledge several limitations of this study. First, the construction of perception bias relies on the assumption that non-parametric regressions fully account for the effects of child age. This may not always hold, since residual age-related variation could still influence the standardized scores and introduce bias into our estimates. To mitigate potential confounding, we included child age (in months) as a covariate in our analyses. Second, the measurement of perception bias is based on two specific instruments, which limit the generalizability of our findings to other self-report instruments. Third, although our sample size of 137 is the largest of LENA-based studies worldwide to date, it remains small relative to studies using other assessment approaches. Future research should validate and expand our findings using larger, representative samples to enhance statistical power. Despite these limitations, the study makes several noteworthy contributions. To the best of our knowledge, this is the first study to examine associations between caregiver mental health and LENA-generated measures of language development and the home language environment in LMICs. It is also among the first to quantify the perception bias in caregiver self-report assessments of early development and to examine the association between this bias and their mental health issues. Despite the exploratory nature of our analysis, our findings provide initial evidence that depressive and anxiety symptoms can distort caregiver assessment of their children’s language skills and the home language environment, calling for greater caution when administering self-report assessments in ECD research. Conclusion This study provides novel evidence that caregiver mental health symptoms, particularly depression, anxiety and stress, are significantly associated with both diminished home language environments and child language development. Those symtpoms are also associated with perception biases in caregiver-reported assessments of children’s language development. These results underscore the importance of incorporating caregiver mental health considerations into both the design and interpretation of assessments in early development studies. When direct assessments are not feasible, researchers should adjust for potential reporting biases and consider developing correction benchmarks to enhance the accuracy of caregiver-reported data. Abbreviations AWC: Adult Word Count CDI: MacArthur–Bates Communicative Development Inventory CTC: Conversational Turn Count CVC: Child Vocalization Count DASS-21: Depression, Anxiety, and Stress Scale–21 FCI: Family Care Indicators LENA: Language Environment Analysis (LENA) technology LMICs: Low- and Middle-Income Countries OLS: Ordinary Least Squares Declarations Ethics approval and consent to participate The study was approved by the Stanford University Institutional Review Board (Protocol ID 49552). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from the legal guardians or parents. Enumerators introduced the study, allowed time for questions, and used a standardized script in both Mandarin and the Sichuanese dialect to obtain consent. Caregivers were made aware that their recordings would be collected and reviewed for research purposes. Consent for publication Not applicable Availability of data and materials Data and analytic code necessary to reproduce the analyses presented in this paper are available from the first author upon reasonable request. The analyses presented here were not preregistered. Competing interests None to declare. Funding The study was supported by an unrestricted gift from the Enlight Foundation, Palo Alto, CA, USA. Authors' contributions QJ : Conceptualization, Investigation, Methodology, Software, Formal Analysis, Writing- Original draft preparation, Writing- Reviewing and Editing. YQ: Writing- Reviewing and Editing, Methodology, Formal Analysis. MD: Investigation . HZ: Writing- Reviewing and Editing. EZ: Writing- Original draft preparation. ED: Writing- Reviewing and Editing. TF : Investigation. YM: Conceptualization, Data curation. SR: Conceptualization, Writing- Reviewing and Editing. 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Descriptive Information among the participants (N=137) Panel A: Demographic characteristics Child age (months) 21 (1.6) Child is male (%) 80 (58%) Mother is the primary caregiver (%) 80 (58%) Primary caregiver age (years) 37 (13) Primary caregiver graduated from high school (%) 74 (50%) Family asset index -0.01 (1.3) Number of adults at home (n) 2.8 (1.0) Sample Strata Urbanized rural households (%) 40 (29%) Rural migrant households (%) 27 (20%) Rural households (%) 70 (51%) Panel B: Caregiver mental health Caregiver Mental Health Symptoms Depressive symptoms (%) 17 (12%) Anxiety symptoms (%) 21 (15%) Stress symptoms (%) 11 (8%) Panel C: Child language development Recorded Child Language Development Child vocalizations count (CVC, n) 1923 (800) Caregiver-report Child Language Development CDI language score 45 (29) Panel D: Home language environment Recorded Child Language Environment Adult word count (AWC, n) 13,773 (5609) Conversational turns count (CTC, n) 557 (286) Caregiver-report Child Language Environment Read books yesterday (mins) 5.4 (18) Told story yesterday (mins) 4.8 (11) Sang songs yesterday (mins) 4.9 (9.3) Played games yesterday (mins) 28 (39) Note: Family asset index was calculated using polychromic principal component analysis based on whether households owned or had access to a number of household items such as tap water, computer, internet, and a car. Caregiver mental health was assessed using the Depression, Anxiety, and Stress Scale-21 (DASS-21). CDI refers to the Macarthur-Bates Communicative Development Inventory. CVC, AWC, and CTC were measured using the LENA technogy for 16 hours and then standardized into 12 hours. Caregiver-report language environment was measured using Family Care Index (FCI). Table 2. Regressions of Caregiver Mental Health Problems on Child Language Development, Language Environment, and Caregiver Reporting Bias (N=137) Panel A Language Development Panel B Language Environment Panel C Perception Bias in Language Development Panel D Perception Bias in Language Environment CVC CDI AWC CTC FCI Using CVC Using AWC Using CTC Depressive Symptoms -0.38 -0.12 -0.24 -0.51 ** 0.15 0.26 + 0.39 0.66 *** (0.30) (0.33) (0.26) (0.20) (0.20) (0.14) (0.25) (0.14) Anxiety Symptoms -0.44 *** 0.00 -0.20 -0.54 *** 0.10 0.44 ** 0.30 0.63 (0.13) (0.19) (0.20) (0.12) (0.52) (0.17) (0.35) (0.43) Stress Symptoms -0.75 *** -0.57 *** 0.03 -0.62 -0.36 0.18 -0.39 0.26 (0.26) (0.22) (0.33) (0.39) (0.24) (0.17) (0.24) (0.29) Note: (1) + p<0.10; ** p<0.05; *** p<0.01. (2) Each row and column represent independent regressions. All regressions control for maternal age, maternal education, child age, child sex, the mother being the primary caregiver, and the family asset index. Regressions are bootstrapped 1,000 times, with cluster-robust standard errors estimated at the sample source level (urbanized, migrant, or rural). (3) CVC refers to LENA Child Vocalization Count, CDI refers to the Macarthur-Bates Communicative Development Inventory, AWC refers to LENA Adult Word Count, CTC refers to LEAN Conversational Turns Count, and FCI refers to the Family Care Indicator. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":155561,"visible":true,"origin":"","legend":"\u003cp\u003eLENA Child Vocalizations Count (CVC) by Caregiver Mental Health Symptoms\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7661882/v1/973b81ad74c170cb19a98736.png"},{"id":94687274,"identity":"a6412dc3-6e16-438f-aa2d-c399b6acf9c8","added_by":"auto","created_at":"2025-10-29 15:47:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":184653,"visible":true,"origin":"","legend":"\u003cp\u003eLENA Child Language Environment by Caregiver Mental Health Symptoms\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7661882/v1/c7181fedab1905a7bb8b1d19.png"},{"id":94687272,"identity":"a776c6ee-1b59-4331-b0b7-821abe5ec71d","added_by":"auto","created_at":"2025-10-29 15:47:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":136438,"visible":true,"origin":"","legend":"\u003cp\u003eBias in Child Language Development by Caregiver Mental Health Symptoms\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7661882/v1/bfc4967bc10b6138af29bbb8.png"},{"id":94728255,"identity":"f9e2da59-995e-42cb-b765-86007873a6f1","added_by":"auto","created_at":"2025-10-30 07:03:25","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":178984,"visible":true,"origin":"","legend":"\u003cp\u003eBias in Child Language Environment by Caregiver Mental Health Symptom\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7661882/v1/6fe81e3a244e517babf0dac2.png"},{"id":102785196,"identity":"3e99e861-3377-41c8-9e88-afd95c22718e","added_by":"auto","created_at":"2026-02-16 16:02:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1272918,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7661882/v1/ec3ab685-3e70-4271-90d9-a0a79ef596f6.pdf"},{"id":94687278,"identity":"8914ee4a-2715-4cc0-aab8-369b46af6602","added_by":"auto","created_at":"2025-10-29 15:47:34","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26287,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7661882/v1/ea50d7371f49ce690fa518cd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Associations between Caregiver Mental Health, Early Childhood Language Outcomes, and Caregiver Perception Bias: Evidence from Rural China","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLanguage development during the first three years of life is a fundamental component of early childhood development that lays the groundwork for future language, cognitive, and learning outcomes. Delays in early language development can have lifelong consequences, such as low education attainment and diminished employment performance [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Unfortunately, many children in low- and middle-income countries (LMICs) are at risk of early language delays. In rural China, for example, a recent meta-analysis revealed that 46% of young children failed to reach their language development potential [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Growing evidence indicates that poor home language environments, characterized by insufficient verbal interactions between children and their caregivers, is a main predictor of early language developmental delay in LMICs [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Identifying the factors that hinder an interactive, stimulating home language environment is crucial for improving early language development in low-income regions.\u003c/p\u003e\u003cp\u003eCaregiver mental health substantially influences child development outcomes, but its specific impact on language development remains unclear. One in five mothers in LMICs reported depressive symptoms in LMICs during the post-partum period [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. A suvey of 2541 participants suggested that 39% of primary caregivers (mothers and grandmothers) of children under age three living in rural China reported depressive, anxiety, or stress symptoms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A substantial body of research links caregiver depressive symptoms to impaired child cognitive, motor, and social-emotional development, as well as disturbances in early attachment and increased behavior problems [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A Lancet review suggests that depressive symptoms contribute to these developmental adversities by altering the early caregiving environment, particularly the caregiver\u0026rsquo;s parenting practices and interactions with the child [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the much smaller body of literature has focused on early childhood language development and other mental health symtpoms beyond depression.\u003c/p\u003e\u003cp\u003eResearch on caregiver mental health and early language development is further complicated by the perception bias associated with caregiver mental health symptoms. Perception bias, the discrepancies between caregiver self-assessments and the actual status of child language outcomes, occurs when caregivers experiencing mental health symptoms misinterpret or overlook their own and their children\u0026rsquo;s behaviors, making distorted assessments. When perception bias results in negative attributions, caregivers could misinterpret typical child behaviors as problematic or deliberately disobedient rather than situationally driven [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Caregiver mental health symptoms could also impair their capacity to pay attention to the child [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], thus reduce the accuracy of caregiver-reported measurements. Desipite most widely implemented measurements of child development rely on caregiver self report, few studies have tried to quantify whether caregiver mental health symptoms were associated with their perception bias in caregiver self-assessments of child language development and their home language environment [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecent advances in the Language Environment Analysis (LENA) technology have enabled the recording and analysis of sounds in the child\u0026rsquo;s surrounding environment and those produced by the child, which allow for an objective measure of child language development and the verbal interactions that form the home language environment. Leveraging LENA data as benchmark objective measurements, the goals of the current study are to a.) investigate the association between caregiver mental health symptoms, child language development, and the home language environment; and b.) examine the association between those symptoms and perception bias in caregiver-reported assessments of child language development and their language home environment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy Location\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData were collected from households in two distinct areas (a peri-urban district and two rural counties) in Sichuan Province, China. The peri-urban district is in the suburbs of Chengdu, the provincial capital, and has rapidly transitioned from an agricultural economy into one of the fast-developing areas in the province. Due to rapid urbanization, the district hosts a large population of a.) households with rural backgrounds, including rural migrants, that migrated from rural regions without access to urban public welfare benefits due to their rural rural household registration status, and b.) urbanized rural households, whose farmland in the area had been acquired by the government. In 2019, the average per capita disposable income of rural residents in this district was 30,405 RMB (4,403 USD), much lower than the average per capita income in the Chengdu\u0026rsquo;s central urban districts (49,193 RMB or 7,613 USD) [18]. The second sampling location was in two counties in a rural, prefecture-level city in Sichuan. The average per capita income for rural residents in this prefecture was 14,670 RMB (2,124 USD), less than half of the average per capita income of urban residents in Sichuan (36,153 RMB or 5,235 USD) [19].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe participants in the study are children aged 18 to 24 months and their primary caregivers, within the households with rural backgrounds. We focus on toddlers aged 18 to 24 months due to the rapid language development that occurs during this period: Around 18 months of age, many children experience a \u0026ldquo;vocabulary burst\u0026rdquo; and start to acquire new words at a much faster rate than before (Goldfield \u0026amp; Reznick, 1990). By this age, they can also distinguish are grammatically correct or incorrect placement of familiar function words (Santelmann \u0026amp; Jusczyk, 1998). By 24 months, the speed and accuracy in spoken word understanding increase dramatically over the second year of life (Fernald et al., 1998). Therefore, any disparity in the home language environment at this stage is likely to have measurable impacts on the child\u0026rsquo;s language skills.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSampling protocol\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDue to the geographic and administrative differences between the rural and peri-urban communities, the research team separately sampled participants from the two study locations. To select the peri-urban sample, the research team followed a two-step protocol. First, the research team obtained a list of children between 18 and 24 months of age based on birth records from two local hospitals. Second, households were then randomly selected from the list and trained enumerators screened them for eligibility via phone calls. Households were invited to participate in a survey if their residency status met the legal criteria for rural migrants or urbanized farmers: A household was considered a rural migrant family if a.) the legal residence of either parent was in a rural area outside of Chengdu Municipality; and b.) one parent had lived in the sample district for at least 6 months. To be considered urbanized farmers, a.) the legal residence of either parent must be within the district; b.) all or part of the household\u0026rsquo;s farmland must have been reclaimed by the government; and c.) any remaining cultivated land owned by the household must be less than 200 square meters per adult family member on average. Following this protocol, a total of 109 households were enrolled in the survey. Of these, 81 consented to the collection of home language environment data (34 rural migrant households, 47 urbanized rural households).\u003c/p\u003e\n\u003cp\u003eTo select the rural sample, the research team followed a three-step protocol. First, all townships in the two sample counties were included in the study, except the townships that housed the county seat, which are typically wealthier and more urbanized than townships In the the rest of the county. This resulted in 11 townships. Second, we obtained a list of households with children aged between 18 and 24 months based on birth records from the township governments, which resulted in a total of 175 households across the 11 townships. Third, we excluded those that were not legally classified as rural residents and enrolled all remaining 109 eligible households in the study. Of these, 77 consented to the collection of home language environment data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOf the 158 households that completed home language environment data collection, we excluded 21 in which the primary caregiver was not the respondent of the household survey. The final analytic sample includes 137 households: 40 urbanized rural, 27 rural migrant, and 70 rural households. A balance test found no significant differences in demographic information between households that consented to LENA data collection and those that did not [See Apendix Table 1]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Collection\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe research team collected data on the home language environment, caregiver mental health, child language development, and demographic characteristics of the household young children and their households. Trained enumerators collected data from all sample households in the summer and fall of 2020 following a standardized four-day protocol. On the first day, enumerators surveyed the primary caregiver of each sample child at their home or the hospital. After the survey, caregivers were instructed on how to record home language environment data with LENA. Caregivers then recorded their home language environment during the second and third days. On the fourth day, enumerators retrieved the recording devices and conducted an exit interview to ensure compliance with the data collection protocol.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMeasures\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCaregiver mental health\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo measure caregiver mental health, enumerators administered the Depression, Anxiety, and Stress Scale-21 (DASS-21) to the primary caregiver of the child, identified by each household as the person primarily responsible for the child\u0026rsquo;s daily care. The DASS-21, a short-form version of the DASS-42 [20], is a self-report questionnaire with three subscales evaluating if the caregiver was at risk for the depression, anxiety, and stress, respectively (and the severity of the risk). Caregivers were asked to rank, on a scale of 0 to 3, how each of 21 statements (seven describing each mental health issue) applied to them in the past week. The score on each subscale is the sum of their ratings for the seven statements multiplied by two. Hence, the score for each subscale could range from 0 to 42, with higher scores indicating more severe symptoms. Following the DASS-21 scoring guidelines, participants were considered experiencing symptoms of mental health if they scored above 9 for depression, 8 for anxiety, and 14 for stress [20]. Notably, while the score cannot be used for clinical diagnosis, studies in multiple countries, including China, have demonstrated the validity of DASS-21 as a measurement of the severity of depression, anxiety, and stress symptoms [21, 22].\u003c/p\u003e\n\u003cp\u003eHome language environment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe direct-assessment of children\u0026rsquo;s home language environment used the LENA system. LENA consists of a small recording device worn by the child and the corresponding software that records and analyzes all sounds in the child\u0026rsquo;s surrounding environment over the course of a day [23]. Previous research has shown LENA to be a valid and reliable measure of language environments in American English [24], Spanish [25], Dutch [26], Korean [27], Vietnamese [28], and Mandarin-speaking populations [29, 30].\u003c/p\u003e\n\u003cp\u003eEach sample household was given a LENA recording device, a specialized LENA shirt, and a LENA charger. Caregivers were instructed to record 16 hours per day over two days that were representative of what their child typically experienced at home. The recording device was placed in the chest pocket of the LENA shirt which the child wore throughout the day and was removed only when the child bathed or slept at night. Caregivers also was instructed to charge the LENA device overnight between the first and second days of recording.\u003c/p\u003e\n\u003cp\u003eIn this study, the home language environment is measured by two variables automatically generated by the LENA software: The first is the adult word count (AWC), defined as the number of words spoken to or near the child by adults in the recording. The second is conversational turn count (CTC), defined as the number of adult-child alternations in conversation in the recording.\u003c/p\u003e\n\u003cp\u003eIn addition, the caregiver-report home language environment was measured using the four items in the Family Care Indicators (FCI) scale. The FCI is a validated survey instrument developed by UNICEF to evaluate the quality of the home environment and quantify the different types of parenting practices [31]. Caregivers reported the time they spent with their child in the previous day on interactive reading, storytelling, singing, and playing. These four parenting practices were selected because they are the most commonly reported measures of stimulating parenting practices for language development in the literature on rural China [4]. Factor analysis also was used to generate a standard index for stimulating parenting practices for language development.\u003c/p\u003e\n\u003cp\u003eChild language development\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe LENA-generated measure on child\u0026rsquo;s language development is the child vocalization count (CVC). CVC captures the frequency of child-produced utterances, including all sounds, words, vocalizations that are not vegetative noises, cries, or coughs. Notably, researchers have proposed that children\u0026rsquo;s vocalizations can indicate the quality of the home language environment (Ram\u0026iacute;rez-Esparza et al., 2014; Werwach et al., 2021) because they are driven by the children\u0026rsquo;s interactions with other social entities (Moeller et al., 2007) and, as auditory feedback models suggest, hearing one\u0026apos;s own voice supports language development (Brainard \u0026amp; Doupe, 2000). Nevertheless, we focus on CVC as an indicator of children\u0026rsquo;s language development in this study because it has been widely used as a measure of language development (Ram\u0026iacute;rez-Esparza et al., 2014) and has been shown to be highly predictive of language skills later in life (Y. Wang et al., 2020; Werwach et al., 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe caregiver-report measure on child language skills is the Chinese version of the short-form MacArthur-Bates Communicative Development Inventory (CDI). The CDI measures expressive vocabulary of children aged 16 to 30 months [32], and the short-form CDI has been validated in Mandarin Chinese [33]. The primary caregiver was given an inventory of 113 words and asked to identify the words that their child could say. For words the child could say, caregivers were asked to give an example of the context in which the child said the word. The number of words the child could say were then summed to reach a final CDI score which could range between 0 and 113, following CDI scoring guidelines [33].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCaregiver perception bias\u003c/p\u003e\n\u003cp\u003ePerception bias is measured as the discrepancy between the caregiver-report assessment and the LENA-generated measures of child language development and language environment. Since the LENA measures, CDI, and the parenting practices index are on different scales, direct comparisons between them are not feasible. To enable meaningful within-sample comparisons and account for increases in the raw scores with the child\u0026rsquo;s age, we internally standardize the scores by removing the effect of age (using the child\u0026rsquo;s age for child measures and caregiver\u0026rsquo;s age for caregiver measures) [34]. We compute internal z-scores based on age-specific averages and standard deviations, which are estimated through non-parametric regression. This method reduces sensitivity to outliers and small sample sizes, producing smooth, standardized scores with a mean of zero across all age groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThen, we compute differences between the standardized scores to derive perception bias. Specifically, the perception bias in child language development is defined as the difference between the self-reported CDI score and the objectively collected CVC. The perception biases in child language environment are similarly defined as the difference between a parenting practices index computed from self-reported FCI items and AWC, as well as the difference between the parenting practices index and CTC. For the resulting bias scores, a positive score indicates an overestimation of the child\u0026rsquo;s language development or language environment relative to their LENA outcomes, while a negative score indicates underestimation.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe standardized the LENA measurements, including AWC, CTC, and CVC. The two 16-hour recordings were standardized into 12-hour data to adjust for skewing that is common for count data. We used Chebyshev polynomials transformation to normalize the data: First, we used LASSO regression models to select the final Chebyshev polynomials model for transforming the data. We also predicted residuals with the final model. Then, we estimated the residualized count variables from the transformed data and rescaled them back to the original count metric.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe used ordinary least squares (OLS) regression models to examine the associations between caregiver mental health, child language environment, and language development, as well as the association between caregiver mental health and perceptions bias. The models controlled for demographic information and sample strata fixed effects (urbanized rural, rural migrant, or rural), with cluster-robust standard errors estimated by the sample strata. Demographic information including child age, sex, whether mother was the primary caregiver, primary caregiver\u0026rsquo;s age and education level, family assets, and the number of adults stayed at home were collected through a questionnaire administered by trained enumerators to caregivers. To estimate family assets, caregivers reported whether they owned or had access to a series of household items like tap water, computer, internet, and a car. A family asset index was then calculated using polychromic principal component analysis [35]. Given the small sample size, we used bootstrap resampling with replacement (1,000 replications) to obtain more robust estimates [36].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eSummary statistics\u003c/h2\u003e\u003cp\u003eThe demographic characteristics of the participants are presented in Panel A, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The average age of the children was over 21 months, 58% of them were male, and 58% were primarily cared for by their mothers. The average age of the primary caregivers was approximately 37 years, and 50% of them (n\u0026thinsp;=\u0026thinsp;74) had completed high school. Households from the rural counties make up 51% of the sample (n\u0026thinsp;=\u0026thinsp;70), while another 29% were urbanized rural households (n\u0026thinsp;=\u0026thinsp;40), and the rest 20% were rural migrant households (n\u0026thinsp;=\u0026thinsp;27).\u003c/p\u003e\u003cp\u003eOf the sample caregivers, 17 (12%) reported depressive symptoms, 21 (15%) reported anxiety symptoms, and 11 (8%) reported stress symptoms (Panel B). The average CDI score was 45 words (out of 113), and the average CVC was 1,923 vocalizations (Panel C). The average AWC was 13,773 words and the mean CTC was 557 turns. On average, caregivers reported spending 5 minutes reading books, 5 minutes telling stories, 5 minutes singing songs, and 28 minutes playing with their child throughout the day prior to the survey (Panel D).\u003c/p\u003e\u003cp\u003e[insert Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eCaregiver mental health symptoms and child language development\u003c/h2\u003e\u003cp\u003eThe raw distributions of CVC were left-skewed for caregivers who reported depressive, anxiety or stress symptoms, compared to those who did not (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), suggesting an unadjusted association between caregiver mental health symptoms and reduced CVC. After adjusting for demographic characteristics and sample status fixed effects (Table\u0026nbsp;2, Panel A), caregiver anxiety symptoms were significantly associated with lower CVC (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e= -0.44, 95% CI [-0.69, -0.18], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and caregiver stress symptoms were significantly associated with both lower CVC (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e= -0.75, 95% CI [-1.27, -0.24, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and lower CDI score (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e= -0.57, 95% CI [-1.00, -0.15], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e[insert Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here]\u003c/p\u003e\u003cp\u003e[insert Table\u0026nbsp;2 here]\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eCaregiver mental health symptoms and child language environment\u003c/h2\u003e\u003cp\u003eThe raw distributions of both AWC and CTC were also left-skewed among caregivers who reported depressive, anxiety, or stress symptoms, compared to those who did not (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), indicating that, without adjustment, caregiver mental health symptoms were linked to lower AWC and CTC. Controlling for demographic characteristics and sample status fixed effects (Table\u0026nbsp;2, Panel B), AWC was not significantly associated with any mental health symptoms. In contrast, lower CTC was significantly associated with caregiver depressive symptoms (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e= -0.51, 95% CI [-0.91, -0.12], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011) and anxiety symptoms (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e= -0.54, 95% CI [-0.76, -0.31], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e[insert Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here]\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eCaregiver mental health symptoms and perception bias in child language development\u003c/h2\u003e\u003cp\u003eThe mean of the distributions of caregiver perception bias in child language development were right of zeros for caregivers with depressive and anxiety stymptoms (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After controlling for confounders (Table\u0026nbsp;2, Panel C), there is a marginally significant association between caregiver depressive symptoms and a positive bias (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e= 0.26, 95% CI [-0.02, 0.54], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.064). Caregiver anxiety symptoms were also significantly associated with a positive bias (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e= 0.44, 95% CI [0.10, 0.77], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012). These findings suggest that caregivers experiencing depressive and anxiety symptoms were more likely to overestimate their children\u0026rsquo;s language development.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e[insert Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e here]\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eCaregiver mental health symptoms and perception bias in child language environment\u003c/h2\u003e\u003cp\u003eThe mean of perception bias in child language environment among caregivers were right or zeros for caregivers with depressive, anxiety, or symptoms, suggesting a tendency of overestimation linked to those symptoms (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). After adjusting for demographic characteristics and sample status fixed effects (Panel D, Table\u0026nbsp;2), depressive symptoms were significantly associated with a stronger positive bias using CTC (\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\beta\\:\\)\u003c/span\u003e\u003c/span\u003e= 0.66, 95% CI [0.40, 0.93], \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01), suggesting that caregivers with depressive symptoms were more likely to overestimate their home language environment. No significant associations were observed between anxiety or stress symptoms and perception bias in child home language environment.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e[insert Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here]\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDrawing on novel Language Environment Analysis (LENA) data collected from low-resource households with rural backgrounds in China, this study examines the associations between caregiver mental health, the home language environment, and children\u0026rsquo;s language development. The paper also investigates whether mental health symptoms are associated with the perception bias of caregivers in those outcomes.\u003c/p\u003e\u003cp\u003eAs measured by LENA, we found that caregiver anxiety and stress symptoms were significantly associated with lower levels of child language development. Additionally, caregivers with depressive or anxiety symptoms engaged in fewer verbal interactions with their children. These findings align with prior studies using caregiver-report meausres, which have shown that maternal mental health symptoms affect children\u0026rsquo;s language development in both high-income countries [\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] and LMICs [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Caregiver mental health symptoms are associated with reduced engagement in interactive parenting, including numerous studies in rural China [\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Our results also support recent studies from high-income countries using LENA, which suggests that caregiver depression and anxiety symptoms were associated with adverse home language environment [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCaregiver mental health symptoms were also associated with perception biases in their assessments of their children\u0026rsquo;s language development and the home language environment. Specifically, caregivers with depressive symptoms were more likely to overestimate their children\u0026rsquo;s language development. Depressive symptoms often manifest as persistent negative thoughts and cognitions [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e], causing caregivers to adopt a more pessimistical view of their children\u0026rsquo;s language skills and undervalue the developmental milestones they reach. Additionally, the fatigue and low energy associated with depression may reduce caregiver\u0026rsquo;s awareness of their children\u0026rsquo;s day-to-day behaviors [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and lead them to overlook developmental achievements. These factors suggest a tendency toward underestimation\u0026mdash;making the observed overestimation unexpected. These results highlight the need for furture research to explore why caregiver depression may be linked overestimation of child langauge development.\u003c/p\u003e\u003cp\u003e Caregivers with depressive and anxiety symptoms also tended to overestimate how many verbal interactions they had with their children. While existing studies have documented a general tendency for caregivers to overreport verbal interactions [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], our result suggests that this bias could be more pronounced among those experiencing depressive or anxiety symptoms. One possible explanation is that verbal interactions may demand greater physical, cognitive, and emotional effort for individuals experiencing depression, making the interactions more salient to them and thus more likely to be overestimated [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition, anxiety symptoms have been linked to heightened concerns on social evaluation and a greater susceptibility of social desirability bias [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], suggesting that caregivers with anxiety symptoms may overreport their children\u0026rsquo;s language milestones to present the household in a more favorable light. Furthermore, anxiety symptoms are often associated with maintaining positive illusions that lead to overly optimistic assessments of oneself and the world [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. In this context, caregivers may exaggerate their children\u0026rsquo;s language skills to mitigate distress about their children\u0026rsquo;s development.\u003c/p\u003e\u003cp\u003eThe perception bias associated with caregiver mental health symptoms are concerning, as most assessments of child development and parenting practices rely on caregiver self-reports [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In LMICs, where caregiver mental health symptoms are common, such bias may compromise the accuracy of these measures. Relying on caregiver reports in surveys may introduce bias in estimation of intervention impacts on child development if caregiver mental health changes differentially between treatment and control groups over time. Similarly, using caregiver-reported assessments to screen for developmental delays may fail to identify vulnerable children, particularly those whose caregivers experience depression or anxiety symptoms.\u003c/p\u003e\u003cp\u003eThese findings highlight the need for caution when using and interpreting self-report tools in early childhood development research. Whenever possible, researchers should employ direct-assessment tools to measure child outcomes. When self-reports are unavoidable, studies should account for caregiver mental health status during both data collection and analysis periods. Additionally, developing benchmarks that adjust for caregiver mental health symptoms may improve the accuracy of caregiver-reported assessments.\u003c/p\u003e\u003cp\u003eWe acknowledge several limitations of this study. First, the construction of perception bias relies on the assumption that non-parametric regressions fully account for the effects of child age. This may not always hold, since residual age-related variation could still influence the standardized scores and introduce bias into our estimates. To mitigate potential confounding, we included child age (in months) as a covariate in our analyses. Second, the measurement of perception bias is based on two specific instruments, which limit the generalizability of our findings to other self-report instruments. Third, although our sample size of 137 is the largest of LENA-based studies worldwide to date, it remains small relative to studies using other assessment approaches. Future research should validate and expand our findings using larger, representative samples to enhance statistical power.\u003c/p\u003e\u003cp\u003eDespite these limitations, the study makes several noteworthy contributions. To the best of our knowledge, this is the first study to examine associations between caregiver mental health and LENA-generated measures of language development and the home language environment in LMICs. It is also among the first to quantify the perception bias in caregiver self-report assessments of early development and to examine the association between this bias and their mental health issues. Despite the exploratory nature of our analysis, our findings provide initial evidence that depressive and anxiety symptoms can distort caregiver assessment of their children\u0026rsquo;s language skills and the home language environment, calling for greater caution when administering self-report assessments in ECD research.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides novel evidence that caregiver mental health symptoms, particularly depression, anxiety and stress, are significantly associated with both diminished home language environments and child language development. Those symtpoms are also associated with perception biases in caregiver-reported assessments of children\u0026rsquo;s language development. These results underscore the importance of incorporating caregiver mental health considerations into both the design and interpretation of assessments in early development studies. When direct assessments are not feasible, researchers should adjust for potential reporting biases and consider developing correction benchmarks to enhance the accuracy of caregiver-reported data.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAWC: Adult Word Count\u003c/p\u003e\n\u003cp\u003eCDI: MacArthur\u0026ndash;Bates Communicative Development Inventory\u003c/p\u003e\n\u003cp\u003eCTC: Conversational Turn Count\u003c/p\u003e\n\u003cp\u003eCVC: Child Vocalization Count\u003c/p\u003e\n\u003cp\u003eDASS-21: Depression, Anxiety, and Stress Scale\u0026ndash;21\u003c/p\u003e\n\u003cp\u003eFCI: Family Care Indicators\u003c/p\u003e\n\u003cp\u003eLENA: Language Environment Analysis (LENA) technology\u003c/p\u003e\n\u003cp\u003eLMICs: Low- and Middle-Income Countries\u003c/p\u003e\n\u003cp\u003eOLS: Ordinary Least Squares\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Stanford University Institutional Review Board (Protocol ID 49552). The study was conducted in accordance with the Declaration of Helsinki. Informed consent was obtained from the legal guardians or parents. Enumerators introduced the study, allowed time for questions, and used a standardized script in both Mandarin and the Sichuanese dialect to obtain consent. Caregivers were made aware that their recordings would be collected and reviewed for research purposes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eData and analytic code necessary to reproduce the analyses presented in this paper are available from the first author upon reasonable request. The analyses presented here were not preregistered.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNone to declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study was supported by an unrestricted gift from the Enlight Foundation, Palo Alto, CA, USA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQJ\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e Conceptualization, Investigation, Methodology, Software, Formal Analysis, Writing- Original draft preparation, Writing- Reviewing and Editing. \u003cstrong\u003eYQ:\u003c/strong\u003e Writing- Reviewing and Editing, Methodology, Formal Analysis. \u003cstrong\u003eMD:\u0026nbsp;\u003c/strong\u003eInvestigation\u003cstrong\u003e. HZ:\u003c/strong\u003e Writing- Reviewing and Editing.\u003cstrong\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e\u003c/strong\u003e\u003cstrong\u003eEZ:\u003c/strong\u003e Writing- Original draft preparation. \u003cstrong\u003eED:\u0026nbsp;\u003c/strong\u003eWriting- Reviewing and Editing. \u003cstrong\u003eTF\u003c/strong\u003e: Investigation. \u003cstrong\u003eYM:\u003c/strong\u003e Conceptualization, Data curation. \u003cstrong\u003eSR:\u003c/strong\u003e Conceptualization, Writing- Reviewing and Editing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAttanasio OP. The determinants of human capital formation during the early years of life: theory, measurement, and policies. 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J Health Popul Nutr. 2012;30:472\u0026ndash;86. https://doi.org/10.3329/jhpn.v30i4.13417.\u003c/li\u003e\n\u003cli\u003eFenson L, Marchman V, Thal D, Dale P, Reznick JS, Bates E. MacArthur-Bates Communicative Development Inventories. 2007.\u003c/li\u003e\n\u003cli\u003eTardif T, Fletcher P. Chinese communicative development inventories: user\u0026rsquo;s guide and manual. Peking University Medical Press; 2008.\u003c/li\u003e\n\u003cli\u003eAttanasio O, Cattan S, Fitzsimons E, Meghir C, Rubio-Codina M. Estimating the Production Function for Human Capital: Results from a Randomized Controlled Trial in Colombia. Am Econ Rev. 2020;110:48\u0026ndash;85. https://doi.org/10.1257/aer.20150183.\u003c/li\u003e\n\u003cli\u003eKolenikov S, Angeles G. Socioeconomic Status Measurement with Discrete Proxy Variables: Is Principal Component Analysis a Reliable Answer? Rev Income Wealth. 2009;55:128\u0026ndash;65. https://doi.org/10.1111/j.1475-4991.2008.00309.x.\u003c/li\u003e\n\u003cli\u003eMooney CZ, Duval RD, Duvall R. Bootstrapping: A Nonparametric Approach to Statistical Inference. SAGE; 1993.\u003c/li\u003e\n\u003cli\u003ePaulson JF, Keefe HA, Leiferman JA. Early parental depression and child language development. J Child Psychol Psychiatry. 2009;50:254\u0026ndash;62. https://doi.org/10.1111/j.1469-7610.2008.01973.x.\u003c/li\u003e\n\u003cli\u003eZajicek-Farber ML. The Contributions of Parenting and Postnatal Depression on Emergent Language of Children in Low-Income Families. J Child Fam Stud. 2010;19:257\u0026ndash;69. https://doi.org/10.1007/s10826-009-9293-7.\u003c/li\u003e\n\u003cli\u003eBrookman R, Kalashnikova M, Conti J, Rattanasone NX, Grant K-A, Demuth K, et al. Depression and Anxiety in the Postnatal Period: An Examination of Infants\u0026rsquo; Home Language Environment, Vocalizations, and Expressive Language Abilities. Child Dev. 2020;91:e1211\u0026ndash;30. https://doi.org/10.1111/cdev.13421.\u003c/li\u003e\n\u003cli\u003eQuevedo LA, Silva RA, Godoy R, Jansen K, Matos MB, Tavares Pinheiro KA, et al. The impact of maternal post-partum depression on the language development of children at 12 months. Child Care Health Dev. 2012;38:420\u0026ndash;4. https://doi.org/10.1111/j.1365-2214.2011.01251.x.\u003c/li\u003e\n\u003cli\u003eJie Y, Qi J, Ai Y, Lei T, Jingchun N. Effects of Caregiver Depression on Parenting Behaviors in Poor Rural China. 华东师范大学学报（教育科学版）. 2019;37:97\u0026ndash;106. https://doi.org/10.16382/j.cnki.1000-5560.2019.03.008.\u003c/li\u003e\n\u003cli\u003eZhang S, Dang R, Yang N, Bai Y, Wang L, Abbey C, et al. Effect of Caregiver\u0026rsquo;s Mental Health on Early Childhood Development across Different Rural Communities in China. Int J Environ Res Public Health. 2018;15:2341. https://doi.org/10.3390/ijerph15112341.\u003c/li\u003e\n\u003cli\u003eZhong J, Wang T, He Y, Gao J, Liu C, Lai F, et al. Interrelationships of caregiver mental health, parenting practices, and child development in rural China. Child Youth Serv Rev. 2021;121:105855. https://doi.org/10.1016/j.childyouth.2020.105855.\u003c/li\u003e\n\u003cli\u003eTreat AE, Morris AS, Hays-Grudo J, Williamson AC. The impact of positive parenting behaviors and maternal depression on the features of young children\u0026rsquo;s home language environments. J Child Lang. 2020;47:382\u0026ndash;400. https://doi.org/10.1017/S030500091900062X.\u003c/li\u003e\n\u003cli\u003eBeck AT, Rush AJ, Shaw BF, Emery G, DeRubeis RJ, Hollon SD. Cognitive Therapy of Depression. Guilford Publications; 2024.\u003c/li\u003e\n\u003cli\u003eCanault M, Le Normand M-T, Foudil S, Loundon N, Thai-Van H. Reliability of the Language ENvironment Analysis system (LENA\u003csup\u003eTM\u003c/sup\u003e) in European French. Behav Res Methods. 2016;48:1109\u0026ndash;24. https://doi.org/10.3758/s13428-015-0634-8.\u003c/li\u003e\n\u003cli\u003eHorne SJ, Topp TE, Quigley L. Depression and the willingness to expend cognitive and physical effort for rewards: A systematic review. Clin Psychol Rev. 2021;88:102065. https://doi.org/10.1016/j.cpr.2021.102065.\u003c/li\u003e\n\u003cli\u003eEdwards AL. Social desirability and the description of others. J Abnorm Soc Psychol. 1959;59:434\u0026ndash;6. https://doi.org/10.1037/h0041442.\u003c/li\u003e\n\u003cli\u003eTaylor SE, Collins RL, Skokan LA, Aspinwall LG. Maintaining Positive Illusions in the Face of Negative Information: Getting the Facts Without Letting Them Get to You. J Soc Clin Psychol. 1989;8:114\u0026ndash;29.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"551\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 551px;\"\u003e\n \u003cp\u003eTable 1. Descriptive Information among the participants (N=137)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePanel A: Demographic characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eChild age (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e21 (1.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eChild is male (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e80 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eMother is the primary caregiver (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e80 (58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003ePrimary caregiver age (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e37 (13)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003ePrimary caregiver graduated from high school (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e74 (50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eFamily asset index\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e-0.01 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eNumber of adults at home (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e2.8 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eSample Strata\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eUrbanized rural households (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e40 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eRural migrant households (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e27 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eRural households (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e70 (51%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePanel B: Caregiver mental health\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eCaregiver Mental Health Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eDepressive symptoms (%)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e17 (12%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eAnxiety symptoms (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e21 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eStress symptoms (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e11 (8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePanel C: Child language development\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eRecorded Child Language Development\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eChild vocalizations count (CVC, n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e1923 (800)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 551px;\"\u003e\n \u003cp\u003eCaregiver-report Child Language Development\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eCDI language score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e45 (29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ePanel D: Home language environment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eRecorded Child Language Environment\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eAdult word count (AWC, n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e13,773 (5609)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eConversational turns count (CTC, n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e557 (286)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 551px;\"\u003e\n \u003cp\u003eCaregiver-report Child Language Environment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eRead books yesterday (mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e5.4 (18)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eTold story yesterday (mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e4.8 (11)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003eSang songs yesterday (mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e4.9 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 367px;\"\u003e\n \u003cp\u003ePlayed games yesterday (mins)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 183px;\"\u003e\n \u003cp\u003e28 (39)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Family asset index was calculated using polychromic principal component analysis based on whether households owned or had access to a number of household items such as tap water, computer, internet, and a car. Caregiver mental health was assessed using the Depression, Anxiety, and Stress Scale-21 (DASS-21). CDI refers to the Macarthur-Bates Communicative Development Inventory. CVC, AWC, and CTC were measured using the LENA technogy for 16 hours and then standardized into 12 hours. Caregiver-report language environment was measured using Family Care Index (FCI).\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"913\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"11\" style=\"width: 99.866%;\"\u003e\n \u003cp\u003eTable 2. Regressions of Caregiver Mental Health Problems on Child Language Development, Language Environment, and Caregiver Reporting Bias (N=137)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 116px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePanel A\u003c/p\u003e\n \u003cp\u003eLanguage Development\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 249px;\"\u003e\n \u003cp\u003ePanel B\u003c/p\u003e\n \u003cp\u003eLanguage Environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 173px;\"\u003e\n \u003cp\u003ePanel C\u003c/p\u003e\n \u003cp\u003ePerception Bias in Language Development\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 202px;\"\u003e\n \u003cp\u003ePanel D\u003c/p\u003e\n \u003cp\u003ePerception Bias in Language Environment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 116px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eCVC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003eCDI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eAWC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eCTC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 82px;\"\u003e\n \u003cp\u003eFCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 173px;\"\u003e\n \u003cp\u003eUsing CVC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 109px;\"\u003e\n \u003cp\u003eUsing AWC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 96px;\"\u003e\n \u003cp\u003eUsing CTC\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 116px;\"\u003e\n \u003cp\u003eDepressive Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 98px;\"\u003e\n \u003cp\u003e-0.51\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 173px;\"\u003e\n \u003cp\u003e0.26\u003csup\u003e+\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.66\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e(0.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003e(0.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e(0.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 98px;\"\u003e\n \u003cp\u003e(0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 82px;\"\u003e\n \u003cp\u003e(0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 173px;\"\u003e\n \u003cp\u003e(0.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e(0.25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e(0.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 116px;\"\u003e\n \u003cp\u003eAnxiety Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.44\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 98px;\"\u003e\n \u003cp\u003e-0.54\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 82px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 173px;\"\u003e\n \u003cp\u003e0.44\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e(0.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003e(0.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e(0.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 98px;\"\u003e\n \u003cp\u003e(0.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 82px;\"\u003e\n \u003cp\u003e(0.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 173px;\"\u003e\n \u003cp\u003e(0.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e(0.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e(0.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 116px;\"\u003e\n \u003cp\u003eStress Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e-0.75\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003e-0.57\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 98px;\"\u003e\n \u003cp\u003e-0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 82px;\"\u003e\n \u003cp\u003e-0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 173px;\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e-0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e(0.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 101px;\"\u003e\n \u003cp\u003e(0.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 69px;\"\u003e\n \u003cp\u003e(0.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 98px;\"\u003e\n \u003cp\u003e(0.39)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 82px;\"\u003e\n \u003cp\u003e(0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 173px;\"\u003e\n \u003cp\u003e(0.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e(0.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e(0.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: (1) \u003csup\u003e+\u003c/sup\u003ep\u0026lt;0.10; \u003csup\u003e**\u003c/sup\u003ep\u0026lt;0.05; \u003csup\u003e***\u003c/sup\u003ep\u0026lt;0.01. (2) Each row and column represent independent regressions. All regressions control for maternal age, maternal education, child age, child sex, the mother being the primary caregiver, and the family asset index. Regressions are bootstrapped 1,000 times, with cluster-robust standard errors estimated at the sample source level (urbanized, migrant, or rural). (3) CVC refers to LENA Child Vocalization Count, CDI refers to the Macarthur-Bates Communicative Development Inventory, AWC refers to LENA Adult Word Count, CTC refers to LEAN Conversational Turns Count, and FCI refers to the Family Care Indicator.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"early childhood language development, early childhood language environment, Language Environment Analysis (LENA), caregiver mental health, rural China","lastPublishedDoi":"10.21203/rs.3.rs-7661882/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7661882/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eLanguage development and the home language environment during early childhood are critical for long-term child outcomes. Caregiver mental health may influence early language outcomes directly, but it can also introduce perception bias, which refers to the discrepancies between caregiver self-assessments and the actual status of child language outcomes. This study examines the associations between caregivers mental health symptoms and (i) child language development and home language environment, and (ii) caregiver perception bias in self-report assessments of child language development and home language environment. The stduy recruited 137 rural Chinese households with children aged 16\u0026ndash;24 months. Objective measures of child language development and the home language environment were collected using Language Environment Analysis (LENA) technology. Caregiver perception bias were measured by the descrepency between the objective and caregiver self-report measurements. Results show that caregiver anxiety and stress symptoms were linked to poor child language development, while symptoms of depression and anxiety symptoms were associated with less stimulating home language environment. Caregivers with depressive and anxiety symptoms tended to overestimate their children\u0026rsquo;s language development, and those with depressive symptoms also overestimated their own verbal inputs. These findings call for caution when implementing self-report assessments of early childhood development.\u003c/p\u003e","manuscriptTitle":"Associations between Caregiver Mental Health, Early Childhood Language Outcomes, and Caregiver Perception Bias: Evidence from Rural China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 15:47:30","doi":"10.21203/rs.3.rs-7661882/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-06T11:38:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-05T20:19:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-05T04:06:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9098970997161589997376281483615388417","date":"2025-10-22T13:53:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314615699783420995965299616365580723337","date":"2025-10-22T13:13:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"72683875672292928357792200807160052863","date":"2025-10-17T12:57:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66297285201221476366060157814144431085","date":"2025-10-15T19:09:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159610581740579350516154243902997678582","date":"2025-10-15T14:28:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-15T12:42:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-15T12:29:23+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-25T09:54:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-25T02:39:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-09-25T02:31:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"53a064c2-254a-499e-8b5e-1284f9589a82","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":56866077,"name":"Health sciences/Diseases"},{"id":56866078,"name":"Health sciences/Health care"},{"id":56866079,"name":"Biological sciences/Psychology"},{"id":56866080,"name":"Social science/Psychology"}],"tags":[],"updatedAt":"2026-02-16T16:00:42+00:00","versionOfRecord":{"articleIdentity":"rs-7661882","link":"https://doi.org/10.1038/s41598-026-39674-2","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-02-13 15:57:54","publishedOnDateReadable":"February 13th, 2026"},"versionCreatedAt":"2025-10-29 15:47:30","video":"","vorDoi":"10.1038/s41598-026-39674-2","vorDoiUrl":"https://doi.org/10.1038/s41598-026-39674-2","workflowStages":[]},"version":"v1","identity":"rs-7661882","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7661882","identity":"rs-7661882","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}