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Introduction

Nature of learning and play, categories of play, object play, physical, locomotor, or rough-and-tumble play, outdoor play, social or pretend play alone or with others, development of play, effects on brain structure and functioning, benefits of play, benefits to adults of playing with children, implications for preschool education, modern challenges, role of media in children’s play, barriers to play, role of pediatricians, conclusions, lead authors, contributor, committee on psychosocial aspects of child and family health, 2017–2018, council on communications and media, 2017–2018, the power of play: a pediatric role in enhancing development in young children.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Michael Yogman , Andrew Garner , Jeffrey Hutchinson , Kathy Hirsh-Pasek , Roberta Michnick Golinkoff , COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH , COUNCIL ON COMMUNICATIONS AND MEDIA , Rebecca Baum , Thresia Gambon , Arthur Lavin , Gerri Mattson , Lawrence Wissow , David L. Hill , Nusheen Ameenuddin , Yolanda (Linda) Reid Chassiakos , Corinn Cross , Rhea Boyd , Robert Mendelson , Megan A. Moreno , MSEd , Jenny Radesky , Wendy Sue Swanson , MBE , Jeffrey Hutchinson , Justin Smith; The Power of Play: A Pediatric Role in Enhancing Development in Young Children. Pediatrics September 2018; 142 (3): e20182058. 10.1542/peds.2018-2058

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Children need to develop a variety of skill sets to optimize their development and manage toxic stress. Research demonstrates that developmentally appropriate play with parents and peers is a singular opportunity to promote the social-emotional, cognitive, language, and self-regulation skills that build executive function and a prosocial brain. Furthermore, play supports the formation of the safe, stable, and nurturing relationships with all caregivers that children need to thrive.

Play is not frivolous: it enhances brain structure and function and promotes executive function (ie, the process of learning, rather than the content), which allow us to pursue goals and ignore distractions.

When play and safe, stable, nurturing relationships are missing in a child’s life, toxic stress can disrupt the development of executive function and the learning of prosocial behavior; in the presence of childhood adversity, play becomes even more important. The mutual joy and shared communication and attunement (harmonious serve and return interactions) that parents and children can experience during play regulate the body’s stress response. This clinical report provides pediatric providers with the information they need to promote the benefits of play and and to write a prescription for play at well visits to complement reach out and read. At a time when early childhood programs are pressured to add more didactic components and less playful learning, pediatricians can play an important role in emphasizing the role of a balanced curriculum that includes the importance of playful learning for the promotion of healthy child development.

Since the publication of the American Academy of Pediatrics (AAP) Clinical Reports on the importance of play in 2007, 1 , 2 newer research has provided additional evidence of the critical importance of play in facilitating parent engagement; promoting safe, stable, and nurturing relationships; encouraging the development of numerous competencies, including executive functioning skills; and improving life course trajectories. 3 , – 5 An increasing societal focus on academic readiness (promulgated by the No Child Left Behind Act of 2001) has led to a focus on structured activities that are designed to promote academic results as early as preschool, with a corresponding decrease in playful learning. Social skills, which are part of playful learning, enable children to listen to directions, pay attention, solve disputes with words, and focus on tasks without constant supervision. 6 By contrast, a recent trial of an early mathematics intervention in preschool showed almost no gains in math achievement in later elementary school. 7 Despite criticism from early childhood experts, the 2003 Head Start Act reauthorization ended the program evaluation of social emotional skills and was focused almost exclusively on preliteracy and premath skills. 8 The AAP report on school readiness includes an emphasis on the importance of whole child readiness (including social–emotional, attentional, and cognitive skills). 9 Without that emphasis, children’s ability to pay attention and behave appropriately in the classroom is disadvantaged.

The definition of play is elusive. However, there is a growing consensus that it is an activity that is intrinsically motivated, entails active engagement, and results in joyful discovery. Play is voluntary and often has no extrinsic goals; it is fun and often spontaneous. Children are often seen actively engaged in and passionately engrossed in play; this builds executive functioning skills and contributes to school readiness (bored children will not learn well). 10 Play often creates an imaginative private reality, contains elements of make believe, and is nonliteral.

Depending on the culture of the adults in their world, children learn different skills through play. Sociodramatic play is when children act out the roles of adulthood from having observed the activities of their elders. Extensive studies of animal play suggest that the function of play is to build a prosocial brain that can interact effectively with others. 11  

Play is fundamentally important for learning 21st century skills, such as problem solving, collaboration, and creativity, which require the executive functioning skills that are critical for adult success. The United Nations Convention on the Rights of the Child has enshrined the right to engage in play that is appropriate to the age of the child in Article 21. 12 In its 2012 exhibit “The Century of the Child: 1900–2000,” the Museum of Modern Art noted, “Play is to the 21st century what work was to industrialization. It demonstrates a way of knowing, doing, and creating value.” 13 Resnick 14 has described 4 guiding principles to support creative learning in children: projects, passion, peers, and play. Play is not just about having fun but about taking risks, experimenting, and testing boundaries. Pediatricians can be influential advocates by encouraging parents and child care providers to play with children and to allow children to have unstructured time to play as well as by encouraging educators to recognize playful learning as an important complement to didactic learning. Some studies 15 , – 18 note that the new information economy, as opposed to the older industrial 1, demands more innovation and less imitation, more creativity and less conformity. Research on children’s learning indicates that learning thrives when children are given some agency (control of their own actions) to play a role in their own learning. 19 The demands of today’s world require that the teaching methods of the past 2 centuries, such as memorization, be replaced by innovation, application, and transfer. 18  

Bruner et al 20 stressed the fact that play is typically buffered from real-life consequences. Play is part of our evolutionary heritage, occurs in a wide spectrum of species, is fundamental to health, and gives us opportunities to practice and hone the skills needed to live in a complex world. 21 Although play is present in a large swath of species within the animal kingdom, from invertebrates (such as the octopus, lizard, turtle, and honey bee) to mammals (such as rats, monkeys, and humans), 22 social play is more prominent in animals with a large neocortex. 23 Studies of animal behavior suggests that play provides animals and humans with skills that will help them with survival and reproduction. 24 Locomotor skills learned through rough-and-tumble play enables escape from predators. However, animals play even when it puts them at risk of predation. 25 It is also suggested that play teaches young animals what they can and cannot do at times when they are relatively free from the survival pressures of adult life. 26 Play and learning are inextricably linked. 27 A Russian psychologist recognized that learning occurs when children actively engage in practical activities within a supportive social context. The accumulation of new knowledge is built on previous learning, but the acquisition of new skills is facilitated by social and often playful interactions. He was interested in what he called the “zone of proximal development,” which consists of mastering skills that a child could not do alone but could be developed with minimal assistance. 28 Within the zone of proximal development, the “how” of learning occurs through a reiterative process called scaffolding, in which new skills are built on previous skills and are facilitated by a supportive social environment. The construct of scaffolding has been extrapolated to younger children. Consider how a social smile at 6 to 8 weeks of age invites cooing conversations, which leads to the reciprocal dance of social communication even before language emerges, followed by social referencing (the reading of a parent’s face for nonverbal emotional content). The balance between facilitating unstructured playtime for children and encouraging adult scaffolding of play will vary depending on the competing needs in individual families, but the “serve-and-return” aspect of play requires caregiver engagement. 29  

Early learning and play are fundamentally social activities 30 and fuel the development of language and thought. Early learning also combines playful discovery with the development of social–emotional skills. It has been demonstrated that children playing with toys act like scientists and learn by looking and listening to those around them. 15 , – 17 However, explicit instructions limit a child’s creativity; it is argued that we should let children learn through observation and active engagement rather than passive memorization or direct instruction. Preschool children do benefit from learning content, but programs have many more didactic components than they did 20 years ago. 31 Successful programs are those that encourage playful learning in which children are actively engaged in meaningful discovery. 32 To encourage learning, we need to talk to children, let them play, and let them watch what we do as we go about our everyday lives. These opportunities foster the development of executive functioning skills that are critically important for the development of 21st century skills, such as collaboration, problem solving, and creativity, according to the 2010 IBM’s Global CEO Study. 33  

Play has been categorized in a variety of ways, each with its own developmental sequence. 32 , 34  

This type of play occurs when an infant or child explores an object and learns about its properties. Object play progresses from early sensorimotor explorations, including the use of the mouth, to the use of symbolic objects (eg, when a child uses a banana as a telephone) for communication, language, and abstract thought.

This type of play progresses from pat-a-cake games in infants to the acquisition of foundational motor skills in toddlers 35 and the free play seen at school recess. The development of foundational motor skills in childhood is essential to promoting an active lifestyle and the prevention of obesity. 36 , – 39 Learning to cooperate and negotiate promotes critical social skills. Extrapolation from animal data suggests that guided competition in the guise of rough-and-tumble play allows all participants to occasionally win and learn how to lose graciously. 40 Rough-and-tumble play, which is akin to the play seen in animals, enables children to take risks in a relatively safe environment, which fosters the acquisition of skills needed for communication, negotiation, and emotional balance and encourages the development of emotional intelligence. It enables risk taking and encourages the development of empathy because children are guided not to inflict harm on others. 25 , 30 , 40 The United Kingdom has modified its guidelines on play, arguing that the culture has gone too far by leaching healthy risks out of childhood: new guidelines on play by the national commission state, “The goal is not to eliminate risk.” 41  

Outdoor play provides the opportunity to improve sensory integration skills. 36 , 37 , 39 These activities involve the child as an active participant and address motor, cognitive, social, and linguistic domains. Viewed in this light, school recess becomes an essential part of a child’s day. 42 It is not surprising that countries that offer more recess to young children see greater academic success among the children as they mature. 42 , 43 Supporting and implementing recess not only sends a message that exercise is fundamentally important for physical health but likely brings together children from diverse backgrounds to develop friendships as they learn and grow. 42  

This type of play occurs when children experiment with different social roles in a nonliteral fashion. Play with other children enables them to negotiate “the rules” and learn to cooperate. Play with adults often involves scaffolding, as when an adult rotates a puzzle to help the child place a piece. Smiling and vocal attunement, in which infants learn turn taking, is the earliest example of social play. Older children can develop games and activities through which they negotiate relationships and guidelines with other players. Dress up, make believe, and imaginary play encourage the use of more sophisticated language to communicate with playmates and develop common rule-bound scenarios (eg, “You be the teacher, and I will be the student”).

Play has also been grouped as self-directed versus adult guided. Self-directed play, or free play, is crucial to children’s exploration of the world and understanding of their preferences and interests. 19 , 32 , 44 Guided play retains the child agency, such that the child initiates the play, but it occurs either in a setting that an adult carefully constructs with a learning goal in mind (eg, a children’s museum exhibit or a Montessori task) or in an environment where adults supplement the child-led exploration with questions or comments that subtly guide the child toward a goal. Board games that have well-defined goals also fit into this category. 45 For example, if teachers want children to improve executive functioning skills (see the “Tools of the Mind” curriculum), 46 they could create drum-circle games, in which children coregulate their behavior. Familiar games such as “Simon Says” or “Head, Shoulders, Knees, and Toes” ask children to control their individual actions or impulses and have been shown to improve executive functioning skills. 47 Guided play has been defined as a child-led, joyful activity in which adults craft the environment to optimize learning. 4 , 48 This approach harkens back to Vygotsky 28 and the zone of proximal development, which represents the skills that children are unable to master on their own but are able to master in the context of a safe, stable, and nurturing relationship with an adult. The guidance and dialogue provided by the adult allow the child to master skills that would take longer to master alone and help children focus on the elements of the activity to guide learning. One way to think about guided play is as “constrained tinkering.” 14 , 48 This logic also characterizes Italy’s Emilio Reggio approach, which emphasizes the importance of teaching children to listen and look.

According to Vygotsky, 28 the most efficient learning occurs in a social context, where learning is scaffolded by the teacher into meaningful contexts that resonate with children’s active engagement and previous experiences. Scaffolding is a part of guided play; caregivers are needed to provide the appropriate amount of input and guidance for children to develop optimal skills.

How does play develop? Play progresses from social smiling to reciprocal serve-and-return interactions; the development of babbling; games, such as “peek-a-boo”; hopping, jumping, skipping, and running; and fantasy or rough-and-tumble play. The human infant is born immature compared with infants of other species, with substantial brain development occurring after birth. Infants are entirely dependent on parents to regulate sleep–wake rhythms, feeding cycles, and many social interactions. Play facilitates the progression from dependence to independence and from parental regulation to self-regulation. It promotes a sense of agency in the child. This evolution begins in the first 3 months of life, when parents (both mothers and fathers) interact reciprocally with their infants by reading their nonverbal cues in a responsive, contingent manner. 49 Caregiver–infant interaction is the earliest form of play, known as attunement, 50 but it is quickly followed by other activities that also involve the taking of turns. These serve-and-return behaviors promote self-regulation and impulse control in children and form a strong foundation for understanding their interaction with adults. The back-and-forth episodes also feed into the development of language.

Reciprocal games occur with both mothers and fathers 51 and often begin in earnest with the emergence of social smiles at 6 weeks of age. Parents mimic their infant’s “ooh” and “ah” in back-and-forth verbal games, which progress into conversations in which the parents utter pleasantries (“Oh, you had a good lunch!”), and the child responds by vocalizing back. Uncontrollable crying as a response to stress in a 1-year-old is replaced as the child reaches 2 to 3 years of age with the use of words to self-soothe, building on caregivers scaffolding their emotional responses. Already by 6 months of age, the introduction of solid foods requires the giving and receiving of reciprocal signals and communicative cues. During these activities, analyses of physiologic heart rate rhythms of infants with both their mothers and fathers have shown synchrony. 49 , 52  

By 9 months of age, mutual regulation is manifested in the way infants use their parents for social referencing. 53 , 54 In the classic visual cliff experiment, it was demonstrated that an infant will crawl across a Plexiglas dropoff to explore if the mother encourages the infant but not if she frowns. Nonverbal communication slowly leads to formal verbal language skills through which emotions such as happiness, sadness, and anger are identified for the child via words. Uncontrollable crying in the 1-year-old then becomes whining in the 2-year-old and verbal requests for assistance in the 3-year-old as parents scaffold the child’s emotional responses and help him or her develop alternative, more adaptive behaviors. Repetitive games, such as peek-a-boo and “this little piggy,” offer children the joy of being able to predict what is about to happen, and these games also enhance the infants’ ability to solicit social stimulation.

By 12 months of age, a child’s experiences are helping to lay the foundation for the ongoing development of social skills. The expression of true joy and mastery on children’s faces when they take their first step is truly a magical moment that all parents remember. Infant memory, in Piagetian terms, develops as infants develop object permanence through visible and invisible displacements, such as repetitive games like peek-a-boo. With the advent of locomotor skills, rough-and-tumble play becomes increasingly available. During the second year, toddlers learn to explore their world, develop the beginnings of self-awareness, and use their parents as a home base (secure attachment), frequently checking to be sure that the world they are exploring is safe. 55 As children become independent, their ability to socially self-regulate becomes apparent: they can focus their attention and solve problems efficiently, they are less impulsive, and they can better manage the stress of strong emotions. 56 With increased executive functioning skills, they can begin to reflect on how they should respond to a situation rather than reacting impulsively. With the development of language and symbolic functioning, pretend play now becomes more prominent. 57 Fantasy play, dress up, and fort building now join the emotional and social repertoire of older children just as playground activities, tag, and hide and seek develop motor skills. In play, children are also solving problems and learning to focus attention, all of which promote the growth of executive functioning skills.

Play is not frivolous; it is brain building. Play has been shown to have both direct and indirect effects on brain structure and functioning. Play leads to changes at the molecular (epigenetic), cellular (neuronal connectivity), and behavioral levels (socioemotional and executive functioning skills) that promote learning and adaptive and/or prosocial behavior. Most of this research on brain structure and functioning has been done with rats and cannot be directly extrapolated to humans.

Jaak Panksepp, 11 a neuroscientist and psychologist who has extensively studied the neurologic basis of emotion in animals, suggests that play is 1 of 7 innate emotional systems in the midbrain. 58 Rats love rough-and-tumble play and produce a distinctive sound that Panksepp labeled “rat laughter.” 42 , 59 , – 64 When rats are young, play appears to initiate lasting changes in areas of the brain that are used for thinking and processing social interaction.

The dendritic length, complexity, and spine density of the medial prefrontal cortex (PFC) are refined by play. 64 , – 67 The brain-derived neurotrophic factor ( BDNF ) is a member of the neurotrophin family of growth factors that acts to support the survival of existing neurons and encourage the growth and differentiation of new neurons and synapses. It is known to be important for long-term memory and social learning. Play stimulates the production of BDNF in RNA in the amygdala, dorsolateral frontal cortex, hippocampus, and pons. 65 , 68 , – 70 Gene expression analyses indicate that the activities of approximately one-third of the 1200 genes in the frontal and posterior cortical regions were significantly modified by play within an hour after a 30-minute play session. 69 , 70 The gene that showed the largest effect was BDNF . Conversely, rat pup adversity, depression, and stress appear to result in the methylation and downregulation of the BDNF gene in the PFC. 71  

Two hours per day of play with objects predicted changes in brain weight and efficiency in experimental animals. 11 , 66 Rats that were deprived of play as pups (kept in sparse cages devoid of toys) not only were less competent at problem solving later on (negotiating mazes) but the medial PFC of the play-deprived rats was significantly more immature, suggesting that play deprivation interfered with the process of synaptogenesis and pruning. 72 Rat pups that were isolated during peak play periods after birth (weeks 4 and 5) are much less socially active when they encounter other rats later in life. 73 , 74  

Play-deprived rats also showed impaired problem-solving skills, suggesting that through play, animals learn to try new things and develop behavioral flexibility. 73 Socially reared rats with damage to their PFC mimic the social deficiencies of rats with intact brains but who were deprived of play as juveniles. 66 The absence of the play experience leads to anatomically measurable changes in the neurons of the PFC. By refining the functional organization of the PFC, play enhances the executive functioning skills derived from this part of the brain. 66 Whether these effects are specific to play deprivation or merely reflect the generic effect of a lack of stimulation requires further study. Rats that were raised in experimental toy-filled cages had bigger brains and thicker cerebral cortices and completed mazes more quickly. 67 , 75  

Brain neurotransmitters, such as dopamine made by cells in the substantia nigra and ventral tegmentum, are also related to the reward quality of play: drugs that activate dopamine receptors increase play behavior in rats. 76  

Play and stress are closely linked. High amounts of play are associated with low levels of cortisol, suggesting either that play reduces stress or that unstressed animals play more. 23 Play also activates norepinephrine, which facilitates learning at synapses and improves brain plasticity. Play, especially when accompanied by nurturing caregiving, may indirectly affect brain functioning by modulating or buffering adversity and by reducing toxic stress to levels that are more compatible with coping and resilience. 77 , 78  

In human children, play usually enhances curiosity, which facilitates memory and learning. During states of high curiosity, functional MRI results showed enhanced activity in healthy humans in their early 20s in the midbrain and nucleus accumbens and functional connectivity to the hippocampus, which solidifies connections between intrinsic motivation and hippocampus-dependent learning. 79 Play helps children deal with stress, such as life transitions. When 3- to 4-year-old children who were anxious about entering preschool were randomly assigned to play with toys or peers for 15 minutes compared with listening to a teacher reading a story, the play group showed a twofold decrease in anxiety after the intervention. 24 , 80 In another study, preschool children with disruptive behavior who engaged with teachers in a yearlong 1-to-1 play session designed to foster warm, caring relationships (allowing children to lead, narrating the children’s behavior out loud, and discussing the children’s emotions as they played) showed reduced salivary cortisol stress levels during the day and improved behavior compared with children in the control group. 81 The notable exception is with increased stress experienced by children with autism spectrum disorders in new or social circumstances. 82 Animal studies suggest the role of play as a social buffer. Rats that were previously induced to be anxious became relaxed and calm after rough-and-tumble play with a nonanxious playful rat. 83 Extrapolating from these animal studies, one can suggest that play may serve as an effective buffer for toxic stress.

The benefits of play are extensive and well documented and include improvements in executive functioning, language, early math skills (numerosity and spatial concepts), social development, peer relations, physical development and health, and enhanced sense of agency. 13 , 32 , 56 , 57 , 84 , – 88 The opposite is also likely true; Panksepp 89 suggested that play deprivation is associated with the increasing prevalence of attention-deficit/hyperactivity disorder. 90  

Executive functioning, which is described as the process of how we learn over the content of what we learn, is a core benefit of play and can be characterized by 3 dimensions: cognitive flexibility, inhibitory control, and working memory. Collectively, these dimensions allow for sustained attention, the filtering of distracting details, improved self-regulation and self-control, better problem solving, and mental flexibility. Executive functioning helps children switch gears and transition from drawing with crayons to getting dressed for school. The development of the PFC and executive functioning balances and moderates the impulsiveness, emotionality, and aggression of the amygdala. In the presence of childhood adversity, the role of play becomes even more important in that the mutual joy and shared attunement that parents and children can experience during play downregulates the body’s stress response. 91 , – 94 Hence, play may be an effective antidote to the changes in amygdala size, impulsivity, aggression, and uncontrolled emotion that result from significant childhood adversity and toxic stress. Future research is needed to clarify this association.

Opportunities for peer engagement through play cultivate the ability to negotiate. Peer play usually involves problem solving about the rules of the game, which requires negotiation and cooperation. Through these encounters, children learn to use more sophisticated language when playing with peers. 95 , 96  

Play in a variety of forms (active physical play, pretend play, and play with traditional toys and shape sorters [rather than digital toys]) improves children’s skills. When children were given blocks to play with at home with minimal adult direction, preschool children showed improvements in language acquisition at a 6-month follow-up, particularly low-income children. The authors suggest that the benefits of Reach Out and Play may promote development just as Reach Out and Read does. 97 When playing with objects under minimal adult direction, preschool children named an average of 3 times as many nonstandard uses for an object compared with children who were given specific instructions. 98 In Jamaica, toddlers with growth retardation who were given weekly play sessions to improve mother–child interactions for 2 years were followed to adulthood and showed better educational attainment, less depression, and less violent behavior. 3  

Children who were in active play for 1 hour per day were better able to think creatively and multitask. 22 Randomized trials of physical play in 7- to 9-year-olds revealed enhanced attentional inhibition, cognitive flexibility, and brain functioning that were indicative of enhanced executive control. 99 Play with traditional toys was associated with an increased quality and quantity of language compared with play with electronic toys, 100 particularly if the video toys did not encourage interaction. 101 Indeed, it has been shown that play with digital shape sorters rather than traditional shape sorters stunted the parent’s use of spatial language. 102 Pretend play encourages self-regulation because children must collaborate on the imaginary environment and agree about pretending and conforming to roles, which improves their ability to reason about hypothetical events. 56 , 57 , 103 , – 105 Social–emotional skills are increasingly viewed as related to academic and economic success. 106 Third-grade prosocial behavior correlated with eighth-grade reading and math better than with third-grade reading and math. 17 , 107  

The health benefits of play involving physical activity are many. Exercise not only promotes healthy weight and cardiovascular fitness but also can enhance the efficacy of the immune, endocrine, and cardiovascular systems. 37 Outdoor playtime for children in Head Start programs has been associated with decreased BMI. 39 Physical activity is associated with decreases in concurrent depressive symptoms. 108 Play decreases stress, fatigue, injury, and depression and increases range of motion, agility, coordination, balance, and flexibility. 109 Children pay more attention to class lessons after free play at recess than they do after physical education programs, which are more structured. 43 Perhaps they are more active during free play.

Play also reflects and transmits cultural values. In fact, recess began in the United States as a way to socially integrate immigrant children. Parents in the United States encourage children to play with toys and/or objects alone, which is typical of communities that emphasize the development of independence. Conversely, in Japan, peer social play with dolls is encouraged, which is typical of cultures that emphasize interdependence. 110  

Playing with children adds value not only for children but also for adult caregivers, who can reexperience or reawaken the joy of their own childhood and rejuvenate themselves. Through play and rereading their favorite childhood books, parents learn to see the world from their child’s perspective and are likely to communicate more effectively with their child, even appreciating and sharing their child’s sense of humor and individuality. Play enables children and adults to be passionately and totally immersed in an activity of their choice and to experience intense joy, much as athletes do when they are engaging in their optimal performance. Discovering their true passions is another critical strategy for helping both children and adults cope with adversity. One study documented that positive parenting activities, such as playing and shared reading, result in decreases in parental experiences of stress and enhancement in the parent–child relationship, and these effects mediate relations between the activities and social–emotional development. 111 , – 113  

Most importantly, play is an opportunity for parents to engage with their children by observing and understanding nonverbal behavior in young infants, participating in serve-andreturn exchanges, or sharing the joy and witnessing the blossoming of the passions in each of their children.

Play not only provides opportunities for fostering children’s curiosity, 14 self-regulation skills, 46 language development, and imagination but also promotes the dyadic reciprocal interactions between children and parents, which is a crucial element of healthy relationships. 114 Through the buffering capacity of caregivers, play can serve as an antidote to toxic stress, allowing the physiologic stress response to return to baseline. 77 Adult success in later life can be related to the experience of childhood play that cultivated creativity, problem solving, teamwork, flexibility, and innovations. 18 , 52 , 115  

Successful scaffolding (new skills built on previous skills facilitated by a supportive social environment) can be contrasted with interactions in which adults direct children’s play. It has been shown that if a caregiver instructs a child in how a toy works, the child is less likely to discover other attributes of the toy in contrast to a child being left to explore the toy without direct input. 38 , 116 , – 118 Adults who facilitate a child’s play without being intrusive can encourage the child’s independent exploration and learning.

Scaffolding play activities facilitated by adults enable children to work in groups: to share, negotiate, develop decision-making and problem-solving skills, and discover their own interests. Children learn to resolve conflicts and develop self-advocacy skills and their own sense of agency. The false dichotomy between play versus formal learning is now being challenged by educational reformers who acknowledge the value of playful learning or guided play, which captures the strengths of both approaches and may be essential to improving executive functioning. 18 , 19 , 34 , 119 Hirsh-Pasek et al 34 report a similar finding: children have been shown to discover causal mechanisms more quickly when they drive their learning as opposed to when adults display solutions for them.

Executive functioning skills are foundational for school readiness and academic success, mandating a frame shift with regard to early education. The goal today is to support interventions that cultivate a range of skills, such as executive functioning, in all children so that the children enter preschool and kindergarten curious and knowing how to learn. Kindergarten should provide children with an opportunity for playful collaboration and tinkering, 14 a different approach from the model that promotes more exclusive didactic learning at the expense of playful learning. The emerging alternative model is to prevent toxic stress and build resilience by developing executive functioning skills. Ideally, we want to protect the brain to enable it to learn new skills, and we want to focus on learning those skills that will be used to buffer the brain from any future adversity. 18 The Center on the Developing Child at Harvard University offers an online resource on play and executive functioning with specific activities suggested for parents and children ( http://developingchild.harvard.edu/wp-content/uploads/2015/05/Enhancing-and-Practicing-Executive-Function-Skills-with-Children-from-Infancy-to-Adolescence-1.pdf ). 120  

Specific curricula have now been developed and tested in preschools to help children develop executive functioning skills. Many innovative programs are using either the Reggio Emilia philosophy or curricula such as Tools of the Mind (developed in California) 121 or Promoting Alternative Thinking Strategies–Preschool and/or Kindergarten. 122 Caregivers need to provide the appropriate amount of input and guidance for children to develop optimal problem-solving skills through guided play and scaffolding. Optimal learning can be depicted by a bell-shaped curve, which illustrates the optimal zone of arousal and stress for complex learning. 123  

Scaffolding is extensively used to support skills such as buddy reading, in which children take turns being lips and ears and learn to read and listen to each other as an example of guided play. A growing body of research shows that this curriculum not only improves executive functioning skills but also shows improvement in brain functioning on functional MRI. 6 , 124 , – 126  

Focusing on cultivating executive functioning and other skills through playful learning in these early years is an alternative and innovative way of thinking about early childhood education. Instead of focusing solely on academic skills, such as reciting the alphabet, early literacy, using flash cards, engaging with computer toys, and teaching to tests (which has been overemphasized to promote improved test results), cultivating the joy of learning through play is likely to better encourage long-term academic success. Collaboration, negotiation, conflict resolution, self-advocacy, decision-making, a sense of agency, creativity, leadership, and increased physical activity are just some of the skills and benefits children gain through play.

For many families, there are risks in the current focus only on achievement, after-school enrichment programs, increased homework, concerns about test performance, and college acceptance. The stressful effects of this approach often result in the later development of anxiety and depression and a lack of creativity. Parental guilt has led to competition over who can schedule more “enrichment opportunities” for their children. As a result, there is little time left in the day for children’s free play, for parental reading to children, or for family meal times. Many schools have cut recess, physical education, art, and music to focus on preparing children for tests. Unsafe local neighborhoods and playgrounds have led to nature deficit disorder for many children. 127 A national survey of 8950 preschool children and parents found that only 51% of children went outside to walk or play once per day with either parent. 128 In part, this may reflect the local environment: 94% of parents have expressed safety concerns about outdoor play, and access may be limited. Only 20% of homes are located within a half-mile of a park. 129 , 130 Cultural changes have also jeopardized the opportunities children have to play. From 1981 to 1997, children’s playtime decreased by 25%. Children 3 to 11 years of age have lost 12 hours per week of free time. Because of increased academic pressure, 30% of US kindergarten children no longer have recess. 42 , 129 An innovative program begun in Philadelphia is using cities (on everyday walks and in everyday neighborhoods) as opportunities for creating learning landscapes that provide opportunities for parents and children to spark conversation and playful learning. 131 , 132 For example, Ridge et al 132 have placed conversational prompts throughout supermarkets and laundromats to promote language and lights at bus stops to project designs on the ground, enabling children to play a game of hopscotch that is specifically designed to foster impulse control. By promoting the learning of social and emotional skills, the development of emotional intelligence, and the enjoyment of active learning, protected time for free play and guided play can be used to help children improve their social skills, literacy, and school readiness. Children can then enter school with a stronger foundation for attentional disposition based on the skills and attitudes that are critical for academic success and the long-term enjoyment of learning and love of school.

Media (eg, television, video games, and smartphone and tablet applications) use often encourages passivity and the consumption of others’ creativity rather than active learning and socially interactive play. Most importantly, immersion in electronic media takes away time from real play, either outdoors or indoors. Real learning happens better in person-to-person exchanges rather than machine-to-person interactions. Most parents are eager to do the right thing for their children. However, advertisers and the media can mislead parents about how to best support and encourage their children’s growth and development as well as creativity. Parent surveys have revealed that many parents see media and technology as the best way to help their children learn. 133 However, researchers contradict this. Researchers have compared preschoolers playing with blocks independently with preschoolers watching Baby Einstein tapes and have shown that the children playing with blocks independently developed better language and cognitive skills than their peers watching videos. 34 , 134 Although active engagement with age-appropriate media, especially if supported by cowatching or coplay with peers or parents, may have some benefits, 135 real-time social interactions remain superior to digital media for home learning. 136  

It is important for parents to understand that media use often does not support their goals of encouraging curiosity and learning for their children. 137 , – 141 Despite research that reveals an association between television watching and a sedentary lifestyle and greater risks of obesity, the typical preschooler watches 4.5 hours of television per day, which displaces conversation with parents and the practice of joint attention (focus by the parent and child on a common object) as well as physical activity. For economically challenged families, competing pressures make it harder for parents to find the time to play with children. Encouraging outdoor exercise may be more difficult for such families given unsafe playgrounds. Easy access to electronic media can be difficult for parents to compete with.

In the 2015 symposium, 137 the AAP clarified recommendations acknowledging the ubiquity and transformation of media from primarily television to other modalities, including video chatting. In 2016, the AAP published 2 new policies on digital media affecting young children, school-aged children, and adolescents. These policies included recommendations for parents, pediatricians, and researchers to promote healthy media use. 139 , 140 The AAP has also launched a Family Media Use Plan to help parents and families create healthy guidelines for their children’s media use so as to avoid displacing activities such as active play, and guidelines can also be found on the HealthyChildren.org and Common Sense Media (commonsensemedia.org) Web sites.

There are barriers to encouraging play. Our culture is preoccupied with marketing products to young children. 142 Parents of young children who cannot afford expensive toys may feel left out. 143 Parents who can afford expensive toys and electronic devices may think that allowing their children unfettered access to these objects is healthy and promotes learning. The reality is that children’s creativity and play is enhanced by many inexpensive toys (eg, wooden spoons, blocks, balls, puzzles, crayons, boxes, and simple available household objects) and by parents who engage with their children by reading, watching, playing alongside their children, and talking with and listening to their children. It is parents’ and caregivers’ presence and attention that enrich children, not elaborate electronic gadgets. One-on-one play is a time-tested way of being fully present. Low-income families may have less time to play with their children while working long hours to provide for their families, but a warm caregiver or extended family as well as a dynamic community program can help support parents’ efforts. 144 The importance of playtime with children cannot be overemphasized to parents as well as schools and community organizations. Many children do not have safe places to play. 145 Neighborhood threats, such as violence, guns, drugs, and traffic, pose safety concerns in many neighborhoods, particularly low-income areas. Children in low-income, urban neighborhoods also may have less access to quality public spaces and recreational facilities in their communities. 145 Parents who feel that their neighborhoods are unsafe may also not permit their children to play outdoors or independently.

Public health professionals are increasingly partnering with other sectors, such as parks and recreation, public safety, and community development, to advocate for safe play environments in all communities. This includes efforts to reduce community violence, improve physical neighborhood infrastructure, and support planning and design decisions that foster safe, clean, and accessible public spaces.

Pediatricians can advocate for the importance of all forms of play as well as for the role of play in the development of executive functioning, emotional intelligence, and social skills ( Table 1 ). Pediatricians have a critical role to play in protecting the integrity of childhood by advocating for all children to have the opportunity to express their innate curiosity in the world and their great capacity for imagination. For children with special needs, it is especially important to create safe opportunities for play. A children’s museum may offer special mornings when it is open only to children with special needs. Extra staffing enables these children and their siblings to play in a safe environment because they may not be able to participate during crowded routine hours.

Recommendations From Pediatricians to Parents

Adapted from pathways.org ( https://pathways.org/wp-content/uploads/2019/07/PlayBrochure_English_LEGAL_FOR-PRINT_2022.pdf ).

The AAP recommends that pediatricians:

Encourage parents to observe and respond to the nonverbal behavior of infants during their first few months of life (eg, responding to their children’s emerging social smile) to help them better understand this unique form of communication. For example, encouraging parents to recognize their children’s emerging social smile and to respond with a smile of their own is a form of play that also teaches the infants a critical social–emotional skill: “You can get my attention and a smile from me anytime you want just by smiling yourself.” By encouraging parents to observe the behavior of their children, pediatricians create opportunities to engage parents in discussions that are nonjudgmental and free from criticism (because they are grounded in the parents’ own observations and interpretations of how to promote early learning);

Advocate for the protection of children’s unstructured playtime because of its numerous benefits, including the development of foundational motor skills that may have lifelong benefits for the prevention of obesity, hypertension, and type 2 diabetes;

Advocate with preschool educators to do the following: focus on playful rather than didactic learning by letting children take the lead and follow their own curiosity; put a premium on building social–emotional and executive functioning skills throughout the school year; and protect time for recess and physical activity;

Emphasize the importance of playful learning in preschool curricula for fostering stronger caregiver–infant relationships and promoting executive functioning skills. Communicating this message to policy makers, legislators, and educational administrators as well as the broader public is equally important; and

Just as pediatricians support Reach Out and Read, encourage playful learning for parents and infants by writing a “prescription for play” at every well-child visit in the first 2 years of life.

A recent randomized controlled trial of the Video Interaction Project (an enhancement of Reach Out and Read) has demonstrated that the promotion of reading and play during pediatric visits leads to enhancements in social–emotional development. 112 In today’s world, many parents do not appreciate the importance of free play or guided play with their children and have come to think of worksheets and other highly structured activities as play. 146 Although many parents feel that they do not have time to play with their children, pediatricians can help parents understand that playful learning moments are everywhere, and even daily chores alongside parents can be turned into playful opportunities, especially if the children are actively interacting with parents and imitating chores. Young children typically seek more attention from parents. 46 Active play stimulates children’s curiosity and helps them develop the physical and social skills needed for school and later life. 32  

Cultural shifts, including less parent engagement because of parents working full-time, fewer safe places to play, and more digital distractions, have limited the opportunities for children to play. These factors may negatively affect school readiness, children’s healthy adjustment, and the development of important executive functioning skills;

Play is intrinsically motivated and leads to active engagement and joyful discovery. Although free play and recess need to remain integral aspects of a child’s day, the essential components of play can also be learned and adopted by parents, teachers, and other caregivers to promote healthy child development and enhance learning;

The optimal educational model for learning is for the teacher to engage the student in activities that promote skills within that child’s zone of proximal development, which is best accomplished through dialogue and guidance, not via drills and passive rote learning. There is a current debate, particularly about preschool curricula, between an emphasis on content and attempts to build skills by introducing seat work earlier versus seeking to encourage active engagement in learning through play. With our understanding of early brain development, we suggest that learning is better fueled by facilitating the child’s intrinsic motivation through play rather than extrinsic motivations, such as test scores;

An alternative model for learning is for teachers to develop a safe, stable, and nurturing relationship with the child to decrease stress, increase motivation, and ensure receptivity to activities that promote skills within each child’s zone of proximal development. The emphasis in this preventive and developmental model is to promote resilience in the presence of adversity by enhancing executive functioning skills with free play and guided play;

Play provides ample opportunities for adults to scaffold the foundational motor, social–emotional, language, executive functioning, math, and self-regulation skills needed to be successful in an increasingly complex and collaborative world. Play helps to build the skills required for our changing world; and

Play provides a singular opportunity to build the executive functioning that underlies adaptive behaviors at home; improve language and math skills in school; build the safe, stable, and nurturing relationships that buffer against toxic stress; and build social–emotional resilience.

For more information, see Kearney et al’s Using Joyful Activity To Build Resiliency in Children in Response to Toxic Stress . 147  

American Academy of Pediatrics

brain-derived neurotrophic factor

prefrontal cortex

Dr Yogman prepared the first draft of this report and took the lead in reconciling the numerous edits, contributions, and suggestions from the other authors; Drs Garner, Hutchinson, Hirsh-Pasek, and Golinkoff made significant contributions to the manuscript by revising multiple drafts and responding to all reviewer concerns; and all authors approved the final manuscript as submitted.

The opinions and assertions expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Uniformed Services University or the Department of Defense.

FUNDING: No external funding.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

Michael Yogman, MD, FAAP

Andrew Garner, MD, PhD, FAAP

Jeffrey Hutchinson, MD, FAAP

Kathy Hirsh-Pasek, PhD

Roberta Golinkoff, PhD

Virginia Keane, MD, FAAP

Michael Yogman, MD, FAAP, Chairperson

Rebecca Baum, MD, FAAP

Thresia Gambon, MD, FAAP

Arthur Lavin, MD, FAAP

Gerri Mattson, MD, FAAP

Lawrence Wissow, MD, MPH, FAAP

Sharon Berry, PhD, LP – Society of Pediatric Psychology

Amy Starin, PhD, LCSW – National Association of Social Workers

Edward Christophersen, PhD, FAAP – Society of Pediatric Psychology

Norah Johnson, PhD, RN, CPNP-BC – National Association of Pediatric Nurse Practitioners

Abigail Schlesinger, MD – American Academy of Child and Adolescent Psychiatry

Karen S. Smith

David L Hill, MD, FAAP, Chairperson

Nusheen Ameenuddin, MD, MPH, FAAP

Yolanda (Linda) Reid Chassiakos, MD, FAAP

Corinn Cross, MD, FAAP

Rhea Boyd, MD, FAAP

Robert Mendelson, MD, FAAP

Megan A Moreno, MD, MSEd, MPH, FAAP

Jenny Radesky, MD, FAAP

Wendy Sue Swanson, MD, MBE, FAAP

Justin Smith, MD, FAAP

Kristopher Kaliebe, MD – American Academy of Child and Adolescent Psychiatry

Jennifer Pomeranz, JD, MPH – American Public Health Association Health Law Special Interest Group

Brian Wilcox, PhD – American Psychological Association

Thomas McPheron

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• Published: 22 May 2021

Fostering socio-emotional learning through early childhood intervention

• Christina F. Mondi   ORCID: orcid.org/0000-0003-1619-6389 1 ,
• Alison Giovanelli 2 &
• Arthur J. Reynolds 3  

International Journal of Child Care and Education Policy volume  15 , Article number:  6 ( 2021 ) Cite this article

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Educators and researchers are increasingly interested in evaluating and promoting socio-emotional learning (SEL) beginning in early childhood (Newman & Dusunbury in 2015; Zigler & Trickett in American Psychologist 33(9):789–798 https://doi.org/10.1037/0003-066X.33.9.789 , 1978). Decades of research have linked participation in high-quality early childhood education (ECE) programs (e.g., public prekindergarten, Head Start) to multidimensional wellbeing. ECE programs also have demonstrated potential to be implemented at large scales with strong financial returns on investment. However, relatively few studies have investigated the effects of ECE programs on SEL, particularly compared to smaller-scale, skills-based SEL interventions. Furthermore, among studies that have examined SEL, there is a general lack of consensus about how to define and measure SEL in applied settings. The present paper begins to address these gaps in several ways. First, it discusses conceptual and methodological issues related to developmentally and culturally sensitive assessment of young children’s socio-emotional functioning. Second, it reviews the empirical research literature on the impacts of three types of early childhood programs (general prekindergarten programs; multi-component prekindergarten programs; and universal skills-based interventions) on SEL. Finally, it highlights future directions for research and practice.

Fostering socio-emotional learning through early childhood programming

What are the best ways to assess the effectiveness of early childhood intervention programs? This question has been debated for decades, and the answer has tremendous implications for public policy. During the mid-twentieth century, many research studies primarily examined whether intervention participation led to improvements in children’s IQ scores. Some researchers, however, argued for a more multidimensional approach to assessing intervention outcomes. Edward Zigler, one of the architects of Head Start, notably proposed that the primary outcome of interest in early childhood interventions should be children’s “social competence” (Raver & Zigler, 1997 ; Zigler & Trickett, 1978 ). Interest in social competence grew in the second half of the twentieth century, with numerous studies indicating that socio-emotional and motivational variables exert significant impacts on wellbeing in childhood and beyond (Greenberg et al., 2003 ; Jones et al., 2015 ). By the turn of the twenty-first century, a national sample of teachers reported that they believed that the ability to regulate emotions and behaviors is the most important component of school readiness (Rimm-Kaufman et al., 2000 ).

Today, educators and researchers continue to be interested in evaluating and promoting socio-emotional learning (SEL) starting in early childhood. Early childhood SEL skills develop rapidly, are uniquely malleable, and are strongly associated with later social, academic, cognitive, and health outcomes (Zins et al., 2007 ). Skills-based interventions that specifically target children’s SEL have been a major area of investigation (McClelland et al., 2017 ). However, relatively less is known about the impacts of large-scale early childhood education (ECE) programs on SEL, despite the potential of such programs to effect broad impacts. Furthermore, despite the growing enthusiasm surrounding the concept of SEL, many of the same methodological issues that Zigler and colleagues described in the 1970s still persist. Review of the literature reveals a lack of consensus among researchers and practitioners regarding how to define, evaluate, and promote SEL.

McCabe and Altamura ( 2011 ) previously reviewed the impact of a variety of preschool interventions on SEL, including both skills-based interventions and comprehensive classroom- and home-based programs. The authors reported that many programs were associated with short-term SEL benefits, but that there was a need for additional longitudinal research in this area. Notably, the authors did not explicate their review methodology or inclusion criteria, making it difficult to ascertain the representativeness and comprehensiveness of their findings. This limitation, combined with the publication of a number of studies since 2011, signal the need for an updated review of different intervention strategies for preschool-aged children.

The present paper reviews the most methodologically rigorous research that is available on the relationship between preschool intervention and SEL. We begin by discussing what the construct of SEL is (and is not)—a topic that that has been the subject of some debate and confusion in the literature. Having outlined a conceptual and methodological framework for SEL, we will then describe specific study aims and methods.

Socio-emotional competencies in early childhood

During the early 1990s, the Collaborative for Academic, Social, and Emotional Learning (CASEL) attempted to organize decades of empirical research on socio-emotional development into a socio-emotional learning (SEL) framework (Newman & Dusunbury, 2015 ). Since then, the CASEL framework has been widely used by researchers, practitioners, and policymakers alike, informing the development of federal and state state legislation and learning standards.

According to CASEL researchers, SEL is the process of learning to “integrate thinking, feeling, and behaving to achieve important life tasks” (Zins et al., 2007 , p. 194). SEL encompasses children’s emerging abilities to “form close and secure…relationships; experience, regulate, and express emotions in socially and culturally appropriate ways; and explore the environment and learn—all in the context of family, community, and culture” (Yates et al., 2008 , p. 2). CASEL’s SEL framework is grounded in research on typical and atypical socio-emotional development and highlights five core competency areas: (a) self-awareness; (b) self-management; (c) social awareness; (d) relationship skills; and (e) responsible decision-making (Collaborative for Social & Emotional Learning [CASEL], 2012 ; “Core SEL Competencies”, 2019 ; Weissberg et al., 2016 ). These competences are outlined in Table 1 .

Importantly, while CASEL’s five core competency areas are common across most cultures, specific aspects of adaptive SEL functioning may vary based on race/ethnicity, language, socioeconomic status, and other cultural factors. Cognitive, linguistic, and behavioral traits that are considered to be adaptive and desirable in non-majority culture communities may be perceived as problematic or even pathological by majority culture educators (Phillips, 1993 ; West-Olatunji et al., 2008 ). These perceptions may be partially attributed to educators’ own biases, and to disparities between the culture and structure of children’s home and school environments (Boykin, 1983 ; Han & Thomas, 2010 ; Ladson-Billings, 1995 ; McCarthy et al., 2006 ; Webb-Johnson, 2002 ). Thus, when assessing children’s SEL, researchers and educators should carefully consider the role that culture plays in shaping children’s behavior, and avoid conflating cultural behavioral differences with disorder.

Conceptual and measurement issues

Distinguishing sel from executive function.

SEL skills have often been referred to as “non-cognitive” skills in research and practice. Yet many researchers have argued that this designation is a misnomer, given that SEL skills are often grounded in skills related to cognition, learning, and memory. Among the most significant contributors to SEL are executive functioning (EF) skills, which include the cognitive processes necessary for planning, organizing, and problem-solving. Several studies have linked EF deficits to concurrent SEL deficits, and longitudinal work has indicated that EF skills in early childhood predict SEL competence later in life (e.g., Riggs et al., 2006 ). Thus, EF and SEL competencies, (including self-management, as identified by CASEL’s framework) can be conceptualized as distinct but related, and at times overlapping, constructs.

Distinguishing SEL from psychopathology

Psychologists increasingly agree that mental health is most accurately conceptualized on a continuum, ranging from clinically significant psychopathology to psychological wellbeing or flourishing (Keyes, 2002 ). Within this model, mental health or wellbeing is conceptualized not only as the absence of psychopathology symptoms, but as the presence of competencies that enable individuals to withstand adversity and to work towards positive outcomes. As Darling-Churchill and Lippman ( 2016 , p. 3) stated: “Problems and strengths do not fall neatly on a single continuum, and the absence of problems does not guarantee the presence of competencies; thus, it is important to measure both.” From this perspective, it is imperative that researchers and practitioners avoid conflating emergent SEL deficits with psychopathology (Halle & Darling-Churchill, 2016 ).

Children exhibiting emergent SEL deficits may or may not have comorbid psychiatric disorders. Children with diagnosable psychopathology must exhibit symptoms that coalesce into specific patterns and that are associated with significant functional impairment. The latter group would likely benefit from clinical treatment. Meanwhile, many children do not currently meet diagnostic criteria for a disorder, but exhibit emergent deficits in SEL skills relative to same-age peers (Jones et al., 2002 ; Wille et al., 2008 ). A multitude of factors may contribute to lagged SEL, including early deprivation or trauma, inconsistent caregiving, and cultural differences in socio-emotional expression. Children with emergent SEL deficits would likely benefit from broader-based interventions that provide opportunities for them to interact with high-quality caregivers, establish peer relationships, and practice SEL skills in the environments that they are already in (e.g., early care and education settings).

Emergent SEL deficits are distinct from clinical disorder; however, it is important to acknowledge the demonstrated link between early SEL deficits and long-term risk for the development of psychopathology. This link reflects the phenomenon of heterotypic continuity , in which an early behavior predicts the subsequent emergence of a different behavior in the same individual (Rutter et al., 2006 ). The concept of developmental cascades has been invoked as a potential mechanism for heterotypic continuity; in this case, an individual’s early SEL competencies interact with other individual and environmental factors (e.g., genetic, family, school) over time, influencing his or her risk of developing psychopathology (Burke et al., 2005 ). For example, a child who is lagging in SEL may have negative interactions with caregivers and peers and fall behind academically. These experiences may, in turn, increase the child’s probability of academic, psychological, and other difficulties over time. Conversely, a child who exhibits developmentally appropriate SEL will likely experience more social and academic success, which can lay foundations for lifelong wellbeing.

Other measurement issues

As noted above, it is critical that researchers utilize measures that assess children’s SEL skills (as distinguished from EF skills or psychopathology symptoms).

Several additional issues merit consideration when assessing SEL in early childhood (Committee on Developmental Outcomes, 2008 ; Darling-Churchill & Lippman, 2016 ; Halle & Darling-Churchill, 2016 ). Measurement should ideally occur across multiple time-points, as longitudinal assessment allows for stronger inference of causal relationships. Collecting repeated measurements over time will also allow researchers to observe trajectories of socio-emotional development over time. Finally, collecting data from multiple informants is considered ideal in order to gain more comprehensive, reliable pictures of children’s functioning. Integrating reports from different informants, who may perceive children’s behaviors differently or observe different behaviors in different settings (e.g., home versus school), can be challenging; however, several methodological solutions to this problem have been proposed (e.g., Offord et al., 1996 ).

Present review

The present paper reviews the current state of the literature on SEL interventions for preschool-aged children. This review makes several unique contributions. First, whereas previous reviews have primarily focused on skills-based SEL interventions, this review compares and contrasts the effects of three types of early childhood interventions on SEL: (a) general prekindergarten programs; (b) multi-component prekindergarten programs; and (c) skills-based interventions. This review specifically focuses on universal programs in each of the three categories (e.g., programs that are not specifically targeted to children with emergent SEL deficits or psychopathology). Second, whereas several previous reviews have examined the effects of early intervention on child psychopathology (e.g., internalizing, externalizing symptoms), the current review examines SEL outcomes, defined as children’s acquisition of developmentally appropriate social and emotional skills. Finally, rather than reviewing the entire literature, this review focuses on the most methodologically rigorous (e.g., peer-reviewed, longitudinal) extant research. Given these combined foci, the present review offers a thorough, up-to-date overview of the effects of different types of early childhood interventions on young children’s SEL.

Notably, while we believe that it is imperative to evaluate the strength of programs’ evidence bases using specific uniform criteria, our review reveals variable methodology and construct validity across individual studies, making it challenging to assess program efficacy in a reliable or systematic way. As such, we emphasize that the purpose of this review is not to make statements about the efficacy of individual programs, but rather to describe programs that are most promising and to identify knowledge gaps for future research to investigate.

Having reviewed key conceptual and methodological issues, we will now describe our review of universal interventions for preschool-aged children. We conducted searches in Web of Science, PsycInfo, Google Scholar, and PubMed. Numerous search terms were employed, including ones referencing socio-emotional skills (e.g., “socio-emotional”, “emotion regulation”, “non-cognitive”, “prosocial”), early childhood and ECE programming (e.g., “preschool,” “Head Start”), and commonly used SEL measures (e.g., “ Behavior Assessment System ”, “Conners”). Backwards and forward searches were conducted on landmark and highly cited articles.

Studies had to meet six inclusion criteria to be included in the present review. The purpose of these criteria was to identify the most methodologically rigorous studies on modern universal interventions and SEL. (1) studies had to be published in English in peer-reviewed journals by December 31, 2020. (2) Only studies that investigated prekindergarten interventions implemented in 1990 or later were included. (3) Interventions had to be universal (e.g., not specifically targeted to children with baseline SEL deficits or psychopathology) and delivered by laypeople (e.g., not researchers). (4) Critically, given that the focus of the present paper is the relations between intervention and SEL included, studies had to measure one or more SEL skills as previously defined. Studies were not included if they solely measured psychopathology outcomes (e.g., externalizing or internalizing symptoms, problem behaviors) or EF outcomes. (5) Studies had to assess children’s SEL skills at a minimum of two time-points, as skill development over the course of intervention can only be examined within longitudinal research designs. (6) Studies had to include a comparison or control group.

The first and second authors independently reviewed the titles and abstracts of identified studies to determine whether they met inclusion criteria. During this review process, both authors also determined which intervention category applied to each study. General public prekindergarten programs were defined as publicly funded programs administered by state and local agencies. Multi-component ECE programs were defined as programs which provide multiple academic, family and social support services (e.g., Head Start, the Child–Parent Center (CPC) Program, The High/Scope Perry Preschool Project), typically in center-based settings. Skills-based SEL interventions were defined as discrete interventions aimed at enhancing children’s SEL via direct skills instruction for children and/or their ECE caregivers (e.g., Al’s Pals, The Incredible Years). In cases of disagreement, both authors reviewed and discussed until consensus was reached. Overall, based on these criteria, the following studies are included in the present review: (a) one empirical study of a general public prekindergarten program; (b) three empirical studies of multi-component ECE interventions; (c) 23 empirical studies of skills-based SEL interventions; (d) three systematic reviews or meta-analyses of multi-component ECE interventions; and (e) five systematic reviews or meta-analyses of SEL skills-based interventions. See Tables 2 , 3 , 4 , 5 and 6 for details on these studies, including sample characteristics.

General public prekindergarten and multi-component ECE programs (Tables 2 , 3 , 4 )

General public prekindergarten and multi-component ECE programs (e.g., Head Start, the CPC program) are comprehensive ECE interventions, and stand in contrast to skills-based interventions which primarily target SEL. Nonetheless, there are several important distinctions between general public prekindergarten programs and multi-component ECE programs (e.g., Head Start, the CPC Program). There is often significant variability in general prekindergarten models and populations served, both across and within public school districts in the United States (Phillips et al., 2017 ). Meanwhile, multi-component ECE programs typically incorporate similar program elements and serve comparable populations across sites. Multi-component programs often operate in center-based settings, and typically provide a wider range of support services for children and families than general public prekindergarten programs.

Despite the differences between general public prekindergarten and multi-component ECE programs, we present our findings for both program types simultaneously below. This is because, based on our review and to our knowledge, only one peer-reviewed study (Weiland & Yoshikawa, 2013 ) has examined the effects of general public prekindergarten participation on SEL. A small number of studies have examined the relations between public prekindergarten participation and emotional and behavioral problems in childhood (e.g., internalizing and externalizing symptoms) (e.g., Gormley et al., 2011 ; Magnuson et al., 2007 ); however, as previously discussed, the focus of this review is on the relationship between intervention and SEL, not psychopathology symptoms. The lack of research on SEL in the context of public prekindergarten is a major gap that we will discuss in more depth later in this paper. In the interim, we present our findings on both types of non-SEL-skills-based interventions (general public prekindergarten and multi-component ECE programs).

Meta-analyses and reviews (Table 3 )

Our review did not uncover any peer-reviewed meta-analyses or systematic reviews of the relations between public prekindergarten programming and SEL. On the contrary, several peer-reviewed meta-analyses and systematic reviews have investigated the effects of multi-component ECE programs on SEL. The authors of these publications have typically constructed outcome variables using a combination of measures assessing SEL skills, mental health symptoms, and outcomes from other domains that are related to socio-emotional functioning (e.g., special education placement, criminal justice system involvement). These publications will be briefly reviewed herein.

Nelson et. al. ( 2003 ) published one of the first meta-analyses examining preschool prevention programs for low-income children and families. Inclusion criteria included (1) presence of a prospective research design, (2) control or comparison group, and (3) at least one follow-up assessment in elementary school or beyond. In all, 34 qualifying interventions were identified. The authors reported that preschool programs exerted small to moderate effects on socio-emotional functioning in both the short-term (Kindergarten through eighth grade; d  = 0.27) and long-term (high school and beyond; d  = 0.33). Age at program entry was not related to program impacts; however, higher program dosage was linked to stronger effects on socio-emotional functioning. Results also indicated that African American children were more likely to participate in the most intensive interventions, and that programs that predominately served the latter group were associated with the greatest socio-emotional benefits.

Several years later, Camilli et. al. ( 2010 ) conducted another meta-analysis examining the effects of ECE participation on child outcomes. To be included in the meta-analysis, interventions had to: (1) be center-based, (2) provide direct educational services to children, with a strong focus on cognitive and/or language development; (3) take place for at least 10 h per week for two months, and (4) serve the general population. Studies also had to have a comparison group. The authors identified 123 studies spanning five decades that met inclusion criteria; however, only 43 of these examined socio-emotional outcomes. The authors combined “social/emotional and anti-social outcome[s]” for analysis, including children’s self-esteem, school adjustment, educational goals, aggression, and antisocial behaviors (p. 592). Results indicated that participation in ECE programs was associated with modest positive effects on children’s social skills and school progress (unweighted mean ES = 0.16 for treatment versus control group analyses). These treatment effects were maintained over the course of longitudinal follow-up. Two instructional practices were positively correlated with socio-emotional gains among treatment group members: teacher-directed instruction and small-group learning.

D’Onise et. al. ( 2014 ) conducted a systematic literature review examining the effects of center-based preschool programs on health outcomes. They identified 13 studies that examined the effects of program participation on “social competence” between grades one and 11. Several of these studies utilized measures that assessed both positive social behaviors (e.g., cooperation, self-control) and problem behaviors (e.g., externalizing and internalizing problems, hyperactivity). D’Onise and colleagues reported that eight of the 13 studies identified beneficial effects of preschool participation on social competence, broadly construed, whereas six found no significant effects. Program duration and quality were not significantly associated with impacts on socio-emotional functioning.

Studies not included in meta-analyses and reviews (Tables 2 and 4 )

Several additional studies have been published since the aforementioned meta-analyses and reviews on the relationship between early intervention and SEL. This notably includes the only peer-reviewed study on the relations between public prekindergarten participation and SEL that our review uncovered: Weiland and Yoshikawa’s ( 2013 ) investigation of the Boston Public Schools prekindergarten program (Table 1 ). Boston Public School preschoolers were compared to control group members who had a variety of experiences during the prekindergarten year, ranging from familial care to center-based preschool programming. All participants completed performance-based and observational assessments of SEL across the preschool year. Results indicated that public prekindergarten participants exhibited significantly greater growth in emotion regulation and inhibitory control over time than the control group.

Several recent studies have also investigated the relations between multi-component ECE program participation and SEL. For example, Brown and Sax ( 2013 ) reported on the SEL of preschoolers attending an arts-integrated Head Start site, the Settlement Music School’s Kaleidoscope Preschool Arts Enrichment program (“Kaleidoscope”). The Kaleidoscope site combined traditional early learning strategies with comprehensive arts programming (e.g., visual art classes, dance and creative movement, music). This programming drew from varied cultural traditions, and was designed to support children’s creativity and emotional expression. Results indicated that Kaleidoscope participants exhibited significantly greater growth in both positive and negative emotion regulation over the course of the school year, compared to children attending a traditional Head Start site. These results underscore the potential value of multi-component programming (including arts enrichment) in promoting young children’s SEL.

Several years later, Reynolds et. al. ( 2016 ) published an evaluation study examining the effects of the Child–Parent Center (CPC) program on SEL. The CPC program provides comprehensive, center-based educational and family support services to low-income children between Preschool and third grade. Reynolds and colleagues’ study utilized a quasi-experimental, matched-group cohort design which included 1724 children who attended CPC preschool, and a comparison group of 906 children who attended alternative prekindergarten programming. Teachers rated children’s SEL across the preschool year using the observation-based Teaching Strategies Gold Assessment System (TSGOLD). Overall, teachers rated CPC participants as having significantly higher overall SEL (including self-regulation, sustaining positive relationships, and participating constructively in group situations) at the end of preschool than comparison group members (standardized mean difference = 0.44). These results should be interpreted in the context of the non-randomized design and reliance on teacher ratings; however, they suggest that participation in public school-based ECE programs may enhance the SEL of low-income children.

Richardson et. al. ( 2017 ) also examined SEL in the context of the CPC program. Their study’s intervention group included 1289 low-income children who attended CPC preschool in Chicago. The comparison group included 591 children who attended public preschool programs at matched school sites. Teachers rated children’s SEL skills at three time-points throughout the preschool year using TSGOLD. Results indicated that teachers rated CPC participants as having significantly higher SEL school readiness than control group members. Positive impacts were detected for children who attended both the full- and half-day CPC programs, and for children from free-lunch eligible and Spanish-speaking families.

Skills-based SEL interventions

Discrete skills-based interventions to augment SEL are appealing in that they can be delivered by a teacher in the school setting, and generally require a finite investment of time, training, and resources. These types of interventions often target student competencies through a combination of indirect methods such as teacher skills augmented through professional development and strategies to alter classroom quality or parent training, and direct methods like didactic teaching and practice of socio-emotional and self-regulation skills.

It should be noted that many programs that may come to mind when discussing interventions focusing on social skills within preschool programs use measures of psychopathology outcomes (e.g., emotional or behavioral disorders; symptoms of Attention-Deficit/Hyperactivity Disorder or clinically significant conduct problems) as proxies for “socio-emotional competencies” and as such, were not included in this review for reasons of construct validity discussed above. Several studies were also excluded from the present review due to lacking a control group, having a cross-sectional design, or taking place before 1990. Few studies collected long-term follow-up data, and therefore in many cases sustained effects of skills-based interventions are unknown. Every effort was made to review a representative body of evidence for the programs described below; however, for several programs, we were only able to identify one empirical study that met our inclusion criteria.

Reviews of skills-based SEL interventions (Table 5 )

While there have been several reviews of programs designed to reduce challenging and increasing prosocial behaviors, only two comprehensive, peer-reviewed systematic reviews focused on skills-based SEL programs for young children had been published by our cutoff (Barton et al., 2014 ; Joseph & Strain, 2003 ). The scope of these reviews is somewhat broader than that of the present paper, as both included studies of interventions across the elementary years in addition to those targeting preschoolers, as well as interventions that focused primary on parents and parenting practices. However, both reviews did evaluate the evidence base for many programs relevant to the current review—namely, universal SEL skills-based programs designed to be implemented by teachers in preschool settings.

Both Joseph and Strain ( 2003 ; Fig. 1 ) and Barton et. al. ( 2014 ; Fig. 2 ) have published reviews of socio-emotional curricula. In both reviews, studies had to meet the following criteria: (a) intervention targeted socio-emotional and behavioral competencies, (b) intervention targeted children from birth to age five, (c) intervention had a published manual, and (d) findings were published in a peer-reviewed journal article. Figures 1 and 2 summarize the number of studies that the authors identified, and the criteria that they used to judge program efficacy and implementation success. In both studies, programs were rated as having high, medium, or low levels of empirical evidence.

Summary of Joseph and Strain’s ( 2003 ) review of skills-based SEL interventions

Summary of Barton et. al.’s ( 2014 ) review of skills-based SEL interventions

The aforementioned reviews have served as a valuable and informative starting point for the present study’s investigation of the current state of the research on skills-based SEL programs; however, the criteria for choosing studies in the present paper differed considerably. Specifically, several of the interventions evaluated in Joseph and Strain’s ( 2003 ) and Barton et. al. ( 2014 ) reviews were last evaluated prior to 1990; were primarily focused on mental health, psychopathology, or antisocial behavior as opposed to socio-emotional functioning; or were evaluated in kindergartners or older elementary school aged children. Overall, most studies did not evaluate SEL using independent observers or multiple raters, and long-term follow-up was rare.

Meanwhile, two recently published meta-analyses investigated the effects of skills-based SEL interventions on young children’s SEL (Luo et al., 2020 ; Murano et al., 2020 ). Luo et. al. ( 2020 ) meta-analysis investigated the impacts of classroom-wide social-emotional interventions (e.g., universal, skills-based interventions) on preschoolers’ social, emotional, and behavioral functioning. They identified 30 studies which reported sufficient data to calculate effect sizes, and which examined intervention effects on social competence. Meta-analytic results indicated that classroom-wide interventions had moderate positive effects on social competence ( g  = 0.42, z  = 5.77, p  < 0.001, k  = 34), though there was significant heterogeneity in effect sizes across studies. Follow-up analyses indicated that interventions that incorporated family-focused programming had greater impacts on social competence than those that did not include family members. Meanwhile, in meta-analysis of 12 studies that examined emotional competence, Luo and colleagues reported that classroom-wide interventions had moderate positive effects on emotional competence ( g  = 0.33, z  = 2.85, p  = 0.004, k  = 14). Interestingly, univariate moderator analyses did not identify linkages between most intervention variables (including dosage) and children’s SEL outcomes.

In another recent meta-analysis, Murano et. al. ( 2020 ) examined the effects of both universal and targeted skills-based SEL interventions on preschoolers’ SEL skills and problem behaviors. They identified 48 empirical studies which met their inclusion criteria, and reported that both universal and targeted interventions had moderate effects on children’s social and emotional skills ( g  = 0.34 and g  = 0.44, respectively). Similar to the findings reported by Luo et. al. ( 2020 ), Murano and colleagues indicated that there was significant heterogeneity in effect sizes across studies, and that 83% of this heterogeneity was attributable to the specific intervention implemented. They also reported that interventions that included family members had stronger impacts on children’s SEL than those that did not include family members—also in keeping with Luo and colleagues’ results.

Taken together, Luo et. al. ( 2020 ) and Murano et. al. ( 2020 ) meta-analyses support the effectiveness of skills-based SEL interventions in promoting young children’s SEL. Their results indicate that both universal and targeted interventions can be beneficial, and that interventions that operate at multiple social-ecological levels tend to be most effective. Building on these findings, we will now summarize the empirical evidence bases for several SEL skills-based interventions in depth. Our intention is to describe several high-quality interventions, as a way of highlighting exemplary research as well as conceptual and methodological issues for future researchers to address.

Child and teacher-focused skills-based interventions

This group of interventions provides a teacher-training component combined with a child curriculum consisting of discrete, manualized lessons on SEL topics. These curricula often take the form of teaching didactic SEL skills instruction to children, typically in group-based settings in the context of Head Start and other publicly funded preschool programs. Due to space constraints, three exemplar programs will be discussed in detail below. Table 6 describes additional skills-based interventions meeting our criteria.

One child and teacher-focused skills-based intervention is the Promoting Alternative Thinking Strategies (PATHS) curriculum (Domitrovich et al., 2004 ). PATHS is one of the most extensively evaluated SEL programs for young children (Arda & Ocak, 2012 ; Domitrovich et al., 2007 ; Hamre et al., 2012 ; Hughes & Cline, 2015 ; Stefan & Miclea, 2012 ). The developers describe PATHS as based on the Affective–Behavioral–Cognitive–Dynamic (ABCD) model of development (Greenberg & Kusche, 1993 ), which “suggests that emotional development is an important precursor to other cognitive and language skills and that the successful development of emotion knowledge and regulation is foundational to the development of the broad spectrum of social competencies described previously as central to school success (Hamre et al., 2012 , p. 811).” Although implementation appears to vary slightly by site and evaluation team, the curriculum generally consists of several dozen lessons, delivered once per week by Head Start preschool teachers during “circle time,” and focuses on emotion knowledge, regulation, prosocial skills, and problem-solving. The intervention also often includes extension activities that were intended to generalize the weekly lessons and to foster an environment that would encourage children’s use of socio-emotional skills. Teachers are generally provided with support, ranging from access to a website with examples of teachers implementing PATHS to ongoing site visits and consultation from designated PATHS coordinators. Implementation fidelity has also been monitored in a variety of ways, including via the site visits or through submission and coding of videos. Studies utilized a range of tools for assessing outcomes, including direct assessment, observation, and parent and teacher reports of emotion knowledge, prosocial and problem behavior, and attentional skills. Evaluators generally reported medium effect sizes, ranging from 0.20 to 0.50, across socio-emotional and behavioral domains. However, as in many of the studies included here, parents and teachers in all of the evaluations were not blind to the intervention condition, which could have biased ratings.

Stefan and Miclea ( 2012 ) evaluated the implementation of a program that they called “Fast Track,” in which PATHS was the SEL intervention, in a preschool population in Romania. In addition to teacher training, they utilized a parent component, which was delivered via group and individual training sessions, and focused on positive discipline strategies and increasing parents’ knowledge of how to support their child’s social and emotional development. The authors found medium to large intervention effects for all outcomes. Children in medium and high-risk subgroups appeared to benefit more from the intervention even when controlling for baseline differences on tasks. This study is distinguished by the fact that the authors conducted follow-up assessments three months after the post-intervention data was collected, and found that intervention effects were maintained for both social and emotional competencies. However, there was no direct observation of child classroom behaviors, and as teacher, parent, and child components were delivered concurrently, mechanisms of effects are unknown.

Head Start REDI

Another Head Start-based program, Head Start Research-based, Developmentally Informed (REDI), which uses PATHs to target socio-emotional skills in the context of a broader program intended to enhance both social competence and literacy in preschoolers, has been the subject of several studies with long-term follow-up (Bierman et al., 2014 ; Bierman, Domitrovich, et al., 2008 ; Bierman, Nix, et al., 2008 ; Nix et al., 2016 ). Initial investigations of the REDI program on preschoolers found small to medium effect sizes for social competence and executive functioning outcomes (Bierman, Domitrovich, et al., 2008 ; Bierman, Nix, et al., 2008 ). Results of a 1-year follow-up on children in Head Start REDI as preschoolers compared to those who had attended “usual practice” Head Start indicated sustained direct effects for social problem-solving ( d  = 0.40) and parent and teacher-rated aggressive behaviors ( d  = − 0.20 and d  = − 0.25, respectively) for kindergarten children who were in REDI as preschoolers, with effect sizes at the 1-year follow-up equal to or larger than those at the end of the intervention year. Teacher-rated social competence was also significantly higher for intervention students ( d  = 0.26), but only for those in kindergarten at schools where overall student achievement was low (Bierman et al., 2014 ). Several years later, Bierman et. al. ( 2017 ) combined the samples of the two previous randomized trials to investigate the sustained effects of REDI, three years post-intervention. Intervention group participants received either the REDI Classroom Program (REDI-C), or both REDI-C and the REDI-Parent home visiting program (REDI-P). Comparison group members attended standard Head Start programming. Results indicated that REDI-C graduates exhibited significantly higher classroom participation ( d  =  ~ 0.25), social competence ( d  =  ~ 0.25), and student–teacher relationships ( d  =  ~ 0.4) in second grade relative to the comparison group. Children who had received both REDI-C and REDI-P exhibited higher perceived social competence ( d  =  ~ 0.75) compared to children who had only received REDI-C.

Taken together, these studies provide strong evidence that the PATHS curriculum, when implemented with fidelity, can effectively increase the SEL competencies of preschoolers both within the context of the literacy-promoting REDI intervention and when used independently.

Kindness Curriculum

The Kindness Curriculum, a mindfulness-based intervention designed to increase empathy, prosocial behavior, and self-regulation in preschoolers, has been evaluated in two empirical studies meeting our criteria (Flook et al., 2015 ; Poehlmann-Tynan et al., 2016 ). In both evaluations, the 10-h training was delivered to preschoolers over the course of 12 weeks via stories, music, and movement. The program emphasizes kindness, emotion regulation, and attentional capacity. Flook et. al. ( 2015 ), in the initial study, found via teacher ratings and direct assessment that the intervention group showed greater improvements across domains of social competence ( d  = 0.26–0.29) compared to the control group, in addition to significant effects for cognitive flexibility ( d  = 0.43) and delay of gratification ( d  = 0.23–0.37). Children who were initially lower in social competence and executive functioning skills evinced larger gains in social competence.

Poehlmann-Tynan et. al. ( 2016 ) also found promising effects when investigating this curriculum in economically disadvantaged preschoolers and assessed prosocial behavior (e.g., empathy and compassion), self-regulation, and executive functioning via direct assessment and observation. They found that the children in the KC intervention group increased their capacity for self-regulation and attention (partial η 2  = 0.26–0.33) relative to the control group; however, unlike Flook, they found no changes in observer-rated or directly assessed prosocial behaviors. The positive effects, however, persisted at a 3-month follow-up assessment. It is important to note that the curricula were delivered by “experienced mindfulness instructors.” The evidence base for effectiveness and scalability of the KC intervention in a preschool setting would be strengthened by an investigation of the program delivered by classroom teachers.

Skills-based interventions incorporating parent involvement

This group of interventions supplements skills-based interventions for children and/or teachers with parent involvement initiatives. Due to space constraints, three exemplar programs will be discussed in detail below. Table 6 describes additional skills-based interventions.

The RECAP intervention

Han et. al. ( 2005 ) have published the only study to date evaluating the Reaching Educators, Children, and Parents (RECAP) program in preschoolers. The study aimed to enhance preschoolers’ problem solving and social skills and also attempted to incorporate a parenting component. The program included curricular and behavior management components, provided teachers with weekly trainings and ongoing consultations, and offered a bi-weekly parent group. Study participants were primarily low-income 4 to 5-year-old children in public prekindergarten classrooms. The evaluators collected parent- and teacher-report of internalizing and externalizing behaviors and social skills. They found no changes in children’s parent-rated functioning over time. However, they did find significant improvements for intervention group participants on teacher-rated total social skills ( F [1, 144] = 5.73, p  < 0.05), cooperation ( F [1, 144] = 3.99, p  < 0.05) and assertion ( F [1, 144] = 7.12, p  < 0.01). Notably, parent group attendance was extremely low, and as such, the effectiveness of the parent component of this intervention was not able to be evaluated. Other limitations included the self-report nature of the outcome measures, and baseline group differences in teacher-reported levels of problem behaviors and skills, and on family income.

Making choices and strong families (Conner & Fraser, 2011 )

The Making Choices program is one of the few studies of an SEL skills-based curriculum for preschoolers that included a successfully implemented parenting component. The SEL-focused component, Making Choices, is a manualized program with theoretical bases in social information processing, designed for preschool-aged children. The program was delivered twice weekly for 14 weeks with the aim of strengthening social information processing, emotion regulation skills, and prosocial interactions with peers. The parent training component, Strong Families, had distinct but complementary goals, including increasing positive parent–child interaction patterns and decreasing coercion. The study sample was drawn from a group of part-day preschool centers, and the comparison group received typical Head Start services. Investigators directly assessed child-level competencies (e.g., academic competence, achievement motivation, social competence, peer acceptance, depression/anxiety and aggression/hostility) and family and child functioning. Results revealed significant effects for all child competencies ( F [20, 46] = 3.05, p  < 0.001; r 2  = 0.35), with higher gain scores among intervention group participants, as well as positive changes in caregiver behaviors ( F [10, 56] = 6.88, p  < 0.001; r 2  = 0.36). While these outcomes are promising, the sample sizes are quite small, and about 35% of eligible families moved or otherwise became ineligible before assignment to a treatment group. No follow-up or replication studies in preschoolers have been conducted to date, and as the interventions were delivered together, it is unclear if one or both was driving effects.

Incredible Years (IY)

The Incredible Years program was originally designed as a treatment for children with Oppositional Defiant Disorder or Conduct Disorder diagnoses (Webster-Stratton, 1990 ), with theoretical bases in social learning theory and the effects of adult–child interaction processes in child behavior. The program has been adapted for use with several age groups and populations, including as a classroom-based prevention program aiming to augment socio-emotional skills and decrease problem behaviors in preschoolers. Of particular interest to the present review are the IY Teacher Classroom Management Training (TCM), the IY Child Program: Dinosaur Classroom Curriculum, and the IY Parent Program used in conjunction with the teacher or child programs. The IY programs, implemented as universal prevention programs in preschool-aged children, have been evaluated by Webster-Stratton and colleagues (Webster-Stratton, 1998 ; Webster-Stratton & Reid, 2004 ; Webster-Stratton et al., 2001 , 2008 ). Several independent evaluations of IY programs have also been conducted; however, many specifically evaluated children with high levels of disruptive or oppositional behaviors in the preschool setting (e.g., Baker-Henningham et al., 2012 ), did not utilize a control group (e.g., Shernoff & Kratochwill, 2007 ), or did not measure SEL outcomes (e.g., Williford & Shelton, 2008 ). As such, they did not meet our inclusion criteria.

Webster-Stratton et. al. ( 2001 ) evaluated IY TCM program in combination with the Parent Training as a universal prevention program in Head Start. The intervention group parents and teachers participated in the IY programs, and the control group received usual practice Head Start services. The teacher training consisted of 36 h of training on classroom management, child development, and promotion of prosocial and reduction of antisocial behaviors. The parent training had similar content, adapted for the home context and focused on reducing coercive discipline and increasing positive parenting practices. Teachers and parents in the intervention group evinced more positive practices, while children engaged in more prosocial behavior and were rated as more socially competent. Specifically, 71% of intervention group children rated as having problems with social competence at baseline fell in the normative range at the end of school, compared to 36.6% of the control group children initially rated as lower in social competence ( χ 2 [1, 26] = 4.12, p  < 0.04).

Webster-Stratton and colleagues have also evaluated the IY TCM program in combination with the Dinosaur School curriculum in Head Start settings (Webster-Stratton et al., 2008 ). Children received 30 bi-weekly lessons promoting socio-emotional skills, problem-solving, self-regulation, and school behavior over the course of a year, communicated via vignettes, small-group activities, puppets, and games. Teachers participated in 28 h of workshops focused on classroom management and promotion of socio-emotional competence, spread out over four months. A research staff-member led lessons alongside the classroom teacher to ensure implementation fidelity. Outcomes were measured via classroom observations, as well as direct assessment of competencies such as problem-solving skills and emotion knowledge. The authors reported that teachers in the intervention were more likely to use teaching strategies to promote SEL (e.g., teaching prosocial behavior, problem-solving, shaping peer play, encouraging feelings language, and promoting social competence) in intervention group teachers ( d  = 0.96). The intervention was also associated with higher levels of teacher-reported child social competence and self-regulation (effect sizes not reported), particularly for students with low levels at baseline, as well as improvements in problem-solving ( η 2  = 0.41) and feelings knowledge ( η 2  = 0.14).

Overall, the evidence base for the Incredible Years intervention is encouraging; however, evaluation methodology has been inconsistent and further investigation is needed to determine efficacy of the program as a universal prevention strategy for preschool-aged children.

Teacher-focused skills-based interventions

This group of interventions provides training and other forms of professional development to teachers, with the aim of improving teacher–child interactions and children’s socio-emotional functioning.

Pyramid Model

The Pyramid Model for Promoting Young Children’s Socio-Emotional Competence (the “Pyramid Model”; PM) is a professional development intervention that includes research-informed practices for promoting healthy socio-emotional development and high-quality relationships between caregivers and children. PM practices include universal strategies for teachers to promote family engagement and children’s peer social skills, as well as individualized interventions strategies for children exhibiting challenging behaviors. These practices are taught through multi-day workshops and implementation guides. Teachers also receive classroom materials (e.g., puppets, books) for implementing the practices.

Hemmeter et. al. ( 2016 ) conducted a cluster-randomized controlled potential efficacy trial to evaluate the effects of classroom-wide implementation of PM on teacher practices and child outcomes. Teachers in the intervention group participated in the initial PM workshops, and subsequently received weekly individualized coaching, which included in-classroom observation. Results indicated that children whose teachers participated in PM had higher teacher-rated social skills at post-test than children whose teachers did not participate in PM ( d  = 0.43). These results are promising, but should be interpreted with caution given the study’s reliance on teacher ratings of children’s social skills.

Foundations of Learning (FOL)

Foundations of Learning is a professional development intervention that combines teacher training and mental health consultation. FOL teachers participate in workshops on proactively supporting positive behavior and managing challenging behaviors in the classroom, and on personal stress management. They also receive weekly classroom-level mental health consultation, and individualized mental health consultation as needed for children exhibiting persistent challenging behaviors. FOL’s teacher training component is adapted from the Incredible Years curriculum; the intervention is also based on the previously discussed, smaller-scale Chicago School Readiness Project (CSPR) intervention.

Morris et. al. ( 2013 ) conducted a cluster-randomized controlled study to evaluate the effects of FOL on preschool teacher practices and child outcomes. Results revealed positive impacts on teachers’ ability to manage challenging behaviors and promote a positive emotional climate in the classroom. At the child outcome level, results indicated that children whose teachers participated in FOL exhibited less problem behaviors (e.g., peer and teacher conflict, as rated by trained observer) than children whose teachers did not participate in FOL. However, no significant effects on either observer- or teacher-rated positive social behavior (e.g., communication, sociability, compliance) were detected between groups. Positive intervention effects on children’s approaches to learning (e.g., self-control, focus, and participation in classroom activities) were detected at the trending level ( p  < 0.10).

Jensen et. al. ( 2017 ) evaluated the VIDA (a Danish acronym for Knowledge-based efforts for socially disadvantaged children in daycare) intervention, which aims to augment socio-emotional functioning in preschool children by altering their social context. The primary mode of change is via teacher training to improve the preschool environment. Intervention teachers attended 17 full days of training over the course of 2 years, gaining theoretical knowledge about child development and the bioecological system, encouraging reflection, enhancing communication with students, and requiring teachers to use the training to design their own activities focused on socio-emotional skills (e.g., improving friendships, managing conflict). Jensen et. al. ( 2017 ) explain:

“The initial step of the teachers’ learning process takes place as a top-down process that presents participants with predefined topics [...] Through reflection, everyday experiences are related to the research-based knowledge and the teaches are using this to change their practice. The process transforms what was initially top-down, course-based theoretical knowledge into bottom-up, practice-oriented teacher learning and innovation” (p. 28).

Teacher ratings revealed a trending effect of the intervention on prosocial behavior. Further evaluation of the program is warranted, and results may not be generalizable due to the high dosage of the program. It is also unclear whether students retained the same teacher over the course of the intervention, which could be an important confounding factor. Finally, conclusions would be strengthened by measurement of SEL outcomes via more diverse tools, as the only outcome measure in the present study was teacher-reported.

Comparing program types

General public prekindergarten programs.

Access to public prekindergarten programs has expanded dramatically in the United States over the last several decades, with approximately one-third of 4-year-old children enrolled in state-funded programs in 2017 (National Institute for Early Education Research [NIEER], 2018 ). These programs have historically focused on enhancing children’s pre-academic skills (e.g., language, numeracy), but have also increasingly targeted SEL.

Participation in public prekindergarten may enhance SEL by several mechanisms. For example, high-quality teacher–child relationships have been linked to improvements in children’s SEL (Merritt et al., 2012 ). Prekindergarten participation also provides children with consistent opportunities for socialization with peers and social skill practice. Finally, improvements in children’s academic and cognitive skills at the individual and classroom levels may also contribute to improvements in SEL over time through spillover effects. For most children, this may be sufficient, but it is important to evaluate whether public prekindergarten programs can exert significant and sufficient benefits on children’s SEL, or whether more targeted SEL services are needed.

Our review identified only one peer-reviewed study examining the effects of a general public prekindergarten program (Boston Public Schools) on SEL (Weiland & Yoshikawa, 2013 ). Major strengths of this study include the socioeconomically diverse sample, utilization of performance-based measures of SEL skills, and examination of subgroup effects by race/ethnicity and free/reduced lunch status. Effect sizes on cognitive inhibitory control and emotion recognition were small, but statistically significant. The authors posited a “spill-over” hypothesis to explain program impacts on inhibitory control. The results of this study suggest that high-quality general public prekindergarten programming may have a positive impact on children’s SEL, but that children who exhibit delays in developmentally appropriate SEL skills may benefit from more targeted intervention. This finding is consistent with a significant body of research suggesting that children with higher needs tend to benefit more from early childhood intervention (Reynolds et al., 2011 ; Washington State Institute for Public Policy, 2014 ). Nonetheless, given that prekindergarten programs vary widely by school district, there is a need for additional studies in this domain. There is a particular need for studies examining the differential contributions of various program components. This is an important consideration in Weiland and Yoshikawa’s ( 2013 ) study given the unusually high quality of the Boston Public Schools prekindergarten program, which includes equal educational requirements and pay scale for teachers from prekindergarten through high school, a research-based academic curriculum and a district-designed teacher coaching system.

Multi-component ECE programs

Multi-component ECE programs (e.g., Head Start, the Child–Parent Center (CPC) Program) typically provide a more comprehensive array of academic and family support services than general public prekindergarten programs. These programs also commonly prioritize enrollment of low-income children, who often lag behind in acquisition of pre-academic and SEL skills. Previous research has demonstrated that participation in these programs is most beneficial for children with the lowest levels of skills and the highest levels of psychosocial risk at program entry (Karoly & Bigelow, 2005 ; Reynolds et al., 2007 ). Hypothetically, multi-component programs may enhance children’s SEL by addressing risk and protective factors at multiple social-ecological levels. This is accomplished through a variety of means, from comprehensive academic curricula to wraparound family and social services.

The present review identified several literature reviews and meta-analyses examining the effects of multi-component prekindergarten programs on SEL. Many of these studies constructed outcome variables that combined SEL and mental health outcomes; thus, their results should be interpreted with significant caution. Nonetheless, aggregate results indicated that program participation was associated with small to moderate gains in SEL compared to comparison group members, with multiple studies reporting that children affected by the highest psychosocial risk exhibited the greatest gains. Findings on the impact of program duration were mixed. One meta-analysis reported that didactic instruction and small-group learning were positively associated with participants’ SEL gains (Camilli et al., 2010 ), suggesting that a balance of teacher-directed instruction, and child-initiated and small group activities may be beneficial for SEL. Meanwhile, two additional studies indicated that participation in the CPC prekindergarten program was associated with moderate enhancements in SEL for low-income children from diverse backgrounds (Reynolds et al., 2016 ; Richardson et al., 2017 ).

This body of research is small, but suggests that multi-component programs hold promise for promoting SEL. Notably, most studies did not examine the differential impacts of various program components on SEL (e.g., professional development, curricula, classroom structure), making it difficult to determine whether SEL benefits were driven by the overall combination of program components or a small number of “active ingredients.”

There is no shortage of skills-based SEL interventions for young children; however, they vary widely in scope, focus, size, theoretical foundations, and quality of the evidence base. Generally, such programs are based on manualized curricula, and are designed to supplement or enrich typical preschool programs. This type of intervention can be efficient, cost-effective, and scalable. For example, schools are not required to adopt an entirely new multi-component educational program, and the explicit targeting of specific SEL skills through games, songs, vignettes, role playing and modeling, and didactic teaching, and/or through teacher professional development and parent coaching can be a developmentally appropriate, engaging, and effective way to reach preschool-aged children. All of these factors likely contribute to the abundance of skills-based programs meeting our criteria for review in the present article.

We first identified two previously published reviews of skills-based SEL interventions (Barton et al., 2014 ; Joseph & Strain, 2003 ). Importantly, the authors state that they only reviewed studies of programs used in “at-risk” populations or with children demonstrating behavioral challenges. This review, in contrast, intentionally focused on empirical studies of the effectiveness of programs (some of which also appeared in the aforementioned reviews) in a general classroom setting. We felt that this was crucial, as all children can benefit from SEL skills training, and expanding the use of high-quality universal programs can help to shift the paradigm from pathologizing children with SEL “deficits” to normalizing and encouraging SEL growth for all children. Strain of the 2003 review was also an author on the 2014 paper, and as such, both papers used the same criteria for inclusion and assessment of quality. Ultimately, their conclusions were quite mixed. Of the SEL-focused programs evaluated in preschool settings after 1990s, the authors of both reviews identified one program with “high” levels of evidence, three with “medium” levels of evidence, and four with “low” levels of evidence.

We also identified two recently published meta-analyses, which examined the evidence base on skills-based SEL interventions for preschoolers (Luo et al., 2020 ; Murano et al., 2020 ). These meta-analyses indicated that both universal and targeted skills-based interventions had significant, moderate effects on preschoolers’ SEL skills. Both studies also reported limited evidence for moderating effects, and noted that interventions with family components were more effective than those that did not include family members. These results provide the strongest evidence to date that skills-based interventions can support the SEL of young children, including those affected by sociodemographic risk factors.

Overall, the results of the aforementioned systematic reviews and meta-analyses are consistent with the present review. We found considerable variation in delivery methods, assessment methods, and outcomes across interventions, in addition to variation in the use of control groups, random assignment, outcome measurement, follow-up, and other crucial elements of empirical research. While some programs were explicitly grounded in theory (some in social learning theory and principles of social information processing; others in more broadly defined developmental, self-regulation, and systems theories), effect sizes varied considerably within and across programs.

Despite these challenges, several programs with strong theoretical bases have been evaluated with large sample sizes, random assignment, multiple sources of outcome assessment, and short-term follow-up, and as such, it is our cautious conclusion that skills-based programs can be an effective way to augment SEL skills in young children. Whether such programs are the optimal way to augment these skills (as opposed to the other approaches examined in the present paper) remains to be seen. The next step is to investigate impacts in well-designed quasi-experimental or randomized designs, while establishing and maintaining construct validity around SEL and ensuring that programs can be effectively delivered in real-world settings.

Synthesis: three intervention approaches

There are clear benefits and drawbacks to the three intervention approaches that were reviewed in the present paper. From a developmental perspective, there is considerable evidence for the use of multi-component ECE programs, which aim to promote holistic development by enhancing protective factors and reducing risk factors at multiple social-ecological levels. However, there is also promising evidence for several skills-based SEL programs, which have the benefit of facilitating adoption and implementation within existing frameworks.

Decades of developmental research have indicated that sensitive, responsive caregiving is an essential catalyst for healthy development in infancy and early childhood (Ainsworth et al., 1978 ; Landry et al., 2000 ). Given this evidence, prekindergarten programs that facilitate high-quality teacher–child relationships (e.g., via professional development, small class sizes) and safe, stable learning environments are likely to exert positive impacts on children’s SEL. Multi-component ECE programs, which typically include interventions at multiple levels of children’s social ecologies, may have an advantage in this domain over skills-based SEL programs. To this end, multi-component ECE programs fall under the category of promotion programming, as identified by the Center on the Social and Emotional Foundations for Learning (CESFEL; Duran et al., n.d.). Promotion programming includes interventions, practices, and policies that ensure that all children are receiving high-quality caregiving and education, which will facilitate developmentally appropriate SEL. Universal skills-based interventions that are offered to all children in a classroom may also fall under the promotion realm. Skills-based interventions may also be offered at the prevention level (Duran et al., n.d.). Programming at the prevention level provides targeted SEL support services for children with emergent SEL challenges, with the goal of addressing these challenges before they develop into more serious psychopathology. Offering skills-based SEL interventions at the prevention level for indicated populations may be more cost-effective than universal implementation; however, this strategy requires a screening process for identifying children at risk. School-based, skills-based SEL interventions may not be sufficient for children with more serious SEL deficits and/or clinical psychopathology; this population may benefit from more intensive intervention services in a mental health setting (Duran et al., n. d.).

Beyond program efficacy, several other factors must be considered when selecting an intervention, including cost, ease of implementation, and scale-up potential. Substantial financial resources and infrastructure are required to implement multi-component ECE programs and public prekindergarten programs; however, cost–benefit analyses have indicated that these initial investments may yield significant returns over time. For example, Heckman and colleagues have estimated that high-quality ECE programs can produce financial returns of as much as 13% per annum (Garcia et al., 2016 ). Longitudinal research has also demonstrated that ECE programs can exert enduring benefits on many aspects of wellbeing (e.g., Consortium for Longitudinal Studies, 1983 ; Reynolds & Ou, 2011 ).

Researchers have also investigated the monetary value of interventions that specifically target SEL, and have found that such programs can yield substantial economic returns (e.g., Belfield et al., 2015 ). Studies indicate that these savings stem from improved functioning among program graduates, including reductions in substance abuse and increases in earnings, often mediated through variables such as educational attainment and self-esteem (Araujo & Lagos, 2013 ; Klapp et al., 2017 ). Aspects of SEL often characterized as “self-control” variables (e.g., executive functioning, self-regulatory skills) may also help to explain returns on investment in SEL programs. Childhood self-control has been found to predict costly outcomes, including physical health, substance use, income, and crime in adulthood (Moffitt et al., 2011 ). Finally, several studies have investigated a subset of SEL-informed intervention programs which narrowly focus on reducing delinquency and substance use. They note that these programs tend to target a small subset of SEL-related skills (e.g., impulse control) and can yield cost savings by reducing involvement in the criminal justice system (Miller & Hendrie, 2008 ).

Future research directions

The present paper aimed to review the highest quality literature available on the relationship between prekindergarten programs and SEL. Our review indicated a number of common methodological issues which should be addressed in future work.

Definitions and measurement of SEL

Evaluation studies of prekindergarten programs have typically examined cognitive and academic outcomes, with few studies investigating impacts on children’s SEL. Meanwhile, studies that have examined socio-emotional outcomes have typically focused on maladaptive behaviors and psychopathology (e.g., internalizing and externalizing symptoms). This is problematic, given that prekindergarten programming is not primarily intended to prevent or treat psychological symptoms. Rather, prekindergarten programs are designed to promote acquisition of developmentally appropriate skills. As such, researchers should carefully attend to construct validity by: (a) clarifying whether they are measuring psychopathology outcomes, SEL, or both; and (b) specify the SEL domains they are investigating, how they are operationalizing them, and how they are tracking growth in SEL competencies over time. At the broader field level, efforts must also be made to develop consensus on critical issues related to SEL measurement, concepts, and dimensions of relevance. While the work of CASEL ( 2012 ) and others has provided some clarity on these issues, researchers continue to use a wide array of labels for SEL phenomena (e.g., SEL, social competence, wellbeing, self-regulation) without clear definitions or parameters. Many studies have also stated that they are investigating “SEL” or similar phenomena, while solely utilizing outcome measures that assess psychopathology. Developing consensus on these issues will help to ensure construct validity, and also enable more rigorous comparative evaluations of different interventions.

When examining all three types of interventions addressed in this review, it is also important for researchers to consider other potentially salient program components. For example, curriculum type, parent involvement, timing and duration of SEL components, and teacher and student supports that are not necessarily explicit components of the SEL training may all affect children’s outcomes.

Cultural considerations

The present review indicates that relatively few studies have carefully attended to potential differential impacts of prekindergarten interventions on SEL for children from diverse cultural backgrounds. Research examining whether and how interventions impact the SEL of different subgroups of children could inform efforts to tailor interventions to the needs of specific populations.

Researchers should also carefully select assessment measures that are appropriate for use with multicultural populations. The present review indicates that most previous studies have utilized deficits-focused outcome measures (e.g., assessing the effects of intervention on psychopathology symptoms). Moving towards strengths/skills-focused outcome measures (e.g., assessing the effects of intervention on developmentally and culturally appropriate SEL skills) will likely increase the cultural sensitivity of research in this domain, and help to ensure that children from non-dominant cultures are not being improperly identified as having SEL deficits.

Our review revealed that numerous studies relied on non-blinded, single-informant reports of SEL outcomes—typically, reports from classroom teachers who were delivering interventions. Previous research has demonstrated the importance of utilizing multiple informants to minimize reporting bias (Totura et al., 2009 ). For example, surveying both teachers and parents can provide a more nuanced perspective on children’s SEL skills in multiple environments (school and home). The use of trained observers or performance-based measures may also yield unique information about children’s functioning.

Control groups

Our review identified and excluded a number of program evaluation studies that lacked control/comparison groups. The absence of control groups makes it impossible to determine whether changes in children’s SEL are due to program participation as opposed to other factors like developmental maturation. It is essential that future studies include well-defined control/comparison groups so that program impacts can be adequately estimated.

Measurement of multiple intervention components

Several of the skills-based programs had professional development, didactic child skills, and parent-focused aspects, with little investigation of differential impacts of each program element or mechanism. The issue of mechanisms is not confined to multi-pronged interventions; rather, none of the programs reviewed analyzed how child-focused programs transmit positive impacts to the outcomes of interest. Future research should determine which and how specific aspects of programs (e.g., didactic instruction in problem-solving and conflict resolution; teacher-facilitated emotion recognition and expression) impact knowledge and behavior.

Implementation fidelity

We identified relatively few studies that provided information about implementation fidelity. Fidelity measurement is essential to accurately estimate program impacts. Fidelity measurement can also provide important information about whether program scale-up is feasible, or whether adaptations are needed to increase the program’s practicality or cultural relevance (e.g., replacing doctoral-level clinicians with trained laypeople).

Longitudinal follow-up

Our review revealed a paucity of studies examining the longitudinal impacts of prekindergarten programs on SEL. Studies that did include multiple time-points rarely continued past early elementary school. This is an important limitation that raises questions about the stability of program impacts on SEL over time. Moving forward, there is a need for longitudinal studies that include pre-program assessments of baseline SEL, and that investigate participant outcomes through the school years and beyond.

Conclusions and implications

Interest in scalable strategies for enhancing children’s SEL has grown steadily since the 1970s, when Edward Zigler argued that promoting ‘social competence’ should be the primary aim of early childhood interventions (Zigler & Trickett, 1978 ). During the 1990s and 2000s, the development of the interdisciplinary SEL framework spurred additional research and policy initiatives in this domain. Numerous skills-based interventions have been developed for use in early care and education settings (Tables 5 , 6 ), and general public prekindergarten programs and multi-component interventions have also demonstrated impacts on SEL (Tables 2 , 3 , 4 ). These developments are promising; however, moving forward it is essential that stakeholders define and measure SEL in ways that are consistent, developmentally appropriate, and culturally sensitive. Collaboration among diverse groups of stakeholders (e.g., community-based researchers, policymakers, parents, and early childhood leaders) will be essential to accomplishing these aims.

Finally, investments should be made into efforts to support children’s SEL at multiple ecological levels, from home- and school-based interventions to public policies that support healthy development. Specifically, early childhood educators should place SEL skills alongside literacy and numeracy skills as an important part of a balanced early childhood curriculum. Policymakers, parents, and early childhood leaders can assist teachers in implementing SEL interventions or infusing SEL into existing programming by advocating for increased funding and materials for these efforts.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Please contact the authors with any questions.

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Perhaps more than ever, mental health and social interactions have been on the minds of many over the past year. A pandemic, ongoing systemic injustices, and a contentious political season combined to create uncertainty and stress for adults and children alike. What do these stressors mean for the mental health of our youngest learners? In what ways can early childhood educators nurture the social and emotional lives and learning of children from birth through age 8?

This issue of  Young Children  offers research-supported responses to these questions with a cluster of articles devoted to intentional practices that promote social and emotional development: The first four articles in this cluster focus on the specific social and emotional needs of infants and toddlers, and the development of these important articles represents a unique collaboration between NAEYC and ZERO TO THREE to collectively concentrate our respective journals on the emotional health of infants and toddlers.

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Tapping into these same powers of observation and reflection, Claire Vallotton, Jennifer Mortensen, Melissa Burnham, Kalli Decker, and Marjorie Beeghly present “Becoming a Better Behavior Detective: Applying a Developmental and Contextual Lens on Behavior to Promote Social and Emotional Development.” Educators can use this 5-Step Reflective Cycle to identify and be responsive to infants’ and toddlers’ behaviors and needs. Of course, following these steps depends on our own emotional presence and well-being. In an accompanying piece to this article, Holly Hatton-Bowers and colleagues offer recommendations for “Cultivating Self-Awareness in Our Work with Infants, Toddlers, and Their Families: Caring for Ourselves as We Care for Others.”

Finally, in “When in Doubt, Reach Out: Teaming Strategies for Inclusive Early Childhood Settings,” Christine Spence, Deserai Miller, Catherine Corr, Rosa Milagros Santos, and Brandie Bentley capture how an early childhood educator learns to actively participate in early intervention processes through effective communication and collaboration. This cluster also features a special Rocking and Rolling column defining IECMH and outlining how early childhood educators play a role in fostering infants’ and toddlers’ emotional well-being.

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Early life stress and development: potential mechanisms for adverse outcomes

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• Seth D. Pollak 1  

Journal of Neurodevelopmental Disorders volume  12 , Article number:  34 ( 2020 ) Cite this article

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Chronic and/or extreme stress in early life, often referred to as early adversity, childhood trauma, or early life stress, has been associated with a wide range of adverse effects on development. However, while early life stress has been linked to negative effects on a number of neural systems, the specific mechanisms through which early life stress influences development and individual differences in children’s outcomes are still not well understood.

The current paper reviews the existing literature on the neurobiological effects of early life stress and their ties to children’s psychological and behavioral development.

Conclusions

Early life stress has persistent and pervasive effects on prefrontal–hypothalamic–amygdala and dopaminergic circuits that are at least partially mediated by alterations in hypothalamic–pituitary–adrenal axis function. However, to date, this research has primarily utilized methods of assessment that focus solely on children’s event exposures. Incorporating assessment of factors that influence children’s interpretation of stressors, along with stressful events, has the potential to provide further insight into the mechanisms contributing to individual differences in neurodevelopmental effects of early life stress. This can aid in further elucidating specific mechanisms through which these neurobiological changes influence development and contribute to risk for psychopathology and health disorders.

Early life experiences represent an important influence on children’s neural, behavioral, and psychological development, having long-lasting effects across a wide range of domains [ 1 , 2 ]. Experience shapes neural plasticity and through this behavior and psychological processes throughout the lifespan [ 3 , 4 ]. Infancy and early childhood are periods of particularly high rates of synaptic regrowth and remodeling in the brain, during which experience can have long-lasting effects on development [ 5 , 6 ]. Neuroscience has greatly illuminated our understanding of how both positive and negative early life experiences affect brain development, with implications for children’s mental and physical health. In this paper, we review the literature examining the neurobiological effects of early experiences and discuss where there is a need for further research related to individual differences in children’s responses to their early environments.

An early experience that has garnered much attention is that of chronic and/or extreme stress in early life. Experiences of chronic and/or severe stress during early childhood, often also conceptualized as early life stress, childhood adversity, child maltreatment, or childhood trauma, have persistent and pervasive consequences for development [ 7 , 8 ]. The term stress refers to the psychological response elicited when an individual perceives themselves to be under threat or challenge and is generally beneficial, eliciting a range of behavioral and physiological changes aimed at addressing the perceived threat. However, chronic and/or extreme stress results in extended activation of these psychological, behavioral, and physiological stress response systems leading to dysregulation and negative psychological and behavioral outcomes [ 9 , 10 ]. Here, we use the term early life stress broadly to refer to stress occurring in childhood (prior to the age of 18). It is a term which encompasses many different kinds of adverse experiences a child might encounter, including, but not limited to, exposure to toxins, nutritional restriction, abuse, neglect, and limited family resources. Severe and chronic exposure to these types of situations has long-term negative consequences on a wide range of cognitive, emotional, and behavioral processes [ 11 , 12 , 13 ]. However, the neural mechanisms supporting these effects are less well understood, and advances in neuroscience are critical for uncovering causal mechanisms linking exposure to early life adverse experiences with well-being across the lifespan.

Below, we review the current state of the literature on the effects of early experiences of stress on neurobiological circuits and the implications these effects have for children’s development. We start by introducing two prevalent approaches toward conceptualizing early life stress and its effects on development. We then highlight common findings across these different approaches related to the neural effects of early life stress, with a particular focus on the effects on prefrontal–hippocampal–amygdala and dopaminergic circuits. Finally, we address opportunities for new ways in which to advance our understanding of the mechanisms through which early life stress shapes the developing brain, and in turn children’s health outcomes. Together, these data can inform the development of more effective and targeted interventions for at risk children.

Models for conceptualizing early life stress: elucidating neurobiological mechanisms

Researchers have employed a variety of models aimed at conceptualizing early life stress, with the goal of better elucidating the neurobiological mechanisms through which stress exerts effects on development. While the question of how to best conceptualize early childhood adversity and stress has shifted over time [ 14 , 15 ], the two predominant models of early life stress fall into the categories of (1) General or “lumping” models, in which various types of stressors are treated as a heterogeneous, broad category, often labeled “adversity,” “early life stress,” or “negative life events” [ 16 , 17 , 18 , 19 ]; and 2) Specific or “splitting” models, which are based on the premise that different types of adversity each confer specific effects, and links to neurobiological or cognitive systems may be masked by heterogeneous samples [ 20 , 21 , 22 ]. Both types of models have provided a wealth of knowledge surrounding early childhood adversity and its effects on development and provided initial insight into some of the potential neurobiological mechanisms underlying these effects. However, there is still much the field does not understand about what bio-behavioral mechanisms account for individual patterns of developmental change following extreme adversity. In the following sections, we will review the literature supporting general and specific effects of early life stress on neurobiological systems.

Insights from general models

One common general approach to conceptualizing early adversity is that of cumulative measures of adversity. In this approach, individuals are queried about whether they experienced a pre-defined set of potential adverse events in childhood, and their total exposure to events from that list is summed [ 23 , 24 ]. Examples of these methods include variations on Life Stressors Checklists [ 25 ] and the Adverse Child Experiences Scale (ACES) [ 18 , 26 ]. This approach is based in animal literature that suggests repeated exposure to stress, regardless of type, through chronic activation of stress response systems (i.e., HPA, immune, and autonomic nervous system), alters neural synaptic plasticity leading to cognitive deficits, anxiety, and depressive-like behaviors, and poorer health [ 9 , 27 ]. Similarly, in humans, cumulative measures of adversity have been linked to differences in hippocampal, PFC, and amygdala volume, and changes in prefrontal–amygdala connectivity [ 28 , 29 , 30 ]. These models have also been associated with changes in peripheral stress responses systems, including altered cortisol and autonomic nervous system reactivity to laboratory stressors [ 31 , 32 , 33 ], epigenetic changes [ 34 , 35 ], and increases in markers of inflammatory activity and immune dysregulation [ 36 , 37 ]. Longitudinal studies tend to provide support for cumulative or general effects [ 38 , 39 , 40 ]. A recent longitudinal study from 18 months to mid-adulthood found that cumulative stress rather than physical abuse alone was predictive of adult depressive symptoms [ 40 ]. Another study, which followed children from birth to age 37 years, found that childhood stress interacted with current life stress, regardless of type of stressor, to predict diurnal cortisol patterns in adulthood [ 38 ]. However, while cumulative models have greatly informed our understanding of the aggregate effects of stress on individuals, they have lacked consistent insight into the neurobiological mechanisms underlying individual differences to children’s responses to stress [ 14 ]. This suggests that counting types of stressors alone is not sufficient to explain variation in children’s development outcomes after early life stress.

Insights from specific methods

Specific models represent a reaction to cumulative models and an attempt to more precisely identify the neurobiological mechanisms linking early experience to development [ 20 , 41 ]. These approaches are based in animal models that demonstrate some specificity in the effects of certain types of stressors on neurobiological systems [ 42 , 43 ]. Based on this evidence, specific models assume that different types of stressors will have distinct and separable effects on developing neural systems. While there are many different variants of this approach [ 41 , 44 , 45 ], an increasingly prevalent one is to conceptualize potential stressors as a lack of expected inputs (i.e., “deprivation”—consisting of things like neglect, food deprivation, and institutionalization) or a presence of direct threat to the child (i.e., “threat”—consisting of things like physical abuse, sexual abuse, and exposure to violence) [ 46 , 47 , 48 ].

The rapidly expanding literature taking this approach has provided insight into some of the potential mechanisms supporting the effects of early life stress on development. For example, this literature appears to find more consistent evidence for the association between “threat” and psychopathology being mediated by alterations in stress response systems (including autonomic and HPA reactivity). In contrast, it finds less evidence for the association between “deprivation” and psychopathology being mediated by alterations in stress response systems [ 49 , 50 ]. However, there are also findings that suggest similar effects of “threat” and “deprivation” experiences on stress response systems and the neural systems supporting them [ 51 , 52 , 53 , 54 ]. As an example, both threat and deprivation have been linked to negative PFC–amygdala connectivity in late childhood and adolescence [ 51 , 55 ]. Additionally, both threat experiences such as abuse and deprivation experiences such as neglect have been demonstrated to have specific effects on hippocampal volume [ 53 , 56 , 57 ].

One potential explanation for these commonalities in the effects of different types or categories of stressors is that different types of stressors often co-occur [ 58 , 59 ]. This co-occurrence creates a number of conceptual issues and makes it difficult to determine if one specific type or dimension of stressor is indeed driving an effect (for extensive discussion see [ 60 ]). To illustrate, imagine a study in which a sample of children exposed to physical abuse demonstrate dampened PFC–amygdala connectivity in response to threat. It could be this association is driven by exposure to physical abuse. But, given physical abuse is associated with many other co-occurring risk factors [ 61 , 62 , 63 ], it could also be driven by any one of these other risk factors. This makes it difficult to determine what effects are the causal result of just physical abuse, or even if physical abuse itself elicits a neurobiological response. Despite these issues, together general and specific models have provided insight into how early life stress may be shaping neurobiological systems; below, we review commonalities in findings across the two approaches on the development of neurobiological systems.

Neurobiological consequences of early life stress

While strong arguments have been made for using one type of conceptualization over another [ 14 , 15 , 47 ], careful examination of this literature suggests that there are commonalities in findings across the two approaches. Here, we focus on some general recent themes across this literature with implications for human development. Early life stress is consistently associated with altered functioning of the hypothalamic pituitary adrenal (HPA) axis and autonomic nervous system [ 33 , 54 , 64 ]. These systems are critical to facilitating motived psychological and behavioral responses to the environment, particularly environmental threats and challenges [ 65 , 66 ]. Additionally, growing evidence suggests that early life stress is associated with alterations in the immune system and inflammatory activity, which is increasingly implicated in producing shifts in individuals’ behavioral responses to their environment [ 46 , 67 ]. Together, these changes in peripheral physiological systems are critical for facilitating adaptive responses to threat and challenge. In addition, altered activity of these systems is associated with negative mental and physical health consequences after stress exposure [ 68 , 69 , 70 ]. The effects of early life stress on these peripheral stress response systems are thought to be a result of altered neural plasticity in circuits integral to stress responses, including the prefrontal cortex (PFC), hippocampus, amygdala, and striatal circuits [ 15 , 71 ]. There is also a growing corpora of research implicating epigenetic changes in the regulation of many of these effects [ 34 , 72 ]. Many of these changes have been hypothesized to represent adaptive responses to environments of high threat which become problematic within the broader social context [ 73 , 74 ]. Below, we review the current state of the literature linking early life stress to altered brain function, and some of the potential hormonal, psychophysiological, neural, and genetic mechanisms thought to support these effects.

Neural consequences of early life stress and their proposed mediating mechanisms

Alterations in prefrontal–hippocampal–amygdala circuits.

Research in both non-human animals and humans suggests that early life stress is linked to pronounced effects on the development of prefrontal–hippocampal–amygdala circuits. These circuits play an important role in facilitating peripheral stress responses through the release of corticotrophin reducing hormone (CRH) and glucocorticoids and regulation of the autonomic nervous system [ 9 , 75 ]. Additionally, these circuits are implicated in emotion processing, self-regulation, and memory and learning [ 76 , 77 , 78 ]. Rodents exposed to abusive maternal behaviors or maternal separation as pups show decreased dendritic arborization throughout the PFC and hippocampus [ 79 , 80 ]. Experiences of chronic restraint stress in adult rodents result in increased dendritic arborization in the amygdala [ 81 , 82 ], and there is some evidence for similar effects in the amygdala after experiences of stress as pups [ 83 ]. In association with these structural changes, rodents demonstrate modifications in synaptic signaling and epigenetic changes in the hippocampus and amygdala [ 34 , 84 , 85 , 86 ]. These changes in synaptic structure and signaling are thought to produce increased sensitivity to threat in the environment, through decreased regulation of the amygdala by the PFC and hippocampus [ 87 , 88 ]. Additionally, they have been associated with increased anxiety and depressive-like behaviors in animals after experiences of early life stress [ 89 , 90 , 91 , 92 ]. Changes in hippocampal synaptic plasticity have also been linked to altered memory and learning processes, with rodents’ demonstrating reduced spatial memory [ 93 , 94 ] and enhanced threat learning [ 95 , 96 ].

The changes throughout the PFC, hippocampus, and amygdala and their associated effects on behavior, memory, and learning appear to be at least partially mediated by chronic exposure to CRH and glucocorticoids induced by chronic stress [ 93 , 97 , 98 , 99 ]. For example, rat pups exposed to chronic stress in the form of fragmented maternal behaviors demonstrate augmented expression of CRH in the hippocampus and memory deficits. Blocking CRH receptors resulted in improved memory performance and prevented dendritic atrophy in the hippocampus [ 93 ]. Chronic maternal separation stress in mice is associated with decreases in glucocorticoid receptor mRNA in the brain, especially so in the amygdala, which is in turn associated with alterations in anxiety-like and social behaviors. Restoring the glucocorticoid receptor mRNA deficit in the amygdala reverses the changes in anxiety and social behavior [ 100 ]. Additionally, in male mice, enhanced freezing behavior in the context of a conditioned threat paradigm after exposure to fragmented maternal behaviors can be reversed by blocking glucocorticoid receptors [ 95 ].

In humans, similar changes in brain structure and function after experiences of stress in childhood are evidenced in the amygdala, PFC, and hippocampus. Indeed, one of the most reliable findings in children exposed to early life stress is reduced hippocampal volume [ 29 , 53 , 56 ]. Reduced hippocampal volume in children exposed to a range of different types of early life stress, including abuse, neglect, and living in poverty, has been linked to increased symptoms of psychopathology [ 101 , 102 , 103 , 104 ]. Additionally, changes in hippocampal volume are thought to be associated with deficits in learning processes in children who experience early life stress [ 7 , 105 , 106 ]. A growing literature also indicates that early life stress is associated with changes in amygdala and PFC reactivity to emotional stimuli as well as altered connectivity between the two regions [ 51 , 52 , 107 ]. Cumulative stress, severe neglect from early institutionalization, and abuse have all been associated with heightened amygdala reactivity to emotional images [ 28 , 108 , 109 ]. This heightened reactivity appears to be at least partially a result of altered PFC–amygdala connectivity, leading to increased sensitivity to emotionally salient cues [ 107 , 110 , 111 ]. Indeed, children with a history of maltreatment, which includes emotional, physical, and sexual abuse and emotional and physical neglect, appear to demonstrate atypical connectivity between the amygdala and inferior frontal gyrus [ 112 ], and children growing up in poverty is associated with atypical ventrolateral PFC–amygdala connectivity [ 113 ]. Longitudinal work suggests that children exposed to various forms of early life stress demonstrate an atypical trajectory of age-related changes in PFC–amygdala connectivity as compared to peers who were not exposed to early life stress [ 51 ]. The strength of PFC–amygdala connectivity appears to mediate the relationship between maltreatment exposure and anxiety and depressive symptoms [ 114 , 115 ]. Structural and functional alterations in PFC–hippocampal–amygdala circuits in individuals exposed to various forms of early life stress suggests that alterations in these circuits play an important role in the relationship between early life stress and its effects on development.

As with non-human animals, there is also evidence that changes in CRH and glucocorticoid function may partially mediate the neural effects described above [ 34 , 54 ]. Indeed, there is some evidence that humans demonstrate similar epigenetic changes in glucocorticoids to those observed in non-human animals, and these alterations are associated with changes in the hippocampus, symptoms of psychopathology, and altered learning processes [ 72 , 116 , 117 , 118 ]. Additionally, abnormal hypothalamic pituitary adrenal responsivity is often observed after a variety of experiences of early life stress, including poverty, family violence, maltreatment, and institutional deprivation, although this varies with age [ 54 , 68 ]. This, in parallel with the animal literature demonstrating that extended exposure to glucocorticoids leads to hippocampal atrophy and dysregulation of the HPA axis [ 119 , 120 ], has given rise to the hypothesis that chronic activation of the HPA axis through exposure to severe and/or extended stress leads to neural alterations in the PFC, hippocampus, and amygdala. This in turn produces dysregulation in systems responsible for responding to potential threats and challenges in the environment [ 64 , 71 ]. This dysregulation of stress response systems can lead to increased risk for both mental and physical health issues [ 121 , 122 , 123 ].

The effects of early life stress on PFC–hippocampal–amygdala circuitry are thought to be in part related to alterations in emotion processing produced by the types of early inputs children in high stress environments experience. Relative to non-maltreated children, children who experience physical abuse have heightened perceptual and physiological sensitivity to angry facial expressions [ 124 , 125 ] and are more likely to perceive emotional situations as demonstrating anger as early as preschool age [ 41 ]. Physically abused children also more readily categorize faces that are morphed between two different emotions as angry [ 126 ] and require less perceptual information to identify faces as angry than non-maltreated children [ 124 ]. Additionally, physically abused children show biases to angry faces during cognitive tasks. They respond more quickly to angry faces during a Go/No-Go paradigm [ 22 ] and seem to require greater cognitive resources to disengage their attention from angry faces, showing delayed disengagement when angry faces served as invalid cues in a selective attention paradigm [ 127 ]. Children who are exposed to extreme threat appear to preferentially attend to and identify facial movements that are associated with threat, such as a scowling facial configuration [ 125 , 128 , 129 , 130 , 131 ], and more reliably track the trajectory of facial muscle activations that signal threat [ 132 ]. This close attention to cues of anger likely shapes how abused children understand what facial movements mean. For example, one study found that 5-year-old abused children tended to believe that almost any kind of interpersonal situation could result in an adult becoming angry; by contrast, most non-abused children understand that anger is likely in particular interpersonal circumstances [ 133 ].

Studies of maltreated children (including those who experience neglect and other forms of abuse) also show less accurate identification of facial emotions in general [ 41 , 131 ] and particular difficulty identifying positive emotions [ 134 ]. In addition, these children demonstrate abnormalities in the expression and regulation of emotions [ 135 ]. Neglected children show delays in perceiving emotions in the ways that adults do [ 41 ]. Maltreated children also show higher levels of rumination (repeatedly dwelling on past negative experiences), which has been associated with an attention bias to sad faces [ 136 ] and may contribute to risk for depressive symptomatology. The combination of difficulties with emotional recognition, expression, and regulation may increase children’s risk for a broad range of maladaptive outcomes. For example, misreading others’ facial emotion might impair peer interactions, while problematic emotion regulation and expression may contribute to rumination and/or aggressive behavior. The effects of maltreatment on children’s recognition of and attention to emotion are thought to, in part, be shaped by the broader environment in which they are raised. Children who grow up in environments where emotional interactions with caregivers are highly atypical have different developmental trajectories than do those growing in more consistently nurturing environments [ 8 ]. Parents from these high-risk families signal emotions unclearly, and express more anger [ 14 , 29 , 137 , 138 ]. Together, this suggests that exposure to increased levels of potential threat alters children’s perceptual processes such that they become more likely to perceive situations others may not find threatening as threat, likely resulting in extending activation of prefrontal–hippocampal–amygdala circuits and associated peripheral stress response systems.

Alterations in prefrontal–striatal dopaminergic circuits

Recent evidence suggests that early life stress also has a range of negative effects on dopaminergic circuits involved in motivation, specifically those related to reward processing [ 138 , 139 ]. Animal models of early life stress have been associated with changes in circuits classically implicated in motivation to obtain and pursue rewards, including the ventral striatum, prefrontal cortex, and amygdala [ 140 , 141 ]. Chronic repeated separation of rodent pups from their mothers alters the number of dopaminergic glial cells, affects rate of cell proliferation and death, and promotes aberrant dopaminergic signaling in the ventral tegmental area and substantia nigra in adulthood [ 142 , 143 , 144 ]. Additionally, alterations in maternal care have been associated with reduced connectivity between the PFC and caudate putamen [ 145 ] as well as structural and functional alterations in the nucleus accumbens [ 79 , 146 ]. These changes have been linked to increased anhedonia-like behaviors [ 147 , 148 ] and altered sensitivity to reward, both hyper- and hyposensitivity depending on the paradigm utilized [ 149 , 150 ]. As with changes in the hippocampus and amygdala, chronic exposure to glucocorticoids, through interactions with dopaminergic neurons, appears to play an important role in mediating some of these effects [ 151 , 152 , 153 ].

In humans, disruptions during reward processing have been observed in the nucleus accumbens, ventral tegmental area, ventral striatum, and PFC after experiences of early life stress [ 154 , 155 , 156 , 157 ], and these disruptions are associated with depressive and anxiety symptoms in adolescents and adults [ 158 , 159 , 160 , 161 ] as well as altered reward learning [ 11 , 15 ]. Specifically, children who experienced maltreatment demonstrate decreased striatal, orbitofrontal cortex, and hippocampal activation during reward learning [ 157 ], and children with high early life stress demonstrate decreased activation of the putamen and insula when anticipating future losses [ 138 ]. Additionally, in children exposed to early life stress, ventral striatal activation has been demonstrated to mediate variation in reward related learning [ 162 ]. Importantly, these circuits are highly connected with both the amygdala and prefrontal cortex, which together play a key role in psychological and behavioral responses to stress, emotional and social learning, and self-regulatory processes [ 163 , 164 ]. These disruptions likely then place children at increased risk for maladaptive behaviors, along with negative mental and physical health outcomes later in life.

Despite the relationships between early life stress and alterations in both PFC–hippocampal–amygdala and dopaminergic reward circuitry outlined above, we still understand relatively little about how these changes are associated with altered learning and behavioral patterns and how they increase risk for mental and physical health disorders and disease. Additionally, it is still unclear which changes are important for different types of health risks and what supports individual differences in children’s outcomes after experiences of early life stress. While the frameworks for conceptualizing early life stress outlined above were developed to try and address this question, there are still many findings that are not fully accounted for, suggesting that additional factors may also be critical for shaping children’s neurobiological responses to stress.

Promising future approaches to elucidating the mechanisms of early life stress

A commonality across both general and specific models is a focus on identifying types of events a child may or may not be exposed to that meet the criteria of a stressor based on some outside determination (be it criteria set by child protective services for abuse or neglect, economic guidelines for poverty, or researchers determination that one thing represents a stressor over another). But an additional insight into the neurobiological mechanisms underlying the effects of early life stress may lie with an individual child’s interpretation or perception of those events. Even in non-human animal models, which do evidence specificity in responses to stress [ 165 , 166 ], there are a range of individual differences in behavioral responses to the same type of stressor [ 167 ]. These individual differences in behavior are supported by different physiological and neural mechanisms [ 168 , 169 , 170 ]. Similar variability in response to adverse events is observed in humans across neurobiological stress responses systems [ 66 , 171 , 172 , 173 ], and this variability has been linked to differential health behaviors and symptoms [ 174 , 175 , 176 ].

This range of variability in neurobiological responses to similar types of stressors has led to the proposition that it is not the type or features of an adverse event, but rather the organisms’ perception and interpretation of that event, that that has different effects on neurobiological systems [ 166 , 177 , 178 ]. There is now a wealth of research in adults demonstrating that individual variability in neurobiological responses to stress is informed through the assessment of factors that shape perceptions and interpretations of stress [ 10 , 179 , 180 ]. For example, individual variability in cortisol responses to social speech stress is positively related to how individuals rate their perceived stress during the stressor [ 175 ]. Shifts in how humans and animals perceive the controllability and predictability of a stressor will change their physiological responses to that stressor [ 181 , 182 , 183 , 184 ]. In humans, individual differences in perceptions of control have been linked to differential cortisol responses to acute laboratory stress, differences in brain volume, and differences in brain reactivity to stress in regions including the hippocampus, amygdala, and prefrontal cortex [ 185 , 186 , 187 ]. Additionally, perceived adversity, and its associated neurobiological responses, can occur in the absence of any specific identifiable environment event through rumination over previous experience or events or anxiety about future events [ 188 , 189 , 190 ]. Recent evidence in children suggests a similarly important role for perception in variability in stress responses. One study utilizing machine learning approaches found that event exposures are not highly predictive of children’s outcomes [ 191 ] and another found reported exposure to abuse or neglect is more predictive of children’s mental health outcomes than exposure identified through court reports [ 192 ].

There is a growing literature suggesting that the chronicity, developmental timing, and intensity of adversity exposure are important factors shaping the effects of adversity on children [ 68 ]. In animal research, the precise timing of when during development a stressor occurs can be tightly controlled, and has demonstrated strong effects as described in a number of recent reviews [ 46 , 68 , 193 , 194 ]. However, the developmental period in which adversity occurs is tightly intertwined with the chronicity of adversity (that is, adversity that begins early in a child’s life may be longer lasting and chronic than adversity that begins later in a child’s life), which also demonstrates profound effects on variability in responses to stress [ 82 , 195 ]. Children with high scores on the Life Stress Interview (LSI), which quantifies the intensity of children’s stress exposure, have smaller amygdala and hippocampal volumes than children exposed to less intense levels of early life stress [ 29 ]. Children with high levels of early life stress demonstrate altered activation in circuits involved in value processing during anticipation of rewards and losses [ 138 ]. Retrospectively reported severity of early stress exposure in childhood has also been associated with increased dorsal medial PFC responses to a social stressor [ 196 ] and altered global connectivity of the ventrolateral PFC [ 197 ]. Both severity and amount of maltreatment in children have been linked to epigenetic changes of the glucocorticoid receptor gene [ 198 ]. Additionally, variations in intensity of early adversity appears to modulate HPA responses with retrospectively reported intensity of stress, rather than type of stress, during early childhood being associated with increased levels of cerebrospinal fluid (CSF) CRH [ 199 ], and increased cortisol responses to acute social speech stress [ 200 ]. Children’s rated intensity of adversity also interacts with age to predict cortisol awakening responses [ 201 ].

Another potential factor in shaping child development may be features of the early environment such as predictability and contingent responding of caregivers (or, alternatively, chaos and lack of stability) [ 140 , 202 ]. Parent–child relationships are stereotypically repetitive, highly predictable, and marked by contingent parental responses. In normative contexts, adult caregivers reliably respond to infant cries, comfort a child who is hurt, and provide support to a child who is dysregulated [ 203 , 204 ]. Lack of predictable and contingent input from caregivers affects children’s expectations of the environment, leading to uncertainty and perceptions of vulnerability [ 11 , 137 ]. While there is limited research directly assessing variation in the predictability of children’s environments, there is a growing literature that suggests it has the ability to provide great insight into the mechanisms underlying experiences of early life stress. Longitudinal research assessing early influences on adolescents’ externalizing behaviors finds that unpredictability of the environment during childhood, quantified using changes in maternal employment, changes in residence, and changes in cohabitation, is associated with increased externalizing behaviors in adolescence while SES was not related [ 205 ]. Recent research in rodents suggests that these observed effects are a result of altered functioning in prefrontal–hippocampal–amygdala circuits, finding that unpredictable maternal inputs are associated with altered connectivity between the medial prefrontal cortex (PFC) and amygdala [ 91 ] as well as decreased dendritic arborization in the hippocampus [ 206 ] beyond effects produced by types of maternal inputs. These effects are linked to PTSD and depressive-like behaviors as well as deficits in learning [ 140 ]. Together, this body of work suggests that variation in the predictability, stability, and/or degree of contingent responding of adult caregivers to the needs of the developing child is a factor in shaping children’s responses to adversity through alterations in prefrontal cortical and subcortical stress response circuits. It indicates that assessment of predictability of early environments, along with exposure to negative events, has the potential to provide increased insight into individual differences in the neurobiological effects of early adversity on child development that is not captured when focusing solely on types of adverse events.

Last, increasingly research supports a role for perceived safety in contributing to variations in children’s responses to stress. Safety/security in early childhood has been characterized in a variety of different ways, with things such as parental presence/adult “buffering,” sensitivity, responsivity, and support thought to be cues of safety, and lack of parental input, through isolation, maternal separation, or neglect, or abusive parenting behaviors being cues of lack of safety [ 207 , 208 , 209 ]. Cues of safety early in development play an important role in engaging the prefrontal circuits that inhibit threat response circuits, which will have implications for how children perceive and interact with their environment later in life [ 210 ]. Indeed, evidence from non-human primate and rodent models supports this finding that early parental presence plays an important role in inhibiting neurobiological threat response systems, with both rodent pups and infant primates demonstrating reduced glucocorticoid release and decreased amygdala activation in the presence of the mother [ 207 , 211 ]. However, in cases of abusive maternal rearing, maternal presence does not appear to exhibit buffering effects. Under these circumstances, rodent pups and primate infants demonstrate enhanced glucocorticoid responses to stress [ 207 , 212 ] as well as alterations in both the structure and function of the amygdala and prefrontal cortex [ 213 , 214 , 215 ]. From this literature, it is clear that parental presence, a salient early cue of safety, is important to supporting typical development of the neurobiological stress response systems.

There is some evidence indicative of similar early regulatory effects of parental presence on the development of stress response systems in humans [ 208 , 216 ]. In parallel to the rodent and primate literatures, parental presence has been demonstrated to dampen both cortisol [ 217 , 218 ] and amygdala reactivity [ 219 ] to stress in children. Presentation of parent voice during speech stress has been associated with faster cortisol recovery post-stressor [ 218 ], suggesting that parent support does not necessarily need to be physical to buffer children’s responses to stress. There is also evidence that early adversity is associated with altered prefrontal–amygdala connectivity, and these alterations have been linked to children’s risk for psychopathology [ 51 , 114 , 220 ]. This points to disruptions in the development of these circuits in children lacking early cues of safety that have implications for their behaviors and mental health. However, in cases of adversity where children still receive high levels of support from their parents, these effects are mitigated, with adolescents living in poverty showing altered connectivity in prefrontal cortical networks involved in executive functioning and emotion regulation, but not if they reported having high levels of parent support [ 221 ]. Additionally, support provided by other adults or peers may diminish some of the bio-behavioral effects of adversity, with reported social support from family and friends being associated with reduced risk of psychopathology in children who experience maltreatment [ 222 , 223 ]. This suggests that, at least in humans, individuals outside of the parent–child relationship may be able to supplement these safety cues when they break down. Consistently incorporating assessment of factors that represent early cues of safety, such as parental support, when studying how children respond to early adversity, has the potential to greatly illuminate the neurobiological mechanisms through which negative environments shape development.

There is consistent evidence that early life stress exposure changes neural plasticity and function, and these changes have implications for children’s mental and physical health across the lifespan. Studies assessing differential effects of events along with timing and intensity of events, predictability and contingency of environmental inputs, and perceptions of safety and social support suggest that these factors differentially shape biological systems involved in stress. Of course, it is the case that there are probably bidirectional effects between exposure to potentially stressful events shaping children’s perceptions of their environment in turn resulting in children perceiving their environment as more stressful. For this reason, it may seem like it is easier to establish causality through approaches focusing on identifying events and their associated outcomes. However, while events themselves likely contribute to how children perceive their environment, approaches which focus only on events are missing a multitude of other sources of variation in these perceptions. Further incorporation of factors that may shift how individuals interpret their environment, in combination with event based methods of assessment of stress and rigorous longitudinal studies with assessments at multiple timepoints, has the potential to provide increased insight into the specific neurobiological mechanisms influencing children’s development. This type of approach can aid in identifying what may produce resiliency to negative mental and physical health outcomes in children who experience early life stress.

In this article, we have highlighted recent research speaking to the neural mechanisms underlying the effects of early life stress on development. The existing literature supports effects of early life on the development of the prefrontal cortex, hippocampus, hypothalamus, and amygdala, along with communication across those areas, in ways that produces increased vulnerability to mental and physical health disorders later in life. These changes appear to be at least partially mediated through hormonal and neuropeptide alterations in the HPA axis along with interactions with genetic and epigenetic factors. Additionally, there is increasing evidence for a role of dopaminergic reward circuits in these relationships. However, to date, we still lack a good understanding about how these changes come about, what aspects of the child’s environment produces these changes, and, given not all children who experience early life stress develop later psychopathology, what their role is in individual differences in children’s outcomes after early life stress.

Availability of data and materials

Not applicable.

Abbreviations

Prefrontal cortex

Hypothalamic–pituitary–adrenal

Corticotropin-reducing hormone

Cerebrospinal fluid

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Acknowledgements

This work was supported by the National Institute of Mental Health through grant R01MH61285, a James McKeen Cattell Fund Fellowship, and by a core grant to the Waisman Center from the National Institute of Child Health and Human Development (U54 HD090256) to SDP. KES was supported by an Emotion Research Training Grant (T32MH018931-30) from the National Institute of Mental Health.

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Smith, K.E., Pollak, S.D. Early life stress and development: potential mechanisms for adverse outcomes. J Neurodevelop Disord 12 , 34 (2020). https://doi.org/10.1186/s11689-020-09337-y

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Defining quality in early learning and child care (ELCC) settings is complex. With an increased emphasis on universal ELCC systems to support greater access for families, research is needed to provide clarity on the concepts that contribute to high-quality programs. In this scoping review, 41 literature sources met our criteria (of a possible 6335) to determine what is known about high-quality early childhood programming in publicly-funded, school-based settings using a systems framework. Using a thematic analysis and consistent with a systems lens, our results suggest an overarching influence from system-level policies that intersect with practice, people and place within early childhood education and care.

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Introduction

Quality early learning and child care (ELCC) impacts both labour market growth and child development (Burger, 2010 ; McLeod et al., 2018 ). There is greater understanding of the early development of the brain (Mustard, 1999 ) that has led to increased attention on the importance of environments that support children’s growth and learning. Systematic examination of ELCC settings has highlighted the differential impacts on child developmental outcomes and the importance of quality in ELCC settings and systems (Burger, 2010 ; Magnuson & Shager, 2010 ; McCain et al., 2007 ). Internationally, attention to the concept of quality has been ongoing and has evolved as approaches to ELCC policy, programming, and processes shift to meet the changing needs of a population. At the same time, there has been increased emphasis on universal ELCC systems to support greater access for families, especially for those at socioeconomic disadvantage. As an example, the Canadian federal government through their Canada-Wide ELCC agreements with provincial and territorial governments has committed to work towards the creation of an affordable, accessible, high-quality, and inclusive system of ELCC (Doering, 2021 ). Further, universally funded programs targeting children prior to entry into the formal school system (typically four-years old or Pre-Kindergarten age) and co-located in existing school settings is a recent model for the delivery of ELCC (Carolan et al., 2020 ; Corter et al., 2012 ; Peters et al., 2016 ). Although there is an established body of research examining the general concept of quality (Layzer & Goodson, 2006 ; Slot, 2018 ), there is less known about specific quality elements reflected within ELCC programs that are universally funded and co-located in schools. Therefore, the purpose of this paper was to conduct a scoping review to examine what was known about high-quality early childhood programming in publicly-funded, school-based settings.

Well-designed ELCC programs can meet a number of objectives for families and children; along with social support for parents, there is the potential for rich educational experiences for children to shape their collective future (Friendly & Prentice, 2009 ; Pacini-Ketchabaw et al., 2021 ). The increasing focus on quality programming in ELCC systems demonstrates recognition of the value of intentional and responsive programming during the early years. Quality is most often discussed within the categories of structural and process quality (Ishimine et al., 2009 ; Slot, 2018 ). Structural quality refers to measurable program aspects that are determined by regulations which are believed to effect classroom quality (Bigras, 2010 ; Howes et al., 2008 ; Ishimine et al., 2009 ; Pianta et al., 2005 ; Slot, 2018 ). These elements include educator qualifications and training, adult-child ratios, and class group sizes. Process quality refers to more intangible aspects around the interactions and experiences of those within the program, including teachers, caregivers, and children (Bigras, 2010 ; Howes et al., 2008 ; Ishimine et al., 2009 ; Pianta et al., 2005 ; Slot, 2018 ). Structural elements of quality are often regulated and are considered precursors to process quality (Slot, 2018 ). For example, an educator’s qualifications can influence their interactions and relationships with children (Bigras, 2010 ). However, quality is a complex concept that can vary based on individual perspectives and experiences (Layzer & Goodson, 2006 ). For example, parents might be more likely to place an importance on school readiness and safety, whereas educators and other program staff may put an emphasis on working conditions like the physical space and co-worker relations (Friendly et al., 2006 ).

As the perception of child care shifts from being, predominantly, a labour-market support to that of a public service (All for Child Care, 2018; Bennett 2008 ; Savigny, 2017 ), an emphasis is placed on developing equitable systems that allow all families access to high-quality ELCC programs, not only those with higher income and education who can choose and pay for higher quality programs (Farran & Hofer, 2011 ). To this end, some regions are working towards universal access through the development and provision of programs for children the year before school entry, often focused on four-year old children (e.g., referred hereafter as Pre-K, also known Pre-Kindergarten, Junior-Kindergarten or Pre-primary) (Clifford et al., 2005 ; Friendly et al., 2021 ), which has been suggested as an opportunity to reduce socio-economic inequalities (West et al., 2010 , p. 155). Pre-K programs can be located in a variety of settings, including within public schools, which offers a unique connection to the broader education system (Clifford et al., 2005 ). Co-locating ELCC programs within a public-school system offers a further advantage to universal programs by providing an infrastructure that allows all families to access publicly-funded, high quality ELCC within their community (McIsaac et al., 2019 ). This universal approach reaches children from low-income and vulnerable families along with families who are not considered vulnerable and has been associated with better-quality outcomes as compared to programs targeted to vulnerable populations (Akbari et al., 2021 ; Barnett, 2010 ).

Theoretical Framework

The application of systems thinking as a theoretical framework can be used to further understand the impacts that environments and interactions have on influencing quality in ELCC. Viewed through a systems framework, macro-level sociocultural (values and beliefs) and meso-level temporal (political, economic and environmental circumstances within a jurisdiction) factors are critical overarching elements required to implement and sustain quality programs within an ELCC system (Kagan & Roth, 2017 ). Infrastructure sub-systems, such as program quality, assessment and family/community engagement all interact as related elements that operationalize high-quality programs at a proximal level within the broader ELCC system (Kagan & Roth, 2017 ). A systems framework allows consideration of change over time (i.e., chronosystem) and identification of different levels of influence (Bronfenbrenner, 1977 ; Paquette & Ryan, 2001 ) that can provide a roadmap to ensure high-quality programming.

Study Purpose

There is growing attention to universal, publicly-funded programs and an understanding that high-quality programs are necessary to achieve the developmental goals for children (Barnett, 2010 ). However, given the unique nature of universal ELCC programs, particularly those that are co-located in schools, it is important to clarify the concepts that relate to program quality in these settings and to identify knowledge gaps (Munn et al., 2018 ). A scoping review methodology provides a valid systematic search process to address the purpose of this study which focused on the following research question: What is known about high-quality early childhood programming in publicly-funded, school-based settings? Scoping reviews offer a relevant approach to summarizing literature to map the scope and range of literature to provide a definition and conceptual boundary for a complex topic (Arksey & O’Malley, 2005 ; Peters et al., 2015 ). A systems framework was used to help interpret the findings of the review and advance our understanding about high-quality early childhood programming specifically in publicly-funded, school-based settings.

Identifying Relevant Studies

Given the expected complexity and heterogeneity of the literature (i.e., non-peer reviewed sources indexed outside of traditional academic databases), a modified scoping review process (Cooper et al., 2018 ) was used to involve a selection of experts to identify relevant academic and grey literature in addition to the methodological approach recommended by the PRISMA-ScR checklist (Tricco et al., 2018 ). A list of 28 international early childhood education experts was developed by the research team based on published expertise in early childhood program quality. Experts were contacted by email and were provided an outline of our review question, initial inclusion/exclusion criteria, and were asked to recommend potential research articles and other pertinent literature.

With support from an evidence synthesis expert and with a selection of target articles, we developed a key word search strategy that initially focused on the population context, “early childhood,” AND “public system/education.” Next, the results from this search were combined with the search concept of “program quality” OR “assessment.” Variations for each key word were combined with the “OR” operation to maximize results. EBSCO was the primary electronic database that was searched, which included literature from January 2000-May 2020 indexed within ERIC, Education Research Complete (ERC), Child Development and Adolescent Studies (CDAS), Canadian Business and Current Affairs (CBCA) Complete, and Scopus. We also explored grey literature using an advanced Google search within the websites of key organizations or associations focusing on key terms (see Supplementary Material for Search Translation information).

Our inclusion and exclusion criteria were developed as we gained familiarity with the literature (Arksey & O’Malley, 2005 ), focusing on population/context, concept, types of literature (see Table  1 ). We were interested in literature that included the following three population criteria related to early childhood programs that were: (1) delivered through universal, publicly-funded system in high-income countries (OECD, 2020 ; The World Bank, n.d. ); (2) connected to education or school systems, and (3) focused on children in the year before public school entry. Included literature also needed to provide an explicit definition or contribute to the identifying elements of program quality in the respective early childhood setting. We excluded literature that did not focus on the above stated population criteria or contribute to the concept of program quality, as well as being published prior to 2000 and that were not written in the English language.

Following the electronic searches and expert recommendations, all literature was imported into a systematic review management platform (Covidence) for screening. Duplicates were removed before the process of reviewing and assessing literature to determine if they fit the inclusion criteria. Two reviewers independently completed the first level (title and abstracts) and second level (full-text) of screening title and abstracts, and conflict resolution through reviewer discussion occurred as needed. Team consultation was used when the conflict could not be resolved between the reviewers. For grey literature, one reviewer scanned the first two pages of the search results from the organization and potentially relevant literature was screened by two reviewers to determine if it met the inclusion criteria.

Data Abstraction and Synthesis

We synthesized the included literature using a process of independent charting by two researchers using Microsoft Excel focusing on key characteristics including: author(s); publication year; geographic location; article title; purpose statement; research study design; child age in program term; child age in years, theoretical frameworks/perspectives; program details; connection to school; funding structure; universal access; measures of quality; and standards of quality (see Supplementary Item). Further study abstraction included a descriptive numerical summary that focused on frequency counts on key study elements as well as a thematic analysis of the quality descriptions across the included literature (Braun & Clarke, 2006 ). Open coding was applied using MAXQDA to the quality descriptors by two researchers to identify common concepts that were used to describe/define quality in the included literature. Following open coding, the two researchers grouped concepts together informed by a systems framework (Kagan & Roth, 2017 ) to capture how common concepts of quality effect the different levels of the ELCC system, including at the system, program, and individual level.

Search Outcome

Following the retrieval of documents from electronic databases, field experts, and grey literature, and the removal of duplicates, a total of 6335 (6201, 87 and 47 respectively) literature sources remained for screening. Figure  1 depicts the screening process resulting in a total of 41 included literature sources. Table  1 provides a descriptive overview of the included literature sources and includes categorical definitions for key charting components of funding, access and connection to school. The majority of the literature were considered descriptive reports (n = 27) and were related to ELCC contexts in the United States of America (n = 26). Other countries with literature included Canada (n = 3), Australia (n = 3), United Kingdom (n = 3), and there was one each from Chile, Spain, and Ireland. Four sources included multiple countries and in two cases, on more than one continent. Much of the included literature discussed mixed funding (59%), meaning both private and public provision, with the remaining literature directly referencing public funding. Included literature often referenced programs that were categorized as located in schools (n = 21), such as publicly administered preschool or Pre-K classrooms. Other literature was categorized as either being administered by a public system (n = 3), mixed delivery in schools and administered by the public system (n = 7), or that it was not clearly identified (n = 10). The most frequently referenced types of access were mixed programs (42%), meaning that the source discussed two or more different types of programs, including programs delivered through a universal, targeted, or hybrid model. Universal (n = 11), targeted (n = 5) and hybrid (n = 3) programs were also identified with some being not clearly identified (n = 5).

Prisma Flow Chart

Qualitative Thematic Analysis: Quality Descriptions

A thematic analysis was completed on the quality descriptions noted in the included literature and a systems-thinking approach to identify the relationships among these identified elements. The resulting figure demonstrates the identified themes impacting quality within publicly-funded, universally accessible, programming for four-year-olds connected to the public-school system. Consistent with a systems lens, our results suggest an overarching influence from system-level policies that intersect with practice, people and place within early childhood education and care (Fig. 2 ).

Themes identified as influencing early childhood education and care in universal, publicly-funded settings

This overarching theme included references to internal and external policies related to ELCC systems that can influence quality at all systems levels and includes elements such as government investment/funding, regulations and standards, assessment and evaluation.

Government Investment

Sufficient levels of government investment and funding (n = 10) was found to be an important foundation of quality ELCC to both develop and maintain a system that meets the needs of children and families (Friendly et al., 2006 ; Kagan & Rigby, 2003 ; Minervino, 2014 ). Given that this review focused on publicly-funded programs, it was expected that government involvement would be an included element; however, several sources in the review specifically noted it was an essential component of quality (Barbarin et al., 2006 ; Jenkins, 2003 ; Saluja et al., 2001 ; Bertram & Pascal, 2016 ) further noted that countries with a high quality ELCC have a policy strategy that is led by government. The most referenced form of public funding was government/public funds (e.g., national/regional level or departmental), as well as grants and subsidies.

Regulations and Standards

A prominent influence on quality identified within the literature was the development and application of regulations and standards (n = 11). Regulations and standards, generally developed and monitored by a jurisdictional regulatory body, (e.g., a government department or ministry), provide a minimum floor of quality for programs to meet (Jenkins, 2003 ; Bertram & Pascal, 2016 ) noted in their examination of early childhood systems in eight countries that the development and application of ELCC regulations, standards, and services are better managed when they fall under one regulatory authority, yet in many jurisdictions the responsibility of ELCC is often split into two or more departments. Regulatable features, which generally focus on children’s health, safety, well-being, and protection, often include maximum class sizes, educator qualification levels, and educator to child ratio (Early Childhood Development Steering Committee, 2009 ; Kagan, 2008.; Kagan & Reid 2008 ). Specific to the focus of this review, two of the literature sources noted that additional regulations and standards should be considered for elements specific to school-based locations, such as playground accessibility, school principal training, and school environments (Farran, 2017 ; Sandstrom, 2012 ).

Assessment and Evaluation

Assessment of the ELCC system was discussed as a way of supporting quality through both child outcomes and assessment of programs (n = 13). Assessment can allow for the improvement in quality, as it is a tool to gather evidence about how quality can be improved (Frede, 2005 ; Dwyer et al., 2000 ) noted that program assessments can serve a variety of purposes including a way to communicate with parents, monitor goals, identify supports needed for inclusion, and as a general tool that can be used in both monitoring and planning instruction. Regular program assessment and evaluation was also suggested as contributing to quality by allowing for data-driven decision-making related to funding, programming, policies, and long-term strategic planning (Weisenfeld et al., 2018 ). Monitoring and accreditation (n = 8) were also referenced as components of a quality ELCC system. Specifically, using program monitoring to identify areas of improvement and collecting data for the purposes of accreditation were viewed as a means to support quality in ELCC programs (Bertram & Pascal, 2016 ; Early et al., 2006 ; Murphy, 2015 ). Accreditation was described as motivating programs to go beyond base level standards by providing them with rewards, recognition, or financial incentives as a means of acknowledging and promoting quality (Jenkins & Englander, 2016 ; Kagan & Rigby, 2003 ; Pianta et al., 2016 ).

This theme includes components of pedagogy; adult-child ratios, and class sizes; educator/child interactions; and inclusion and diversity.

Pedagogical elements are an integral part of a high-quality care environment and were often described in the literature (n = 34). Many jurisdictions have introduced curriculum frameworks to guide the practice of ECEs working with young children in the years before formal school entry. In their examination of European curriculum frameworks, Melhuish et al., ( 2015 ) found that there was an emphasis on optimal child development through activities that “follow children’s individual ways of learning, and encourage play, exploration, and self-expression” (p.54). Bertram & Pascal ( 2016 ) studied pedagogical approaches across eight countries and found that most used a play-based approach.

Adult-Child Ratios and Class Sizes

Other commonly referenced program features included adult-child ratios (n = 27) and class sizes (n = 23). Lower adult-child ratios and class sizes were noted as being elements of higher quality programming (Bogatic et al., 2017 ; Gallagher et al., 2001 ; Jenkins & Englander, 2016 ; McCartney et al., 2011 ; Peterson, 2013 ; Rouse et al., 2005 ; Minervino, 2014 ) found that in high-quality Pre-K programs, the classrooms had two adults and a class size of twenty-two children or less. Rebell et al., ( 2013 ), recommended that for those classrooms that have children requiring additional support (e.g., children with disabilities, English language learners), programs should have lower-class sizes. One literature source in Ireland noted that lower adult-child ratio was a standard quality measure, and those programs that did not meet this standard, resulted in ‘poor outcomes’ for children with disabilities (The National Disability Authority, 2014 ).

Educator-to-Child Interactions

The various interactions that occur within the ELCC program were also described as influencing quality, such as those that involved educator-to-child (n = 14) and child-to-child (n = 4). The type and quality of interactions children experience can support their development, specifically, their language development, social and cognitive development, and self-regulation (Siraj et al., 2016 ). Quality measures should include the nature of educator-child interactions, with a focus on ensuring positive relationships (Boufford, 2014 ; Little, 2018 ; Magnuson & Waldfogel, 2005 ; Sylva et al., 2010 ; Goelman et al., 2008 ) described how good quality programs were those which included “adult-child interactions that were responsive, cognitively challenging, and encouraged joint attention and negotiation of sustained shared thinking” (p.8).

Inclusion and Diversity

High quality ELCC programs were described as being inclusive of all children, acknowledging and celebrating diverse abilities, cultural backgrounds, and family structures (n = 13). As described by Goelman et al., ( 2008 ), cultural, linguistic, and socioeconomic differences between families and communities may create access barriers to ELCC programs. Further, the importance of having a range of additional services to meet the diverse needs of at-risk children and families was described in the literature as important to ensuring equitable access (Pianta et al., 2009 ; Rebell et al., 2013 ).

The place, or location of an early learning program was commonly referenced as a component of quality ELCC programing, as was the time spent in the place. In the literature that specifically referenced universally accessible programs, the care environment was the element of quality most frequently mentioned.

Learning Environment

This component was described through references to the physical space, such as access to materials and equipment and space furnishings as well as location within a school environment (n = 15). Intangibles, such as the emotional climate and safety, were also included when examining the care environment. Early et al., ( 2007 ), noted that even the most highly qualified educators need the necessary classroom characteristics, such as adequate materials, to create a quality learning experience.

Although there were few examples in the included literature that directly connected location to quality, there was some evidence in several sources (n = 5) that situating ELCC programs within a public-school system can provide easier access for families and allows for increased public investment through the creation of integrated ministries/departments for both education and care. Goelman et al., ( 2008 ) describe what this successful integration looks like in the Nordic countries where seamless sets of services are provided for children allowing them to remain in one physical space, rather than being moved between different environments. Locations in schools provide a stable infrastructure for universal Pre-K program delivery and provide the opportunity for collaboration between Pre-K and Kindergarten teachers (Kagan & Reid, 2008 ; Little, 2018 ).

The amount of time spent within the space (dosage) was related to positive outcomes for children (n = 8) both in terms of the number of years that a child attended and the number of hours per day and days per week that a child attended a program (Little, 2018 ; Minervino, 2013 ; Pianta et al., 2016 ; Preston et al., 2011 ). In a review of the research on early intervention and early learning programs, Goelman et al., ( 2008 ) found that “developmental outcomes depend upon program duration (how long the child has attended the program) and intensity (the coherence, clarity, and implementation of the learning activities”.

This theme identifies the influences of early childhood educators on quality programming as well as the impacts that other stakeholders have including school personnel, families, and community and partnerships among these individuals, on the quality of ELCC programs in publicly-funded, school-based settings.

Educator Qualifications and Experience

The majority of literature included in this review (n = 36), referenced educator qualifications as playing an important role in quality programming. These literature sources highlight that higher, more formal qualifications meant educators were better able to provide quality programming that met the developmental needs of this age group. As Melhuish & Gardiner ( 2019 ) found, while state-funded nurseries had less favorable ratios, they still showed higher process quality compared to private programs, most likely due to higher caregiver qualifications (Melhuish & Gardiner, 2019 ; Goelman et al., 2008 ) stated that teacher education is a “major predictor of children’s developmental outcomes” (p. 7).

In addition to post-secondary qualifications, having experience specific to early childhood education (n = 5) was another element of quality cited in the literature and was commonly linked to qualifications. Multiple literature sources suggested that “even a good curriculum cannot replace experienced teachers who have an in-depth understanding of early childhood development and education and are more likely than other teachers to make the most effective use of the chosen curriculum” (Saluja et al., 2001 , p. 20).

Professional Development and Training

Professional development and training were cited as indicators of quality in almost half of the included literature sources (n = 19). Access and participation in professional development supports high quality care, regardless of educational background (Pascoe & Brennan, 2017 ; Marshall et al., 2002 ), found that those educators with “additional training in early childhood education were more likely to provide the levels of stimulation associated with greater school readiness” (p.6). Access to PD and training appeared to be consistently noted as an important tool in ensuring and/or to improve quality (Bertram & Pascal, 2016 ; Early et al., 2006 , 2007 ; Leyva et al., 2014 ; Melhuish et al., 2015 ; Minervino, 2014 ; Peterson, 2013 ; Pianta, 2011 ; Weiland, 2016 ).

Wages and Working Conditions

Wages and working conditions included elements such as, staff turnover (n = 4), wages (n = 9), working conditions (n = 2), and sufficient staffing (n = 2). Higher staff/educator wages and lower turnover are common features of high-quality programming (Jenkins, 2003 ; Melhuish & Gardiner, 2018 ; Minervino, 2014 ; Saluja et al., 2001 ). Two sources also indicated that turnover can have a negative effect on children and argued that programs in public school systems may be able to ensure lower turnover rates. (Early et al., 2007 ; Saluja et al., 2001 ).

Partnerships with Administrative Staff, Teaching Assistants, and Principals

Personnel such as administrative staff, teaching assistants and principals were identified as affecting the level of quality in a program, as they provide support for educators and can influence program features. Leadership (n = 7) was the most identified feature, followed by qualified personnel (n = 5). A principal in place who understands early childhood education, either through formal training or previous experience, seemed to make a difference in the success and quality of preschool programs located in schools (Early et al., 2007 ; Farran, 2017 ; Jenkins, 2003 ; Saluja et al., 2001 ).

Involvement of Families and Communities

Through the included literature, both family (n = 12) and community (n = 3) engagement were recognized as elements of program quality. One study commented on the physical, cultural and social inclusion of children and families in ELCC, placing an emphasis on the need to support Indigenous peoples with the development of ELCC for their communities. Another source spoke to how educators can work to encourage parental involvement in their children’s learning, outlining expectations for parent involvement by setting indicators which included respecting parents, encouraging trust and participation, communicating daily and on an ongoing basis with parents, outlining specific expectations for parent engagement, and involving parents in the design of the program in order to meet the needs of their child(ren) (Dwyer et al., 2000 ).

Cultural context also played a role in family engagement, with sources noting differing perceptions of quality related to cultural background. One source found that African Americans viewed home-partnerships as important, more so than other groups included in the study (Barbarin et al., 2006 ). Another focused on quality care for Indigenous groups and communities and noted the importance of engaging parents and the community (Preston et al., 2011 ). They suggested empowerment of Indigenous communities by promoting family participation (Preston et al., 2011 ; Dwyer et al., 2000 ) also highlighted the need for educators to be competent in working with diverse families. Recommendations for educators and/or staff included having knowledge of the cultural and social contexts that children exist in, having respect for diverse families and their traditions and values, and accommodating a family’s preferred language when communicating.

The purpose of this review was to identify what is known in the literature about high-quality early childhood programming in publicly-funded, school-based settings. Defining quality in this specific setting is not a straightforward process, given the complexity of the concept and the unique characteristics of this setting (Layzer & Goodson, 2006 ). There are different systems and perspectives to consider and, for this reason, confining the conversation to the more traditional categories of structural and process quality (Ishimine et al., 2009 ; Slot, 2018 ) is likely incomplete. Using systems-thinking as a theoretical framework, this scoping review expanded the image of quality to include internal and external influences on quality programming, specifically examining the themes of policies, practice, place, and people. In this section, we discuss these broader themes to provide considerations to further support quality in early learning programs, both directly and indirectly.

A key finding of this review is the foundational importance of the initial and ongoing policies that govern publicly-funded, school-based early learning programs. Sustainable funding, adherence to regulations, government investment and ongoing assessment and evaluation are key to the provision of quality programming (Friendly et al., 2006 ; Friendly & Beach, 2005 ). Ongoing, planned, and well-resourced assessment and evaluation of such programs could also contribute to supporting high quality practice, by determining if programs are reaching goals and ensuring funding effectiveness (Friendly et al., 2006 ). Practices identified in the literature that support high quality programs in Pre-K include following a pedagogical approach that is responsive to children’s ways of learning, for example using a play-based approach that supports exploration and self-expression. Other practices described in the literature as being indicators of quality include lower adult-to-child ratios (Friendly et al., 2006 ), with even smaller class sizes and ratio depending on the individual support needs of children within the classroom (Rebell et al., 2013 ). In addition to group size, warm, responsive, and positive relationships between educators and children were also identified in the review, with these relationships being seen as critical to supporting joint attention and sustained shared thinking. The extent to which programs support and promote inclusion and diversity was also found to be related to the quality of the program. Inclusion referred to the acknowledgement and celebration of diverse abilities, cultural and linguistic backgrounds, family structures, and differences in socioeconomic differences (Goelman et al., 2006 ). It could also include any reference to additional or specialized service supports that are provided to children and families in the program (Pianta et al., 2009 ; Rebell et al., 2013 ).

The location and the time spent in the learning environment, as well as the structure of the learning environment itself are all considered important components of quality under the theme of place . Location in schools provides a stable infrastructure for the programming and allows for potential collaborations between early childhood educators and the primary (i.e. Kindergarten) teachers. The time spent in the program, or ‘dosage’ is an important component of quality, as well. Therefore, the more time spent in a quality early learning program designed for children in the year prior to school entry supports positive outcomes for children (Minervino, 2013 ). Further, as with most educational programs and care environments, the people who work and participate in Pre-K programs determine the quality of the program being offered. For educators, their level of post-secondary education specific to early childhood education is a major indicator of positive developmental outcomes for children (Howes et al., 2003 ); more formal qualifications often related to better quality programming (Manning et al., 2017 ). As well, having experience specific to early childhood education was also cited as a predictor of quality (Jenkins, 2003 ; Saluja et al., 2001 ), as was their ongoing professional development and training (Marshall et al., 2002 ; Son et al., 2013 ). Most jurisdictions require more ECEs with post-secondary qualifications than are currently working in the field and, therefore, the development of a workforce strategy, focusing on key aspects related to qualifications, remuneration, and working conditions can help to strengthen and maintain a qualified ECE workforce (Barnett, 2003 ; Friendly et al., 2006 ; Halfon & Langford, 2015 ). Further, those who partner with educators in these universal early learning settings also determine the level of program quality. Specifically, personnel such as school administrators, principals, and teaching assistants were identified as having an influence on the quality of programming in similar school-based settings (Bish et al., 2011 ). Finally, the literature in this review identified that the involvement of families and communities has an impact on program quality (Dwyer et al., 2000 ). When parents, families, and community members are welcomed to participate in an early learning setting at a level that is possible for them in terms of their resources and availability, educators become more aware of families’ perspectives of quality and gain knowledge of the cultural and social contexts of the children in their program. This is essential if programs are to be inclusive and responsive to the needs of the families and the community.

Limitations

While this review identified many essential elements of quality, there are elements that have likely been missed or limited in their prominence within the literature. The most prominent discussion missing surrounds the role of culture and diversity in quality programming (Ishimine & Tayler, 2014 ; Jalongo et al., 2004 ; Tobin, 2005 ). While this discussion was limited within the literature, there is an increasing awareness about the need to ensure that programs and ELCC systems, including post-secondary training programs are responsive to the different stakeholders involved in the program, including families, children, staff, communities, and marginalized groups. The increased understanding of the importance of providing culturally responsive and diverse programs requires a rethinking of the possibility or the appropriateness of creating an all encompassing or universal definition of quality. There is a need to examine quality definitions with the understanding that any definitions, and consequential standards governing publicly-funded programs, need to be responsive to the various communities in which they operate.

Conclusions

This scoping review provides insight into the complexities involved when attempting to define quality in early learning programs, especially in relation to school-based, universal, publicly-funded Pre-K programs. With that said, the literature did identify specific factors that appear to influence quality. These factors are situated within the overarching theme of policies that govern the operation of Pre-K programs which is, in turn, linked to the three distinct themes of people, place and practice. Broadening the definition of quality to include these themes underscores the connections between the many systems and stakeholders involved in the development and operation of early learning programs and how the quality of these programs is affected at any and all of these levels. The findings of this scoping review also point to gaps in the literature specific to defining and assessing quality in publicly-funded, school-based early learning programs, highlighting the need for further research in this area.

Data Availability

Not applicable.

Code Availability

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Acknowledgements

This research is dedicated in memory of Shelley Thompson, a champion for sustainable investment and progressive public policy in early childhood development. The authors would like to thank the content experts for providing their recommendations for literature for this review, Denver Hilland for initial project coordination and Leah Boulos from the Maritime SPOR SUPPORT Unit for assistance with developing and executing our search strategy.

This research was funded by the Margaret and Wallace McCain Family Foundation in partnership with the Nova Scotia Department of Education and Early Childhood Development. This research was also undertaken, in part, thanks to funding from the Canada Research Chairs program.

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McLean, C., McIsaac, JL.D., Mooney, O. et al. A Scoping Review of Quality in Early Childhood Publicly-Funded Programs. Early Childhood Educ J 51 , 1267–1278 (2023). https://doi.org/10.1007/s10643-022-01372-9

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Process evaluation of implementation of the early stages of a whole systems approach to obesity in a small Island

• Brittney MacKinlay 1 ,
• Kate Heneghan 2 ,
• Alexandra J. Potts 3 ,
• Duncan Radley 3 ,
• George Sanders 3 &
• Ian F. Walker 1  

BMC Public Health volume  24 , Article number:  1376 ( 2024 ) Cite this article

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The small Atlantic island of St Helena is a United Kingdom Overseas Territory (UKOT) with a high prevalence of childhood obesity (over a quarter of 4–5 and 10–11 year olds) and, anecdotally, adulthood obesity and its associated health detriments. St Helena have taken a whole systems approach to obesity (WSAO) to address the issue. A WSAO recognises the factors that impact obesity as a complex system and requires a ‘health in all policies’ approach. UK academic and public health technical support was provided to the local St Helena delivery team. This process evaluation sought to explore the early stages of the WSAO implementation and implications for the transferability of the approach to other small island developing states and UKOT.

Data was collected via eight semi-structured interviews, paper based and online surveys, and document analysis. Thematic analysis was used to analyse the data.

The analysis identified three factors which aided the first phase of WSAO implementation: (1) senior leaders support for the approach; (2) the academic support provided to establish and develop the approach; and (3) effective adaptation of UK Government resources to suit the local context. Key challenges of early implementation included: maintaining and broadening stakeholder engagement; limited local workforce capacity and baseline knowledge related to obesity and systems thinking; and limited capacity for support from the UK-based academic team due to contract terms and COVID-19 restrictions.

Conclusions

Early stages of implementation of a WSAO in a UKOT can be successful when using UK’s resources as a guide and adapting them to a small island context. All participants recommended other small islands adopt this approach. Continued senior support, dedicated leadership, and comprehensive community engagement is needed to progress implementation and provide the foundation for long-term impact. Small island developing states considering adopting a WSAO should consider political will, senior level buy-in and support, funding, and local workforce knowledge and capacity to enable the best chances of successful and sustainable implementation.

Peer Review reports

Obesity is of great global public health concern [ 1 ] and one that is a challenge in many small islands, such as St Helena. St Helena is a small island located in the South Atlantic Ocean and is part of the UK Overseas Territory (UKOT) of St Helena, Ascension, and Tristan da Cunha. St Helena has a population of 4,534 [ 2 ]. Obesity is associated with reduced life expectancy [ 3 , 4 ] and, particularly in adulthood, is a risk factor for chronic diseases such as cardiovascular disease, type 2 diabetes, at least 12 kinds of cancer [ 5 ], liver and respiratory disease [ 6 ], and some mental health conditions [ 7 ]. While BMI data for the general adult population is not available among St Helena adult residents (Saints), over one in three older adults (65–79 years) have diabetes, and one in two adults have high blood pressure [ 8 ]. Despite exact prevalence numbers being unavailable, in 2018 the St Helena government identified obesity as a priority health challenge to address (along with the high prevalence of NCDs) in their Strategic Framework for Health Promotion [ 9 ].Childhood obesity is associated with obesity in later life as well as premature death and disability [ 1 ]. Moreover, there are acute issues with childhood obesity such as breathing difficulties, increased risk of fractures, hypertension, early markers of cardiovascular disease, insulin resistance and psychological effects [ 1 ]. On St Helena, over a quarter of 4–5 year olds and 10–11 year olds were living with overweight or obesity in 2021 [ 10 ]. Preventing and addressing obesity in childhood seeks to break the intergenerational nature of obesity [ 11 ]. As such, it is important work is done to address a reduction in obesity at all stages of the life cycle.

In response to the increasing awareness of the complexity of many public health problems including obesity, a whole systems approach (WSA) has become a promising tactic [ 12 ]. Obesity is a complex, multi-causal problem with no one single solution. Addressing such an entrenched issue requires a long-term, system-wide approach that needs co-ordinated action across a broad range of disciplines and stakeholders, is tailored to local needs, and works across the life course [ 13 ]. A WSA to obesity epitomises a ‘Health in All Policies’ [ 14 ] approach and works with communities and stakeholders to both understand the problem and to support the identification and testing of solutions. A WSA can offer a sustainable, collaborative, community centred approach to address the complex problem of obesity whilst also having a positive impact on other local agendas, such as employability and productivity and reduced demand for social care. The World Health Organization’s (WHO) “Acceleration Plan to Stop Obesity” advocates for a multisector approach to address obesity [ 15 ].

United Kingdom (UK) Government guidance on implementing a whole systems approach to obesity (WSAO) provides local authorities in England with a practical approach to implementation [ 16 ]. This guidance includes a six-phase step by step process and a comprehensive range of supporting resources including an action mapping tool, network analysis tool, and guidance on system mapping. A mixed method evaluation undertaken in seven local authorities in England, indicated several short-term impacts [ 17 ]including: commencement of mindset changes and a move towards systems thinking; increased number of engaged partners; increased knowledge and understanding of systems science and obesity amongst partners and indicators of shifts towards targeting wider determinants of health rather than individual lifestyle factors. A process evaluation of seven local areas in Scotland implementing a WSAO found that the UK Government’s guidance helped to establish the approach by providing a well-structured, process-led framework and supported the development of a shared understanding and vision [ 18 ].

In 2021 St Helena began implementation of a WSAO using the UK guidance [ 16 ] alongside technical support (capacity building in systems thinking and methods and advice on implementation) from a team of UK public health experts. This provided the opportunity to evaluate the implementation of this approach. The clear need for such evaluation was highlighted in a recent systematic review, where the authors stated “evidence of how to operationalise a whole systems approach to address public health problems is still in its infancy” and “evidence highlights the limited progress that has been made in the practical implementation and evaluation of WSAs to public health issues to date” [ 13 ]. Therefore, this paper aims to present the first process evaluation of WSAO implementation on a small island setting.

Whole system approach to obesity

The process implemented on St Helena is based on the UK Government’s six-phase WSAO guide [ 16 ], of which St Helena is currently at phase four. The guide provides a structured approach on how to put a WSAO into practice, including understanding the causes of obesity in local populations and co-producing actions and interventions to reduce population levels of obesity (see Fig.  1 ). Phase one aims to secure senior-level support and establishes the necessary governance and resource structure to implement the approach. During phase two a compelling narrative is built describing why obesity matters locally and creates a shared understanding of how obesity is currently addressed. Phase three brings stakeholders together to create a comprehensive map of the local system that is understood to cause obesity in what is known as “workshop one”. During phase four, stakeholders come together to prioritise action areas in the local system and propose collaborative and aligned interventions in what is known as “workshop two”. Phase five focuses on maintaining momentum by developing the stakeholder network and an agreed action plan and phase six aims to get stakeholders to critically reflect on the process of undertaking a WSAO and consider opportunities for strengthening the process. St Helena has not yet begun these last two phases.

At the time of this report, the St Helena WSAO was part-way through phase four of the UK Government process as they had delivered workshop two, a key milestone for creating a local system map. The process continues and St Helena are currently drafting the action plan. Therefore, this process evaluation focuses on the first four stages of implementation of the WSAO to learn lessons for implementation and disseminate key learning outcomes promptly.

: Process for implementing whole systems approach to obesity [ 16 ]

The aim of this process evaluation was to explore the challenges and enablers during the early stages of the WSAO implementation within a small island context and implications for the transferability of the approach to other small island developing states and UKOTs. In theory, this approach might be transferrable to UKOTs because it is designed for local context (small populations), the UK guidance is often used in UKOTs, there is emerging evidence of it working well in local UK contexts supports its use in piloting in UKOTs and there are some similarities in health systems.

Process evaluations seek to understand how complex interventions work. They also seek to understand how well implementation maintained fidelity to the planned approach, how feasible and acceptable the intervention is in the context, and reasons why it may not have worked as intended.

Technical support

The implementation team in St Helena had limited, if any, experience of whole systems approaches to obesity and limited knowledge about systems thinking and obesity management and prevention strategies. The team in St Helena is also very small with competing priorities. The technical assistance provided by Leeds Beckett University (LBU) aimed to address some of these shortfalls to: build local capacity in systems methods, tools, and approaches; advise and support St Helena with the implementation of the first four-phases set out in the WSA to obesity guide and adapting content to reflect the local context; better understand the local drivers of obesity from a multi-disciplinary approach.

The technical support provided by LBU, included a bespoke training and support package for the implementation team in St Helena consisting of three training sessions which lasted two to three hours each. The training, which took place prior to the main programme workshops, included: (1) an introduction to systems and systems thinking; an overview of WSA and the stages of the UK Government guidance; (2) a practical example of an English WSA to obesity from Oxford City Council; (3) workshop preparation and facilitation; an introduction to systems change; and (4) training on methods and tools to support the process, including qualitative systems mapping, stakeholder mapping, action mapping, and action register completion. Fourteen people attended the facilitator training ahead of workshop one and six attended the facilitator training ahead of workshop two. Attendees included people working in the health promotion team, core working group members, health care and allied health professionals, Ministry of Education staff and retail business owners.

LBU’s support also included facilitation of support from the Oxford City Council’s Public Health team which took the form of two virtual meetings to share learning about their experience of setting up a WSAO and provide peer support when required to the Saint Helena team. During phase three, LBU provided support in the form of reviewing presentation slides used for workshops, virtual presentation of material during the workshops and preparation of systems maps. Throughout the first four-phases of implementation, LBU provided support when needed and virtual attendance at core working team meetings. During the project, St Helena had several COVID-19 related restrictions in place, so activities were undertaken virtually.

Implementation

St Helena began implementation of phase one of WSAO in 2021 by setting up a core working team (CWT) to undertake the day-to-day operations and coordinate the approach. The CWT was made up of health promotion team members, partners from other sectors (e.g., representative from the equality and human rights commission and a conservation officer), and senior leadership including the Chief Secretary and Health Minister. In early 2022, St Helena worked with the academic team at LBU to collect data to build the local picture of obesity (phase two). St Helena at the time had limited health data available so this stage involved requesting information from partners and making use of what scarce data there was, which often included qualitative data from interviews. Mapping the local system (phase three), brought together stakeholders in a half day workshop to achieve two objectives (1) map out the local system to show how the different factors and interrelated, and (2) begin to develop an overall shared vision for the programme of work. A shared vision is a clear and aspirational statement of what the whole systems approach is trying to achieve. Results of the systems mapping exercise can be found in Appendix 4. Workshop one took place in February 2022 for half a day. Invites were sent to 53 people and 23 attended. As part of phase four, stakeholders were brought together to prioritise areas for action in the local system and propose collaborative and aligned actions. Workshop two took place in May 2022 for half a day. Invites to workshop two were sent out to 46 people and 17 attended. Among the 17 attendees were representatives from the health promotion team, environment and agriculture sector, non-governmental organisations, health care professionals, senior government leaders, social care professionals, Ministry of Education staff and business sector.

Data collection

A combination of semi-structured interviews, online surveys, and reflections and feedback forms were used to collect data. Semi-structured interviews were chosen because they allowed for detailed information on the views and experiences of people who were involved in implementation of the first four phases of the WSAO. Purposive sampling [ 19 ] was used to recruit interviewees to ensure a range of different stakeholders were represented. Purposive sampling has been adopted in interview and survey research previously [ 20 ] and thus, this sampling strategy allowed for the recruitment those that had significant involvement in implementation and, therefore, may allow us access to a diverse participant pool and rich data from the quality of data collected. Suitable interviewees were identified by the local health promotion lead in partnership with LBU and OHID (Office for Health Improvement and Disparities). Nine stakeholders were invited to be interviewed and eight interviews were conducted from the following sectors/groups: CWT members; senior partners (e.g., senior stakeholders supporting WSAO); community groups and Non-Governmental Organisations (NGOs); high school students; and local private businesses. Data collection took place between February and November 2022. An experienced qualitative researcher undertook interviews in person which lasted between eight and 29 min (M duration =21 min ). The semi-structured interview discussion guide (Appendix 1) included 11 open-ended questions, based on the research objectives, structured to prompt discussion with probes and follow-up questions adopted as needed. Questions addressed participants’ expectations and perceived challenges and successes of the process of implementing WSAO so far. Questions were pilot tested with a member of the team in St Helena prior to any interviews, with the content and order subsequently agreed upon by the research team. All data collection locations were free from background noise, where interviewees could not be overheard, in isolated rooms. Interview data were digitally recorded and transcribed verbatim. All data were anonymized to ensure confidentiality.

A range of other sources were used to collect qualitative data to support and validate data collected from the interviews and add further detail including:

Workshop participant feedback forms (Appendix 2) (paper-based forms distributed at the end of both workshop one and two, designed with the implementation team in St Helena to capture the extent to which expectations were met, what went well and what needed improvement).

Online stakeholder survey (Appendix 3) on WSAO implementation progress sent out to 47 people including CWT members, people who attended the facilitator training and workshop attendees. The survey was co-designed with the implementation team in St Helena and circulated via email two months after workshop two. The purpose of the survey was to gather a wider set of participants’ feedback (in addition to interviewees) and experiences about the implementation of a whole systems approach so far to better understand the positive and negative aspects.

Other documentation (minutes from CWT meetings, key informant reflective notes and the LBU end of project report).

Table  1 gives detail to the participants who contributed to this evaluation. In respect of anonymity, especially on a small island, demographics are not provided, and random participants numbers assigned in quotes.

Data analysis

Thematic analysis was used to provide rich, comprehensive, and complex account of data [ 21 ] and to allow identification, analysis, and to report on patterns and themes related to the research objectives within the data [ 22 ]. Specifically, the six phases to thematic analysis were followed: familiarisation with the data, generating initial codes, theming codes, reviewing themes, defining themes and writing up [ 22 ]. First, verbatim transcripts of interviews, survey responses and documents were read and re-read to allow familiarization which, assisted in coding relevant segments of data that addressed our research questions i.e. a theoretical thematic analysis approach rather than an inductive one. Open coding was used to be able to develop and modify the codes during the analysis, rather than pre-set codes. A charting and mapping exercise was then carried out to draw out the main themes and sub-themes (by researcher BM). These themes were developed both deductively, based on the research objectives, and inductively which allowed data to be classified in such a way that was relevant to the research objective, but while maintaining the openness for unforeseen themes to emerge. A second senior researcher (IFW), experienced in qualitative research, oversaw the data analysis process by reviewing the themes, prompting discussing between the two researchers to define the final themes.

The study was approved by St Helena Research Council Ethics committee and included both the implementation work and the research evaluation aspects of this project (institutional ethics reference: 101,068). Informed consent was obtained from all the participants and/or their legal guardians. No vulnerable individuals or those under the age of 16 were recruited.

The main barriers and facilitators to implementation are summarised in Table  2 . and discussed in further details below.

Evaluation by phase of process

Phase one: set up.

Several key factors were identified by participants from all data sources regarding the successful implementation of the initial set up phase of the project, such as the importance of senior level support such as senior civil servants to help progress the early stages of the approach. CWT participants frequently mentioned in interviews the lack of capacity to become a member of the CWT (phase one barrier):

“We’ve had several different partners who have wanted to be a part of the CWT but have been unable to commit due to other priorities and commitments” (participant three).

Participants also noted the need to broaden CWT membership to include a more diverse range of people (phase one barrier). One participant explained how a more representative CWT would make it feel more like a community project rather than a government project. One participant suggested having less frequent CWT meetings may have attracted more members.

Although one participant attributed their prior knowledge and experience of using the UK Government’s guidance and implementing a WSA in the UK to helping with the set up and early stages of implementation, this was not the case for all participants. Overall CWT members had limited baseline knowledge and understanding of obesity, public health, and WSAs. Related challenges included internet restrictions meaning pre-reading was a challenge; the transient nature of the CWT membership which meant new people joined later and needed to be caught up; and the public health team having low knowledge and experience levels of systems thinking (phase one barriers):

“Before initiating a WSA on a small island developing state (SIDS) [UKOT] it would be helpful to assess the knowledge, experience, and capacity of the public health team leading the WSA to identify if preliminary work to support the team’s knowledge and experience in healthy weight and obesity should be completed first”. (participant nine). “Partners, including CWT partners have limited access to the internet and printers. Therefore, sometimes information needs to be printed out for partners and time allocated in meetings for people to read information, that would usually be sent and read ahead of attending a meeting.” (participant nine). “Current and former members [of the CWT] have joined/left at different stages which has perhaps contributed to differing baseline knowledge and understanding of the WSA.” (participant nine).

Participants found the academic support useful (phase one facilitator):

“Without the collaboration I think it would have been difficult for St Helena to have established the approach as far as we have, particularly in regard to the practical expertise and experience from LBU and OHID (Office of Health Improvement and Disparities) in having implemented this approach in different areas…. Having the collaboration and expertise has helped to gain interest and engagement with partners across the island. It is seen as an opportunity by partners for St Helena, especially in being part of an academic partnership with LBU and the UK government, but in also being a pilot for UKOTs” (participant three).

The academic teams’ whole systems and facilitator training was outlined as being helpful in the online stakeholder survey, as it improved confidence and competence in the local workforce. The use of well-chosen locally relevant examples and the theory helped understanding for the whole process and was highlighted as essential in future projects.

LBU’s presentations in workshop one were well received as participants felt their expertise added value to the workshop. However, meeting minutes showed that the CWT felt LBU’s workshop facilitator training was rushed and the academic team felt the technological issues of delivering virtual training meant two-way interaction was extremely difficult, which is an important part of participants understanding concepts that are new to them. One participant from the CWT explained that a wider range of people needed to attend the training.

The opportunity to learn from a local authority in England and how they adapted UK resources for their context was reported as useful, particularly developing the system maps (phase one facilitator). Some participants felt that the timeframes, rather than the amount or type of support, for the academic support contract were too short as its mis-aligned with the normal ways of working on the island which meant that it had a detrimental impact on other health promotion work.

Phase two: building the local picture

Fifteen responses were received from the online stakeholder survey (32% response rate). A total of 86% of online survey respondents said that a clear local picture about obesity in St Helena was “fairly well” developed suggesting that the lack of local data that was available for collection limited the ability to accurately and fully describe the burden of obesity in St Helena.

A member of the health promotion team noted in reflective notes that there were challenges in obtaining statistics for obesity and noncommunicable diseases (NCDs) for St Helena and other SIDS/UKOTs (phase two barrier):

“UKOTs will have differing levels of local health data available to be collated and analysed. This will need to be considered during the early stages of the WSA when collating information to share with stakeholders to help set the local scene in relation to obesity, and when trying to monitor changes ” (participant nine).

Also stigmatising terminology and language was perceived to be a key issue, as noted in reflective notes (phase two facilitator):

“Consider language used (healthy weight, living with obesity, etc.) as the use of ‘obesity’ was highlighted quite early on by partners, especially from a stigma point of view and partners highlighting that this could disengage people. At several different points people asked what obesity is, so this should be considered when thinking about when engaging partners and when facilitating workshops (UK starting point vs UKOT starting point). Consider cultural norms around body weight/shape and the language used around this. This was highlighted by partners in workshop two and is an important point to consider when empowering, educating, and engaging partners”. (participant nine).

An addition was made to workshop one activities outlined in the UK guidance [ 16 ]. Stations around the room were created, with questions posted on flipchart paper on the walls such as “What Should we Call our Approach?” and “Language we Want to use”. These stations served as an interactive tool which encouraged participants to discuss ideas and were then used as a springboard for discussions in workshop two.

Half of the survey respondents were satisfied with the information and support that was given to prepare and participate in the workshops. Suggestions for further information and support included: system mapping exercises, online talks by health experts on healthy living and systems mapping, information about the academic team’s input into the project, case studies on systems approaches implemented around the world, strengths, weaknesses opportunities and threats analysis of the existing system in St Helena and more information on obesity with specific relevance to St Helena.

Phase three: mapping the local system

Responses were received from 18 participants responded to the feedback forms (78% response rate) and 10 participants (59% response rate) for workshop one and two, respectively.

After workshop one, most (90%) workshop feedback survey respondents felt they had a better understanding of how obesity connects with their work. All respondents felt they had a better understanding of systems thinking and how it applies to their work (100%). Most (90%) said that the workshop increased their awareness of the complexity of obesity and the types of actions required to address obesity. However, it was noted by workshop attendees that there was a need for more introductory material to be provided, such as attendee introductions and contextual information (phase three barrier).

Following workshop one, most survey respondents (94%) felt the WSAO process would deliver change. One participant explained that funding from other sources was needed and there was limited budget for stakeholder engagement activities:

“… we want to promote stuff and we got no funding so that will be a challenge” (participant six).

Conversely, another participant thought it was encouraging that there was a St Helena Government (SHG) budget for this work and indicated that SHG wants to see change:

“I think the fact that the government has continued to fund the Health Promotion workers post submission indicating that they want to see change ” (participant seven).

Workforce constraints including sustainability issues of a transient workforce and competing priorities with other health promotion work was a frequently mentioned concern regarding successful delivery of the WSAO (phase three barrier). Concerns around the lack of momentum of the work were also made, partly due to the challenge of competing public health priorities.

“Three participants out of the eight who were interviewed, alluded to the need to measure progress against more regular, incremental milestones to improve stakeholder and senior level engagement with this work as ultimately it is a long-term approach where impact will not be seen for a while: “… if you’ve been able to see results a little bit quicker, then people might have been able to stay on board with something actually happening rather than just talking about what we’re going to do” (participant five).

After workshop one, all feedback survey respondents (100%) felt that the time, resource, and work capacity commitments required from them were feasible. Most feedback survey respondents (94%) felt that the WSAO process will help them to engage and collaborate with other stakeholders on the issue of obesity. Participants noted that the opportunities and activities for group thinking were useful in workshop one. Survey feedback indicated that the workshop provided a good opportunity to hear views from a range of different stakeholders from different sectors:

“…great opportunity to hear from other people from different areas of work and ages” (participant 10).

All participants explained that a broader range of stakeholders was needed at the workshop (phase three barrier). For instance, the private sector were not represented well as the workshop clashed with a key cargo ship arrival for merchants. This may have resulted in underrepresentation and diversity of workshop attendees. One participant suggested a way to address this issue in the future:

“I think we went about the approach backwards. We chose people and now we want to promote it, but we should have promoted it and seen who wanted to come with us and then invite people” (participant six).

92% of respondents agreed that a shared vision had started to develop during workshop one through stakeholders coming together in workshops and agreeing priorities and actions that everyone could take to address the common challenge of obesity. The systems mapping and action plan activities had helped to create this shared vision. All respondents agreed that during workshop one, stakeholders started to effectively map the local system to see where and how they can help to prevent and manage obesity and what they are collectively trying to achieve (i.e., “a healthier population” ). The final versions of these maps can be found in Appendix 4. The creation and development of these maps were inspired by the Foresight Obesity System Map [ 23 ]. During the workshop, as per the UK Government guidance, attendees mapped out local causes and contributors to obesity to see where, and how, they can help to prevent and manage obesity in their own personal and professional fields. Mapping the local system also helped to identify where actions may have the greatest potential leverage. Some respondents mentioned the value of exchanging ideas and views amongst a broad range of stakeholders when developing and agreeing the map of the local system.

Respondents mentioned time constraints of workshop one as something that did not work well during the development and agreement of the map of the local system although they did not specify how much more time was needed (phase three barrier). Respondents felt that four hours was not enough time to work through the map, to add detail and allow all participants to contribute. Furthermore, participants said that the mapping exercise was challenging but useful. Some participants felt more time was needed for attendees to ask questions and perhaps another break. These challenges were illustrated in reflective notes:

“The system mapping was quite a difficult exercise for many as people were unsure as to which direction the arrows so, I think having trained facilitators at each table really helped. I’d recommend training/run through of the activities for any future islands in this approach, especially as systems thinking is a new way of working for the area, or of it is a small team delivering the workshops. When walking around there were lots of queries, so one lead person walking around the room could not answer all of the questions coming from the tables.” (participant nine).

Participation fatigue was discussed in slightly different contexts. One participant explained that it is often the same people on island that get asked to participate in projects such as this which can result in participation fatigue but also means that some people may be being consistently missed out in these types of projects (phase three barrier):

“With a smaller population and workforce on a SIDS/UKOT, there are less people available to be surveyed and request information from. Teams leading the WSA should be mindful of survey fatigue and novel approaches to data collection may be required, especially in communities with limited access to the internet and e-mail” (academic partner).

There were practical issues in the delivery of the workshop, such as not enough expert leads and trained facilitators to facilitate the discussions. Generally, there was positive feedback on the pace, planning, delivery, and informative content of the workshop. Most survey respondents said the workshop’s activities were above or met their expectations. Furthermore, interviewees said that the information in the workshops was easy to understand, despite the complex nature of the work. A key learning identified was to provide a more in-depth introduction to the topic of obesity and to introduce all attendees to each other at the start of the workshop. Participants said that the main outcome from workshop one was around awareness of the issue of obesity.

One participant explained that the templates in the UK Government implementation guidance were useful, however others described some examples of local context adaptions were needed. In addition to the need to use local examples in training and presentations, the importance of using culturally appropriate language when talking about obesity was stressed, for example, the term “obesity” and “overweight” was considered offensive and stigmatising:

“ the use of “obesity” was highlighted quite early on by partners, especially from a stigma point of view and partners highlighting that this could disengage people” (participant three).

Phase four: action planning

The aim of this phase was for stakeholders to refine the shared vision and to propose actions that may provide the greatest opportunity to change the system. A facilitated workshop (workshop two) helped participants with this process. While an action plan has not yet been agreed at the time of this early phase process evaluation, most survey respondents (80%) felt they had a better understanding of how obesity connects with their work and that the process will help them engage and collaborate with other stakeholders about obesity (90%) after workshop two. Most respondents (90%) also felt they had a better understanding of how the WSAO on St Helena will operate and how it will deliver change (80%).

After workshop two, most respondents (70%) felt that the time, resource, and capacity commitments required from them were feasible. However, many (75%) noted that there was not enough time in workshop two, especially for feedback from the activities, networking, and reviewing the maps (phase 4 barrier). This was echoed in interviews by the team leading the implementation on St Helena. One key enabler of the workshop that was noted was the senior level support shown by the attendance of the Minster and Chief Secretary.

Whilst LBU noted that most of the preparation for the workshop was carried out in-line with the UK guidance, some additions were made to the content. An additional activity was added to review and provide feedback on the system maps:

“Adding the activity to review and provide feedback to the local system map was a very valuable inclusion to the workshop agenda. It provided an interactive opportunity for the CWT and LBU team to show the development of the local system map and for the attendees to see how their initial input had been developed. The review of the system map enabled further discussions about the local system to happen, that had not been made at workshop one, e.g., using other priorities (food security and climate change) to engage and initiate change” (participant nine).

All participants said they would recommend implementing a WSAO for other UKOTS:

“I would say just go for and get stuck into it and take advantage of the opportunity” (participant four).

Phases five and six: next steps in implementation

At the time of this report, St Helena had not yet begun phases five and six, however participants shared plans and proposed suggestions for how the WSAO would progress during these final two phases. For example, participants discussed the need to develop a clear stakeholder engagement strategy to spread awareness and knowledge about obesity causes and consequences amongst the St Helena community and use consistent messaging. Getting the community involved in what type of messaging would resonate locally is a key consideration for the future steps of implementation. One participant explained that it was important to embed this work into other public health initiatives to align efforts:

“ The limited capacity of the CWT and the lack of budget potentially makes the sustainability of the project a risk. It is therefore important when identifying possible actions, strategies, and policies that they tie in with local priorities (e.g., climate change, food security). This will help ensure the work is embedded and sustainable.” (participant nine).

A number of wider issues were also raised by participants that may be pertinent to the approach going forward and are outlined in Table  3 below.

Overall, the early stages of the WSAO were successfully adapted and implemented on this small island. All participants were supportive of the approach and recommended it to other small islands to adopt. Awareness and understanding of obesity and whole system approaches grew and there was reasonably good engagement across most sectors. Several concerns were expressed about the continuation of the approach to lead to multi-sectoral action.

Key findings in the context of existing evidence

Local context and adaptations to the implementation guide

The suggestions made for further information and support that would have been helpful in advance of the workshops, mirror the insights from Halton Borough Council’s pilot which showed ideas to help familiarise new attendees with the process up until that point by providing a written overview of workshop one [ 16 ].

As part of the stigmatising language issues that arose, the name of the WSAO was also highlighted as something that would need to be changed for St Helena as workshop attendees felt it was important to contextualise the work and not include “obesity” in the title. A similar issue was mentioned by Gloucestershire County Council, a pilot site for the WSAO. Community insight from Gloucestershire County Council showed that families would not engage with the planned “Food and Health” project but changing the name to “Food and Families” made the project more relevant to the community, improving engagement [ 16 ].

These are encouraging findings as they suggest that there are not significant barriers to implementation of the UK Government’s guidance to a WSAO in small islands and with existing guidance and expert support, early stages of successful implementation are possible.

Whilst this process evaluation on WSAO is valuable for small island contexts in particular, more should be done on other WSAO projects around the world to gain practical evidence of implementation.

Senior level support and stakeholder engagement

Strong leadership for the approach from the health promotion team and from senior civil servants and politicians was recognised by interviewees and appeared to be the main aspect that has been working well so far.

The importance of strong and trusting relationships between multi-sector stakeholders within whole systems approaches are stressed in the UK implementation guidance especially for creating a sustainable foundation to encourage community ownership of the approach [ 16 ]. Work that is co-produced and an approach that works closely with local people will help to successfully deliver change [ 24 ]. This process evaluation found evidence that key stakeholders and community members have been identified and participated in the early phases of the approach. Insights from the London Borough of Lewisham and Oldham Council’s pilot showed having a senior representative present made stakeholders feel listened to and stressed the importance of the issues being discussed. Efforts to build strong relationships with the private sector and wider community are needed as this is considered a key aspect to influencing effectiveness [ 25 ]. Participants from the health sector talked about the need to engage people who don’t normally get involved with projects such as this. Engaging these non-traditional partners such as community champions can help to disseminate messages and actions [ 26 ].

It was recommended by a member of the health promotion team that other UKOTs should conduct early community engagement before the workshops. Doing so promotes the project to the community first, indicating who is interested in being involved and this may lead to increased workshop attendance and future community engagement. This aligns recommendations made by partners in a similar process evaluation in Australia to “engage community members first through assets they provide for community action, not agencies or organisations they represent” [ 27 ].

Common features of successful multi-level, community wide interventions reported in process evaluations, and deemed key to building a successful WSA, included engagement of partners and community; time to build relationships, trust, and capacity [ 13 , 17 , 27 ]. Engaging communities in a WSA is a key implementation element. Participants from the CWT talked about how stakeholder engagement momentum has been lost over time and there is a need to maintain this community interest as well as keeping senior leadership team engaged. Participants from the CWT explained the challenge of partner commitment issues and whilst they may have interest in the work their capacity to be involved is limited. These are a similar finding to Scotland’s process evaluation of early adopters, where stakeholder engagement has been difficult because of limited capacity to be involved and difficulties encouraging certain sectors to recognise their role and influence [ 18 ]. Maintaining stakeholder engagement will be challenging as WSAO is a long-term initiative and significant impact on population weight status is unlikely to be seen for several years. The importance of recognising that the WSAO is an iterative approach and no immediate results seen was highlighted by participants. Instead, long-term change will be the impact and success of the approach.

Stakeholder fatigue has also been found to be an issue during the implementation and was experienced due to the demands the stakeholders experienced, particularly due to the frequency of the meetings stakeholders were required to attend. This was cited as a reason for limited stakeholder engagement in Scotland [ 18 ] and, therefore, is something that future WSAs, especially in small islands, need to be mindful of when working with stakeholders.

Capacity issues affecting implementation

Participants from the health promotion team discussed the starting point for the workforce and stakeholder’s baseline understanding of obesity and public health was lower than that typically of a local authority in England. This is an important consideration when implementing such an approach on St Helena and should be addressed through improved communications and information sharing with stakeholders to develop their understanding of the issue and the approach. Some suggested topics to improve on are listed in the local context and adaptations section. In Scotland, communications activities before workshops were used to “warm [stakeholders] up to the WSA process” as well as informal sessions to shape stakeholder’s expectations of the process and provide further information [ 18 ].

Limited capacity of a small workforce was also noted as an implementation challenge, especially as unexpected situations such as the COVID-19 pandemic impacted heavily on the team’s small resource, and it also had knock on effects of pausing other health promotion related work as there was a time pressure of LBU’s contracted support. As found in St Helena, other SIDS and UKOTs typically have small populations and workforces can be more transient compared to larger countries. However even in Scotland, communities struggled with staff capacity to deliver the process as the time required for preparing and delivering a WSA was an extensive commitment, especially on local leads and administrative support but also on CWT members and wider partners [ 18 ].

The difficulties of establishing the project because of workforce limitations (e.g., small team, limited baseline knowledge, and competing work priorities) were mitigated somewhat by the technical support provided by LBU and OHID such as taking on some tasks from the local team. However, maintaining sustainability with a limited and transient workforce and population was a concern of many of the participants. Adaptations to the structure of the CWT and the networks that surround the CWT are needed to ensure knowledge and labour are spread broadly across a wide network of individuals and organisations. These human resource factors are common to other complex implementation experiences [ 28 ].

Infrastructure

The nature of St Helena being a small island was described as being an opportunity for success as there is potential for this work to reach across the whole population through existing communication channels like radio which has a very large audience, and word of mouth, through a closely knit community. There is also opportunity for strong measures and levers to be used such as fiscal and legislative measures to the food and built environments.

Limitations

Limited venue space, unreliable internet, and limited equipment availability meant logistics for CWT meetings took more time to coordinate which had a knock-on effect on speed of implementation and on the delivery team’s workload.

A key limitation of the academic support was that it was all virtual/remote due to the COVID-19 pandemic restricting travel. Two-way interaction was difficult and made it harder for participants’ understanding new and complex concepts and the unreliable internet connection in St Helena interfered with this support offering. Prior research notes the superiority of in-person attendance and interactions in increasing local understanding and building rapport [ 16 ]. This is in accordance with participants’ views that physical attendance from the academic team would have been really valuable, particularly during the workshops.

Limitations of this evaluation included that only a small sub-sample of stakeholder groups were recruited. This, along with a lack of representation of some community members, means that the results may be limited in their generalisability. The self-reported nature of the data are also a limitation, as is the presence of self-selection bias which resulted from the sampling methods adopted. There was a relatively large variation in interview length (between 8 and 29 min) which suggests that certain interviewees provided more detail and thus insightful in responses, perhaps because some were more involved in implementation compared to others.

This process evaluation was conducted by staff who had been involved in some of the support provided to St Helena. Therefore, it was not an independent evaluation. However, the research team was not heavily involved in the early implementation processes as most of the technical expertise and support was provided by LBU and other staff with specific WSAO experience. This process evaluation was conducted during the first phases of implementation. A second process evaluation should be conducted during the next phases of implementation to ensure adaptations, challenges and enablers are reflected to contribute to the evidence for and support other SIDS/UKOTS with their implementation of WSAO.

Early stages of implementation of a WSAO in a UKOT can be successful when using the UK’s resources as a guide and adapting them to the local context, providing academic and expert support to the local workforce and securing senior leader support and participation. This process evaluation has identified risks to the future stages of implementation and sustainability of the approach. Dedicated leadership, securing appropriate budget, and comprehensive stakeholder engagement plans are needed to drive the future stages of implementation. There is an urgency to embarking on the next stages as there is risk of the work losing momentum, stakeholder interest and senior buy-in. It is recommended that another process evaluation takes place once St Helena implements the remaining phases (five and six) included in the UK WSAO guidance to identify lessons learned for this approach in small island settings.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Whole systems approach to obesity

United Kingdom Overseas Territory

Leeds Beckett University

Office of health improvement and disparities

St Helena government

• Small island developing states

Core working team

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Acknowledgements

Acknowledgements to the participants in St Helena who responded to the surveys and interviews.

The UK Overseas Territories programme, delivered jointly by the UK Health Security Agency and Office for Health Improvement and Disparities, is funded by the Foreign and Commonwealth Office, UK Government.

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BM and IW developed the framework for evaluation with input from KH, DR, AP and GS. BM and IW collected the data.BM transcribed, analysed, and interpreted the data and drafted the initial manuscript. KH and IW were major contributors in editing the manuscript. DR, AP, and GS reviewed the manuscript and provided edits. All authors read and approved the final manuscript.

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As part of Leeds Beckett University’s work with St Helena, OHID was included as collaborators in their work and ethics approval for their work included the interviews undertaken as part of the process evaluation. The study was approved by St Helena Research Council Ethics committee. Informed consent was obtained from all the participants and/or their legal guardians. Institutional ethics reference: 101068.

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MacKinlay, B., Heneghan, K., Potts, A.J. et al. Process evaluation of implementation of the early stages of a whole systems approach to obesity in a small Island. BMC Public Health 24 , 1376 (2024). https://doi.org/10.1186/s12889-024-18876-1

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Developmental stages of social emotional development in children.

Fatima Malik ; Raman Marwaha .

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• Continuing Education Activity

To apply knowledge regarding human growth and development, healthcare professionals need to be aware of 2 areas: (1) milestone competencies, for example, growth in the motor, cognitive, speech-language, and social-emotional domains, and (2) the eco-biological model of development, specifically, the interaction of environment and biology and their influence on development. This activity reviews the developmental stages of social-emotional development and discusses the role of the interprofessional team in educating parents on when they should expect children to achieve each milestone.

• Identify milestone competencies in children.
• Implement the eco-biologic model of development in children.
• Assess social-emotional development in children.
• Communicate the developmental stages of social-emotional development and the role of the interprofessional team in educating parents on when they should expect children to achieve each milestone.
• Introduction

To understand human growth and development, healthcare professionals need to understand and learn about 2 areas:

• Knowledge of milestone competencies:  Growth in the motor, cognitive, speech-language, and social-emotional domains
• The eco-biological model of development:  The interaction of environment and biology and their influence on development  [1] [2]  

This topic reviews the developmental stages of social-emotional development. It also discusses the role of the interprofessional team in identifying the cause of social-emotional problems and, therefore, intervening effectively. 

Social-emotional development covers 2 important concepts, including the development of self or temperament and relationship to others or attachment. Clinicians can identify and intervene to resolve social-emotional problems in early childhood if they have a better understanding of these concepts. 

Temperament

Temperament is an innate attribute that defines the child's approach to the world and his interaction with the environment across 9 dimensions, which are activity level, distractibility, the intensity of emotions, regularity, sensory threshold, and the tendency to approach versus withdrawing, adaptability, persistence, and mood quality. We can define temperament as the child's "style" or "personality," which is intrinsic to a child. It influences child behavior and interaction with others. Based on the above attributes that define temperament, researchers have categorized young children's temperament into 3 broad temperamental categories:

• Easy or flexible: This category includes children who are friendly and easygoing, comply with routines such as sleep and mealtimes, adapt to changes, and have a calm disposition.
• Active or feisty:  Fussy children do not follow routines, have irregular feeding and sleeping schedules, are apprehensive of a new environment and new people, have intense reactions, and get easily upset.
• Slow to warm up or cautious: Children who may be less engaged or active have a shy disposition toward new situations and new people and may withdraw or react negatively. They become more comfortable and warm up with repeated exposure to a new environment or person.

This classification is for ease of discussion, and all temperaments do not fit into 1 or other categories exactly. Discussing temperament with parents and caregivers can better identify the child's strengths and needs. Based on this, caregivers can adapt their management and caregiving styles to match the child's temperament. This can mold a child's behavior and facilitate the child's successful interaction with the environment, defined as "goodness of fit." [3]

The social-emotional development begins with parental bonding with the child. This bonding allows the mother to promptly respond to the child's needs and soothe their newborn. The consistent availability of the caregiver results in the development of "basic trust" and confidence in the infant for the caregiver during the first year of life. Essential trust is the first psychosocial stage described by Erickson. This allows the infant to seek parents or the caregiver during times of stress, known as attachment. [4]

Even before acquiring language, babies learn to communicate through emotions. One may argue that knowing emotional regulation and impulse control may determine later success in life more than IQ. There is a rapid growth in social and dynamic areas of the brain during the first 18 months of life. The nonverbal parts of the right brain, including the amygdala and the limbic system, receive, process, and interpret stimuli from the environment that produce an emotional response and build the body's dynamic and stress regulatory systems.

The lower limbic system

The lower limbic system, outside the cortex, dictates most of our spontaneous, automatic emotional responses, like fear resulting in a racing heart or weak knees.

The upper limbic system

The upper limbic system part of the cerebral cortex, known as the limbic cortex, controls conscious awareness of emotions and refines the responses according to the environmental culture of the individual.

The amygdala

The amygdala is an almond-shaped structure that lies at the junction of the cortex and subcortical areas of the brain. It plays a pivotal role in sensing emotions and connects them to higher and lower limbic structures.

During the second half of infancy, emotional information from the more inadequate limbic system moves up and becomes part of the babies' consciousness. Frontal lobe activity increases, and myelination of the limbic pathways also begins during this time. With this gain in the limbic system, a caregiver's soothing and consistent response to the child's emotions develops into the child's attachment to the caregiver, usually the mother. Attachment is regarded as a pivotal event in a person's emotional development. It lays the foundation of a child's security, harbors self-esteem, and builds emotional regulation and self-control skills.

In healthy children, social-emotional stages develop on an expected trajectory, and monitoring these milestones is an imperative part of preventative health supervision visits. The caregiver's sensitive and available supportive role is essential to establish attachment and the skill set that follows.

Three distinct emotions are present from birth: anger, joy, and fear, which are revealed by universal facial expressions. Cognitive input is not required for emotional response at this stage. During the brief periods of alertness in the newborn period, newborns may return a mother's gaze. Soon after, infants begin to explore their faces.

1 to 2 Months of Age

The first measurable social milestone is around 1 to 2 months of age: infants begin to smile socially in response to parental high-pitched vocalizations or smiles. They recognize the smells and voices of their caregivers and respond to gentle touch. Infants can use a distinct facial expression to express emotions in an appropriate context after 2 months of age.

2 to 3 Months of Age

In the first 2 to 3 months, infants learn to regulate physiologically and need smooth routines. They progressively know how to calm themselves, give a responsive smile, and respond to gentle calming.

4 to 5 Months of Age

Sensitive cooperative interaction with caregivers helps infants learn how to manage tension. Around 4 months of age, turn-taking conversations (vocalizations) begin. Infants then learn to manipulate the environment. They let their caregivers know whether taking away their toy upsets them or if they are happy when held. A sensitive but firm response from the caregiver helps infants manage emotional stress. They can recognize the primary caregiver by sight at around 5 months of age. 

6 to 12 Months of Age

In between 6 to 12 months effective attachment relationships establish with a responsive caregiver. Stranger anxiety emerges as infants distinguish between the familiar and the unfamiliar. Infants become mutually engaged in their interactions with caregivers and seek a caregiver for comfort, help, and play. They show distress upon separation. Around 8 months of age, joint attention skills develop. Infants look in the same direction as their caregivers and follow their gaze. Eventually, they look back at the caregiver to show that they share the experience.

12 to 18 Months of Age

Between 12 to 18 months, infants learn to explore their environment with support from a caregiver. By 12 months of age, proto-imperative pointing emerges; in other words, infants request by pointing at the object of interest and integrating it with eye contact between the object and the caregiver. Proto-declarative pointing follows at 16 months of age when children point with eye-gaze coordination to show interest. Around 18 months of age, children bring objects to show or give to the caregiver.

Around 12 months of age, the child takes part in interactive play like peek-a-boo and pat-a-cake. They use gestures to wave bye-bye and communicate their interests and needs. At around 15 months of age, empathy and self-conscious emotions emerge. A child reacts by looking upset when they see someone cry or feel pride when applauded for doing a task. The child imitates his environment, helps with simple household tasks, and explores the environment more independently.

18 to 30 Months of Age

Between 18 and 30 months, individuation (autonomy) emerges. The confidence in the child-parent relationship and continued firm parenting help the child face environmental challenges on his own more persistently and enthusiastically. The child's temperament manifests itself more, and they are aggressive and reserved or friendly and cooperating. Around 18 to 24 months, they learn to pretend-play, such as talking on a toy phone or feeding a doll and playing next to or in parallel with another child. they may imitate other child's play and look at him but he cannot play in a cooperative, imaginative way with another child yet. During preschool years, they learn to manipulate their subjective emotions into a more socially accepted gesture. He uses a "poker face", and exaggerates or minimizes emotions for social etiquette. For example, they say thank you for a present he didn't like. The child refers to himself as "I" or "me," and possessiveness, "mine," and negativism "no" emerge.

30 to 54 Months of Age

Between 30 and 54 months, impulse control, gender roles, and peer relationship issues emerge. A caregiver plays a major role in helping preschoolers define values and learn flexible self-control. Testing limits on what behaviors are acceptable and how much autonomy they can exert is an expected phenomenon. Thoughtful parenting with a balance between setting limits and giving choices successfully establishes a child's sense of initiative and decreases anxiety from guilt or loss of control. At 30 months, pretend play skills emerge, and the child shows evidence of symbolic play, using an object as something different, like pretending a block to be a telephone or a bottle to feed a doll. The play scenarios become more complex with themes and storylines. By 3 years of age, the child engages more in interactive play, masters his aggression, and learns cooperation and sharing skills. They can play with 1 or 2 peers, with turn-taking play and joint goals. Imaginative and fantasy play begin by pretending to be a cat, and role-play skills develop. The child, however, cannot yet distinguish between reality and imagination, and it is common to be afraid of imaginary things. They master this skill to differentiate between real and imaginary around 4 years of age. They enjoy playing tricks on others and are worried about being tricked themselves. Imaginary scenarios and play skills are developing and becoming more complex. They can play with 3 to 4 peers, with more complex themes and pretend skills.

5 and 6 Years of Age

At 5 and 6 years of age, the child can follow simple rules and directions. They learn adult social skills like giving praise and apologizing for unintentional mistakes. They like to spend more time in peer groups and relate to a group of friends. Imaginative play gets more complex, and he likes to play dress, and act out his fantasies.

7 and 8 Years of Age

At 7 and 8 years of age, the child fully understands rules and regulations. They show a deeper understanding of relationships and responsibilities and can take charge of simple chores. Moral development furthers, and he learns more complex coping skills. At this age, a child explores new ideas and activities, and peers may test his beliefs. Children identify more with other children of similar gender and find a best friend in common.

9 and 10 Years of Age

At 9 and 10 years of age, peer and friend groups take precedence over family. Children at this age show increasing independent decision-making and a growing need for independence from family. Parents can use responsibilities and chores to earn time with friends. A positive, nurturing relationship with a caregiver with praise and affection and setting up a reasonable balance between independence and house rules builds self-confidence and self-assurance. Promoting supportive adult relationships and increasing opportunities to take part in positive community activities increases resilience.

Greater independence and commitment to peer groups drive the transition to adolescence. This includes indulging in risky behavior to explore uncertain emotions and impress peer groups. Social interactions include complex relationships, disagreements, breakups, new friendships, and long-lasting relations. Normally adolescents learn to cope with these stresses with healthy adult relationships and guidance to make independent decisions. As young adulthood approaches, school success and work-related activities become important. For a healthy transition to adulthood, positive and supportive adult guidance and opportunities to take part constructively in the community play a pivotal role.

• Issues of Concern

The inability to reach age-appropriate milestones can be a manifestation of psychosocial disturbance and needs further exploration. Examples of early childhood social-emotional disturbance include autism, reactive attachment disorder, social anxiety disorder, generalized anxiety disorder, attention-deficit hyperactive disorder, bullying, oppositional defiant disorder, conduct disorder, and post-traumatic stress disorder, among others.

• Clinical Significance

A failure to follow the expected trajectory of social-emotional development can lead to undetected mental and emotional health problems. Adverse childhood experiences can alter development significantly. Thus, alongside screening for child development, actively screening for family dysfunction and supporting families in establishing a healthy, nurturing environment is vital. By having a thorough knowledge of developmental pathways and adverse childhood experiences, and having a close follow-up established with families in the medical home, pediatricians and medical professionals are in a prime position to identify risk factors and developmental delays timely.

Medical professionals taking care of children should begin with identifying and addressing the family's concerns, asking open-ended questions regarding social-emotional milestones, and intentionally observing parent-child interaction and the child's interaction with the environment, including themselves. While examining the patient, they should observe age-appropriate developmental interaction.  should give teenagers the opportunity to engage in health visits in a private and safe environment without a caregiver. Also, should be able to address questions about parenting advice. These include advice on temper tantrums and defiant behaviors, child care and preschool guidance, referring to parent training management when appropriate, and counseling on temperament differences and "goodness of fit" models. 

The American Academy of Pediatrics (AAP) and Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents emphasize active screening for developmental delays and environmental risk factors on top of clinical surveillance. This includes the use of standardized screening tools for social-emotional development and for environmental risks appropriate to the risk level of the population you serve. Environmental risk factors should include caregiver and family functioning, caregiver mental health, socio-economic stress, refugee or immigrant status, safety concerns, caregiver drug addiction, etc. AAP recommends screening for autism spectrum disorder at both the 18- and 24-month health supervision visits, and whenever concerns are raised. When using screening tests, one should be cognizant of some potential limitations including the inability to administer and score the screening tool correctly, using it as a diagnostic tool, failure to incorporate other available clinical data, and using a linguistic or culturally inappropriate tool. [5]  

If screening identifies any risk factor or delays, it should always follow with further assessment and evidence-based interventions. Screening for maternal depression, especially during the first year of childbirth, is important. Identifying and intervening for maternal depression early on can avoid attachment and social-emotional problems in the child later. With clear delays in social and language development, it is important to initiate services even before a confirmed diagnosis, as early intervention is the key. If the child is younger than 3 years should be referred to local early intervention services. A child 3 years of age or older should be referred to their school district. Anticipatory guidelines should include evidence-based strategies for age-appropriate behavioral interventions, such as the management of temper tantrums for toddlers. Implementing the use of developmental screening tools in clinical practice has shown an encouraging trend though still, a wide gap in practice remains. [6]  Practices that have successfully established screening are struggling with coordinating referrals and monitoring progress. [7]  We need further research to identify barriers to the use of standardized tools and the coordination of services and interventions.

Standardized Screening Instruments

Caregiver functioning

• Adverse Childhood Experience Score
• Parenting Stress Index-Short Form
• Depression, Anxiety, and Stress Scale
• Patient Health Questionnaire-2
• Edinburgh Postnatal Depression Screening
• Center for Epidemiologic Studies Depression Scale                                        
• Carey Temperament Scales

Infancy to early childhood

• Ages and Stages Questionnaire: Social-Emotional 
• Survey of Well-Being of Young Children
• Communication and Symbolic-Behavior Scale
• Developmental Profile, Infant Toddler Checklist
• Brief Infant-Social Emotional Assessment

Early childhood to adolescence

• Eyberg Child Behavior Inventory
• Pediatric Symptom Checklist
• Pictorial Pediatric Symptom Checklist

Multidimensional

• Infant-Toddler Social-Emotional Assessment
• Nursing Child Assessment Satellite Training ( NCAST) Parent-Child Interaction Feeding and Teaching Scale
• Achenbach System of Empirically Based Assessment
• Behavior Assessment Scale for Children Second Edition
• Connors Comprehensive Behavior Rating Scales
• Child Symptom Inventories-4
• Vanderbilt Parent and Teacher Assessment Scales

Single-dimension attention-deficit or hyperactivity disorder

• Conners Third Edition
• Attention Deficit Disorders Scale
• Brown Attention Deficit Disorder Scales

Single-dimension anxiety or depression

• Beck Youth Inventories

(Adapted from Duby JC, Social and Emotional Development. In: Voigt RG, Macias MM, Myers SM, eds. Developmental and Behavioral Pediatrics. Elk Grove Village, IL: American Academy of Pediatrics; 2011:241–248)

• Enhancing Healthcare Team Outcomes

Optimal child growth and development need to orchestrate enhanced communication between the pediatrician/primary care provider and various medical specialties, including but not limited to the mother's obstetrician, nursery or neonatal intensive care unit (NICU) teams, nursing staff, psychology, psychiatry, child life, and social work. Twenty percent to 25% of children seen in primary care clinics experience social-emotional problems that are clinically significant. Access to mental health services, parenting classes, and education is limited due to stigmatization, cost, and availability. In 2004, the AAP organized a Task Force on Mental Health to enhance identification and intervention for social-emotional problems in primary care pediatric practice. One of the key findings in its report was having integrated models of care with collaboration with psychologists, social workers, psychiatrists, and others in the community to formulate a comprehensive care plan. 

With help from other professionals, primary care practice should be able to put together a list of clinical and family concerns, coach the family on self-management techniques, and create a resource list including professionals involved in care, community partners available to the family and child, and treatment goals and strategies. [8]  Building a comprehensive system of care with a focus on prevention and early intervention can address the unmet needs of social-emotional development and behavioral problems in children. To achieve such a system, it is imperative to establish training models with an integrated system of care. Such a model will encourage and train professionals to collaborate mutually to prevent, identify, consult, educate, and plan treatment for patients. [9]

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Disclosure: Fatima Malik declares no relevant financial relationships with ineligible companies.

Disclosure: Raman Marwaha declares no relevant financial relationships with ineligible companies.

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