qualitative research early years

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Qualitative Research in Early Childhood Education and Care Implementation

• Wendy K. Jarvie 1  

International Journal of Child Care and Education Policy volume  6 ,  pages 35–43 ( 2012 ) Cite this article

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Governments around the world have boosted their early childhood education and care (ECEC) engagement and investment on the basis of evidence from neurological studies and quantitative social science research. The role of qualitative research is less understood and under-valued. At the same time the hard evidence is only of limited use in helping public servants and governments design policies that work on the ground. The paper argues that some of the key challenges in ECEC today require a focus on implementation. For this a range of qualitative research is required, including knowledge of organisational and parent behaviour, and strategies for generating support for change. This is particularly true of policies and programs aimed at ethnic minority children. It concludes that there is a need for a more systematic approach to analysing and reporting ECEC implementation, along the lines of “implementation science” developed in the health area.

Introduction

Research conducted over the last 15 years has been fundamental to generating support for ECEC policy reform and has led to increased government investments and intervention in ECEC around the world. While neurological evidence has been a powerful influence on ECEC policy practitioners, quantitative research has also been persuasive, particularly randomised trials and longitudinal studies providing evidence (1) on the impact of early childhood development experiences to school success, and to adult income and productivity, and (2) that properly constructed government intervention, particularly for the most disadvantaged children, can make a significant difference to those adult outcomes. At the same time the increased focus on evidence-informed policy has meant experimental/quantitative design studies have become the “gold standard” for producing knowledge (Denzin & Lincoln, 2005 ), and pressures for improved reporting and accountability have meant systematic research effort by government has tended to focus more on data collection and monitoring, than on qualitative research (Bink, 2007 ). In this environment the role of qualitative research has been less valued by senior government officials.

Qualitative Research-WhatIs It?

The term qualitative research means different things to different people (Denzin & Lincoln, 2005 ). For some researchers it is a way of addressing social justice issues and thus is part of radical politics to give power to the marginalised. Others see it simply as another research method that complements quantitative methodologies, without any overt political function. Whatever the definition of qualitative research, or its role, a qualitative study usually:

Features an in depth analysis of an issue, event, entity, or process. This includes literature reviews and meta studies that draw together findings from a number of studies.

Is an attempt to explain a highly complex and/or dynamic issue or process that is unsuited to experimental or quantitative analysis.

Includes a record of the views and behaviours of the players — it studies the world from the perspective of the participating individual.

Cuts across disciplines, fields and subject matter.

Uses a range of methods in one study, such as participant observation; in depth interviewing of participants, key stakeholders, and focus groups; literature review; and document analysis.

High quality qualitative research requires high levels of skill and judgement. Sometimes it requires pulling together information from a mosaic of data sources and can include quantitative data (the latter is sometimes called mixed mode studies). From a public official perspective, the weaknesses of qualitative research can include (a) the cost-it can be very expensive to undertake case studies if there are a large number of participants and issues, (b) the complexity — the reports can be highly detailed, contextually specific examples of implementation experience that while useful for service delivery and front line officials are of limited use for national policy development, (c) difficultyin generalising from poor quality and liable to researcher bias, and (d) focus, at times, more on political agendas of child rights than the most cost-effective policies to support the economic and social development of a nation. It has proved hard for qualitative research to deliver conclusions that are as powerful as those from quantitative research. Educational research too, has suffered from the view that education academics have over-used qualitative research and expert judgement, with little rigorous or quantitative verification (Cook & Gorard, 2007 ).

Qualitative Research and Early Childhood Education and Care

In fact, the strengths of qualitative ECEC research are many, and their importance for government, considerable. Qualitative research has been done in all aspects of ECEC operations and policies, from coordinating mechanisms at a national level (OECD, 2006 ), curriculum frameworks (Office for Children and Early Childhood Development, 2008 ), and determining the critical elements of preschool quality (Siraj-Blatchford et al., 2003 ), to developing services at a community level including effective outreach practices and governance arrangements. Qualitative research underpins best practice guides and regulations (Bink, 2007 ). Cross country comparative studies on policies and programs rely heavily on qualitative research methods.

For public officials qualitative components of program evaluations are essential to understanding how a program has worked, and to what extent variation in outcomes and impacts from those expected, or between communities, are the result of local or national implementation issues or policy flaws. In addition, the public/participant engagement in qualitative components of evaluations can reinforce public trust in public officials and in government more broadly.

In many ways the contrast between quantitative and qualitative research is a false dichotomy and an unproductive comparison. Qualitative research complements quantitative research, for example, through provision of background material and identification of research questions. Much quantitative research relies on qualitative research to define terms, and to identify what needs to be measured. For example, the Effective Provision of PreSchool Education (EPPE) studies, which have been very influential and is a mine of information for policy makers, rely on initial qualitative work on what is quality in a kindergarten, and how can it be assessed systematically (Siraj-Blatchford et al., 2003 ). Qualitative research too can elucidate the “how” of a quantitative result. For example, quantitative research indicates that staff qualifications are strongly associated with better child outcomes, but it is qualitative work that shows that it is not the qualification per se that has an impact on child outcomes-rather it is the ability of staff to create a high quality pedagogic environment (OECD, 2012 ).

Challenges of Early Childhood Education and Care

Systematic qualitative research focused on the design and implementation of government programs is essential for governments today.

Consider some of the big challenges facing governments in early childhood development (note this is not a complete list):

Creating coordinated national agendas for early childhood development that bring together education, health, family and community policies and programs, at national, provincial and local levels (The Lancet, 2011 ).

Building parent and community engagement in ECEC/Early Childhood Development (ECD), including increasing parental awareness of the importance of early childhood services. In highly disadvantaged or dysfunctional communities this also includes increasing their skills and abilities to provide a healthy, stimulating and supportive environment for young children, through for example parenting programs (Naudeau, Kataoka, Valerio, Neuman & Elder, 2011 ; The Lancet, 2011 ; OECD, 2012 ).

Strategies and action focused on ethnic minority children, such as outreach, ethnic minority teachers and teaching assistants and informal as well as formal programs.

Enhancing workforce quality, including reducing turnover, and improved practice (OECD, 2012 ).

Building momentum and advocacy to persuade governments to invest in the more “invisible” components of quality such as workforce professional development and community liaison infrastructure; and to maintain investment over significant periods of time (Jarvie, 2011 ).

Driving a radical change in the way health/education/familyservicepro fessions and their agencies understand each other and to work together. Effectively integrated services focused on parents, children and communities can only be achieved when professions and agencies step outside their silos (Lancet, 2011 ). This would include redesign of initial training and professional development, and fostering collaborations in research, policy design and implementation.

There are also the ongoing needs for,

Identifying and developing effective parenting programs that work in tandem with formal ECEC provision.

Experiments to determine if there are lower cost ways of delivering quality and outcomes for disadvantaged children, including the merits of adding targeted services for these children on the base of universal services.

Figuring out how to scale up from successful trials (Grunewald & Rolnick, 2007 ; Engle et al., 2011 ).

Working out how to make more effective transitions between preschool and primary school.

Making research literature more accessible to public officials (OECD, 2012 ).

Indeed it can be argued that some of the most critical policy and program imperatives are in areas where quantitative research is of little help. In particular, qualitative research on effective strategies for ethnic minority children, their parents and their communities, is urgently needed. In most countries it is the ethnic minority children who are educationally and economically the most disadvantaged, and different strategies are required to engage their parents and communities. This is an area where governments struggle for effectiveness, and public officials have poor skills and capacities. This issue is common across many developed and developing countries, including countries with indigenous children such as Australia, China, Vietnam, Chile, Canada and European countries with migrant minorities (OECD, 2006 ; COAG, 2008 ; World Bank, 2011 ). Research that is systematic and persuasive to governments is needed on for example, the relative effectiveness of having bilingual environments and ethnic minority teachers and teaching assistants in ECEC centres, compared to the simpler community outreach strategies, and how to build parent and community leadership.

Many countries are acknowledging that parental and community engagement is a critical element of effective child development outcomes (OECD, 2012 ). Yet public officials, many siloed in education and child care ministries delivering formal ECEC services, are remote from research on raising parent awareness and parenting programs. They do not see raising parental skills and awareness as core to their policy and program responsibilities. Improving parenting skills is particularly important for very young children (say 0–3) where the impact on brain development is so critical. It has been argued there needs to be a more systematic approach to parenting coach/support programs, to develop a menu of options that we know will work, to explore how informal programs can work with formal programs, and how health programs aimed young mothers or pregnant women can be enriched with education messages (The Lancet, 2011 ).

Other areas where qualitative research could assist are shown in Table 1 (see p. 40).

Implementation Science in Early Childhood Education and Care

Much of the suggested qualitative research in Table 1 is around program design and implementation . It is well-known that policies often fail because program design has not foreseen implementation issues or implementation has inadequate risk management. Early childhood programs are a classic example of the “paradox of non-evidence-based implementation of evidence-based practice” (Drake, Gorman & Torrey, 2005). Governments recognise that implementation is a serious issue: there may be a lot of general knowledge about “what works”, but there is minimal systematic information about how things actually work . One difficulty is that there is a lack of a common language and conceptual framework to describe ECEC implementation. For example, the word “consult” can describe a number of different processes, from public officials holding a one hour meeting with available parents in alocation,to ongoing structures set up which ensureall communityelementsare involved and reflect thespectrum of community views, and tocontinue tobuild up community awareness and engagement over time.

There is a need to derive robust findingsof generic value to public officials, for program design. In the health sciences, there is a developing literature on implementation, including a National implementation Research Network based in the USA, and a Journal of Implementation Science (Fixsen, Naoom, Blasé, Friedman & Wallace, 2005 ). While much of the health science literature is focused on professional practice, some of the concepts they have developed are useful for other fields, such as the concept of “fidelity” of implementation which describes the extent to which a program or service has been implemented as designed. Education program implementation is sometimes included in these fora, however, there is no equivalent significant movement in early childhood education and care.

A priority in qualitative research for ECEC of value to public officials would then appear to be a systematic focus on implementation studies, which would include developing a conceptual framework and possibly a language for systematic description of implementation, as well as, meta-studies. This need not start from scratch-much of the implementation science literature in health is relevant, especially the components around how to influence practitioners to incorporate latest evidence-based research into their practice, and the notions of fidelity of implementation. It could provide an opportunity to engage providers and ECE professionals in research, where historically ECEC research has been weak.

Essential to this would be collaborative relationships between government agencies, providers and research institutions, so that there is a flow of information and findings between all parties.

Quantitative social science research, together with studies of brain development, has successfully made the case for greater investment in the early years.There has been less emphasis on investigating what works on the ground especially for the most disadvantaged groups, and bringing findings together to inform government action. Yet many of the ECEC challenges facing governments are in implementation, and in ensuring that interventions are high quality. This is particularly true of interventions to assist ethnic minority children, who in many countries are the most marginalised and disadvantaged. Without studies that can improve the quality of ECEC implementation, governments, and other bodies implementing ECEC strategies, are at risk of not delivering the expected returns on early childhood investment. This could, over time, undermine the case for sustained government support.

It is time for a rebalancing of government research activity towards qualitative research, complemented by scaled up collaborations with ECEC providers and research institutions. A significant element of this research activity could usefully be in developing a more systematic approach to analysing and reporting implementation, and linking implementation to outcomes. This has been done quite effectively in the health sciences. An investment in developing an ECEC ‘implementation science’ would thus appear to be a worthy of focus for future work.

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This paper was originally prepared for the OECD Early Childhood Education and Care Network Meeting, 24 January 2012, Oslo, Norway.

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Jarvie, W.K. Qualitative Research in Early Childhood Education and Care Implementation. ICEP 6 , 35–43 (2012). https://doi.org/10.1007/2288-6729-6-2-35

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“It’s Embedded in What We Do for Every Child”: A Qualitative Exploration of Early Childhood Educators’ Perspectives on Supporting Children’s Social and Emotional Learning

Claire blewitt.

1 Health and Social Care Unit, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC 3004, Australia; [email protected] (C.B.); [email protected] (A.O.); [email protected] (H.M.); [email protected] (R.G.)

Amanda O’Connor

Heather morris, andrea nolan.

2 School of Education, Faculty of Arts and Education, Deakin University, 1 Gheringhap Street, Geelong, VIC 3220, Australia; [email protected]

3 Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Level 1, 42-51 Kanooka Grove, Clayton, VIC 3168, Australia; [email protected]

Rachael Green

Amalia ifanti.

4 Department of Educational Sciences and Early Childhood Education, University of Patras, 26504 Patras, Greece; rg.sartapu@itnafi

Kylie Jackson

5 Bestchance Child Family Care, 583 Ferntree Gully Road, Glen Waverley, VIC 3150, Australia; ua.gro.ecnahctseb@noskcaJK

Helen Skouteris

6 Warwick Business School, Warwick University, Coventry CV4 7AL, UK

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Early childhood educators play an important role in supporting children’s social and emotional development. While a growing body of research has examined the impact of curriculum-based social and emotional learning (SEL) programs on child outcomes, the approaches educators use to strengthen children’s social and emotional functioning through their everyday practices are less defined. This study explored Australian early childhood educators’ perspectives on children’s social and emotional development, the approaches educators use to encourage children’s social and emotional skills, the enablers and barriers to SEL within the preschool environment, and the additional support needed. Thirty Early Childhood Education and Care professionals participated in semi-structured interviews and focus group discussions. Findings suggest children’s social–emotional development is at the forefront of educator planning, practice, and reflection. Participants described utilising various approaches to support children’s social and emotional skills, embedded within interactions and relationships with children and families. Specifically, strategies could be grouped into four broad categories: a nurturing and responsive educator–child relationship; supporting SEL through everyday interactions and practice; utilising the physical environment to encourage SEL; and working in partnership with caregivers. There was, however, inconsistency in the variety and type of approaches identified. Time constraints, group size, educator confidence and capability, high staff turnover, and limited guidance regarding high-quality social and emotional pedagogy were identified as key barriers. Participants sought practical strategies that could be embedded into daily practice to build upon current knowledge.

1. Introduction

Early childhood presents a unique window for social and emotional skill development. Social and emotional competence in young children has been described as an emerging ability to establish secure relationships with both adults and peers, experience, regulate and express emotions, explore the environment, and learn. This development occurs within the context of family, community and culture [ 1 ]. Frameworks of social–emotional functioning in early childhood grapple with the rapid growth that takes place during this period and the overlap between various skills and behaviours. As such, scholars often suggest domains of development and discrete skills that sit within each [ 2 , 3 ]. Drawing on a review of social–emotional domains most often captured in theoretical models, Halle and Darling-Churchill [ 4 ] offer social competence, emotional competence, self-regulation, and behaviour problems as central to understanding and assessing child development. Executive functioning is increasingly included as a distinct but related dimension, referring to the cognitive processes which enable children to organise their thinking and behaviour, facilitating self-regulation and learning.

This is also a period when social and emotional difficulties can first emerge. Australian research suggests between 13% and 19% of children aged 1.5 to 3 years display clinically significant difficulties with social, emotional or behavioural functioning, increasing to almost 20% by six years of age; however, only 16% of these access support from specialist mental health services [ 5 ]. Increasing understanding of the epidemiology of mental health problems indicates a robust link between social, emotional, and behavioural difficulties in childhood and later mental health problems [ 6 , 7 ], in addition to other maladaptive outcomes including obesity, diabetes and heart disease, lower rates of tertiary education, and reduced vocational opportunities [ 7 , 8 , 9 , 10 ].

The social and emotional skills that provide a foundation for ongoing learning and wellbeing are largely shaped by a child’s early relationships and care experiences [ 11 , 12 ]. Socioecological perspectives of child development [ 13 ] offer a framework to consider the multiple relationships and environments in which child development occurs. While family is recognised as the first and foremost influence on children’s wellbeing, other individuals, such as early childhood educators, can play an important role in supporting healthy development. Many children access Early Childhood Education and Care (ECEC) in the formative years before formal schooling [ 14 ], offering a pathway to reach children at their point of need. High-quality ECEC includes both structural and process elements. According to the Organisation for Economic Co-operation and Development, this encompasses a stimulating environment, high-quality pedagogy and teacher–child interactions, highly qualified educators, and positive working conditions [ 15 ]. Together, these factors can strengthen children’s social, emotional, and cognitive functioning and subsequent school readiness, with research suggesting improvement in short- and long-term learning, health, and vocational outcomes [ 16 , 17 , 18 , 19 ]. This can be especially important for children showing signs of early social and emotional difficulty, and children exposed to other individual or familial risk factors, such as socioeconomic disadvantage [ 20 , 21 , 22 ].

Knowledge of the importance of high-quality early learning experiences has seen children’s social and emotional skills prioritised in learning policy and curricula across countries, including Australia [ 23 ], the United States [ 24 ], England [ 25 , 26 ], and Singapore [ 27 ]. Social and emotional learning (SEL) describes the process by which children acquire and apply knowledge, skills, and attitudes relating to self-awareness, social awareness, self-management, relationship skills, and responsible decision making [ 28 ]. Research evidence shows early childhood educators can strengthen these emerging social and emotional competencies that promote future learning, health, and wellbeing in a similar way that they foster language and early literacy skills; through explicit instruction, teacher practices, integration within broader early learning pedagogy, and systemic integration across early childhood classrooms, settings, families, and communities [ 29 , 30 , 31 ]. Subsequently, there is increasing availability of SEL programming designed for ECEC to support educators to foster children’s social and emotional health [ 29 , 30 , 31 , 32 , 33 , 34 ].

Teachers’ perspectives on SEL can influence adoption and sustainability and may moderate impact child outcomes [ 35 , 36 ]. These have been investigated by examining the social validity of SEL programming [ 37 , 38 , 39 , 40 ], and exploration of educators’ views relating to classroom-based SEL programs [ 41 ]. In a recent qualitative study, early childhood teachers (pre-kindergarten to Grade 3) in urban classrooms in the United States contended that they, with parents, were responsible for supporting children’s social and emotional competences. Educators wanted SEL curricula but did not want scripted programs as these placed restrictions which some perceived to limit their ability to effectively implement interventions. They also highlighted that SEL programming should reflect school and classroom culture, children’s racial and ethnic background, and the culture of children’s community, and that tangible resources and support from professionals was critical for successful implementation. Barriers to SEL included limited time, lack of support, insufficient resources, devaluing the teaching of social and emotional competences, and programs that were not contextually relevant [ 41 ].

Studies have also examined how educators facilitate SEL through their everyday practice and interactions, without deliberate intervention (i.e., without utilising an explicit SEL program). Aubrey and Ward [ 42 ] used survey (n = 46) and follow-up interviews (n = 3) to explore the views of early years practitioners in the United Kingdom regarding early intervention for young children experiencing difficulties in personal, social, and emotional development (PSED). They identified a variety of strategies to strengthen PSED including modelling, establishing clear expectations, formally teaching social skills, dialogue and explanation, shared games and activities, and scaffolding. A similar mixed-methods approach was adopted by Hollingsworth and Winter [ 43 ] in the United States who explored preschool teachers’ beliefs relating to social–emotional competencies and the teacher practices that support these skills. In a study involving 32 Head Start and pre-kindergarten teachers, educators placed higher importance on social–emotional skills than early language, literacy, and math and employed a variety of responsive practices to promote prosocial skills, pretend play, and friendship formation. In contrast, Papadopoulou and colleagues explored the perceptions of 34 educators working in childcare centres in Greece. While educators acknowledged the importance of social and emotional competencies, they did not report consistent use of practices to promote these skills in the ECEC setting. The authors argued this may be influenced by a lack of formal pedagogical childcare curricula, guidelines or practices focused on social and emotional development, structural barriers, and a belief that social and emotional development is beyond their sphere of influence [ 44 ].

1.1. The Australian Context

SEL literature recognises that while children have common developmental needs, cultures differ in how competences are expressed, and approaches to aid SEL must empower children within their unique environment [ 45 , 46 ]. Similar to other countries, Australia has seen rapid interest and expansion in SEL across all levels of education, including ECEC. Australian ECEC providers operate under the National Quality Framework [ 47 ], incorporating national law and regulations, the National Quality Standard, the assessment and quality rating process, and learning frameworks including Being, Belonging, Becoming: Early Years Learning Framework 2009 (EYLF) [ 23 ]. This framework guides early childhood curriculum and pedagogy to address the developmental needs, interests, and experiences of each child, while taking into account individual differences. The EYLF describes the expected outcomes for all children who attend ECEC services, with a strong emphasis on social and emotional wellbeing, including that they have a strong sense of identity, are connected with and contribute to their world, have a strong sense of wellbeing, and are confident and involved learners and effective communicators. This Framework calls attention to child-centred and integrated teaching approaches to facilitate knowledge and skill acquisition, while recognising children learn at different rates, in different ways, and at different times. Further, it acknowledges educator practice and decision making is based on knowledge and skill, knowledge of children, families and communities, self-awareness of how their own beliefs and values impact children’s learning, personal styles, and past experiences. Underpinning the EYLF learning philosophy is contemporary knowledge of early social and emotional development, encouraging educators to consider children’s learning and development within daily practice, curriculum decisions, planning, and reflection. In Victoria, where the current study was conducted, the Victorian Early Years Learning and Development Framework, aligned to the pedagogy of the EYLF, also informs the practice of Victorian professionals working with young children [ 48 ].

1.2. The Present Study

National policy and frameworks set a clear expectation that Australian educators foster children’s social and emotional competencies. However, many educators have not received formal preservice or professional learning in SEL or strengthening children’s social and emotional capabilities through teacher–child interactions [ 41 , 49 , 50 ]. Furthermore, little is known about educators’ perceptions of how they encourage SEL within the early learning environment, and there lacks research investigating the barriers and enablers for SEL delivered as part of everyday ECEC practice.

To inform the development of an intervention to support educators to foster children’s social and emotional development in Australian early childhood settings, an understanding of educator knowledge and perceptions of their current practice was needed. Exploration of educators’ perspectives regarding children’s social and emotional development and the role they play could uncover important strengths and limitations in current practices, highlighting opportunities to support the sector to improve outcomes for young children.

The aim of this study, therefore, was to examine educators’ perspectives on children’s social and emotional development within the ECEC environment, the approaches educators use to encourage children’s social and emotional skills, the enablers and barriers for educators in fostering social and emotional skills within their classroom, and the supports that could strengthen practice across the sector. To address this topic in depth, a qualitative design with semi-structured interviews and focus group discussions was adopted.

2. Materials and Methods

2.1. participants.

A convenience sample of 30 professionals working within the ECEC sector were recruited to participate in this study [ 51 ]. Participants included early childhood educators working in kindergarten and long day-care rooms from four Melbourne-based ECEC providers (n = 20), 5 non-teaching staff who held a leadership or executive management position with oversight of ECEC service provision, 3 researchers with expertise in early child development within ECEC, and 2 staff from non-government agencies with knowledge or involvement in efforts to increase early social and emotional development. These non-teaching professionals were included to provide further insight and validation of educators’ perspectives. A list of potential participants was generated by the research team and invited to participate via email. The demographic characteristics of participants are provided in Table 1 . The ECEC providers who participated in this study manage services within culturally diverse communities across the Greater Melbourne region.

Demographic characteristics of the participants.

2.2. Interviews and Focus Group Discussions

This study included both individual in-depth telephone interviews (n = 13) and in-person focus group discussions (n = 17). The inclusion of individual interviews and focus group discussions was informed by the availability and preference of participants. In-depth interviews were carried out with 13 professionals. Participants were provided a Plain Language Statement from the research team via email. Where informed, written consent was provided, an interview was conducted via phone by a member of the research team (CB). Each interview was audio-recorded. While recognising in-person interviews are often considered the gold standard [ 52 ], studies show telephone interviewing can offer an effective mechanism for data collection [ 53 , 54 , 55 ]. In one of the four participating ECEC centres, educators were invited to take part in a focus group discussion with their peers during a planned professional development session. All educators received a Plain Language Statement and a member of the research team described the project. Educators (17 in total) who provided informed, written consent were separated into three groups. A member of the research team facilitated each group discussion using the interview schedule, which was audio-recorded.

Interview questions were designed by the authors of this study. The topics in the interview guide (provided in Supplementary Materials ) related to participants’ knowledge of children’s social and emotional development in early childhood, approaches utilised to support children to develop both socially and emotionally in ECEC settings, perceived barriers to SEL, and potential pathways to overcome these barriers. The structure of the discussions included an introductory statement on each topic (knowledge, approaches, barriers, and pathways), followed by a series of open-ended questions. Ethics approval to conduct the study was granted by the Deakin University Human Ethics Advisory Group.

2.3. Analysis

Inductive thematic analysis was used to identify the patterns and themes reported [ 56 ]. Our analyses were guided by the approach used by O’Connor, Nolan, Bergmeier, Williams-Smith, and Skouteris in their qualitative study investigating early childhood educator perspectives of supporting parent–child relationships and children’s social and emotional development [ 57 ]. Specifically, the five phases of inductive thematic analysis used were: (i) become familiar with the data; (ii) generate initial codes; (iii) search for themes; (iv) review themes; and (v) define and name themes [ 56 ]. Interviews and focus group discussions were transcribed verbatim. Two researchers (CB, AO) independently read, re-read, and coded 20% of transcripts to ensure the identification of consistent themes. Each transcript was read multiple times and initial codes identified. Similar initial codes were then grouped into more general themes, guided by the study aims. An Excel spreadsheet was used to assist with data management, coding, and analysis. Researchers compared and refined codes, themes, and subthemes, and any differences in independent coding were resolved by discussion. One author (CB) coded the remaining transcripts according to the coding structure. Members of the research team then reviewed and cross-checked codes, themes, and subthemes to ensure accurate coding of participant perspectives.

Four core themes emerged from the analyses, described in detail below, relating to: (1) educator knowledge; (2) mobilising knowledge—social and emotional learning is embedded within interactions; (3) barriers—capacity and capability; and (4) strengthening educator skill—building knowledge through practical strategies. Quotes are verbatim comments from participants (E = Educator, individual interview, FG = Educator, focus group, and P = ECEC professional in a non-teaching role).

3.1. Educator Knowledge

Participants referred to a broad range of competencies to describe early social and emotional development. Social development was recognised through prosocial interactions and communication with peers, caregivers, and groups, ability to communicate own needs, and confidence to separate from parents or caregivers. Emotional skills included understanding, labelling, expressing, and regulating emotion, recognising emotion in others, and displaying empathy. Self-awareness and identity, confidence, responsible decision making, resilience, and coping were also identified. Professionals who were not employed directly within the classroom (i.e., ECEC leaders, researchers, and program managers) were more likely to describe social and emotional development as the demonstrated growth in capabilities against expected milestones or norms, compared with educators who described observed behaviours and reflected on their own encounters and experiences working with children. Only two participants discussed the relationship between social–emotional development and mental health; however, all recognised social–emotional functioning as one of the most important areas of focus for ECEC, and foundational for future development:

Really for me social and emotional development is the most important thing to focus on for young children, I think all of the academic stuff will come if they have the right sort of social and emotional development [E08]

When asked to describe the factors that influence children’s social and emotional skills, educators and other ECEC professionals referred to individual, interpersonal, and environmental aspects. At the individual level, child temperament, communication skills, stage of development, confidence, and resilience were identified. Most emphasised the importance of secure, consistent relationships with parents and caregivers, as well as other adults outside the family. In addition, organisational and environmental factors were acknowledged in many interviews as important determinants of social and emotional growth, including the home environment, general surroundings and experiences, cultural influences, high-quality early years learning programs, and exposure to environments that encourage exploration.

Participants pointed to various indicators of early social challenges. Behavioural problems including aggression, attention seeking, lack of initiative, and excessive physical expression were highlighted, as well as difficulty engaging in prosocial interaction and play, evident through high levels of conflict, lack of confidence, and social disconnection. A number of educators identified difficulty separating from parents, internalising behaviour, over-reliance on the educator, and speech and language delays as indicative of broader social difficulties. Similar themes were identified as markers of emotional problems. Several respondents also referred to dysregulated emotional responses as an important indicator of potential emotional challenges. ECEC professionals recognised the need to consider children’s behaviour in terms of what would be expected of a child that age, as well as the “normal” behaviour of the individual child.

Educators reported that they derived knowledge through structured learning experiences such as pre-service education, professional development, online training, and conferences, as well as educator-led learning through internet and print research, sourcing journal articles, and referring to theory. Many discussed drawing on their experiences in the early learning environment, working with children and families with diverse and individual needs, knowledge gained through the trial-and-error nature of the ECEC educator role, observation of their peers, insights from parents, knowledge gained from being a parent themselves, and interaction, discussion, and reflection with colleagues:

It’s talking amongst our peers too, and observing, and learning as you go along with the children [FG5]

Further, several highlighted the benefits of working closely with other professionals, including preschool field officers and early intervention services who can provide targeted and intensive strategies and assistance. One service offered educators monthly consultations with a clinical psychologist. During each session, an educator presented on a child exhibiting difficult or challenging behaviour. The group then worked together on strategies, and the psychologist offered input and advice in relation to mental health and possible influential family factors.

Educators were asked if they used a curriculum to support children’s social and emotional development. Responses were mixed. Several noted their practice was guided by the EYLF. Others did not use a specific curriculum but indicated practices to support social and emotional development were embedded within a shared philosophy and approach, experience and understanding of the dynamics of the children and group, planning for children’s learning, reflection, and professional development. A small number of respondents suggested they would welcome specific SEL curricula:

I think a curriculum would be a great thing, because then you could be quite sure what all children are getting…. all the children would have the same foundation [E08]

I would say it’s possibly the forgotten area a little bit. I think there’s a big focus on literacy, a big focus on numeracy, STEM is the big buzz word at the moment, that everybody is focusing on, which is fantastic but as these things come into fashion, some of the other things fall off a bit and I think because social and emotional [development] is different, I don’t think there is a one size fits all…… just from an intentional teaching perspective, I think it’s something we could definitely do some more work on [E14]

3.2. Mobilising Knowledge—SEL Is Embedded within Interactions

Participants described various approaches to support children’s social and emotional skills. These were embedded within relationships and interactions with children and families.

3.2.1. Educator–Child Relationship

The educator–child relationship was widely acknowledged by educators and other professionals as critical to children’s development. Through a responsive and nurturing relationship, educators “tune into” children, gaining knowledge and understanding of each child’s individual needs. They can then identify concerns quickly and predict possible future behaviour. Staff from ECEC services (both educators and management) described this relationship in terms of attachment theory, emphasising that educators offer security by building trust and being emotionally available. One educational leader noted how this secure and safe base allows children to feel supported and build confidence as they experience “big feelings” and practise the skills to master them; the conversations children have with educators help them to make sense of what they are feeling.

I think it’s just really being available to the children, so really being in tune with them, to their emotions and being emotionally available yourself so that you can respond to children appropriately, you know you can support them through managing their emotions appropriately [P03]

3.2.2. Supporting SEL through Everyday Interactions

Targeted strategies to support SEL were embedded within everyday experiences and interactions, during child-directed play and learning, guided play and learning, and adult-led learning. Educators discussed utilising a broad range of approaches tailored to children’s needs; however, there was variation in the breadth of strategies identified across interviews. As noted by an ECEC leader:

Supporting children with social and emotional [development] shouldn’t sit separate to what we do every day with every child…it’s embedded in what we do for every child [P01]

Educator role modelling was identified as especially beneficial for children experiencing behavioural difficulty. Educators discussed allowing children to observe and absorb appropriate behaviour without expectations and gradually participate at their own pace. Many educators also discussed assisting children in identifying and labelling their emotions, understanding there is nothing wrong with their feelings, and building strategies and skills to move forward. The following comment is representative of findings:

We label the emotion, “I can see you’re really angry that your friend walked away from you, and I can see that made you upset, let’s try and solve the problem together” and getting in the moment rather than teaching on the mat [FG5]

Tapping into teachable moments during child-led play was identified by several participants, who recognised the learning that occurs through responsive interactions and gentle conversations. Individual and small group discussions allow educators to work alongside children, talk about how they are feeling, and help them to identify the words to explain their emotions. Educators also described working with children through adult-led teaching, using social stories, structured activities, songs, books, games, puppets, and role play. As one educator noted, stories are an especially effective way to help children to identify with what might be happening around them, and how they and others might be feeling, thereby starting to develop empathy:

Children are quite egocentric and our role is to get them to start thinking about how our behaviours and actions can affect other people as well [E14]

3.2.3. Physical Environment Supports SEL

The influence of the layout and organisation of the preschool classroom on children’s development was also highlighted. Educators noted visual aids (e.g., visual schedules and visual cards) are especially helpful for children with additional needs (requiring or able to benefit from specific considerations or adaptations). These can assist children in understanding and predicting what the day will look like, self-regulating, and controlling their emotions. Educators used the physical resources and materials within the room as a behaviour management technique—for example, redirecting children to activities or play stations which educators knew were enjoyable for that child, and setting up play spaces that responded to different sensory needs. The variety of play spaces and activities available encourage creativity, social interaction, and quiet time. As one educator explained:

I think everything in a kindergarten setting is set up to help children socially and emotionally, from the types of play spaces that are provided, they’re active, there are quiet play spaces, there’s play spaces for one child, there’s places for four children, everything in the room is set up to help them engage socially in their environment and with the people around them [FG4]

3.2.4. Working with Caregivers

Participants consistently emphasised the importance of working in partnership with caregivers to support children’s social and emotional functioning. Parents were recognised as the most important influence on their child’s life, and therefore, any strategies implemented in the preschool classroom are unlikely to be effective without reinforcement and consistency at home. Educators built relationships with families, recognised the individual needs of the child and family, and worked with the family to identify and implement strategies. ECEC centres use a range of approaches to build this partnership, including intake interviews, questionnaires, meetings, making parents feel welcome when dropping off and picking up their child from the centre, online learning stories (written observations and photographs shared with caregivers via an online system), and home visits.

3.3. Barriers—Capacity and Capability

Several barriers to supporting social and emotional skills were identified: a lack of time to focus on SEL, group size, educator capability, confidence and training, high staff turnover, difficulty engaging with families, perceived lack of recognition of the educator’s role, and a lack of consistency across services. Most respondents identified that time constraints and high educator-to-child ratio (in Australia, centre-based ratio requirements are as follows: birth to 24 months: 1:4, between 24 and 36 months: 1:4 or 1:5 depending on the state, over 36 months and up to preschool age: 1:10 or 1:11 depending on the state) negatively influenced educators’ ability to embed social and emotional learning. Several emphasised children need one-on-one time to work through emotions and challenges at the time they experience them, but this is often not possible due to competing priorities. Challenges associated with a perceived increased proportion of children attending ECEC services with additional or undiagnosed additional needs were identified. These included ensuring the service caters to the needs of all children, the time required to complete documentation to access additional support, and the risk of overlooking the needs of both children experiencing social, emotional, and behavioural difficulties as well as typically developing preschoolers.

Educator capability to nurture social and emotional skills was identified as a potential barrier in several interviews, with respondents acknowledging capability is shaped by preservice education and professional development, experience in different settings, time in the sector, and motivation. Two participants in ECEC leadership positions suggested a lack of confidence and self-esteem can influence educator practice, with one noting educators often develop attachments with children and will instinctually know how to support social and emotional skills but lack confidence and belief in the importance of their role. Gaps in educators’ skillset were also identified by a small number of respondents, specifically working with children experiencing social and emotional difficulty, and engaging with parents whom the educator may perceive as difficult to communicate with. Educator motivation to up-skill and explore the resources available, and their ability to be mindful and reflective in prioritisation of activities, was also noted as a potential barrier (e.g., what is most important to do for the child). Participants working directly with children did not specifically discuss their capability to attend training. A number of respondents suggested tertiary training programs needed to place greater emphasis on social and emotional competencies, and evidence-based approaches to translate concepts to effective practice.

Notwithstanding the importance of working in partnership with families, engaging with caregivers regarding children’s social and emotional development was emphasised as a significant challenge, particularly due to parental expectations. For example, a number of educators noted a disconnect between some parents’ focus on literacy and numeracy, compared to social and emotional development, which was described as the critical developmental focus from the educator perspective. Educators can find it difficult to communicate the value of SEL to parents, while being respectful of their culture and beliefs. One educator described a lack of interaction with parents as a barrier to learning more about their child. In addition, the complexity of working with parents of children who may be experiencing difficulties was noted, particularly when the educator perceived parents were not ready or able to engage in a dialogue or accept that their child may be having difficulty.

And a lot of families they don’t get it, that social and emotional is so important for school [it’s language and literacy] that if they’re not coping and they’re not managing at school just with their emotions and socially, they’re not going to be happy therefore they’re not going to learn and they don’t understand that [they don’t make that connection] [FG4]

Sometimes it’s hard to have that initial conversation with the parent, so you just have to know and understand what the family structure is about because you can’t sort of go in and go “your child’s got…”, you have be quite tactful [respectful]…One of the children in my room, it took me 12 months to have that conversation because it was never ever the right time and then one time it happened and I was there ready to go, you know [FG5]

Educators and other professionals identified an extensive range of programs to support SEL within preschool. The KidsMatter Early Childhood Framework [ 58 ] had been utilised by several participants. Other programs which centres were currently or had previously implemented included Animal Fun [ 59 ], 1-2-3 Magic [ 60 ], Circle of Security [ 61 ], PALS Program [ 62 ], and Early ABLES [ 63 ]. However, some highlighted the volume of programs available and increasing expectations placed upon educators meant programmatic approaches were less likely to be embedded and sustained within ECEC services over time:

…you know every couple of years there’s a revolution in childcare, everyone’s got a new idea and everyone’s got to implement the new idea and then you go back to 10 years ago, and go this worked then [FG4]

Two educators noted the approach to implementation was ad hoc, with classrooms within the same centre independently selecting certain components or themes each year. Another respondent (researcher) discussed the lack of clarity regarding what a high-quality SEL pedagogy looks like, suggesting if you asked a group of educators to describe the key elements of SEL, the key capabilities, progression, and pedagogies that support learning, you would likely receive different responses:

Educators can’t pick up a journal and see that example, a really well targeted description of what capabilities in SE look like, progression low to high, what effective pedagogy looks like, what effective measurement and clinical practice looks like [P10]

3.4. Strengthening Educator Skill—Building Knowledge through Practical Strategies

Participants identified a need for support that responds to the unique context and requirements of ECEC centres, aligned with the National Quality Standard and EYLF, and not requiring additional time or resources to implement. That is, resources that are accessible, easy to use, and can be embedded into daily practice and routines, as reflected in the following comment:

It needs to be something that’s easy to implement, that’s quickly accessible, that you can put into your program without having to think too much about it, so it naturally fits in, it links it with everything that’s already existing, it links with the NQS, it links with the EYLF, it links with all those things, but it’s not something else to learn, we don’t have to go oh my gosh, it’s another box we have to tick, it’s another thing we have to meet, it’s another criteria that has to be acknowledged in the program and then adding to it, it would be nice if it just fit nicely into the social and emotional area in everything [FG4]

Up-skilling educators in practical strategies and techniques that foster SEL was suggested by several participants, who noted that tools need to respond to the different ways educators build knowledge, considering sensory learning styles and delivery modalities, for example:

Educators always want practical stuff. Tell me how to do it, they like to have the information, but then give me the strategies, what do I have to do? So, practical stuff is really important, whether that’s conversation starters, actual sentences that you can use with children to support that, and I think video can be useful as well, just seeing how an educator does approach that kind of development in action is often, I think useful as well [E14]

Coaching and mentoring were highlighted as effective in building capability within ECEC classrooms. Two ECEC providers had implemented a mentoring program to nurture and develop educator practice, with participants noting more was needed. Increased opportunity to reflect, collaborate, and share knowledge with team members was suggested. Greater focus on explicit social and emotional skill instruction in addition to warm and responsive play, approaches tailored to the developmental stage of the child, and greater emphasis on collecting and interpreting data relating to child progress were also raised as mechanisms to strengthen educator practice and child outcomes.

4. Discussion

The current study examined ECEC professionals’ understanding of early social and emotional development, the practices and approaches that encourage children’s social and emotional skills, the enablers and barriers for early childhood educators in fostering skill growth, and the additional resources and support that could assist in this respect. The findings suggest children’s social and emotional development is at the forefront of educator planning, practice and reflection, supporting findings from similar research with early childhood educators in the United Kingdom [ 42 ], United States [ 41 , 43 , 64 ] and Singapore [ 65 ]. Participants unanimously endorsed the role of early childhood educators in fostering children’s social and emotional skills, in partnership with families, as the building block for healthy learning and development.

Social–emotional competence is a multifaceted concept based on emotional, cognitive, and behavioural knowledge and skill [ 66 ]. The current study suggests early childhood educators recognise this breadth and complexity of social–emotional skills, and the linkages that exist between social and emotional competencies. For example, several participants discussed the importance of the secure attachment that can form between an educator and child, and how this encourages the child to feel safe and explore the social world and provides a model for social interactions on which to build future relationships.

Participants described utilising a broad range of approaches to support children’s social and emotional development, which could be grouped into four categories: (1) nurturing and responsive educator–child relationships; (2) supporting SEL through everyday interactions and practice; (3) utilising the physical environment to encourage SEL; and (4) working in partnership with caregivers. Similar groupings have been reported by other researchers who have classified SEL strategies in early childhood settings. For example, O’Conner and colleagues [ 67 ] identified three classroom factors (beyond using a SEL curriculum) associated with social and emotional skill development for children aged three to eight years: positive classroom climate (modifying the physical space and materials, classroom management strategies and routines, and a supportive and emotionally positive environment), instructional strategies (modelling, reacting to, and instructing about children’s emotional expression) and teacher’s own social and emotional competence (supported through direct training, reflective supervision and relationship building, and stress-reduction strategies).

Educators in this study appeared to value and utilise programs and interventions to support SEL at the class-wide level, yet perceived embedding SEL into everyday interactions as the most effective way to foster children’s strengths and meet the unique needs of each child in the moment. Hollingsworth and Winter [ 43 ] similarly reported teachers foster prosocial skills by setting the tone of the social environment and responding to situations as they arose. This points to the potential utility of both universal class-wide SEL intervention in addition to fostering every child’s SEL through tailored and responsive supports embedded within interactions. Knowledge and insight from families was also recognised as vital for children’s SEL. Educators work with caregivers to understand the unique needs and context for each child, identify proactive, preventative, and early intervention strategies, and scaffold learning across home and service settings. In early childhood, family–child relationships are the primary source of learning experiences. SEL activities in the preschool environment can be reinforced and enhanced by enlisting families as partners in the overall SEL approach [ 28 , 68 ].

The findings of this research, however, indicated inconsistency across ECEC providers in the variety and type of strategies educators use to support social and emotional skill growth. There may be a lack of guidance on translating the EYLF into practice with regard to preschoolers’ social and emotional development. As a result, children’s exposure to high-quality interactions, strategies, and techniques that facilitate SEL is influenced by the knowledge, skill, and confidence of educators, and the culture, leadership, philosophy, and structural quality of each service, including educator-to-child ratio, space, resources, staff qualifications, programs, and curricula. This aligns with a recent exploration of Australian early childhood educators’ perceptions of the EYLF. This research reported educators are engaged with the content but seeking ways to transform the professional concepts embedded in the EYLF into their practice [ 69 ].

Teaching in early childhood is often characterised by continuous analyses of children’s understanding, and decisions about curriculum and pedagogy. This highlights the importance of understanding the knowledge educators draw on in their decision-making processes [ 70 ]. Regarding how educators understood and conceptualised social and emotional development, and how they perceived they supported children’s social and emotional skills, participants in this study appeared to draw on both explicit and tacit knowledge. Explicit knowledge refers to objective and rational knowledge that can be easily transferred through words and sentences [ 71 ]. It is knowledge that educators are consciously aware that they are using and that can be documented and communicated—for example, the EYLF, manualised SEL programs, and the step-by-step description of strategies where educators could clearly articulate why they were using the approach and the desired outcome for children. Tacit knowledge, by contrast, is personal and subjective, relating to the mental models, values, beliefs, perceptions, insights, and assumptions that educators form when working with children and families over time [ 72 , 73 ]. This knowledge may be more difficult to transfer to others. Across several interviews, educators suggested their practice was based in their knowledge and relationships with children, but they found it challenging to describe the specific strategies and techniques applied, which may reflect their tacit knowledge base.

Making educator knowledge explicit is critical to support teacher learning [ 74 ]; however, research indicates much teacher knowledge is implicit and not articulated [ 75 ]. Reliance on tacit knowledge also limits the opportunity to replicate high-quality, evidence-based practice across settings. The findings of this study highlight that although social–emotional development is a priority for early years professionals, there is inconsistency in training and application of support to enable this to occur. ECEC professionals seek practical strategies that will support them to strengthen children’s social and emotional skills through their everyday interactions and practice. Building upon educators’ practical (tacit) knowledge through the provision of explicit, documented techniques tailored to the breadth of strengths and needs within the room could allow educators to integrate formal learning with personal experience. More could also be done to assist educators in connecting with families to foster social–emotional development within the home environment.

5. Study Limitations

There are several limitations to this study. First, it relied on a convenience sample. While the authors invited educators from several different ECEC providers and included non-teaching ECEC professionals to validate the findings, these cannot be generalised, as is the nature of qualitative research. This approach was, however, appropriate to address the research aims, representing the perspectives of the participants, and feasible within the time and resourcing constraints of the study. Second, the research methodology included both in-depth interviews and focus group discussions. Recognising it would have been preferrable to individually interview all participants, this format was most feasible for participants, and a pragmatic decision to integrate both methods was made. Furthermore, this research focused on educators’ perceptions of supporting children’s social and emotional development in the ECEC environment. This is important because educators’ perceptions and judgments affect teaching practice. However, it is not possible to draw conclusions regarding their actual practices and behaviour. It would be beneficial to conduct observations of educators in the early learning classroom to better understand what teachers do in practice. Finally, while this study provides insights on the perspectives of Australian ECEC professionals, we did not explicitly explore how participants’ beliefs and practices were informed by either their own cultural background, or the cultural background of children in their care. While beyond the scope of the current study, this would be valuable to consider in future research.

6. Conclusions

This study adds to the literature through its focus on how the Australian ECEC sector approaches SEL in preschool classrooms. Aligned to the EYLF, ECEC professionals uniformly conceptualised children’s social and emotional skills as critical to ongoing development and a primary focus for the sector. However, findings suggest the breadth of strategies and techniques to support this development vary across organisations, influenced by a range of factors including structural quality, educator knowledge, skill and confidence, and qualifications and experience. Educators acknowledge trial and error is necessary in early years settings, and an approach that works for one child may not have the same impact or benefit for the next. Attention towards ensuring all children receive the type of interactions that will support positive social and emotional outcomes is warranted. Strengthening knowledge through a variety of explicit and practical strategies that can be embedded into daily practice was recommended by participants. These findings will inform the development of a pedagogical intervention to promote SEL and positive mental health in preschool classrooms and may offer valuable insights to support the pedagogical practices championed in Australian early learning policy.

Acknowledgments

The research team wishes to express their sincere gratitude to all participants, including early childhood educators, ECEC leaders, researchers and other professionals who took part in this research study and shared their valuable insights and experiences.

Supplementary Materials

The following are available online at https://www.mdpi.com/1660-4601/18/4/1530/s1 , Table S1: Interview Guide.

Author Contributions

Conceptualisation, C.B., H.S., H.M., A.N., and A.O.; methodology, C.B., H.S., H.M., A.N., A.O., and R.G.; investigation: C.B., H.S., H.M., and A.O.; validation, C.B., H.S., and A.O.; formal analysis, C.B., H.S., and A.O.; writing—original draft preparation, C.B.; writing—review and editing, C.B., H.S., H.M., A.N., A.O., R.G., K.J., A.I., and A.M.; supervision, H.S., H.M., A.N., A.M., and K.J.; project administration, C.B. All authors have read and agreed to the published version of the manuscript.

This research received no external funding.

Institutional Review Board Statement

Ethics approval to conduct the study was granted by the Deakin University Human Ethics Advisory Group- Health (ID: 39_2017).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

At the time this study was conducted, Claire Blewitt was engaged by one of the organisations included in this study as a Research Assistant. The role was not within the Early Years team, or with any of the educators or other professionals involved in this study. Kylie Jackson is employed by one of the ECEC organisations who participated in this study. Her role is not within the Early Years team, or with any of the educators or other professionals involved in this study. Helen Skouteris has an academic relationship with some organisations included in this study. All other authors declare they have no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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Understanding Research in Early Childhood Education

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Understanding Research in Early Childhood Education: Quantitative and Qualitative Methods prepares readers to be informed consumers of early childhood research. Rather than following the traditional format of covering quantitative and qualitative methods separately, this innovative textbook offers side-by-side coverage and comparison about the assumptions, questions, purposes and methods for each, offering unique perspectives for understanding young children and early care and education programs.

Understanding Research in Early Childhood Education is broadly based across the major research paradigms, and numerous examples are offered throughout the text. Through the use of this book, students will be able to more knowledgeably read, evaluate, and use empirical literature. These skills are becoming more important as early childhood educators are increasingly expected to use evidence-based research in practice and to participate in collecting and analyzing data to inform their teaching.

TABLE OF CONTENTS

Chapter | 6  pages, introduction, part | 100  pages, structures of research, chapter | 13  pages, how do we know, chapter | 10  pages, the culture and context of research in early childhood education, chapter | 16  pages, methodologies, chapter | 12  pages, qualitative research, chapter | 15  pages, analyzing and reporting findings in qualitative research, quantitative research, chapter | 20  pages, statistical analyses in quantitative research, part | 58  pages, examining research questions, chapter | 11  pages, research questions about children, research questions about the adults in children's lives, research questions about classrooms and curriculum, research questions about institutions and policy, teacher research, part | 6  pages, chapter | 4  pages, research and practice.

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Understanding quantitative and qualitative research in early childhood education.

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Home / Publications & Research / Early Years Development / Understanding the early years workforce: Qualitative research findings

Understanding the early years workforce: Qualitative research findings

A new report from the National Centre for Social Research (NatCen), produced as part of a programme of research led by the Education Policy Institute (EPI) and funded by the Nuffield Foundation, investigates the barriers and incentives in recruitment, retention and development within the early years workforce.

Through detailed interviews with nursery staff, managers and childminders, the report identifies:

• The different “professional journeys” typically taken by early years workers
• The attributes practitioners identify as indicators of quality in the early years workers
• The barriers to staff recruitment and retention, and access to continuing professional development (CPD) within the sector

Based on this analysis, the research identifies three areas for policy focus:

• Improving pathways for the retention and progression of early years staff
• Professionalising the early years workforce
• Enhancing the status of the early years sector

You can access the full report here .

This research is the third strand of a wider research project, funded by the Nuffield Foundation . The project consists of 4 research strands in total:

• Strand 1 , The early years workforce in England (January 2019) , identified variations in qualification levels, pay, and demographic background within the early years workforce, and between it and the rest of the education system. The report raised concerns around an ageing, low-paid early years workforce which is often reliant on benefits.
• Strand 2 , Early years workforce development in England: Key ingredients and missed opportunities (January 2020) investigated the impact of four major early years policies from the last 15 years on the qualifications of early years workers. It found clear evidence of a positive effect of one major policy, and recommended a renewed commitment to improving staff skill levels and the establishment of a long-term vision for sector development.
• Strand 4 (Summer 2020) of this research will investigate how workforce characteristics, and particularly qualification levels, relate to children’s outcomes, investigating workforce qualification at a level beyond “graduate v non-graduate”.

Further EPI early years research

• The latest EPI Annual Report has found that the disadvantage gap (the difference in progress between disadvantaged and non-disadvantaged children) is already 4.5 months by the time children finish early years education, with this gap continuing to widen as children make their way through the education system.
• Previous EPI research in early years has identified key indicators of workforce quality , investigated the impact of early years entitlement policies upon take-up rates, and compared the working conditions, qualifications and demographics of the workforce to those working in retail.

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Understanding the Early Childhood Workforce: Qualitative research findings

In recent years, although there has been a sizable increase in take-up and provision of early years education in the UK, the sector has struggled to recruit and retain practitioners. This has been partly driven by limited development opportunities and low pay. This qualitative study is part of a multi-strand research project conducted in collaboration with the Education Policy Institute (EPI) and funded by the Nuffield Foundation. The study sought to improve understanding of recruitment and retention challenges in the sector and explore perceptions of ‘quality’ within the workforce.

Methods The research comprised two elements carried out concurrently:

• Provider case studies – 9 settings were purposively selected as case studies. Across these 23 in-depth interviews were conducted with managers and practitioners.
• Timeline interviews – 19 in-depth interviews tracing professional journeys into and through the sector were conducted with early years professionals

Jonah Bury, Molly Mayer, Fiona Gogescu, Tom Bristow, Fatima Husain

Preliminary developmental challenges of children at risk for specific learning disabilities: Insights from parents and teachers—a qualitative study

• Open access
• Published: 26 June 2024

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• Aslı İzoğlu-Tok   ORCID: orcid.org/0000-0002-0063-8448 1 , 2 &
• Özcan Doğan   ORCID: orcid.org/0000-0002-3006-8159 2  

This study aims to uncover the preliminary developmental challenges experienced by children from infancy to their primary school years, who are subsequently diagnosed with specific learning disabilities during their primary education. The ultimate goal is to develop an item pool to identify early symptoms of specific learning disabilities. This qualitative descriptive design study employed semi-structured interviews with 20 participants, comprising both parents and teachers of 10 children aged 8–11. The interviews lasted between 45 and 60 min. To ensure the research's quality and reliability, we applied evaluation criteria and performed six-stage thematic analysis framework. The results indicate that children experienced developmental difficulties from infancy to preschool period that impacted their social-emotional development, language and communication, motor and self-care skills, as well as their perception, memory, attention, and self-regulation capabilities. These challenges were exacerbated during the school years by motivation-related issues. Parental observations primarily highlighted difficulties in language and communication, such as pronunciation, initiating conversations, and speech, during the first three years of life. Significant issues in social-emotional development included introversion, a need for physical contact, challenges in maintaining relationships, and adherence to rules. These challenges emerged during the first three years of children and progressively worsened across all developmental domains. This study contributes valuable insights into the literature by providing past observations from parents and teachers, thus enhancing understanding of the preliminary developmental challenges faced by children at risk of specific learning disabilities.

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Introduction

SLD is classified as a neurodevelopmental disorder characterized by significant disparities between intelligence scores, which are within the normal or above-normal range, and performance in key academic areas such as reading, mathematics, and written expression (American Psychiatric Association [APA], 2013 ; Melekoğlu, 2020 ). SLD encompasses three primary types: dyslexia, dyscalculia, and dysgraphia. Diagnostic criteria are drawn from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the International Classification of Diseases (ICD-10), and the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (APA, 2013 ; World Health Organization, 2019 ).

Originating from neurobiological factors, SLD's management focuses on early educational interventions rather than pharmacological treatments, highlighting the importance of early assessment and intervention (Thapar et al., 2017 ). The reason for this is that if children are not intervened in the early period, the difficulties they experience will increase (Sullivan et al., 2017 ; Zhang et al., 2020 ). Therefore, intervention services provided in the early period can also contribute to reducing the negative effects (Lange & Thompson, 2006 ). The importance of the situation is further underscored by the prevalence of SLD.

SLD was identified as the most common disability among students aged 6 through 21 in the U.S., with 37.1% of those receiving special education services diagnosed with SLD (U.S. Department of Education, 2021 ). Additionally, 15% of the European population is affected by SLD (Institute of Entrepreneurship Development, 2019 ). Despite these striking rates, Turkey reports a notably lower prevalence rate of approximately 3%, highlighting a significant discrepancy in the identification and diagnosis of SLD, and pointing to a need for improved diagnostic tools and data collection methodologies (Melekoğlu, 2020 ). The fact that children at risk of SLD show similar characteristics to normally developing children makes early diagnosis even more difficult (Steele, 2004 ).

Research is advancing in early diagnosis by concentrating on identifying children at risk of SLD and preventing issues before they arise. Researches underscore the importance of early indicators in predicting future SLD, focusing on areas such as early literacy, rapid naming, phonological awareness, and working memory (Ozernov-Palchik et al., 2017 ; Snowling et al., 2019 ). Moreover, early quantitative challenges, such as deficiencies in understanding number relations, might lead to future difficulties in mathematics for children (Bull et al., 2021 ; Zhang et al., 2020 ). When viewed within the framework of developmental domains, early challenges in language, social-emotional development, psychomotor skills, cognitive development, and self-care skills are identified as predictors of SLD (Firat & Bildiren, 2024 ; İzoğlu-Tok & Doğan, 2022 ). International researches also focus on intervention programs (Almulla et al., 2021 ; Aunio et al., 2021 ; Sakellariou et al., 2020 ), development of identification tools (Flores et al., 2022 ; Hellstrand et al., 2020 ; Navarro Soria et al., 2020 ), and profiles of children at risk (Bonti et al., 2021 ; Quiroga Bernardos et al., 2022 ). These studies emphasize the critical role of early detection and intervention.

The situation in Turkey

In Turkey, the pathway to diagnosing SLD and providing special education services involves a multi-step process that engages both educators and medical professionals. Within the Turkish education system, primary education spans a four-year period following preschool, during which children undergo initial assessments. Notably, when special needs are suspected, classroom teachers play a pivotal role by referring children to medical or guidance and research centers for further evaluation. This diagnostic journey emphasizes the significance of teachers' insights into the children's academic and developmental profiles.

Specialized educational support requires obtaining a Special Needs Report for Children (SNRC), which is contingent upon a formal medical diagnosis. Importantly, the evaluation of a child's academic progress over a minimum span of six months forms a critical component of this diagnostic framework. Considering that the diagnosis process takes an average of one year, it is obvious that we cannot provide support to children in the early stages. However, both national and international research always emphasizes the importance of early detection (Chordia et al., 2020 ; Firat & Bildiren, 2024 ; Kaya-Döşlü & Bağlama, 2022 ; Roama-Alves et al., 2020 ; Thapar et al., 2017 ). Therefore, research on the characteristics of at-risk children is essential to inform the development of intervention programs, evaluation tools, and understanding children's profiles.

The current study

While existing literature underscores the significance of early identification of children at risk of SLD, there remains a noticeable knowledge gap regarding the characteristics of children in Turkey. This gap about which areas and what difficulties children experience is evidenced by the limited availability of early assessment tools (Melekoğlu, 2020 ). Therefore, the primary sources of information crucial for fill this knowledge gap are the child's parents and teachers. who possess invaluable insights into early indicators of SLD due to their extensive interactions with the child during the preschool and early school years. With this regard, this study aims to identify the difficulties experienced by children diagnosed with SLD in the preschool and school periods, with the ultimate goal of creating an item pool for identifying early symptoms of SLD. The quality of the relationship that professionals establish with parents and school personnel can affect the quality of the children's assessment process (Lange & Thompson, 2006 ). Engaging with families and teachers for their insights is deemed crucial for a comprehensive understanding of children at risk for SLD, informing strategies for health and education professionals to enhance early intervention services. By addressing these challenges, we expect that this study will enhance the comprehension of the challenges faced by children at risk of SLD, and facilitate the development of assessment tools and intervention strategies. This study offers comprehensive insights into the challenges faced by children, addressing the roles of adults both in school and at home. The research question regarding the challenges experienced by children with SLD in pre-school (0–3 years and 3–6 years) and school periods guided the study.

Study design

This qualitative study employed a qualitative descriptive design aimed at offering descriptions of experiences and perceptions, especially in areas with limited understanding (Sandelowski, 2010 ). This qualitative study utilized semi-structured interviews and thematic analysis to delve into the experiences and perspectives of parents and teachers regarding children’s developmental challenges from infancy up to the present. The reporting guidelines of “Standards for Reporting Qualitative Research- SRQR” (O’Brien et al., 2014 ) and “Consolidated Criteria for Reporting Qualitative Research- COREQ” (Tong et al., 2007 ) were followed. The study was adhered to a postpositivist paradigm. In the postpositivist paradigm, researchers integrate the diverse perspectives of participants rather than relying on a singular viewpoint and employ various validity approaches (Creswell & Creswell, 2017 ). Consequently, in this study, we brought together the perspectives of both parents and teachers and applied validity approaches.

Sampling and participants

Participants were selected through typical case sampling, a targeted method aimed at obtaining a representative cross-section of cases. For parents, the criteria were: (1) having a child diagnosed with SLD in primary school, and (2) no additional diagnoses besides ADHD, given its frequent co-occurrence with SLD (Araz Altay & Gorker, 2017 ). For teachers, we included those who taught the children of the interviewed parents.

The first author conducted interviews with 20 participants: parents and teachers of 10 children who are currently attending primary school. All participants, including the children, were monolingual Turkish speakers, hence the interviews were conducted in Turkish. Prior to conducting the interviews, arrangements were made to meet primarily with one parent-typically the mother due to their predominant role in care and education involvement. This selection was made acknowledging that recalling past experiences might be affected by the passage of time. Therefore, our focus was on the primary school period, during which the children were first medically diagnosed.

All educators involved were classroom teachers, with the duration of their acquaintance with the children varying due to school changes or different grade levels. Typically, classroom teachers remain with the same group of students from the first to fourth grade unless their assignment changes.

The size of the sample was determined based on data saturation and representativeness (Guest et al., 2006 ). Coding commenced concurrently with the interviews and persisted until the parents and teachers of the 10th child were interviewed. The decision to conclude the interviews was made when no new codes emerged, indicating that the data had reached saturation. Details on the participating parents (P) and teachers (T) are provided in Table  1 .

Recruiting participants

Approval was obtained from the [Blinded] University Clinical Research Ethics Committee (KA-19141), along with administrative permissions from the Turkish Ministry of National Education (MoNE). The first author contacted school administrators to introduce the study to parents and teachers, focusing on children diagnosed with SLD.

Interviews were initiated following verbal confirmations from parents and subsequent confirmations from teachers regarding the children's diagnosis and inclusive education status.

Written informed consent was then collected via Google Forms. Due to COVID-19 pandemic restrictions, interviews were conducted by phone from September to November 2020, with durations ranging from 45 to 60 min.

Developing interview schedule

We developed two semi-structured interview schedules, distinct for teachers and parents, informed by a comprehensive literature review on developmental stages. These schedules were then refined based on feedback from three faculty members specializing in special needs education. The interview for parents comprised eleven main questions across three categories: general information, past experiences, and current status. Parents were prompted with questions designed to elicit their insights and reflections on their children's development from infancy up to the present, including the diagnostic journey and aspects of school life (detailed in Appendix A). Similarly, the teachers' interview schedule featured six main questions, organized into the same three categories. Teachers, were questioned about the developmental traits, diagnostic procedures, school experiences, and peer interactions they've noted from the commencement of the children's primary education to the present (outlined in Appendix B).

To ensure the integrity and reliability of our research, we adhered to Lincoln and Guba ( 1985 ) criteria. The interviews were conducted with 20 participants, with the first author allowing flexibility in timing to enhance the credibility and internal validity. She probed further when responses were unclear, ensuring comprehensive understanding. The diverse perspectives from both teachers and parents enriched the internal validity. Data saturation was confirmed when no new information emerged from the interviews.

For external validity criterion, transferability , we meticulously outlined the inclusion and exclusion criteria, aiming to ascertain that our findings could be applicable in various contexts (Lincoln & Guba, 2013 , p. 103). Our methodical approach, from participant recruitment to the detailed explanation of our analysis process, supports the study's transferability. The coding process and its rationale are elaborated under the findings section, with clear definitions and descriptions to facilitate understanding.

Dependability was achieved through a rigorous and transparent process, defining key concepts like social-emotional and language development, motor skills, self-care, perception, memory, attention, and motivation based on prior literature. Each participant's experiences were deductively analyzed within these frameworks. An external researcher with expertise in early intervention and qualitative methods reviewed the themes, further validating the study's reliability by assessing code accuracy and researcher impartiality (Lincoln & Guba, 1985 ).

Confirmability and objectivity were reinforced through data triangulation, collecting data from multiple sources—teachers and parents—to verify consistency across different perspectives (Lincoln & Guba, 2013 , p. 106). The first author meticulously transcribed interviews, with all data securely stored in MAXQDA qualitative research software (version 20.4.1), ensuring a robust framework for our qualitative analysis.

Researcher background

In qualitative research, the experience of researchers is pivotal for knowledge generation (Creswell & Creswell, 2017 ). Our team, composed of academic staff, undertakes clinical studies to assess and support children and offers family counseling services focused on child development. Acknowledging the influence of our backgrounds and experiences, we endeavored to mitigate potential biases. We documented our initial assumptions, insights from the literature, and our theoretical and practical expertise. Engaging in continuous reflection and dialogue throughout the study (Watt, 2015 ), we maintained a postpositivist perspective, anticipating a variety of developmental challenges. For instance, we defined the possible areas we expected to emerge by keeping in mind that there may be different areas of development where difficulties may arise.

Data analysis

Following Braun and Clarke ( 2021 ) six-stage thematic analysis framework, our approach facilitated both inductive and deductive analysis. To prevent data loss, the first author meticulously transcribed the interviews, resulting in a comprehensive document of 231 pages. This document was analyzed using MAXQDA qualitative research software, starting with a thorough reading to gain an overall understanding of the data.

In the first procedure, familiarizing with the data , we read transcripts to look at the data holistically. In the second procedure, systematic data coding , we read and coded the transcriptions line by line. We outlined the distinct early developmental characteristics observed by teachers and parents in children diagnosed with SLD compared to peers. For example, one parent commented: “ He was having too many accidents compared to his peers. He was constantly getting injured. We never missed a visit to the hospital anyway. He still has a scar on his eyebrow. He burned his arm. So, he was always clumsy. He loses his balance and falls on the straight road.” . We coded this comment as ‘difficulty with balance skills.’

In the third procedure, generating initial themes from coded and collated data , we organized the codes into potential themes and sub-themes, ensuring all related codes were considered. In the fourth procedure, developing and reviewing themes , we checked coded quotations, potential categories, and themes to see if they were related. We made additions or substructions during this control process. A thematic map was created by establishing a relationship between quotation, code, category, and theme. In the fifth procedure, refining, defining, and naming themes , we named each theme so that it could create a related story for the research. In the sixth procedure, writing the report , we determined compelling quotations for inclusion in the report. After compiling the study into a report in Turkish, we translated the text into English with an expert support.

Our analysis, presented through thematic maps, adopted a developmental lens, offering a comprehensive view of the children's developmental indicators for SLD from infancy to the school years. This approach, grounded in a developmental model (Kass & Maddux, 2005 ), aimed to present a holistic understanding of the identified early symptoms of SLD.

Declaration of generative AI and AI-assisted technologies in the writing process

While composing this work, the authors used Scholar Chat-GPT by Open-AI in order to improve the readability and use of existing language. It is crucial to emphasize that Scholar Chat-GPT was solely employed to enhance the quality of the writing and facilitate better communication of ideas, and not to generate new content. Following the application of this tool, the authors reviewed and edited the content as needed and takes full responsibility for the content of the publication.

Four maps were created regarding the early symptoms after the data analysis of the interviews. In these maps, categories or periods are indicated by different symbols.

Early developmental symptoms of SLD

In Map 1 , the early developmental symptoms of SLD in the preschool period fall under nine categories: social-emotional development, language and communication development, motor development, self-care skills, perception, memory, attention, self-regulation, and other difficulties.

From ages 0–3, parents frequently noticed issues with their children's language and communication development. Problems with speaking, pronunciation, and starting conversations were common in this age group. After turning three, kids started showing difficulty in expressing their feelings and thoughts, often relying on fillers like "err" and "umm." One parent (P9) shared about their child's struggle to initiate conversation:

“When he wanted to be friends and get closer, but he did not get a reaction, he gave up. So, he was very eager to have friends, but he had difficulty establishing that friendship. He was not a child who communicated a lot with his friends, nor was he social.”

For social-emotional development, parents noticed early symptoms such as a need for physical contact and introverted behavior from ages 0–3. Between the ages of three and six, parents reported their children facing challenges with following rules, sustaining peer relationships, making friends, experiencing low self-esteem, becoming victims of bullying, displaying emotional overreactions, and preferring to play alone.

In the motor development category, parents reported that their children, between the ages of 0–3, encountered difficulties with activities requiring coordination, speed, or strength. They described these challenges as clumsiness during running or an inability to participate in games like football. Between the ages of 3–6, the difficulties shifted towards activities that demand balance, drawing skills, and holding a pen properly.

In the perception category, parents identified issues related to visual and auditory perception, including difficulties in perceiving auditory stimuli, recognizing colors, writing and learning numbers, interpreting visual or auditory inputs, and slow perception speed. These difficulties became apparent to the parents after their children reached the age of three. Additionally, in other areas, parents observed challenges with direction skills.

Parents also highlighted that their children experienced difficulties with memory, attention, and self-regulation. They observed issues with memory, particularly in recalling information. Furthermore, there were struggles with maintaining attention during games or tasks that required concentration. Both parents and teachers shared the belief that the children could accomplish any task if they managed to focus. Challenges in self-regulation were noted as well, especially in terms of being tidy at home and in school settings. One parent (P1), who has twins, with one diagnosed with SLD, discussed memory difficulties by drawing comparisons in the developmental process between her twins:

“… about describing the picture she saw.... Whenever I asked her, she had a blank stare on her face. Later, when we read stories together, I used to realize she did not remember anything about the story.”

In general, the challenges identified between the ages of 0–3, with the exception of speaking difficulties, continue into the ages of 3–6. This means that issues such as pronunciation, initiating communication, introverted behavior, and difficulties with tasks requiring coordination, speed, or strength that begin to emerge from ages 0–3 tend to persist through to ages 3–6.

In Map 2 , which focuses on the school period, the early developmental symptoms of SLD are categorized into ten areas: social-emotional development, language and communication development, motor development, self-care skills, perception, memory, attention, self-regulation, motivation, and other difficulties. Within the language and communication development category, difficulties were reported in initiating communication, expressing feelings and thoughts, overusing fillers, and speaking in context.

Difficulties in social-emotional development emerged as a category in which parents and teachers predominantly share their observations. The frequency of codes in this field has increased in school age. Parents have observed challenges in engaging in casual conversations and difficulty in defense own rights, while teachers have identified reluctance, choosing to play individual games, and difficulty maintaining communication. Both participant groups have highlighted a range of early symptoms including low self-esteem, bully victimization, exclusion, introversion, emotional overreactive state, willingness to be invisible, and difficulty in following the rules. One child’s parent (P6) and teacher (T6) expressed low self-esteem as follows:

“She constructs barriers in unfamiliar situations, quickly abandoning tasks and expressing self-doubt. She often declares, ‘I cannot do this. Why do you insist? That is enough; it is not working; give up.” (P6) “There was a situation like this where her self-esteem was low and quite challenging. She frequently began sentences by stating, ‘I cannot do it.’ While many students experience this to some degree, she struggled with it more than most.” (T6)

Parents and teachers used the phrase “vulnerable, sensitive, and combative” to describe the emotionally overreactive state of the children. One child’s parent (P8) and teacher (T8) expressed bullying victimization as follows:

“I did not know if he was beaten so much. He suffered a lot from a friend. He was a quiet kid. He was not a kid who defended his rights.” (P8) “He was an oppressed child. One child in the classroom put him under the pressure. He could not defend himself. When he wanted to protect himself, he was doing it wrong.” (T8)

In the perception category, difficulties with matching letters to sounds were commonly reported by both parents and teachers. Furthermore, teachers noted challenges in interpreting stimuli and understanding instructions. Both parents and teachers reported difficulties in the self-regulation category such as external audit, disorganized notebook, and difficulty in planning. Difficulties in the field of attention, memory, motivation, and self-care skills were expressed by both parents and teachers during the school period as well. They expressed difficulty paying attention to a game/task, difficulty recalling information, reluctance, and low self-motivation about a game/task in the field of attention, memory, and motivation. Considering other difficulties, the teachers emphasized that children made more effort to learn, were reluctant to go to school, and could only learn until a certain difficulty level.

Early academic symptoms of SLD

In Map 3 , the early academic symptoms of SLD in the school period appeared under three categories: reading, writing, and mathematics.

In the reading category, reading comprehension was the most emphasized difficulty. Mixing letters, reading slowly, making reading mistakes, and reluctance to read were expressed by both parents and teachers. One child’s parent (P1) and teacher (T1) expressed the mixing of letters as follows:

“I turned the house into a map. Because I thought she could not forget letters if she saw them all the time. But she would do a lot of constant b-d shuffling.” (P1) “When I realized she was confusing the letters b-d, I thought this was not a problem. Because my four or five students made the same mistake as her… There was an application in the curriculum that I found very wrong. When I taught the letter groups b-d in the first grade, there was only one letter (s) between them. In other words, children are more confused because these letters are given one after the other… When these two letters are taught in proximity, students often experience confusion. Therefore, there is a need for change in this regard.” (T1)

Most of the difficulties in the writing category were expressed by both parents and teachers. Difficulties holding the pencil, writing numbers in the correct direction, leaving appropriate spaces between words, legible writing, the proportionality of letters, and making spelling mistakes emerged in this area. In the mathematics category, both parents and teachers expressed difficulty solving problems.

Overview of developmental symptoms

We created Map 4 by considering the chronological and developmental processes. Firstly, the parents observed differences in their children’s language and communication development. In particular, they emphasized difficulties in speaking, pronunciation, and limited vocabulary. In the following process, difficulties in social-emotional development were remarkably noted by the parents. This development area was that what both parents and teachers most expressed. Afterward, they started to mention motor development difficulties. Although parents believed their children had difficulties in motor development in preschool, they determined this to be an issue during school years.

Developmental symptoms pyramid of children at risk for SLD

This situation proceeded similarly for self-care, perception, attention, and memory. While self-care skills were tolerated in preschool, the child was expected to become independent in the first grade. All the difficulties above started to show their effects more clearly in the academic field during school years.

When we look at the developmental process holistically, social-emotional development and motivation challenges become more pronounced in school life. Parents and teachers have reported that children exhibit a notable lack of motivation in addition to other difficulties. They tend to be invisible, become introverted, show reluctance in both their social and academic lives, and strive to be unnoticed.

We also saw the process progress increasingly in the seven steps. For instance, language difficulties emerged in the 0–3 age period and continued to increase and intensify during the school period. The frequency of codes in socioemotional development has increased in school age. While the difficulties that appeared on the pyramid's base were expanded, new difficulties accrued on top of them. That was why we visualized this process as a pyramid . One child’s parent (P2) expressed the increase in difficulties experienced as follows:

“He began speaking later than his peers and entered kindergarten at five. During that time, his speech development lagged, causing communication challenges with his teacher and impacting his ability to form friendships. Even now, he faces difficulties in making friends. When my son started first grade, I became suspicious of his learning difficulties as he struggled with reading words composed of two letters, often reading them backward. I shared my concerns with his teacher, who insisted on waiting. Despite waiting patiently, the difficulties persisted and even worsened. At this point, the formal reporting process was initiated.” (P2)

When examining the pyramid, it is evident that there is an increase in the child's symptoms, coupled with a reluctance to understand, difficulty in motivation, and lack of self-esteem. Parents describe this situation as “ He has potential, but he believes he cannot do it, ” “ He gives up quickly, ” or “ It is tough to break his prejudice that he cannot do it .” Consequently, researchers believe that all the difficulties experienced by children point to a theme linked to challenges in their perception of themselves. Hence, we have labeled the final step of the pyramid “ negative self-concept .” Self-concept encompasses an individual's perceptions of themselves across various aspects, including physical appearance, achievements in sports and academics, behavior, social acceptance, and interpersonal relationships (Butler & Gasson, 2005 ). We referred to the negative self-concept when children held negative perceptions of themselves in these areas.

In general, the findings reveal difficulties across 13 areas. Only parents or teachers reported some of these difficulties. Both parents and teachers expressed some of the other difficulties. Table 2 presents all the difficulties mentioned above, categorized by developmental areas, period, and the individual expressing the difficulty.

This study aimed to explore early developmental challenges of children diagnosed with SLD and to contribute to the creation of an item pool for early symptom identification. Through qualitative interviews with parents and teachers, we identified a broad range of developmental symptoms from infancy to primary school, including difficulties in language and communication, social-emotional and motor development, self-care skills, perception, memory, attention, self-regulation, and academic challenges. These findings underscore the multifaceted nature of SLD and the importance of early identification and intervention.

According to the findings, parents and teachers highlighted difficulties in 13 distinct areas. We categorized these difficulties to create an item pool for early symptoms. We created an item pool at the end of the study and organized it by age groups (0–3, 3–6 and school age, outlined in Appendix C).

Our results showed that, according to parent observations, children primarily experienced language and communication difficulties—such as challenges with pronunciation, initiating communication, and speaking—during the first three years of their lives. After age three, they also struggled to express their feelings and thoughts and tended to overuse fillers in their speech. Previous studies have consistently identified these difficulties in language and communication development as early symptoms (Aunio et al., 2021 ; İzoğlu-Tok & Doğan, 2022 ; Price et al., 2022 ; Quiroga Bernardos et al., 2022 ). Longitudinal research emphasizes that children diagnosed with SLD face challenges in both receptive and expressive language skills during early developmental stages. Consistent with our findings, these challenges persist into later years (Carroll et al., 2014 ; Thompson et al., 2015 ; van Viersen et al., 2017 , 2018 ). Van Viersen et al. ( 2017 ) reported that children diagnosed with SLD begin to lag behind their peers in receptive language skills around the 17th month and in expressive language skills around the 23rd month. Unlike this study, our participants did not report any challenges related to receptive language skills. Parents in Turkey apparently prioritize their children's speech over their receptive language skills. Thus, it is plausible that parents primarily focus on expressive language skills when considering language development. Consequently, assessing language and communication development skills should be central to identifying risk groups. The literature supports the inclusion of these difficulties in the item pool. However, difficulty in speaking was not reported between the ages of 3 and 6. Lyytinen et al. ( 2005 ) found that late-talking toddlers with expressive delays caught up to their peers in language proficiency by the age of 3.5 years. Therefore, we suggest including this difficulty as a topic in preliminary interviews rather than incorporating it into assessment tools.

The most pronounced difficulties identified in our study relate to social-emotional development. Parental observations indicated that children exhibited symptoms such as introversion and a need for physical contact within the first three years of life. After the age of three, challenges in maintaining relationships and adhering to rules became apparent. Both parents and teachers noted an increase in introversion upon the children's entry into first grade, describing them as feeling excluded and invisible. Previous research has highlighted the importance of recognizing difficulties in social-emotional development as early indicators of potential issues (İzoğlu-Tok & Doğan, 2022 ; Sakellariou et al., 2020 ; Tercan & Yıldız-Bıçakçı, 2018 ). In particular, a qualitative study by İzoğlu-Tok et al. ( 2021 ) found that children with SLD felt marginalized and invisible due to experiences of bullying, with participation in mainstreaming services often equating to feelings of "rejection" and "not belonging." Reflecting on both our findings and those of previous studies, children were frequently described as "silent," "vulnerable," "sensitive," and "introverted." Thus, it is essential that these characteristics be considered as potential risk factors and integrated into the item pool for developing assessment tools.

Another significant observation was that children showed challenges in motor skills that require coordination, speed, application of strength, balance, and drawing abilities. Parents often described these challenges as clumsiness during physical activities, such as running or playing basketball. These issues were noted to persist throughout the school years. Similar challenges have been highlighted as early indicators of SLD in prior studies (Flores et al., 2022 ). Westendorp et al. ( 2011 ) determined that a greater learning lag in children correlates with poorer motor skill scores. Firat and Bildiren ( 2024 ) observed that children with SLD often began walking later than typical in the 0–2 age range and faced challenges in both fine and gross motor skills as they grew older. Although our study provides additional insights from parents regarding motor development issues, there is a general agreement that difficulties in motor skills are critical for identifying children at risk. Hence, it's essential to include these challenges in the item pool for early identification of SLD.

Parents reported that children faced difficulties with self-care skills after the age of three, a concern that aligns with findings from previous studies (İzoğlu-Tok & Doğan, 2022 ; Tercan & Yıldız-Bıçakçı, 2018 ). In Tercan and Yıldız-Bıçakçı ( 2018 ) qualitative study, parents emphasized the challenges their children encountered during toilet routines and the dressing process. It was also observed that close relatives often described the child as “unskillful” during early childhood. Consequently, challenges associated with self-care skills should be considered when developing the item pool for an assessment tool.

Our study revealed that children encountered difficulties with perception after age three. According to parents, these challenges were related to visual and auditory stimuli. Previous research on children at risk for or diagnosed with SLD has also underscored the significance of perception skills. Some studies have focused on difficulties in color and shape perception, while others have addressed challenges with numbers (Aunio et al., 2021 ; Hellstrand et al., 2020 ; Quiroga Bernardos et al., 2022 ). Additional research has highlighted challenges in letter knowledge, speech perception, and following instructions (Quiroga Bernardos et al., 2022 ; Snowling et al., 2019 ). In our study, parents did not report difficulties with letter knowledge. This may be influenced by the prevailing belief in Turkey that children should not learn letters before formal education begins. However, in the literature, visual perception is connected with reading difficulties and phonological awareness (Baluoti et al., 2012 ; Frostig, 1972 ). The phonological approach posits that children diagnosed with learning disabilities have trouble recognizing and manipulating phonemes in speech and making letter-sound matches during early phases (Wolf, 2017 , p. 173). Therefore, perception skills play a crucial role in the learning process. Thus, we suggest that challenges related to perception should be included in any assessment tool developed on this topic.

Our results also showed that children had significant escalation in self-regulation difficulties during the school period. Parents and teachers reported that children struggled with planning and maintaining the organization of their notebooks, which often required external audits. This finding aligns with findings from other studies in the literature (Tercan & Yıldız-Bıçakçı, 2018 ; Thompson et al., 2015 ). A thorough review makes it clear that challenges in this particular area are crucial and, therefore, should be included in the item pool for early identification of SLD.

Moreover, our study has demonstrated that children face challenges with paying attention to games or tasks from preschool onwards, as reported by both parents and teachers. This observation aligns with findings from previous research, where children exhibited difficulties in initiating, maintaining, or completing activities or tasks (Firat & Bildiren, 2024 ; Squarza et al., 2016 ; Tercan & Yıldız-Bıçakçı, 2018 ). Our findings indicate that parents and teachers believe that children could achieve any task if they were able to focus their attention. Consequently, problems related to attention could be mistakenly conflated with other difficulties. A common dilemma faced by parents is discerning whether the challenges with attention are a result of learning difficulties or if the inability to complete tasks stems from inherent attention issues. As such, our analysis suggests that difficulties in various domains are often attributed to an overarching issue of attention deficit by both parents and teachers.

In the context of diagnoses accompanying SLD, attention deficiency is commonly identified (Araz Altay & Gorker, 2017 ; Squarza et al., 2016 ). Thus, while attention is a necessary condition for any learning activity, it is not sufficient for diagnosing the early symptoms of SLD (Learning Disabilities Association, 2001 ). Assessing learning disabilities based solely on attention can risk misidentification as Attention Deficit and Hyperactivity Disorder (ADHD), another neurodevelopmental disorder (APA, 2013 ). Therefore, challenges related to attention should be considered alongside other difficulties when developing an assessment tool.

Our results also indicated that children have faced difficulties with memory recall since preschool, a symptom corroborated by previous research (Bonti et al., 2021 ). Studies have demonstrated a significant correlation between memory deficits and learning challenges, particularly in reading and mathematics (Mammarella et al., 2018 ; Moll et al., 2016 ; Peng et al., 2018 ). For instance, Moll et al. ( 2016 ) found that verbal memory deficits are linked to disorders in reading and mathematics, while visuospatial memory impairments are specifically associated with mathematics disorders. Although our study primarily relied on reports from parents and teachers, thus lacking detailed data on memory, the recurring theme of memory challenges emphasizes its importance. According to the information processing approach, memory plays a crucial role in learning, further highlighting memory as a key symptom to consider when identifying children at risk for SLD (Baddeley & Hitch, 1974 ). This underscores the necessity of including memory-related difficulties in the item pool for an assessment tool aimed at early detection of SLD.

Our findings showed that children have shown difficulty with location-orientation skills after age three, a challenge highlighted in previous studies (Açıkgöz, 2019 ; İzoğlu-Tok & Doğan, 2022 ). Research into the causes of SLD points to communication issues between the brain hemispheres, particularly noting that problems in the right hemisphere can impede the acquisition of directional concepts (Silver, 1989 ; Vellutino, 1987 ). Therefore, this skill is essential for inclusion in the item pool.

After preschool, parents reported that their children exerted more effort to learn, exhibited reluctance to attend school, and could only advance to a certain level of difficulty in other areas. We interpreted these behaviors as outcomes of the cumulative difficulties experienced across all areas. For example, an increased effort to learn may stem from perception challenges (Karakoç, 2020 ). The DSM-5 also points out a decline in academic performance as a distinguishing feature of SLD from other neurodevelopmental disorders (APA, 2013 ), suggesting that children may need to work harder to achieve the same performance level as their peers in early stages. These indicators should, therefore, enhance the comprehensibility of the item pool.

Our findings underscore that motivation is a critical early symptom in the developmental process, especially post-preschool. Previous research has identified a lack of motivation as an early indicator of SLD (Firat & Bildiren, 2024 ; Pesova et al., 2014 ). The decrease in motivation during the school period may be attributed to ongoing difficulties. Since strong motivation and a positive self-image are essential for learning, challenges in this domain can significantly obstruct educational progress (Aro & Ahonen, 2011 ). Pesova et al. ( 2014 ) observed that many students with SLD often remain unnoticed for extended periods, further complicating their learning, motivation, and confidence. Thus, early detection is vital. Accordingly, challenges related to motivation should be included in the item pool of any assessment tool designed to identify children within the risk group.

According to our research, difficulties in reading, writing, and mathematics become evident during the school period, as specified in the DSM-5 (APA, 2013 ). Additionally, similar challenges have been recognized as early symptoms in previous literature (Hellstrand et al., 2020 ; Navarro Soria et al., 2020 ; Quiroga Bernardos et al., 2022 ).

Reading has been the most extensively studied area (Ozernov-Palchik et al., 2017 ; Quiroga Bernardos et al., 2022 ; Snowling et al., 2019 ) as it represents the most common difficulty associated with SLD (APA, 2013 ). Parents and teachers in our study reported that children faced challenges with reading comprehension, letter mixing, slow reading, frequent reading errors, and reluctance to read. Partanen and Siegel ( 2014 ) found that children at risk of reading difficulties in kindergarten scored lower in word and letter recognition, phonological processing, and rapid naming compared to their peers not at risk. Unlike other studies, our research did not identify challenges in early literacy skills, such as phonological awareness and letter knowledge, among preschool children. This discrepancy may be attributed to the Turkish curriculum, which discourages the teaching of reading and writing, including letter introduction, before formal education begins (Ministry of National Education, 2013 ). Hence, it's likely that parents did not recognize their children’s difficulties in this area as notable challenges during the preschool period. Apart from reluctance to read, all other difficulties align with the DSM-5 diagnostic criteria (APA, 2013 ), suggesting that reluctance to read may stem from underlying challenges.

One teacher we interviewed suggested revising the curriculum, especially regarding the teaching of certain letters, such as'b' and'd'. In Turkish, each sound corresponds to a letter, and when teaching reading, letters are introduced in groups. For example, the third group includes six letters ('ö','r','ı','d','s','b'), taught consecutively, placing'b' and'd' close together, which can confuse many children. This curricular approach may influence teachers' perceptions of these issues as early symptoms of SLD in Turkey.

Challenges in writing and mathematics are consistent with DSM-5 diagnostic criteria and existing literature (APA, 2013 ; Fırat & Erdem, 2020 ; Zhang et al., 2020 ). Fırat and Erdem ( 2020 ) found that a significant portion of students who struggled with mathematics in the 1st grade continued to face challenges in the 4th grade, including issues with rhythmic counting, concept comprehension, problem-solving, number knowledge, and making comparisons. Mathematics skills are often less emphasized compared to literacy skills in early education. Thus, difficulties in reading, writing, and mathematics should be integral to the item pool for early SLD detection.

A significant finding from our study is the progressive increase in difficulties experienced by children at risk for SLD, which closely follows the critical stages of their development. Initially, parents noted early symptoms in language and communication skills, identifying developmental language disorders and language skill difficulties as potential indicators of future SLD (Quiroga Bernardos et al., 2022 ; Thompson et al., 2015 ; van Viersen et al., 2017 , 2018 ).

We observed that language development difficulties became evident in social settings, potentially impacting children's social development (Sakellariou et al., 2020 ). Consequently, social-emotional development challenges may arise following difficulties in language and communication. Socialization introduces environments where motor skills are actively utilized, making differences in motor development noticeable as children engage with their surroundings. Similarly, parents did not perceive challenges in perception, attention, and memory as significant until entering the first grade. These early developmental symptoms can influence academic performance later on.

Our study uncovered developmental symptoms across multiple areas at early life stages, suggesting that accumulating difficulties prevent children from realizing their full potential. This accumulation leads to diminished motivation and self-esteem, driving children towards invisibility-a phenomenon we described as a negative self-concept.

Parents and teachers reported developmental difficulties early on, noting that foundational challenges expanded as new difficulties emerged. We depicted this progression as a pyramid, illustrating the Matthew effect—where initial disadvantages lead to compounded challenges, echoing the adage "the rich get richer, and the poor get poorer" (Gladwell, 2008 ). This effect, evident in both reading and mathematics, highlights the escalating nature of difficulties in development (Flores et al., 2022 ; Ozernov-Palchik et al., 2017 ; Zhang et al., 2020 ).

Analyzing these challenges, we noted the influence of the developmental model, which suggests a complex interplay of factors in a child's development. Before facing academic challenges, children experience difficulties in multiple developmental areas, underlining the potential long-term impact on learning behaviors (Kass & Maddux, 2005 ).

Theories from Piaget, Vygotsky, and others highlight critical periods in development. Observations from parents and teachers suggest that learning difficulties are often perceived as delays in achieving expected milestones. For instance, a delay in language development can affect social interactions, emphasizing the importance of recognizing and addressing challenges early. In Turkey, regulations emphasize early intervention for children with diverse needs (Decree-Law No. 573, 1997). However, SLD diagnoses typically occur after the first grade, underscoring the need for earlier assessment and intervention tools.

This study has provided researchers with a crucial item pool sample, facilitating the development of comprehensive screening tools tailored to various age groups (0–3, 3–6, and school age). Collaboration with families, educators, and health professionals ensures the validity and reliability of these tools across different populations. Moreover, the research contributes to expert and educator training, offering sessions on early sign recognition across multiple developmental domains. By identifying specific areas of concern like language, communication and social-emotional skills, the study informs the creation of early intervention programs. Advocating for the integration of screening and intervention protocols into educational systems, including kindergartens and primary schools, underscores the importance of early support for children at risk of SLD. This research sheds light on the needs of children from infancy, informing policymakers and education officials. Longitudinal tracking of children with difficulties ensures ongoing assessment and progress monitoring, empowering families and educators to intervene early and improve developmental outcomes and educational success for affected children.

The exploration of early developmental challenges among children diagnosed with SLD presented in this study illuminates the multifaceted nature of this condition and underscores the critical importance of early identification and intervention. Through qualitative interviews with parents and teachers, a comprehensive item pool was established, delineating difficulties across various developmental domains from infancy through primary school. The findings highlight that challenges in language and communication emerge as early as infancy, followed by social-emotional, motor, perceptual, attentional, self-regulatory, memory, and academic difficulties during subsequent developmental stages. The study's thorough examination not only contributes to the existing literature on early symptoms of SLD but also emphasizes the necessity of integrating these findings into assessment tools for timely identification and intervention. By elucidating the progression of challenges experienced by children at risk for SLD, this research underscores the cumulative impact of developmental difficulties and advocates for proactive measures to support affected children's holistic development. Moreover, the study's insights hold significant implications for practitioners and policymakers, emphasizing the imperative of early intervention strategies aligned with the developmental needs of children with SLD, ultimately fostering their optimal growth and learning outcomes.

Limitations

This study primarily examined the past observations of teachers and parents. Additionally, it was confined to the research questions formulated by the researchers, which encompass information about the children's preschool and pre-diagnosis school period. A notable limitation of this research is the potential variance in the levels of perception and expression skills among participants in the study group.

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Code availability

The code conducted from the findings of this study is available on request from the corresponding author. The code is not publicly available due to privacy or ethical restrictions.

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Acknowledgements

We would like to express our gratitude to the children, parents, and teachers who generously shared their experiences and time with us. Additionally, a heartfelt thank you to our colleagues for their valuable contributions.

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1st author: conceptualization, data curation, formal analysis, investigation, methodology, software, writing– original draft, visualization, validation.

2nd author: visualization, supervision, writing– review & editing.

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İzoğlu-Tok, A., Doğan, Ö. Preliminary developmental challenges of children at risk for specific learning disabilities: Insights from parents and teachers—a qualitative study. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-06231-x

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Accepted : 03 June 2024

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DOI : https://doi.org/10.1007/s12144-024-06231-x

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May 5-8, 2024

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Public Perspectives on Emerging Multi-Cancer Early Detection (MCED) Tests: A Qualitative Study

Crossnohere N 1 , Campoamor N 1 , Negash R 1 , Wood M 2 , Studts J 3 , Jonas D 1 , Elsaid M 1 , Donneyong M 4 , Bridges JFP 5 1 The Ohio State University, Columbus, OH, USA, 2 University of Colorado, Aurora, CO, USA, 3 University of Colorado School of Medicine, Aurora, CO, USA, 4 Ohio State University, Columbus, OH, USA, 5 The Ohio State University College of Medicine, Columbus, OH, USA

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• MCED Public opinion interviews V1138095.pdf

OBJECTIVES: The emergence of multi-cancer early detection (MCED) tests has the potential to transform cancer screening. MCEDs can identify up to 50 types of cancers before symptom onset through a single blood test. While studies focusing on the efficacy and effectiveness of MCED are underway, there is a paucity of research regarding public views on these tests. We sought to explore public perspectives on the use of MCEDs.

METHODS: A qualitative study was conducted using one-on-one interviews with members of the public aged 45-70 recruited through a national survey panel. After viewing a brief educational video about MCEDs, semi-structured interview approaches explored sentiments about MCEDs and considerations for integrating MCEDs into clinical care and overseeing/regulating MCEDs. Data were analyzed using content analysis with a deductive coding approach.

RESULTS: We conducted 20 interviews with members of the public who averaged 64 years of age (SD=6.4). Half were Black, Indigenous, or other people of color, 20% were male, and 25% had a history of cancer. Participants universally liked the principle of MCEDs and valued their convenience and ability to improve early detection for many cancers (100%). Participants identified future applications for MCEDs, including developing precision-MCEDs looking for cancers based on individual susceptibility (40%) and using MCEDs for cancer monitoring and therapy selection (10%). Participants were receptive to using MCEDs in clinical care if providers disclosed that MCEDs are a new technology without long-term efficacy data. Participants expressed concern with the high out-of-pocket cost ($1,000), deemed personally prohibitive (100%) and unethical (10%), and with perceived inconsistencies in oversight/regulation as compared to other cancer screenings (90%).

Medical Technologies, Patient-Centered Research

Topic Subcategory

Diagnostics & Imaging, Stated Preference & Patient Satisfaction

Medical Devices, Oncology

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• Views of emergency care providers in providing healthcare for asylum seekers and refugees
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• http://orcid.org/0009-0007-0664-237X Cal Doherty 1 ,
• http://orcid.org/0000-0002-2351-3875 Joanna Quinn 2 ,
• http://orcid.org/0000-0003-4866-2049 David John Lowe 3 , 4 ,
• Amal Khanolkar 1
• 1 King's College London , London , UK
• 2 NHS National Services Scotland , Edinburgh , UK
• 3 Institute of Health & Wellbeing , University of Glasgow , Glasgow , UK
• 4 Emergency Department , Queen Elizabeth University Hospital , Glasgow , UK
• Correspondence to Dr Cal Doherty, King's College London, London, UK; cal_doherty{at}hotmail.co.uk

Background The number of asylum seekers awaiting decisions on their claims in the UK has more than tripled since 2014. How we meet international obligations to provide appropriate healthcare to asylum seekers and refugees (ASRs) is therefore an increasingly important issue. The views of frontline healthcare workers are vital to ensure the development of sustainable and effective health policy when it comes to caring for this group.

Method A single-centre qualitative study in the form of semistructured interviews was conducted at the Queen Elizabeth University Hospital ED in Glasgow, Scotland, between January and March 2023. Volunteering ED care providers (EDCPs)—doctors and nurses—working in the ED were interviewed and the data analysed and presented through a thematic analytical framework.

Results 12 semistructured interviews were conducted—6 doctors and 6 nurses. Analysis revealed four themes: (1) ‘staff attitudes’ highlighted in particular the positive views of the participants in providing care for ASRs; (2) ‘presentation patterns’ revealed significant variations in opinion, with one-third of participants, for example, believing there was no difference in presentations compared with the general population; (3) ‘challenges to optimal care’ outlines multiple subthemes which impact care including the unique challenge of the ED triage system; and (4) ‘transition in care’ discusses participant concerns regarding arranging safe and appropriate follow-up for ASR patients. Ethical dilemmas in providing care, as highlighted in previous studies, did not feature heavily in discussions in this study.

Conclusion This study provides an insight into the views of EDCPs in providing care to ASRs in the ED. Study findings can potentially contribute to the development of ED-specific guidelines as well as inform wider health policy and provide a focus and direction for further research.

• qualitative research
• global health

Data availability statement

Data are available upon reasonable request. Data will be stored on King’s College London secure SharePoint database, for the minimum period of time up to 7 years pending final publication.

https://doi.org/10.1136/emermed-2024-213899

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Handling editor Kirsty Challen

X @joannaquinn1

Contributors CD was the principal investigator (PI) and led all aspects of study including the development of the methodology, conducting interviews and reporting of the study. AK was the PI university supervisor for the project and reviewed the methodology and the final report and assisted in obtaining KCL REC and HRA approval. JQ was the second analyst of the interview data and assisted in the final report. DJL primarily assisted in gaining local site approval and gave practical support in conducting the study as well as reviewing the final report. AK and CD are joint guarantors.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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• Commentary Restoring hope Mary Dawood Emergency Medicine Journal 2024; - Published Online First: 27 Jun 2024. doi: 10.1136/emermed-2024-214259

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