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Hano and Prof. Jen-Tsung Chen",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10539.jpg",keywords:"Plant Description, Botany, Phylogeny, Genome, Phytochemical Analysis, Extraction, Phytochemical Diversity, Phytochemical Analysis, Extraction, Phytochemical Diversity, Biotechnological Production, Traditional Medicinal Uses",numberOfDownloads:533,numberOfWosCitations:0,numberOfCrossrefCitations:1,numberOfDimensionsCitations:1,numberOfTotalCitations:2,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 8th 2020",dateEndSecondStepPublish:"November 23rd 2020",dateEndThirdStepPublish:"January 22nd 2021",dateEndFourthStepPublish:"April 12th 2021",dateEndFifthStepPublish:"June 11th 2021",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 years",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Assistant Professor at the University of Orleans at Research INRAE Lab LBLGC USC1328 and a member of the Cosm'ACTIFS Research Group (CNRS GDR3711). 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1. Introduction
1.1 Adult scoliosis instability
1.1.1 Bracing history
Lyon has always had a great tradition of orthopedic, and Charles Gabriel Pravaz was not only the inventor of the syringe, but he also created in Lyon a great orthopedic institute to treat scoliosis 200 years ago. The first Lyon brace, which was made of leather and steel, was created by Stagnara 70 years ago. It undergone a first change with the replacement of leather by polymethacrylate. This brace was used in adults in addition to surgery while waiting for the graft fusion, at a time when osteosynthesis did not have the current quality. In 2013, the use of adult ARTbrace in Europlex’O in polyamide and asymmetry allowed to avoid the plaster cast which has always been the characteristic of the Lyon management. The use of polyamide and digital allows treatment of thoracic and double major curves.
1.1.2 Frequency of adult scoliosis
Vanderpool et al. [1] shows that the frequency of scoliosis in adults increases steadily with age, from 6% of scoliosis after the patient reaches 40 years until it reaches 10% of the population at age 65. The sex ratio was 2 females to 1 male. It is women who have the most painful instabilities and imbalances. Their bone mass is lower than that of men with a vertebral fracture threshold at age 65. Pregnancy and menopause could be also aggravating factors [2].
1.1.3 Adult patients are different
Akbarnia et al. [3] described the key features as curve stiffness, degeneration of the discs, osteoporosis, spinal imbalance both coronal and sagittal, rotary subluxation, spinal stenosis, and higher rate of complications (pulmonary, etc.). The esthetic aspect is not negligible, and even surgery performed during adolescence does not solve everything. Edgar and Mehta [4] has shown that self-image representation and social life is different after surgery in adolescence. 82% of adult scoliosis without surgery was married compared to 60% of scoliosis operated in adolescence. O’Brien [5] analyzes the consequences of scoliosis in adulthood. He noted that for adult scoliosis abnormal physical appearance and diminished self-esteem may always be present, but breathing limitations, inability to function, and other quality of life issues generally become the driving forces for clinical examination, diagnosis, and treatment.
1.1.4 Complications of surgical treatment vs. non-operative
The complications were analyzed by many authors. For Baron and Albert [6] the incidence of medical complications ranges between 40 and 86%. Local complications include infection, pseudarthrosis or failure of instrumentation, and neurological and adjacent-level degeneration or instability. Common medical complications include pneumonia, atelectasis, ileus, delirium, and cerebrovascular incidents. Smith et al. [7] studied the incidence of complications according to age. His conclusions were the following: the oldest age group (65–85 years) has nearly four times the number of minor complications and nearly five times the number of major complications when compared with the youngest age group (25–44 years). As invasive surgical therapy needs a perfect understanding of risk/benefit, Ogilvie [8] suggests that the decision to proceed with surgical treatment even if justified in many cases must be based on a thorough understanding of the anticipated benefits from surgical treatment and the risk of serious complications. These potential complications lead to multiple surgeries with results that can be less desirable than the original condition. The results of conservative orthopedic treatment are more difficult to assess. Kluba et al. [9] compares surgical and conservative treatment for degenerative lumbar scoliosis. He finds a significantly higher rate of spinal stenosis and degenerative spondylolisthesis in the group of patients with surgery. However no significant difference was evident between the two groups in terms of lumbar back pain after 4 years, respectively.
Everett and Patel [10] conducted a systematic review of non-operative treatment. There is indeterminate, level III/IV evidence on the effectiveness of any conservative option; level IV evidence on the role of physical therapy, chiropractic care, and bracing; and level III evidence for injections in the conservative treatment of adult deformity. The use of rigid or hard bracing in adult scoliosis is generally not recommended. This is due to the risk of muscle weakening effects from hard bracing and the fact that this could accelerate the degenerative process in some cases. Chuah et al. [11] notes that bracing may sometimes help the symptoms, but it has no effect on curve progression.
Pain is not synonymous with deformity progression. Some stable scoliosis patient report pain, and others evolve without pain. It will be necessary to try to make the difference between the “physical” pain and the “emotional” suffering when the patient does not support his deformation anymore.
1.2 Anatomo-pathological classification of painful instabilities
Thoracolumbar pain often corresponds to minor joint instability.
The pain of convexity is of muscular origin.
The pain of the concavity is posterior: facet syndrome.
The lumbosacral pain is of ligament origin.
These pains respond perfectly to physiotherapy.
When scoliosis progresses, it is either (1) the evolution in adulthood of an adolescent idiopathic scoliosis, (2) a de novo scoliosis usually of discal origin, or (3) a camptocormia of muscular origin. In all cases, there may be a disc disease with sometimes rotatory dislocation, postural impairment with imbalance, extrapyramidal muscle involvement, and bone involvement (osteoporosis). In these progressive cases of instability, bracing or surgery may be necessary.
1.3 Classification of painful instabilities according to age
From 20 to 30 years old, the main problem is the anatomical pain.
From 30 to 50 years old, the main problem is the discal decompensation.
After 50 years old, there are two main problems: degenerative scoliosis very rigid with arthrosis and camptocormia reducible with paravertebral muscular atrophy.
1.4 Natural history of idiopathic scoliosis from adolescent to adulthood
Early works on scoliosis progression in adulthood were pessimistic [12], but at this time, idiopathic scoliosis, especially rachitic infantile, is mixed with neurological poliomyelitis that no longer exists.
In 2003 Weinstein published the spontaneous evolution of 117 idiopathic scolioses over more than 50 years [13]. Thoracic curves of more than 50 degrees at skeletal maturity progressed with an average of 29.4 degrees. Thoracolumbar curves between 50 and 75 degrees increased with an average of 22.3 degrees. Lumbar curves had the most progression, especially when the L5 vertebra was not well seated and when the apical rotation was greater than 33%. He does not observe a functional respiratory or painful repercussion below 70°. This angulation could be currently the functional surgical Cobb limit. Pregnancy does not change the progression of scoliosis in adulthood, except in cases of twin pregnancy.
1.5 The two distinct entities
In 2007 Marty-Poumarat [14] describes two specific adult scoliosis entities: adolescent scoliosis in adult (ASA) and degenerative de novo scoliosis (DDS).
Group A (ASA) = adult progression of AIS > 40° with first dislocation at 45 years. The progression can be sometimes regular, sometimes chaotic.
Group B (DDS) = de novo scoliosis with low Cobb after 50°, first dislocation at 52 years after menopause. DDS is more progressive than AIS. Because DDS is a result of degenerative disc instability, it is almost always progressive. Lumbar and thoracolumbar are the most progressive degenerative curves. Duval-Beaupere and Dubousset [15] have first described the mechanism of rotatory subluxation. Following their work, many authors have insisted on the importance of the lumbo-pelvic parameters [16, 17, 18].
1.6 Risk factors for instability
The radiological risk factors for instability are (1) rotatory dislocation with lateral olisthesis (Figure 1), (2) L3–L4 inclination, (3) hypolordosis, and (4) increased thoracolumbar kyphosis [19, 20].
Figure 1.
De novo scoliosis with constitution of a rotatory dislocation in 2 years, then scoliosis worsening by osteoporotic cuneiformization.
1.7 Indications of bracing
The physical activity and fracture rate of adult scoliosis is identical to that of the general population, except for operated patients who have less physical activity [21]. Unlike adolescence, when bracing is systematic when scoliosis progresses, the corrective bracing indication in adults is less related to Cobb angulation but more to the instability which results in pain, abnormal angular evolution, or imbalances (Figure 2).
Figure 2.
Clinical imbalances in the frontal and the sagittal planes.
From a database started in 1998, we selected all adult scoliosis in which conservative orthopedic treatment has been proposed to, even if the treatment had not been achieved by the patient. Scoliosis treated during adolescence and monitored in adulthood were excluded [22]. In this case series study, we analyzed 779 patients referred for nonsurgical treatment, and we correlated three parameters: the etiology, age, and Cobb angulation (Table 1).
Indications ARTbrace adult (n = 779)
Rate %
Mean age
Mean angulation
Rotatory dislocation (n = 361)
46.5%
59.73 y ± 13.50
39.08° ± 16.56
Segmental instability (n = 150)
19%
46.03 y ± 15.49
25.29° ± 12.29
Instability post-surgery (n = 86)
11%
53.09 y ± 12.91
40.49° ± 15.38
Camptocormia (n = 68)
9%
69.78 y ± 12.19
38.09° ± 14.23
Kyphosis (thoracolumbar) (n = 62)
8%
60.73 y ± 15.51
43.34° ± 21.48
Disabling pain (n = 33)
4%
48.36 y ± 13.73
36.45° ± 21.48
Spondylolisthesis and spinal stenosis (n = 19)
2.5%
Table 1.
Main indications for adult scoliosis bracing with frequency classification.
The rate of dropout patients not wearing the brace is 17% which is not excessive, especially since the plaster cast at that time was made before the brace discouraged patients.
A tentative classification according to etiology, age, and angulation is proposed (Figure 3).
Figure 3.
Indications of nonsurgical treatment by etiology (n = 739).
More than half of the indications concern the rotational dislocation, which is the specific complication of adult scoliosis. The rotary dislocation is visible on the CT scan with subluxation and joint narrowing on the sliding side and widening of the articular space on the opposite side.
One-fourth of the indications concern disc instability, which can be considered as the early stage of rotational dislocation.
The other etiologies are less frequent: lumbar-pelvic-femoral kyphosis, secondary instability under arthrodesis, root pain, and rarely spinal stenosis which requires neurosurgery. Camptocormia is linked to weakness of the deep posterior musculature [23]. The patient increases kyphosis gradually to tighten his weak paravertebral muscles. There is often an extrapyramidal context of Parkinson’s disease [23]. MRI cross sections highlight the fatty degeneration. Some authors have mentioned paravertebral myopathy [24].
According to age, there is no Cobb angle difference between patients aged 39 and 80 years old, even if we notice a slight worsening between patients aged 80 and 90 years old. It can be concluded that after 40 years, for the same angulation, the risk of decompensation does not depend on age [22].
If we examine in more detail the distribution of patients according to Cobb angle, we find that Cobb angle is not a discriminating factor like aging.
1.8 Eligibility test
One of the bracing eligibility tests especially for camptocormia is self-correction by using the hands on the thighs, even if this self-correction does not last long in time. The second test of reducibility is carried out in supine position. The occipital patient must rely on the plane of the examination table. The placement of the ARTbrace is performed by the patient who stabilizes the brace at the pelvic level then unrolls the spine using the rigidity of the posterior bar and finally blocks the upper part. As for children, the “mayonnaise tube” effect of the two lateral hemi-valves completes the correction in the sagittal plane.
2. Methodology and results
2.1 Evolution of management
Adult scoliosis bracing is performed only in technically equipped medical clinics. Hospitalization is not essential because the use of the brace must be integrated into the patient’s environment. On the other hand, physiotherapy scoliosis-specific exercises (PSSE) is mandatory.
The brace wearing time protocol is a total time of 24 hours a day during 3 weeks with a plaster cast (or digital cast) to adjust the length of the ligaments with plastic deformation and, then, at least 4 hours per day for a minimum of 6 months, including systematically for 2 hours after the practice of sports activity (Table 2).
Management
Wearing time
Particularity
Follow-up examination
First 3 weeks
Total time 24/24
Only 10′ for shower, no work interruption
At the end of total time without X-ray
First 6 months
4 hours/24
Systematically for 2 hours after physical activity
At 6 months with X-ray
6 m to 2 years
On demand and 2 hours after sport
In case of pain, in prevention before major efforts
At 2 years with X-ray
After 2 years
No specific indication
Brace is kept for safety
AT 5 years with X-ray, then every 5 years
Table 2.
Adult bracing management (Lyon ARTbrace).
Wearing the brace for a “total time” allows the patient to relearn all the gestures of daily living in a good posture, for example, the sitting writing posture with feet behind the chair and buttocks in front of the seat. The lower part of the chest touches the anterior edge of the table, and the forearms rest on the desktop.
The digital cast is made in three blocks according to the deviations as in the teenager, but in deep inspiration. In many cases, only a scan in maximum corrective posture perfectly balanced is performed. The corrective posture is derived from Schroth. The sagittal plane and the frontal plane are simultaneously corrected, ensuring the overall balance of the spine. The spine is placed in maximum extension to promote lumbar lordosis and reduce thoracic hyperkyphosis. The convex hand is placed on the vertical support, the concave hand is placed on the head, and the operator supports the patient’s elbow (Figure 4).
Figure 4.
Digital cast with simultaneous correction in the frontal and in the sagittal planes.
The thickness of Europlex’O used in adults is 3 mm. The digital cast is made in blocks according to the deviations as in the teenager, but in deep inspiration. The advantages are manifold: (1) The patient can maintain the maximum corrected position for a few seconds while standing; (2) breathing is controlled, and the patient can be asked to perform maximum inspiration; and (3) the accuracy of the eight structure sensors is less than 1 mm. The 3 mm Europlex’O with very high rigidity can be used instead of polyethylene. It is possible to work bare skin, but the thin optical vest in jersey allows the use of landmarks for the superposition of the three blocks. The processing with a specific software allows the creation of a positive which will be milled by a digital milling machine. The CPO has all the tools to rework on the captured shapes. After a period of 3 weeks of “total time,” the brace is worn for a minimum of 4 hours/24 for 6 months, then on demand.
2.2 Aims of rigid bracing
2.2.1 Instability pain management
Instability pain management is obtained by:
A skin contact of the brace like a massage.
A discharge of the lumbar discs and vertebral body by the “composite beam effect.” The discharge of 30% is provided by the waist grip in the frontal plane, while the sagittal plane is free to prevent an excessive abdominal pressure.
A rebalancing spine in the frontal and sagittal plane.
A limitation of extreme postures.
2.2.2 Muscle strengthening
The rigid brace is an active brace. The patient spontaneously tends to contract the paravertebral musculature in the sense of self-active axial elongation. Associated physiotherapy is however essential.
2.2.3 Esthetics
The brace can reshape the waist. It can also symmetrize the body for the largest scoliotic curves by the adjunction of a foam cushion in the concavity.
2.2.4 Saving spine: development of compensations
The lock automatically performed by the brace facilitates motion and strengthens the musculature of the lower limbs. There is also a better mobility of shoulder girdle because of the stabilization of shoulder blades in a more physiological position.
2.3 Lyon method of physiotherapy for adult scoliosis
The wearing of a rigid brace is obligatorily supplemented by physiotherapy scoliosis-specific exercises. The ideal is to act when the spine begins to disrupt or becomes painful, indicating instability. The therapeutic progression is usual:
2.3.1 Aims
Analgesia.
Preventing muscle atrophy lumbo-abdominal strengthening in isometric and improving paravertebral deep muscles (Figure 5).
Promoting more flexible self-active axial elongation (Figure 6).
Correcting 3D spine balance: in the frontal plane, rebalance of the occipital axis; in the sagittal plane, restoration of sagittal lumbar and pelvic curvatures (pelvic anteversion and lumbar lordosis (strengthening of the iliopsoas)); and in the horizontal plane, dissociation of pelvic and shoulder girdles.
Developing compensation at the lower and upper limbs: relaxation under pelvic extension (hamstring stretching) (Figure 7).
Stimulating the mechanisms of postural correction with reharmonization of the paravertebral tensions (muscular chains) (Figure 8).
Figure 5.
Isometric strengthening of the deep front line with correction of thoracolumbar kyphosis.
Figure 6.
Self-active axial elongation in closed kinetic chain (hands/espalier).
Figure 7.
Posture of stretching posterior chains of the lower limbs.
Figure 8.
Reharmonization of paravertebral tensions with mirror control.
The main differences between adolescent and adult scoliosis are demonstrated in Table 3.
Physiology and biomechanics
Adolescent
Adult
No specific pain in adolescents. Painful instability in adults
No pain relief techniques
Pain relief techniques, massage, and others
Flat back in the teenager. Loss of lordosis and hyperkyphosis in adults
Restoration of physiological sagittal curves (arms projected forward)
Physiotherapy in lumbar lordosis (hands crossed in the back)
The brace aims to stiffen the spine (rust the spring). Spine mobilization in adults can lead to curve progression
Spine mobilization during cast and brace in all the amplitudes
No spine mobilization beyond the corrected posture
Strengthening muscle fibers (adult sarcopenia)
Reinforcement of the reticulospinal system (aerobic)
Reinforcement of voluntary musculature in anaerobic metabolism.
Translation along the vertical axis
Active axial self-elongation in standing position (grand porter) Open kinetic chain
Active axial self-elongation trunk bent at 90°, hands resting on the espalier. Closed kinetic chain
No specific stretching. Global training without excessive resistance
Stretching of the posterior chain at the level of the lower limbs
One-third of the thorax volume develops after the end of the stature growth
Resistance breathing exercises (inflating a balloon)
Breathing exercises in forced expiration
Table 3.
Main differences between adolescent and adult scoliosis Lyon method physiotherapy.
2.3.2 Lyon method during the total time
First week. Physiotherapy is for analgesic purposes and is performed in the supine position by soft traction and a muscular work with irradiation of the short external rotators. Breathing is controlled because of the limitation of the abdominal expansion. The thoracic breathing is facilitated by the mobilization of the intercostal muscles.
Second week. The iliolumbar angle is mobilized to adjust tension at the iliolumbar level. The hump can be modeled with progressive closure of the ratcheting buckle. Physiotherapy is performed in sitting position.
Third week. Physiotherapy is more global, more general, more tonic, and stronger. The lever arm of shoulder and pelvic girdles is used. The sessions are made in standing position.
2.3.3 Physiotherapy during partial time bracing
We first determine the sagittal direction of muscular work, usually lordosis for lumbar and thoracolumbar scoliosis. For each session there is a progression from supine to sitting and standing position.
2.3.3.1 Examples of basic exercises
Rib hump erasing. Having refocused the spine from the vertical in the sagittal plane and in the frontal plane, the patient is asked to lengthen from the brace at the rib hump level. The movement is controlled manually. The trapezius muscle is relaxed.
Sagittal tensioning girdles. The aim is to relax the posterior chain muscles while avoiding cervical lordosis. The exercise is made with control of inspiration breathing.
Self-axial lengthening. The patient straightens his head, his hands resting on the anterosuperior part of the brace. It can be done in a sitting position using a proprioceptive system. When the head is at the correct high position, a sound and a light stimulate the patient. If the spine is close to a wall, a cushion at the cervical level must be stabilized by the patient. This exercise can be completed with the upper limb extension.
Posture memorization. Exercise can be more complete with the work of the lower limbs. The starting position is knees bent for self-axial elongation of the spine; the upper limbs are fixed on the espalier. The patient is asked to stand up to a position of global extension. This exercise improves the quadricep muscle that will be key to saving the spine.
Strengthening of weak muscles: quadriceps and abdominals. The exercise will be started in a supine position. The pelvis is locked in the brace posture. This work is associated with an isometric tension of the posterior chain and expiration. This exercise is completed by a stabilization of the shoulder girdle with a stick and control of the rotation of the hip by a ball between the knees. The solicitation is obtained by an oblique manual push on the side of the patient. By gradually lowering the legs, it also seeks the rectus femoris. The anterior chain has been stretched, and it is in this posture of extension that strengthening is performed with isometric contract-relax muscular work.
Stretching strong muscles: hamstrings and short external rotators. It starts at the lumbosacral junction with pelvic-femoral, tricep, and hamstring stretch in lumbar lock controlled by the brace. It also stretches the psoas and rectus femoris. We can stimulate muscular work by manual push on the pelvis. The buttocks and the latissimus dorsi are solicited in the prone position, emphasizing the control of the cervical lordosis. When sitting, it stretches the anterior chain by adjusting the hip. Stretching can also be controlled at home on a stair. The exercise at the bar also allows global stretching.
Proprioceptive rehabilitation. On a Klein Vogelbach ball, it transfers the body weight in all plans, with emphasis on relaxation of tone and breathing control. The muscle tonicity is improved by changes in posture, standing, and lying and by the addition of loads. The global proprioceptive work prepares the patient for the definitive weaning of the brace.
2.3.4 Advice
In case of major disc degeneration, physiotherapy will be conducted in physiological lordosis, rather than in a standing position.
In case of major facet joint degeneration, physiotherapy will be conducted in physiological lordosis in prone position, legs bent or in a sitting position.
In case of leg length discrepancy, the feet imbalances adjustment with a shoe lift of 5 mm if it improves both pelvic and spine alignment.
In the sagittal plane, one can use small high heel stubs from 3 to 5 cm to reduce a lumbar kyphosis.
The food control helps to reduce overweight.
The postural control concerns mainly the workstation.
The regular practice of physical activity outside is essential. It is necessary to insist on the strict brace wearing during 2 hours after the sports activity.
2.3.5 Difficulties
Excessive mobilization of passive structures may lead to a progression of scoliosis, so the hyper flexibility is avoided and a position closest to that of the brace is better.
High thoracic breathing is less efficient than the usual abdominal breathing, and we must insist on improving the vital capacity for thoracic or double major curves. If lumbar scoliosis is treated, the risk of an increase of scoliosis during inspiration is low; however, breathlessness is to be avoided.
As the brace can be asymmetrical in the direction of the rebalancing of the spine, it will, however, always ensure the balance of the shoulder girdle.
2.3.6 Practice of sport
When the body is fully developed, we advise high-impact sports such as running and dance, to favor the fixation of the calcium on the bone and the constitution of an important bony mass.
In a specific way when ribs are asymmetric, we recommend avoiding deep and quick inhalation which favors the vertebral rotation and therefore the breathlessness during the practice of sports.
For lumbar curves, we advise, as well, against the quick flexions of the trunk forward or the position extending with an anterior flexion of the trunk.
During the period of maximal tensegrity up to 40 years, all sports can be performed at a high level as long as the spine is straight.
After 40 years, decreased intervertebral disc height and sarcopenia reduce the body’s performance.
After 65 years, osteoarthritis is predominant. Swimming avoids overloading the lower limbs and helps maintain lumbar lordosis (Table 4).
Age (girls)
Physiology
Activity (example)
15–21 years
Before complete bone mass
Jogging and running Axial impact and spiral chains
21–40 years
Before sarcopenia and osteopenia (tensegrity)
Fitness, sports reinforcing spiral chains
40 to retirement
Before extrapyramidal weakness (postural system)
Nordic walking, cycling
Retirement
Osteoarthritis, Pisa syndrome
Swimming
Table 4.
Sports activity according to the age.
2.4 Results
2.4.1 Bivalve polyethylene short brace with lateral overlap for lumbar scoliosis
Immobilization braces made of polyethylene have been used for more than 50 years in case of mechanical pain. They complement classical physiotherapy by reducing load by 30% at the lumbar spine. We specifically studied the 158 patients with 5-year follow-up from our prospective database [25].
The principle of bracing is completely different from that of adolescent scoliosis. Indeed, we try to:
Decompress the discs with the “sandglass effect” lifting the trunk under the ribs and transferring the load on the pelvis.
Rebalance the spine in both the frontal plane and in the sagittal planes, mostly by recreating lumbar lordosis.
Relieve pain by the analgesic effect of rigid low back brace.
A specific frame is used to stabilize the patient in the most corrective posture in the frontal and the sagittal plane.
For those patients who had a progressive scoliosis, Cobb angle is stabilized or improved by more than 5° in 80% of cases, and only 20% of scoliosis remain candidates for surgery [25].
The frontal and horizontal clinical parameters are improved, but not the sagittal parameters with the forward trunk projection (Figure 9).
Figure 9.
Insufficient correction in the sagittal plane.
The sternoclavicular support is poorly tolerated, and due to reduced dexterity in the older person, lateral closure is a handicap for elderly patients, even if adaptations are possible, that is why we currently use the 3 mm Europlex’O.
2.4.2 Nonsurgical orthopedic treatment of 62 adult vertebral deviations treated with adult ARTbrace
Instability in adulthood is frequent, and surgery is the most frequently offered solution despite the high rate of complications, as there was no alternative to date for thoracic and thoracolumbar curves. Only overlapped bivalve polyethylene braces were used for lumbar scoliosis with good frontal stabilization but no control in the sagittal plane (Figure 9). The ARTbrace in Europlex’O which allows an average reduction of 70% for the children has been used since 2015 in the adult for all the deviations.
The results of a consecutive series of 62 patients (6.2% of all ARTbrace patients) were treated between 2015 and 2016, as an alternative to surgery.
Nine patients (15%) which constitute the dropout were not seen at 6 months, which is very little considering the general condition and age of patients. The percentage of dropouts is identical to the previous series of lumbar curves treatments. Despite the very high rigidity, Europlex’O which needs a precision of 1 mm is therefore as well tolerated as polyethylene.
In the frontal plane, the average in-brace reduction is 27%, slightly higher for lumbar and thoracolumbar curvatures. The reduction to 2 years without brace is 15%, and especially the symptomatology of instability disappears. It is now possible to stabilize all thoracolumbar, thoracic, and double major scoliosis (Figure 10).
Figure 10.
Reduction in the frontal plane after decompensation upon arthrodesis.
In the sagittal plane, the average in-brace reduction is 32% and at 2 years without brace of 25% (Figure 11).
Figure 11.
Correction of kyphosis in the sagittal plane.
In the horizontal plane, some characteristic case study with EOS 3D confirms that adult ARTbrace is indeed, as in the child, a detorsion brace. Adult ARTbrace is the only brace to correct kyphosis and thus compensate for the insufficiency of polyethylene whose sternoclavicular support was not tolerated (Figure 12).
Figure 12.
EOS 3D confirms thoracolumbar spine detorsion in ARTbrace.
3. Discussion
Adult deformity is a major demographic health issue in the geriatric population. Surgeons are often very conservative in the treatment of adult scoliosis because of the complication rates associated with the surgeries and the marginal bone quality endemic to this population. Medical complications are a major concern in adult spinal deformity surgery [26]. The incidence ranges between 40% and 86%, but there is indeterminate level III/IV evidence on the effectiveness of any usual conservative care option. There is currently a lack of consensus on the most efficacious conservative treatments for adult deformity.
Very few results have been published concerning scoliosis adult bracing. Most of them only concern low back pain [27, 28]. Pain is the usual reason of medical consultation. Pain means instability when combined with the following clinical signs:
Frontal and sagittal Imbalance. The lumbar kyphoscoliosis is due to pelvic retroversion. The hips are extended under a retroverted pelvis, femurs were oriented downward and forward, and knees and ankles compensate with flexion deformity. Pelvic retroversion is limited by osteoarthritis of the hip, flexion deformity of the knee is poorly tolerated, and the patient will use a walking stick to walk. The thorax can enter in conflict with the pelvis at the concavity level pushing the viscera down. The patient suffers from breathing difficulty; digestive disorders are common and promote abdominal hypertension and sphincter disorders. The loss of lumbar lordosis has multiple causes: a decrease in the anterior height of the disc, hypertrophy of the facet joints and spinous process increasing the posterior height, and loss of extensors muscle strength [29].
In the horizontal plane, there is a rotation of the shoulder girdle as if the patient looks on the concave side of thoracic scoliosis. The pelvis is drawn by lumbar scoliosis. The convex hemi-pelvis moves back, and the hip is placed in internal rotation, while the concave hemi-pelvis moves forward, and the hip is placed in external rotation.
On each occasion when examining a patient at least every 5 years, verification X-ray is necessary in order to define a progression while being aware that in many cases the progression is chaotic.
The most characteristic sign of decompensating is the disc height loss that can sometimes exceed 10 mm. The disc corruption results in loss of physiological lordosis and ligament instability by hypermobility.
The losses of the gluteal muscles are very distinct when we make the plaster cast. It explains in part the pelvic retroversion; the spine tends to relocate along the line of gravity.
Muscular atrophy is a common criticism for rigid braces. In fact, the conservative orthopedic treatment does not suffer approximation. Its teamwork incorporates a specific physical therapy, the continuation of normal activity, and the practice of regular physical activity. No patient is wearing the brace for pleasure. The risk of overtreatment is zero.
Usually the total time bracing relieves pain, and the partial time bracing extends the improvement obtained. When the patient is not relieved, we can discuss the surgery with better arguments. The nonsurgical treatment treats the cause of lumbar instability mainly by discharging the pressure in the disc and stabilizing the lumbar area in lordosis to restore the tensegrity of the spine.
The esthetic improvement of the rib hump and asymmetrical waist is logical; the orthopedic brace is the best way to remodel a trunk. The cosmetic result continues 5 years after starting the treatment, with improvement of the rib hump measured with the plumb line and the Bunnel angle of trunk rotation (Figure 9).
The nonsurgical treatment can fit into a therapeutic progression. The indications may be progressive: observation, physiotherapy, medicine, conservative orthopedic Treatment, and surgery.
The good surgical indications concern the degenerative scoliosis not relieved by bracing, or relieved by total time, but insufficiently by partial time and especially if there is a spinal stenosis. It can also be used to complete surgery if remaining instability.
The Greek study [30] associating Schroth and Chêneau brace shows that patients have great difficulty to follow the protocol. For the quarter of patients following the protocol, the results are correct on pain and posture, but in 39% of patients, Cobb angle continues to increase.
Josette Bettany [31] confirms that for adult scoliosis, there are only a few studies on the effectiveness of PSSEs and a conclusion cannot yet be drawn. Recently a RCT proves the effectiveness of a motor and cognitive rehabilitation [32].
3.1 Differences between adult and non-adult bracing
The motivation of the patient is fundamental. The brace should be designed as a tool to facilitate physiotherapy.
The use of an instantaneous and accurate CAD/CAM is better because the adult patient can only maintain the corrected position for a few seconds.
The scan is made in deep inspiration to not limit the vital capacity.
The management is 4 hours a day including systematically for 2 hours after any physical activity. Physiotherapy is even more important than during adolescence [33].
4. Conclusion
The frequency of adult scoliosis makes it a public health problem. The new digital technologies have changed the adult scoliosis bracing, and conservative care in general may be a helpful option for adult deformity, but evidence for this decision was lacking. Lyon nonsurgical treatment is effective and offers new perspectives to adult scoliosis bracing. Not only does the brace relieve pain and support the spine, but for the first time, it corrects deviations in the frontal, sagittal, and horizontal planes. Immobilization braces in polyethylene allow a treatment of the cause of pain without side effects. Worn a few hours in the day, they complement physiotherapy. The first results confirm the excellent tolerance of Europlex’O adult ARTbrace with its ease of implementation and corrections unmatched to date in adults. These corrections make it possible to restore stability of the deviations without surgery. Adult scoliosis bracing as an alternative to surgery could be possible. Initially reserved for the most severe cases, this management deserves to be more widely used for adult scoliosis. The increasing number of CPO using the most modern CAD/CAM technologies should facilitate research in the field of very high rigidity.
Acknowledgments
Thanks to my daughter Agnès Thornton de Mauroy, for proofreading in English.
\n',keywords:"adult scoliosis, bracing, de novo scoliosis, camptocormia, Lyon method, nonsurgical, PSSE, ARTbrace",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/70179.pdf",chapterXML:"https://mts.intechopen.com/source/xml/70179.xml",downloadPdfUrl:"/chapter/pdf-download/70179",previewPdfUrl:"/chapter/pdf-preview/70179",totalDownloads:731,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:0,impactScore:0,impactScorePercentile:34,impactScoreQuartile:2,hasAltmetrics:0,dateSubmitted:"May 7th 2019",dateReviewed:"October 17th 2019",datePrePublished:"November 23rd 2019",datePublished:"April 14th 2021",dateFinished:"November 23rd 2019",readingETA:"0",abstract:"Unlike adolescent idiopathic scoliosis, bracing was used in adults less and was used more as a way of reducing pain. There is little publication of adult scoliosis series in the literature. The use of very high-rigidity and high-precision CAD/CAM technologies currently makes it possible to create corrective braces for the adult. The digital CAD/CAM cast in three blocks allows for precise correction at the pelvic, lumbar, and thoracic levels. This chapter presents the results of a series of 62 consecutive adult scoliotic patients treated with a corrective asymmetric detorsion brace of very high rigidity made in 2014–2016. Tolerance and angular correction results will be compared to those of 158 patients treated with the former bivalve polyethylene overlapping immobilization brace mainly used for lumbar scoliosis. The new Lyon adult ARTbrace is a detorsion brace adapted to all the curvatures which controls the sagittal plane. Despite a resistance four times greater than that of polyethylene of the same thickness, the tolerance of the Europlex’O is excellent as it is a “shock absorber,” and the anterior opening facilitates the use for very old people. Consequently, the aim of this chapter is to consider if it is possible to envisage for some patients an alternative to surgery, thanks to the new technologies of bracing.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/70179",risUrl:"/chapter/ris/70179",book:{id:"9154",slug:"spinal-deformities-in-adolescents-adults-and-older-adults"},signatures:"Jean Claude de Mauroy, Fabio Gagliano, Rosario Gagliano and Piera Lusenti",authors:[{id:"103819",title:"Dr.",name:"Jean Claude",middleName:null,surname:"De Mauroy",fullName:"Jean Claude De Mauroy",slug:"jean-claude-de-mauroy",email:"demauroy@aol.com",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/103819/images/2585_n.jpg",institution:null},{id:"304321",title:"Dr.",name:"Fabio",middleName:null,surname:"Gagliano",fullName:"Fabio Gagliano",slug:"fabio-gagliano",email:"fabio_gagliano@tiscali.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"304322",title:"Mr.",name:"Rosario",middleName:null,surname:"Gagliano",fullName:"Rosario Gagliano",slug:"rosario-gagliano",email:"r.gagliano@rogaenna.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"309354",title:"Dr.",name:"Piera",middleName:null,surname:"Lusenti",fullName:"Piera Lusenti",slug:"piera-lusenti",email:"lusentipie@libero.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_1_2",title:"1.1 Adult scoliosis instability",level:"2"},{id:"sec_1_3",title:"1.1.1 Bracing history",level:"3"},{id:"sec_2_3",title:"1.1.2 Frequency of adult scoliosis",level:"3"},{id:"sec_3_3",title:"1.1.3 Adult patients are different",level:"3"},{id:"sec_4_3",title:"1.1.4 Complications of surgical treatment vs. non-operative",level:"3"},{id:"sec_6_2",title:"1.2 Anatomo-pathological classification of painful instabilities",level:"2"},{id:"sec_7_2",title:"1.3 Classification of painful instabilities according to age",level:"2"},{id:"sec_8_2",title:"1.4 Natural history of idiopathic scoliosis from adolescent to adulthood",level:"2"},{id:"sec_9_2",title:"1.5 The two distinct entities",level:"2"},{id:"sec_10_2",title:"1.6 Risk factors for instability",level:"2"},{id:"sec_11_2",title:"1.7 Indications of bracing",level:"2"},{id:"sec_12_2",title:"1.8 Eligibility test",level:"2"},{id:"sec_14",title:"2. Methodology and results",level:"1"},{id:"sec_14_2",title:"2.1 Evolution of management",level:"2"},{id:"sec_15_2",title:"2.2 Aims of rigid bracing",level:"2"},{id:"sec_15_3",title:"2.2.1 Instability pain management",level:"3"},{id:"sec_16_3",title:"2.2.2 Muscle strengthening",level:"3"},{id:"sec_17_3",title:"2.2.3 Esthetics",level:"3"},{id:"sec_18_3",title:"2.2.4 Saving spine: development of compensations",level:"3"},{id:"sec_20_2",title:"2.3 Lyon method of physiotherapy for adult scoliosis",level:"2"},{id:"sec_20_3",title:"Table 3.",level:"3"},{id:"sec_21_3",title:"2.3.2 Lyon method during the total time",level:"3"},{id:"sec_22_3",title:"2.3.3 Physiotherapy during partial time bracing",level:"3"},{id:"sec_22_4",title:"2.3.3.1 Examples of basic exercises",level:"4"},{id:"sec_24_3",title:"2.3.4 Advice",level:"3"},{id:"sec_25_3",title:"2.3.5 Difficulties",level:"3"},{id:"sec_26_3",title:"Table 4.",level:"3"},{id:"sec_28_2",title:"2.4 Results",level:"2"},{id:"sec_28_3",title:"2.4.1 Bivalve polyethylene short brace with lateral overlap for lumbar scoliosis",level:"3"},{id:"sec_29_3",title:"2.4.2 Nonsurgical orthopedic treatment of 62 adult vertebral deviations treated with adult ARTbrace",level:"3"},{id:"sec_32",title:"3. Discussion",level:"1"},{id:"sec_32_2",title:"3.1 Differences between adult and non-adult bracing",level:"2"},{id:"sec_34",title:"4. Conclusion",level:"1"},{id:"sec_35",title:"Acknowledgments",level:"1"},{id:"sec_35",title:"Acronyms and abbreviations",level:"1"}],chapterReferences:[{id:"B1",body:'Vanderpool DW, James JI, Wynne-Davies R. Scoliosis in the elderly. Journal of Bone and Joint Surgery. 1969;51:446-455'},{id:"B2",body:'Schroeder JE, Dettori JR, Ecker E, Kaplan L. Does pregnancy increase curve progression in women with scoliosis treated without surgery? Evidence-Based Spine-Care Journal. 2011;2(3):43-50'},{id:"B3",body:'Akbarnia BA, Ogilvie JW, Hammerberg KW. Debate: Degenerative scoliosis: To operate or not to operate. Spine. 2006;31:S195-S201'},{id:"B4",body:'Edgar MA, Mehta MH. Long term follow-up of fused and unfused idiopathic scoliosis. Journal of Bone and Joint Surgery. 1988;70-B:712-716'},{id:"B5",body:'O’Brien J. Living with scoliosis: An adult perspective. 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Case reports: Orthotic treatment of adult scoliosis patients with chronic back pain. Scoliosis. 2014;9:18. DOI: 10.1186/1748-7161-9-18'},{id:"B29",body:'York PJ, Kim HJ. Degenerative Scoliosis. Current Reviews in Musculoskeletal Medicine. 2017;10(4):547-558'},{id:"B30",body:'Papadopoulos D. Adult scoliosis treatment combining brace and exercises. Scoliosis. 2013;8(Suppl 2):O8. DOI: 10.1186/1748-7161-8-S2-O8'},{id:"B31",body:'Bettany-Saltikov J, Turnbull D, Ng SY, Webb R. Management of spinal deformities and evidence of treatment effectiveness. The Open Orthopaedics Journal. 2017;11(Suppl-9, M6):1521-1547'},{id:"B32",body:'Monticone M, Ambrosini E, Cazzaniga D, Rocca B, Motta L, Cerri C, et al. Adults with idiopathic scoliosis improve disability after motor and cognitive rehabilitation: Results of a randomised controlled trial. European Spine Journal. Oct 2016;25(10):3120-3129. Epub 2016 Mar 25'},{id:"B33",body:'de Mauroy JC, Vallèse P, Lalain JJ. Lyon conservative treatment of adult scoliosis. Minerva Ortopedica e Traumatologica. 2011;62(5):385-396'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Jean Claude de Mauroy",address:"demauroy@aol.com",affiliation:'
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1. Introduction
It is a characteristic of our common human identity that young children are endowed with a high level of curiosity and are eager to learn. Making sense of their world is critical not just for their well-being but for their very survival. How the adult world responds to this is overwhelmingly crucial that has been recognized for generations and enshrined in the famous Jesuit saying: give me the child till he is seven and I will give you the man [1]. Yet, history tells us that children have not always been treated positively at the hands of adults. It was the philosopher Jean-Jacques Rousseau at the end of the eighteenth century in his iconic book ‘Emile’ who challenged the prevailing social attitude to children at that time as being born in sin, the consequence for the adult world being to make children good [2]. Rousseau turned this deeply embedded attitude on its head and advocated that children were actually born good with the consequence that it was the responsibility of adults [and Education] to keep them good and shield them from evil.
History also tells us that the adult world’s responsibility to children has often been wanton. In the nineteenth century when the industrial revolution in the western world was at its height children as young as five years of age were sent to work for long hours in factories. They were treated as slaves. In the twentieth century children were often regarded as a necessary nuisance. Children should be seen and not heard was the social attitude of the adult world at that time. Even in contemporary times, the abuse of children by adults is all too frequently evident. It is beyond belief to any reasonable person that not an insignificant number of adults get gratification by inflicting children to profound traumas. Less dramatic but of equal concern is the attitude of many parents that it is their right to be able to punish children physically for behavior considered unacceptable by inflicting pain, a ‘right’ that was very recently overturned in Scotland by legislation making it illegal for parents to smack their child [3]. But, for the vast majority of children, childhood can be a happy and challenging time which, at last, is being recognized by governments and society at large. There is widespread determination and resolve to provide children with experiences that will have positive proven long-term effects on the quality of their lives. How these experiences are designed largely depends both on our understanding of childhood and the prevailing ideology in any given society.
2. Constructions of childhood
It was the work of Berger and Luckman [4] that first alerted scholars to the fact that the adult world through culture and ideology imposes conceptual constructions on different groups in society. Childhood and senior citizenship are two examples. Different cultures attribute different characteristics to the different stages in the human life span (for example, innocence in the case of children, relative helplessness in the case of senior citizens) such that their individual members are treated in the context of these constructions often in conflict with their actual reality. In terms of childhood, social constructionism seeks to understand how children and knowledge about childhood is constructed by whom, why and most substantially what purpose it serves [5]. The social construction of childhood plays a powerful role not only in shaping the experiences afforded to children by the adult world but also in the emergence of their individual identities (what am I?) and subjectivities (who am I?). This powerful process of cultural socialization takes place at the hands of both parents (and carers) and the architects of education- teachers, administrators and politicians, often subconsciously.
Any specific social construction of childhood is not universal. It differs remarkably in different parts of the world. Childhood is neither universally similar nor natural rather it is tied close to social circumstances and cultural process [5]. Such cultural process forms part of what Bronfenbrenner described as the macro-level of social influence in his work on the ecology of childhood [6]. In the contemporary world, it is possible to identify three macro constructions of childhood: the tabula rasa child, the developing child and the agency child. Each one of these constructions have fundamental implications for Education. They exert a significant influence on how education is defined, understood and practised in different countries.
The tabula rasa construction of childhood basically regards children as ‘empty’ vessels that have to be filled with knowledge and skills through a process of instruction augmented by extensive assessment. It has been and continues to be a very evident construction in Asian countries. At the elementary school stage, the learning space in schools has been organized in a traditional way with individual desks facing the front of the classroom in which the teacher was expected to impart the subject knowledge of the ‘lesson’. Furthermore, many parents considered this to be the ‘right’ way that their children should be educated. To this day, parents in Asian countries exert pressure on their children to get high grades in a formal ‘test- loaded’ pedagogy as their child’s life-chances depend on such grades. It comes as no surprise that the performance of children in the fields of math, science and reading in the tiger-economic countries such as Singapore, Japan and Hong Kong are at the top of international league tables such as PISA [7].
The developing child construction regards childhood as a period in the human life span when children naturally pass through universal and sequential stages of development. One of the chief proponents of this construction was the Swiss psychologist Jean Piaget whose work contributed to the growth of the academic field of activity known as Developmental Psychology. It was considered that children’s natural maturation processes interact with their experiences of the world which then make them ‘ready’ for the next more mature stage. One can find this construction of childhood very much in evidence in public documents and institutions in countries such as the UK and the US and is often embedded in the documentation of national guidelines for teachers in the early childhood education and care sector (ECEC). One consequence of this construction was the emergence of ‘child-centred’ and progressive education. In the 1960’s national reports issued by educational review bodies set up by the UK Government [8, 9] trumpeted the virtues of locating the child’s needs at the centre of the education process. Children’s natural curiosity and the desire for understanding had to be respected in the form of learning through experience and activity. Although this approach to the education of children was formally accepted in the 1960’s, it had been advocated in a formal review of Primary Education some 30 years previously which recommended that the curriculum is to be thought of in terms of activity and experience rather than knowledge to be acquired and facts to be stored [10].
The agency child construction is relatively new and has emerged from Scandanavian countries in the last 25 years, particularly in Sweden. Fundamentally, ‘agency’ is a mind-set that brings us face to face with the political question of how we can motivate ourselves and others to work for social change and economic justice [11]. In Sweden, children are encouraged to learn how to take control of their own lives through a process of self-formation such that they consciously resist the ‘technologies of domination’ that operate in society [12]. Central to this process is the importance attached to democracy at all levels of society. Children are taught from a very early age not only about the importance of democratic decision-making but they are also taught to be critical and to question the authority of grown-ups. Children’s ‘voices’, their opinions and their preferences are given validity not only throughout the Education system in Sweden but in individual families even when children are young [13].
Each of the above constructions of childhood is both culturally and ideologically located. How any given society at any given time endorses a specific political ideology determines which construction of childhood plays out in the ecology of children’s lives though in many societies there is an on-going conflict between different constructions particularly in the US. In most countries throughout the word the State now plays an active role in determining what counts as Education. It is part of the ideological State apparatus first articulated by Althusser [14] to maintain social order and stability.
3. Ideology and early childhood education
A major challenge for ECEC is the ideology in which both the policy and practice are rooted. The term ‘ideology’ emerged from the political and revolutionary turmoil in France at the end of the eighteenth century [15, 16] though as a concept it was first used by Francis Bacon in the sixteenth century. It was originally associated with a profound shift in a ‘world view’ from an essentially disposition based on superstition and religious dogma to a disposition based on scientific and logical thought rooted in the Scottish Enlightenment associated with two Scottish philosophers Adam Smith and David Hulme [17]. It is a disposition that initiated the period of intellectual thought now known as ‘Modernity’ in Western and other English-speaking countries and resulted in significant financial prosperity for some and devastating poverty for others. However, during the subsequent 100 or so years its meaning evolved into its present conception based on fundamentally different sets of axiomatic principles concerning a society’s social and economic arrangements in particular the relationship between the State, its institutions, the family and the individual.
In present-day democratic and capitalist countries policy and practice in Education, particularly in ECEC, has been influenced by three dominant political ideologies which are competing for our future. They are: Conservatism, Liberalism and Social Democracy. Each of these ideologies has a set of powerful social and economic principles, often adopted by people with fervent belief though there are significant contested variants and overlaps both within and between them [18].
Of the three democratic ideologies conservatism has perhaps the longest lineage in history. Its variant or extreme form, referred to as neo-liberalism, has been and continues to be highly influential, particularly in present-day USA [19, 20]. In basic and perhaps over simplified terms, one of conservatism’s dominant principles is often referred to as the laissez-faire principle. This means that the State should play a minimalist role in social and economic affairs and allow individuals to flourish whose behavior is driven by self-interest and the accumulation of wealth and prestige. Extensive provision of welfare is regarded as counter- productive to encouraging self-discipline and the ‘work-ethic’. Welfare should only be provided by the State as the ultimate ‘safety net’. The family or private foundations should take responsibility for supporting the vulnerable by providing the necessary welfare. In its more extreme form (that is, neo-liberalism) ‘market-forces’ should be encouraged not only in business and financial institutions but also in social services particularly in education, welfare and often health. Secondly, a society’s prosperity is generated by unregulated competition as competition encourages greater efficiency and value for money. Thirdly, inequalities of wealth and prestige reflect ‘natural’ human differences so it is inevitable that some people will become wealthy and some people will become poor. The State should therefore refrain from initiatives in ‘social-engineering’ as they are doomed to fail. Fourthly, priority should be given to the maintenance of law, order and respect for a strong hegemony where citizens know and accept the existing social hierarchy.
In contrast, at the heart of Liberalism is the freedom, well-being and welfare of the ‘individual’ though there is some divergence between the original principles of Liberalism and individuals being liberal-minded [15]. It is taken for granted that if individuals seek to improve themselves morally, socially and educationally society will also improve. Liberalism maintains that the State should allow individuals to be free to choose their own life - style, to be free to express their views/opinions without fear of punishment or recriminations as these matters, according to Liberal ideology, make a profound contribution to the ‘sum of human happiness’. In addition, citizens in a democratic society should be allowed to choose how they are governed by the State as this principle is the bedrock of democracy. Coupled with this, people are expected to be self-reliant, tolerant and to show respect for others. Cooperation at all levels of society, respect for human rights and social justice and the provision of welfare for the vulnerable are also basic principles of Liberal ideology. Critically important for Education is that the State should pursue policies aimed at providing opportunity for all irrespective of ‘race’, gender, socio-economic status, sexual preference and disability.
Social Democracy, described in the UK as the Third Way [21], is a relatively new ideology and has some overlap with Liberalism. The hallmark of Social Democracy is the concept of the Managed State whereby the State promotes social inclusion, social justice and individual happiness such that every citizen can participate, should they so choose, in fair and free social services (including Education, medical services and leisure activities) provided by the State throughout their lives. Inevitably such universal provision by the State requires citizens in employment to pay relatively high taxes in countries where Social Democracy is dominant, for example, in Sweden. However, Social Democracy should not be confused with the ideology of Socialism where the State controls the social and economic affairs in the name of egalitarianism. Under Social Democracy individual choice is paramount. In addition, throughout government, its institutions and the family there should be no authority without democracy. The application of this principles requires anyone who is invested with authority such as parents, teachers and school principals to negotiate their decision -making with students and children and not to resort to authoritarian dogma.
In countries where conservative ideology is highly influential, the tabula rasa construction of childhood is highly visible. This is reflected in both the policy and practice of ECEC. In many ECEC establishments there is an overwhelming emphasis on instrumental learning where young children are expected to acquire both knowledge about their world and skills to operate in the world [22]. This has been the modus operandi both in many Asian countries and recently in sections of US and UK societies, particularly in the private sector of ECEC provision where parents can exert considerable influence by financial means. As a result, childcare markets with their business priorities have been created which appeal to narrowly defined individualized self-interest where parents are treated as consumers. Accompanying the rise of the market has been a discourse of childcare as a commodity-a commodity marketed and sold to its consumers (read parents) as a private benefit [23].
In the US the origins of this development can be found the federal report Good Start, Grow Smart [24] which called for state agencies that receive federal dollars to provide education programs for children three to five to develop early learning standards on pre-reading, language skills and mathematical knowledge [22]. As a consequence, children’s performance on academic type tests in ECEC became the marker of the success of the ECEC system thereby severely limiting children’s learning experience to instrumental learning to the detriment of experiential learning in terms of affective, esthetic, emotional, and social learning. If a kindergarten was failing to meet the set standards many parents were eager to transfer their child to the private sector if they could afford it. This is also the situation in Taiwan where the cost of sending a young child to a high-status kindergarten in the private sector can be four times more than the annual fee for a university place for an older child [25]. However, many professional ECEC educators, particularly in the US, have challenged the childcare market mentality by raising the awareness of teachers in training to the limitations of this approach as it does not help children to become critically engaged democratic citizens [22].
In contrast to the above, Liberal ideology with its emphasis on the individual and alignment with the developing child social construction of childhood has a very different perspective on Education. It became dominant in the UK in the 1960’s and played a powerful role in reshaping the entire Educational systems in three of the countries that are constituent parts of the UK, that is, England, Wales and Scotland. As far as ECEC was concerned a pedagogy firmly rooted in a holistic approach by supporting young children to learn though play was universally adopted. Instruction and formal assessment by ‘testing’ children had no place in ECEC. In Scotland, Figure 1 shows the aims of ECEC which were set out by Government in 1994.
Figure 1.
Aims of pre-school education in Scotland [26].
These aims were subsequently incorporated into the national curriculum guidelines for children aged 3 to 5 and adopted by ECEC establishments in both the public and private sectors [27]. To the present day, the aims outlined in Figure 1 act as a yardstick for a ‘quality’ ECEC experience. They are fundamental to the recent re-structuring and integration of the school curriculum in Scotland referred to as the Curriculum for Excellence [28] in which the same eight themes are common to the schooling process from age 3 to 18. However, as in many countries, the availability of ECEC services is based on a mixed economy model that consists of public, private and voluntary services with the provision of childcare regarded as a form of social welfare for children in vulnerable circumstances. Although ECEC services in the UK are now free and universally available for all children aged 3 to 5, the provision financed by the State is only available on a part-time basis.
The agency social construction of childhood is very much evident in the ideology of Social Democracy which emerged in Sweden in 1995 with the election of a Social Democratic government. In Sweden, Education from the age of one (with no upper limit) is virtually free for all children and adults and funded by the State. In a child’s first year of life parents are entitled to generous parental leave allowance from work with return to their job protected by law after one year. All children are entitled to six years of full -time ECEC before formal schooling starts at the age of 7. Whilst ECEC in Sweden endorses many of the educational aims associated with Liberal ideology (see Figure 1) it gives much greater priority to children learning about democracy, social justice and the environment from an early age. Listening to ‘children’s voices’ is very much part of day-to-day activity. Another hallmark of education under the mantle of Social Democracy is the concept of integration. The curriculum from age 1 to 18 is integrated and the same themes are used throughout the schooling system. Welfare (when needed) is integrated into all ECEC provision. In Sweden, children are encouraged to express criticism of the experiences provided by adults without fear of recrimination and without the adults feeling threatened. It is not surprising therefore that the Swedish system of ECEC has been widely applauded [13]. Neither is it surprising to find that children in Sweden, on the whole, are confident, capable and successful.
4. Contemporary challenges for early childhood education and care
The overwhelming challenge for ECEC in the modern world that is now required is to address the deep divisions, both social and economic, that have emerged in many countries throughout the word during the Age of Modernity and at the same time both to respect and celebrate diversity in a way that children come to understand how they can make a positive contribution to this process. The challenge is both exciting and daunting as it requires enlightened professionals, politicians and parents to engage in a new dialog informed by a fundamental awareness of the deep-seated problems facing humanity. But where to start? There is a very powerful case for ECEC being in the vanguard of educational reform.
First, over the past 30 years there has been several large-scale longitudinal studies which have reported on the long-term effects of ‘quality’ ECEC [29, 30, 31, 32]. The findings of these studies consistently show that young children’s experience of high quality ECEC has a long-lasting positive effect on their later opportunities and success both in schooling and in adulthood. Secondly, and more specifically, there are studies that demonstrate the economic benefits of ECEC particularly in terms of productivity and economic efficiency in the workplace [31]. Thirdly, recent developments in neuroscience, particularly in the field of social cognitive neuroscience, provide evidence that socio-emotional competence develops as a function of changes in the dynamic interaction between regulatory processes that lesson such reactions as stress and anxiety [33]. Fourthly, and very important, is the research in the field of health, both mental and physical well-being which shows that ECEC can help to prevent disease and mental instability [34].
It is now abundantly clear that, taken as a whole, this body of research and scholarship makes an immensely strong case for investment and reform in ECEC.
4.1 The challenge to governments
Drawing on the Swedish system of ECEC where there is a common educational experience for children in their pre-school years financed from public funds, the challenge for governments in the developed world is to reform the relationship between the public and private sectors in ECEC provision in countries where such a division exists. One example of a national government currently taking a policy initiative is in Scotland. The Scottish Government and local authorities have committed to making an unprecedented investment in ECEC through near doubling of the funded entitlement from August 2020 for all three- and four-year old children and eligible two-year olds in all ECEC sectors- public, private and voluntary [35].
Scotland has had a devolved administration since 1997 and currently has a minority Nationalist government which ideologically is liberal and centre-left politically. It is very committed to expanding and improving early learning and childcare (referred to as ELC in Scotland) by allocating considerable new resources to the sector.
Since the introduction of free part-time places 20 years ago for all three- and four-year old children subject to parental wishes, virtually all can now access two years of free ELC before the start of primary school at age 5 (see Table 1 below). The new policy also includes the provision of ELC for ‘eligible’ two-year old children. The criteria for such eligibility are aimed at those children who experience the greatest disadvantage from their circumstances and includes children from low socio-economic status families receiving State benefits who are often single-parent families with vulnerable children.
Type of setting
%
Local Authority nursery school/class
62
Other local authority setting
15
Private and voluntary providers
23
Table 1.
Percentage of children in Scotland aged 5 by 2015 attending an ELC setting by type [32].
From Table 1 it can be seen that access to ELC in Scotland is very high. The problem, however, is not that places aren’t available but that places in the public sector are largely part-time (3 hours per day). Private sector provision tends to be open most of the day and throughout the year and is more compatible with the routine of working parents. The problem largely impacts on women either by limiting their scope for a successful career or by downloading stress in the management of their domestic arrangements.
With regard to the specific aspects of the policy [35] the principles and practice focus on the expansion and improvement of ELC services in public, private and voluntary provision. It intends to do this by requiring all providers of ELC services which enter into a contract with the local authority to meet new ELC National Standards (see Figure 2) in order for the private and voluntary sectors to access direct government funding for providing an ELC service for 1140 hours per year for each child who is admitted. Included in the 10 National Standards is the requirement for the private and voluntary sectors to provide a common educational experience consistent with the National Curriculum.
Figure 2.
The list of National Standards for ELC provision in Scotland [35].
To ensure compliance with the above Standards the National Care Inspectorate (NCI) will make unannounced visits to ELC settings and publish reports which will be available in the public domain making them universally accessible. With regard to National Standard 3 in Figure 2, new arrangements are currently being developed to instigate joint inspections of all ELC settings between the NCI and Her Majesty’s Inspectorate for Education (HMIE). If a specific setting is considered unacceptable on any of the Standards, the NCI can require that the setting address its shortcomings within a given time period and has powers to close the setting altogether in acute circumstances.
The policy of the Scottish Government is a bold attempt to bring the private and public sectors of ECEC provision into close alignment whilst still recognizing the parents should be able to make choices for their children which are not based on their ability to pay expensive fees for high-status institutions in the child-care market. The new policy adopts a ‘funding follows the child approach’ whereby parents (and carers) can access their child’s funding entitlement from any ELC setting in the public, private or voluntary sectors. The criteria for choosing an ECEC setting for one’s child will now become wider and based more on the geographic location, the opening hours of the setting and the NCI inspection reports as opposed to family income.
The second major challenge for national and local governments is to instigate a root and branch review of national curriculum guidelines for ECEC with a view that the guidelines be re-structured. To do so, requires governments to outline what they regard as the primary purpose of ECEC. The detailed re-structuring should then be undertaken by representatives of the various stakeholder groups in ECEC.
4.2 The challenge to ECEC settings and ECEC professionals
In the modern world, the thinking associated with post-modernism is gathering momentum [36]. It is crucially relevant for ECEC [13]. At the onset of the Age of Modernity some 250 years ago the dominant intellectual challenge and inspiration at that time was to differentiate between rational/scientific thinking and thinking based on superstition rooted in religious dogma. It is a mode of thinking that has dominated the English- speaking world for over two centuries and still acts as a dominant driver for many people. The world now faces a new challenge, the challenge of post-modernism which requires us to differentiate between the ‘self’ and the ‘social’ in our understanding, awareness and behavior. ECEC is heavily implicated in the transition from modernity to postmodernism and carries an immense responsibility.
Central to this responsibility is the requirement to focus children’s learning to encompass the two concepts of social justice and social responsibility. Social justice encompasses three main themes: fairness, opportunity and respect and are axiomatic to how the adult world intersects with childhood. The challenge for ECEC settings is to make a public declaration that the principles of social justice are pursued in the setting in which children are encouraged to become aware about fairness, to take up new and challenging opportunities and to respect the views of others [25]. Such a declaration needs to be negotiated with the children’s parents as it contains sensitive and potentially threatening challenges to many parents whose mind-sets may be deeply rooted in a particular ideology outlined above. Keeping parents informed about all aspects of the setting is a vital part of effective communication [12], not least to offer advice about ensuring that their child is enthusiastically engaged in the learning process and is aware of the importance of social responsibility.
Throughout 2020 and well into 2021 the lack of social responsibility particularly in many western countries has become a matter of deep concern and deeply shameful. The rapid spread of the deadly virus covid 19 has taken place as a consequence of enormous number of people rejecting the scientific advice aimed at limiting the spread of the virus. Is this a failure of education on a massive scale such that acceptance of constraints on individual freedom in times of crisis has been abandoned? ECEC settings and professionals need to recognize that fundamental rethinking is required. The curriculum needs to be restructured to embrace social justice at the core. In addition, teachers need to become more aware about how the ‘hidden curriculum’ impacts on children’s subjectivity. The discourse that teachers use, often subconsciously, with children both individually and collectively, plays a significant role in shaping children’s social attitudes [37].
A critical issue in this transformation is the professional education of teachers. Initially, the selection of students for access to courses of initial teacher education (ITE) should be revisited such that those admitted be required to display a commitment to social justice. Specific courses in social justice should be included in the curriculum. Furthermore, the organization of ITE courses needs to be re-thought. Without too much upheaval, it should be possible to introduce new arrangements such that all ITE students attend the same classes and courses for at least the first year in order to acquire a common understanding of what it means to be a ‘teacher’ such as currently happens in Sweden [13].
Another challenge to ECEC professionals is the need for each ECEC centre to develop policies and practices that are inclusive of all children’s contemporary diverse characteristics. These policies are more effective when they are developed in consultation with staff, families, communities and relevant stakeholders so that different perspectives are included (12). The celebration of diversity should indeed resonate throughout each ECEC centre where staff offer all children guidance and support in developing positive attitudes towards all people [38].
4.3 The challenge to parents
It has become evident in many countries throughout the world that parents now understand the value of ECEC and want access to ECEC services for their young children before they start elementary school. This is a major change in social attitude from that 50 years ago when the education of young children was regarded as the sole responsibility of the family, principally mothers. Yet, under the influence of ne0liberalism, many parents are ignoring the long- term benefits of ECEC for their child’s psychological and social well-being for the possible short- term advantages which they think will lead to greater economic benefits for their child in the future [23].
However, even though their child may attend an ECEC setting, this does not mean that parents should take ‘a back seat’. Parents still have a responsibility to engage with their children in helping them to understand, be knowledgeable, be socially competent and gradually become aware of the wider world. The challenge to parents in supporting their children to be successful is to ‘raise your game’ through more meaningful engagement both with the child and the ECEC setting. Children learn a great deal about their identity and subjectivity from their parents in the first few years of life. The foundations of their social attitudes are subconsciously transmitted from parent to child through discourse that often contains deeply held values about the world at large [36]. This means that parents need to become more aware of how they interact with their children even at a casual level. All too often many parents with busy lives are content to have their children self-engaged with, for example, an electronic device to play games or watch a video over lengthy periods of time. Such action on the part of parents is a form of abuse of the parent–child relationship and can lead to an addiction which is socially disengaged.
Reading stories with children is another activity that is popular with many parents. However, the choice of stories is critical. Parents should not shy away from choosing stories that contain sensitive issues regarding race, gender, socio-economic status and even same-sex relationships as well as stories that feed children’s imagination. Such situations are ideal for helping children to learn how to regulate their socio-emotional learning and for parents to encourage children to reflect on the behavior of others as actors in the stories keeping in mind the principles of social justice and social responsibility.
Social responsibility can also be practiced in the family even when children are young.
Children should be encouraged to participate in domestic routines. Helping to plan and prepare meals and tidy up afterwards as collaborative activities are valuable situations for the effective socialization of children.
Parents can also help their child to establish social networks with other children and show an active interest in their child’s social relationships. A key aspect of children’s learning about relationships is their awareness of ‘others’. Parents have considerable influence in helping children to raise their consciousness concerning how their actions impact on others such that they are able to regulate their actions with friends, family members and strangers especially at the level of micro-social engagement.
5. Conclusion
It is becoming evident to many that the education of children, particularly young children, now faces a daunting challenge. The increasing social and economic divergence in the modern world is staggering and potentially a major threat to our stability and security. But can the key stakeholders in education recognize the challenge and embrace a commitment to adapt policies and practices to address a fundamental re-alignment in the mind-set of children in terms of their social attitudes and social justice? First, it requires an awareness that education is deeply implicated in efforts to bring about greater fairness, more opportunities for young people and respect for others. Teachers have a very considerable responsibility in their day-to-day engagements with children so they need to be persuaded not only that reform in a post-modernist context can be achieved but also that many current social attitudes and injustices must be challenged. Reform is possible, but it needs the understanding, the commitment and the vision in those empowered to instigate it. Second, it needs parents to become more aware about the power they exert over their children and to use that power in a more democratic way to promote social justice. Such is the challenge for the education of children in modern times.
\n',keywords:"young children, education, ideology, postmodernism, social justice, social responsibility",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/77529.pdf",chapterXML:"https://mts.intechopen.com/source/xml/77529.xml",downloadPdfUrl:"/chapter/pdf-download/77529",previewPdfUrl:"/chapter/pdf-preview/77529",totalDownloads:230,totalViews:0,totalCrossrefCites:0,dateSubmitted:"January 30th 2021",dateReviewed:"June 15th 2021",datePrePublished:"July 14th 2021",datePublished:"December 15th 2021",dateFinished:"July 13th 2021",readingETA:"0",abstract:"Over the past two centuries the Age of Modernity has dominated intellectual thought and related actions predominantly in the English-speaking world. It is now becoming increasingly recognized by academics and powerful organizations both nationally and internationally that the consequence of this mode of thinking has generated immense problems for the contemporary world. The level of social and economic inequalities that continue to increase has now become the concern of many, particularly those who identify with the thinking and ideas associated with the emerging Age of Post-Modernity. The challenge to Education is profound not least so in how young children’s awareness, knowledge and understanding about the society in which they live is transmitted, often unwittingly, initially in families and subsequently in kindergartens and schools. This paper first addresses the main social constructions of childhood that can be identified in democratic countries and then links these constructions to the three dominant ideologies that exert axiomatic influence on the education process in different countries. Emerging from this brief analysis the paper identifies three fundamental and important challenges to those with responsibility and influence on young children’s education be they in governments, educational institutions or families.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/77529",risUrl:"/chapter/ris/77529",signatures:"John Eric Wilkinson",book:{id:"9535",type:"book",title:"Education in Childhood",subtitle:null,fullTitle:"Education in Childhood",slug:"education-in-childhood",publishedDate:"December 15th 2021",bookSignature:"Olga María Alegre de la Rosa, Luis Miguel Villar Angulo and Carla Giambrone",coverURL:"https://cdn.intechopen.com/books/images_new/9535.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83969-015-0",printIsbn:"978-1-83969-014-3",pdfIsbn:"978-1-83969-016-7",isAvailableForWebshopOrdering:!0,editors:[{id:"338767",title:"Prof.",name:"Olga María",middleName:null,surname:"Alegre de la Rosa",slug:"olga-maria-alegre-de-la-rosa",fullName:"Olga María Alegre de la Rosa"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"338161",title:"Dr.",name:"John",middleName:"Eric",surname:"Wilkinson",fullName:"John Wilkinson",slug:"john-wilkinson",email:"j.e.wilkinson@educ.gla.ac.uk",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Constructions of childhood",level:"1"},{id:"sec_3",title:"3. Ideology and early childhood education",level:"1"},{id:"sec_4",title:"4. Contemporary challenges for early childhood education and care",level:"1"},{id:"sec_4_2",title:"4.1 The challenge to governments",level:"2"},{id:"sec_5_2",title:"4.2 The challenge to ECEC settings and ECEC professionals",level:"2"},{id:"sec_6_2",title:"4.3 The challenge to parents",level:"2"},{id:"sec_8",title:"5. Conclusion",level:"1"}],chapterReferences:[{id:"B1",body:'Donohue J W. Jesuit Education. New York: Fordham University Press; 1963'},{id:"B2",body:'Rousseau J J. Emile. London: J.M. Dent & Sons Ltd; 1911'},{id:"B3",body:'Scotland Act Children (Equal protection from Assault); 2019'},{id:"B4",body:'Berger P, Luckman T. The Social Construction of Reality. Harmondsworth: Penguin; 1966'},{id:"B5",body:'Norozi S A, Moen T. Childhood as social construction. 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Maidenhead: Open University Press; 2006. 13:9780335216826'},{id:"B13",body:'Cohen B, Moss P, Petrie P, Wallace J. ANew Deal for Children. Bristol: Polity Press; 2004. 1 86134 528 3'},{id:"B14",body:'Althusser L. Ideology and ideological state apparatuses. In Sharma A, Gupta A. (editors) An Anthology of the State-a Reader. Oxford: Blackwell; 2006'},{id:"B15",body:'Eccleshall R, Geoghegan V, Jay R, Wilford R. Political Ideologies. London: Hutchinson; 1984. 0 09 156131 0'},{id:"B16",body:'Matheson C. Ideology in Education in the United Kingdom. In Matheson D. (editor), An Introduction to the Study of Education. London: Routledge; 1994. 13: 978-0-415-45365-3'},{id:"B17",body:'Smith C. The Scottish Enlightenment: unintended consequences and the science of man. Journal of Scottish Philosophy, 7(1), 9-28; 2009. 1479-6651'},{id:"B18",body:'Ecceleshall R, Geoghagan V, Jay R, Kenny M, MacKenzie I, Wilford R. Political Ideologies: And Introduction [second edition]. London: Routledge; 1994'},{id:"B19",body:'Hursch D. Neo-liberalism, markets and accountability: Transforming education and undermining democracy in the United States and England. Policy Futures in Education, 3, 3-15; 2005'},{id:"B20",body:'Nonini D M. Thinking about neo-liberalism as if it mattered. New York: Berghahn Publishing; 2005'},{id:"B21",body:'Giddens A. The Third Way. Bristol: Polity Press; 1998. 0-7456-2267-4'},{id:"B22",body:'Brown C P. Confronting the contradictions: A case study of early childhood teacher development in neoliberal times. Contemporary Issues in Early Childhood, 10(3), 240-259; 2009'},{id:"B23",body:'Press F, Woodrow C, Logan H, Mitchell L. Can we belong in a neo-liberal world? Neo-liberalism in early childhood education and care policy in Australia and New Zealand. Contemporary Issues in Early Childhood, 19(4), 328-339; 2018'},{id:"B24",body:'Office of the White House Good Start, Grow Smart: the Bush administration’s early childhood initiative; 2002. http://www.whithouse.gov/infocus/earlychildhood/sect.html'},{id:"B25",body:'Wilkinson J E. Social Justice in Educational Policy and Practice with Particular Reference to Early Childhood. In Papa R, (editors). Handbook of Social Justice in Education. Springer: Cham; 2019. 10.1007/978 3 030 14625 2 7'},{id:"B26",body:'The Scottish Office Education of Children under5 in Scotland. Edinburgh: The Scottish Office; 1994. 0 7480 0872 1'},{id:"B27",body:'Learning and Teaching Scotland. A Curriculum Framework for Children 3 to 5. Glasgow: Learning and Teaching Scotland; 1999. 1-85955-670-1'},{id:"B28",body:'Education Scotland. A Curriculum for Excellence. Glasgow: Education Scotland; 2013'},{id:"B29",body:'Berrutta-Clement J R, Schweinhart L J, Barnett W S, Epstein A S, Weinhart D P. Changed Lives-the Effects of the Perry Preschool Program on Youths through 19. Monograph 8, High/Scope Educational research Foundation. Ypsilanti: High/Scope Press; 1984. 0-931114-28-4'},{id:"B30",body:'Sylva K, Mellhuish E, Siraj-Blatchford B, Taggart, B. The effective provision of pre-school education [EPPE] project: final report. Annesley: Department for Education and Skills; 2004'},{id:"B31",body:'Heckman J J. The economics of inequality: the value of early childhood education. American Educator, 35(1), 3; 2011'},{id:"B32",body:'Knudsen L, Currie E, Bradshaw P. Change in Early Learning and Childcare Use and Outcomes at Age 5: comparing two Growing Up in Scotland Cohorts. Edinburgh: ScotCen Social Research; 2017'},{id:"B33",body:'Zelazo P D, Lyons K E. The potential benefits of mindfulness training in early childhood: a developmental social cognitive neurological perspective. Child Development Perspectives, 6(2), 154-160; 2012'},{id:"B34",body:'Conti G, Heckman J J, Pinto R. The effect of two influential early childhood interventions on health and healthy behaviour. The Economics Journal, 126(596), F28-F65; 2016'},{id:"B35",body:'Scottish Government. A Blueprint for 2020: The Expansion of Early Learning and Childcare in Scotland: Principles and Practice. Edinburgh: Scottish Government; 2018'},{id:"B36",body:'Usher R, Edwards R. Postmodernism and Education. London: Routledge; 1994. 0-415 1028-1022'},{id:"B37",body:'Foucault M. Power/Knowledge (c. Gordon, trans.). New York: Pantheon Books; 2018'},{id:"B38",body:'Siraj-Blatchford I. Diversity, Inclusion and Learning in the Early Years. In Pugh G & Duffy B. (editors) Contemporary Issues in the Early Years. London: SAGE; 2010. 978-1-84787-592-1'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"John Eric Wilkinson",address:"jericwilkinson@hotmail.com",affiliation:'
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