To describe the application of the model Precede-relevant for a family intervention aimed at promoting oral communication and the establishment of standards parenting in a preschool with language delay.

Method: Case Study, in which a family analyzed through the model of family assessment Calgary, consisting of a preschool 2 - year delay in the development of oral language, who lives be presented with his mother and grandmother, where There is normalization of the absence of language, lack of stimulation and absence of established norms. Six psycho educational interventions aimed at educating the family on stimulation strategies, the consequences of the lack of stable norms and the lack of stimulation in the language were carried out. The Precede-Procede model was used in order to facilitate the process of change in the family.

Results: language preschool increased from one to 30 words in three weeks, this behavior improved and decreased the number of tantrums, strengthening the emotional bond between the child and his mother turn.

Conclusion: The application of the model Precede-family proceeds applied facilitated the development of language preschool.

Keywords: language development disorders, child rearing, preschool, family nursing, family health

In primary health care, the nurse is in charge of child health control. In Chile, all monitoring activities in child health and child are framed within the policy of child protection called Chile Grows with You.¹ In this way, the nurse is in charge of the systematic investigation of children with risk or delay in psychomotor development, applying the following standardized scales: Psychomotor Development Evaluation Scale (EEDP) for children from month to 24 months and The Psychomotor Development Test for children between 2 and 5 years old (TEPSI) in infant and preschool health controls. It is also responsible, to complement the results obtained with active strategies early stimulation in these.¹ A child with a functional developmental delay is one who is not able to perform the functions that he or she has to set up for the age. According to the latest Survey of Quality of Life and Health in Chile 11% of children have delayed psychomotor development.² In assessments of psychomotor development, language is the frequently compromised, however, the real magnitude of this problem is unknown at the national level.³ Therefore, it is important that the nursing professional manage strategies that allow him to respond to this important health problem. The development of the child in the first three years of life is characterized by important acquisitions and cerebral elasticity. At this stage there are major advances in motor, cognitive and social area as well as in the acquisition and mastery of language, which are essential for the overall development and learning in children.⁴ In this sense, the family and especially parents exert a powerful influence on the child 's progress, playing a key role in the teaching-learning.⁵ Father absence, permanent feature found in homes of low socioeconomic and cultural level limits the child's acquisition of experience and, therefore, the development of socialization and adaptation.⁵

Despite the aforementioned, the role of women as a promoter of child development is widely recognized. In sociocultural and economically disadvantaged, the mother of children under six years old, he is promoting the development of their children and also determining factor in overcoming poverty within their community.⁵

In addition, the presence of high psychosocial risk in the child 's home environment, indicates a probability four times, he has problems in expressive language development.⁴ Language is a transcendent phenomenon for humans. Its specific characteristics, typical of the species, help build life in society, knowledge of the world, learning and cultural transmission.³ The children are capturing and accumulating the "speech" of their environment, they detect the phonemes from their frequency and repetition. Then by imitation, begin to produce those sounds and phonemes, intonation and rhythm with which belong to the language of the environment.⁶ To advance in this process of language construction, particularly in the early years, children require the support and communicative interaction with their mother. At the stage of stammering, the higher and better the interaction with the mother, the child vocalizations made more and better quality, more resonant syllables, indicating the importance of early communicative ties.⁶ Another variable that is significantly associated with lexical development is family per capita income and parental education, that is, the lower the socioeconomic level, the greater the probability that the lexical development averages are low.⁷ However, in these same poor families, there are psychosocial variables, such as the mother's self-esteem, the mother's satisfaction with the child and her partner, and the frequency with which she claims to talk to her child, which are positively related to development lexicon.⁷ This allows us to target the mother of families at psychosocial risk, as a stimulator of children's vocabulary. Here lies the importance and necessity of supporting the family in its educational work, even more those living in poverty.⁷ In others, early investigation of delayed development of the area of language allows a timely intervention, which would improve the prognosis of those affected. In the absence of appropriate intervention, problems persist into adulthood in proportions close to 40 to 60%.³

Risk factors psychosocial identified as adverse for global and language development, are neutralized by effective support measures that promote successful outcomes during development.⁴ The lexical development plays a key role throughout the child's education. The current national context values ​​equity and equality of opportunities as fundamental pillars of both educational reform and health reform, therefore it seems imperative to take the necessary steps to ensure that each child has the necessary experience to build optimally vocabulary.⁷ Through a clinical case, a family belonging to a commune at social risk in the city of Santiago, Chile, will be presented through the family valuation model of Calgary, composed of a preschooler of 2 years 2 months, diagnosed with delay In the development of oral language, who lives with his mother and grandmother. Both normalize the absence of language and lack of stimulation due to lack of time. The intervention is framed within the application of the precede-proceed model in order to facilitate the process of change in the family that allows to normalize the psychomotor development of his son.

Andrés,¹ 2 preschool years 2 months, lives with his mother 31 years and her maternal grandmother of 49 years. His father, 31, maintained a non-legal relationship with his mother for a year after the birth of Andrés, currently separated. He lives in the neighborhood of Santiago and visits him every two weeks spending the night in the home of the child's maternal grandmother during the visiting weekends. The father also calls daily to the child's home, to know the state of the child. The maternal grandmother refers that during her visits, the conscious father in everything to Andres and the latter does not obey the rules stipulated previously. In addition, he says that every time the father leaves, Andrés cries intensely, making it difficult to get used to the routines of the home. His mother works temporarily and currently serves as a pollster. Refers to arrive at night tired, not being able to share much time with his son. Andres sleeps with her in the same room. The maternal grandmother works at home as a seamstress and also refers not having much time to dedicate to Andrés.

In the last evaluation of the psychomotor development corresponding to the 18 months, it is identified delay of this in the area of ​​language. Although the child is able to express himself effectively through non-verbal language and understands what is being said, his vocabulary is limited to a single word, "ani", to describe all the actions, needs, objects and people around him. So following the recommendations of the professionals of the Health Center, he has been attending two weeks ago with his grandmother, the group sessions of a stimulation workshop that works in the same health center. Both Andres's grandmother and her mother normalize the child's delay in the language area, indicating that as the child grows, the child will achieve the appropriate skills. In addition, both refer, who do not have time to stimulate the child as a result of their respective work activities; nor do they read stories to him, justifying this action in which the child destroyed them when he was younger. They also point out that it does not relate to other children. Both the mother and the grandmother tell that the preschooler always does his will and as they "do not have much patience", the challenges are frequent and the punishments are applied by shouting, slamming and pulling ears. Here are the most important aspects of family assessment will be presented following the model family rating Calgary:⁸

1^st Category, family structure

Structural internal

Structural external

2^nd Category: development

Life cycle stage and tasks: According to the family cycle stages described by Evelyn Duvall,¹⁰ this family is living in two stages of the life cycle. The first according to his grandmother and mother, corresponding to the postpartum stage, middle stage with reincorporation to the nucleus of origin. In this the main task is the acceptance to the generational change of roles, in which the remarkable change of the stage is to assume the role of grandparents. In addition to this family there is a sub-nucleus in the stage with preschool children, depending on the mother and the child, whose main task is the raising of this one and among the changes associated to this stage is the beginning of the process of socialization and control and The tensions between the family and work roles of the parents.

3^rd Category: functions of the family

1. Communication: In this family there is an effective emotional, verbal and non-verbal communication.
2. Problem solving: In the presence of some type of problem or family conflict, an attempt is always made to reach an agreement through the discussion between the maternal grandmother and the mother of the child.
3. Roles: The maternal grandmother fulfills the role of provider, mistress of house, grandmother, mother and fulfills the role of caretaker of Andrew, when the mother is not at home, in turn the mother has the role of mother and provider.
4. Power and authority: In this family the authority is the maternal grandmother and Andrés the power.    
5. Alliances and coalitions: In this family there is an alliance composed of the maternal grandmother and the mother for the upbringing of Andrés and the economic maintenance of the home.

1. Family dynamics: In terms of cohesion, this family is in equilibrium and in terms of adaptability it is flexible.
2. Symptom and function of the symptom: From the systemic point of view in this family, no symptoms are observed.

Monkey family extended. In relation to the stages of the life cycle this is a post-parental family with reincorporation of a nucleus with preschool children. Regarding family dynamics: family cohesion is in balance and adaptability is flexible. Family without symptoms, in normative family crisis with preschool children.Identified problems:

The following strategies were used: description of normal characteristics of preschool children, installation of norms and limits, use of strategies to facilitate change, reinforcement of achievements and promotion of family health.

Since there is a lack of knowledge of the characteristics of the preschool in this family, with their respective achievements, the family was presented with a picture of a child, in which the child was asked to identify and relate the child's characteristics to those of the child. Own of a preschool. Based on the results, the family reflected on the achievements of Andrés and the expected ones according to their state of development. Associated with the above, the family was guided to identify the risks associated with non-compliance with the achievements of the preschool stage, emphasizing communication and language. In addition, strategies to stimulate verbal language and the importance of establishing rules and limits for children were presented to the family.

In the following session, the family was asked to agree on the rules and regulations that Andrés must comply with, indicating the respective prizes and sanctions. Then the relevance of the selected norms and limits and the importance of their application were analyzed together. Four of the most important rules were selected, which were closely related to the potential damage it could cause in Andres, such as climbing the roof, taking the scissors, placing the hands on the sewing machine and playing with sources of hot liquids. The sanction chosen was the explanation that the action was wrong, placing the adult at the same height as the child and in the presence of tantrums remove the child from the middle for a few minutes until it calms down, without leaving it at any time alone.

As a way to reaffirm the agreements made; these were written on a card titled "Walking Together", which was stuck in the room where Andres' grandmother worked at its seams. At the end of the session, the motivation of the family diminished by referring to the feeling of not feeling able to carry out the proposed sanction when appropriate, due to the lack of time and custom.

Given these results we worked with the family based on the Precede- Procede model in which the general objective was that the family understands that there are factors that can limit or facilitate the process of change in favor of the development of Andrés. For this, the family was asked about the results, with respect to the norms and limits established in Andrés, as agreed in the previous session. The family commented that the greatest achievement had been to implement the agreed strategy, when Andrés performed an act that did not correspond to his norms or did tantrums. In relation to this, the family was asked to remember and mention the knowledge they have acquired in the previous sessions, regarding the consequences of the delay and the fulfillment of the expected achievements related to language and the application of parenting guidelines. In this way, it was intended to ensure that the family possessed and understood the necessary knowledge to facilitate the decision-making process. The family mentioned the acquired knowledge and together with it, the table of the Model Precede-Procede was completed. In this way the family was able to identify the factors that would make it difficult to impose the norms and stimulate the language, the factors that would facilitate this action and those that would reinforce them. Among the aspects to be highlighted is the fact that the family identified as a facilitating factor the motivation generated by enabling the socialization process of Andrés with other children. As for the predisposing aspects, such as the lack of time, consensus was reached with the family so that they were not a barrier in the process, dividing the goals.

The next session focused on supervising, guiding and motivating the family in the activities they had to carry out as part of the change process. In this, the family identified the achievements and difficulties in the application of previous agreements. The following sessions were aimed at making the family aware of new strategies to promote the integral development of Andrés. For this, the anticipatory guides based on the Chile Grow with You program of the Ministry of Health and web pages with educational and recreational content to stimulate the language of Andrés were delivered and explained. In addition, the progress made by Andrés in the last month in relation to language was assessed.

The evaluation of the process was carried out addressing the cognitive, affective and motor areas. The cognitive area was evaluated by means of questions of application of knowledge in different daily events and through the realization of questions that contrast the motive that would support an action by the maternal grandmother and the mother over another. The affective area was evaluated through the granting of a degree of value or importance on the part of the mother of the emotions generated in the different activities carried out with Andrés, such as the reading of stories, the explanation of the reason for the sanction staying at their level and the application of sanctions always keeping close to Andrés. And the motor area was evaluated based on the observation of how the family applied the rules, sanctions and stimulation activities. In addition, the family was asked to contrast the number of times they shared with Andres in stimulation activities before and at the end of the intervention process and in this same way compare the number of times he sanctioned his son through the new strategy with which I used previously. As psycho education was used in each session, it was expected that the family responded favorably to 80% of the aspects evaluated, thus exceeding this percentage value.

Among the highlights of the evaluation process is the importance assigned by the maternal grandmother to the reading of stories to Andrés, saying that he discovered a new way of sharing with him, that he notices that his son is entertained by her and that he has strengthened the bond between both. She also verbalizes that now Andrés does not cry when the father leaves the house and that he remains more at his side. In relation to the application of norms and limits, the mother answers positively, since this was allowing to have a better relationship with the child, in addition the family compared the previous behavior and the one after the application of limits and verbalized great advances, especially in the obedience of Andrés adding that he understands him better, that he has been able to avoid the blows to correct him, that he feels that he is not hurting him. In relation to the area of ​​language, the maternal grandmother is taking Andres to buy stories at least once a week and read to her every day at night. Andres’s vocabulary has increased to approximately 30 words and he tries to put sentences together.

The interventions carried out in conjunction with the family were based mainly on the establishment of norms and limits towards Andrés and the stimulation of language. Regarding the stimulation of language, if we take into account that in the development of preschool children interact internal and external factors that influence their affective, social, language or motor skills; One way to stimulate and enrich speech is through reading aloud.¹¹ Thus, reading stories, as a method of stimulation, was an important tool since it also facilitated the mother - child bond. This coincides with what the literature mentions, alluding to the fact that the maximum potential of reading stories is linked to emotional development and deep relational links established between mother and child, extending to the whole family.¹² words of the story, connect the child with life and with affection and this experience is a substrate to enrich the communication in the family and to promote good treatment, which confers (to reading) an enormous preventive power from the emotional point of view.¹² Based on this theme, the family reported that Andrés enjoyed reading stories and asked them to tell him the same story; This coincides with Ciriani (2005), where he points out that children like to hear the same story over and over again, because they like to imagine what they want to be or do, through identification with the characters.¹¹ In this way, the child realizes that there are different ways to respond to different situations and gives him the possibility to develop his emotional intelligence. Another point to highlight of the interventions was the importance of establishing norms and limits in Andrés to favor their future development. The participation of the family in the establishment of norms and limits, and the application of these under the same criteria, are important to give meaning and coherence to the discipline at home and prevent the child from becoming disoriented.¹³ In this context, the interventions aimed to incorporate norms and limits based on good treatment. The incorporation of rules and limits based on good treatment, these become a contribution to improve coexistence and are a necessary tool to resolve conflicts that naturally occur in human relationships. Thus, as children learn about these and internalize them early, it will be easier for them to develop socially. This coincides with that referred by the family, which gave great importance to the acquisition of norms and limits in Andrés, so that the child did not have problems of socialization. This last point became an important facilitator of the intervention, since it allowed the family to be motivated to establish and maintain norms and limits towards the child. So it is important that the child learn little by little why they are incorporating standards, and that these are not arbitrariness of the parents, but are to improve their overall development, and that for this a good alternative is to explain what is the action punished The family of Andrés, at the beginning of the interventions, did not find it necessary to carry out these actions but later, he realized that when applied, Andrés' reaction was totally contrary to the tantrums that he carried out. Therefore, the interventions regarding the establishment of limits and norms towards Andrs also focused on changing the style of imposing them. You can differentiate four styles or ways of behaving with children (as), these styles are: democratic, authoritarian, permissive and indifferent.¹⁴ In the case of Andres's family, there was a predominantly permissive style, in which limits were not used and there was no control over the child's behavior. The intervention was aimed at establishing a democratic style, in which affectivity, communication, rules and clear limits were present, the supervision of behavior and the development of autonomy. The change in style improved the mother-child relationship and increased Beatriz's self-efficacy in relation to her role as mother.

To be able to intervene in a more effective way, part of the Precede-Procede Model was used, which is based on the systematic planning process that tries to empower individuals with: understanding, motivation and skills to participate actively in the resolution of the problems of the community (family) in order to improve the quality of life.¹⁵ From this model, we extracted the predisposing, facilitating and reinforcing factors of the change. Completing each of the factors with the family, this could better visualize the factors that made it difficult, those that facilitated and those that reinforced the setting of rules and limits and the stimulation of language. This allowed the family to reduce their anxiety about the changes and establish themselves, real goals in relation to the behavior they would adopt with Andres, coinciding with the objectives of the model.

Another important point to mention is that the family belongs to 33.3% of Chilean households headed by a woman.¹⁶ In relation to this characteristic, Luisi & Santelices¹⁷ mention that it can be a risk when evaluating emotional and social competences in children, especially when they are in the school stage.¹⁷ But Jadué⁵ refers that there are protective factors to avoid this situation such as: psychological well-being of the father who stays with the child, characteristics of the child, frequent contact of the child with the father who does not live with him and the functional relationships with the others members. These factors are present in the family of Andrés, therefore his emotional and physical development would not be affected and the role of nursing, in this case was to promote promotion to further the development of the child.⁵ Finally, the disclosure of anticipatory guidelines regarding the development of Andrés, facilitated the family to know the characteristics of the preschool and motivated to stimulate some aspects that were deficient in him, especially language. This intervention is related to what was mentioned in Nelson,¹⁸ where it is mentioned that the granting of anticipatory guidelines facilitates the promotion of the child's development and brings benefits in the creation of healthy habits.¹⁸ The previous orientation about children in the affective, cognitive and social area; provides knowledge to parents, decreases their anxiety about parenting and motivates them to take measures to achieve better development in their children.¹⁸ Therefore, it is recommended that in each Child Growth and Development Supervision, these guidelines be delivered in order to promote better health for the child and his or her family.

The applications of the Calgary assessment model offers systematization in the family assessment process that allows identifying in a comprehensive and joint way the factors that could favor or hinder the family functionality. In this way, more relevant and prioritized diagnoses will be obtained later. For the execution of interventions, the use of the model proceeds acquires special relevance in the process of planning and evaluation of a health intervention to achieve the change of behavior of individuals and families. The application of this model facilitated the process of changing family behavior thanks to the identification of the factors that would hinder the change, those that would facilitate them and those that would reinforce it. In this way, the family actively participated in the process that would help establish norms and limits for the child effectively handle tantrums and favor the development of preschool language. These are always linked to the approach of good treatment in the upbringing of children, which together allowed the family to optimize and improve the quality of time delivered to the child as a result of the intervention, increasing the bond between family members. Finally, because the nursing professional is responsible for supervising the correct growth and development of the child, it is essential to manage different tools through the application of models that optimize obtaining better results.

None.

Author declares that there is none of the conflicts.

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