Abstract
Child health researchers are increasingly aware of children’s rights to express their views and to be heard in all matters affecting them, as expressed in article 12 in the Convention on the Rights of the Child. This includes research, but it is unusual for young children to be involved as co-researchers in health research. Child-facing professionals and researchers sit on experience-based knowledge and practical skills, which could inform young children’s involvement in research. We investigated perspectives and conceptualisations on child participation, for the ages 3–5 years, among professionals and researchers outside of the health sciences, by interviewing fifteen informants. We present the findings on three levels; meta, meso and micro. The interviewees described child participation as something that forms the basis for the practices they performed, independent of their profession; we theorized this as understandings of child participation on an overarching meta level, where active child participation both becomes an ‘established ideology’, and something difficult to put into words and describe. What also united the interviewees was their description of foundations or prerequisites for participation to take place; we theorized this as understandings of child participation on a meso level, where descriptions of the need for building relations with the children, the importance of space and place, and the focus on child-centred activities were common themes. Finally, the interviewees described methods that they used in meetings with children; this is theorized as understandings of child participation on micro level, categorized as methods for understanding children’s worlds, methods for engaging children in conversations and methods to ensure children’s consent. We discuss these understandings of child participation to untangle if they represent a child perspective or children’s perspectives. In the longer term, this knowledge will serve as the conceptual basis for a guide to children’s meaningful involvement in health research.
Introduction
With the Convention on the Rights of the Child (UNCRC) (UN, 1989) came a progressive movement to involve children themselves in research, rather than relying on parents or carers to speak on their behalf. UNCRC is now an internationally accepted standard for human rights for children. In Sweden, where this study is located, it has been law since 2020. Article 12 states that children have the right to express their views and to be heard in all matters affecting them, and that the views of the child shall be taken into account in accordance with his or her age and maturity. For children involved in research, this means these rights do not only apply to the individual child as study participant - but also that children’s voices should be heard and their opinions involved in the actual decisions made about the research, i.e., the design, conduct and dissemination of research. Thus, UNCRC can be claimed to form a common base involving young children in research, where children’s autonomy, agency and empowerment are promoted (Loveridge & Cornforth, 2014; Smith, 2011).
Participation and Involvement
In this text, we will use two concepts for when children partake in research and non-research activities. The first concept is child participation, which Unicef defines as “the informed and voluntary involvement of children, including those from marginalized groups, children of different ages and different abilities, in every issue that affects them, either directly or indirectly”. Using the term child participation is common in some academic fields (such as child and youth studies) and in many professional child-centred settings, such as pedagogy and health care. For example, within childhood studies and early childhood education research, doing research with children is common, and almost an axiom (Bodén, 2021) – and in this academic field, often referred to as child participation. Within the broader health field, like in child health services, and child and adolescent psychiatry, as well as in research fields like childhood studies and early childhood education research, the inclusion of the youngest children as active participants is often emphasized (James & Prout, 2015; Kellett, 2005) – under the term child participation. These child-focused activities also take place in public areas such as libraries, museums and art galleries. Thus, child participation as a concept exists in professional and academic settings – although with different meanings – and there are professionals with a wealth of experience and knowledge from participation with young children.
In health research, the term ‘participation’ is associated with study participation, i.e., where a person gives consent (or assent) to become an object of study in research, and does not necessarily describe active participation. To address active participation in health research, we introduce a second concept: involvement, and more specifically children’s involvement. Here, we refer to involvement in research. In the health sciences, involvement is commonly defined as “research conducted with or by the public rather than on, to, or about them” (NIHR, 2021), or as “the active involvement in key research decisions of people whose lives are at the centre of the research” (Abma et al., 2019; Inge, 2024). The level of involvement can range from advising about projects to leading projects. A main argument is the ethical value of involving the public in decisions relating to and affecting their lives. Another argument is related to relevance and feasibility of the research, where it is argued that involvement improves the quality and impact of research (Inge, 2024). Involvement in research is related, but not identical, to approaches like participatory action research, community-based participatory research, co-production, and user-led research.
It is unusual for young children to be involved as experts or knowledge-producers in health research. This role can have different names; here, we will use the term co-researcher. A review of child and youth involvement in health research activities (Rouncefield-Swales et al., 2021) found that the majority of activities had been conducted with adolescents. Although some projects have involved younger pre-school children - either in focus groups or advisory committees - they have contributed as part of a wider age group; the review found no examples of research activities carried out exclusively with children under 11 years. That children are rarely involved in research is especially true for the youngest children. One explanation for this could be the presumed difficulty of informing young children about the research, what is expected of them, and how to obtain consent from those who cannot enter into a legal contract (Ericsson & Boyd, 2017). Another obstacle might be the presumed difficulty of obtaining information from young children. They do tend to provide less information and detail than older children (Baker-Ward et al., 1993; Fivush & Nelson, 2004). One explanation for this is that their memory retrieval strategies and capacities are still developing (Schwenck et al., 2009). Even though children’s language and narrative abilities improve over the years from 2 to 5, they are still dependent on adults to help them organize their experiences through language. Therefore, younger children need to be approached with methods that are adapted and adhere to their developmental capacities.
Thus, although the terms child participation and children’s involvement are sometimes used interchangeably, we use them in specific ways in this manuscript. We chose the concept child participation as it best represents the shared knowledge that we seek to collect, and stay close to the language that our respondents use. We then aim to use this knowledge to inform children’s involvement, which we come back to in the discussion.
Perspectives on Children’s Involvement in Research
By working with the UNCRC as a point of departure and combining this with insight from the involvement field, new ways of understanding children’s participation in health research are enabled. Along with UNCRC, concepts like children’s rights, children’s voices, child perspective and children’s perspectives have become important in Swedish and Nordic policy and research (Bergnehr, 2019), as means to better understand young children’s lives, practices and experiences (Christensen & James, 2017; James & Prout, 2015). These concepts can be understood as theoretical tools to analyze ways of describing children’s participation. This is also how the concepts of child perspective and children’s perspectives are engaged within this paper: as theoretical tools to analyze how the child-facing professionals talk about child-participants in the different arenas they work in.
The distinction between child perspective and children’s perspectives is often described as a difference in who is formulating the area of interest. In this sense, a child perspective has come to denote circumstances when someone representing the children, often an adult, sets the agenda. A child perspective aims to work for the best interests of children or to safeguard them, for example through studying how different political decisions entail possibilities or opportunities for children. To enable this, information is not necessarily provided by the children themselves (Halldén, 2003), and is more about the adult trying to understand the children’s experiences (Bergnehr, 2019). Children’s perspectives, is instead about aiming to establish a view or capture understandings that are the children’s own, and enabling opportunities for the children themselves to set the agenda. For this, it is necessary to work closely together with children (Halldén, 2003). It is thus about trying to take the stance of the child, to see with the eyes of the child, so to speak. This perspective attempts to represent children’s own experiences and perceptions.
Merging Knowledge on Child Participation
Scholarly work within childhood studies and early childhood education research highlights that the most important aspect is to acknowledge children as subjects and competent actors (Christensen & James, 2017), and to avoid a ‘looking down’ standpoint that views children or childhood from an adult perspective (Alanen, 1998). Scholars from these fields can thus contribute with interdisciplinary insights of children’s involvement in research, from outside of the health sciences. In this study, we further aim to combine the knowledge obtained from these fields with knowledge from child-facing professionals outside of academia. When people share the same professional frame of reference, there is a risk of ‘groupthink’ whereby cohesion takes precedence over the appraisal of alternative courses of action (Janis, 1972). A collective rationalisation can take place, in which professionals recommit to past conceptualisations and actions without considering alternatives. The integration of external opinions when characterising issues within a professional context is a way to prevent groupthink (Riordan & Riordan, 2013). We argue that child-facing professionals can contribute with new insights on children’s participation, especially when such knowledge is ‘translated’ into a research context. Looking beyond health sciences, to both other child-facing professions and to researchers in other fields, offers opportunities to explore cross-professional conceptualisations of child participation and the varying ways in which the concept is enacted.
Health researchers seeking to engage young children can therefore benefit from the perspectives of professionals inside and outside academia. Combining insights from everyday practice with those from scientific inquiry strengthens understandings of how participation is defined and supported. In this paper, we investigate child-facing professionals’ perspectives on participation with children aged 3–5 years. Specifically, we ask: How do professionals conceptualise child participation with children aged 3–5 years? What do professionals working with children aged 3–5 years say is needed to work on participation with children? Which methods do professionals working with children aged 3–5 years use to work on child participation?
Method and Analysis
Data were collected through semi-structured interviews with child-facing professionals. The professionals were recruited through our networks within the community of child-facing professionals, and invited via email. When selecting participants, we aimed for professional diversity, to include different ways of working with child participation, as well as different workplaces, education and practical circumstances. Once we started interviewing, we also used snowball technique where interviewees suggested other potential interviewees or fields we should look into. All interviewees received written and verbal information about the study and that participation is voluntary before agreeing to participate. All interviewees provided written consent.
The Interviewees’ Professions, Current Place of Work and Experience From Working With Children 3–5 Years Old
A number of methodological considerations have been important for us in order to approach child participation and understand the findings. First, the interviewees worked with child participation, but in very different professional and academic fields. We acknowledge that the understandings of child participation are likely to differ between these fields. Thus, we asked ourselves: How do we ensure we talk about the same thing? Could it be that the interviewees don’t use the same language as we do, and actually work more or less with child participation than we understand from the interviews? We were aware of the many terms and methods used for child participation, and introduced the pictorial support as a way to align the understanding of the term between the interviewer and interviewee. The pictorial support consisted of a paper with three pictures, representing three levels of involvement; consultation, co-creation and child-led activities, as well as one paper with a picture of the research cycle. We were aware of the many terms and methods used for child participation, and introduced the pictorial support as a way to align the understanding of the term between the interviewer and interviewee. The interviewees were offered to refer to it when describing the level of involvement they had worked on, if they found this helpful, and we used the picture of the research cycle to discuss which phase of the research cycle their child participation activity might relate to. Developing pictorial support required preparatory work and testing. Some of the interviewees appeared to find the pictorial support helpful and used it, while other chose to not use it at all but rather explained using their own words. When introducing material during an interview there is always a risk of steering the interviewees. To counteract this, we stressed that there is no ‘better’ way of working with child participation, e.g., on a ‘higher’ level, but that we were interested in how they worked in order to learn. Our overall impression is that it contributed to an increased common understanding of the core concepts during the interviews, between professionals’ knowledge grounded in everyday practices and scientific knowledge from research fields working with young children.
We were also concerned with the risk of social desirability bias; being interviewed by a child researcher risked introducing expectations among the interviewees around their work with child participation. This concern was strengthened during the interviews, when we saw that child participation was seen as an ‘established ideology’ (see Findings). To counteract this bias, we asked the interviewees about specific situations, to describe occasions where they worked with child participation in practice and about specific methods and prerequisites. Several interviewees offered to show the interviewer around, which had the positive effect of putting them in the expert position.
After the first round of interviews, we invited all participants to a member checking session, a process in which study participants are provided with parts of a research report and are invited to reflect on the accuracy (Koelsch, 2013). In a joint member checking session, we presented the preliminary findings and asked for reflections around whether they agreed with our interpretation, if we had missed any important perspectives and if they had ideas on who else we should interview. One interviewee declined participation and four interviewees instead opted for individual online member checking sessions with the first author (EI).
Following the member checking, a second round of interviews took place. This time, to complement the professional perspectives, most interviewees had other professions. Four new interviews with six participants were conducted; two interviews were conducted in pairs on the interviewees’ initiative. The interviewer (EI) followed the same interview guide and complemented this with one question from the member checking process; What kind of knowledge is needed to work with child participation? Interviews continued until the researcher team assessed that data saturation was reached, meaning that no new ideas were generated from new interviews.
The data set thereby consisted of eleven interviews with fifteen interviewees. All were audio recorded, transcribed by an AI tool, and then listened to and corrected by research assistants. The analysis was conducted by EI and LB, who followed the method of qualitative content analysis as described by Graneheim and Lundman (2004). We applied a phenomenological approach to the manifest content; our approach is descriptive and investigates on how participant’ experiences are organised. However, during the analysis process and in the development of the latent theme, we shifted our theoretical position to closer to hermeneutics, as this relates to how participants conceptualize child participation (Graneheim et al., 2017). In a first step, we read the transcripts and listened to the recordings individually, whereby we met to discuss repeatedly. In this familiarization phase, we approached the data inductively. We identified meaning units within the data, which were then condensed and labelled with a code. These codes were sorted into sub-categories, which we eventually abstracted into two categories – these categories and sub-categories constituted the manifest content, with relatively low levels of both abstraction and interpretation. Throughout the abstraction process, the authors met repeatedly to discuss and constructed a theme, which represents the latent content, and acquired a higher level of abstraction and interpretation (Graneheim et al., 2017; Graneheim & Lundman, 2004). Hence, the findings presented below are a product of reflection and thoughtfulness, guided by the research questions and dialectically related to the different contexts the interviewees are located in.
Through considering quality aspects during the data collection, such as using pictorial support to align understandings, and addressing social desirability bias, we aimed to improve the trustworthiness. Credibility was increased by attempts to put the interviewees in the ‘expert position’ and by attempts to reduce social desirability bias. Transferability was considered through providing detailed descriptions and quotes, while dependability was increased through keeping an audit trail, for example the changes made after the member checking process. Finally, we increased confirmability by introducing member checking and by having several authors conducting the data collection and analysis together.
Findings
We conceptualized the findings as a pattern on meta, meso and micro levels. The meta level represents the latent theme, with the underlying meaning as a thread throughout the data, cutting across categories. The meso and micro levels represent categories with the manifest content and both include several subcategories. The interviewees described child participation as an interplay between factors on the meta, meso and micro levels (Figure 1). The meta level mostly concerns how the interviewees conceptualise child participation i.e., a latent theme around how they in different ways talk about child participation as taken for granted in their everyday practices. The meso level describes what the interviewees see as necessary foundations or preconditions for child participation to be enabled. The micro level focuses on the specific methods, or ‘tips-and-tricks’ the interviewees employ. There is of course an interplay between the different levels, where for example the methods on the micro level are dependent on the foundations on the meso level, the foundations on the meso level are dependent on the conceptualisations on the meta level and so on. The findings illustrated: The cloud symbolises the conceptualisations at the meta level, the road the foundations at the meso level, and the cars are the methods at the micro level
Meta Level: Conceptualising Child Participation
In this theme, the interviewed professionals described their view on child participation in relatively similar terms. Child participation was described as an overarching approach: “Participation is everywhere”. This informed their work with children and formed their entire interaction with and relations to children. Interviewee 1: Yes, exactly, how you look at children, kind of. You’re one with the children, we’re not...and we're not in charge of them, but you're theirs all the time. Interviewee 2: Yes, I think these questions are a bit difficult for us because it’s quite obvious to us. (Speech and language therapist and preschool teacher at play therapy)
This initial conceptualisation appeared to make it difficult to provide concrete examples. Child participation was simultaneously seen as an ‘established ideology’ that permeated all work with children, and as something that was difficult to put into words and describe. However, two distinct categories of examples were identified.
One category was centred on children feeling ownership. For example, preschool teachers described their work with child participation as aimed at children having ownership of a project when the project was based on their interests, as interpreted by the preschool teachers. These examples did not provide much details around whether the children actually experienced ownership - at least, this is not expressed in the interviews.
Another category centred around children making decisions within the frame of an adult-run activity. Working with child participation was described as finding aspects that children could decide, within a context where they had very little authority or opportunities for decision-making. For example, when a child at play therapy needed to endure a medical procedure, they did not get to choose if they should do it or not. There were however opportunities for the child to make choices within and around the procedure; which film they want to watch during the procedure, if a parent should hold their hand, etc. Below, a nurse describes how she involved children in all aspects of vaccine administration except the decision whether the child should get the vaccine or not. ‘Which plaster would you choose? This one, do you have it in your hand? Great, let’s put it on.’ So they are involved. They get to choose the arm. They get to choose the syringe. They blow, they get to get the vaccine from the fridge. So I’m just administering the vaccine, like, the rest is done by the child (...) They get to choose everything, except that they shouldn’t have it. (Child health care nurse)
This relates back to the ‘established ideology’ of child participation. Even when professionals are aware that the activity is adult-decided and the children don’t have a say, they try to find room for child participation. This reasoning was consistent throughout the interviews with non-researcher professionals regardless of whether they were preschool teachers, who worked with the same group of children for years, or other professions such as child health care nurses, who only met a child once or a few times. It appears that child participation is highly valued and actively aimed for in all contexts, but that the interpretation of how it should be realised is adapted to the current work context.
Meso: Foundations for Working with Child Participation
In this first category, the interviewees described five necessary foundations for child participation with children aged 3–5 years to be enabled. Although many of the interviewees brought up similar foundations, the ideas around how these affect their work with child participation differed.
Children’s Competence Need be Acknowledged
Several of the interviewees talked about the need to adopt the starting point that children are competent, in order to work with child participation in a meaningful way. They described how adopting this perspective - in which children’s abilities, ideas and contributions are taken seriously - fosters meaningful participation. By acknowledging children as capable contributors, adults create an environment in which genuine participation can take place. A child psychologist reflects that child participation needs to build on models, but also on seeing children as competent. It also needs to be built on creativity and a child-centred approach. Where I show that I think that the child is an important informant and that I will do everything in my power to respect this. (Child psychologist)
Build Relationships and Trust: Show That You are a ‘Good Adult’
The interviewees brought up the need to make children feel safe, and the active work that this requires. A child who does not feel safe will not want to join, participate or express their opinion, they argued. The interviewees used different terms for establishing relationships and building trust, for example ‘showing that you are a good adult’. They suggested a few key approaches to establishing relationships with the child or the group of children, and building this foundation of trust. These approaches were described in similar ways among the interviewees, even if they worked in different contexts. First, show that you are present and will stay around; trust is not built immediately but the child needs to take their time to choose to interact with you. Therefore, you should not force yourself into an interaction with a child, or push them when they are setting a boundary or displaying disinterest; rather, you need to wait for them. Keep inviting every child to join. Extend the open invitation to join to children who are hesitant, but let it be their decision if and when they join the activity. Finally, when a child speaks up or shares their view: listen. Every child needs to feel seen, acknowledged and listened to and listening is essential to establishing a relationship. In addition, some of the interviewees suggested the starting point for building a relationship with the child is to first establish a trusting relationship with the child’s parent(s). They’re so young, I think, when they’re three, four, five years old and they come to a new place and meet a new person. So, I think I rely a lot on the parent, the carer, who is the child’s safe point. (Child psychologist)
Create Spaces Allowing for Child Participation
Several of the interviewees highlighted the importance of the space, for example the room or the preschool environment, for child participation. A child psychologist, for example, described how she prepared the room at her clinic to be welcoming for children. ...when the child comes here with their parents to meet me, I think a bit about how, how the room is. That we have toys out and a carpet on the floor and that it should be inviting. Also the waiting room, that it feels sort of inviting. (Child psychologist)
Adapting the room to be accessible for children’s length, body size and preferences was one aspect. This included low chairs and tables, and a rug on the floor for children who preferred sitting under the table. Other adaptations depended on the activity. The interviewees working in the play therapy and art museum, which children visited a limited number of times, talked about the importance of giving children access to the room through showing them around while simultaneously setting a clear framework for what children could and could not do in that space. For example, in play therapy the children were offered a tour around the facilities together with their parents, but if they preferred to start playing directly this was encouraged; the purpose was to show children that this was a space for creativity, where they were free to use tools and crafting material. In the art museum, framing the room and how children were expected to act there was important for children to meaningfully participate in activities. The interviewees considered children’s knowledge of the space and its rules a foundation for meaningful child participation.
Children’s Consent is Key
The need of and procedures to ensure children’s consent to participate in an activity was discussed differently depending on the setting where the interviewees worked. For the interviewed researchers this was an explicit procedure with thorough consideration and established processes. Here, consent was discussed in relation to ethics regulations as well as to child participation, and was considered important for both reasons. The professionals working with children in groups, i.e., preschools teachers and the art teacher, gave a different perspective. When children participate in an activity as a group, the professionals would not focus on ensuring consent from each child; they were expected to participate as part of a group. However, they were still very aware of signals around interest and willingness to participate from both the group and the individual children, and were prepared to adapt the activity if the children seemed uninterested or unwilling to participate. For example, they described situations where individual children chose to not participate and watched others taking part in an activity before deciding to participate themselves, which the professionals approached with continuous invitation without pushing the children to participate. This reasoning was seen as an indication that they valued consent from the children. I think that you should be honest about why, it should not be that you are deceiving the child (...) They must know that it is honest why they are here and that they feel safe and that it is voluntary. That you can participate as much as you want, when you want. And there you need to be extra sensitive precisely because they are so young, and often relate to us adults to interpret the environment and know what is expected of them (...) We also need to present the possibility of saying no so that it becomes an easy path for the child to take. (Child psychologist)
The interviewees declared that a prerequisite for consent is transparency and accessible information. An interviewed preschool teacher and child researcher pointed out the need to clarify who they were, in relation to other adults in the preschool, to give the children a chance to understand and consent. One of the psychologists explained that she, at the start of every session with a child, would explain what will happen during the session; for example that she will ask questions, that they will play and that she will show the child some cards with teddy bears who have different emotions. The child researcher also gave an example from a project, where her researcher colleague asked a child if they wanted to join a research activity, to which the child responded: ‘No, you explain so badly. So I don’t want to’, which resulted in the child not joining the activity that day. If it is to be voluntary, you need to know what you are saying yes to and what you are saying no to. (Preschool teacher and researcher)
Is Professional Experience of Working with Children Needed?
The interviewees had different opinions on whether working with child participation requires experience from working with children. Some argued that this is essential, as interacting with children in child-appropriate ways is a specific skill that requires knowledge and experience. Knowledge around children’s development, language and concentration span etc. Were brought up as examples, together with experiences from interacting with children and knowledge around group dynamics with children. In this quote, a preschool teacher and researcher explains how years of experience from working with children is now integrated in how she interacts with them. I can talk to children. I am not afraid. I know that I should sit down. I will have the child at eye level. I know I need to be clear but that I don't need to simplify. (Preschool teacher and researcher)
On the contrary, some interviewees argued that there are no specific skills from working with children needed to work with child participation. They argued that experience from working with and meeting people in general is more important, and that viewing children as a ‘separate species’ might be a hindrance for interacting with children in a natural and relaxed way. I think we have a child’s language in us, whether we’ve worked a lot of years with children or not at all, it’s there and we just have to dare to be in it (...) It’s basically about being comfortable and trusting that the child will feel comfortable. (Child psychologist)
An additional perspective, coming from a preschool teacher, was that working with child participation in a group requires knowledge of the children’s personalities and an ability to moderate the different contributions to the group, to make sure that every child has the opportunity to say something. Sometimes, this will mean that a child talks to the adult afterwards rather than in the group. That everyone should have the opportunity to join was stressed as important, which required finding ways to see the individual in the group.
Micro: Methods for Working with Child Participation
Methods for Working With Child Participation
Methods for Understanding Children’s Worlds
Observation is an ‘initiation method’ that is used as a way to understand what the children are interested in. This method was commonly described from the interviewees working with groups of children, and often related to initiating activities on themes already present in the children’s everyday life. For example, a preschool teacher could observe the children’s ‘free play’ and gain an understanding of which themes they are interested in, and use their interest to form a new activity. It was also described by health care professionals, but in a more brief version; a child health care nurse described observing a brief interest in a toy or a print on a t-shirt, and then using that to promote interaction.
Other interviewees argue that it is preferable to interact and play with children, rather than to just observe them, as this would allow them to deliberately pick up on ideas as they organically appear in the children’s everyday lives. This requires presence and attention, as the ideas can appear in any way, form or time – in free play, structured activities or at the lunch table. This can, for example, be done through active play together with the children. ... another way is also to be attentive and follow the child and see what happens in play. Because I think it’s very adult to put your experiences, your thoughts and feelings into words in a dialogue. (...) Yes, and that suits some children, and then that’s a path, but you have to make it possible to express yourself in different ways. And children, I think, express themselves a lot in play (...) And maybe it's just fantasies, pretending and playing like that. But in any case, it can provide openings to ask further questions and get hold of the child's perspective. So I think it's important to be available for play and to sit on the floor, be playful and invite play. (Child psychologist)
Some of the interviewees added that it is essential that the activity is fun; playfulness would increase the children’s desire to participate. Other interviewees questioned the necessity of child-centred activities to always be playful and argued that children can engage in serious activities too. However, most agreed that if the activity is fun, or if the adult can add a playful component, children are more likely to want to participate and the professionals are more likely to get something useful from the interaction.
Methods for Engaging Children in Conversations
While engaging in conversations with children might seem so obvious that it is redundant to state as a method in itself, the interviewees shared perspectives on how conversations can be conducted to support child participation. Invitation to conversations, such as questions, should according to the interviewees always be directed to the child, not to accompanying adults. It is also crucial to show interest in and take the child’s responses seriously. Providing feedback to show that the child’s input has been listened to and incorporated is crucial, which was for example highlighted by a teacher responsible for a preschool child council. A preschool teacher and researcher, who also teaches at a university, reflects around calling these approaches methods: I believe a lot of preschool teachers are very good at it and there are methods that you can learn. I think one of those basic things that I tell students, especially with the youngest children, is sit down, stay, don’t leave, stay, show that you are here because you are interested. It’s so simple that you don’t think it’s a method. But it is a method. (Preschool teacher and researcher)
Some of the methods had a creative focus, where children were invited to create with or without adults, in order to engage them in conversations. One such method is mindmaps, which was used when working in groups, such as at preschools. Photographies were also used to engage children in conversations, where pictures the children had taken themselves served as a good basis for discussion. The art pedagogue also described creative processes with children, such as drawing or creating with clay, as a way of storytelling which opened up for communication for some children, albeit not all. You have to be aware that the visual language... they are very differently good at expressing themselves in images. Not everyone likes to paint and can tell stories in that way. But it is a kind of communication, I would say. (Art pedagogue)
Some more specific methods were ‘In My Shoes’, a computer-based method for interviewing young children, and forum theatre, a method described in preschool settings, intended to help the children to frame and discuss unspoken rules and decide on solutions to a situation. A few of the interviewees - mainly the psychologists - described using different versions of visual representation of emotions, such as the ‘teddy bear cards’ where a child can rate their emotions in order to open up for a conversation. A method called the pizza was also mentioned as a way to map children’s life and talk about their experiences and feelings.
We identified a pattern in how many of the methods were described: The interviewees often described using “common third activities”, i.e., activities that involve a shared social focal point for the adult and the child. It appears that turning a common focus to something else facilitated engaging the children in conversation. I see in one project where we have set up modules with different materials that if you have something to talk about, it is much easier. A concrete material (...) It is generally much easier to get children's participation and interest if you have something to talk about. (Preschool teacher and researcher)
Methods to Ensure Children’s Consent
A few methods for ensuring children’s consent were mentioned. Several interviewees described silent strategies to monitor interest among the children, especially in group activities, which was framed as a way to investigate implicit consent. One approach, that can be seen as a way to ensure children’s implicit consent, is related to building trusting relationships (see Foundation); that children are continuously invited to join an activity, but never pushed, and that they have the option to join at a later stage, if they wish. Examples of concrete methods to decline or retract consent were different versions of a stop sign, which was used by the interviewees as a way to introduce the possibility to say ‘I don’t want to continue’ at any time during an activity. A psychologist reflected on how this works in practice and described that this tool works well if it is introduced and the child has an opportunity to test it. I don’t know if you can call it participation, but I think it is. We talk about how everyone can say stop when they want to (...) Some children test these stop signs a lot. You can say stop with your hand. They say stop and stop and stop. I like that they do that. (Child psychologist)
Another child psychologist reasons around balancing the value of consent and accessing information from a child. At her clinic, they have started using a computer-based programme for talking to children. She finds this very useful for accessing information from the child, but as the programme is quite structured she is concerned it might reduce the child’s possibility to express their own will. She thinks using different methods and following the child is more likely to improve their opportunities to consent.
An interviewed researcher discussed consent procedures during a research project in preschools, where they used multiple methods to explain to the children that they were researchers, not teachers, and that this was a research project. To explain the research, they constructed a book with all the data collection activities in the project, and to explain the voluntariness they used a protocol to make sure they always stated the same thing, every occasion in every preschool. In addition, they used pictures of what they were planning to do to visualise how long it would take. To do this, they constructed a ‘research snake’ with pictures for every time they would visit the preschool which they removed after each visit, so that the children could see how the snake got shorter until then the project was over. With many different adults in the preschool environment, it was easy for the researchers to be seen as ‘just a teacher’, which risked making it unclear to the children what they were actually doing there. The team made several efforts to distinguish themselves from the other adults, from pictures at the entrance so that the children knew that they would attend that day to blue t-shirts with the text “Research ongoing” which the children quickly learned to recognise. T-shirts, the snake, the protocol, pictures of us in the hall, gatherings that were the same everywhere. Every time we were there, we reminded the children that they did not have to join. Research is voluntary. The door is open, you can go whenever you want, you don’t have to. There were some children who tried leaving, coming back, leaving, coming back. (Preschool teacher and researcher)
Discussion
In this study, we have analyzed how child-facing professionals – both inside and outside of academia – describe and conceptualise child participation.
The interviewees describe child participation as something that forms the basis for all the practices they performed, independent of their profession. We have theorized this as understandings of child participation on an overarching meta level, where child participation both becomes an ‘established ideology’, and difficult to put into words. What also unites the interviewees was their description of foundations or prerequisites for participation to take place. We have theorized this as understandings of child participation on a meso level, where descriptions of the need for seeing children’s competence, building relations with the children and the importance of space were common themes. Finally, methods that the interviewees describe was theorized as understandings of child participation on a micro level, categorized as methods for understanding children’s worlds, methods for engaging children in conversations and methods to ensure children’s consent.
The foundations for child participation differed depending on the setting and purpose of the professionals’ work with the children, for example whether they see them every day (e.g., preschool) or if they only meet them once (e.g., health care). The preschool teachers at the play therapy, who have both previously worked in a preschool, described that they used the same conceptualisations for child participation, but the circumstances were very different; therefore, they used different methods or applied them in a different way. The main differences were whether they knew the children, or if they met the child once or a few times, as well as whether they worked with a child individually or with a group of children. Time, especially, created a frame for how they could work with child participation; time, therefore, affected the methods and activities they worked with, and what kind of trust and relationship they could build with a child or group of children. The interviewees generally approached time as a constant, a frame in which they worked with child participation the best they could. Context matters for professionals’ possibilities to work with child participation. In Sweden, where this study was conducted, the Convention on the Rights of the Child was made law in 2020, which theoretically strengthens the case for child participation. There has however been some criticism against if and how the law has been applied and put into use.
Interestingly, the interviewees brought different perspectives on whether experience from working with children was needed for child participation. A UNCRC principle for Ethical and Meaningful Child Participation states that ‘Adults must have the right training, knowledge and preparation to support child participation’, but what this actually encompasses is more difficult to define. Some guidance can come from Angelöw and Psouni’s (2025) guidelines for children’s participation in research, suggesting that training and knowledge around the specific age group is essential for involving children in meaningful and ethical ways.
Meeting the Expectations of Article 12?
The findings can further be interpreted using Lundy’s model of child participation (Lundy, 2007), which was developed as a conceptualisation of Article 12 of the UNCRC. The model emphasises a rights-based approach to involving children in decision-making processes and is built around four key elements: space, voice, audience and influence. First, space refers to creating an environment where children are encouraged and able to express their views freely, which is clearly described by our interviewees, with both space adaptation and space familiarisation raised as important as foundational aspect of child participation. Second, voice ensures that children have the opportunity to participate and express their opinions on matters that affect them. This is not restricted to spoken voice but inclusive of other modalities of expression. Our interviewees provide several examples of this (Table 2), in the methods for working with child participation. The third element, audience, refers to children’s views being heard by the appropriate decision-makers, who listen attentively and consider the child’s perspective. This element of audience is referenced in the micro-level; when reflecting on holding conversations with children, the respondents noted the importance of “providing feedback” to demonstrate that the child has been heard. Finally, influence refers to children’s opinions leading to tangible changes or impacting the decision-making process, which we see at the meta-level of our interpretation; the interviewed professionals often spoke of “ownership” and “decision making” when conceptualising child participation. The notion of influence was, however, problematized by some respondents. For instance, play therapists described how they often met children within a context of limited influence, such as when the child is undergoing a medical procedure. Yet, in this circumstance, the possible degrees of influence were explored with the child. With all elements of the model present in the data, albeit with varying weight, it appears as though the professionals’ accounts of child participation meet the expectations of Article 12.
A Child Perspective - or Children’s Perspectives?
A conclusion based on the conceptualisation at meta level, is that interviewees approached child participation as an ‘established ideology’; they were very aware, at least in the context of the interviews, that child participation was something that they ‘should do’ in their professional roles. We are interested in relating this narrative, which is expressed a bit differently depending on the interviewees’ professions, to the concepts of child perspective and children’s perspectives. A common distinction between these concepts is the difference in who is formulating the area of interest. Hence, do the interviewees focus on participation where adults represent the children (child perspective), or do they talk about participation as trying to capture the children’s own understanding (children’s perspectives) and work from there?
In the conceptualisation of child participation in our findings, we identified examples where interviewees seem to want to ensure elements of child participation within the frame of adult-run activities. Some cases could be interpreted as if the adults try to work with children’s perspectives, even within these adult-run activities. An example of this is when the interviewees work to create the feeling that the children “own” the project, and that a project is based on the children’s own interests. A method for enabling this, described by some of the interviewees, is the observations of what seems to interest the child, that in turn shapes their interaction with the child. More often, however, the children are making decisions steered by the adult-run activity, with less possibilities to influence the activity in it-self. In this way, the conceptualisations fit with the concept of child perspective - the children’s perspectives are filtered through the adults’ interpretations even in situations where the adults show a genuine interest for children’s interests, ideas, wishes, will etc. - and the children have more of a rhetorical influence and less of a real influence (Bergnehr, 2019). There is not an end in itself to work with children’s perspectives. However, if we look at the methods and how the interviewees describe these, our interpretation is that they want to involve children more than they do, i.e., they have an intention of moving their work closer to children’s perspectives. They describe methods they work with in very deliberate ways that would make possible for children’s perspective to be more prominent. So what is hindering them? Is it that they conceptualise child participation closer to child perspectives or is it in fact the foundation for child participation that is not quite allowing them to create space for children’s perspectives?
How can the Findings be Applied to Children’s Involvement in Research?
To advance the meaningful involvement of preschool-aged children in health research, we draw on the perspectives and practices of child-facing professionals. By translating this knowledge into a research context, we aim to establish conceptual foundations for a guide to young children’s participation in health research. As a first step, we have conducted a preliminary mapping of the methods on the health research cycle. Our conclusion of this exercise was that many of the methods identified among non-research professionals appear appropriate and useful for one or more steps in the research cycle. For example, the methods used to understand children’s worlds seem appropriate to use in the early phases of the research cycle, for identifying a research topic that is in line with children’s interests and ideas. The methods used for engaging children in conversation, however, appear to be useful throughout the research cycle. This is not surprising, as much of public involvement activities rely on conversations with both adults and children. For example, there is potential in using these methods for the identification and prioritization of the research topic, for co-creating the design of a study and for analysing data and interpreting results together with children. In addition to the methods, the identified foundations at the meso-level in our findings are a promising contribution to framing children’s involvement in health research.
While we here reflect briefly on the various stages of the research cycle, there are, of course, many considerations to make when involving children in health research. One such consideration is the degree of participation, which was highlighted in the conceptualisations at the meta level. This has been discussed by child participation scholars such as Harry Shier, who have opened for a discussion on varying degrees of child participation across the different stages of a single project, including the complexities in deciding who should be involved when and to what degree (Shier, 2019).
We believe that valuable new insights can be made as this knowledge is translated into a research context. Building on the present study, our future work will focus on developing a guide for young children’s involvement in research. The guide will begin by introducing key concepts, including the idea of the child’s perspective and children’s perspectives, and the principles of public involvement in research, thereby providing readers with a conceptual grounding. It will then follow the research cycle step by step, offering both general considerations for involving children and concrete advice on practical methods that can be applied at each stage. Examples include methods for identifying research questions aligned with children’s interests, approaches to co-designing studies, and techniques for engaging children in data analysis, interpretation and dissemination. To encourage critical reflection and adaptation to diverse contexts, the guide will also incorporate reflective exercises throughout, prompting researchers to examine their assumptions and to consider how methods may need to be tailored to different settings and groups of children.
We recognise, however, that the current study reflects only the perspectives of adult professionals, leaving the children’s voices absent. The next phase of our project will therefore involve preschool-aged children directly in the development of the guide and include an evaluation of its relevance and applicability from their perspective.
Footnotes
Acknowledgements
We want to thank all the interviewees for sharing their time, experiences and knowledge with us so generously, both in the interviews and during the member checking procedure. The data handling was enabled by resources provided by Uppsala University at UPPMAX. We also want to acknowledge the work made by research assistants on transcribing and editing. Finally, the funding for this project was granted by Swedish Research Council for Health, Working Life and Welfare.
Ethical Considerations
According to Swedish legislation and the Swedish Ethical Review Authority, ethical approval is not required for interviewing professionals. In all aspects, research ethics guidelines were followed and ethical aspects considered.
Consent to Participate
All interviewees were given written and verbal information about the study, including that participation is voluntary, as well as time to consider it, before agreeing to participate. All interviewees provided written consent. In addition, in the member checking procedure they were given an opportunity to reflect on the findings and provide additional information.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Swedish Research Council for Health, Working Life and Welfare (Ref. Nr 2023-01130).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The datasets generated during and analyzed during the current study are not publicly available due to details in the transcripts that risk compromising interviewees’ anonymity, but are available from the corresponding author on reasonable request.