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The Swiss Preschoolers' health study (SPLASHY): Objectives and design of a prospective multi-site cohort study assessing psychological and physiological health in young children

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Background: Children's psychological and physiological health can be summarized as the child's thinking, feeling, behaving, eating, growing, and moving. Children's psychological and physiological health conditions are influenced by today's life challenges: Thus, stress exposure and lack of physical activity represent important health challenges in older children. However, corresponding evidence for young children is scarce. The aim of Swiss Preschoolers' Health Study (SPLASHY) is to examine the role of stress and physical activity on children's psychological and physiological health, particularly on cognitive functioning, psychological well-being, adiposity and motor skills in children at an early stage of childhood. We will also assess the role of child and environmental characteristics and aim to define sensitive time points. Methods/design: In a total of 84 child care centers, children at preschool age (2-6 years) are recruited and are assessed immediately and one year later. Assessments include direct measurements of the children in the child care centers and at home as well as assessments of children's behavior and environmental factors through informants (parents and child care educators). Discussion: SPLASHY is one of the first studies in early childhood aiming to investigate the influence of stress and physical activity on children's psychological and physiological health in a community-based longitudinal design. Trial registration: Current Controlled Trials ISRCTN41045021 (date of registration: 21.03.14).
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S T U D Y P R O T O C O L Open Access
The Swiss Preschoolershealth study
(SPLASHY): objectives and design of a
prospective multi-site cohort study
assessing psychological and physiological
health in young children
Nadine Messerli-Bürgy
, Tanja H. Kakebeeke
, Amar Arhab
, Kerstin Stülb
, Annina E. Zysset
Claudia S. Leeger-Aschmann
, Einat A. Schmutz
, Fady Fares
, Andrea H. Meyer
, Simone Munsch
, Susi Kriemler
Oskar G. Jenni
and Jardena J. Puder
Background: Childrens psychological and physiological health can be summarized as the childs thinking, feeling,
behaving, eating, growing, and moving. Childrens psychological and physiological health conditions are influenced
by todays life challenges: Thus, stress exposure and lack of physical activity represent important health challenges
in older children. However, corresponding evidence for young children is scarce. The aim of Swiss Preschoolers
Health Study (SPLASHY) is to examine the role of stress and physical activity on childrens psychological and
physiological health, particularly on cognitive functioning, psychological well-being, adiposity and motor skills in
children at an early stage of childhood. We will also assess the role of child and environmental characteristics and
aim to define sensitive time points.
Methods/design: In a total of 84 child care centers, children at preschool age (26 years) are recruited and are
assessed immediately and one year later. Assessments include direct measurements of the children in the child care
centers and at home as well as assessments of childrens behavior and environmental factors through informants
(parents and child care educators).
Discussion: SPLASHY is one of the first studies in early childhood aiming to investigate the influence of stress and
physical activity on childrens psychological and physiological health in a community-based longitudinal design.
Trial registration: Current Controlled Trials ISRCTN41045021 (date of registration: 21.03.14)
Keywords: Child, Preschool, Stress, Physical activity, Development, Longitudinal, Cognition, Motor skill, Psychology,
* Correspondence:
Endocrinology, Diabetes & Metabolism Service, Centre Hospitalier
Universitaire Vaudois (CHUV), Lausanne, Switzerland
Department of Clinical Psychology and Psychotherapy, University of
Fribourg, Fribourg, Switzerland
Full list of author information is available at the end of the article
© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (, which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
( applies to the data made available in this article, unless otherwise stated.
Messerli-Bürgy et al. BMC Pediatrics (2016) 16:85
DOI 10.1186/s12887-016-0617-7
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
For the first time in history, children have a shorter
lifespan than their parents due to obesity and non-
communicable lifestyle-related chronic disease [1]. Im-
proving childrens overall health represents a major
goal for researchers, practitioners and policy makers.
General health in young children includes high levels
of cognitive functioning and social skills, psycho-
logical well-being, a healthy body weight, and well
developed motor skills. These domains can be sum-
marized as the childs thinking, feeling, behaving,
eating, growing and moving in an optimal way, even
under challenging conditions.
Stress and lack of physical activity (PA) represent two
relevant health challenges in todays modern environ-
ment that may interfere with childrens health [2, 3]. Ex-
posure to environmental stressors (ranging from major
severe life events to daily stress) is omnipresent. On the
other side, lack of physical activity has become the 4th
leading cause of death worldwide. To better elucidate
the impact of these two factors, alone and in combin-
ation, on childrens health, prospective studies starting in
young children are needed. Consequently, SPLASHY
covers health outcomes of various domains such as cog-
nitive functioning, psychological wellbeing, body weight
and motor skills at important developmental transition
time points during childhood. Additionally, parenting
style and familys exposure to critical live events and
daily stress are considered.
Importance of the chosen health outcomes
Cognitive functioning is fundamental for a healthy devel-
opment of the child assuring the mental processing of
information (i.e., the construction of human thoughts
or mental processes). It includes attention, memory,
inhibition, and more complex functions such as pro-
ducing and understanding language, solving problems
and making decisions [4]. Cognitive functioning is a
predictor for school and academic performance deter-
mining the career [5].
Psychological wellbeing: Psychological problems and
mental disorders are common during childhood [6, 7].
They impact substantially on quality of life as well as on
family and school functioning of the child [6] and induce
an increased risk for later suffering from mental disor-
ders [6]. Central to the concept of psychological well-
being are the regulation of mood and eating behavior
and the occurrence of behavior problems as they affect a
broad range of developmental tasks and the daily func-
tioning of the child [6].
Adiposity or absence of healthy body weight: Around
20 % of European and US children are overweight or
obese and prevalence rates are even over 30 % in some
countries [810]. Childhood obesity and overweight
carry a considerable health burden, namely cardiovascu-
lar, orthopedic, reproductive, gastrointestinal, neuro-
logical and psychological problems and a high BMI in
childhood is associated with a 4060 % increase in risk
of all- cause mortality in adulthood [11, 12].
Motor skills are an essential component for develop-
mental processes of children and influence cognitive or
emotional aspects of childrens health (see e.g., [13, 14]).
Normally developed motor skills are important for chil-
drens daily activities and their participation in social en-
gagements. In contrast, impaired motor skills and motor
coordination problems may lead to poorer self-efficacy
and lower life satisfaction in school-age children and ad-
olescents (see for a comprehensive review [15]).
Impact of stress on childrens psychological and
physiological health
Stress is a universal condition of human existence. The
concept of allostasis (see Fig. 1, left column) describes
the active process by which humans adapt to environ-
mental stressors in order to maintain homeostasis and
promote survival [1618]. Stress occurs when environ-
mental stressors exceed and dysregulate the adaptive
capacity (allostasis) of an individual resulting in psycho-
logical and physiological changes. These changes may
lead to disturbances in mental and physical health (allo-
static load) [17, 18] (see Fig. 1).
Environmental stressors (A) are part of childrens life
and include major life events, but also chronic day-to-
day stressors. In children, chronic day-to-day stressors
can comprehend socially disadvantaged family situations,
chronically poor parental health, low parental involve-
ment, exaggerated parental worries concerning childrens
health and high parental stress [1921].
The ability to adjust to environmental stressors is in-
fluenced by the way one perceives this challenge. Stress
perception (B) leads to behavioral responses (C) such as
fight or flightresponses, lifestyle behaviors or adaptive
coping behavior and can be evaluated in the acute and
chronic setting. Stress perception is also linked to
physiological stress responses (D), the most common re-
sponses involving the hypothalamic-pituitary-adrenal
(HPA) axis and the autonomic nervous system (ANS)
that respond both to chronic and acute stress situations.
These two stress systems interact with each other and
with other mediators (neurotransmitters, cytokines etc.)
in a complex non-linear network and impact on differ-
ent processes such as CNS function, metabolism and
cardiovascular function [16]. Serum or salivary cortisol
concentrations are the most frequently used biomarkers
of the activity of the HPA axis. The ANS can be divided
into the parasympathetic and the sympathetic nervous
system (SNS) and both influence heart rate (HR) and
heart rate variability (HRV) as indicators of cardiac
Messerli-Bürgy et al. BMC Pediatrics (2016) 16:85 Page 2 of 16
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response to stressors. Recent data show that salivary
alpha-amylase concentration can be a reliable and useful
marker of the activity of the SNS which stimulates acinar
cells of the salivary glands via beta-adrenergic receptors
[22, 23]. Diurnal cortisol release is typically characterized
by high levels on waking, peaking at approximately
30 min (called the cortisol awakening response, CAR),
and a subsequent decline over the remainder of the day
both in adults and children [24, 25]. On the other side, sal-
ivary alpha-amylase concentrations are low at waking and
increase over the day [23], but data in children are lacking.
The exposure to repetitive environmental stressors
(chronic stressors) can for example alter the diurnal pat-
terns of the biomarkers of the main physiological stress
systems, i.e. of both salivary cortisol and alpha-amylase
[23, 26]. As another example, a high resting HR and/or
reduced HRV present an ANS imbalance with decreased
parasympathetic activity. Although still explorative, cor-
tisol levels in the fingernails may be indicative of chronic
environmental stress exposure, as cortisol is able to dif-
fuse passively from the capillaries into the human nail
matrix and become keratinized [27]. In general, several
types of physiological stress responses can result in mal-
adaptive allostatic load such as 1) frequent stressors with
lack of adaptation possibly leading to 2) failure to shut-
down the persistent elevation of stress hormones or 3)
inadequate response with failure to respond to challenge
[18]. For example, exposure to persistently dysregulated
secretion of stress hormones can subsequently contrib-
ute to cognitive impairment, mental disorders and obes-
ity [16, 17, 2830] (see also below). Similarly, any
imbalance in ANS activity with decreased parasympa-
thetic activity is related to metabolic complications, poor
cognitive function and emotional dysregulation. Thus, a
lower HRV can predict greater psychological problems
in children, while a higher HRV serves as a buffer
against detrimental effects of chronic stressors [31, 32].
In the acute setting, acute stress reactivity to a specific
stressor can be expressed as changes in salivary cortisol
or alpha-amylase concentrations (albeit with different re-
sponse times) or in increases in the HR and decreases in
the HRV in response to a standardized acute stressor
[3336].The level of acute stress reactivity shows the in-
dividual sensitivity or the differential susceptibility to an
environmental stressor and can indicate a risk for the
development of allostatic load. For example, acute stress
reactivity has been associated with childhood adiposity
[37]. Thus, chronic exposure to environmental stressors
in early childhood may have long-term health conse-
quences and acute stress reactivity may have an add-
itional impact. Several factors such as parent (e.g.,
familial atmosphere and positive parenting styles influ-
encing developmental processes) and child characteris-
tics (e.g., genetic predisposition, temperament, physical
health) and early stress experiences moderate the re-
sponse to stressors and can thus help to explain the out-
come variability in stress responses. Thus, multiple
factors determine if a stressor leads to successful adapta-
tion, coping and resilience or to allostatic load.
Stress and cognitive functioning: Environmental stressors
and the subsequent activation of both main physiological
stress systems, that is the HPA axis and the ANS, can have
impairing or enhancing effects on memory, attention and
executive functioning. These differential effects depend on
several factors such as age, type and time course of the
stressor and the moderating role of the environmental
context and support [3840]. Chronic stress exposure
may have an impact on neurocognitive functioning, espe-
cially memory and selective attention [40]. Data suggest
that early and continuous stress exposure might particularly
Fig. 1 Stress concept and operationalization in the current study
Messerli-Bürgy et al. BMC Pediatrics (2016) 16:85 Page 3 of 16
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affect the frontal cortex and possibly also the hippocampus,
but studies in human are controversial [40]. Acute stress
(such as witnessing a threatening situation) reduces chil-
drens performance on vocabulary and reading assessments
for 23 weeks [41]. In experimental settings, acute stress
exposure seems to impair memory retrieval [38]. However,
there are only few data in children and there is a lack of
knowledge about more long-term cognitive effects of
heightened stress reactivity or of chronically high or low
cortisol or SNS activity.
Stress and psychological wellbeing: Repeated or endur-
ing exposure to stressors seems to be crucial for mental
health [42]. Chronic (family) stressors, in contrast to epi-
sodic stress seem to be linked to a gene-environment
interaction with youth possessing special high-risk alleles
being prone to develop depressive symptoms [42]. Re-
cent data show that individual differences in stress re-
activity such as the organisms capacity to respond to
acute and prolonged stressors may be associated with
the development of anxiety and mood disorders [43].
However, data assessing stress response in different sys-
tems such as physiological, behavioral and emotional do-
mains is scarce. Another well-known but unsolved issue
is the question about the impact of the experience of
stress and stress response patterns at different ages
through early childhood. Hence, it is of high relevance
to investigate how the experience of stress and the
childs individual stress reactivity relate to the (later) de-
velopment of psychological well-being and to define pos-
sible moderators.
Stress and adiposity: The exposure to environmental
stressors and the psychological and physiologic stress re-
sponses have been related to childhood obesity, but
there are very few longitudinal data and data in young
children are needed [20, 21, 30, 37, 44]. Urinary free cor-
tisol, urinary cortisol metabolites and morning plasma
cortisol as markers of the HPA axis have been associated
with BMI, total or central body fat in some cross-
sectional studies [28, 29]. However, as far as we know,
there are no longitudinal data relating plasma or salivary
cortisol levels to BMI in children. A chronic stimulation
of the HPA axis and subsequent increase cortisol expos-
ure in concert with a concurrent cortisol-stimulated ele-
vation in insulin concentrations can increase body fat
accrual and could lead to (central) obesity, insulin resist-
ance and the metabolic syndrome. Studies in children
are needed to further investigate if cortisol is also dir-
ectly related to increased body fat or if stress might act
through behavioral changes such as emotional com-
forteating, impulsive behaviors, selection of specific
foods, lack of sleep and a decrease in physical activity
[30, 45, 46] There is further a need for studies relating
the activity of the ANS to obesity in children which is a
largely understudied field.
Impact of physical activity (PA) on childrens
psychological and physiological health
From a developmental perspective, body motion is a
fundamental condition for adequate motor and cognitive
development as a precondition for childrens global well-
being. Since the spreading burden of chronic disease, PA
has gained a pivotal role in the prevention of psycho-
logical [47, 48] and physical [49] diseases and is believed
to improve cognitive functioning [50]. This is especially
relevant as recent studies indicate that young children
are insufficiently active with 35-year old children
spending around 80 % of their time in activities classified
as sedentary or at most as light PA [51].
PA and cognitive functioning: Epidemiological research
supports experimental findings in animals that (espe-
cially aerobic) exercise can enhance human brain struc-
ture, prevent structural tissue loss and improve cognitive
performance and academic achievements [52]. Diamond
[53] has summarized the current evidence that the pre-
frontal cortex and the cerebellum are co-activated dur-
ing movements and cognitive tasks suggesting that they
are equally important for both motor and cognitive
functions. Yet, few investigations are currently available
which have reported inconsistent findings in terms of
the magnitude and nature of the motor-cognition associ-
ation during childhood (see e.g., [13, 54, 55]). A single
study exists in preschool children performed by an inter-
disciplinary collaboration of the current co-applicants, in
which higher baseline aerobic fitness and motor skills
were related to a better spatial working memory and/or
attention at baseline, and to some extent also to their fu-
ture improvements [56]. Ackerman [57] and Voelcker-
Rehage [58] were suggesting in his model of motor
learning that there is a positive relationship between
motor skills and cognitive functioning in the preschool
period which is thought to decrease with age as motor
skill levels increase.
PA and psychological well-being: PA interventions in
the general population of children have a positive impact
on self-esteem and beneficial effects on anxiety and de-
pression scores [47]. There is evidence that the level of
PA in childhood might protect against depressive symp-
toms in adults, although additional prospective longitu-
dinal studies are needed [59]. We have shown that the
effect of PA on quality of life is especially pronounced in
obese children [60, 61]. As most studies are cross-
sectional and there is an inconsistency between mea-
sures, the relationships between PA and mental health is
still an underinvestigated area of research and even less
is known on the processes linking PA and psychological
well-being. A current review encourages additional
research investigating the moderating role of family at-
mosphere and child characteristics [48] on the associ-
ation between PA and psychological well-being.
Messerli-Bürgy et al. BMC Pediatrics (2016) 16:85 Page 4 of 16
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PA and adiposity: Most studies using objectively mea-
sured PA found inverse relationships between PA and
BMI or body fat, but few data exist in preschoolers and
longitudinal studies show controversial results [62, 63].
Yet, lifestyle interventions including PA performed in
preschool or school age children had a beneficial effect
on body fat [6466].
PA and motor skills: While we know quite well how
motor skills develop from early childhood into school
age (see e.g., [67]), detailed knowledge about the driving
forces for this development is scarce. Intuitively, PA and
repetitive motor training would be the main forces. This
idea builds on the hypothesis that practice through PA
training may lead to an increase in synaptic strengths
that is observed when motor skill training is performed
[68, 69]. Thus, the PA level of young children may tell
us whether they have sufficient amount of practice (i.e.,
PA) or not. In cross-sectional and longitudinal studies,
PA has been positively related to different motor skills in
school [70] and preschool children [63]. Similarly, PA
intervention studies in preschoolers [65, 71, 72] have
demonstrated an improvement in motor skills. However,
the amount of prospective studies is scarce, particularly
in children below the age of 5 years.
PA and stress: The beneficial effect of PA on physio-
logical and mental disorders [52] is at least in part ex-
plained by a reduction in stress responses, resulting in
reduced stress hormones levels [73], higher self-esteem
[47], improved cognitive factors [74] and improved
physiological health with better fitness, less adiposity,
and reduced cardiovascular stress reactivity [75, 76].
Regular PA also leads to a higher parasympathetic activ-
ity, which beside other influences is thought to be one
health-protecting mechanism [77, 78]. Yet, men who
were highly responsive to exercise stress (concerning
HPA-axis) were also highly responsive to psychological
stress, suggesting that there may be a genetic trait deter-
mining responsiveness to stressors [79]. To our best
knowledge, data on acute stress response in terms of
HPA axis and HRV changes (i.e. changes in physiological
parameters in response to challenging conditions) in
children are lacking.
Moderating role of psychological child and environmental
Psychological child and environmental characteristics
are related to environmental stressors, stress responses
and PA, but also to psychological and physiological
health outcomes. The process by which children (psy-
chological child characteristics) regulate and their care-
givers (psychological parent characteristics) co-regulate
stress responses has not yet been given sufficient atten-
tion in literature (see e.g. [6]). It is therefore important
to take these moderators into account when studying
the relationship of stress and PA with childrens health.
Other factors such as physiological health (PA, adiposity,
health problems) and developmental experience can,
where appropriate, also act as moderators.
Psychological child characteristics
Psychological child characteristics such as temperament,
self- or emotion regulation are related to the childs abil-
ity to cope with acute or chronic stressors [80]. For ex-
ample, temperament determines changes in cortisol
concentrations in children visiting child care [81]. Child
characteristics are also related to psychological well-
being, adiposity, motor development and cognitive func-
tioning. Self-regulation capacity represents a general de-
terminant of later competences to control onesbehavior,
thoughts, motor abilities and emotions [82]. We have
shown that correlates of self-regulation capacities are as-
sociated with parental behavior (especially with mothers),
with different styles of eating behavior [83], with PA [84]
and have also been related to adiposity [85].
Environmental characteristics (parents, child care, large
Family setting: Familial socioeconomic status (SES, in-
cluding migrant status, educational level and income),
parenting style, family atmosphere, parental role model-
ing such as their health attitude, behaviour and support
for a healthy lifestyle can all affect childrens PA levels
and physiological and mental health [8688]. Salivary
cortisol has been reported to be higher in children with
lower SES and may be mediated by a greater exposure
to stressful life events [89]. We have shown that parental
SES factors were related to obesity in young children
[9092]. In addition, psychological parent characteristics
such as parenting style [93] and family atmosphere [94]
have a major impact on childrens behavioral responses
in stressful situations.
Child care/ (pre)school setting: Differences in child
care quality and health promotion in the child care/
school setting can impact on childrens health. Child
care centers/schools are essential determinants for PA as
well as for developing motor skills, physical fitness and a
healthy body weight, as we had confirmed in our inter-
vention studies [64, 65]. The quality of child care can
impact on the salivary cortisol levels [81] as well as on
cognitive functioning and behavior [88, 95].
Large sociocultural/neighborhood environment: Differ-
ences between neighborhoods and within Europe high-
light the impact of the sociocultural environment for
lifestyle factors such as PA or obesity in children. Similar
to the well-known European Northsouth-decline in PA
and the corresponding increase in obesity [96], differ-
ences in adult PA levels between the different sociocul-
tural regions (north-eastern German vs south-western
Messerli-Bürgy et al. BMC Pediatrics (2016) 16:85 Page 5 of 16
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French speaking part of Switzerland) have been reported
within Switzerland [97]. In a previous study we have
confirmed this observation in preschool children [90].
Potential sensitive time points
Evidence is accumulating that early life conditions affect
long-term health outcomes [98] and this early impact on
health may limit the effectiveness of later interventions.
The earlier in life stressful life events occur (the period
up to age 5 seems to be especially sensitive), the more
important their (long term) health impact may be, as a
permanent biological embedding of developmental pro-
cesses into regulatory physiological processes may take
place (programming effect) [98, 99].
Up to now, there is a lack of longitudinal studies that
include both potentially challenging and health promot-
ing predictors and their effect on both psychological and
physiological health outcomes. Our study fills this gap
and offers the opportunity to gain insights in potential
sensitive periods where certain fundamental health indi-
cators might be particularly receptive (e.g., for PA pro-
motion) or vulnerable (e.g., to stress exposure). In
conclusion, it remains open how relevant determinants
of todays life, stress and PA, in combination or by inter-
action with different childs and environmental charac-
teristics, influence psychological and physiological
health, i.e. how they think, feel, behave, eat, grow and
move at a given and at future time-points. In conclusion,
the expected study results will contribute to a global as-
sessment of childrens health for research, practice and
policies and thus as a basis for targeted prevention and
early intervention.
The overall aim of Swiss PreschoolersHealth Study
(SPLASHY) is to investigate how stress (as a paradigm
for a potentially health challenging predictor) and PA (as
a paradigm for a potentially health promoting predictor)
influence childrens psychological and physiological
health by focusing on four essential health outcomes, i.e.
cognitive functioning, psychological well-being, adiposity
and motor skills. The main hypotheses for the respective
research questions are the following:
1. Chronic exposure to environmental stressors (major
life events, chronic day-to-day stressors), chronic
physiological stress responses (dysregulations of the
hypothalamic-pituitary-adrenal (HPA) axis, dysregula-
tion of the autonomic nervous system (ANS), and the
dysregulation of acute laboratory induced stress re-
activity to a standardized stressor) are associated with/
predict increased current and prospective adiposity,
reduced cognitive functioning, and reduced
psychological health (i.e., emotional problems, behav-
ioral problems and dysfunctional eating behavior
2. High levels of total physical activity and more time
spent in moderate-to-vigorous physical activity correl-
ate with/predict current and prospective lower levels
of adiposity, better cognitive functioning and motor
skill performance and increased psychological health.
3. Stress exposure and physical activity have an impact
on psychological and physiological stress responses.
4. Aspects of childs development and health (cognitive
and emotional development, self-regulation skills,
adiposity, motor skills) are related to each other.
5. The strength of all these associations vary with age.
6. Environmental characteristics such as sociocultural
environment (German vs French part of
Switzerland), child care center characteristics
(quality, health promoting activities), parental
characteristics (family atmosphere, parenting style,
parenting stress and family lifestyle, parental BMI,
socioeconomic status), psychological child
characteristics (temperament, emotion and self
regulation, pre- and postnatal conditions), and
physiological child characteristics (lifestyle behavior,
adiposity) impact on the above mentioned outcomes
and have a moderating role in the relationship
between stress, PA and psychological and
physiological health of preschool children. It is
further assumed that the strength of association
varies with age and that childrens characteristics
(lifestyle, temperament, emotional well being and
self regulation) and environmental characteristics
(family atmosphere, parental style, socioeconomic
status, child care center characteristics and the
sociocultural environment such as German-French
speaking parts of Switzerland) may moderate the
relationship of stress and physical activity on
psychological and physiological health outcomes.
SPLASHY is a prospective cohort study including chil-
dren during early childhood within two sociocultural
areas of Switzerland (German and French speaking part).
The project uses a multi-site approach including four re-
search groups recruiting child care centers within five
cantons of Switzerland (Aargau, Bern, Fribourg, Vaud,
Zurich) which together made up 50 % of the Swiss
population in 2013.
Study sample
Sample size calculations were based on the data simula-
tion software MLPowSim 2 in combination with R, ver-
sion 2.13.1, with 5000 permutations per simulation. We
thereby selected an effect size r= 0.18 which was the
Messerli-Bürgy et al. BMC Pediatrics (2016) 16:85 Page 6 of 16
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minimum expected effect size in any sub-project in
order to have a sufficiently high sample size to test hy-
potheses in any sub-project. Further conditions were:
statistical power 1β= 0.8, α= 0.05, two-sided test.
Thus, the minimal sample size to have sufficient power
at the third assessment wave was calculated to be 240
children. For reasons of feasibility, we planned to recruit
96 child care centers (24 for each of the four research
groups). Based on a previous study [100] we presumed
that around 12 children per child care center or 1150
children in total would be present and could be invited
on a given afternoon of testing. We assumed a participa-
tion rate of 40 % or 500 children at T1 with 5.2 children
per child care center. In addition, we assumed a worst
case scenario in which the analysis was based on data
from the third assessment wave (T3, not part of the
current study design), where an additional 48 % of the
data was expected to be missing. This estimated dropout
rate of 48 % was based on a dropout rate of 20 % be-
tween T1 and T2 and another 40 % dropout between T2
and T3 resulting in a final sample size at T3 of 240 chil-
dren. The higher dropout of 40 % between T2 and T3 is
based on the situation that merely all children will have
left the child care center by this time and will go to kin-
dergarten elsewhere.
Child care centers were recruited in five cantons
Aargau (AG), Berne (BE), Fribourg (FR), Vaud (VD),
Zurich (ZH) which together contained 50 % of the Swiss
population in 2012 [101]. The selection procedure was
stratified according to one stratum with four levels:
urban community and rural community with high SES
(above-average) and low SES (below-average) each based
on the prevalence of child care centers in the respective
communities. For FR and BE, all child care centers were
invited to participate due to a low number of existing
child care centers in these cantons.
Urban communities were defined as the biggest cities
of each canton as well as cities >100000 inhabitants.
This included Zurich and Winterthur (ZH), Bern (BE),
Fribourg (FR), Aarau (AG), Lausanne (VD). All other
communities were defined as rural communities.
Socioeconomic status was defined by the maternal
education level of the community based on the report of
the 2010 SNF NFP 60 familienergänzende Kinderbe-
treuung und Gleichstellung(REF [102]). Thus, child
care centers for which the communitys proportion of
mothers with a university degree was higher or lower
than the median were accordingly defined to have high
or low SES, respectively.
For the larger urban communities, a different method
for SES stratification was chosen as the community SES
would not represent it appropriately. The list of child
care centers was divided into high and low SES using
the definition of SES according to the Swiss neighbour-
hood index of socioeconomic status [103]. Thereby,
deciles of the index were constructed and high SES
was defined as the deciles 610 and low SES as the
deciles 05.
A total number of 639 child care centers in the French
and German part of Switzerland were contacted in the
period between January 2013 and October 2014 by four
different research groups and were informed on study
participation (see Fig. 2). Of these, 126 child care centers
agreed to participate and to inform the parents. Reasons
for refusals were lack of time (26 %), too few (less than
4) children of the selected age group present in child
care on a given afternoon (21 %), no interest (21 %) and
organizational changes (13 %). Further, 42 centers had to
Fig. 2 Recruitment and participants flow
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be excluded after the preparation of testing dates due
to too few (less than 2) participating children (78 %)
or for other reasons (12 %). The final sample con-
sisted of 84 child care centers that participated, which
is 12 % less than the originally planned number of 96
child care centers.
In addition, instead of the expected number of 12
children per child care center, a mean of 7.6 children
(26 years old) were present at a given assessment after-
noon and were invited to participate. The participation
rate for these was, however, much higher than expected
(73.9 %, n= 476 at T1). In summary, expected and real
recruitment numbers differed by 24 children in the total
sample. Therefore, for T2, new arriving children of the
same child care centers are currently still recruited in
order to obtain the desired number of children at T2
and T3. Note that the number of 240 children at T3
leads to slightly increased power when coming from 84
rather than 96 child care centers because of the reduced
design effect. However, this beneficial effect is expected
to be very small.
Inclusion and exclusion criteria
To attain the largest external validity possible, we aim at
including as many children as possible thereby keeping
exclusion criteria at a minimum. We will inquire about
any medication intake and existing acute and chronic
health problems (e.g., allergies, asthma) and passive
smoke exposure and record this information. We will
exclude children below the age of 2 and above the age of
6 and for certain testing or analyses on a case to case
basis according to the question studied if there may be a
possible interference between their health or treatment
and the testing (e.g., intake of inhaled steroids for the
cortisol measures) or if the child is unable to perform
the test (e.g., motor handicap).
All direct measurements at baseline and one year later
are conducted in the child care centers on three subse-
quent afternoons between 1.30 p.m. and 6 p.m. of the
same weekday (adiposity & motor skills; self-regulation
and cognitive functioning; acute stress reactivity). In
addition, measures of chronic stress (heart rate variabil-
ity overnight, salivary cortisol and alpha amylase over
one weekday and one weekend day, cortisol in finger-
nails) and of physical activity over one week are assessed,
questionnaires are completed by parents and child care
educators and parents conduct an interview on family
atmosphere by using the Five Minutes Speech Sample
[104]. An overview of all measurements is given in
Table 1. Measurements are divided into testings of chil-
dren during the three assessment afternoons in child
care and at home (direct testing) and assessments
with parents and child care educators as informants
(indirect testing).
Follow-up measurements one year later include the
same assessments. Each center defined a team with one
responsible and 2 to 3 assistants per afternoon for the
testing sessions. Testings for the first period have all
been done between February 2014 and November 2014
in parallel in different child care units for the baseline
testing and during the follow up one year later further
children within the same child care centers were re-
cruited between February 2015 and November 2015. Be-
fore starting the testing period all assistants were trained
in assessment techniques on three different days. Quality
check of testings were performed every 3 week by ana-
lyzing videotaped testing sessions of each testing site by
an expert team.
Assessment of stress includes a chronic and an acute
perspective and covers several parts of the allostatic load
model such as environmental stress exposure, perceived
stress, behavioral responses, physiological stress re-
sponses as well as the successful coping or allostatic load
including an increased risk for mental disorders or/and
physical diseases (see Fig. 1).
Chronic setting
The chronic setting involves environmental stressors
and physiological stress responses. Environmental
stressors (parental report as part of the general health
questionnaire) include major life events and chronic
day-to-day stressors. Major life events will be assessed
by a total score of single items including death, serious
disease, accident of a relative or close friend, divorce, ex-
posure to violence/abuse (major negative life events
based on the Coddington Life Events Scale CLES [105].
In a second step a subjective impact rating of each event
(intensity score 13) as previously described will be
done [106]. Chronic day-to-day stressors included par-
ental unemployment [20], socially disadvantaged situa-
tions, parental worries concerning childs health [107],
daily hassles including problems and conflicts, separa-
tions of parents, low parental involvement by the
Alabama Parenting Questionnaire [100], high parental
stress (Parental Stress Scale PSS) [108], and poor paren-
tal health [19]. Physiological stress responses will be
assessed through HR and HRV, salivary cortisol and
alpha-amylase, cortisol in fingernails. Resting HR and
HRV will be measured and analyzed based on standard
procedures over the measurement period with a eMo-
tion HRV (Mega Electronics, Kuopio, Finland) by fixing
two electrodes on the chest of the child that are con-
nected to a little box (35x35x15mm) that is worn and
fixed over the upper chest [109]. A methods paper for
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the measurement of HR and HRV in preschoolers will
be published separately. Measurement of basal salivary
cortisol and alpha-amylase concentrations (during one
weekday with child care and one weekend day; 5 times/
day) include: upon awakening in the morning around
7.308.00 (within 10 min of awakening), 30 min after
awakening (cortisol awakening response- CAR), before
lunchtime (11.3012.00), before snack (16.00) and at
bedtime (20.00). Parents enter the time periods of as-
sessment in a diary. Salivary cortisol and alpha-amylase
samples are collected using Salivette (Sarstedt) collection
devices, which are cotton rolls that children keep in
their mouth for 1 min. The salivettes are collected by
the trainees from the child care centers at the respective
sites and are stored at 20 °C until badge analysis in the
freezer of each center. Salivary cortisol is analyzed using
a commercial chemiluminescence immunoassay (LIA)
(IBL Hamburg, Germany) and alpha-amylase using an
automatic analyser Cobas Mira (assay kits from Roche),
as previously described [110].
The measure of cortisol in fingernails is still explora-
tive. We therefore assess and validate in this project this
innovative and perhaps simpler approach to cortisol as-
sessment. Nail clippings are washed, dried for two hours
at 45° Celsius and then cut into small pieces of 12 mm.
After further purification, cortisol levels in nails are de-
termined by enzyme immunoassay (EIA) [27].
Acute setting
Acute stress reactivity is assessed according a laboratory
stress induction paradigm using an age - appropriate
adaptation task entailing a socially evaluative compo-
nent, perceived uncontrollability and motivated perform-
ance according to Kryski et al. [33].
Table 1 Outcomes and measures. Childrens direct and indirect (parent and child care educator assessment)
Measures Tool informants
Indirect assessment by parents or child care educator
Major life events, chronic day-today stressors, SES, neighborhood,
lifestyle, pre-& perinatal conditions, birth weight, breastfeeding,
early regulatory problems, general health, reported PA
General health questionnaire parents
Parenting style Alabama Parenting Questionnaire (APQ) parents
Parental stress Parental Stress Scale (PSS) parents
Childrens eating behavior Childrens Eating Behavior Questionnaire (CEBQ) parents and child care
Childrens mood and behavior problems Strengths and Difficulties Questionnaire (SDQ) parents
Childrens temperament Emotionality Activity Sociability Temperament
Survey (EAS)
Childrens emotion regulation Index combining EAS scales, observed emotion
regulation behavior, salivary cortisol, HRV during
adaptation task
parents and child
Family atmosphere Parental Expressed Emotions by Five-Minute
Speech Sample (FMSS)
Social contacts (with peers) Child care questionnaire child care educators
Childrens direct assessment at home
Physical activity Accelerometers child
Physiological stress responses in the chronic setting Salivary amylase & cortisol, clipped fingernails,
HR and HRV
Childrens direct assessment at the child care center
Afternoon A:
Adiposity BMI, sum of 4 skinfolds, waist circumference child
Motor skills Zurich Neuromotor assessment (ZNA35) child
Afternoon B:
Cognitive functioning Intelligence and Development Scales-Preschool
(IDS-P) 4 cognitive tests
Self regulation Statue test (NEPSY) child
Afternoon C:
Stress response/acute stress reactivity Adaptation task with stress perception, behavioral
responses, salivary amylase & cortisol, HR & HRV,
Picture Stress Test
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Standardized environmental stressor (adaptation task):
The original protocol of Kryski et al. [33] was adapted
slightly in terms of icons (frogs and ladybirds instead of
ball icons). Additionally an animated picture of a traffic
stoplight on a computer screen was integrated. Feasibil-
ity and acceptance of the testing was established in a
pilot study. The adaptation task is applicated in a separ-
ate room and children are asked to sit together with a
non-familiar experimenter at a table in front of a large
felt board with numerous ladybirds and butterflies
affixed and colored stones (blue and red). At the begin-
ning, the child chooses a prize from an assortment of
small toys. The experimenter explains to the child that
each of the icons have to be covered by a stone and the
child is given some time to practice prior to starting the
task. The child is then told that there is plenty of time
to work when the light is green (2 min 20 s), but when
the light turns yellow, time is running out and when the
light turns red in combination with a loud buzzer (after
another 40 s), time is up. The red light is accompanied
by a loud buzzer sound. The child is told that the adap-
tation task is easy to be done and even small children
are able to finish on time, but that the child must match
all the animals on the board with the stones to receive
their preferred prize. The time limitation is manipulated
by the testing person to allow challenging situations
which are comparable for all the children. Three subse-
quent identical trials are carried through in which chil-
dren are unsuccessful and the chosen present is refused.
After the third trial, the experimenter exclaims that the
light was broken and that the child had not been given
enough time. Therefore, the childs matching skills are
praised and the child receives his preferred toy.
Based on a pilot study, salivary protocol described by
Kryski et al. [33] has been adapted. Cortisol and alpha
amylase is assessed at 7 different time points in total and
HR and HRV will be continuously measured before the
beginning of the adaptation task and up to 75 min after
the end of the task using eMotion HRV. In order not to
interfere with the impact of the diurnal rhythm as well
as PA or food intake, we perform testing in the early
afternoon (starting between 1.30 and 3.30 p.m.), at least
60 min after waking up from day nap, at least 90 min
after lunch and at least 60 min after a light snack eating,
or drinking as done in the study of Kryski et al. in the
same age group [33]. Children are not allowed to be
physically active in between lunch and this testing.
The childs stress perception is assessed using an age -
adapted nonverbal test (Picture Stress Test) using the re-
sponse format of the Harter scales [111]. This adapted
child stress perception scale assesses feelings of distress
using gender specific pictures (e.g., sadness, anxiety, ten-
sion, shame, guilt, anger/aggression). For each item, two
pictures are presented simultaneously. One depicts the
critical symptom, while in the other picture the symp-
tom is not shown (neutral). The child is asked which
rabbit he or she resembles and indicates the degree of
his or her feeling on a 4-point-scale [112]. Videotaped
emotional and behavioral stress responses including fa-
cial, verbal and physical display of childrens positive and
negative emotions (PE and NE) are assessed and coded
using visual analogue scales (VAS) ranging from 0 to 5
(0 = no PE/NE or low intensity/number of expressions of
PE/NE or 5 = high intensity/number) according to the
Kryski protocol [33]. Baseline PE and NE measures are
assessed during the introduction of the task and imme-
diately after stress induction when the child is told that
it runs out of time. Changes in baseline PE and NE rela-
tive to stressful events will be calculated by subtracting
summed instances and intensity of emotions expressed dur-
ing the introduction from that expressed during the stress-
ful period of the task thereby controlling for the duration of
these two periods. PA levels will be rated using a 0 to 5
VAS with anchoring points (very low PA to high PA).
Physical activity is monitored with an accelerometer
(MTI/CSA wGT3X+, Actigraph, Shalimar, FL, USA),
which children continuously wear around the hip for five
weekdays and two weekend days during each measure-
ment period. ActiGraph wGT3X+ is a triaxial acceler-
ometer that is used to measure the amount and
frequency of accelerations of the body. The monitor is
small and lightweight, measures 4.6 cm* 3.3 cm* 1.5 cm
and weighs 19 g. The ActiGraph monitors are affixed
above the iliac crest of the right side of the hip with an
elastic belt. Data acquisition storage is set at 3-s epochs.
The output includes activity counts (vertical x, horizon-
tal y, and diagonal z axes), vector magnitude, which is
equal to the square root of ((amplitude x)
+ (amplitude
+ (amplitude z)
), and number of steps taken. Times
of 20 min and more of 0 readings will be removed and
considered as non-wear time. Each sample will be
summed over a 15-s or 60-s epoch according to valid-
ation studies for preschool children [113, 114] to deter-
mine the level of overall PA (in counts per minute,
cpm), and time spent in different levels of PA as recently
suggested [115, 116]. For an initial evaluation, individual
childs physical activity data will be accepted as valid if at
least three weekdays (at least one day at the child care
center) and one weekend day of measurements with a
minimum of 10 h are recorded. Children that do not ful-
fill these quality criteria are remeasured. We also assess
the time when the child gets up and goes to bed to as-
sess time awake and control compliance. Each statistical
model will be controlled for differences in wearing time.
Further, a questionnaire is used to assess the extent and
pattern of childrens physical activity including sports
club and leisure time sports participation, as well as par-
ental support for and attitude towards physical activity.
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Three different measures are used to assess adiposity:
Body mass index, body fat and waist circumference. To
define body mass index, standing height and body
weight are measured using an electronic scale (Seca, Ba-
sel, Switzerland; accuracy 0.05 g) and BMI percentiles
are calculated for age and gender of each child. Over-
weight and obesity will be also pooled for some analyses
due to the relatively low prevalence at this age, labeled
together as overweightand defined according to WHO
criteria [117], the International Obesity Task Force
(IOTF) criteria [118, 119] and the national Swiss percen-
tiles [120, 121]. Total body fat is assessed by skinfold
measurements. The skinfold thickness is measured in
triplicate to the nearest 0.1 mm with Harpenden calipers
(HSK-BI, British Indicators, UK) calibrated to exert a
pressure of 10 g/cm2 to the skin. A maximal difference
of 1 mm between the 3 measurements will be allowed
for data to be valid. Four sites (triceps, biceps, subscapu-
lar and suprailiac) are measured based on standard pro-
cedures and the sum of four skinfolds calculated [122].
Waist circumference (midway between the iliac crest
and the lowest border of the rib cage) is measured in du-
plicate to the nearest 0.1 cm by a flexible tape. A max-
imal difference of 0.5 cm between the 2 measurements
will be allowed for data to be valid. Waist circumference
is an indicator for central body fat.
Cognitive functioning is assessed by using the IDS-P
(Intelligence and Development Scales- Preschool) [123].
The advantage of this test battery is its development in a
Swiss population and the possibility to use it in our lon-
gitudinal design not having to change test items for dif-
ferent ages with a version for 3- to 5- year-old and then
for 5- to 10-year-old children allowing longitudinal com-
parisons. The full test battery is used to determine the
state of development of cognitive functioning as well as
general development in psycho-motor abilities, social-
emotional competency, mathematics and language as
well as performance motivation. For the younger age
group, internal consistency (Cronbach α) ranged from
0.550.96, and was around 0.8, except for some single
exceptions. For the older age group of 5- to 10-year-old
children correlation between general intelligence scores
measured by IDS and HAWIK-IV was 0.83 [124]. The
test battery has a high construct validity for age trends,
shows high intercorrelation of individual scales and fac-
tor loading, as well as criterion validity for the HAWIK-
IV and differential validity for giftedness or children with
attention-deficit-hyperactivity disorder. As cognitive test-
ing in preschool is not evident, simple reliable measures
that cover major executive functions and have been
shown to be responsive to physical activity as described
in the above cited studies were selected. These include
four tests described in detail in the IDS Manual [123]:
visual perception, selective attention, visual special
working memory, figural reasoning. We will base our
analysis on a normalized summary score that is calcu-
lated by summing the age and gender based IDS z-
scores of the respective tests.
Psychological well-being: Parents are asked to respond
to different questions regarding mood, temperament, be-
havioral problem, eating behavior and self-regulation
capacities of their child. We assess parentsratings of
childs emotional and behavioral problems using the
Strengths and Difficulties Questionnaires (SDQ [125]).
Parentsrating of the childs eating behavior and tem-
perament is assessed using the Child Eating Behavior
Questionnaire (CEBQ [126]) and the Emotionality Activ-
ity Sociability Temperament Survey (EAS [127]) respect-
ively. Additionally, the child care educators evaluate the
eating behavior of the children according to the CEBQ
[126]. Further, a correlate of self-regulation is assessed
by the statue test of the Neuropsychological Assessment
for Children, NEPSY [82], where the child is told to
stand still like a statue, while the experimenter tries to
attract attention of the child.
Emotion regulation as the ability to modify the
valence, intensity, or time course of emotional reactions
will be assessed as suggested by Adrian et al. [128] in a
multi-method approach. This includes the parents rat-
ings of emotionality and sociability of the EAS [127],
physiological markers (delta baseline-to max salivary
cortisol and HR) self-rated and observed emotion regu-
lation behavior (Stress perception according to AcSS;
PE, NE/gestures/emotion regulation categories) assessed
during the laboratory stress induction paradigm: the
childs gestural behavior will be analyzed according to
the NEUROGES-ELAN coding system [129] and ges-
tures directed towards the body and self-touch gestures
reflecting emotion regulation behavior will be coded.
The NEUROGES coding inventory consists of object-
ively defined kinetic and functional movement categor-
ies, developed based on neuropsychological gesture
research of recent decades. The ELAN annotation tool
has been proved to be a reliable instrument for assessing
gestural behavior. Further, trained raters will estimate
emotion regulation categories such as cognitive change,
emotional support, instrumental intervention, instru-
mental support, attentional deployment, response modu-
lation and denial according to Gross & Thompson [130].
For this purpose, a coding system will be developed.
Motor tests will be performed by trained testers of the
ZNA35 [67] and the ZNA518 [131] which has been
developed to assess fine and gross motor functioning in
young and older children. The ZNA518 is a well-
standardized motor instrument with good psychometric
properties (see for more information [132]. The tasks of
the ZNA35 [67] include adaptive and pure motor tasks,
static and dynamic balance tasks. Furthermore, during
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the performance of these tasks the associated move-
ments are determined which occur when the children
are performing the motor test. The tasks are demon-
strated prior to the testing and explained verbally. For
the time-based tasks, we measured how long the child
takes for a certain movement, while for the dynamic
motor tasks; performance is quantified on a 5-point
scale. The tests will be recorded on video and analyzed
off line. A total sum score is calculated for the quantifi-
cation of fine and gross motor skill performance as well
as for the associated movements which are a measure of
neurological maturity of the child (see [67]).
Furthermore, environmental factors such as parenting
style and family atmosphere is assessed through parents
ratings. All parents are asked to complete the APQ [100,
133] to assess parenting style and will be interviewed to
assess family atmosphere (FMSS) [104], especially
expressed emotions in the family. During this interview
parents are asked to describe general thoughts and atti-
tudes towards the child in a free, unstructured manner.
The standardized introduction is: I would like you to
speak for five minutes about your thoughts and feelings
about (childs name) in general without my interrupting.
The interview is audiotaped and parents expressed emo-
tions (EE) in terms of emotional over-involvement and
critical comments are coded.
Besides this, parents are asked about familial socioeco-
nomic status (parental education, occupation, work load,
income, place of birth), parental role modeling (e.g.,
sports club participation, being active with the children,
parental BMI), health attitude and support (e.g., avail-
ability of PA equipment for a healthy lifestyle, lifestyle of
the child including physical activity, sport club, screen
time and sleep duration), chronic illness and any medical
illness or accident which necessitate medical attention
and/or hospitalization; passive smoking exposure and
general home situation using the general health ques-
tionnaire. This questionnaire also includes questions
about the pre-, peri- and postnatal conditions. These
questions focus on pregnancy complications (e.g., pre-
mature contractions, vaginal bleeding, intrauterine
growth retardation or other maternal medical problems,
use of steroids or tocolytics, delivery problems), birth
weight, gestational age, postpartum problems needing
medical help, breastfeeding and early regulatory prob-
lems (e.g., crying, fussing etc.).
To clarify the role of child care settings, educators of
each child care centers are asked to complete a ques-
tionnaire which focus on child care quality and health
promotion. This includes the general child care quality
[134], time spent in child care and health promoting ac-
tivities (participating or not in Youplà bouge/Purzel-
baum). Further, information is collected about the
parental home situation and the childs social network
within the child care center including behavior and play-
mates on child care days. Furthermore, sociocultural as-
pects including recruitment site (French or German
speaking area) and child care center characteristics (rural
or urban level and low-high SES levels of the child care
center) are reported for all child care centers.
Ethical considerations
The study protocol was approved by the Ethical Committee
of the Canton of Vaud as the main applicant (No 338/13)
and those of the other testing sites (Northwestern and
Central of Switzerland, Berne, Fribourg and Zurich) and is
in accordance with the Declaration of Helsinki. All parents
receive written information about the aim of the study,
benefits and risks of participation and the exact study pro-
cedure before giving their written informed consent to par-
ticipate in the study. At that time all participants are
informed that they can cancel participation without disclos-
ing any reason at any time during the study.
Participation is not related to any physical or psycho-
logical risk. All assessments are well proven and cur-
rently used in the clinical settings and in other studies.
The participating children receive small presents on
each of the testing afternoons (including t-shirts, soft
toy, ball, stickers, children tattoos etc.). Furthermore, all
parents receive CHF 200 for each period of testings. The
study has been registered at the ISRCTN registry (no.
ISRCTN41045021, DOI 10.1186/ISRCTN41045021).
Statistical analysis
The main analyses will be carried out according to the
study analysis plan. First, descriptive statistics will be
used for child care centersand childrens characteristics.
Analyses will be adjusted for participantsdifferences
and/or cluster baseline characteristics i.e. age, gender
and for further covariates such as SES depending on the
respective research question. Multilevel models will be
used to analyse the main outcomes of the study with
child care center as upper and child as lower hierarchical
level. For certain analyses, missing values are dealt with
using either multiple imputation or maximum likelihood
procedures which have repeatedly shown to provide un-
biased parameter estimates under the missing at random
(MAR) condition [135]. Internal validation will be used
for assessing the self-developed Picture Stress Test. Fur-
ther, longitudinal data will be analysed using multilevel
models with child as upper and time within child as
lower hierarchical level. This model can be extended by
including child care center as an additional uppermost
level if appropriate.
This study examines the influence of stress and physical
activity on childrens psychological (cognitive functioning,
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psychological well-being) and physiological (adiposity and
motor skills) health. So far, no longitudinal study exists
that specifically evaluates the influence of these factors in
children at preschool age. Given the fact that childrens
health needs to be improved to diminish illness and risk
factors, the detection of the influence of potentially chal-
lenging and health promoting predictors at different stages
of early childhood is of high importance. Moreover, inves-
tigating the role of childs and environmental characteris-
tics and their effect on stress regulation might help to
specify the mechanisms related to stress reactivity in early
childhood. Additionally, the relationship between the
childs psychological and physiological health factors will
be investigated and the potential sensitive periods where
certain fundamental health indicators are particularly re-
ceptive (e.g., for physical activity promotion) or vulnerable
(e.g., to stress exposure) can be identified according to the
longitudinal assessment.
There are several strengths of the study. Firstly, a
community-based longitudinal healthy cohort of children
in Switzerland will be assessed by including children from
important socio-culturally diverse regions starting at an
early and sensitive stage of their childhood. Secondly, very
relevant challenging and health promoting factors (stress
and physical activity) on childrens health condition will be
assessed and its influence on the childs development will
be investigated in all facets (i.e. motor skills, cognitive
skills, emotional skills, social skills). Thirdly, the concept
of stress used in this study integrates a time dimension
(acute and chronic stressors) and a dual assessment ap-
proach (psychological and physiological stress response)
which allows identifying a differentiated stress reaction.
Forthly, most of the measurements used are objective and
well-validated. By including relevant moderators which
might explain the variance of physical activity and stress
enables the identification of personal sensitivity and the
impact of the context and further allows to promote the
development of tailored interventions. Furthermore, the
combination of a laboratory and observational design
within this project and the direct measurements on one
hand including novel and partly explorative parameters
(i.e. salivary alpha- amylase, cortisol in fingernails and
HRV in preschool children, assessment of nonverbal early
correlates of emotion regulation) and on the other hand
in combination with a multi-informant approach allows
increased validity of the data.
There are also limitations of the study design. Assessment
of physiological measures (i.e. salivary alpha- amylase, corti-
sol levels in nails and HRV monitoring) and assessment of
subjective stress perception (PST) at this age is novel and
cannot be compared with earlier studies, but will help to
understand stress conditions in preschool children.
In conclusion, up to now, it remains open how relevant
determinants of todays life (stress and physical activity) in
combination or interaction with different childs and en-
vironmental characteristics, influence psychological and
physiological health at different time points of childhood.
A global assessment of childrens health at the early stage
of childhood and longitudinal data collection during child-
hood is a basis for further evidence of vulnerable stages
and therefore for targeted prevention and early treatment.
Trial status
Recruitment of participants, beginning in March 2014,
ended in December 2015, as new children were invited
to participate in this second wave. Participants data col-
lection is ongoing.
ANS, Autonomic nervous system; APQ, Alabama Parenting Questionnaire; BMI,
Body mass index; CC, Child care center; CEBQ, Childrens Eating Behaviour
Questionnaire; CNS, Central nervous system; EAS, Emotionality Activity Sociability
Temperament Survey; ES, Effect size; FMSS, Parental expressed emotions Five
Minute Speech Sample; HPA, Hypothalamic-pituitary-adrenal axis; HR, Heart rate;
HRV, Heart rate variability; IDS-P, Intelligence and Development Scales- Preschool;
NEPSY, Statue test NEPSY; PSS, Parenting Stress Scale; PST, Picture Stress Test; SDQ,
Strengths and Difficulties Questionnaire; SES, Socioeconomic status; SNS, Sympa-
thetic nervous system; ZNA3-5, Zurich Neuromotor Assessment
The study is funded by the Swiss National Research Foundation
(CRSII3_141908) and the Jacobs Foundation. We would like to thank all
children, families and day care centers that contributed data to SPLASHY. We
also thank all students and the research team for their valuable contribution.
The main responsibility for the study design and project management is
with the principal investigators JJP, SM, SK and OGJ. All authors contributed
to the development of the study design and data collection. NMB drafted
the manuscript. All authors read and commented on drafts and approved
the final manuscript. The Swiss National Research Foundation and the Jacobs
Foundation neither interfered with the design of the study nor provided
direct support (e.g., subject recruitment).
Competing interests
The authors declare that they have no competing interests.
Author details
Endocrinology, Diabetes & Metabolism Service, Centre Hospitalier
Universitaire Vaudois (CHUV), Lausanne, Switzerland.
Department of Clinical
Psychology and Psychotherapy, University of Fribourg, Fribourg, Switzerland.
Child Development Center, University Childrens Hospital Zurich, Zurich,
Childrens Research Center, University Childrens Hospital Zurich,
Zurich, Switzerland.
Epidemiology, Biostatistics and Prevention Institute,
University of Zurich, Zurich, Switzerland.
Department of Psychology,
University of Basel, Basel, Switzerland.
Division of Pediatric Endocrinology,
Diabetology and Obesity, Centre Hospitalier Universitaire Vaudois (CHUV),
Lausanne, Switzerland.
Received: 29 December 2015 Accepted: 29 June 2016
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... The study sample consisted of 555 children of the Swiss Preschooler's Health Study (SPLASHY), a multi-site prospective cohort study recruited in 84 childcare centers of Switzerland (ISRCTN41045021; for details see Messerli-Bürgy et al. [16]). The study was approved by all local ethical committees (No 338/13 for the Ethical Committee of the Canton of Vaud as the main ethical committee (site of Lausanne). ...
... Details of the study design and the overall objectives have been previously described [16]. Parents were asked to let their children participate in the study and provided written informed consent. ...
... The children had a mean SES level of 62.54 (SD 15.5). Mean time point of walking onset was 13.26 months (SD 2.36, range [8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. A total of 156 children experienced any kind of perinatal risk whereof 105 experienced one perinatal risk, 28 two, 14 three and 9 experienced four perinatal risks. ...
Full-text available
Background The onset of walking is thought to be an indicator of early development. However, evidence is mixed and clear data on this relationship at preschool age is missing. The study aimed at investigating if walking onset and motor and cognitive development in preschool children are related. Methods A total of 555 children (mean age 3.86 years) of the Swiss Preschoolers’ Health Study SPLASHY were tested twice at their childcare center (at baseline and one year later). Motor skills and cognitive skills were assessed by standardized testing procedures and parents were asked to provide information on walking onset of their child. Results Late onset of walking was related to poorer motor skills (fine motor skills, static and dynamic balance (all p < 0.003)) and poorer cognitive skills (selective attention and visual perception ( p = 0.02; p = 0.001) in late preschool age. Conclusions For children with late walking onset a close monitoring of their development in the regular pediatric child health visits may be reasonable. Trial registration: ISRCTN41045021 .
... Perceived stress was measured 10 times via a visual analog scale (VAS) rating from 1 = not at all stressed to 5 = extremely stressed (Figure 1) [54]. Perceived stress was assessed at the beginning and the end of the baseline phase, during the stress phase, at the end of the anticipation period and of the psychosocial and cognitive stressors, and, finally, during recovery at each time point of saliva sampling. ...
Full-text available
Stress reactivity is typically investigated in laboratory settings, which is inadequate for mothers in maternity settings. This study aimed at validating the Lausanne Infant Crying Stress Paradigm (LICSP) as a new psychosocial stress paradigm eliciting psychophysiological stress reactivity in early postpartum mothers (n = 52) and to compare stress reactivity in women at low (n = 28) vs. high risk (n = 24) of childbirth-related posttraumatic stress disorder (CB-PTSD). Stress reactivity was assessed at pre-, peri-, and post-stress levels through salivary cortisol, heart rate variability (high-frequency (HF) power, low-frequency (LF) power, and LF/HF ratio), and perceived stress via a visual analog scale. Significant time effects were observed for all stress reactivity outcomes in the total sample (all p < 0.01). When adjusting for perceived life threat for the infant during childbirth, high-risk mothers reported higher perceived stress (p < 0.001, d = 0.91) and had lower salivary cortisol release (p = 0.023, d = 0.53), lower LF/HF ratio (p < 0.001, d = 0.93), and marginally higher HF power (p = 0.07, d = 0.53) than low-risk women. In conclusion, the LICSP induces subjective stress and autonomic nervous system (ANS) reactivity in maternity settings. High-risk mothers showed higher perceived stress and altered ANS and hypothalamic–pituitary–adrenal reactivity when adjusting for infant life threat. Ultimately, the LICSP could stimulate (CB-)PTSD research.
Full-text available
Motorische Basiskompetenzen sind eine zentrale Voraussetzung für die gesunde Entwicklung von Kindern und die Teilhabe an der Bewegungs- und Sportkultur. Das von der Pädagogischen Hochschule Schweiz (PHZH) finanzierte Forschungsprojekt hatte zum Ziel, den motorischen Förderbedarf von Kindern der ersten und zweiten Klasse in der Schweiz festzustellen und relevante Faktoren zu identifizieren, welche mit den motorischen Kompetenzen der Kinder in Zusammenhang stehen. Im Rahmen der Studie konnten insgesamt Daten von 877 Kindern der ersten und zweiten Klasse (bzw. 3H und 4H) in der italienisch- und französischsprachigen Schweiz erfasst werden. Der Abschlussbericht zeigt das Niveau der motorischen Kompetenzen sowie Zusammenhänge mit verschiedenen Faktoren auf. Zudem konnten die Ergebnisse in den beiden Sprachregionen sowie die Stichproben im Tessin aus den Jahren 2020 und 2021 miteinander verglichen werden.
Full-text available
Motorische Basiskompetenzen sind eine zentrale Voraussetzung für die gesunde Entwicklung von Kindern und die Teilhabe an der Bewegungs- und Sportkultur. Das von der Gesundheitsförderung Schweiz (GFCH) und der Pädagogischen Hochschule Zürich (PHZH) finanzierte Forschungsprojekt hatte zum Ziel, den motorischen Förderbedarf von Kindergartenkindern in der Schweiz festzustellen und relevante Faktoren zu identifizieren, welche mit den motorischen Kompetenzen der Kinder in Zusammenhang stehen. Im Rahmen der Studie konnten insgesamt Daten von 1169 Kindern des Kindergartens in der Deutschschweiz sowie der italienisch- und französischsprachigen Schweiz erfasst werden. Der Abschlussbericht zeigt das Niveau der motorischen Kompetenzen sowie Zusammenhänge mit verschiedenen Faktoren auf. Zudem konnten die Ergebnisse in den drei Sprachregionen sowie die Stichproben im Tessin aus den Jahren 2020 und 2021 miteinander verglichen werden.
In keiner anderen Entwicklungsphase erweitert das Kind seine Fähigkeiten mehr als im Alter zwischen ein und vier Jahren. Es entwickelt ein Verständnis für räumliche, zeitliche und kausale Zusammenhänge, lernt die Sprache und wie es mit anderen Menschen wirksam kommunizieren kann. Außerdem entwickelt es die Fähigkeit, die Wünsche und Vorstellungen von anderen Menschen zu verstehen – die sogenannte Theory of Mind. Auch erweitert es seinen Bewegungsradius und wird zunehmend selbstständiger. Gleichzeitig bleibt es aber emotional stark an seine Bezugspersonen gebunden und kann nicht ohne sie sein. Besonders in der frühen Kindheit zeigt sich, wie unterschiedlich rasch die Entwicklung von Kindern erfolgt (beispielsweise in der motorischen Entwicklung). Auch weist die Sauberkeitsentwicklung eine außerordentlich große Spannbreite auf. Diese große Variabilität kann stark verunsichern, ist aber durchaus normal. Besonders die frühe Kindheit zeigt, dass jedes Kind sein eigenes Entwicklungstempo hat.
Bei den Gesetzmäßigkeiten der kindlichen Entwicklung stehen drei Aspekte im Fokus, die in diesem Kapitel genauer erklärt werden: die Variabilität zwischen Kindern, die Stabilität der Entwicklung über die Zeit und das Zusammenspiel zwischen Anlage und Umwelt. Mit statistischen Darstellungen und praktischen Erklärungen wird die enorm große Variabilität zwischen Kindern gleichen Alters beschrieben und begründet. Die Unterschiede in verschiedenen Entwicklungsbereichen innerhalb eines einzelnen Kindes (die sogenannte intraindividuelle Variabilität) werden anhand des Entwicklungsprofiles illustriert. Auch werden Begriffe wie Entwicklungsphasen und -stufen, Entwicklungsalter, biologisches Alter, relatives Alter, Reifung, Entwicklungstempo und Lernen definiert. Schließlich werden die Grundlagen zur genetischen Anlage und zu den Umweltbedingungen vermittelt und dabei deren Wechselwirkungen erklärt.
Die Pädiatrie zeichnet sich als medizinisches Fachgebiet dadurch aus, dass sich der Kinderarzt mit einem Organismus beschäftigt, der sich ständig verändert. Das Kind wächst und entwickelt sich über viele Jahre. Es verändert seine Gestalt und eignet sich ständig neue Fähigkeiten und Verhalten an. Ausreichende Kenntnisse über die kindliche Entwicklung sind eine notwendige Voraussetzung, um Kinder und Jugendliche und ihre Familien umfassend betreuen zu können. In diesem Kapitel werden grundsätzliche Kenntnisse zur kindlichen Entwicklung in verschiedenen Entwicklungsbereichen, zu Entwicklungsmodellen und -theorien, zum Zusammenwirken von Anlage und Umwelt sowie zur Variabilität in der kindlichen Entwicklung vermittelt. Die Entwicklung in verschiedenen Altersperioden wird in separaten Kapiteln beschrieben.
Zwischen dem 2. und 5. Lebensjahr erweitert das Kind seine geistigen Kompetenzen mehr als in jeder anderen Altersperiode. So entwickelt es ein Verständnis für zeitliche, räumliche und kausale Zusammenhänge sowie eine für den Alltag ausreichende Sprache und Kommunikation. Diese Fähigkeiten machen das Kind zunehmend selbstständiger. Gleichzeitig bleibt es emotional so stark an seine Eltern und andere Bezugspersonen gebunden, dass es ohne sie nicht auskommen kann. Dieses Kapitel beschreibt die wichtigsten Entwicklungsschritte im Kleinkindalter.
Die Pädiatrie zeichnet sich als medizinisches Fachgebiet dadurch aus, dass sich der Kinderarzt mit einem Organismus beschäftigt, der sich ständig verändert. Das Kind wächst und entwickelt sich über viele Jahre. Es verändert seine Gestalt und eignet sich ständig neue Fähigkeiten und Verhalten an. Ausreichende Kenntnisse über die kindliche Entwicklung sind eine notwendige Voraussetzung, um Kinder und Jugendliche und ihre Familien umfassend betreuen zu können. In diesem Kapitel werden grundsätzliche Kenntnisse zur kindlichen Entwicklung in verschiedenen Entwicklungsbereichen, zu Entwicklungsmodellen und -theorien, zum Zusammenwirken von Anlage und Umwelt sowie zur Variabilität in der kindlichen Entwicklung vermittelt. Die Entwicklung in verschiedenen Altersperioden wird in separaten Kapiteln beschrieben.
Full-text available
At preschool age, motor skills and cognitive functions are regularly examined at well‐child visits. Although reliable screening depends on the stability of the assessed developmental domains, little is known about the stability of motor and cognitive performance in preschool children. The aim of the present study was to investigate how stable motor skills and cognitive functioning are in the preschool years and whether they can predict their own and respective outcome 1 year later. 509 children were examined (46.4% female; M = 3.9 years; SD = 0.6; range 3.0–6.0 years) from the Swiss Preschoolers' Health Study (SPLASHY) at baseline and 1 year later. A Latent Variable Cross‐lagged Panel Model revealed that both motor skills and cognitive functioning are highly stable in the preschool age (.65/.67). Cross‐lagged coefficients were smaller (.37/.22). However, as the cross‐lagged paths did not differ significantly from each other, no reliable conclusions for the prediction of motor skills and cognitive functions may be drawn. We conclude that cognitive functioning and motor skills are highly stable already in the preschool years. Although small cross‐lagged predictive values were found, motor skills and cognitive functions may not to be reliable predictors of their respective outcomes. Future studies should test cross‐lagged predictive effects in clinical samples, where the effects might be larger. • This study investigated the stability and predictive value of motor skills and cognitive functioning in 3–6‐year‐old typically developing children. • Motor skills and cognitive functioning were highly stable already in preschool age, however, predictive values for their respective outcomes are lower and may not to be reliable predictors of their respective outcomes. • As motor and cognitive development are highly stable at preschool age, they could be applied for the identification of children at risk.
Objective: Previous data from our group and others have shown that salivary alpha-amylase activity increases in response to stress. It has been suggested that salivary alpha-amylase may be a marker for adrenergic activity. Less is known about other determinants of salivary alpha-amylase activation. The objective of the current study was to describe the diurnal pattern of salivary amylase and its determinants. Methods: Saliva samples were collected immediately after waking-up, 30 and 60 min later, and each full hour between 0900 and 2000 h by 76 healthy volunteers (44 women, 32 men). Compliance was controlled by electronic monitors. In order to control factors which might influence the diurnal profile of salivary alpha-amylase (such as momentary stress, mood, food, or body activity), at each sampling time point the subjects filled out a diary examining the activities they had carried out during the previous hour. Results: Salivary alpha-amylase activity shows a distinct diurnal profile pattern with a pronounced decrease within 60 min after awakening and a steady increase of activity during the course of the day. Mixed models showed a relative independence of diurnal salivary alpha-amylase from momentary stress and other factors, but significant associations with chronic stress and mood. Conclusions: Our results suggest that diurnal profiles of salivary alpha-amylase are relatively robust against momentary influences and therefore may prove useful in the assessment of sympathetic nervous system activity. The findings underscore the need to control for time of day in studies using salivary alpha-amylase as a dependent variable.
Physical growth from birth to adulthood in healthy Swiss children born 1954-1956 is described. The data are based on the First Zurich Longitudinal Study in which 137 individuals of each sex have been followed from birth to adulthood between 1954 and 1976. Distance standards of 20 anthropometric measurements such as weight, height and head circumference are presented as mean values and standard deviations or as median values (for weight and skinfold thickness) with smoothed empirical centiles. Velocity standards are provided for seven anthropometric parameters. The following standard growth charts for clinical use are presented: weight, length/height and head circumference in the perinatal period, in the age range of 0-48 months and in the age range of 1-18 years (including some data on puberty), as well as weight for length/height and height velocity (cross-sectional and peak height centered). Comparison of the growth standards with those of previous Swiss studies and of recent foreign studies revealed only minor differences. Various aspects relevant for the clinical use of growth standards, such as measurement error or secular trend, are discussed.