IDA study: post-COVID-19 school readiness vulnerability in children entering primary school in Lazio Region

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Background

Studies conducted during and after the COVID-19 pandemic have brought attention to the changes in children’s learning and mental health.^1,2 A 2022 Italian report³ emphasized that «the neurodevelopment and mental health problems of children and young people manifested during the pandemic are at risk of becoming chronic and spreading on a large scale». ‘School Readiness’ is an indicator of mental health and well-being, communication, and general literacy skills, emotional maturity, social skills, cognitive and language development to delineate the set of social-emotional and cognitive skills a preschool child should possess to adapt to the new school environment. It includes the competencies concerning emotional and relational maturation and pre-literacy and pre-mathematics.⁴ These skills may not be achieved by the time the child enters primary school;⁵ in this case, the child may express vulnerability. School Readiness Vulnerable children (SRCV) are those who, without additional support and care, are more likely to experience difficulties in their school years and beyond. 
This condition, if not treated, may tend to consolidate and produce negative effects on health. In fact, children with a lack of school readiness may exhibit antisocial behaviour⁶ and school failure⁷. Low educational attainment has been correlated with early pregnancies⁸ and, in adulthood, with obesity⁹, depression and anxiety¹⁰, coronary heart disease¹¹, and type 2 diabetes¹². A 2020 study showed that a lower educational level reduced cognitive function and worsened health status after age 45.¹³
Children with SRV encounter various difficulties that affect their ability to cope with daily activities (such as being inappropriately dressed, often being late, hungry, or tired). Children identified as vulnerable in the social skills are more likely to have problems relating to other children in a regular way and encounter difficulties following class rules and routines. Emotionally vulnerable children encounter various difficulties related to emotion regulation. They are prone to problems with managing aggressive behaviour and may be inclined towards disobedience or be inattentive and impulsive. Moreover, they encounter various difficulties with reading, writing, and numbers. They may not be able to read or write simple words, may not be interested in trying, and often fail to associate sounds and letters.¹⁴
The COVID-19 pandemic and the lockdown have altered the growth and developmental stages of the children causing an increase of school readiness difficulties. United States studies have shown that, during the pandemic, many children as early as kindergarten showed limitations in social, emotional, cognitive, and physical development.^1,2,15 Children younger¹⁶ or older than 6 years of age^17,18 showed behavioural problems and regression symptoms¹⁶ in the transition from preschool to primary school.¹⁹ A Uruguayan study¹⁹ compared two cohorts of children between the ages of 4 and 6 and showed that the cohort affected by pandemic-related limitations was characterized by a deterioration in motor and cognitive development and by an approach to learning characterized by internalizing behaviour. These results were less pronounced among children belonging to families with better socioeconomic conditions. A British study examining 3,253 children attending the first year of primary school (4-5 years old)²⁰ showed that the pandemic had led to a deterioration in social-emotional well-being, language, and numeracy skills compared to what might have been expected based on the previous year cohort. Moreover, the percentage of children achieving a good level of development was 13% lower than pre-pandemic (58.7% vs 72%). Other international studies have confirmed how widespread the negative consequences of the COVID-19 pandemic are on the mental health of children and young people.²¹
Besides, families are still experiencing, as a result of the COVID-19 pandemic, the additional threat of the economic recession, leading to increased levels of poverty. This condition in children can lead to long-term consequences on health,¹⁷ well-being,¹⁸ and learning goals¹⁹. A United Nations international Children’s Emergency Fund (UNICEF) report showed how the pandemic has led to a worsening of inequalities and socioeconomic conditions, negatively affecting the educational status of children from the most vulnerable social groups.²²
The study carried out, therefore, aimed to estimate the prevalence of SRVC and their characteristics out of 43,800 children at the beginning of primary school, to stimulate the attention of decision-makers to the problem and the implementation of specific and timely intervention by the school community. Preventing this condition from becoming consolidated with negative consequences on the psycho-physical health of the children and, in the long term, an increase in health expenditure, would be an essential objective for public health authorities and decision-makers. For this reason, the analyses here presented are of a confirmatory character, investigating whether the data from the literature are valid in the Lazio Region (Italy) and the transition from kindergarten to primary school.

Methods

Participants

In September 2022, according to estimates from the Regional School Office,²³ 43,726 children distributed across 2,420 classes started primary school in the Lazio Region. 
The study population consisted of children who were enrolled in the first year of primary school in the 2022/2023 academic year, aged between 67 and 89 months (5-7 years old), and attending public and private schools. For the sake of efficiency, a two-stage cluster sampling approach was selected for the study design.24 The number of classes (clusters) to be selected was calculated using the following formula:

k = (1.96² * p * (1-p) * deff) / (d² * m) = 147 (146.7)

where:

• k is the number of sample classes;
• 1.96 is the confidence level;
• p (0.50) is the expected prevalence of vulnerability;
• deff (1.1) is the Assumed Design Effect;
• d (3%) is the absolute precision desired;
• m (8) is the number of sample units within each cluster.

The sample size of the first primary classes selected was 147. Regarding the sampling unit, 8 children were then randomly drawn from each selected class.
At the beginning of the analysis, 1,130 Italian-speaking children from 80 classes were included. After the random selection of 8 children per class, the final sample considered for analysis was 628: 52.2% males, 46.5% female, and 1.3% unknown (Table S1, online supplementary materials). The mean age of the sample was 76 months ± 3.78 SD and the median age was 76 months. In the age distribution, the most represented tertile was 73-79 months (Table S1). The great majority of children were selected from white families of intermediate socioeconomic status.

Materials and procedures

Data were collected through two questionnaires: the ‘Early Identification of Learning Difficulties’ (IPDA), validated and used in many Italian school settings,⁵ which is an observational tool completed by teachers, and the demographic-socioeconomic questionnaire, which was completed by parents. All extracted boys and girls who started the first grade of primary school in the Lazio Region were included. Only pupils who had already been diagnosed with neurodevelopmental disorders by specialist medical personnel at the time of IPDA completion and whose parents had not provided informed consent were excluded.

IPDA questionnaire

The IPDA questionnaire consists of 43 items and requires a maximum of 10 minutes for completion by a trained teacher after observing the child for at least one week. It is divided into two main sections: “general skills” (items 1-9: Behavioral Aspects; items 10-11: Motor Skills; items 12-14: Language Comprehension; items 15-19: Oral Expression; items 20-23: Metacognition; items 24-33: Other Cognitive Skills) and “specific skills” (items 34-40: Pre-literacy; items 41-43: Pre-math). The answers to the questions are scored on a 4-point scale: 1: not at all/never; 2: a little/most of the time; 3: quite a lot/most of the time; 4: a lot/always. The score used for reference in this study is the one recommended in the IPDA User’s Manual in May of the last year of kindergarten (Table 1).⁵ 

Demographic-socioeconomic questionnaire

The questionnaire, completed by parents, is divided into 6 sections: child’s biographical data, preschool facilities attendance, household composition, changes in the child’s behaviour perceived by parental adults and attributable to the pandemic period, according to parental figures, parental education, and parental employment.

Statistical Analysis

Analyses were performed using Epi Info (version 7.2.5.0). The analysis plan included calculating the frequency of distribution, mean, and standard deviation, and assessing the normal distribution (skewness and kurtosis) of the main variables (total IPDA, areas of IPDA, age and sex, preschool attendance, parental education and work, parental occupation), using a 95% confidence interval. The association between total IPDA and the main independent variables was investigated by bivariate analysis. Multivariate analysis (logistic regression) was also used to reduce the effect of confounding and suggest a risk profile for children exposed to pandemic limitations.
The school’s name, the class, and any elements heading the children were not reported on the paper or computer-based questionnaire. The database does not contain any useful element to reference the data to a particular school or child. 

Procedures and data collection

In September 2022, the Local Health Authorities (ASLs) of the Lazio Region were contacted, and 7 out of 10 accepted to participate. Among the adhering ASLs, not all provided the number of clusters proportionally assigned using the probability proportional to size method. As a result, the classes included in the final database were 80 instead of 147 as initially planned. During the first 2 weeks of October 2022, online training of school staff was carried out, then the survey material was delivered to the participant schools. The questionnaires were filled and collected in the second part of October 2022. In case of incomplete or incorrect compilation, teachers and parents were asked to provide additional data. In November 2022, the data were entered by 2 persons in Excel. If less than 5 values were missed in any IPDA questionnaire, the weighted average of all scores of the other items was considered, as indicated by the authors of the IPDA Manual. If there were more than 5 missing values, the questionnaire was dropped. A data quality check was carried out before and during data entry. Any error in the compilation, e.g., caused by contradictory data, wrong scores or missing data, were examined and corrected. The data analysis was conducted between December 2022 and January 2023. 

Results

Descriptive statistics

In Figure 1 the IDA sample is compared with the reference study values.5 The median score was 130 compared to 148 and the mean was 130 ± 25.9 SD (No. 628) compared to 145 ± 21.2 SD (No. 659). The non-parametric Wilcoxon test showed a significant difference between the medians (p<0.001).

The curves from the IDA study and the reference study were both skewed to the left (-0.42 for the curve for the survey, -0.84 for the reference study). The IDA curve was platykurtic (kurtosis -0.3) while the study curve was leptokurtic (kurtosis 0.4). Furthermore, the IDA study scores distribution around the mean was broader and had greater variability than the reference curve where the scores were closer to the arithmetic mean with lower variability. Both curves did not have a normal distribution (Test of Shapiro-Wilk: p<0.001). 
The arithmetic mean in males was 129.4 ± 25.5 SD (No. 328) while in females was 136.0 ± 24.5 SD (No. 292), showing about 7 points lower in males than in females. Figure 2 shows the smoothed distribution of males’ and females’ IDA study score curves.

The results showed that 44.9% of the sample had a score equal to or less than 127 (meaning medium-high and high-risk SRVC), of which 15.4% (No. 97) was medium-high SRVC and 29.5% (No. 185) was high SRVC with a need for immediate intervention, according to the IPDA study Manual (Figure S1).
The 36.3% of males (119 among a total of 328) and 21.6% of females (63 among a total of 292) were part of the ‘high SRVC’ group. 
In particular, motor skills, pre-mathematics, and pre-literacy were the worst areas with 76.1%, 75.6%, and 71.0%, respectively, of the total sample of children showing to be vulnerable. In all areas, males reported lower scores.
Children who attended kindergarten for ≥ 20 months (86.2%) reported a higher average IPDA score compared to those with lower or no attendance (131.5 ± 25.1 SD and 121.3 ± 28.4 SD respectively). 
Among the children, 13.8% (85/615) had a mother and 21% (129/607) had a father with a low-level of education. However, having only a mother with a lower level of education was significantly associated with SRVC. 
The variables investigated in the demographic-socioeconomic questionnaire completed by parents showed that the children at greatest risk were males, with low kindergarten attendance, with a low level of parental education, especially of the mother, and with the mother not employed (Figure S2).

Association between SRV and socioeconomic and demographic variables

A significant association was found between the medium-high and high SRVC (IPDA ≤ 127) and the following variables: younger age children, male gender, lower kindergarten attendance, low level of mother, father and both parents’ education, mother and both parents’ unemployment (Table 2).

In the logistic regression, the medium-high and high SRV were associated with male gender, age less than 76 months, and lower kindergarten attendance. The educational level of single or both parents and the unemployment of the mother did not prove to be associated (Table 3).

Discussion

«The prolonged school closures and other significant disruptions to the education system caused by the pandemic have resulted in a substantial loss of learning. Emerging data from various countries indicate that the challenges related to COVID-19 and school closures have led to an increase in the number of out-of-school children».²²
The IDA study confirmed that the COVID-19 pandemic has worsened the prevalence of children with SVR entering primary school also in the Lazio Region, where the median score worked out was 130, significantly lower (-10.3%) than the reference study score of 145.⁵ In the sample of this study, 44.9% are SRVC with a surveyed developmental level similar to the IPDA standards for children one year younger.
According to a UK report,²⁰ the prevalence of reduced socioemotional performance, language, and math skills among 4-5-year-old children was around 41% observed in May 2022 compared to 28% in 2019. A 2021 US study found that the prevalence of ‘healthy and ready-to-learn’ children aged 3 to 5 years was 42%.²⁵ A UNICEF report, conducted in 32 low- and middle-income countries,²² highlighted that the pandemic will have a negative impact on essential reading skills, particularly for children under the age of 5-6 years, with an anticipated reduction of 27% by the time they reach Grade 9 (13-14 years) if development support strategies are not implemented.
Regarding IDA, children had the lowest scores in motor skills (76.1%), pre-mathematics (75.6%), and pre-literacy (71.0%). A study on children aged 4 to 6 years¹⁹ also showed a decline in language and logical-mathematical skills compared to pre-COVID, particularly in the areas of cognitive development and motor skills, as observed in this study. The impact on motor skills may be explained by the reduced physical activity due to the lockdown and the time children spent confined at home.²⁶ Issues related to pre-mathematics and pre-writing skills may be associated with reduced attendance at preschool.
In the IDA study, 52.7% of males (173 among a total of 328) were part of the ‘medium-high and high SRVC’ group, with an average IPDA score of 126, while 35.6% of females (104 among a total of 292) were part of the same group, with an average IPDA score of 135. This difference can be observed across all areas of development. In this regard, a Canadian study²⁷ found contrasting results; girls demonstrated better performance in certain skills necessary for school readiness, while boys performed better in other areas. No differences were found in vocabulary, number knowledge, effort, and cooperative play.
Children with low preschool attendance showed lower IPDA scores. This data confirms the importance of early childhood education for the development of school prerequisites, which «contributes to the education and affective, psychomotor, cognitive, moral, religious, and social development of children, promoting their potential in relationships, autonomy, creativity, and learning, aiming to ensure effective equality of educational opportunities».²⁸
SRV is associated with low educational levels of the mother, father, or both parents, as well as with maternal and paternal unemployment. Also in the IDA study, the level of education and occupational status proved to act as determinants of health, negatively influencing the health status of individuals and the population they belong to. This result confirms that the pandemic has negatively affected the socioeconomic status of families.²² A Chinese study from 2022²⁶ investigated the vulnerability and resilience of two groups of children of different ages (2-5 years and 6-12 years) during the COVID pandemic, and the results showed that school closures worsened existing inequalities in families with special educational needs (SENs), especially for families with members with psychiatric disorders and single parents. Income inequality is indeed one of the main causes of learning problems. Furthermore, parental involvement in their children’s education is important for achieving basic learning skills.²²
In the IDA study, children under 76 months of age showed lower IPDA scores and therefore a higher SRV compared to older children (≥76 months). However, the low correlation level between age and score (r²=0.03, coefficient of determination) suggests that lower scores are due to the physiological lag in development rather than a particular vulnerability caused by the pandemic.
Out of the 147 clusters sample identified in the study protocol, data were collected from 80 clusters due to only partial participation of some school districts. This limitation may have introduced a selection bias. On average, the design effect worked out for the different variables had a low value (DE=1.1), so it was assumed that there is no significant difference for the children and families’ variables among different clusters.
Another limitation is the observational nature of the application of the IPDA questionnaire, which is exposed to the subjectivity of the compiling teachers. Moreover, students’ performance during the observation period may have been influenced by external factors. Some items about the child’s attitudes and behaviours referred to in the questionnaire filled in by parents may also resent the different cultural and sensitivity. The strength of the IDA study lies in being the first to assess the impact of the COVID-19 pandemic on children’s learning difficulties in the Lazio Region and Italy. A similar investigation using the same IPDA instrument was conducted simultaneously in the extended area of the town of Palermo (Sicily) by researchers from the Italian National Health Institute.²⁹ 

Conclusions

Given the average delay of one year that children have shown in their development, it is necessary to intervene promptly and effectively to address this problem of such broad dimensions and harbinger of negative consequences for the children’s current and future health. 
Interventions aimed at recovering school skills that were not adequately developed during the COVID-19 pandemic should therefore be timely implemented. 
Hence, the study’s findings have significant implications for various stakeholders involved in education and child development. 
Education authorities and policymakers need to recognize the effects of the pandemic on children’s school readiness and the need for targeted interventions to address vulnerabilities. Policies should be developed to ensure equal access to quality early childhood education, especially for children from socioeconomically disadvantaged backgrounds.
Schools and educators play a crucial role in identifying and addressing vulnerabilities in students, taking into consideration that the study underscores the importance of assessing and supporting children’s developmental needs. Schools can collaborate with parents and caregivers to create strategies for supporting children’s development.
Parents and caregivers should be informed as soon as possible about the impact of the pandemic on children’s school readiness and they are expected to engage in activities that promote motor skills at home.
Non-governmental organizations and community groups can play a role in providing additional support to vulnerable children and families, particularly for those from disadvantaged backgrounds.
Health professionals should be aware of the developmental challenges faced by children due to the pandemic and can offer guidance to parents and caregivers on activities that promote children’s physical and cognitive development.
Research community is involved, because the study’s results provide valuable insights into the impact of the pandemic on children’s development, but further research is needed to investigate the long-term effects of these vulnerabilities on educational outcomes and propose evidence-based interventions;
Government and funding agencies can allocate resources to support programmes that address school readiness vulnerabilities, notably in early childhood education and support services, particularly for vulnerable populations.
Collaborative efforts among these stakeholders are essential to mitigate the negative effects of the pandemic on children’s school readiness. By recognizing the challenges highlighted in this study, stakeholders can work together to design effective interventions, policies, and programmes that promote equitable access to quality education and support the holistic development of young children.

Conflicts of interest: none declared.

Acknowledgements: the Authors would like to thank the “Identificazione precoce delle difficoltà dell’apprendimento/Early Identification of School Readiness Vulnerability (IDA) Study Group” (Annachiara Di Nolfi, Angela Giusti, Stefania Spila Alegiani, Francesca Zambri, from the National Institute of Health/Istituto Superiore di Sanità), teachers, parents, and children who participated in the survey for their collaboration.

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