child development research articles

Articles about Child Development

Key findings, featured articles, scientific articles.

Parenting Groups – Do They Change How Mothers Think About Parenting? Read about mothers who participated in the Legacy for Children™ parenting group program, and how it affected their views on parenting.

Treatment of Disruptive Behavior Problems – What Works? Learn about current evidence on the most effective treatments for behavior problems in children

Factors Associated with Mental, Behavioral, and Developmental Disorders in Early Childhood . Learn about family, community and health-care factors related to children’s mental, behavioral or developmental disorder

Reassessing the approach of the Learn the Signs. Act Early. campaign. Learn about parents’ responses to the Learn the Signs. Act Early materials

Supporting Parents To Help Children Thrive Learn how CDC helps parents get the support and information they need.

Developmental Milestones Matter! Learn about the CDC Milestone Tracker.

Improving Children’s Behavioral Health Learn what CDC is doing about gaps in behavioral treatment for children.

Parenting Matters Parents are among the most important people in the lives of young children.

Helping Children Thrive in Rural Communities Information on children with mental, behavioral, and developmental disorders in rural and urban areas.

* These CDC scientific articles are listed in order of date published

Psychometric Assessment of Pilot Language and Communication Items on the 2018 and 2019 National Survey of Children’s Health Academic Pediatrics, 2021, Dec 27;S1876-2859 Helena J. Hutchins, Lara R. Robinson, Sana N. Charania, Reem A. Ghandour, Kathy Hirsh-Pasek, Jennifer Zubler [ Read article ]

Short Sleep Duration Among Infants, Children, and Adolescents Aged 4 Months–17 Years — United States, 2016–2018 Morbidity and Mortality Weekly Report (MMWR) 2021; 70(38) Anne G. Wheaton  & Angelika H. Claussen [ Read article ]

Behavioral and Socioemotional Outcomes of the Legacy for Children Randomized Control Trial to Promote Healthy Development of Children Living in Poverty, 4 to 6 Years Postintervention . Journal of Developmental and Behavioral Pediatrics, 2022 Jan 1;43(1):e39-e47 Caroline M. Barry, Lara R. Robinson, Jennifer W. Kaminski, Melissa L. Danielson, Corey L. Jones, Delia L. Lang [ Read summary ]

Healthy and Ready to Learn: Prevalence and Correlates of School Readiness among US Preschoolers Academic Pediatrics. 2021;21(5): 818-829. Reem M. Ghandour, Ashley H. Hirai, Kristin A. Moore, Lara R. Robinson, Jennifer W. Kaminski, Kelly Murphy, Michael C. Lu, Michael D. Kogan [ Read summary ]

Home Quality and Child Health: Analysis of the Survey of Income and Program Participation Journal of Child Health Care. 2021, 25(4): 603–615. Samantha Boch, Deena Chisolm, Jennifer W. Kaminski, Kelly Kelleher [ Read article ]

Factors Associated with Self-regulation in a Nationally Representative Sample of Children Ages 3–5 Years: United States, 2016 Maternal and Child Health Journal, 2021, 25, 27–37. Angelika H. Claussen, Lara R. Robinson, Jennifer W. Kaminski, Sana Charania, Joseph R. Holbrook, Marvin So, Reem Ghandour, Camille Smith, Ashley Satterfield-Nash, Georgina Peacock & Coleen Boyle [ Read article ]

Parent Engagement in An Original and Culturally Adapted Evidence-based Parenting Program Legacy for Children™. Infant Mental Health Journal, 2020 ;   41(3):356-377. Marvin So, Ana L. Almeida Rojo, Lara R. Robinson, Sophie A. Hartwig, Akilah R. Heggs Lee, Lana O. Beasley, Jane F. Silovsky, Amanda Sheffield Morris, Kelly Stiller Titchener, Martha I. Zapata. [ Read summary ]

Trends over Time and Jurisdiction Variability in Supplemental Security Income and State Supplementary Payment Programs for Children with Disabilities Journal of Public Health Management & Practice. 2020; 26(Suppl 2 ADVANCING LEGAL EPIDEMIOLOGY): S45–S53. Lara R. Robinson, Russell F. McCord, Lindsay K. Cloud, Jennifer W. Kaminski, Amy Cook, Jessica Amoroso, Maya Hazarika Watts, Kim Kotzky, Caroline M. Barry, Rebecca Johnson, Kelly J. Kelleher. [ Read article ]

Prevalence and Trends of Developmental Disabilities among Children in the US: 2009–2017. Pediatrics, 2019; 144(4):e20190811 Benjamin Zablotsky, Lindsey I. Black, Matthew J. Maenner, Laura A. Schieve, Melissa L. Danielson, Rebecca H. Bitsko, Stephen J. Blumberg, Michael D. Kogan, Coleen A. Boyle [ Read key findings ] [ Read article ]

The Legacy for Children TM Randomized Control Trial: Effects on Cognition Through Third Grade for Young Children Experiencing Poverty. Journal of Developmental & Behavioral Pediatrics. 2019; 40(4): 275–284. Ruth Perou, Lara R. Robinson, Melissa L. Danielson, Angelika H. Claussen, Susanna N. Visser, Keith G. Scott, “Leila Beckwith, Lynne F. Katz, D. Camille Smith. [ Watch video ] [ Read article ]

Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders and Poverty among Children Aged 2–8 years — United States, 2016. Morbidity and Mortality Weekly Report (MMWR) 2018;67(5):1377-1383. Robyn A. Cree, Rebecca H. Bitsko, Lara R. Robinson, Joseph R. Holbrook, Melissa L. Danielson, Camille Smith, Jennifer W. Kaminski, Mary Kay Kenney, Georgina Peacock. [ Read article ]

Effects of Prenatal Marijuana Exposure on Neuropsychological Outcomes in Children Aged 1-11 Years: A Systematic Review. Paediatric and Perinatal Epidemiology, 2018; 32(6), 512-532. Saida R. Sharapova,  Elyse Phillips, Karen Sirocco, Jennifer W. Kaminski, Rebecca T. Leeb, Italia Rolle. [ Read article ]

Prevalence of Parent-Reported Traumatic Brain Injury in Children and Associated Health Conditions. JAMA Pediatrics . Published online September 24, 2018;172(11):1078-1086. Juliet Haarbauer-Krupa, Akilah Heggs Lee, Rebecca H. Bitsko, Xinjian Zhang, Marcie-jo Kresnow-Sedacca. [ Read article ]

Maternal Perceptions of Parenting Following an Evidence-based Parenting Program: A Qualitative Study of Legacy for Children™ Sophie A. Hartwig, Lara R. Robinson, Dawn L. Comeau, Angelika H. Claussen, and Ruth Perou. Infant Mental Health Journal, 2017, 38(4), 499-513. [ Read article ]

Differences in Health Care, Family, and Community Factors Associated with Mental, Behavioral, and Developmental Disorders Among Children Aged 2–8 Years in Rural and Urban Areas — United States, 2011–2012 Morbidity and Mortality Weekly Report (MMWR) Surveillance Summaries 2017; 66(No. SS-8):1–11. Lara R. Robinson, Joseph R. Holbrook, Rebecca H. Bitsko, Sophie A. Hartwig, Jennifer W. Kaminski, Reem M. Ghandour, Georgina Peacock, Akilah Heggs, Coleen A. Boyle. [ Read article ] [ Read Key Findings ]

Targeting Parenting in Early Childhood: A Public Health Approach to Improve Outcomes for Children Living in Poverty Child Development. 2017 , 88 (2), 388–39. Amanda Sheffield Morris, Lara R. Robinson, Jennifer Hays-Grudo, Angelika H. Claussen, Sophie A. Hartwig, Amy E. Treat. [ Read summary ]

A Qualitative Study of Cultural Congruency of Legacy for Children™ for Spanish-speaking Mothers. Children and Youth Services Review. 2017, 8(79):299-308. Lana O. Beasley, Jane F. Silovsky, Hannah C. Espeleta, Lara R. Robinson, Sophie A. Hartwig, Amanda Sheffield Morris, Irma Esparza [ Read summary ]

Interpreting the Prevalence of Mental Disorders in Children: Tribulation and Triangulation Health Promotion Practice 2017, 18(1): 5-7. Joseph R. Holbrook, Rebecca H. Bitsko, Melissa L. Danielson, Susanna N. Visser. [ Read article ]

Health-care, Family, and Community Factors associated with Mental, Behavioral, and Developmental Disorders in Early Childhood – United States, 2011-2012. Morbidity and Mortality Weekly Report (MMWR) 2016 Mar 11 ; 65(9);221–226 Rebecca H. Bitsko, Joseph R. Holbrook,  Jennifer W. Kaminski,  Lara R. Robinson, Reem M. Ghandour, Camille Smith, Georgina Peacock. [ Read article ] [ Read Key Findings ]

Mental Health Surveillance Among Children, United States 2005–2011 Morbidity and Mortality Weekly Report (MMWR) 2013;62(Suppl; May 16, 2013):1-35. CDC [ Read article ] [ Read summary ]

Behavioral and Socioemotional Outcomes through Age 5 of the Legacy for Children™ Public Health Approach to Improving Developmental Outcomes among Children Born into Poverty American Journal of Public Health, 2013;103:1058–1066. Jennifer W. Kaminski, Ruth Perou, Susanna N. Visser, Keith G. Scott, Leila H. Beckwith, Judy Howard, D. Camille Smith, Melissa L. Danielson. [ Read Key Findings ]

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• v.4(Suppl 4); 2019

Early childhood development: an imperative for action and measurement at scale

Linda richter.

1 Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg-Braamfontein, South Africa

Maureen Black

2 RTI International, Research Triangle Park, North Carolina, USA

3 Early Childhood Development, Unicef USA, New York City, New York, USA

Bernadette Daelmans

4 Department of Maternal, Newborn, Child and Adolescent Health, WHO, Geneva, Switzerland

Chris Desmond

5 DST-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa

Amanda Devercelli

6 Early Childhood Development, World Bank Group, Washington, District of Columbia, USA

7 Department of Mental Health and Substance Abuse, WHO, Geneva, Switzerland

Günther Fink

8 Household Economics and Health Systems, Swiss Tropical and Public Health Institute, Basel, Switzerland

9 Global Health and Population, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA

Jody Heymann

10 Fielding School of Public Health and WORLD Policy Analysis Center, University of California, Los Angeles, California, USA

Joan Lombardi

11 Early Opportunities, Washington, District of Columbia, USA

Chunling Lu

12 Division of Global Health, Brigham and Women's Hospital and Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA

Sara Naicker

Emily vargas-barón.

13 RISE Institute, Washington, District of Columbia, USA

Experiences during early childhood shape biological and psychological structures and functions in ways that affect health, well-being and productivity throughout the life course. The science of early childhood and its long-term consequences have generated political momentum to improve early childhood development and elevated action to country, regional and global levels. These advances have made it urgent that a framework, measurement tools and indicators to monitor progress globally and in countries are developed and sustained. We review progress in three areas of measurement contributing to these goals: the development of an index to allow country comparisons of young children’s development that can easily be incorporated into ongoing national surveys; improvements in population-level assessments of young children at risk of poor early development; and the production of country profiles of determinants, drivers and coverage for early childhood development and services using currently available data in 91 countries. While advances in these three areas are encouraging, more investment is needed to standardise measurement tools, regularly collect country data at the population level, and improve country capacity to collect, interpret and use data relevant to monitoring progress in early childhood development.

Summary box

• New knowledge of the extent to which experiences during early childhood shape health, well-being and productivity throughout the life course has prompted action to improve early childhood development at the country, regional and global levels.
• Advances have been made in three areas of measurement needed to achieve these goals: population-level child assessments, population proxies of children at risk of poor childhood development, and country and regional profiles of drivers and supports for early childhood development.
• Regular, country-comparable, population-level measurements of childhood development, as well as threats to development and available supports and services, are needed to drive progress and accountability in efforts to improve early childhood development.

Introduction

Scientific findings from diverse disciplines are in agreement that critical elements of lifelong health, well-being and productivity are shaped during the first 2–3 years of life, 1 beginning with parental health and well-being. 2 The experiences and exposures of young children during this time-bound period of neuroplasticity shape the development of both biological and psychological structures and functions across the life course.

Adversities during pregnancy and early childhood, due to undernutrition, stress, poverty, violence, chronic illnesses and exposure to toxins, among others, can disrupt brain development, with consequences that endure throughout life and into future generations. 3 4 Children whose early development is compromised have fewer personal and social skills and less capacity to benefit from schooling. These deficits limit their work opportunities and earnings as adults. 5 A corollary of early susceptibility to adversity includes responsiveness to opportunities during these early years. As a result, interventions during the first 3 years of life are more effective and less costly than later efforts to compensate for early adversities and to promote human development. 6

It is estimated that, in 2010, at least 249 million (43%) children under the age of 5 years in low-income and middle-income countries (LMICs) were at risk of poor early childhood development (ECD) as a consequence of being stunted or living in extreme poverty. 7 This loss of potential is costly for individuals and societies. The average percentage loss of adult income per year is estimated at 26%, increasing the likelihood of persistent poverty for these children, families and societies. 5 Assuming 125 million children are born each year with a global average of poor infant growth, 8 the estimated annual global income loss is US$177 billion. 9 These impacts have serious consequences on economic growth. Recent World Bank estimates suggest that the average country’s per capital gross domestic product would be 7% higher than it is now had stunting been eliminated when today’s workers were children. 10 At the global level, human capital accounts for as much as two-thirds of the wealth differences between countries. ECD is the foundation of human capital. 11

Supported by a growing body of evidence and increasing global interest in this field, ECD is included in the 2015 United Nations Sustainable Development Goals (SDGs). Target 4.2 is ‘improved access to quality early childhood development, care and pre-primary education’. Progress towards achieving this target is measured by indicator 4.2.1, ‘the proportion of children under 5 years of age who are developmentally on track in health, learning and psychosocial well-being, by sex’. ECD is closely linked to other SDGs as well, for example, eradicate poverty (1), end hunger and improve nutrition (2), ensure healthy lives (3), achieve gender equality (5), reduce inequality in and among countries (10), and promote peaceful societies (16), and it is implied in several more. 5

The United Nations Global Strategy for Women’s, Children’s and Adolescents’ Health, 2016–2030 synthesises the 17 SDGs in three strategies: survive, thrive and transform. Survive refers to sustained and increased reductions in preventable deaths of women, newborns, children and adolescents, as well as stillbirths; thrive refers to children receiving the nurturing care necessary to reach their developmental potential; and transform refers to comprehensive changes in policies, programmes and services for women, children and adolescents to achieve their potential. 12

ECD has also become an important component of other global agendas, including Scaling Up Nutrition, the Global Partnership for Education, the Global Financing Facility for Every Woman Every Child, the Every Woman Every Child movement, the work plans of the WHO, Unicef and the World Bank Group, the G20, 13 international funding agencies, and philanthropic foundations. 7

These multifaceted findings have generated political momentum to improve ECD as a critical phase in the life course, making it urgent to develop measurement tools and indicators to monitor progress globally and in countries. Advances in measurement are needed to support efforts to motivate and track political and financial commitments, and to monitor implementation and impact. This means that we must be able to determine how many and which children are thriving, and on track in health, learning and psychosocial well-being.

Measurement of children’s progress in childhood is acknowledged to be challenging because development is by nature dynamic and children have varying individual trajectories. Well-validated instruments of individual development are complex and require extensive training and expertise. These challenges are amplified in efforts to make measurements across populations of children. Taking these limitations into account, we review progress in three areas of measurement that are contributing data to the current political momentum for ECD and efforts to monitor implementation and impact. Progress is being made to construct a feasible country-comparable measure of young children’s development that could be incorporated into national surveys, to improve proxies of population levels of young children at risk of poor early development, and to generate country profiles of determinants, drivers and coverage for early childhood development and services, using currently available data.

A new initiative to construct a population measure of ECD

A direct measure of the development of children 0–5 years that could be administered globally and used both within and across countries is urgently needed. Efforts have been made since the 1980s to develop a globally applicable measure of ECD, with the major challenges being individual and cultural variations in the onset of early skills. 14

Currently, the Early Child Development Index (ECDI) is included as the indicator of SDG goal 4, target 4.2. It is a composite index, first introduced in Unicef’s fourth Multiple Indicator Cluster Survey (MICS) in 2010. It is derived from 10 caregiver-reported questions designed for children aged 36–59 months to assess four domains of development: literacy-numeracy, learning/cognition, physical development and socioemotional development. Some items are acknowledged to be unsuitable for assessing development, 15 and efforts are under way to revise the index, as well as to include items applicable to children younger than 3 years of age.

Three research efforts have collaborated to create the Global Scale for Early Development (GSED): the Infant and Young Child Development from the WHO, 16 the Caregiver-Reported Early Development Instrument from the Harvard Graduate School of Education, 17 and the Developmental Score from the Global Child Development Group at the University of the West Indies. 18 The goals of the GSED are to develop two instruments for measuring ECD (0–3 years) globally: a population-based instrument and a programme evaluation instrument, as described in table 1 .

Global Scale for Early Development: population and programme measures

The GSED takes advantage of large-scale and cohort studies from many countries and is harmonising efforts to generate population-based and programmatic evaluation measures of the development of children aged 0–3 years old that can be used globally ( table 2 ). The scale will be available for country testing in 2019. The aim is to have the population-based measure incorporated into national surveys, including Unicef’s MICS and the US Agency for International Development’s Demographic and Health Surveys (DHS), to produce globally comparable monitoring data. Efforts are also under way to harmonise the revision of ECDI and the development of GSED to align on child outcome measurement from birth to 59 months of age.

Development and validation of the Global Scale for Early Development

CREDI, Caregiver-Reported Early Development Instrument; D-score, Developmental Score; IYCD, Infant and Young Child Development.

A country-comparable proxy for population levels of risk of poor childhood development

Information about children’s risk for poor development is important, as is identifying areas for intervention. To track these, a proxy measure of population levels of young children at risk of suboptimal development has been calculated.

Stunting and poverty were used in the first published estimation in 2007 of the global prevalence of risk to children’s development. The initial choice of indicators was based on evidence that they both predict poor cognitive development and school performance. 19 20 Additional advantages are that their definitions are standardised and many countries have data on both indicators. 21

Lu et al 21 updated the earlier values to 2010, using the 2006 WHO growth standards and World Bank poverty rates (US$1.25 per person per day), leading to an estimate of 249 million children or 43% of all children under 5 years of age in LMICs being at risk of poor childhood development. The accuracy and comparability of the later estimates benefited greatly from major advances in both data availability and estimation methods. 21

To estimate the long-term consequences of poor ECD, studies focus on estimating the impact on subsequent schooling and labour market participation and wages. The current estimate, that the average percentage of annual adult income lost as a result of stunting and extreme poverty in early childhood is about 26%, is supported by follow-up adult data from early life interventions. Two programmes have found wage increases between 25% in Jamaica attributed to a psychosocial intervention 22 and 46% in Guatemala attributed to a protein supplement. 23

In order to improve the estimate of risk, efforts are under way to include additional risks experienced in ECD known to affect health and well-being across the life course. For example, adding low maternal schooling and exposure to harsh punishment to stunting and extreme poverty, for 15 countries with available data from MICS in 2010/2011, increased the number of children estimated to be at risk of poor childhood development substantially. 5

Country profiles of ECD

Population-based measures of early child development and proxies of children at risk give an indication of prevalence, and indicators of disparity can be derived according to gender, urban–rural location and socioeconomic status. However, they do not include drivers, determinants nor coverage of interventions that could improve childhood development.

The Countdown to 2015 for Maternal, Newborn and Child Survival , established in 2005, set a precedent by creating mechanisms to portray multidimensional aspects of progress towards improving maternal and child health, and is testimony of its value. 24 Countdown to 2030 , which tracks maternal, child and adolescent health and nutrition goals, has expanded to address the broader SDG agenda, including ECD, health in humanitarian settings and conflict, and adolescent health and well-being. 25 26 It includes coverage and equity of essential interventions, as well as indicators of determinants and the enabling environment provided by policies.

This approach has been applied to ECD using the Nurturing Care Framework, 27 launched at the 71st World Health Assembly. The concept of nurturing care was introduced in the 2017 Lancet Series Advancing Early Child Development: From Science to Scale . Nurturing Care Framework comprises conditions for early development: good health and nutrition; protection from environmental and personal harm; affectionate and encouraging responses to young children’s communications; and opportunities for young children to learn through exploration and interpersonal interactions. 7

These early experiences are nested in caregiver–child and family relationships. In turn, parents, families and other caregivers require support from a facilitating environment of policies, services and communities. Policies, services and programmes can protect women’s health and well-being, safeguard pregnancy and birth, and enable families and caregivers to promote and protect young children’s development. 6

The Nurturing Care Framework has been used to produce ECD profiles for 91 LMICs. 28 Countries were selected either to ensure alignment of ECD with Countdown to 2030 , or because more than 30% of children are estimated to be at risk of poor ECD in 2010, using the methods described in Lu et al 21 and Black et al . 7

These country profiles, which consist of currently available data from LMICs, are laid out to represent the Nurturing Care Framework. The profiles consist of the following sections:

• Selected demographic indicators of the country relevant to early child development: total population, annual births, children under 5 years of age and under-5 mortality.
• Threats to ECD, including maternal mortality, young motherhood, low birth weight, preterm births, child poverty, under-5 stunting, harsh punishment and inadequate supervision.
• The prevalence of young children at risk of poor child development disaggregated by gender and rural–urban residence, and lifetime costs of growth deficit in early childhood in US dollars.
• The facilitating policy environment for caregivers and children, as indexed by relevant conventions and national policies.
• Support and services to promote ECD in the five areas of nurturing care: early learning, health, nutrition, responsive caregiving, and security and safety.

Most of the existing data are published in Unicef’s annual State of the World’s Children. Convention and policy data come from, among others, the United Nations Treaty Collections and the International Labour Organization.

Figure 1 shows an example of the country profiles, with the country name replace by ‘Country Profiles’.

An example of an early childhood development (ECD) country profile. CRC, convention on the rights of the child.

In a forthcoming paper, Lu and Richter (2019) describe in detail the updated estimates of children at risk of poor childhood development using the newly released poverty line of US$1.9 per person per day to estimate that, in 2015, 233 million children or 40.5% of children under 5 years of age were at risk of poor childhood development. Figures 2 and 3 show the estimates of risk for poor ECD across a decade, from 2005 to 2010 and 2015, and using the 2010 data variations between children at risk living in rural and urban areas. Gender is not illustrated here because, in most countries, the differences are small and not statistically significant.

Decline in the number of countries with high proportions of young children at risk of poor development between 2005 and 2015.

Differences in risk of poor development among urban and rural children in 63 countries (most recent years with available data).

Figure 2 shows that, between 2005 and 2010, countries with two-thirds of young children at risk (>67%) declined in both central Europe and South-East Asia. There was little change in countries with high proportions of young children at risk in sub-Saharan Africa during this period, and by 2015 countries with the highest proportion of children at risk were in Central and Southern Africa.

Estimates on the prevalence of children at risk of poor development in urban and rural areas were derived using DHS, MICS and country data for 63 countries with available data in most recent years ( figure 3 ). The differences are strikingly high, with more rural children at risk than their urban counterparts in 50 countries (differences of more than 20%). Almost all countries with 40% point differences were in sub-Saharan Africa. 28

There are additional indicators that ideally should be included in a monitoring framework, but currently lack comparable country data. Data are usually unavailable because reliable, valid instruments feasible for multicountry administration are still in development, or the instruments are not yet included in representative surveys. In particular, there are as yet no global population-based indicators for assessing responsive caregiving. Suggestions have been made that data should be collected on whether information about ECD and caregiver–child interaction is publicly disseminated, whether home visits or groups are provided for parents at high risk of experiencing difficulties providing their children with nurturing care, and whether affordable good quality child day care is available for families who need it. 29 National data on laws and policies that support responsive caregiving are also insufficient, for example, wages and other forms of income to enable families to provide for their young children. 30

Additional data gaps concern risks arising from poor parental mental health, 31 low maternal schooling, and maternal tobacco and alcohol use, among others, prevalence of childhood developmental delays and disabilities, 32 and maltreatment and institutionalisation of young children. 33 There is also no comparable information on government budget allocation to ECD or household expenditure on ECD services care, among others.

Multidisciplinary scientific evidence and political momentum are focusing on ECD as a critical phase in enhancing health and well-being across the life course. Additional measurements and indicators for monitoring and evaluation are urgently needed to support expansions in implementation and investment, and to report progress. New data will stimulate global, regional and national action, and in turn motivate for more areas of ECD to be covered in national surveys.

The Nurturing Care Framework provides a platform for three important areas of work. First, very significant progress is being made through the revision of the ECDI and the development of the GSED, a short caregiver-reported population measure of ECD that could feasibly be included in DHS, MICS and other nationally representative household surveys. The GSED will enable ECD to be tracked at population levels, and for programmes and services to be monitored and evaluated in comparable ways.

Second, a country-comparable proxy of the risk of poor ECD developed from 2004 data and updated with 2010 data has been extended to 2015, enabling comparisons to be made globally, regionally and by country across the last decade. Plans are in place to update these estimates regularly, and to add new risks as data for more countries become available.

Third, using these estimates, data included in Countdown to 2030 , and additional data from MICS and policy databases, initial profiles have been constructed for 91 LMICs. The profiles are organised according to the ecological model of the Nurturing Care Framework with policies, services and programmes supporting families and caregivers to provide good health and nutrition, security and safety, opportunities for early learning, and responsive caregiving for young children to thrive. The further development of these profiles is overseen by a multiagency committee as part of Countdown to 2030 and are freely available ( http://www.ecdan.org/countries.html and https://nurturing-care.org/?page_id=703 ). Unicef will update the country data annually and the profiles will be reproduced every 2 years.

However, as indicated earlier, substantial gaps in national and global data on topics of concern to ECD remain. The current global estimation on burden of risks, for example, does not include known risk factors other than stunting and extreme poverty, as a result of which the existing burden calculation is considerably underestimated. 5 The limited information on ECD investments at the country and global levels is exacerbated by the lack of appreciation of what constitute essential and continuous services, standard indicators for measuring ECD interventions and policies, as well as systematically collected data. Country capacity needs to be strengthened and ECD costing modules integrated into existing household income or expenditure surveys, and routinely collected from specific types of programmes. Clear definitions are needed to track donor contributions to ECD, and efforts should be made to address data issues, including collecting data from emerging donor countries (eg, China), foundations and international non-governmental organisations that are playing an increasing role in financing ECD, as has been called for by the G20. 33 National policies, strategic plans and laws which support ECD through nurturing care should be tracked for this intersectoral area.

To improve measurements of risks, intervention coverage, policies, financial commitments and impact on young children’s development, more investment is needed to regularly collect and disseminate data at the national and subnational levels. Analytical gaps at the country and global levels exist, especially with respect to equity analyses by household wealth, maternal education and rural–urban location, as well as by gender and child age within 0–5 years.

In conclusion, progress has been extremely positive, but too slow and too fragmented for the bold global agenda of ECD and the Nurturing Care Framework. The alliance with Countdown to 2030 is helpful as there is much to be learnt from the initiative’s experience under the Millennium Development Goals (MDGs), as well as collaboration with the SDGs. The country profiles boldly portray what we currently know about ECD in some of the most at-risk conditions and will prove a valuable tool for advocacy and implementation, including to improve measurement. Successful implementation and impact are dependent on accountability supported by regularly updated reliable and valid information.

Acknowledgments

Robert Inglis (Jive Media Africa, Pietermaritzburg, South Africa) and Frank Sokolic (EduAction, Durban, South Africa) for assistance with the country profiles and maps.

Handling editor: Seye Abimbola

Contributors: All authors meet the conditions for authorship: substantial contributions to the conception or design of the work, or the acquisition, analysis or interpretation of data; drafting the work or revising it critically for important intellectual content; final approval of the version published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding: This study has been funded by Conrad N Hilton Foundation and the Bill and Melinda Gates Foundation.

Competing interests: None declared.

Patient consent for publication: Not required.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data sharing statement: Data on the country profiles are publicly available on the websites cited in the paper.

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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.

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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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Early Childhood Development: the Promise, the Problem, and the Path Forward

Subscribe to the center for universal education bulletin, tamar manuelyan atinc and tamar manuelyan atinc nonresident senior fellow - global economy and development , center for universal education @tamar_istanbul emily gustafsson-wright emily gustafsson-wright senior fellow - global economy and development , center for universal education @egwbrookings.

November 25, 2013

• 17 min read

Access more content from the Center for Universal Education here , including work on early childhood education .

Early Childhood: The Scale of the Problem

More than 200 million children under the age of five in the developing world are at risk of not reaching their full development potential because they suffer from the negative consequences of poverty, nutritional deficiencies and inadequate learning opportunities (Lancet 2007).  In addition, 165 million children (one in four) are stunted, with 90 percent of those children living in Africa and Asia (UNICEF et al, 2012).  And while some progress has been made globally, child malnutrition remains a serious public health problem with enormous human and economic costs.  Child death is a tragedy.  At 6 million deaths a year, far too many children perish before reaching the age of five, but the near certainty that 200 million children today will fall far below their development potential is no less a tragedy.

There is now an expanding body of literature on the determining influence of early development on the chances of success later in life.  The first 1,000 days from conception to age two are increasingly being recognized as critical to the development of neural pathways that lead to linguistic, cognitive and socio-emotional capacities that are also predictors of labor market outcomes later in life. Poverty, malnutrition, and lack of proper interaction in early childhood can exact large costs on individuals, their communities and society more generally.  The effects are cumulative and the absence of appropriate childcare and education in the three to five age range can exacerbate further the poor outcomes expected for children who suffer from inadequate nurturing during the critical first 1,000 days.

The Good News: ECD Interventions Are Effective

Research shows that there are large gains to be had from investing in early childhood development.  For example, estimates place the gains from the elimination of malnutrition at 1 to 2 percentage points of gross domestic product (GDP) annually (World Bank, 2006).  Analysis of results from OECD’s 2009 Program of International Student Assessment (PISA) reveals that school systems that have a 10 percentage-point advantage in the proportion of students who have attended preprimary school score an average of 12 points higher in the PISA reading assessment (OECD and Statistics Canada, 2011).  Also, a simulation model of the potential long-term economic effects of increasing preschool enrollment to 25 percent or 50 percent in every low-income and middle-income country showed a benefit-to-cost ratio ranging from 6.4 to 17.6, depending on the preschool enrollment rate and the discount rate used (Lancet, 2011).

Indeed, poor and neglected children benefit disproportionately from early childhood development programs, making these interventions among the more compelling policy tools for fighting poverty and reducing inequality.  ECD programs are comprised of a range of interventions that aim for: a healthy pregnancy; proper nutrition with exclusive breast feeding through six months of age and adequate micronutrient content in diet; regular growth monitoring and immunization; frequent and structured interactions with a caring adult; and improving the parenting skills of caregivers.

Related Content

Emily Gustafsson-Wright, Izzy Boggild-Jones, Sophie Gardiner

September 5, 2017

Brookings Institution, Washington DC

3:00 pm - 5:30 pm EDT

The Reality: ECD Has Not Been a Priority

Yet despite all the evidence on the benefits of ECD, no country in the developing world can boast of comprehensive programs that reach all children, and unfortunately many fall far short.  Programs catering to the very young are typically operated at small scale and usually through external donors or NGOs, but these too remain limited.  For example, a recent study found that the World Bank made only $2.1 billion of investments in ECD in the last 10 years, equivalent to just a little over 3 percent of the overall portfolio of the human development network, which totals some $60 billion (Sayre et al, 2013).

The following are important inputs into the development of healthy and productive children and adults, but unfortunately these issues are often not addressed effectively:

Maternal  Health. Maternal undernutrition affects 10 to 19 percent of women in most developing countries (Lancet, 2011) and 16 percent of births are low birth weight (27 percent in South Asia).  Malnutrition during pregnancy is linked to low birth weight and impaired physical development in children, with possible links also to the development of their social and cognitive skills. Pre-natal care is critical for a healthy pregnancy and birth. Yet data from 49 low-income countries show that only 40 percent of pregnant women have access to four or more antenatal care visits (Taskforce on Innovative International Financing for Health Systems, 2009). Maternal depression also affects the quality of caregiving and compromises early child development.

Child Care and Parenting Practices. The home environment, including parent-child interactions and exposure to stressful experiences, influences the cognitive and socio-emotional development of children.  For instance, only 39 percent of infants aged zero to six months in low and middle-income countries are exclusively breast-fed, despite strong evidence on its benefits (Lancet, 2011).  Also, in half of the 38 countries for which UNICEF collects data, mothers engage in activities that promote learning with less that 40 percent of children under the age of six.  Societal violence and conflict are also detrimental to a child’s development, a fact well known to around 300 million children under the age of four that live in conflict-affected states.

Child Health and Nutrition. Healthy and well-nourished children are more likely to develop to their full physical, cognitive and socio-emotional potential than children who are frequently ill, suffer from vitamin or other deficiencies and are stunted or underweight.  Yet, for instance, an estimated 30 percent of households in the developing world do not consume iodized salt, putting 41 million infants at risk for developing iodine deficiency which is the primary cause of preventable mental retardation and brain damage, and also increases the chance of infant mortality, miscarriage and stillbirth.  An estimated 40 to 50 percent of young children in developing countries are also iron deficient with similarly negative consequences (UNICEF 2008).  Diarrhea, malaria and HIV infection are other dangers with a deficit of treatment in early childhood that lead to various poor outcomes later in life.

Preprimary Schooling. Participation in good quality preprimary programs has been shown to have beneficial effects on the cognitive development of children and their longevity in the school system.  Yet despite gains, enrollment remains woefully inadequate in Sub-Saharan Africa and the Middle East and North Africa.  Moreover, national averages usually hide significant inequalities across socio-economic groups in access and almost certainly in quality. In all regions, except South Asia, there is a strong income gradient for the proportion of 3 and 4 year olds attending preschool.

Impediments to Scaling Up

So what are the impediments to scaling up these known interventions and reaping the benefits of improved learning, higher productivity, lower poverty and lower inequality for societies as a whole?  There are a range of impediments that include knowledge gaps (especially in designing cost-effective and scalable interventions of acceptable quality), fiscal constraints and coordination failures triggered by institutional organization and political economy.

Knowledge Gaps . Despite recent advances in the area, there is still insufficient awareness of the importance of brain development in the early years of life on future well-being and of the benefits of ECD interventions.  Those who work in this area take the science and the evaluation evidence for granted. Yet awareness among crucial actors in developing countries—policymakers, parents and teachers—cannot be taken for granted.

At the same time much of the evaluation evidence from small programs attests to the efficacy of interventions, we do not yet know whether large scale programs are as effective. The early evidence came primarily from small pilots (involving about 10 to 120 children) from developed countries. [1] ;While there is now considerable evidence from developing countries as well, such programs still tend to be boutique operations and therefore questions regarding their scalability and cost-effectiveness.

There are also significant gaps in our knowledge as to what specific intervention design works in which context in terms of both the demand for and the provision of the services. These knowledge gaps include the need for more evidence on:  i) the best delivery mode – center, family or community based, ii) the delivery agents – community health workers, mothers selected by the community, teachers, iii) whether or not the programs should be universal or targeted, national or local, iv) the frequency and duration of interventions, of training for the delivery agents and of supervision, v) the relative value of nutritional versus stimulative interventions and the benefits from the delivery of an integrated package of services versus sector specific services that are coordinated at the point of delivery, vi) the most effective curricula and material to be used, vii) the relative effectiveness of methods for stimulating demand – information via individual contact, group sessions, media, conditional cash transfers etc.  In all these design questions, cost-effectiveness is a concern and leads to the need to explore the possibility of building on an existing infrastructure.  There is also a need for more evidence on the kinds of standards, training and supervision that are conducive to Safeguarding the quality of the intervention at scale.

Fiscal Constraints .  Fiscal concerns at the aggregate level are also an issue and force inter-sectoral trade-offs that are difficult to make.  Is it reasonable to expect countries to put money into ECD when problems persist in terms of both access and poor learning outcomes in primary schools and beyond?  Even though school readiness and teacher quality may be the most important determinants of learning outcomes in primary schools, resource allocation shifts are not easy to make for policymakers.  In addition, as discussed above, we do not yet have good answers to the questions around the cost implications of high quality design at scale.

Institutional Coordination and Political Context.   Successful interventions are multi-sectoral in nature (whether they are integrated from the outset or coordinated at the point of delivery) and neither governments nor donor institutions are structured to address well issues that require cross-sectoral cooperation.  When programs are housed in the education ministry, they tend to focus on preprimary concerns.  When housed in the health ministry, programs ignore early stimulation.  We do not know well what institutional structure works best in different contexts, including how decentralization may affect choices about institutional set ups.

There are also deeper questions about the nature of the social contract in any country that shapes views about the role of government and the distribution of benefits across the different segments of the population.  Some countries consider that the responsibilities of the public sector start when children reach school age and view the issues around the development of children at a younger age to be the purview of families.  And in many countries, policies that benefit children get short shrift because children do not have political voice and their parents are imperfect agents for their children’s needs.  Inadequate political support then means that the legislative framework for early year interventions is lacking and that there is limited public spending on programs that benefit the young.  For example, public spending on social pensions in Brazil is about 1.2 percent of GDP whereas transfers for Bolsa Familia which targets poor children are only 0.4 percent of GDP (Levy and Schady 2013).  In Turkey, only 6.5 percent of central government funds are directed to children ages zero to 6, while the population above 44 receives a per capita transfer of at least 2.5 times as large as children today (World Bank, 2010).  Finally, the long gestation period needed to achieve tangible results compounds the limited appeal of ECD investments given the short planning horizon of many political actors.

The Future: An Agenda for Scaling Up ECD

Addressing the constraints to scaling up ECD requires action across a range of areas, including more research and access to know how, global and country level advocacy, leveraging the private sector, and regular monitoring of progress.

Operational Research and Learning Networks. Within the EDC research agenda, a priority should be the operational research that is needed to go to scale.  This research includes questions around service delivery models, including in particular their cost effectiveness and sustainability.  Beyond individual program design, there are broader institutional and policy questions that need systematic assessment. These questions center on issues including the inter-agency and intergovernmental coordination modalities which are best suited for an integrated delivery of the package of ECD services.  They also cover the institutional set-ups for quality assurance, funding modalities, and the role of the private sector.  Finally, research is also needed to examine the political economy of successful implementation of ECD programs at scale.

Also necessary are learning networks that can play a powerful role in disseminating research findings and in particular good practice across boundaries. Many of the issues regarding the impediments for scaling up are quite context specific and not amenable to generic or off-the-shelf solutions.  A network of peer learning could be a powerful avenue for policymakers to have deeper and face-to-face interactions about successful approaches to scaling up.  South-South exchanges were an enormously valuable tool in the propagation of conditional cash transfer schemes both within Latin America and globally. These types of exchanges could be equally powerful for ECD interventions

Advocacy. There is a need for a more visible global push for the agenda, complemented by advocacy at country or regional levels and a strong role for business leaders.  It should be brought to the attention of policymakers that ECD is not a fringe issue and that it is a matter of economic stability to the entire world. It is also in the interest of business leaders to support the development of young children to ensure a productive work force in the future and a thriving economy.  Currently, there is insufficient recognition of the scale of the issues and the effectiveness of known interventions. And while there are pockets of research excellence, there is a gap in the translation of this work into effective policies on the ground.  The nutrition agenda has recently received a great deal of global attention through the 1000 days campaign and the Scaling up Nutrition Movement led by the United States and others.  Other key ECD interventions and the integration and complementarities between the multi-sectoral interventions have received less attention however.  The packaging of a minimum set of services that all countries should aspire to provide to its children aged zero to six would be an important step towards progress.  The time is ripe as discussions around the post-2015 development framework are in full swing, to position ECD as a critical first step in the development of healthy children, capable of learning and becoming productive adults.

Leveraging the Private Sector.   The non-state sector already plays a dominant role in providing early childhood care, education and healthcare services in many countries.  This represents both a challenge and an opportunity.  The challenge is that the public sector typically lacks the capacity to ensure quality in the provision of services and research evidence shows that poor quality child care and education services are not just ineffective; they can be detrimental (Lancet 2011).  The challenge is all the greater given that going to scale will require large numbers of providers and we know that regulation works better and is less costly in markets with fewer actors.  On the opportunity side of the ledger, there is scope for expanding the engagement of the organized private sector.  The private sector can contribute by providing universal access for its own workforce, through for-profit investments, and in the context of corporate social responsibility activities.  Public-private partnerships can span the range of activities, including providing educational material for home-based parenting programs; developing and delivering parent education content through media or through the distribution chains of some consumer goods or even financial products; training preprimary teachers; and providing microfinance for home or center-based childcare centers. Innovative financing mechanisms, such as those in the social impact investing arena, may provide necessary financing, important demonstration effects and quality assurance for struggling public systems.  Such innovations are expanding in the United States, paving the way for middle and low-income countries to follow.

ECD Metrics.  A key ingredient for scaling up is the ability to monitor progress. This is important both for galvanizing political support for the desired interventions and to provide a feedback loop for policymakers and practitioners. There are several metrics that are in use by researchers in specific projects but are not yet internationally accepted measures of early child development that can be used to report on outcomes globally.  While we can report on the share of children that are under-weight or stunted, we cannot yet provide the fuller answer to this question which would require a gauge of their cognitive and socio-emotional development.  There are some noteworthy recent initiatives which will help fill this gap.  The UNICEF-administered Multiple Indicator Cluster Survey (MICS) 4 includes an ECD module and a similar initiative from the Inter-American Development Bank collects ECD outcome data in a handful of Latin American countries.  The World Health Organization has launched work that will lead to a proposal on indicators of development for zero to 3 year old children while UNESCO is taking the lead on developing readiness to learn indicators (for children around age 6) as a follow up to the recommendations of the Learning Metrics Task Force (LMTF) which is co-convened by UNESCO and the Center for Universal Education at Brookings.

The LMTF aims to make recommendations for learning goals at the global level and has been a useful mechanism for coordination across agencies and other stakeholders.  A related gap in measurement has to do with the quality of ECD services (e.g., quality of daycare). Overcoming this measurement gap is critical for establishing standards and for monitoring compliance and can be used to inform parental decisions about where to send their kids.

ECD programs have a powerful equalizing potential for societies and ensuring equitable investment in such programs is likely to be far more cost-effective than compensating for the difference in outcomes later in life.  Expanding access to quality ECD services so that they include children from poor and disadvantaged families is an investment in the future of not only those children but also their communities and societies.  Getting there will require concerted action to organize delivery systems that are financially sustainable, monitor the quality of programming and outcomes and reach the needy.

Lancet (2007). Child development in developing countries series. The Lancet, 369, 8-9, 60-70, 145, 57, 229-42.  http://www.thelancet.com/series /child-development-in-developing-countries.

Lancet (2011). Child development in developing countries series 2. The Lancet, 378, 1325-28, 1339- 53.  http://www.thelancet.com/series/child-development-in-developing-countries-2.

Levy, S. and Schady, N. (2013). Latin America’s Social Policy Challenge: Education, social Insurance, Redistribution. Journal of Economic Perspectives 27(2) , 193-218.

OECD and Statistics Canada (2011). Literacy for Life: Further Results from the Adult Literacy and Life Skills Survey. Paris/Ottawa: Organisation for Economic Co-operation and Development/Canada Minister of Industry.

Sayre, R.K., Devercelli, A.E., Neuman, M.J. (2013). World Bank Investments in Early Childhood: Findings from Portfolio Review of World Bank Early Childhood Development Projects from FY01-FY11. Draft, March 2013, Mimeo.

Taskforce on Innovative International Financing for Health Systems (2009). More money for health, and more health for the money: final report. Geneva: International Health Partnership. http://www.internationalhealthpartnership.net//CMS_files/documents/taskforce_report_EN.pdf

United Nations Children’s Fund (2005). Multiple Indicator Cluster Survey 3. UNICEF. http://www.childinfo.org/mics3_surveys.html.

United Nations Children’s Fund (2008). Sustainable Elimination of Iodine Deficiency: Progress since the1990 World Summit on Children. New York: UNICEF.

United Nations Children’s Fund, World Health Organization and The World Bank (2012). UNICEF- WHO-World Bank Joint Child Malnutrition Estimates. New York: UNICEF; Geneva: WHO; Washington D.C.: The World Bank.

World Bank (2006). Repositioning Nutrition as Central to Development: A Strategy for Large-Scale Action. Directions in Development series. Washington D.C.: The World Bank.

World Bank (2010). Turkey: Expanding Opportunities for the Next Generation-  A Report on Life Chances. Report No 48627-TR. Washington D.C.: The World Bank.

World Bank (2013). World Development Indicators 2013. Washington D.C.: The World Bank.

[1] The Perry preschool and Abecedarian programs in the United States have been rigorously studied and show tremendous benefits for children in terms of cognitive ability, academic performance and tenure within the school system and suggest benefits later on in life that include higher incomes, higher incidence of home ownership, lower propensity to be on welfare and lower rates of incarceration and arrest.

Early Childhood Education Global Education

Global Economy and Development

Center for Universal Education

Elyse Painter, Emily Gustafsson-Wright

January 5, 2024

Brenna Hassinger-Das, Katelyn Fletcher

September 20, 2023

Maysa Jalbout

March 31, 2022

InBrief: The Science of Early Childhood Development

This brief is part of a series that summarizes essential scientific findings from Center publications.

Content in This Guide

Step 1: why is early childhood important.

• : Brain Hero
• : The Science of ECD (Video)
• You Are Here: The Science of ECD (Text)

Step 2: How Does Early Child Development Happen?

• : 3 Core Concepts in Early Development
• : 8 Things to Remember about Child Development
• : InBrief: The Science of Resilience

Step 3: What Can We Do to Support Child Development?

• : From Best Practices to Breakthrough Impacts
• : 3 Principles to Improve Outcomes

The science of early brain development can inform investments in early childhood. These basic concepts, established over decades of neuroscience and behavioral research, help illustrate why child development—particularly from birth to five years—is a foundation for a prosperous and sustainable society.

Brains are built over time, from the bottom up.

The basic architecture of the brain is constructed through an ongoing process that begins before birth and continues into adulthood. Early experiences affect the quality of that architecture by establishing either a sturdy or a fragile foundation for all of the learning, health and behavior that follow. In the first few years of life, more than 1 million new neural connections are formed every second . After this period of rapid proliferation, connections are reduced through a process called pruning, so that brain circuits become more efficient. Sensory pathways like those for basic vision and hearing are the first to develop, followed by early language skills and higher cognitive functions. Connections proliferate and prune in a prescribed order, with later, more complex brain circuits built upon earlier, simpler circuits.

The interactive influences of genes and experience shape the developing brain.

Scientists now know a major ingredient in this developmental process is the “ serve and return ” relationship between children and their parents and other caregivers in the family or community. Young children naturally reach out for interaction through babbling, facial expressions, and gestures, and adults respond with the same kind of vocalizing and gesturing back at them. In the absence of such responses—or if the responses are unreliable or inappropriate—the brain’s architecture does not form as expected, which can lead to disparities in learning and behavior.

The brain’s capacity for change decreases with age.

The brain is most flexible, or “plastic,” early in life to accommodate a wide range of environments and interactions, but as the maturing brain becomes more specialized to assume more complex functions, it is less capable of reorganizing and adapting to new or unexpected challenges. For example, by the first year, the parts of the brain that differentiate sound are becoming specialized to the language the baby has been exposed to; at the same time, the brain is already starting to lose the ability to recognize different sounds found in other languages. Although the “windows” for language learning and other skills remain open, these brain circuits become increasingly difficult to alter over time. Early plasticity means it’s easier and more effective to influence a baby’s developing brain architecture than to rewire parts of its circuitry in the adult years.

Cognitive, emotional, and social capacities are inextricably intertwined throughout the life course.

The brain is a highly interrelated organ, and its multiple functions operate in a richly coordinated fashion. Emotional well-being and social competence provide a strong foundation for emerging cognitive abilities, and together they are the bricks and mortar that comprise the foundation of human development. The emotional and physical health, social skills, and cognitive-linguistic capacities that emerge in the early years are all important prerequisites for success in school and later in the workplace and community.

Toxic stress damages developing brain architecture, which can lead to lifelong problems in learning, behavior, and physical and mental health.

Scientists now know that chronic, unrelenting stress in early childhood, caused by extreme poverty, repeated abuse, or severe maternal depression, for example, can be toxic to the developing brain. While positive stress (moderate, short-lived physiological responses to uncomfortable experiences) is an important and necessary aspect of healthy development, toxic stress is the strong, unrelieved activation of the body’s stress management system. In the absence of the buffering protection of adult support, toxic stress becomes built into the body by processes that shape the architecture of the developing brain.

Policy Implications

• The basic principles of neuroscience indicate that early preventive intervention will be more efficient and produce more favorable outcomes than remediation later in life.
• A balanced approach to emotional, social, cognitive, and language development will best prepare all children for success in school and later in the workplace and community.
• Supportive relationships and positive learning experiences begin at home but can also be provided through a range of services with proven effectiveness factors. Babies’ brains require stable, caring, interactive relationships with adults — any way or any place they can be provided will benefit healthy brain development.
• Science clearly demonstrates that, in situations where toxic stress is likely, intervening as early as possible is critical to achieving the best outcomes. For children experiencing toxic stress, specialized early interventions are needed to target the cause of the stress and protect the child from its consequences.

Suggested citation: Center on the Developing Child (2007). The Science of Early Childhood Development (InBrief). Retrieved from www.developingchild.harvard.edu .

Related Topics: toxic stress , brain architecture , serve and return

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• Open access
• Published: 07 October 2016

Analyzing early child development, influential conditions, and future impacts: prospects of a German newborn cohort study

• Sabine Weinert 1 ,
• Anja Linberg 2 ,
• Manja Attig 3 ,
• Jan-David Freund 1 &
• Tobias Linberg 3  

International Journal of Child Care and Education Policy volume  10 , Article number:  7 ( 2016 ) Cite this article

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The paper provides an overview of a German cohort study of newborns which includes a representative sample of about 3500 infants and their mothers. The aims, challenges, and solutions concerning the large-scale assessment of early child capacities and skills as well as the measurements of learning environments that impact early developmental progress are presented and discussed. First, a brief overview of the German regulations related to early child education and care (ECEC) and parental leave as well as the study design are outlined. Then, the assessments of domain-specific and domain-general cognitive and socio-emotional indicators of early child functioning and development are described and the assessments of structural, orientational, and process quality of the children’s learning environment at home and in child care are presented. Special attention is given to direct assessments and their reliability and validity; in addition, some selected results on social disparities are reported and the prospects of data analyses are discussed.

Early childhood and early child education are an important basis for later development, educational performance, and pathways as well as for lifelong learning and well-being. This important claim has been made repeatedly (Caspi et al. 2003 ; Noble et al. 2007 ), and even critical phases of development have been suggested (e.g., Mayberry et al. 2002 ). Nevertheless and despite the existence of quite a few longitudinal studies addressing this issue, empirical evidence concerning effective conditions, differential child progress, and how the early phases of life impact future development and prospects is still rare.

From an educational and political point of view, it is alarming that various studies have documented profound disparities in child development according to family background when children are merely 3 years of age (Brooks-Gunn and Duncan 1997 ; Dubowy et al. 2008 ; Hart and Risley 1995 , 1999 ; Weinert et al. 2010 ). Even in the first year of life, very early roots of social disparities have been demonstrated which increased substantially over the next few years (Halle et al. 2009 ). In addition, some studies show a high stability of interindividual differences and social disparities from age three onward across preschool (Weinert and Ebert 2013 ; Weinert et al. 2010 ) and school age (Law et al. 2014 ). Notably, the stability of individual differences in children’s test performance has been shown to be even more pronounced in educationally dependent domains of development, like language and factual knowledge, than in more domain-general and less culture-dependent facets of children’s cognitive functioning, as indicated by non-verbal intelligence test scores (Weinert et al. 2010 ).

Drawing on a bioecological model of development (Bronfenbrenner and Morris 2006 ), developmental progress and child education are influenced from early on by the interaction between (developing) child characteristics, skills, and competencies and the quality of structural and process characteristics of the learning environment at the child’s home (Bakermans-Kranenburg and van Ijzendoorn 2011 ; Bradley and Corwyn 2002 ; Ebert et al. 2013 ; Weinert et al. 2012 ) as well as in child care (Anders et al. 2013 ). Longitudinal studies shed light on these interactions and how they impact later development and education, which is of great importance for gaining a better understanding of the underlying processes and influential conditions. It is important to note that the form and organization of the various learning environments are affected by state regulations, which differ between countries, resulting in different support systems, offers and regulations for parents from child birth until her/his formal school enrolment (Waldfogel 2001 ).

Regulations in Germany

Maternity leave regulations in Germany prescribe a period of 14 weeks for maternity leave which is divided into two phases: 6 weeks before and 8 weeks after birth. Mothers receive maternity pay from public funds in addition to their employer’s contribution which amounts to 100 % of their former income. After this period, parents are offered various options for taking parental leave until the child’s third birthday. Specifically, parents may interrupt their employment to provide child care and are legally protected from dismissal during this 3-year period; parents also receive parental pay during their parental leave (substitution of income) amounting to two-thirds of her/his prior salary (ranging from € 300.- up to € 1800.-) for a maximum period of 14 months.

Governments also support families through child care policies. The German early child education and care (ECEC) system covers institutional care and education before and alongside elementary and secondary school. Since 1993 children from age of three onward have had a legal right to institutional child care which is primarily organized by local communities and welfare organizations providing care to mainly age-mixed groups at centers with varying opening hours (Linberg et al. 2013 ). However, during the last decade, there has been growing demand for ECEC for children under the age of three that led to the enactment of laws on the demand-driven expansion of child care (“Tagesbetreuungsausbaugesetz TAG”) and the expansion of child care infrastructure for infants and children (“Kinderförderungsgesetz KiföG”) in 2005 and 2008, respectively. Additionally, the legal right to institutional ECEC was expanded in 2013 to include 1-year-old children and political leaders from local, state, and federal levels agreed to provide enough places for 35 % of the children.

Accordingly, the actual use of child care for young children under the age of three has rapidly changed during recent years: Within 8 years (2005–2013), the child care rates for the under 3-year olds increased from 7 to 23 % in the Western states of Germany and from 36 to 47 % in the Eastern states, which have their own distinct tradition and infrastructure concerning early care and education (Kreyenfeld and Krapf 2016 ). In 2015, the nation-wide care rate amounted to 32.9 % with mean values of 28.2 % for the Western and 51.9 % for the Eastern states (Statistisches Bundesamt 2016 ).

However, despite rising rates of early education, a child’s family still is the first and often only environment for developmental processes during the first years of life. Thus, there is a substantial need for analyzing the decision mechanisms as well as the effects of the various options available for early child care.

To summarize, longitudinal studies that provide a basis for analyzing the conditions which significantly contribute to early developmental progress are of great importance for the individual child as well as for society. These studies produce relevant knowledge on how children’s abilities, skills, and competencies develop based on individual resources and conditions; how learning opportunities influence their development in different contexts; how disparities emerge early in life; and how all this impacts educational careers, lifelong learning, well-being, and participation in society.

The German National Educational Panel Study

(NEPS) Footnote 1 has been set up to substantially contribute to these issues (Blossfeld et al. 2011 ). The idea of a multicohort panel study was brought up by the German Federal Ministry of Education and Research (BMBF). A nation-wide interdisciplinary scientific network of researchers was established to develop this idea further and to prepare a proposal for a longitudinal representative large-scale educational study to investigate, monitor, and compare competence development and educational processes in Germany. In light of the specific challenges associated with sampling and measurement of early child characteristics, a newborn cohort study was not initially included in the main NEPS program, but was planned to be conducted as an associated add-on project. However, the study was incorporated into the NEPS study design on behalf of the international evaluation committee organized by the German Research Foundation (DFG) for two main reasons: the growing research on the importance of early child development and education and the rapid changes taking place in early child care, including new social policies being implemented in Germany (see above).

The NEPS is carried out by a network of excellence. It features a longitudinal multicohort sequence design and comprises more than 60,000 target persons as well as 40,000 context persons. In particular, the NEPS design encompasses six longitudinal panel studies conducted simultaneously, which cover a wide range of ages and educational stages. NEPS data are disseminated in a user-friendly way to the scientific community. According to the sensitivity of data, the access is given by a web download, a remote access solution, or on-site in a secure environment. All data are documented in English and are available for use by national and international researchers. In addition to providing substantial analyses of the data themself, it can be used as a benchmark for intervention research, international comparison, and for evaluating issues such as the differences and changes in the use of institutional child care.

At the moment, more than 1100 researchers from more than 700 projects are drawing on the NEPS data already published. The data are used for research in a variety of scientific disciplines and also for educational monitoring—especially, the indicator-based National Report for Education. In order to facilitate access to results for a wide range of professions interested in education—including policy, administration, and practice—scientific papers with important conclusions and empirical evidence are currently summarized by the Leibniz Institute for Educational Trajectories (LIfBi) for public communication and information beyond science and are distributed via the NEPS webpage. Moreover, results are regularly fed back to these groups by presentations and newsletters.

The present paper provides an overview of the NEPS newborn cohort study and its analytic potential. First, the design of the study will be presented with a special emphasis on the aims, challenges, and solutions for the assessment of child characteristics and learning environments. We will then report a few selected results (a) concerning the validity and reliability of the measures used and (b) on early social disparities.

Design of the newborn cohort study of the NEPS: a brief overview

Like all other cohort studies of the NEPS, the cohort study of newborns addresses five research perspectives (Blossfeld et al. 2011 ). Drawing on a theoretical framework, various domain-specific as well as domain-general indicators of early child capacities, characteristics, and developments are assessed as well as measures of structural and process characteristics of their (different) learning environments and their social, occupational, and educational family background. In addition, there is a special focus on families with a migration background, on educational decisions (e.g., concerning child care), and—especially in the newborn cohort study—on patterns of coparenting and child care arrangements. By combining direct observational measures, interview data, and questionnaires, the newborn cohort study allows for in-depth analyses of developmental progress and influential conditions that affect the development of educationally relevant competencies and the stability or changes of interindividual differences. Therefore, it provides insight into the mechanisms through which social disparities emerge, change, and impact children’s future prospects and returns to education.

Sampling strategy

To ensure a representative sample, a two-stage procedure was implemented: 84 German municipalities were used as primary sampling units, explicitly stratified according to three strata of urbanization (via the number of inhabitants; see Aßmann et al. 2015 ). Within these municipalities, addresses were sampled and divided into two birth tranches (infants born between February and April 2012 and between May and June 2012) in order to guarantee a small age range for the infant sample. Starting from a gross sample of about 8500 families, a total of about 3500 families (response rate 41 %) took part in the first assessment wave. In the second wave, the realized sample still included about 2850 families (panel stability 83 %).

Assessment waves and data collection

During the very early phases of child development, three successive assessment waves were carried out when children were on average 7 months (wave 1), 17 months (wave 2), and 26 months of age (wave 3). In the first and third wave video-taped observations and computer-assisted personal interviews (CAPI) were conducted at the family’s home for the entire sample. In the second wave, families were surveyed by computer-assisted telephone interviews (CATI), while video-taped observational measures at the child’s home were only assessed in half of the sample (subsample approx. 1500) in accordance with the study’s design. After wave 3 (i.e., from age two onward) children and their context persons were and will be surveyed every year. Data are collected by trained interviewers. Mothers are the primary respondents, as they can provide valid information about conditions and feelings during and after their pregnancy. Each assessment wave is preceded by a longitudinal pilot study, which runs 1 year before the main study is conducted, to test all instruments and procedures.

Measuring early child characteristics: aims, challenges, and solutions

The assessment of a child’s capacities, characteristics, and early development is pivotal for analyzing the effects of environmental conditions and the impact of early child development and education on later development, educational achievement, career, and life satisfaction or other outcomes and returns. In particular, measuring child characteristics is essential to the modeling of intra-individual progress and changes in interindividual differences, including the emergence of social disparities in various domains of development across childhood. At the same time, it is crucial for analyzing the mechanisms of change, the effects of learning environments and opportunities, and their interactions with the individual capacities and characteristics of the children, while taking the risk or protecting factors of the individual child and his/her environment into account, as well as for controlling for basic interindividual differences if necessary.

However, measuring early child characteristics is a major challenge for longitudinal studies, especially large-scale studies. This is due to various issues and questions, such as which aspects and indicators of early child development should be assessed, how should they be measured, and how can the standardization and validity of measurements be ensured in large-scale assessments of very young children.

Early child development: domain-specific challenges for the child

Developmental psychology has convincingly documented for a long time that neither the development of children nor the development of infants is a homogeneous endeavor. Since the time of Piaget’s ( 1970 ) overarching stage theory of development, it has been empirically demonstrated that development is domain-specific, i.e., demands, prerequisites, effective environmental stimulations differ according to the developmental domain under study (e.g., the acquisition of language, of mathematical competencies, of competencies in natural science, or of an intuitive psychology) (Karmiloff-Smith 1999 ). Even in infancy domain-specific precursors of e.g., mathematical and psychological knowledge and competencies are observable (Goswami 2008 ). Determining how educationally relevant competencies emerge from the interplay of these domain-specific precursors and domain-general basic capacities of the child (like basic reasoning abilities, speed of information processing, or executive functions including cognitive flexibility, inhibition, working memory) on the one hand and of the environmental conditions in the family and in child care on the other is an important issue to be addressed by educational studies. It is important to note that (interindividual differences in) basic capacities also change with age and environmental conditions, although not to the same extent as culture- and education-dependent competencies, and that stimulation of and progress in one developmental domain may enhance, hinder, or compensate for those in other domains.

General NEPS framework for assessing competencies

Within the NEPS, a general framework for assessing educationally relevant abilities and competencies has been developed (Weinert et al. 2011 ). Specifically, the assessments include (a) domain-general cognitive abilities/capacities captured by the constructs of “fluid intelligence” (Cattell 1971 ) or “cognitive mechanics” (Baltes et al. 2006 ); these refer to performance differences in speed of basic cognitive processes, the capacity of working memory, and the ability to apply deductive or analogical thinking in new situations (Brunner et al. 2014 ); (b) domain-specific cognitive competencies, e.g., language competencies, mathematical competencies, and natural science competencies are to be assessed longitudinally and as coherently as possible; and not least (c) meta-competencies, including self-regulation (in the cognitive, behavioral, and emotional domain) and socio-emotional competencies are to be measured (see Weinert et al. 2011 for an elaborated rational of the assessments).

Selecting and measuring relevant and predictive indicators of early child development: a challenge for research

As already mentioned, even in infancy and early childhood, there is no overall indicator for children’s capacities and development. Considering the fact that there are thousands of studies into infant competencies, the indicators have to be carefully selected—not least because of the limited study time and other constraints associated with large-scale assessments, especially those concerning infants and young children who cannot be tested in group settings and whose attentional capacities are still limited. Within the NEPS, the selection draws on the general framework outlined above, including domain-general basic capacities, domain-specific precursors and early roots of language and mathematics as well as indicators of socio-emotional development and early self-regulation.

However, deciding on how to measure these early child characteristics and developments is a major challenge for theoretically sound educational large-scale assessments. Just relying on parents’ reports is problematic since the parents’ judgements might be affected, for example, by their (different) knowledge of child development, by possible restrictions/differences in how they observe the child, and by their particular cultural and individual beliefs and biases. In addition, major aspects of domain-general and domain-specific cognitive functioning and development are not easily observable and need sophisticated assessment methods developed in infancy research.

If newborn cohort studies took direct measures into consideration in addition to interviews and questionnaires, they often relied on the Bayley Scales of Infant Development (Bayley 2006 ; Schlesiger et al. 2011 for a brief overview). However, the NEPS feasibility and pilot studies revealed that the standardized administration of test items (using an educationally sound selection of items) turned out to be highly error-prone for trained interviewers who are usually experts in administering interviews but not tests. In addition, the sensorimotor indicators of developmental status measured by the Bayley Scales have been shown to be rather instable across situations (Attig et al. 2015 ) and infancy (McCall et al. 1977 ) and were hardly predictive for later cognitive functioning (e.g., Fagan and Singer 1983 ). Therefore, an indicator of basic information processing abilities was introduced within the NEPS newborn cohort study which has predominantly been used in baby lab studies, namely, the children’s visual attention and speed of habituation within a habituation–dishabituation paradigm. Within this paradigm, the child’s visual attention and the decrease of her/his visual attention when being presented with a series of identical or categorically similar stimuli are used as indicators of the child’s ability to build up a cognitive representation of a stimulus or a stimulus category (Pahnke 2007 ; Sokolov 1990 ). In addition, a new stimulus (or a stimulus from a new category) is presented in the dishabituation phase of the paradigm and a new increase of the child’s visual attention is interpreted as a signal of her/his ability to distinguish stimuli or categories presented during the two phases of the paradigm and to show a preference toward new information. These measures have been shown to be highly predictive of later intelligence scores or other indicators of cognition and language (Bornstein and Sigman 1986 ; Fagan and Singer 1983 ; Kavšek 2004 ). Thus, this paradigm was used to assess early domain-general information processing/categorization abilities; it was also used to measure early precursors of numeracy and word learning (see Table  1 ). To assure standardization and reliability, pictures were presented on a computer screen and the child’s looking behavior (look at/away from the respective stimulus) was video-taped (as were all other direct measures) and coded afterward on a 30 frames per second basis. A third direct indicator of early child characteristics relevant to learning and education is her/his interactional behavior (cognitive, behavioral, and socio-emotional aspects) in mother–child interaction (see “ Assessment of mother–child interaction: direct measurement of the home-learning environment and of the child’s characteristics in mother–child interaction ” section). Table  1 summarizes the measurements of child characteristics and development assessed in the first three waves of the NEPS newborn cohort study.

In addition to direct assessment, mothers were asked (see Table  1 ) about the child’s skills and development as well as about the child’s health. The questions on the child’s skills and development cover items on cognition (e.g., means-end task and object categorization), communicative gesture (e.g., to draw someone’s attention, negation/headshaking), gross and fine motor skills (e.g., climbing up steps, stacking of toy blocks) as well as language (e.g., size of productive vocabulary, comprehension of short instructions). A short version of the Infant Behavior Questionnaire (IBQ-R, Gartstein and Rothbart 2003 ) was used to assess facets of the child’s temperament, specifically orienting/regulatory capacity (items like “if you sing or speak to <target child’s name>, how often does she/he calm down instantly?”) and negative affectivity (items like “when <target child’s name> can’t have what she/he wants, how often does she/he get angry?”) (Bayer et al. 2015 ). In wave 3, a German language checklist and, for bilingual children, an additional Turkish or Russian language checklist (versions of the well-known MacArthur Communicative Development Inventory (CDI); Fenson et al. 1993 ) was introduced.

Measuring learning environments: aims, challenges, and solutions

Likewise, measuring learning environments that impact child development is an important challenge for longitudinal large-scale educational studies. As suggested by bioecological theories (Bronfenbrenner and Morris 2006 ), it is not enough to just focus on the home-learning environment; the use and features of non-parental care and other learning environments like parent–child programs, which 55 % of the children in the newborn cohort study experience in their first year of life, should also be assessed. Moreover, it is not sufficient to only measure quantitative structural characteristics, since domain-general and domain-specific qualitative aspects have been shown to be especially important (e.g., Anders et al. 2012 ; Sylva et al. 2006 ); however, indispensable direct observational measurements are hard to obtain in large-scale studies. It is important to note that the meaningfulness of the specific features/aspects assessed for characterizing the different learning environments and the constraints of the measurements have a large impact on the validity of subsequent analyses and conclusions.

General framework of the NEPS

To deal with these issues coherently across cohorts, the measurement of important characteristics of learning environments draws on a general framework which subdivides three different dimensions: Structural quality , which refers to relatively persistent general conditions; orientational quality , like values, norms, and attitudes of an actor; and process quality , which refers to the interaction of the individual with her/his learning environment (Bäumer et al. 2011 ).

Selection and measurement of indicators

For the assessment of the process quality of the home-learning environment as the central learning environment in the very early years, the NEPS newborn cohort study relies on both interviews/questionnaires and direct observations (see below).

In addition, as approx. 24 % of the children of the newborns’ cohort sample were using supplementary non-parental care settings in wave 2, the dimensions specified above were also surveyed in these child care settings using self-administered drop-off questionnaires for center-based ECEC as well as for child minders. Because the NEPS has to rely on survey data, the validity of the quality of non-parental care settings gained from the questionnaire is tested by conducting a sub-study, which compares observational methods with the questionnaire used in the NEPS study. The questionnaire covers structural characteristics as well as process characteristics (see Table  2 for examples).

Besides external day care, the newborn cohort study of the NEPS places a strong emphasis on the home-learning environment—especially in very early childhood—as it is of central importance for later development (NICHD 1998 ). Large-scale longitudinal studies mostly focus on the structural aspects of the home-learning environment to account for variability in infants’ and toddlers’ cognitive and social skills (Halle et al. 2009 ; Hillemeier et al. 2009 ). However, process variables account for additional variance in both social and cognitive child outcomes and may even mediate the effect of structural characteristics (Flöter et al. 2013 ; NICHD 1998 ). Therefore, the assessment of the home-learning environment is not only limited to measuring structural aspects like sociodemographics, but also includes orientations (see Table  3 ); in particular, special emphasis is given to the assessment of processes . Mothers are asked about issues, such as joint activities and their language use at home and the quality of these interactions is also assessed by means of videotaping mother–child interactions during the first three assessment waves (see Table  3 ; “ Assessment of mother–child interaction: direct measurement of the home-learning environment and of the child’s characteristics in mother-child interaction ” section).

Assessment of mother–child interaction: direct measurement of the home-learning environment and of the child’s characteristics in mother–child interaction

On the one hand, the assessment of mother–child interactions as a dyadic process allows a deeper look into maternal interaction behavior as a crucial characteristic of the home-learning environment; on the other hand, it captures additional information about the relevant characteristics of the child.

The quality of maternal interaction behavior has been shown to impact a child’s language (Nozadi et al. 2013 ; Tamis-LeMonda et al. 2001 ), cognitive (NICHD 1998 ; Pearson et al. 2011 ), and socio-emotional development (Bigelow et al. 2010 ; Meins et al. 2001 ). High-quality maternal interaction behavior in very early childhood is mostly described as interaction behavior that provides the child with emotional support in terms of sensitivity, which is defined as a prompt, warm, and contingent reaction to the child’s needs and signals (Ainsworth et al. 1974 ). But stimulating interaction behavior in the sense of scaffolding behavior (Wood 1989 ) is also regarded as high-quality maternal behavior, even in early childhood.

However, maternal interaction behavior cannot be considered separately from the child’s behavior, as interaction is a dyadic process in which both partners’ behavior refers to each other in a reciprocal way. It is well acknowledged that children play an active role in the dyadic interaction process from the very beginning, initiating interactions (van den Bloom and Hoeksma 1994 ) and influencing their occurrence and appearance (Lloyd and Masur 2014 ). Additionally, the child’s temperament (e.g., fear, excitement, protesting, and crying) can become effective in an interaction (Mayer 2013 ).

Accordingly, the NEPS newborn cohort study assesses maternal as well as filial interaction behavior via observation. The mother–child interactions are videotaped in the family home and are rated afterward by trained coders. The interaction itself takes place in a semi-standardized play situation in which the mother and the child play with a standardized toy set (Sommer et al. 2016 ). The play situation is adapted to the different age-related requirements: In the first wave, the mother–child interaction is videotaped for 5 min in which toys from the NEPS toy set are provided. In waves 2 and 3, the mother and child are observed while carrying out a three-bag procedure in which the mother and child played for 10 min with toys from three different bags in a set order (NICHD 2005 ).

Maternal as well as filial interaction behavior is assessed using a macro analytic rating system whereby various interactional characteristics are evaluated on five-point-rating scales with qualitatively specified graduations ([EKIE]; Sommer and Mann 2015 ). The assessment of maternal behavior covers emotional supportive interaction behavior (like sensitivity to distress and non-distress, positive regard for the child, emotionality) and stimulating interaction behavior, including a common rating for language and play stimulation in the first two waves and differentiating language and mathematical stimulation in wave 3 when children were 2 years of age (see Table  3 ). The mother’s intrusiveness, detachment, and negative regard of the child were also rated. The coding of the child’s behavior and emotions focuses on the child’s mood, activity level, social interest in the mother, and sustained attention to objects.

Some selected results

NEPS data are disseminated among the scientific community for analysis and provide an important basis for substantive longitudinal and comparative research. In particular, the various measurements of child characteristics and the detailed measures of the home-learning environment, including the observation of mother–child interactions, enable in-depth analyses to be conducted. In the first section, the results on the reliability and validity of these direct measures and information on the underlying constructs are given, while the second section contains an analysis of early social disparities in the mother’s behavior and child’s development. In addition to using the data from the newborn cohort study (wave 1), Footnote 2 we also draw on the data obtained from the “ViVA project,” Footnote 3 which aims to validate the NEPS measures as one of its objectives.

Reliability and validity of measures of mother–child interaction

Assessing interactions in a large-scale assessment is challenging with regard to validity and reliability of the measurements and ratings. In the NEPS newborn cohort study, these challenges were solved quite successfully: Weighted inter-rater reliability ranged from 84 to 100 % and the ecologic validity of the observed maternal interaction behavior seems to be high, as the data from the ViVA project show that interaction behavior assessed in the semi-structured play situation is comparable to maternal interaction behavior in other situations, i.e., natural feeding and diapering situations (Friedman test comparing differences between interaction situations: χ 2  = 0.74, p  = 0.69; Intra-Class-Correlations of maternal interaction behavior in different situations: ICC  = 0.68, p  < 0.001; n  = 23–30; Vogel et al. 2015 ).

Assessing the quality of the mother’s interaction behavior is a core construct of the home-learning environment in the first waves of the newborn cohort study and focuses on socio-emotional aspects as well as on stimulation. Although the assessed indicators address different aspects of maternal interaction behavior, some of them are related to each other (see Table  4 ). It is worth noting that aspects, like intrusiveness, detachment, or negative regard, are not simply the negative end of the more or less pronounced positive dimensions.

From a theoretical point of view, high-quality interaction behavior includes both sensitivity and stimulation behavior. To test the assumption that a rather broad composite indicator of quality of interaction behavior is not only theoretically but also empirically meaningful, a confirmatory factor analysis was conducted (see Fig.  1 ). Items in the socio-emotional domain ( sensitivity to non - distress , Footnote 4 positive regard , and emotionality ) as well as stimulation loaded substantially on quality of interaction behavior (all standardized coefficients above 0.45). Positive regard (0.69) and stimulation (0.77) contributed the most to this factor. Internal consistency was high (Cronbach's α = 0.80).

Results from confirmatory factor analysis for the latent variable Q uality of interaction behavior (Linberg et al. 2016 ). N  = 2190; Chi 2 (2) = 16.05, p  < .000; RMSEA  = 0.06; CFI  = .99; based on all German-speaking mother–child interactions in wave 1

One should note, however, that this broad measure of the quality of interaction behavior is only slightly, albeit significantly, related to other aspects of the home-learning environment which were assessed via the parents interview: This includes issues, like the overall amount of joint activities with the child ( r  = 0.13, p  < 0.000) and special activities (joint picture book reading, r  = 0.13, p  < 0.000; joint construction play, r  = 0.07, p  < 0.000; and talking to the child, r  = 0.07, p  < 0.000).

Reliability and validity of measures of early child characteristics

Given the sample size and household setting, the available data on child characteristics provide a rather detailed insight into the early stages of development, especially with respect to early cognitive capacities and child temperament, which are both measured by multiple indicators. As expected, the first results revealed that these multiple assessment approaches refer to different facets of early child development.

The mother’s report on the child’s temperament deals with the reactions of the child to stressful situations and her/his susceptibility to calming related behavior. In line with previous evidence, this is hardly related to the indicators of child’s temperament, which were assessed in a fairly relaxed mother–child interaction situation ( r  = 0.05, p  < 0.05; Freund and Weinert 2015 ). At the same time, there is evidence supporting the validity and reliability of these measurements. In the ViVA validation study, the information from the questionnaire has been shown to represent the complete subscales of the IBQ-R from which the items were selected ( r  = 0.51 for negative affectivity/0.70 for orienting/regulatory capacity, p  < 0.01; Bayer et al. 2015 ). In addition, it is correlated with the children’s reactions to stress-inducing maternal behavior in a still-face-paradigm where the mother is instructed not to react to her child’s signals ( r  = 0.34–0.43, p  < 0.05; Freund and Weinert 2015 ).

Likewise this can be shown for the assessments of early cognitive capacities/competencies. In the ViVA study, the items on sensorimotor development (assessment of developmental status) were highly correlated with the complete cognition and motor subscales of the Bayley Scales, respectively ( r  = 0.48–0.63, p  < 0.01; Attig et al. 2015 ). Hence the data on sensorimotor development as well as the data on basic information processing abilities (habituation–dishabituation paradigm; 85 % of the videos codable; non-completion of child <1 %; inter-coder reliability in wave 1: κ = 0.91) both rely on scientifically well-established and successfully applied assessments. Nevertheless, they are hardly correlated with each other and thus seem to cover different aspects of early development ( r  = 0.06/0.14, p  < 0.05; Weinert et al. 2016 ).

Although the findings always have to be considered within the context in which the assessments were made (e.g., short version/time), the validity of the various measurements of child characteristics and maternal interaction behavior seems to be apparent.

Early roots of social disparities in child development

The data of the NEPS newborn cohort study allow for an analysis of early social disparities with respect to both early child characteristics and their mother’s interaction behavior. Analyses of data from the first assessment wave when children were 6–8 months of age are in accordance with a bioecological model of child development (Weinert et al. 2016 ). As hypothesized, the mother’s interaction behavior in the video-taped mother–child interaction situation varied significantly according to her educational background. With regard to the broad concept of quality of interaction behavior described above, the mother’s education accounted—even in these early phases of child development—for 4 % ( p  < 0.001) of the variance within the German subgroup of participants. However, as expected we did not find substantial disparities in child characteristics in early childhood, like basic information processing abilities (habituation–dishabituation paradigm), developmental status (sensorimotor scale), or socio-emotional child characteristics coded during mother–child interaction. Interestingly, some early roots of social disparities were observed in child’s characteristics, such as sustained attention to objects and activity level in mother–child interaction. Notably, as predicted, mother–child interaction turned out to be a mutual endeavor: Interactional characteristics of the child (especially the child’s mood, her/his social interest, and continuing sustained attention to objects) and the child’s temperament (orienting/regulatory capacity) accounted for 29 % ( p  < 0.001) of the differences in the overall quality of the mother’s interaction behavior, over and above the control variables (age, sex) and socio-economic conditions (equivalized family income, education of mother, living in partnership) (Weinert et al. 2016 ). Of course, it is still an open question whether the differences observed between children result from former or actual differences in the mother’s behavior or whether the differences in child characteristics and behavior are effective in eliciting their mother’s behavior. In fact, the interrelation between mother and child behavior may vary according to other factors, e.g., additional protective or risk factors (Freund et al. 2016 ). Future findings from the NEPS cohort study of newborns will contribute to explaining how social disparities (suspected at age two and beyond) emerge, how they change over time, which mechanisms contribute to their emergence, and how they impact future development and education.

Prospects and conclusions

Insights and conclusions from longitudinal studies and analyses on the conditions which influence early developmental progress, the emergence of disparities, and their impacts are relevant to educational facilities and social policy and thus to the individual child as well as to society. The present paper focused on the first waves of a large-scale German cohort study of newborns. The various measures will help to better understand the stabilities, changes, and effects of qualitative and quantitative characteristics that early learning environments and other influential conditions have. They also illustrate how the very early outcomes of infant development act as a basis for future development. The child’s development will be measured by testing the development of mathematical, language, and early natural science competencies. Domain-general cognitive abilities will also be assessed (i.e., non-verbal categorization, delay of gratification, verbal memory, and executive functions) along with indicators of socio-emotional development (subscales of the Strength and Difficulties Questionnaire (SDQ), Goodman 1997 ), temperament (subscales of the Children’s Behavior Questionnaire (CBQ), Rothbart et al. 2001 ), and personality (BigFive; short version of the Five Factor Questionnaire for Children (FFFK); Asendorpf and van Aken 2003 ). Learning environments will be measured by interviews and questionnaires which draw on the general framework described above and will be supplemented with assessments of different facets of parenting style. To ensure standardization and reduce administration errors, all tests are carried out on tablet computers in child-oriented, playful settings.

It is worth noting that the kindergarten cohort of the NEPS, which started in 2010, also assessed comparable measures from age five onward. Here a sample of about 3000 children (institutional sample from 279 ECEC centers and 720 groups) was included. Despite differences between cohort designs (e.g., individual vs. institutional sample; child assessments at the children’s home vs. in preschool; playful test administration with vs. without tablet computers; CAPI vs. CATI interviews of the parents) the two cohort studies allow for comparisons while at the same time being characterized by partially complementary strengths and weaknesses (e.g., more elaborate information on home-learning environment vs. on institutional characteristics; extensive assessment of early roots vs. extensive assessment of further development). Among other things, this allows for an in-depth analysis of the interrelation between variations as well as an analysis of the constancies and changes in learning environments and child development, and it also relays important information concerning relevant aspects of early education and how it impacts development, educational career, and future prospects.

A better understanding of the relevant factors and conditions influencing early child development and learning together with their impact on children’s future development, educational success, and well-being is of special importance for ECEC policy. Longitudinal studies are needed because they allow analyses of the mechanism and processes of change in these decisive variables. While in cross-sectional studies causal effects cannot be inferred, longitudinal studies—especially those that enable complex group-specific growth-curve modeling and the modeling of intra-individual change—combined with experimental and quasi-experimental comparisons not only contribute significantly to gaining deeper insights into developmental and educational processes and the conditions influencing them but can also answer important questions relevant to ECEC policy such as how does early compared to late entry to institutional care impact later development in various cognitive and non-cognitive domains? Is early institutional care especially valuable (and to what extent) for different subgroups of children/families (e.g., disadvantaged families, children/families with specific risk factors, children with a migration background, refugees, multilingual children, e.g., children learning German as an (early) second or third language)? What are the determinants of the quality of home-learning environment and its effects on child development and education? What are specific risk (or protective) factors and is it possible to compensate for (or to draw on) them?

Obviously, even longitudinal studies will not deliver straightforward conclusions for ECEC policy. However, they provide an important and essential basis for evidence-based policy by informing about relevant conditions of early child education and how they impact later development (e.g., successful future development, educational drawbacks or opportunities in the social, socio-emotional, and cognitive domain). In fact, it has been suggested that high-quality early education is of special importance from a psychological, an educational, a sociological, and an economic perspective and thus is of significant relevance not only to the individual but also to society as a whole (Heckman 2013 ; Sylva et al. 2011 ). NEPS data are especially helpful when it comes to gaining a better understanding of the development of competencies and decisive conditions over the life course—the samples are carefully drawn, the validity of data is high, and longitudinal data are available in a user-friendly form for analyses and even for international comparisons.

From 2008 to 2013, NEPS data were collected as part of the Framework Program for the Promotion of Empirical Educational Research funded by the German Federal Ministry of Education and Research (BMBF). As of 2014, NEPS is carried out by the Leibniz Institute for Educational Trajectories (LIfBi) at the University of Bamberg, Germany, in cooperation with a nation-wide network.

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“Video-based Validity Analyses of Measures of Early Childhood Competencies and Home Learning Environment” (ViVA)—project funded by the German Research Foundation (DFG; grant to S. Weinert) within the priority program 1646.

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SW conceptualized and drafted the overall manuscript, sequence alignment, and revisions. In addition she cooperatively conceived the design and assessments of the studies, in particular the assessment of early child competencies, and the analyses of social disparities. AL especially drafted the part on the learning environments and the assessment of mother-child interaction; she conducted the data analyses on mother-child interaction and supported the analyses on ecologic validity of mother-child-interaction. MA contributed to the description of the overall design and did the analyses on early roots of social disparities. She is also involved in the conceptualization and coordination of data assessment of the infant cohort study. TL drafted the part on regulations in Germany and contributed to the description of the assessment of learning environments. He is also involved in the conceptualization of the assessment of this data. JDF did the analyses on the reliability and validity of measures of early child characteristics; he drafted this part and cooperatively planned and conducted the validation study. All authors were involved in the sequence alignment and revisions, and approved the final manuscript. All authors read and approved the final manuscript.

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Weinert, S., Linberg, A., Attig, M. et al. Analyzing early child development, influential conditions, and future impacts: prospects of a German newborn cohort study. ICEP 10 , 7 (2016). https://doi.org/10.1186/s40723-016-0022-6

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Theories of Child Development and Their Impact on Early Childhood Education and Care

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Developmental theorists use their research to generate philosophies on children’s development. They organize and interpret data based on a scheme to develop their theory. A theory refers to a systematic statement of principles related to observed phenomena and their relationship to each other. A theory of child development looks at the children's growth and behavior and interprets it. It suggests elements in the child's genetic makeup and the environmental conditions that influence development and behavior and how these elements are related. Many developmental theories offer insights about how the performance of individuals is stimulated, sustained, directed, and encouraged. Psychologists have established several developmental theories. Many different competing theories exist, some dealing with only limited domains of development, and are continuously revised. This article describes the developmental theories and their founders who have had the greatest influence on the fields of child development, early childhood education, and care. The following sections discuss some influences on the individuals’ development, such as theories, theorists, theoretical conceptions, and specific principles. It focuses on five theories that have had the most impact: maturationist, constructivist, behavioral, psychoanalytic, and ecological. Each theory offers interpretations on the meaning of children's development and behavior. Although the theories are clustered collectively into schools of thought, they differ within each school.

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Saracho, O.N. Theories of Child Development and Their Impact on Early Childhood Education and Care. Early Childhood Educ J 51 , 15–30 (2023). https://doi.org/10.1007/s10643-021-01271-5

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Original research article, retention in junior giants, a sport-based youth development program: what factors are associated with intentions to return.

• 1 Department of Kinesiology, San Francisco State University, San Francisco, CA, United States
• 2 Department of Health & Human Performance, Texas State University, San Marcos, TX, United States
• 3 Experience Industry Management Department, Cal Poly San Luis Obispo, San Luis Obispo, CA, United States

Introduction: While evaluation research shows that physical activity-based youth development (PA-PYD) programs can have a positive impact on social and emotional growth, less is known about which participants return year after year and what factors are associated with their continued participation. The Junior Giants is a sport-based youth development program for 5–18-year-old boys and girls that is non-competitive and free to participate. The 8-week program uses baseball and softball as platforms for teaching life skills and fostering social emotional competencies. This mixed-methods study evaluated quantitative factors associated with intentions to return to the program the following year and qualitative reasons why parents/caregivers intended not to re-enroll their child.

Method: Parents/caregivers of Junior Giants participants ( N  = 8,495) completed online surveys about their child's demographics, social emotional climate and learning, character development, and intentions to return the following year.

Results: Descriptive data illustrated that parents/caregivers reported quite positive outcomes and experiences for their child. Chi-square and t -test analyses revealed significant differences ( p  < .001) between intended returners ( n  = 7,179, 84.5%) and those who reported no/undecided on returning ( n  = 1,316, 15.5%). Intended returners were significantly more likely to be identified as Latino and be in their second year of participation. Significant predictors of a binomial logistic regression [χ 2 ( df  = 22) = 1,463.25, p  < .001] included age, race/ethnicity, years played, character development, reading, league experiences, physical activity, and perceived support, with small to medium effect sizes. Using responses from a subset of 217 parents/caregivers who reported their child would not return to the program, a thematic analysis resulted in seven themes: Lack of Organization and Communication ; Dissatisfied with Coaching, Didn't Learn Baseball/Softball, Not Competitive Enough, Skill Levels Not Matched, Aged Out, and Non-Program Related Reasons .

Discussion: Quantitative results contribute to the literature on predictors of retention in youth development programs, while qualitative findings echo common motives cited for dropout in youth sport. Both provide opportunities for reflection and potential changes to future programming.

Introduction

Physical activity-based positive youth development (PA-PYD) programs are designed to enhance children's and adolescents' social and emotional growth and life skill development by using physical activity and sport as contexts for developing psychosocial and physical skills and behaviors ( 1 , 2 ). PA-PYD programs can include a variety of structured physical activities (e.g., organized sport, after-school programs) and differ from traditional sport programs because of their intentional goal of nurturing life skills and physical skills simultaneously ( 2 ). Much of the evaluation research on PA-PYD has focused on program impact on participants’ psycho-social growth and development ( 3 , 4 ). However, less attention has been given to understanding participant retention and dropout in these programs. Investigating why participants remain or leave these programs is essential for programmatic changes that will attract and retain as many youth as possible, especially given that these programs have shown to be effective in producing desirable outcomes. The focus of this paper was to examine potential retention and dropout of one sport-based youth development program.

Scholars and practitioners adopting a positive youth development framework focus on how developmental contexts can promote life skill acquisition and personal growth ( 5 – 7 ). This framework positions youth as active agents in their development, rather than problems to be fixed, and has been widely used to understand how programs can be structured for youth to maximize their developmental potential ( 6 ). Those who focus on sport and physical activity contexts have seen value in this framework and sought to identify the features needed for positive outcomes to occur, rather than expecting automatic benefits to occur from participation. According to Petitpas et al. ( 1 ), sport and physical activity contexts can yield developmental growth provided youth interact with caring, significant adults (external assets) and learn interpersonal and self-management skills (internal assets). Studies have shown a positive impact on youth who participate in PA-PYD programs that have an intentional curriculum and use sport or physical activity as a context to teach life skills and other socio-emotional outcomes ( 3 , 4 ). For example, programs such as Teaching Personal and Social Responsibility (TPSR), The First Tee, and Girls on the Run have shown favorable outcomes for youth such as life skills transfer, the 5 C's, and increased physical activity levels [e.g., ( 8 – 10 )]. Overall, results from PA-PYD evaluation studies suggest that engagement in one of these programs can be beneficial to participants, although more rigorous studies are still needed, including longitudinal, intervention, and evaluation designs ( 11 ).

To gain expected benefits from these programs, youth must start and continue participating, as Anderson-Butcher ( 12 p6) suggests, “youth will not benefit if they are not there.” Evidence further suggests that continued participation in these programs can have a sustained impact on participants [e.g., ( 9 , 10 , 13 )]. In a longitudinal evaluation study, Weiss et al. ( 9 ) found that youth in The First Tee program showed improvement or stability in life skills transfer over three years of participation. Fewer studies, however, have focused on what factors can predict why youth continue participating. Anderson-Butcher et al. ( 14 ) compared returners and non-returners in a sport-based youth development program (LiFE sports ) geared toward socially vulnerable youth and used pre- and post-camp variables to predict retention status. They found that youth more likely to return had higher fitness levels, greater perceived social responsibility, lower poverty status, and were younger in age, compared to those who did not return. Anderson-Butcher et al. ( 14 ) also interviewed parents/caregivers of returners and non-returners, with both groups reporting positive experiences (meeting new people; learning sport skills) and negative experiences (peer conflict) at similar rates. In line with Anderson-Butcher's interpretation and the small effect sizes found, more research is needed to further help predict retention in PA-PYD programs.

Less is also known about why participants might not return to PA-PYD programs (i.e., dropout). Studies examining dropout in youth sport point to several reasons why youth may discontinue participating in their activity. Based on a systematic review of the literature and leisure constraints theory, Crane and Temple ( 15 ) determined that youth dropout of sport because of intrapersonal reasons (decreased motivation, change in interest, lack of competence), interpersonal reasons (relationships with peers, teammates, and coaches), and structural reasons (time, money), and that intrapersonal and interpersonal constraints were more often studied. Back et al. ( 16 ) conducted a meta-analysis of studies with adolescent team sport athletes and found that aspects related to motivation, along with social support from coaches, parents, and peers, were related to dropout. Of note, these dropout studies have focused on competitive and recreational youth sport environments, so additional research is needed to understand whether these reasons for dropping out are similar or different from sport programs that also have a youth development curriculum.

The focus of this study was on the potential retention and dropout in one sport-based youth development program—the Junior Giants, which is a co-ed baseball and softball program for 5–18-year-olds established in 1994 ( 17 ). The program is run through The Giants Community Fund, which is the nonprofit arm of the Major League Baseball team the San Francisco Giants. The 8-week summer program is coached by volunteers, who are primarily parents, and includes one practice and one game per week. The program is non-competitive (i.e., no score kept; no wins/losses) and free. All uniforms and equipment are provided by the Giants Community Fund with the intention that cost is not a barrier to participation. In 2022, over 20,000 youth participated across 81 leagues in underserved communities across California, Nevada, and Oregon.

The Junior Giants curriculum is purposefully designed to promote youth development in the following core elements: health and nutrition including physical activity, anti-bullying, education (focused on offsetting summer reading loss), and character development. A “word of the week” signifies the theme for that week, and coaches and team parents are provided a practice plan that includes baseball/softball drills and strategies for integrating the desired developmental outcomes. The goal is seamless integration of the life lessons in a fun, activity-filled setting, and the Junior Giants curriculum supports those efforts by providing coaches and team parents with specifics on when and how best to incorporate the lessons in the context of the baseball/softball instruction. The full program also includes intentionality by way of social-emotional learning; coaches, team parents, and league leadership are encouraged to promote a variety of self-regulatory competencies, emotional control, and a celebration of diversity, equity, and inclusion. The goal is to promote safety and security for all in a reinforcing and supportive environment. Ideally, doing so will not only result in developmental outcomes for participants in the given year but also will involve a return to participation for subsequent seasons (i.e., retention).

While PA-PYD program impact is certainly important and examined extensively in the research, the purpose of this study was to examine the variables that influence intention to return or dropout. Understanding retention intentions is critical to help youth development organizations maximize the potential for participants to receive sustained developmental benefits and maintain enrollment in these programs. Findings will contribute to a gap in the PA-PYD literature by focusing on retention and dropout and allow for a baseline of comparison for other sport-based youth development programs. Specifically, we compared parent/caregiver perceptions of program characteristics and youth social, emotional, and behavioral outcomes for those who intended to return and those who did not intend to return or were undecided. We also explored open-ended responses about why some parents/caregivers did not intend for their child to return to the program.

Participants

The sample ( N  = 8,495) included parents/caregivers of 5–13-year-olds who were currently participating in the Junior Giants program in one of 79 different leagues (see Table 1 ). Parents/caregivers reported their children were almost 8 years old on average ( M  = 7.93 SD  = 2.23), and about 70% said their child was in the first year of the program. With baseball being a predominantly male-dominated sport at all levels, Junior Giants offers both baseball and softball as options in a fully co-educational environment wherein all youth regardless of their gender identity can choose to play baseball or softball (for those locations that offer both). Parents/caregivers reported their child's gender identity as follows: Female (33.2%), Male (66.3%), Non-Binary (0.1%), and Preferred Not to Answer (0.4%). Parent reports indicated a diverse sample of youth participants in terms of race and ethnicity: 37.3% Latino, 22.0% Caucasian, 17.7% Multiple Races/Ethnicities, 10.9% Asian, 6.2% Other, 3.8% African American/Black, 1.3% Pacific Islander, and 0.8% Indigenous.

Table 1 . Descriptives, frequencies, and significance tests for demographic variables.

A subset of the sample that reported they did not plan to return to the program the following year ( n  = 217) included responses from 59 leagues. Compared to the overall sample, these children were reported to be slightly older ( M  = 9.04, SD  = 2.84) and included more Caucasian respondents (35.9%) but a similar gender identity composite (66.4% male).

The survey questions aligned with the program curriculum and expected outcomes and were newly developed by the Junior Giants administrators and collaborative researchers for the purpose of program evaluation. These measures also reflected PA-PYD outcomes commonly studied in the literature ( 18 ), including confidence and character from Lerner's 5Cs ( 7 ), Benson's developmental assets such as integrity and commitment to learning ( 19 ), and life skills such as teamwork and leadership ( 20 ).

Four bases of character development

Four items represented each of the four bases of character development. Parents were asked to “Indicate the level of change you have witnessed in:” followed by one of the four bases of character development (i.e., confidence, integrity, leadership, teamwork). Response options were on a 5-point scale: significant negative change , negative change , no change , positive change , significant positive change. Items were averaged into one scale and demonstrated internal reliability with the current sample ( α  = .90).

Anti-bullying

Three items represented program outcomes related to lessons about anti-bullying attitudes and behaviors. Parents indicated the level of change they noticed in their child (a) being willing to stand up for other kids, (b) showing respect for others, and (c) knowing what to say or do when seeing bullying, with 5 response options ranging from significant negative change to significant positive change. Items were averaged into one scale and demonstrated internal reliability with the current sample ( α  = .90).

League experiences

Three items represented parents'/caregivers' level of satisfaction with aspects of the specific league they participated in. On a 5-point scale ranging from extremely dissatisfied to extremely satisfied , parents/caregivers reported their perceptions of the (a) league communication, (b) league organization and leadership, and (c) coaches. Items were averaged into one scale and demonstrated internal reliability with the current sample ( α  = .87).

Social emotional learning (SEL)

Three items assessed the extent to which their child demonstrated change in their social emotional learning, focusing on self-awareness and self-management competencies more specifically ( 21 ). Parents/caregivers reported the level of change witnessed in (a) confidence in their ability to complete tasks, (b) ability to see a task through to completion, and (c) sense of happiness. Parents responded on a 5-point scale ranging from significant negative change to significant positive change. Items were averaged into one scale and demonstrated excellent internal reliability with the current sample ( α  = .89).

Social emotional learning (SEL) climate

Three individual items assessed separate aspects of the perceived social emotional learning climate. Parents/caregivers were asked, “My child feels [accepted; supported; safe and secure] in the program,” with three response options of never , sometimes , or always .

Three items focused on any changes parents noticed in their child's behaviors related to physical activity and healthy eating, specifically (a) eating fruits, (b) eating vegetables, and (c) amount of physical activity. Response options included less , same , or more . Each single item was analyzed separately.

One item focused on parent/caregiver reports of their children's reading behaviors since participating in the Junior Giants program. Parents/caregivers responded on a 3-point scale ( no , same , yes ) as to whether their child had “spent more time reading.”

Intentions to return

Parents/caregivers were asked, “Will your child play Junior Giants next year?” to assess intentions to return to the program the following season. Response options included no , undecided , or yes . Parents/caregivers who responded no were asked an open-ended follow-up question, “why not?” Another open-ended question was asked for general feedback about the program, which helped further explain intentions not to return to the program.

This study was approved by the Institutional Review Board at a public University in California in the United States prior to initiating data collection. All parents/caregivers who had a child participating in the Junior Giants in the summer of 2022 program ( N  = 22,932) were invited to participate in the study at the end of the program. An online survey was created using Alchemer software, and a link was emailed to all parents/caregivers by the Junior Giants central administration. The survey was created in English and translated into Spanish, and each parent/caregiver was initially provided the option of completing an English or Spanish version of the survey. A consent form was also provided on the first page of the survey, and parents agreed to participate in the survey by clicking to the next page. At the end of the survey, parents/caregivers were provided a link to request tickets to a San Francisco Giants game or be entered into a sweepstakes to win San Francisco Giants memorabilia. The survey took about 14 min to complete on average.

Data analysis

Data were analyzed using SPSS Version 28. Initial screening included missing data analyses and checks for normality. Missing data were considered Missing Completely at Random (MCAR) if Little's MCAR test was non-significant, and values of skewness (<|3|) and kurtosis (<|8|) were considered acceptable ( 22 ). Descriptive statistics were run for all continuous variables, while frequencies and percentages were calculated for all categorical variables. Conceptually similar items were combined to create scales and acceptable internal reliability established if Chronbach's α  > .70. Two groups were used for comparison—intended returners and undecided/intended non-returners. Chi square analyses for categorical variables and t -tests for continuous variables were run to identify group differences by intentions to return. Based on the number of planned comparisons ( N  = 15), we used a Bonferroni correction such that statistical significance was established if p  < 0.003 (0.05/15). For chi square analyses, adjusted residuals >|1.96| were considered statistically significant deviations from expected cell counts ( 23 ). Effect sizes for t -tests were determined by Cohen's d and assessed as small ( d  ≥ .20), medium ( d  ≥ .50), and large ( d  ≥ .80) ( 24 ). A binomial logistic regression was run to assess what factors could predict intentions to return (yes vs. no/undecided). Correlations were first run among all predictor variables to check for multicollinearity ( r  > .70). Another Bonferroni correction was used to account for the planned comparisons, where predictors were considered significant at p  < 0.002 (0.05/24). Odds ratios (OR) were considered small if OR > 1.5, medium if OR > 3.0, and large if OR > 5.0 ( 25 ).

The two open-ended questions were analyzed using thematic analysis ( 26 ). Phase 1, Familiarization, and Phase 2, Coding, were completed by three researchers who independently read through all responses from intended non-returners and coded relevant data. To begin Phases 3–5 (theme development, refining, and naming), the researchers met to discuss codes and create an initial set of themes. These themes, codes, and raw data were provided for another researcher, who reviewed and provided feedback on the cohesiveness, distinctiveness, and labeling of each theme. The final themes were discussed by all four researchers. To establish credibility, crystallization ( 27 ) was achieved by using multiple researcher viewpoints and reaching a complex and in-depth understanding of the data.

Quantitative results

Of the 22,932 participants in the program, 37.0% ( N  = 8,495) of parents/caregivers completed the survey. Data screening identified a very small amount of missing data (<.001%) and Little's MCAR test was non-significant ( p  = .251), suggesting data were missing completely at random, so values were replaced using mean imputation. All continuous variables on a 5-point scale suggested normal distributions and acceptable values for skewness and kurtosis, while the seven items with 3-point response options were skewed and kurtotic. Very few parents/caregivers (<.01%) reported their child ate less fruit or veggies or participated in less physical activity; saw no changes in their time spent reading, or perceived their child never felt accepted, supported, or safe and secure. Collapsing response categories is justified in certain situations with compelling evidence, such as a lack of use ( 28 ). Given the lack of responses for “never”, “less”, and “no”, responses for “never” and “sometimes” were combined for the three SEL climate items; responses for “less” and “same” were combined for the three health items, and responses for “no” and “same” were combined for the one reading item. Based on these modifications, these items were treated as categorical outcome variables for subsequent analyses.

Descriptive data illustrated that responses from parents/caregivers were quite positive (see Tables 1 , 2 ). On average, parents/caregivers reported significant positive change in their child's character development, anti-bullying strategies, and social emotional learning, and that they were satisfied with their league's organization, communication, and coaches. Most also indicated that their child always felt accepted, supported, and safe and secure. A majority reported their child had increased the amount of physical activity they did and the time they spent reading since participating in the program, while only a third of parents/caregivers said their child ate more fruits or veggies.

Table 2 . Descriptives, frequencies, and significance tests for program outcomes.

Tables 1 , 2 also show significant differences and effect sizes for intended returners vs. intended non-returners/undecided. Intended returners were significantly more likely to be identified as Latino ( p  < .001) and be in their second year of participation ( p  = .001), while intended non-returners/undecided were more likely to be identified as Caucasian or Multiple Races/Ethnicities and in their first year in the program. There were no significant differences in intentions to return by binary gender identities (male, female) or age. Parents/caregivers who reported their child would return to the program perceived significantly more positive change in all measured program outcomes, with large effect sizes, compared to those who were undecided about returning or definitely not returning.

The binomial logistic regression with all demographic variables and program outcomes as predictors was statistically significant χ 2 ( df  = 22) = 1,463.25, p  < .001, and explained almost 28% of the variance (Nagelkerke R 2  = 27.6%) (see Table 3 ). The model had an overall classification rate of 86.6%, with 98% of intended returners and 23.9% of intended non-returners/undecided classified correctly. Significant predictors included age ( p  < .001), race/ethnicity ( p  < .001), years played ( p  < .001), character development ( p  < .001), reading ( p  = .002), league experiences ( p  < .001), physical activity ( p  < .001), and perceived support ( p  < .001), with small to medium effect sizes. Compared to Caucasian, youth identified as Latino, African American/Black, or Asian were more likely to report intentions to return to the program (2.21 times, 2.21 times, 1.70, respectively). For every unit increase in positive changes in their child's character development (confidence, integrity, leadership, teamwork), parents/caregivers were 2.38 times more likely to report intentions to return to the program. Parents/caregivers were 2.23 times more likely to be intended returners with every unit increase in league satisfaction. Compared to parents/caregivers who reported their child never or sometimes felt supported in the program, parents/caregivers who reported their child always felt supported were 1.56 times more likely to intend on returning.

Table 3 . Binary logistic regression for intended returners vs. non-intended returners/undecided.

Qualitative findings

Based on thematic analysis, seven themes were created from parents/caregivers' responses: Lack of Organization and Communication, Dissatisfied with Coaching, Didn't Learn Baseball/Softball, Not Competitive Enough, Skill Levels Not Matched, Aged Out, and Non-Program Related Reasons . These themes are based on responses only from the 217 parents/caregivers who chose “no” to the question about returning the following year and were prompted to elaborate on why not. In the following sections, each theme is discussed, highlighted by relevant participant quotations.

Lack of organization and communication

Parents/caregivers noted issues with how the league, practice, and/or games were organized, as well as issues with communication from league administrators and coaches. One participant commented, “It wasn’t as organized as I expected it to be. The kids also never had practice. My son was in another league a year prior and enjoyed it. This year he was very upset.” Another said, “The league was disorganized and unprepared for this season, it hurt the kids the most.” A parent felt disappointed by saying, “Great program but lacking leadership and organizational structure. Emails never get responded to either.”

Dissatisfied with coaching

Parents/caregivers were frustrated with either not having a coach or the quality of the coach they did have. Many of these issues seemed to be related to the fact that coaches were volunteers. One parent/caregiver said, “We didn’t have enough coaches for our teams and volunteers were variable,” while another added, “the problem is because it's free and all volunteers, no one takes it seriously.” One parent/caregiver elaborated on how these coaching issues impacted the kids, “Most of these kids had never played before and had no clue what to do or where to go.” This parent/caregiver offered a solution, “Best to have an experienced coach on each team or one that has completed coach training. Since this is volunteer run, time commitment can be a challenge.”

Didn't learn baseball/softball

Parents/caregivers felt their child did not learn the skills or rules of baseball or softball. One parent/caregiver simply said, “I don’t feel that my son learned much this year.” Another parent/caregiver said, “It was my daughters first time ever playing and there wasn't that much engagement of teaching how to catch or swing.” Other parents/caregivers worried their children were confused about the rules of the game and perhaps even learning bad habits. One parent/caregiver explained, “Though the league is fun and encouraging, I feel that my player is actually fooling around more and developing some bad habits.” One parent/caregiver suggested, “I would like to see the program reflect more of the actual baseball rules, so that they are learning baseball correctly as well as all the great personal/social growth.” One parent/caregiver explained how skills building should still be important even in a non-competitive environment: “Would have liked to see merit based play a little more. I understand the games are not competitive, but I believe even friendly games can teach excellence and skill building with a structure of competition.”

Not competitive enough

Parents/caregivers did not feel the league was at a high enough competitive level for their child. One parent/caregiver noted, “My son plays competitive baseball so it was a step back for him” while another said there was a, “Lack of competitive spirit. Focused more on emotional issues and nutrition instead of the actual game of baseball.” Some parents/caregivers noted that their child wanted to play more competitively, with one writing, “My son is a very competitive person and this isn't the right platform for him,” One parent/caregiver suggested the program provide both competitive and non-competitive opportunities:

Two levels of giants, players who are competitive and want to keep score and play baseball with the rules. And another group who just plays for fun as they do now. I have children who would fit in both categories.

Skill levels not matched

Parents/caregivers shared ways in which they felt the skill level of their child was not matched with the other kids on their team or in the league. Some parents/caregivers, for example, reported their child's skill level was superior. One parent/caregiver said, “My son felt this program was remedial to the level of skill he has. I thought the kids would be grouped by their skills.” This parent/caregiver remarked how their child's skill was less than others by saying, “My child felt embarrassed because all her other teammates were much more skilled than her.” Another elaborated on how this mismatch in skill level affected his son:

I think there should be skill levels or divisions based on experience. My son was actually bored at one point because how advanced he was compared to the others. He's had 4 years little league experience and some teammates needed a tee…That's a big difference in skill level.”

In this theme, parents/caregivers mentioned they would not be returning because their child would be too old to participate the following year. One parent/caregiver said, “He will be 14. If the age is extended, he would return.” Some parents/caregivers said that their child would continue with the program but now as a coach including this one who wrote, “She is going to come back and coach her brothers next year.” One parent/caregiver requested the age range be expanded: “Please expand the age range for older kids who don't necessarily want to play competitive sports but still strive to be a part of a team, feel connected to others their age and stay healthy.”

Non-program related reasons

Parents/caregivers cited several reasons they would not be returning to the program that did not directly relate to the program itself. Reasons included traveling during the summer, hot weather, moving out of state, and having “too much going on.” This theme also included parents/caregivers' responses indicating that their child wanted to play a different sport. One parent/caregiver said, “He has decided he wants to focus on a different sport that happens at the same time,” while another commented, “My daughter prefers gymnastics and dance.” Others noted their child was not interested in baseball specifically. One parent/caregiver wrote, “he realized he wasn’t that into baseball” and another noted, “too much downtime for such an active kid.”

This study offers insight into potential retention and dropout of participants in a sport-based youth development program, contributing beyond what is known about PA-PYD program impact that is more often studied. The results were overwhelmingly positive, with most participants saying their child intended to return to the program and very few reporting their child would not come back. Those parents/caregivers reporting intentions to return also perceived a significantly higher positive program impact on their child. This sample represented 37.0% of all participants in the program (8,495 respondents/22,932 total participants), and it is possible that parents/caregivers who had more positive experiences were those who were more likely to complete the survey. Even accounting for potential sampling biases, these results indicate the program is having a positive impact on many participants, which in turn is linked to an increased likelihood of returning to the program. Thus, the program's focus on youth development is not only beneficial for demonstrating program impact but can also lead to better participant retention.

Our results extend what has been previously discovered about retention in PA-PYD programs. Compared to Anderson-Butcher et al.'s ( 14 ) study, our results identified more significant predictors with equal or larger effects. Our study focused on intentions to return and used responses from parents/caregivers as predictors, whereas Anderson-Butcher et al. ( 14 ) focused on actual retention status (returned vs. did not return) and used data from youth responses. Fredericks and Eccles ( 29 ) highlight the importance of parents as providers of children's sport experiences, being the ones who sign them up for programs and decide whether or not they will continue in that activity. The Junior Giants participants represented in our sample were in childhood, when developmentally, parents' beliefs and actions have a significant influence on their sport and physical activity participation ( 30 ). Our results support the idea that parents' perspectives may be important for retention for this age group.

The finding that intended return rates were similar for boys and girls is encouraging, even though boys represented two-thirds of all participants. Children's participation in sport declines as they enter adolescence, and dropout is more significant for girls than boys ( 31 ). These data suggest the Junior Giants program may be countering this trend and providing a space where girls can and want to continue participating. Furthermore, in the three-year strategic plan for the Junior Giants, one of the priorities is to increase the number of girls in the program from 33% to 50% ( 32 ). Demonstrating that parents/caregivers of most girls already participating in the program planned to return is a positive step toward the Junior Giants reaching their goal.

Findings also revealed several factors that differentiated intended returners from those undecided about returning/intended non-returners. For example, youth identified as Latino, African American/Black, or Asian were more likely to report intentions to return to the program compared to youth identified as Caucasian. The explanation for why these differences by race/ethnicity emerged are complex and should be carefully interpreted. Williams and Deutsch ( 33 ) outline the problems with using race/ethnicity as a single grouping variable because it ignores the distinctiveness of race, ethnicity, and culture, and does not account for within-group heterogeneity (e.g., racial identity, immigration status, language use). They contend that the lived experiences of race and ethnicity influence how youth interpret the world and shape their beliefs about themselves and others, and the intersection of race/ethnicity with other social categories (e.g., gender, social class) is impossible to disentangle. In our study, it is important to note that we did have relatively lower numbers of participants identified as African American/Black, Pacific Islander, and Indigenous, compared to the other race/ethnicity categories, which may have affected the results.

In addition to demographics, other variables associated with retention were directly related to experiences in the program itself. Parents/caregivers who reported intentions to return also perceived a positive change in their child's demonstration of the Four Bases of Character Development (confidence, integrity, leadership, teamwork). Parents/caregivers expect positive benefits when they enroll their children in a program and correspondingly were happy to report intentions to return when they perceived a return on their investment ( 29 ). Perceptions of their child being supported in the program was also a significant correlate and consistent with expected developmental outcomes from PA-PYD programs. Connection, or the relationships that youth develop with their peers and adults, is part of the 5 Cs of youth development ( 5 ) and is a key component to the success of PA-PYD programs ( 5 , 10 ). Finally, whether parents/caregivers were satisfied with the communication, organization, and coaching in the specific league their child participated was also associated with intentions to return. While not commonly cited as a reason for continued participation, these structural issues are certainly cited as reasons for not returning ( 14 ). Indeed, our qualitative results pointed to these aspects as important considerations for intended non-returners as well. Parents/caregivers are the logistical drivers of their child's experiences, so if they are satisfied with the communication and organization, it is more likely they would enjoy returning to the program as a parent/caregiver of a participant.

Qualitative responses provided insight into reasons for not wanting to return to the program and aligned with previous research on youth sport dropout ( 15 , 16 ). Our thematic analysis revealed intrapersonal reasons (not interested in baseball, did not develop skills), interpersonal reasons (issues with coaching, peer comparison in skill level), and structural reasons (too busy in summer to participate, league organization) for why parents/caregivers indicated their child would not return. Most parents/caregivers of non-returners (16 out of 18) in Anderson-Butcher et al.'s ( 14 ) study cited a logistical reason for why they did not return (e.g., family schedule conflicts, missed registration), which matches with our theme of Non-Program Related Reasons . Thus, our findings suggest that youth discontinue PA-PYD programs and youth sport programs for at least some similar reasons.

The finding that youth may not return to the Junior Giants because they want to participate in other sports is developmentally appropriate. According to the Developmental Model of Sport Participation, youth should try out many different sports in their sampling years (6–12 years old) ( 34 ). Evidence suggests that this early diversification of sport experiences can lead to long-term participation in sports and does not impede later success in elite sport. Given the long-term benefits of sport sampling during childhood, the Junior Giants or any PA-PYD program should expect some participants to not return to the program. Moreover, lack of retention because interests have changed, or participants want to pursue other sport activities, should not be viewed as a negative. PA-PYD programs should instead be focused on the reasons for dropout that are within their control (e.g., improving coaching, providing opportunities for skill development).

Two themes— Didn't Learn Baseball/Softball and Not Competitive Enough —warrant further discussion. Parent/caregiver reports that youth did not develop baseball or softball skills was a little surprising since coaches are provided with detailed practice plans and videos for each week, but also understandable because coaches are volunteers and may not have previous coaching experience. More information about the coaches' experience and adherence to the curriculum is needed to better understand this theme. It is also possible the non-competitive nature of the program may hinder participants' ability to learn the game properly. Torres and Hagger ( 35 ) propose that de-emphasizing competition creates confusion for kids and misleads them in understanding what activity they are participating in (e.g., it's called baseball but it's not being played by baseball's rules). This confusion may be heightened for younger children who are more concrete in their thinking ( 36 ). On the other hand, the highly competitive nature of youth sport has documented links to stress, burnout, and withdrawal, providing a strong rationale for why de-emphasizing competition is desirable ( 37 ). Thinking holistically, PA-PYD programs that have a non-competitive focus need to consider how competition can be de-emphasized while continuing to develop sport-specific skills that prepare youth for future physical activities.

Limitations

Notwithstanding several strengths of the study (e.g., large sample size, mixed methods), several limitations must be recognized. First, because the sample included 37% of parents/caregivers in the entire Junior Giants network, it is difficult to know whether these perspectives are representative of all program participants. Future evaluation studies should focus on increased recruitment for survey participation to provide a more complete picture of intentions to return to the program or not. Second, all parents/caregivers provided their socioeconomic status during registration but not when they completed the survey at the end of the season. While we know that 68% of players in the entire program receive free or reduced cost lunch at school, we do not know how many of those were represented in this sample. We were thus unable to examine socioeconomic status as a correlate of intentions to return (nor the interactions with race/ethnicity or gender), and future investigations into the Junior Giants would benefit from such analyses. Third, this dataset focused on intentions to return, and future research should include actual retention and dropout data, since intentions do not always translate to behavior ( 38 ). It would be additionally interesting to compare intentions vs. actual behavior to identify potential factors or windows as to when and how intentions might change. Fourth, survey questions used in this study reflected content validity (e.g., aligned with program outcomes and previous literature) and showed good internal consistency reliability, and would benefit from additional tests for construct validity (e.g., exploratory factor analysis). Finally, only qualitative responses from non-intended returners were included, and gathering similar open-ended data from parents/caregivers who intended to return and were undecided about returning would be fruitful.

Practical applications

These results offer practical suggestions for the Junior Giants and their investment in maximizing retention and curbing dropout. For coach training, it can be emphasized that focusing on teaching the four bases of character development and making kids on their team feel supported could be the difference between a kid returning to the program or not. It would also be useful to focus on the transition from the first year to the second year, and perhaps following up more intentionally after their first season to maximize the chances a first-year participant will return to the program. It seems necessary to revisit the curriculum and consider how children of the same age, yet varying skill levels, are accommodated within the same team. Coaches would benefit from resources and training on how to structure practices and learning experiences that support all levels of skill development. An additional emphasis on marketing that the program is non-competitive seems important to avoid mismatched expectations from participants and their parents/caregivers. There may be misconceptions about the program given that the San Francisco Giants, a major league baseball team, is the sponsor of the program itself and parents and kids alike may assume the league is meant to develop elite players.

Maximizing retention and minimizing dropout are essential to the success of PA-PYD programs. Our findings suggest parents/caregivers may be reliable sources to understand children's intentions to return (or not), and that focusing on youth development goals, such as building character, can increase the likelihood of participants returning. Some reasons for not returning to a program are developmentally expected (e.g., want to try a new sport), while others present opportunities for improvements in programming (e.g., emphasize skill development). While this study focused on the Junior Giants, many findings are transferrable to other PA-PYD programs interested in retaining youth and maximizing their chances of having a sustained impact on participants.

Data availability statement

The dataset presented in this article is not readily available because the data are proprietary to the Giants Community Fund. Requests about the data should be directed to Brian Greenwood, [email protected].

Ethics statement

This study was approved by Cal Poly San Luis Obispo's Institutional Review Board. The study was conducted in accordance with the local legislation and institutional requirements. The participants provided their consent to participate in this study.

Author contributions

NB, LK, and BG all contributed to the original draft, reviewing, and editing of the manuscript. BG and NB conceived the study, while LK and NB completed the data analyses.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article.

Funding was received from the Giants Community Fund for this evaluation research of the Junior Giants program.

Acknowledgments

We'd like to thank Cassandra Hofman, Paul Giuliacci, Sue Petersen, and all the Junior Giants staff and ambassadors who helped with data collection. A special thanks to San Francisco State undergraduate assistants Alexa Carreon and Kimberly Deboer for their assistance with the qualitative data analysis.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: physical activity, developmental sport psychology, youth sport, dropout, parents

Citation: Bolter ND, Kipp LE and Greenwood PB (2024) Retention in Junior Giants, a sport-based youth development program: what factors are associated with intentions to return?. Front. Sports Act. Living 6:1360289. doi: 10.3389/fspor.2024.1360289

Received: 22 December 2023; Accepted: 25 March 2024; Published: 18 April 2024.

Reviewed by:

© 2024 Bolter, Kipp and Greenwood. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Nicole D. Bolter [email protected]

• Open access
• Published: 16 April 2024

Using a priority setting exercise to identify priorities for guidelines on newborn and child health in South Africa, Malawi, and Nigeria

• Solange Durão   ORCID: orcid.org/0000-0001-7028-2638 1 ,
• Emmanuel Effa 2 ,
• Nyanyiwe Mbeye 3 ,
• Mashudu Mthethwa 2 ,
• Michael McCaul 4 ,
• Celeste Naude 4 ,
• Amanda Brand 4 ,
• Ntombifuthi Blose 1 ,
• Denny Mabetha 1 ,
• Moriam Chibuzor 2 ,
• Dachi Arikpo 2 ,
• Roselyn Chipojola 3 ,
• Gertrude Kunje 3 ,
• Per Olav Vandvik 5 , 6 ,
• Ekpereonne Esu 2 ,
• Simon Lewin 7 &
• Tamara Kredo 2 , 4  

Health Research Policy and Systems volume  22 , Article number:  48 ( 2024 ) Cite this article

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Sub-Saharan Africa is the region with the highest under-five mortality rate globally. Child healthcare decisions should be based on rigorously developed evidence-informed guidelines. The Global Evidence, Local Adaptation (GELA) project is enhancing capacity to use global research to develop locally relevant guidelines for newborn and child health in South Africa (SA), Malawi, and Nigeria. The first step in this process was to identify national priorities for newborn and child health guideline development, and this paper describes our approach.

We followed a good practice method for priority setting, including stakeholder engagement, online priority setting surveys and consensus meetings, conducted separately in South Africa, Malawi and Nigeria. We established national Steering Groups (SG), comprising 10–13 members representing government, academia, and other stakeholders, identified through existing contacts and references, who helped prioritise initial topics identified by research teams and oversaw the process. Various stakeholders were consulted via online surveys to rate the importance of topics, with results informing consensus meetings with SGs where final priority topics were agreed.

Based on survey results, nine, 10 and 11 topics were identified in SA, Malawi, and Nigeria respectively, which informed consensus meetings. Through voting and discussion within meetings, and further engagement after the meetings, the top three priority topics were identified in each country. In SA, the topics concerned anemia prevention in infants and young children and post-discharge support for caregivers of preterm and LBW babies. In Malawi, they focused on enteral nutrition in critically ill children, diagnosis of childhood cancers in the community, and caring for neonates. In Nigeria, the topics focused on identifying pre-eclampsia in the community, hand hygiene compliance to prevent infections, and enteral nutrition for LBW and preterm infants.

Conclusions

Through dynamic and iterative stakeholder engagement, we identified three priority topics for guideline development on newborn and child health in SA, Malawi and Nigeria. Topics were specific to contexts, with no overlap, which highlights the importance of contextualised priority setting as well as of the relationships with key decisionmakers who help define the priorities.

Peer Review reports

Globally, more than half of all deaths in children and youth in 2019 were among children under 5 years [ 1 ]. It is estimated that there are 5.2 million deaths among under-fives each year, with Sub-Saharan Africa (SSA) having the highest mortality rate [ 2 ]. Most countries in SSA are not on track to meet maternal and child health targets set by Sustainable Development Goal 3 to ‘ensure healthy lives and promote wellbeing’, specifically the target of 25 or fewer deaths per 1000 live births [ 1 ]. As of December 2021, under-five mortality rates were reported as 113.8, 38.6 and 32.2 deaths per 1000 live births for Nigeria, Malawi and South Africa respectively [ 3 ]. Factors accounting for regional disparities in child mortality rates include poverty, socioeconomic inequities, poor health systems, and poor nutrition, with disease outbreaks adding substantially to the burden [ 4 ].

Addressing these issues requires an evidence-informed approach to ensure that scarce resources are used effectively and efficiently, avoid harm, maximise benefits, and improve healthcare delivery and outcomes [ 5 , 6 , 7 ]. Evidence-informed practices have been growing in SSA [ 5 ], and include the use of recommendations from clinical practice guidelines that are intended to optimise patient care or public health practice [ 8 ]. Guidelines bridge the gap between research evidence and practice and are recognised as important quality-improvement tools that aim to standardise care, inform funding decisions, and improve access to care, amongst others.

The development of evidence-informed, trustworthy guidelines from scratch—also known as de novo guideline development—is a resource-intensive and time-consuming process [ 9 ]. However, guideline developers can adopt or adapt existing recommendations from guidelines developed in other settings, to make the process more efficient while maintaining transparency and minimising waste and duplication [ 10 , 11 , 12 , 13 ]. For example, the World Health Organisation (WHO) produces high-quality global-level guidelines, which may be adopted and implemented in a member country or, alternatively, adapted for that context. Guidelines can be adopted when there is no need to change the recommendation, the evidence base, or how it is implemented in a local setting while considering factors such as cost, workforce, health systems, management options and access to care [ 10 ]. They can also be adapted when there is a need to modify a guideline(s) or recommendation(s) produced in one cultural and organisational setting for application in a different context [ 10 ]. However, adaptation of such guidelines to national contexts is often not well described [ 14 ]. An evaluation of experiences of guideline adaptation across WHO regions found that adaptation is understood and implemented in a variety of ways across countries [ 15 ].

Furthermore, reporting of guidelines in the African context is usually below global standards, specifically regarding their rigor of development. Kredo and colleagues reviewed Southern African Development Community (SADC) guidelines on five specific diseases published between 2003 and 2010 and besides poor reporting they found that guidelines needed broader stakeholder involvement and greater transparency [ 16 ]. Scoping reviews of newborn and child health guidelines in South Africa, Malawi and Nigeria published between 2017 and 2022 and of pre-hospital clinical guidance in sub-Saharan Africa found that the methods and reporting of the identified guidelines do not adhere to global standards [ 17 , 18 ].

In terms of priority setting processes for guideline development in African settings, little information is available. A scoping review of studies describing prioritization exercises published up to July 2019 did not identify any studies from African countries, with most studies being from Europe [ 19 ]. There is thus room for strengthening and supporting guideline development and adaptation in SSA, including the initial priority setting for those guidelines.

The Global Evidence, Local Adaptation (GELA) project focuses on addressing some of these gaps, including improving guideline development processes in SSA. The project aims to maximise the impact of research on poverty-related diseases by enhancing decision makers’ and researchers' capacity to use global research, including existing high-quality global guidelines, to develop locally relevant guidelines for newborn and child health in three sub-Saharan Africa countries: South Africa (SA), Malawi and Nigeria. The first step of this project was to identify priorities for newborn and child health guideline development in each country, and this paper aims to describe our approach.

Priority setting methods

Priority setting is an important step in guideline development [ 9 ]. It enables the identification of the most important issues through an iterative, inclusive and explicit process [ 7 , 20 ], and ensures efficient resource use by identifying topics for which guidelines are truly needed [ 19 , 21 ].

A variety of methods and approaches for priority setting for research and for guidelines have been used in the literature but there is no existing gold standard method for priority setting [ 19 , 22 ]. Researchers have analysed priority setting exercises and proposed good practice principles that can be followed during such exercises [ 22 , 23 ]. These principles, or elements, of priority setting are linked to the different stages in the process: pre-prioritisation, prioritisation, and post-prioritisation stages, as described in Fig.  1 [ 19 , 22 , 23 , 24 , 25 ]. In the pre-prioritisation stage, they include (i) involving internal and external stakeholders in the decision-making process, (ii) use of an explicit and transparent process, (iii) information management, (iv) consideration of values and context in which the priorities are being set, including those of stakeholders, staff and patients, and (v) planning for implementation, i.e. planning for translation of the priorities into practice. In the prioritization stage they include (i) using relevant criteria to identify priorities and (ii) choosing a method to decide on priorities, which could be consensus-based, such as the 3D Combined Approach Matrix (CAM), or metric-based approaches, such as the Child Health and Nutrition Research Initiative (CHNRI) approach [ 26 ]. In the post-prioritisation phase, they include (i) an evaluation of the priority setting process, and (sii) putting in place mechanisms for reviewing decisions.

Elements of each priority setting stage (adapted from El-Harakeh 2020, Jo 2015, Sibbald 2009, Tong 2019, Viergever 2010)

We followed good practice priority setting method, as described above. Our approach included a pre-prioritisation stage to identify potential priority topics through stakeholder engagement and review of the literature, and a prioritisation stage for consultation and finalisation of the priority topics through online surveys and consensus meetings, using specific criteria (Fig.  2 ). Country teams were responsible for implementing each step in their respective countries and any differences in the process due to practical or other factors within the three countries were captured as part of the documentation of the process.

Overview of priority setting approach overview

Pre-prioritization

Stakeholder identification and engagement.

We engaged with two different pre-specified groups. The first were the members of the Guideline steering group set up in each GELA project country. Up to 13 individuals were identified and invited to participate from the relevant national departments or ministries of health, professional associations, country-level WHO offices, and any other individuals suggested by these bodies in each country. They were identified through existing contacts of the researcher team within national departments of health responsible for guideline development and working within newborn and child health area, with whom they had worked before. These individuals then also made suggestions of other members from other stakeholder groups such as academia, non-governmental organisations, etc., who worked in the field of newborn and child health. The steering group provided initial suggestions of priority topics, made the final decisions regarding which to prioritise, and provided general oversight and technical advice on the in-country implementation of the project.

The second stakeholder group was broader and included individuals or organisations who are involved, can affect or are affected by national decisions or actions related to priority topics in the field of newborn or child health in sub-Saharan Africa [ 27 , 28 ]. These included policymakers, guideline developers, health professionals, civil society representatives, patient advocacy groups as well as WHO Afro representatives, specifically those linked to potential priority topics identified. To identify them, we carried out a stakeholder mapping exercise, which included reviewing secondary data, such as existing guidance and publications and searching the websites of ministries of health, relevant professional associations, universities, NGOs and civil society groups. The national GELA Guideline Steering group members also made suggestions. This process was guided by the stakeholder power-interest matrix where those who have the most influence, and capacity to change practice for impact were prioritised and invited [ 29 ]. Participants were invited, via email, to complete a priority setting survey.

Identifying a long list of topics

We generated an initial long list of potential priority topics through (i) reviewing existing and planned WHO guidelines on newborn and child health, from which potential topics were extracted based on existing recommendations; (ii) consulting with the GELA guideline Steering Group; and (iii) reviewing the disease burden/technical data related to newborn and child health in each country, which was identified through targeted literature searches. WHO guidelines were used as a starting point as these are prepared following rigorous methods and are intended for implementation across the various member countries. Potential topics were organised according to the disease/condition being addressed and the type of intervention (e.g., diagnosis, prevention, treatment, or rehabilitation), and were collated into a spreadsheet or word document.

Prioritization stage

Online survey.

The potential topics identified in the first phase were included in online surveys with stakeholders. We first user-tested the survey among the GELA project team to ensure it was readable and understandable. We then invited all identified stakeholders, via email, to complete the survey developed using REDCap [ 30 ]. In Nigeria, the survey invitation was also circulated via WhatsApp to specific stakeholders. In the invitation emails, we also asked stakeholders to forward the email to any colleagues that may have an interest in the topic.

The landing page of the survey provided information about the study’s purpose, that it was a collaboration with the national department/ministries of health, what we were asking participants to do, and a link for more details about the GELA project, after which participants were required to provide consent before they could complete the survey. The survey asked respondents to rate the listed topics according to five criteria (Box 1 ) using a 6-point Likert scale (6—very critical and 1—not important at all) [ 22 , 31 ]. The criteria used were identified through a survey conducted with the GELA research team in which they rated the top five criteria of 22 criteria for priority setting for guidelines identified by El Harakeh et al. [ 32 ]. An explanation for each criterion was provided in the survey. Originally, we had intended that stakeholders would rate each topic according to each criterion, but we asked instead that they consider the five criteria as a whole when rating a topic. We decided that this approach was less onerous for survey respondents and less likely to lead to poor response rates. Topics rated as being of ‘critical importance’ and ‘very critical importance’ were selected for presentation at the consensus meetings with the Steering Group. The first part of the survey also collected demographic information such as type of stakeholders, what they are primarily practicing as and for how many years, the percentage of time spent in patient care, and the type of institution they are primarily based at.

The surveys remained open for 3–4 weeks. Reminder emails were sent to those who were originally invited to participate, once in SA and Malawi, and weekly in Nigeria. As we could not track emails forwarded to others, due to the anonymity setting of the survey, it was not possible to remind those who had been invited in this manner.

Box 1. Criteria used in the priority setting process

Health burden—whether there is a high impact of the health problem/condition in the country as measured by financial cost, mortality, morbidity, or other indicators (e.g. QALYs, DALYs)

Urgency—whether there is an urgent need to address the issue or practice gap

Absence of guidance—whether there are no up-to-date existing guidelines addressing the specific topic and the topic would fit into existing national guideline development processes and priorities

Impact on health outcomes—whether a recommendation on the topic would have a beneficial impact on health outcomes in the country

Feasibility of intervention implementation—whether a guideline/recommendation addressing the topic would be feasible to implement in the national context (i.e. if this is through recognised guideline development bodies

Steering Group consensus meeting

Each country convened a meeting of their Guideline Steering Group to identify the final top three priority topics for guideline development. The number of topics per country was based on the number of recommendations that could be addressed in each country over the broader project period given the resources available. The moderator was a member of the research team and guided the meetings and discussions. This meeting was online in South Africa, and in-person in Malawi and Nigeria. We adopted a modified Nominal Group Technique [ 33 ] to achieve consensus, including five steps:

Step 1: the research team presented a summary of how the topics for the online survey were identified, which included consultation with the same steering group, as well as the results of the survey, including the summary of the topics that were rated as critically and very critically important, which needed further prioritisation.

Step 2: With the help of the moderator the group discussed each topic to ensure that all members understood them in the same way, and we elicited their thoughts on the ratings from the survey.

Step 3: The steering group members were asked to vote, anonymously, on the topics rated as critical or very critical in the survey using a Zoom poll (South Africa) or manually using post-its (Malawi). In Nigeria, the steering group decided to reach consensus through discussion to ensure full ownership of the resulting topics by every member of the group In South Africa only one round of voting was done as the members felt there was sufficient consensus after that. When voting, members ranked the importance of each topic on a six-point Likert scale against the same five criteria used in the online survey.

Step 4: The moderator summarised the results of the voting using bar charts to visualise the rating frequency distribution [ 34 ]. The variations for ratings observed were discussed among the group, including potential explanations before another round of voting, in cases where this took place.

Step 5: Consensus on the top three topics was reached. It was originally anticipated that at the end of this meeting three priority topics—formulated as questions in Population, Intervention, Comparator, and Outcomes (PICO) format—would have been identified for the next stages of the GELA project. However, the topics identified were broad, and further scoping of the literature and existing guidelines were needed to unpack and refine them. Several subsequent meetings with the Steering Groups were therefore needed in each country to present this scoping and finalise the three priority PICO questions per country.

Data management and analysis

Data were exported from the REDCap data management software, cleaned, and analysed using R studio [ 35 ] or STATA 12 [ 36 ]. Simple descriptive statistics were used during the analysis. Median and interquartile ranges (IQRs) were used to rank the topics, which were presented graphically and tabulated in descending order from very critically important to not important at all. Frequencies and proportions were used to describe categorical data. Response rates and missing data were noted. The data were considered as missing at random.

Pre-prioritisation

The members identified and invited to join the Steering Group in each country are described in Table  1 .

Stakeholder mapping identified a range of stakeholders for the survey, including 78 in South Africa, 31 in Malawi, and 40 in Nigeria (Table  2 ). In South Africa, there was greater representation from researchers/academics and health professionals; in Malawi from policymakers and researchers/academics; and in Nigeria from policymakers and professional associations, most of whom were academics.

Initial list of topics

In South Africa and Nigeria, the initial lists of topics identified were very long; over 65 topics, across 14 broad topic areas in South Africa, and 51 topics in Nigeria. Through engagement and input from the respective Steering Group members and other experts—via virtual meetings or email—the lists were narrowed down. The survey in South Africa included 14 topics across six conditions, in Nigeria 27 topics across 10 conditions, and in Malawi 30 topics across eight conditions (Table  3 ). Aside from undernutrition, which was a broad topic included in the surveys of all three countries, there was very little overlap in topics across all the countries. Pneumonia/acute respiratory infection and tuberculosis were common to Malawi and Nigeria, and schistosomiasis was common to South Africa and Malawi.

Prioritisation

All the stakeholders described in Table  2 were invited to complete the online survey via email. In Nigeria, WhatsApp messages were also sent to representatives of professional groups (paediatricians, Obstetricians, neonatologists), who then shared on their groups. The surveys were open for approximately three to four weeks at the end of 2022: 10 October to 8 November in South Africa; 7 to 25 November in Malawi; and 10 November to 3 December in Nigeria. Whereas in South Africa and Malawi fewer people accessed the survey compared to the number of people invited (38/78 in SA, 23/61 in Malawi), in Nigeria a greater number of people accessed it (78/57). However, a similar percentage of those that accessed the survey fully completed it (66% in SA, 70% in Malawi, and 68% in Nigeria). Some respondents completed the first part of the survey, i.e. demographic characteristics, but not the section where they were required to rate the importance of the topics. These respondents were not included in the analysis.

Overall, most respondents were health professionals (81%) and had between 5 and 20 years of experience in practice (63%) (Table  4 ). About a third of participants spent more than 75%, or between 50 and 75%, of their time in direct patient care. Most participants were primarily based at a teaching hospital (41%), and at a hospital (17%) or university (16%).

In SA, nine of 14 topics were rated as critically important , five were rated as very important , and no topic was rated as very critically important (Tables 5 , 6 , 7 ). In Malawi, 10/30 topics were rated as very critically important , 14 as critically important , five as very important , and one as important . In Nigeria, 11/27 topics were rated as very critically important , 13 were rated as critically important , one as very important , one as important and one as not important . The topics that were taken through to the discussion with the Steering Groups included all the critically important topics in South Africa, and all the very critically important topics in Malawi and Nigeria. Individual ratings for each topic included in the survey of each country are presented in the Additional file 1 : Fig. S1–S3.

Some survey respondents suggested additional topics. In South Africa 12/25 people suggested an additional 21 topics, six of 16 respondents in Malawi suggested an additional 15 topics, and 30 of 53 respondents in Nigeria suggested an additional 63 topics. In general, there was little overlap in the additional topics suggested and none were taken up as potential priorities across the countries.

Consensus meeting with Steering Groups

The main consensus meetings were held between November and December 2022 across the three countries. These were attended by members of the SG and research teams in each country. Additional individuals who joined the main Steering Group meetings included observers ( n  = 2), the Malawi and Nigeria project leads ( n  = 2) at the South African meeting, the project coordinator (TK) in Malawi, and a representative from the Department of Health Planning, Research and Statistics in Nigeria.

After the presentation of the results of the online survey (Step 1) and discussion about the top-rated topics (Step 2) (Table  5 ), facilitated by the moderator, the Steering Group members voted to identify the top three topics (Step 3). In South Africa, one round of voting indicated some consensus; of seven people who voted, three topics were rated as critically or very critically important by most people, and three topics were not rated by any member as critical/very critical . After further discussion on the results of the voting (Step 4), four topics were prioritized (Step 5). Figure  3 describes what took place in each step. In Malawi, although 10 top-rated topics were presented, the Steering Group members derived 10 new topics from topic 1 and 9, and these were the topics voted on. Two rounds of voting were done, after which three topics were identified. In Nigeria, the Steering Group agreed to reach decisions on topics by consensus. After extensive deliberations, considering the prevalence of health problems in neonates and the primary causes of these, they decided on four priority topics to consider.

Flow diagram of the steps in the modified Nominal Group Technique

Across all three countries, the topics selected by the end of the consensus meeting were very broad, i.e., each one encompassed many potential questions and was not yet sufficiently specific for a guideline process (i.e., in the Population, Intervention, Comparator, Outcomes—PICO format). Therefore, research teams had to do further work to unpack and refine these. To clarify the PICO questions linked to each topic, the teams compared existing national guidance on prioritised topics with recommendations in relevant WHO guidelines and other global guidance; this allowed identification of gaps in national guidance that the project could address. In Malawi, the team also consulted with experts in the field. This process resulted in seven potential PICO questions in South Africa, six in Malawi, and four in Nigeria. These were presented to the Steering Groups in additional meetings and via email communication, several rounds of which were required before final PICO questions were identified (Table  8 ). The final topics were also discussed with stakeholders responsible for developing and implementing national guidance, to clarify whether they linked to national priorities and whether they could fit within existing guideline development processes and infrastructure. Only topics that fit these conditions were taken through to the next stage of the project, the development of recommendations.

We conducted a priority setting exercise to identify topics and inform new guideline development addressing gaps in newborn and child health in South Africa, Malawi, and Nigeria. In each country, the process included engagements with national Steering Groups comprising representatives of various national-level organisations, multi-stakeholder online surveys, and consensus meetings. At the end of the process three priority PICO questions were identified in each country. In South Africa, the topics concerned anemia prevention in infants and young children through iron supplementation and multiple micronutrient powders, and post-discharge support for caregivers of preterm and LBW babies. In Malawi, they focused on enteral nutrition in critically ill children, diagnosis of childhood cancers in the community, and caring for neonates. In Nigeria, the topics focused on identifying pre-eclampsia in the community, hand hygiene compliance to prevent infections, and enteral nutrition for LBW and preterm infants.

The topics identified are informing the next stages of the GELA project, which include a systematic guideline adaptation process, including scoping existing guidelines or systematic reviews addressing the topics, conducting evidence synthesis where necessary, and convening of guideline panels to make recommendations linked to some or all of the priority PICO questions in the three countries [ 10 ]. Through this process we are aiming to highlight best practice methods for guideline development, including priority setting with the involvement of relevant stakeholders through a transparent and systematic process, and through ensuring the guidelines are developed following rigorous methods and clear and transparent reporting.

The priorities identified at the end of the process had limited overlap across the three countries. This highlights the importance of contextualised priority setting processes, one of the good practice principles of priority setting [ 23 ]. Although contextualised priority setting is important because contextual factors drive the needs and the gaps in healthcare delivery and implementation in different countries, there can also be common priorities and issues. Therefore, countries with similar priorities could draw on existing work at a global or country level, for adaptation into their context, to prevent any regional system fragmentation.

Some of the topics included in the online survey were broad, which made it difficult to identify the questions in required format for a guideline question (PICO) at the end of the main expert consensus meetings. This required substantial work to refine the topics, as well as additional meetings with the Steering Groups, which delayed the finalisation of priority topics and the next steps of the project that depended on priority topics being identified. Ideally, the topics included in the survey should have been more specific. Otherwise, some of the work to clarify the top-rated topics identified through the survey could have been done before the Steering Group consensus meeting, to ensure better efficiency. Future priority setting should also consider more frequent meetings with national Steering Groups advising on topics, given the iterative nature of the process. The process may have been more efficient and easier if the starting point had been a narrower topic area, rather than covering all of newborn and child health.

Although this project aimed to identify priority topics in PICO format that would lead to one recommendation, this may not have been clear to all stakeholders involved. In some cases, stakeholders identified topics that were broad in nature and that would lend themselves for a full guideline encompassing different recommendation. This should be better clarified at the start of the process, when engaging with the stakeholders.

We noted better response rates to the online survey where emails inviting stakeholders to participate in the survey were from a recognised institutional address, and supplemented with WhatsApp communication, a method increasingly recognised as valuable for sharing digital health information [ 37 ].

In some cases, certain Steering Group members tended to dominate the consensus discussions. Management of stakeholder input during these meetings is a critical required skill for successfully gathering everyone’s views. In a study done to prioritise childhood cancer supportive care topics for the development of guidelines, Loeffen and colleagues chose to do a Delphi survey as one of the strengths of this method is the lack of face-to-face meetings to prevent dominant voices being introduced [ 38 ].

Strengths and limitations

We followed a good practice method for priority setting including stakeholder engagement and using an explicit process [ 23 ]. We convened Steering Groups with representatives from relevant national decision-makers to advise on the project and topics, working in close collaboration with Departments of Health, aiming to ensure the project addresses national priorities that could fill a gap in national guidelines and guideline development processes. The online survey facilitated engagement with a broader range of stakeholders, to ensure broad representation of views and perspectives. Furthermore, the guideline development groups that would be identified in the next stage of the project to review the evidence and develop recommendations for each of the identified questions would ensure representation of key stakeholders. We also used specific criteria to rate the importance of topics, which were derived from the literature and which also received input to ensure they were understandable and relevant.

Our study had a few limitations. The response rates to surveys were poor, and could perhaps have been improved if they had remained open for longer. We sent reminder emails to those participants we had invited to complete the survey, but it was not possible to do this for others who may have received the link from others. We did not include patients or carers in the survey; research suggests that their perspectives may differ regarding what treatment decisions are important [ 39 , 40 ]. We did, however, include civil society groups which provided perspectives that consider equity and patient and caregiver perspectives.

Through an explicit process, including stakeholder engagement, reviewing of existing global guidelines and burden of disease, and online surveys we identified three priority questions each in South Africa, Malawi and Nigeria for guidelines addressing newborn and child health. We found that the process was not linear but rather iterative in nature, requiring several engagements with stakeholders to help finalise the topics, as well as managing the conflicting priorities of different groups of stakeholders. Our experience highlights the importance of contextualised priority setting, as shown by the limited overlap in topics prioritised across the three countries, as well as of the relationships with key decisionmakers, who help define the priorities.

Availability of data and materials

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

Abbreviations

Global Evidence Local Adaptation

Non-governmental organisation

Non-profit organisation

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Acknowledgements

Carron Finnan, SAMRC corporate communications for the design of Figs. 1 and 2 .

The members of the steering groups in each country.

This project is funded as part of the EDCTP2 programme supported by the European Union (grant number RIA2020S-3303-GELA). The funder had no role in the design of the study, or in the collection, analysis, and interpretation of data, or in writing the manuscript.

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SD, EEf, NM, MMt, MMc, TK, RC, GK, POV, and SL were involved in the conception and design of the study. SD, EE, MC, DA, EEs, DM, NB, GK, RC were involved with data acquisition or analysis. SD, EE, CN, AB, MMc, MC, DA, EEs, NB, and SL were involved in interpreting the findings. All authors contributed to drafting the manuscript or revising it critically and approved the final manuscript to be published.

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This study has been approved in the three countries in which it is taking place. In South Africa the study was approved by the SAMRC Human Research Ethics Committee on 19 July 2022 (protocol ID EC011-6/2022). In Nigeria, the study was approved by the National Health Research Ethics Committee (Approval Number NHREC/01/01/2007-30/06/2022). In Malawi, the study was approved by the College of Medicine Research and Ethics Committee (COMREC) (number P.06/22/3665).

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Additional file1: figure s1..

Rating of importance of survey topics in South Africa. Figure S2. Rating of importance of Malawi survey topics. Figure S3. Rating of importance of the topics included in the Nigeria survey.

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Durão, S., Effa, E., Mbeye, N. et al. Using a priority setting exercise to identify priorities for guidelines on newborn and child health in South Africa, Malawi, and Nigeria. Health Res Policy Sys 22 , 48 (2024). https://doi.org/10.1186/s12961-024-01133-7

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About half of Americans say public K-12 education is going in the wrong direction

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Pew Research Center conducted this analysis to understand how Americans view the K-12 public education system. We surveyed 5,029 U.S. adults from Nov. 9 to Nov. 16, 2023.

The survey was conducted by Ipsos for Pew Research Center on the Ipsos KnowledgePanel Omnibus. The KnowledgePanel is a probability-based web panel recruited primarily through national, random sampling of residential addresses. The survey is weighted by gender, age, race, ethnicity, education, income and other categories.

Here are the questions used for this analysis , along with responses, and the survey methodology .

A majority of those who say it’s headed in the wrong direction say a major reason is that schools are not spending enough time on core academic subjects.

These findings come amid debates about what is taught in schools , as well as concerns about school budget cuts and students falling behind academically.

Related: Race and LGBTQ Issues in K-12 Schools

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Among Republicans, conservatives are the most likely to say public education is headed in the wrong direction: 75% say this, compared with 52% of moderate or liberal Republicans. There are no significant differences among Democrats by ideology.

Similar shares of K-12 parents and adults who don’t have a child in K-12 schools say the system is going in the wrong direction.

A separate Center survey of public K-12 teachers found that 82% think the overall state of public K-12 education has gotten worse in the past five years. And many teachers are pessimistic about the future.

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Why do Americans think public K-12 education is going in the wrong direction?

We asked adults who say the public education system is going in the wrong direction why that might be. About half or more say the following are major reasons:

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About a quarter (26%) say a major reason is that parents have too much influence in decisions about what schools are teaching.

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In turn, Democrats are more likely than Republicans to point to:

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Among Democrats, liberals are especially likely to cite schools lacking resources and parents having too much say in the curriculum.

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