John I. Dawes Early Learning Principles: A Comprehensive Guide

Introduction

The preschool years, spanning ages 3 to 5, are a crucial period for development and lifelong health. During this time, children experience rapid advancements in cognitive, socio-emotional, motor, language, literacy, numeracy, and self-regulation skills. However, in many low-resource settings, developmental delays, sensory impairments, and emerging health risks often go unnoticed. This article explores the principles of early learning, focusing on the importance of early identification and intervention, particularly in low- and middle-income countries (LMICs). It also examines a proposed screening model developed in South Africa to improve early identification and referral in ECCE settings.

The Critical Window of Early Childhood

Early childhood represents the phase of most rapid human development. Between the ages of 2 and 5 years-often referred to as the ‘next 1000 days’-the brain is especially sensitive to stimulation and nurturing. During this period, children make considerable advances in cognitive, socio‐emotional, motor, language, literacy, numeracy and self-regulation skills. Globally, approximately 250 million children under the age of 5 years in low‐ and middle‐income countries (LMICs) are at risk of not reaching their developmental potential due to poverty, malnutrition and limited access to nurturing care. Around 8% of children younger than 5 years are affected by developmental disabilities, while 25% experience developmental delays that are not necessarily linked to a formal diagnosis. Sensory impairments such as vision and hearing loss affect an estimated 2% of children.

Investing in early childhood yields substantial social and economic returns, with estimates of up to 19 times the original investment, reinforcing its prioritisation in global development agendas. This is reflected in the Sustainable Development Goals (SDGs), which call for universal access to quality early childhood care and education (ECCE) by 2030. In South Africa, ECCE is identified as a national priority in both the National Development Plan 2030 and the National Integrated Early Childhood Development (ECD) Policy. These policies promote multisectoral collaboration across the health, education and social protection sectors.

The Need for Early Identification and Intervention

Despite policy commitments, many developmental concerns often go undetected until formal school entry. Up to 50% of children with developmental delays are not identified by the age of 5 years, although signs are often evident by the age of 2 years. Emerging health risks, such as childhood hypertension (HTN), also require early detection. Elevated blood pressure is predictive of adult cardiovascular disease and is associated with genetics, obesity, poor diet, second‐hand smoke exposure and socioeconomic disadvantage.

In South Africa, several interrelated factors continue to undermine early development. The Thrive by Five report card highlights poor dietary diversity, undetected developmental delays and sensory impairments, caregiver mental health challenges, low parental engagement and uneven quality in early learning environments. Nationally, 23% of children are stunted, only 20% meet minimum dietary diversity, and over half do not meet age‐appropriate cognitive and motor milestones. Caregiver mental health and limited involvement in early learning remain major barriers to children's developmental progress.

Timely identification of at‐risk children is critical to improving developmental and health outcomes. Educational settings provide a scalable platform for early detection and referral. Ideally, such services should be delivered through an integrated ‘medical home’ model. In South Africa, the primary healthcare system, particularly when linked to community‐based services, most closely approximates this approach. By the age of 4-5 years, most South African children are enrolled in ECCE programmes, which are delivered through ECD centres.

Integrated Screening in Educational Systems

High‐income countries provide examples of integrated developmental and health screening embedded in educational systems. The United States' Head Start programme is widely regarded as a gold standard. It mandates comprehensive, multi‐indicator screening upon programme entry, including assessments of growth, developmental milestones, vision and hearing, behaviour, general health and family psychosocial risk. Screenings are typically conducted by trained educators and community workers, with referrals made to healthcare professionals for further assessment where needed.

In contrast, ECCE settings in LMICs, including South Africa, are rarely used as platforms for integrated developmental and health screening. Existing efforts tend to be fragmented, lack cross‐sector coordination and frequently omit key components such as psychosocial risk assessment, despite its recognised importance for nurturing care.

A Proposed Screening Model for Low-Resource Settings

This manuscript describes the iterative refinement of an initial screening protocol into a proposed flexible, tiered and developmentally informed screening model, designed to operate within a guiding framework for ECCE settings in low‐resource contexts. Developed within South Africa's early learning system, the model supports integrated, same‐day developmental and health screening and is intended to be culturally responsive, operationally feasible and scalable both within South Africa and across other LMIC settings.

Study Design and Setting

This observational, descriptive study represents the foundational phase of a broader community‐based initiative. It aimed to establish baseline data on development, nutrition, sensory functioning (vision and hearing), and general health (including blood pressure) in preschool‐aged children (3-5 years) attending early childhood development (ECD) centres in under‐resourced communities within the Mangaung Metropolitan Municipality and the Xhariep District, in the Free State Province of South Africa. Ethical approval for this study was obtained from the University of the Free State’s Health Sciences Research Ethics Committee (UFS‐HSD2021/1762/2903), and permission to conduct the research was granted by the appropriate provincial education authority. The study complied with the ethical principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants, and all data were managed confidentially.

The study was conducted in low‐resource urban, peri‐urban and rural communities within a central province of South Africa. In these areas, access to integrated screening services is limited due to health workforce shortages and fragmented coordination between health and education sectors. Many ECD centres are staffed by facilitators without formal training. The province's population is predominantly Black African, comprising approximately 89% of residents. Unemployment is high, at 32.1%, and around 60% of the population lives below the poverty line. Sesotho is the most widely spoken language in the province.

Participant Recruitment and Eligibility

Participant recruitment was initiated at selected ECD centres, where matrons identified interested primary caregivers and recorded their willingness to be contacted. With their permission, caregivers' contact details were shared with the research team. Written informed consent was obtained from all caregivers prior to data collection. Children were enrolled following caregiver consent and verbal assent.

Caregivers were eligible to participate if they were the child's primary caregiver, were able to attend the scheduled screening at the ECD centre and provided written informed consent for both themselves and their child. Children were eligible to participate if they were aged 3-5 years, attended the centre at least three times per week and had caregiver consent. Children also provided verbal assent prior to screening. Those with previously diagnosed developmental or sensory disabilities were excluded.

ECD facilitators were eligible to participate if they were employed at one of the participating centres and were responsible for children within the target age group. These facilitators, who are early childhood educators, implement daily learning and care activities in South African ECD centres.

A convenience sample of 400 caregiver-child dyads was targeted to establish reliable developmental and health profiles of preschool‐aged children in the study setting. In total, 395 caregiver-child dyads were recruited from 16 ECD centres across the Mangaung Metropolitan and Kopanong Local Municipalities. Caregivers were predominantly unemployed mothers responsible for full‐time childcare (mean age = 33 years; range = 18-75 years). Child participants had a mean age of 4 years (range = 3-5 years), with an approximately even biological sex distribution (male/female). In addition, 58 ECD facilitators participated in structured interviews.

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Implementation of the Initial Screening Model

The initial screening model was implemented in 2022 by an interprofessional team, with the aim of providing community‐based, multidimensional screening across key developmental and health indicators, guided by best practice recommendations. However, early versions of the screening protocol included additional assessments informed by the team members' diverse areas of expertise and interest. Initially, caregiver and child screenings were conducted on separate days, requiring double site visits and presenting logistical challenges related to scheduling, staffing and space. Each screening session lasted up to 120 min, and the use of interpreters, when needed, further extended this time.

Screening for caregivers and children was delivered on‐site at ECD centres using an integrated circuit model. Designated assessment stations enabled simultaneous evaluations across multiple indicators by team members, facilitating a holistic and efficient process.

Multidomain developmental screening across motor, language, cognitive, academic, self‐help and behavioural domains. Additional screening testing for children who failed the Vula Vision screen or for whom no measurement could be obtained. Distance visual acuity was assessed using LEA symbols (universal, recognisable optotypes: circle, square, house, apple). Ocular health was assessed through observation of internal and external structures, ocular motilities, alignment and refractive error. Additional vision tests forming part of a comprehensive paediatric eye examination were included at the request of the optometry team members, in line with local guidelines at the time.

Facilitator interviews were conducted during caregiver screening days to minimise disruption to centre routines. Included items on training and qualifications, years of relevant experience, types of care and educational activities offered, availability of resources and the typical daily routine at the ECD centre (including time allocated to learning, physical activity, sedentary activities and sleep). Information on meals provided to children and 24‐h dietary recall was also collected.

The Interprofessional Team

An interprofessional team comprising four physiotherapists, three occupational therapists, two optometrists, three dietitians, one biokineticist, two kinderkineticists and two language practitioners collaboratively contributed to the design, implementation and iterative refinement of the initial multi‐indicator screening protocol. Drawing on collective expertise in neurodevelopment, sensory function, nutrition, cardiovascular health, movement science and linguistic and cultural mediation, the team developed a contextually appropriate, same‐day screening model tailored for low‐resource ECCE settings. The language practitioners played a pivotal role in ensuring the cultural and linguistic inclusivity of the screening process.

To support scalability within resource‐constrained environments, the protocol was designed for delivery by trained lay personnel and student fieldworkers under professional supervision. Approximately 240 undergraduate healthcare student fieldworkers and 15 language practice students were engaged in caregiver interviews, physical assessments and anthropometric measurements as part of a structured work‐integrated learning (WIL) programme. This dual focus on scalability and experiential education addressed workforce constraints while providing students with real‐world opportunities to develop communication, clinical reasoning and interprofessional teamwork skills in community settings.

Guiding Framework

This study is grounded in a holistic, child‐ and family‐centred framework. The Nurturing Care Framework and the Family‐Centred Care model informed caregiver collaboration, while the Social Determinants of Health and Bronfenbrenner's Bioecological Model contextualised development within environmental systems. Content and processes were aligned with the principles of John I. Dawes Early Learning Center, which emphasizes a nurturing environment, individualized attention, and a focus on the whole child. The center, located in Manalapan, NJ, serves a diverse student population and maintains low student-teacher ratios to ensure personalized learning experiences.

Key Barriers and Solutions

Through the PALAR approach, stakeholders identified key barriers, including fragmented caregiver-child scheduling, long assessment sessions, limited interpreter resources, caregiver disengagement and difficulty engaging children with developmental and behavioural challenges. In response, a proposed model was developed to consolidate visits, reduce session duration, enhance interpreter support and streamline screening tools. The flexible, tiered structure of this proposed model allows assessors to tailor screening based on observed functional capacity, improving feasibility, accuracy and cultural responsiveness.

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