Lifestyle programmes are important in the management of type 2 diabetes (T2D). The Diabetes Community Exercise Programme (DCEP) is an exercise and educational programme for adults living with T2D with the aim of enhancing exercise self-efficacy and supporting wellbeing. DCEP is underpinned by a model of person/whānau-centred care and the spirit of Motivational Interviewing. Person-centred care models in the context of rehabilitation and long-term health conditions are still evolving. This paper explores what those involved in DCEP perceived important to its person/whānau-centredness.An evaluative qualitative methodological approach was used with data collected by open-ended interviews and a focus-group at completion of the initial 12-week part of DCEP. Interviews were audio-recorded and transcribed verbatim. Participants were 16 DCEP attendees and 13 healthcare professionals (HCPs) involved in DCEP delivering. Data were analysed using the General Inductive Approach.It's all about relationships’, Balancing the Outside World, and Empowering through Knowledge. Through the experience and motivation of positive person-centred relationships, DCEP addressed attendees' T2D health needs, but they were constantly balancing these needs with those of family, employers, finances, other health needs and life interests. DCEP relationships facilitated ongoing discussions between attendees and between attendees and HCPs. The ability to discuss in a supportive and non-judgmental environment helped attendees to make sense and process the information they gained at DCEP. This empowering through knowledge in turn helped attendees to work out ways of balancing the outside world and thus better address their T2D needs.The three interconnected themes constructed from the analysis were ‘It is “all about relationships” was key to DCEP's person/whānau-centred approach—all other factors related back to the development and maintenance of relationships. These relationships were between all whānau involved: the attendees, their family, the wider community, the healthcare provider organisations, and the HCPs and personnel involved in delivering DCEPs. These relationships created an accepting, understanding and social atmosphere that enabled attendance and facilitated both knowledge exchange and ability to exercise, both considered to be beneficial by attendees. Importantly, these relationships took time to develop, but the benefits were worth the investment. As with most countries world-wide, type 2 diabetes (T2D) is considered a serious health challenge for Aotearoa New Zealand (NZ). The NZ Ministry of Health have made it a priority long-term condition and have developed a holistic management plan, Living Well with Diabetes, to improve the outcomes for people living with T2D . This plParticipation in exercise and/or physical activity is important in the management of T2D , but givIn response to this gap in health services in our region of NZ, in 2008 we developed the Diabetes Community Exercise Programme (DCEP) to encourage people living with T2D and multimorbidity to engage in exercise . EngagemPut simply person-centred care involves an equal partnership between the care recipient and the healthcare professionals; collaborative healthcare that meets the needs, values, and desired outcomes of the care recipient .The natuTo facilitate engagement of Māori and Pacific people we were guided by our obligations to the NZ's Treaty of Waitangi, mindful of the principles of partnership and participation, and the Ministry of Health's Māori and Pacific Health Action Plans , 24. To DCEP has been described in previous publications, but in brief, it comprises an initial twice a week 12-week programme of individually tailored exercise and education sessions, facilitated by a physiotherapist and a nurse, held in a group community setting and followed up by a twice weekly ongoing maintenance exercise class .We previously reported on a qualitative exploration, post the initial 12-week programme, of what DCEP attendees and healthcare professionals (HCPs) who delivered the programme perceived DCEP to be and what motivated attendance. People did engage in DCEP and the key factors identified that encouraged participation were its person-centred focus and social atmosphere. Knowledgeable healthcare professionals trained in delivering person-centered care and well-trained administrative support to organise the programme were also considered important , 32. TheConsidering the knowledge that a focus on person-centered care appeared to enable engagement in DCEP, this paper deepens our previous qualitative exploration to understand what DCEP attendees and the HCPs delivering the programme considered to be key “constituents” of DCEP and whether these constituents reflected the person/whānau-centred approach we aspired to. A thorough understanding of these constituents would not only assist in refining DCEP but would inform similar programmes aimed at improving health and wellbeing of people living with long-term conditions and multimorbidity as well as add to the evolving understanding of person-centred care in rehabilitation. Thus, this study addressed the following research question: what were aspects of DCEP considered by attendees and HCPs to be important to its person/whānau-centredness?To address our research question, and in keeping with our aforementioned study, qualitative evaluative methodology  was applThe research team comprised three females and one male [three academic physiotherapists  and one academic sociologist (with a Master's degree)]. All had extensive experience in qualitative research and held a constructionist stance. Additionally, all had research experience  working with Māori and Pacific peoples and with those living in low social economic background. However, all were Pākehā (non-Māori), and thus were limited in their ability to cast a true cultural perspective to the research.The RCT is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12617001624370p, the protocol of which has been described previously . The NZ via health care providers or public media advertising. Participants for the interviews were recruited from those randomised to the intervention arm of the RCT (attendees) and from all health care providers (HCPs) involved in the delivery of DCEP. Attendees were adults (>35 years) diagnosed with T2D who had clearance from their general practitioner (GP) to participate in exercise. During the consenting process for the RCT, attendees also indicated consent, or not, to be recruited into the process evaluation study. The RCT was conducted in two southern NZ cities and recruitment was over 7 waves (3 waves in city 1 and 4 waves in city 2) with a total of 83 participants randomised to the DCEP group. On completion of the 12-week DCEP programme 2 to 3 consenting DCEP attendees from each wave were sampled for interview, balancing for level of DCEP attendance. HCPs received information pertaining to the process evaluation study and volunteered and consented to participation.Recruitment into the RCT was n = 8) or via a focus group (n = 5), depending on their preference or for logistical reasons, at a clinical venue. The interviews took in duration between 16 min and 1 h and the focus group took 1 h, following which the interviewers wrote field notes for use in the data analysis. All interviews and the focus group were audio-recorded. A commercial transcribing firm transcribed word-for-word all interviews. There were no follow-up interviews or member checking undertaken.Data for the current qualitative inquiry came from semi-structured interviews and a focus group conducted immediately post the 12-week DCEP intervention. Whilst the qualitative interview guide, developed by the research team, was based on the Consolidated Framework for Implementation Research (CFIR) , the ricThe General Inductive Approach guided analysis . In keepIn addition to sharing and seeking advice on the advancing analysis and theme development with the wider research team members, the final analysis was presented, discussed and verified with DCEP attendees and HCPs in workshops held in both cities, a method recommended in the General Inductive Approach .Sixteen DCEP attendees   and 13 . But, overtime, this anxiety eased as people began to feel more comfortable with each other: “I am an awkward bugger … I don't mix with people very well. It takes me a long time to know people and once I know people, I am comfortable within that group… you start talking more freely amongst yourselves” (P373).Anxiety was experiencing by several attendees about attending a group programme, a concern also echoed by HCPs: “no mirrors, no lycra, no judgement”. Further, attendees appreciated how the HCPs would relate and be responsive to both group and individual needs: “When I was gone for 2 or 3 weeks, there were certainly some, “good to see you back” and what not. Which is nice 'cause you like to think you're missed occasionally“ (P175). Consequently, attendees developed high regard for the HCP team who they did not want to let down. Attendees noticed absence: “I hate to see [physiotherapist] out there putting all the equipment out and nobody turning up” (P373).Growing comfortable was facilitated by feeling both welcome and safe, and not judged. A core value of DCEP was acceptance, described by DCEP Developer 1 as “We can go there how we are, we're taken how we are, and get on with it…no one's there to look at what you're wearing or… “(P933) and made them feel comfortable to contribute to group discussions because: “Whatever anybody said, it wasn't wrong. Everybody accepted their opinion, your opinion, and, and maybe just offered different ways to, to do something differently.” (P238).Not being judged was particularly valued by attendees: ”It takes a special type of person to lead it and I think [DCEP physiotherapist and Nurse] were wonderful. … They have got a fantastic approach and way with people. They never at any point and time made you feel a lesser person or embarrassed … full of encouragement all the way” (P205).Staff were described as friendly, approachable, encouraging, with a style perceived as non-threatening: “to support, and help, and guide” (Nurse) in a non-judgemental manner, an approach emphasised in training and orientation. The physiotherapists, particularly, explained how they needed to “let go” (Physiotherapist) of a more traditional directive approach: “I know at times I think I felt I'm a little bit too lenient with that I haven't kinda of you know if they can't attend all the sessions I'm kinda like, ‘That's OK”’ (Physiotherapist). HCPs also recognised the health benefits of being non-judgemental: “Not judging definitely helps with the relationship because then they trust you a little bit more and sometimes what they tell you is just the tip of the iceberg as well so if you're open to that, then they might just delve a little bit deeper and you can actually start to get down to the real problem” (Physiotherapist).HCPs interviewed understood that their role was “But those who have really got involved and started to have conversations, and meet and build the relationships with patients, I think, see the huge value. It's just nursing that's got a different hat on” (Nurse manager).In turn, the HCPs experienced positive feelings about adopting a supportive and non-judgemental approach: “I think it might be obvious to participants because I'm feeling really uncomfortable and I'm trying not to but I'm really struggling.” (Physiotherapist). Also important was a good working relationship between the physiotherapist and nurse: “It's team dynamics, you definitely need a team that can work together and that's not necessarily something you can just choose” (Physiotherapist).Whilst HCPs thought that a non-judgemental approach could be  taught, some described occasions where they felt that other HCPs were hesitant to adopt this role, possibly inhibiting the group fellowship and reducing motivation to attend: “But um, my husband is great support he likes coming along as well. So, that was probably a big part for me was that I had someone I was able to talk to um, about the programme” (P324). This welcome was extended to the education sessions: “I said to [physiotherapist], um, on our last day, you know when the next group starts, when the arthritis man comes could I bring my mum along too? She's got real bad arthritis… and she's [physiotherapist] like “I don't think that will be a problem.””(P238).A further layer of acceptance included the welcome extended to family, friends and support persons. An exercise buddy was encouraged, and this was very motivating for several attendees: “So, there was people from all different walks of life there, that would as a general rule would never have come together. Um, so we had the retired [professional] who was clearly very wealthy… then you had the middle of the road people, like myself … there was a couple of …[different ethnicities].. ladies that came … So, we all rock up there in our cars, some of them were in really flash cars and I am in my Corolla, and then you have got these ladies that came on the bus” (P 686).Attendees described their groups as being diverse in age, gender, ethnicity, nationality, interests, wealth, mode of transport, and length of time being diagnosed with diabetes. This was perceived a unique aspect of DCEP, reflecting acceptance, and something that would not happen elsewhere in the health system: “Well you get motivated because you are with a group and the group you know, you quite enjoy going, I mean I enjoy going but I don't enjoy doing the exercises” (P595). Attendees greeted, laughed, talked, listened, watched and shared food together. Exercise was not easy for many; some felt uneasy about body image and others experienced pain due to health conditions: “I also have um, some pretty bad knee pain and I have um, bursitis in my right hip, so I am in pain a fair bit of the time. So, just getting up and down out of a chair or walking from here to the car is you know pretty crap.” (P686).This sub-theme describes the supportive and encouraging interactions between attendees during exercise, education sessions and, in the community. Through camaraderie, exercising with the group was a motivator for attendance: “amaraderie during exercise appeared to act both as a distraction and as a motivator: “I mean we back chat and chat and that helps you with your exercises, because he will say to me, what are you standing there for and I will say to him, go on bark a bit more” (P595).CCamaraderie was also experienced in education sessions. Attendees listened to each other, shared experiences and asked questions “We were in a particularly good group because they asked questions and they were all, as I say the majority were ladies, ah, and they asked some really good sensible in-depth questions, searching questions I would say” (P205). Attendees actively supported and encouraged each other: “A couple of them were really good at um including her in conversations that you know she was a bit shy” (Nurse).And then, one of the guys that on when I went to the maintenance, he was asking me about have you got your date for surgery and I said no. And he just turned around to me and said ‘Oh well, you're doing so well’“ (P238).Attendees observed each other's progress and, as well as supporting each other within each session, they also supported each other across sessions. People remembered each other's stories and life events which led to attendees feeling visible and heard, for example: “Camaraderie of the group; however, acknowledged that each group was unique and, some groups were more supportive than others. Some HCPs felt able to facilitate Camaraderie intuitively: “when the bikes are together and things like that, you end up having a conversation with two people at the same time and they end up talking and you kind of move on” (Physiotherapist). HCPs felt that including more advanced communication skills could help HCP facilitate more positive group dynamics: “And it's also an endorsing thing, as well, because, actually, sometimes, you need a few more resources in a group to actually shut down conversation that's going to be difficult” (Nurse).HCPs also observed and were rewarded by the Admittedly, I haven't gone as often as I could. But we had a drama-filled March, and then I was way too busy“ (P175). Attendees worked hard to balance health, whānau/family and work with programme attendance. Working attendees felt that the timing of sessions was difficult as they did not fall across regular meal breaks. One attendee indicated that attendance at the programme had affected their income: “I made it work. It was awkward to a financial decrement to me, slightly. But I am not going to go on about that. But I wanted to be in the study so I made sure that I could be there” (P887). Attendees prioritised caring for family: “I think the one, or the odd day that I had no work, I was well enough to go, I had my children because my wife was busy” (P840). Health needs that prevented attendees from attending included pain severity, conflicting hospital appointments and other undisclosed health complications. Occasionally, attendees just did not feel like attending but managed to overcome this because: “There has times where I've thought, ‘I don't think I'll go in today, I might have a rest,’ but then I think, ‘no, I'd only be letting myself down.”’ (P542).DCEP could not however be seen in a vacuum. Attendees volunteered for the study because addressing their T2D needs was important to them: however, this need was balanced with other challenges, demands and priorities: ”So, um, I missed quite a few…Just other commitments, like and because I had to go to Jimmy Barnes [Australian rock icon] in Christchurch. Somethings are way more important…” (P686).Other needs included being warm and sheltered—one attendee who caught the bus would not attend if the weather was bad. Apart from family, health, work, weather and motivation, attendees reminded us that having fun in a way not related to T2D needs was important: “I know like at times I think I felt I'm a little bit too lenient with that like I haven't kinda of you know… if they can't attend all the sessions I'm kinda like, ‘That's OK”’ (Physiotherapist). Furthermore, HCPs recognised that if attendees were forced to make decisions around balancing needs, then they might not choose the programme: “It's almost prioritising them coming to the group versus not coming and knowing how far you can push or not push with that” (Physiotherapist). This approach was different from usual practice , and although difficult for HCPs, was very much observed and appreciated by attendees: “I mean you can't force anybody to do it and um, the physio and the nurse um, they didn't push anybody. No comments were made um, nobody was egged on or um, you made to feel guilty if you know, you were having a bad day as some people were, you know they had woken up in the morning and for whatever reason they were feeling awful, they would still come, they would still come and they would still get their bloods and blood pressure taken by [nurse] They may not do very much, they might just sit there and have a chat” (P324).HCPs recognised that attendees had to balance other needs with programme attendance: “via general practice and public advertising, it was recommendations by friends, whānau and other health care providers that made many attendees decided to participate. Most volunteered as they had goals, such as weight loss, being fitter, reducing or stopping medication, and wanting to learn more about T2D. For some, strong commitment to DCEP in of itself was important: “my only goal was to make sure I got there every time, and I've done it” (P933).Whilst recruitment into the study was essentially It was clear that attendees took and brought knowledge to and from DCEP, and this could not be controlled by the HCP. For most attendees, knowledge appeared to be more: sustained, retained, empowering, meaningful and, motivating than other knowledge sources such as HCP encounters in traditional settings and educational days. Knowledge extended beyond passive information delivery and included knowledge-sharing with friends, family and the land.Like I got no, nothing, no support, no, I didn't know what the hell was going on or, and I didn't know like what was normal or what was my normal and I felt a bit like um, alone and like, you know misinformed” (P238). HCPs also observed this: “Definitely a trend of people being frustrated that they didn't have that access, or they didn't feel listened to or, even people complaining about getting conflicting information from their different providers, where your GP tells you one thing, and your specialist care provider tells you another. And they were just, like, discombobulated of, like, no idea what way's up anymore” (Physiotherapist).Several attendees described feeling powerless at and around diagnosis and felt confused about medication, exercise and diet: “It is just so hammer, hammer. I mean I didn't see anyone that took, no one was enjoying themselves, no one I don't think really learnt much, apparently.” (P639).Other attendees felt that they were given too much information at once—an approach they perceived as unhelpful as they could not process a large amount of information in a short space of time. This attendee described their experiences at a diabetes information day: “So, I think there are, maybe, I think, as diabetics, they just get bashed from all sides and, so, they think, ‘oh my God, another one's [HCP] coming to bash us sometimes”’ (Podiatrist).These perceptions were supported by HCPs who observed: “Um, unique about it. It covered everything, everything you needed to know. Yeah. Not just what they wanted you to… Because, we could say to her, well actually we want to know about this, and she would hook someone up like 3-4 weeks down the track and she would have them there” (P639).In contrast, attendees felt that DCEP delivered more meaningful knowledge: “Well I am more motivated, I know what to do, you see it is just learning curve for me at the moment. I didn't, I didn't know what to do for the best, literally to aid and abet this diabetes” (P917).Meaningful knowledge was motivating for attendees: “Because I can see the benefit of this programme. Like, the education is really important, and I can see, but how much do they take away when they just listen? Very little” (Nurse). However, attendees felt that the opportunity to listen, discuss and ask questions over a 12-week period helped them to retain information: “Because if you just go for one day, you know all those questions, but over 12 weeks there is different things that crop up that you are able to ask. So just on one day you might not think of everything, but with 12 weeks, yeah. And like with having the, like the podiatrists and the dietician and the pharmacists and all those different people, you know, you kind of thought of something and other people asks questions as well, and you think, oh yeah, I had been wondering about that” (P920).Some HCPs were concerned about information retention: “Just acknowledging that some people are not, you know, people are at all different levels with their learning and sometimes you can kind of get people who are kind of you know here [indicating higher] and that's fine but if you've one person down here [indicating lower] that's quite hard to kind of, for them to engage” (Physiotherapist). However, the education sessions were appreciated by all attendees and all felt they slowly increased their understanding: “I didn't have any information before I came to this course. And things throughout the time in the three months that you'll be learning, is was like the little light bulbs were going off ” (P238).HCPs observed that the degree of health literacy varied amongst attendees and were worried that DCEP would be more useful for attendees who had more initial knowledge: “I think that made it easier and easier because like, like sometimes when you have discussions, whatever anybody said, it wasn't wrong. Everybody accepted their opinion, your opinion, and, and maybe just offered different ways to, to do something differently. Gave you another perspective on, on stuff ” (P238).This gradual process of enlightenment was aided by the attendee-driven discussions: “I think some of the others the wives and spouse's ah they got a lot out of the programme, and I think it gave them an understanding of, of exactly what it is that ah diabetes is and um, and how they can um, be a support. I know [spouse] is asking me in the mornings, oh how is your blood sugar this morning, whereas before you know, either of us probably you know, [were not] too concerned” (P324). Furthermore, attendees described experiences where friends and family gained new knowledge through the programme that positively influenced their own health: “It has planted the seed and each time I say I am going to do more, like hubby he's going to see somebody at Sport Southland…this has motivated him to go there to do something, so he has started to um, go for walks at night” (P887). In addition to engaging with discussion within the group, attendees also shared diabetes information outside the DCEP programme: “quite a good friend, her 11-year-old daughter, they discovered she had type 1 diabetes and like she, her mother didn't have a clue of, and so I sort of knew of places that she could go to for help through, yeah having been [to the DCEP programme]” (P920).An important aspect for attendees was the opportunity to share knowledge in a network that involved friends, family, community and the land. Being able to bring support persons (friends and family) to session was helpful: “Goes from me to the next one and then next one. Yeah. And um, unfortunately we still need a lot of work in our health area…And making it, like making it the norm. You know, because I mean there is still the way some of us are eating now is still abnormal for our community. You know it is still junk food…” (P639).Attendees also wanted to share knowledge because they were concerned about the health of their communities: “Only other thing that's there for me is about the land. For me food wise it's about what I can if I can get stuff that's worse than so many kilometers of the house as opposed to hundreds of kilometers. That means to me that for me things are fresher and so are more likely to be better for me.” (P146).Attendees also talked about nutritional knowledge with regards to the land with regards to the importance of knowing about, sourcing and, eating locally grown food: “It made me more aware of my body and yes and the damage I've been doing to it actually. It's made me not want to continue because I don't want to pass early” (P503). Whilst most attendees were happy with the acceptance shown by HCPs, occasionally, an attendee would experience a less helpful approach: “That dictation type thing you know, dictating to people is, it just doesn't work, well it doesn't wash with me” (P639). Sometimes they received confusing and conflicting knowledge: “From the programme and I got really confused, I got really confused about what is right and what is not right. I had started on a diet control management of diabetes and it was working for me and they were telling me something different…” (P639).For some attendees, being empowered with knowledge was difficult. Being reminded about the health effects of diabetes was sad for some: “We explored what those involved in DCEP perceived to be important to its person/whānau-centredness and these were: the importance of relationships, the recognition that people must balance attendance around other priorities in their lives, and the gradual development of co-constructed understanding and knowledge formed reciprocally through respect and trust. Whilst people said they initially attended because they had health-related goals, such as weight loss, being fitter, reducing or stopping medication, and wanting to learn more about T2D, it was the person-centred/whānau focus that appeared to encourage continued attendance in the 12-week programme. These findings reflect McCormack's conceptualisation of the “person” in person-centred care , 23. ThaThe developing nature of the multi-directional relationships and co-creation of knowledge during the initial 12-week DCEP programme reflects what Gibson et al. called “care(ful) tinkering” , p. 1529In T2D management, the key positive outcome is improved glycaemic control . In the The key finding in this study was the importance of relationships, and how this underpinned engagement, echoing Mc Kenzie et al. findings  and thosEmpowering through knowledge is an interesting enigma in healthcare. Educating patients appears to be one of the mainstays of long-term condition self-management, indeed one quality standard of the NZ Ministry of Health's Living Well with Diabetes plan is “All people with diabetes will receive personalised expert advice on lifestyle choices …”. The experts will give advice. Ross et al.  exploredAn interesting finding of our study was the interchange of knowledge, which was reciprocal between attendees and HCPs, between attendees themselves, and between attendees and their whānau/families or communities. Knowledge itself could be considered a relationship; it required reciprocity and trust to “bring it alive”, and not as a one-way exchange of the HCP, from a position of “power” telling the “patient” what to do. This knowledge empowerment could be likened to social capital—a “knowledge capital”—that can only enhance “societies”-management of T2D, beyond that of “self”-management. Allory et al.  stress tThe strength of this study is in the rich and diverse data collected. Limitations include the potential standpoint of participants, in that DCEP may have attracted both people wishing to be involved in a community lifestyle programme and HCPs who were sympathetic with the ethos of the programme and who already held a positive belief of its benefits. Further, these interviews occurred post the initial twelve-week programme and thus did not capture participant's perspectives of the maintenance ongoing part of DCEP. Whilst we had ethnic diversity in our participants and interviewers, this diversity was not extended to the research team analysing the data, thus preventing a Māori perspective being applied to the analysis.We explored what aspects of DCEP were considered by both attendees and HCPs to be important to its person/whānau-centeredness approach. It is ‘all about relationships’ was the key aspect—all other factors related back to the development and maintenance of relationships. These relationships were between all whānau involved—the attendees, their family, the wider community, the healthcare provider organisations, and the HCPs and personnel involved in delivering DCEPs. These relationships created an accepting, understanding and social atmosphere that enabled attendance and facilitated both knowledge exchange and ability to exercise, both considered to be beneficial by attendees. There is nothing novel about us purporting to deliver DCEP in a person-centred care approach, indeed such an approach to the management of T2D is promoted by agencies such as the NZ Ministry of Health  and the The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by New Zealand Health and Disability Ethics Committee, Ministry of Health (HDEC17/CEN/241/AM01). The patients/participants provided their written informed consent to participate in this study.LH was the principle investigator of the research project and wrote the introduction, methods and discussion sections of the paper and edited the findings sections. CH was the lead clinical author on this paper and organized and supervised all the clinical staff involved in the study, developed DCEP, and contributed significantly to data analysis and editing of the paper. DK was the lead project manager and organized all the interviews and facilitated a number of the interviews and contributed significantly to data analysis and editing of the paper. CS led and did most of the qualitative analysis of this project and led the writing of the findings section of the paper and assisted editing the paper overall. All authors contributed to the article and approved the submitted version.This study is funded by the New Zealand Health Research Council (HRC Project Grant 17/233).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Abstract words, terms not referring to here and now, are acquired slowly in infancy. They are difficult to acquire as they are more detached from sensory modalities than concrete words. Recent theories propose that, because of their complexity, other people are pivotal for abstract concepts’ acquisition and use. Eight children (4 girls) and their mothers were observed longitudinally and extensively from 12 to 24 months of age. Video recordings of mother-infant free play with toys were done every two weeks in a laboratory setting with families in the USA. Children progressively use a range of words referring to abstract concepts, with a major shift from 12 to 15 months and again from 22 to 24 months, but the qualitative data testify an incremental growth of abstract concepts. We identified a progression in the acquisition of words denoting abstract concepts in relation to the overall productive vocabulary, suggesting that having more abstract terms in one’s vocabulary promotes faster language acquisition. A microgenetic approach, in which individuals are observed through a period of developmental change and observations are conducted before, during, and after a period of developmental change, can be extremely useful to understand the change processes in development3. In this study, we consider the transition to symbolic communication by examining changes in communication frames in which mother and child jointly participate in the activity of playing with objects and how infants progress from communicating on concrete objects to communicating using more abstract concepts.Research on developmental change based on a dynamic systems perspective5. By participating in social games with parents, infants also gradually develop a sense of self that is initially totally embodied and that gradually develops to include symbols, imagination, and language by the end of the second year8. Symbolic play in particular requires the establishment of collective intentionality and the necessity to negotiate meaning5.Several authors have emphasized the importance of communication frames involving parent-infant play for establishing joint reference, and play is considered a fertile condition through which early language is facilitated and acquired10 underlined how introspection and the social aspects of situations characterize more abstract than concrete concepts. Multiple representation theories have underlined the crucial role not only of sensorimotor but also of linguistic, social, and emotional experiences for the formation and representation of abstract concepts . Within these theories, the Words as Social Tools (WAT) approach has ascribed a special role to social interaction15. Compared to words referring to concrete concepts , abstract words like “friend” and “idea” are generally more complex: they typically do not have a single object as a referent but evoke complex scenes and situations17. Furthermore, they are generally acquired later and through linguistic rather than perceptual modalities, i.e., by verbally explaining their content rather than pointing to their referent , are less iconic—that is—associated to a specific referent through a figurative-symbolic relationship—than concrete words19, and are generally relational20. Abstract-symbolic words require a shared understanding which grows, according to dynamical system theories, via the development of social play communication frames.In recent years a different research stream, focusing on abstract concepts , has emphasized the role of social interaction to develop conceptual knowledge and language acquisition. Barsalou and colleagues21): for example, whereas the members of the concrete category “ball” are perceptually similar, the members of the abstract category “freedom” are very different. According to the WAT proposal, abstract concepts would be more grounded in language developed in shared communication frames than concrete concepts22: because of the heterogeneity of their members, we would need other people and frames with different themes to acquire them and understand their meaning25. Notice that we deem social interaction important both for the acquisition of concrete and abstract concepts, but we contend that its role might be particularly critical for the latter. To clarify: the meaning of a concept like “freedom” might elicit situations as diverse as “running on the grass”, “escaping from prison”, and “flying in the sky”. Thus, the contribution of other people who use the same label across the various communication frames (situations) and eventually explain to us the word meaning is crucial to acquire and comprehend abstract concepts like “freedom”, more than concrete concepts like “ball”. Hence, other people are crucial to acquire abstract words, because explanations from others and linguistic labels are very helpful to put together a variety of heterogeneous experiences, situations, etc. In addition, different people will have different perspectives on the meaning of abstract words. This means that the child must make mental inferences, taken from different social situations, to create or construct a mental concept of, for example, “freedom”. Also, that concept will continue to evolve with different instances as it comes up in discussions. So, what makes something abstract is that it involves “going beyond the information given” and thus the construction of a mental life that goes beyond the concrete world and leads to invention, imagination, creative thinking, inferential thought, curiosity, etc. Notably, not only abstract concepts collect heterogeneous exemplars, but abstract concepts are heterogeneous themselves since they belong to different kinds, from emotions to numerical concepts, as many recent studies on adults have highlighted29. Hence, the dimensions we have mentioned might assume a different weight depending on the considered conceptual kind.Crucially for us, more abstract concepts collect more heterogeneous exemplars than concrete ones , maternal interviews (e.g.33), maternal written reports34, systematic observations (e.g.36), and large repository data from parent-report instruments37—we know that between 10 and 13 months of age most infants begin to produce their first words. They reach the milestone of a 10-word productive vocabulary between 13 and 19 months38. Early words belong to a variety of linguistic categories. Generally, they consist of names for caregivers , small and concrete objects the infant can manipulate and act upon , words used to regulate social interaction , and cognitive-relational words encoding abstract concepts such as failure, disappearance, recurrence, and location 39. Some words are acquired in a social-routine context and later are extended to new contexts. For example, labels for small concrete objects may be initially acquired through associative learning during repeated ‘give and take’ games: parent and infant exchange objects in a playful interaction and the parent often labels the name of the object so that the infant can easily grasp it. First words are acquired very slowly and are context-bound, meaning that there is direct, perceptual information about the link between the word and the object, and infants typically build a 10-word productive vocabulary by adding only one to three words a month38.From developmental research—using diaries  is considered ‘the hallmark of reference’14, we aim at documenting the development and trajectory of the acquisition of abstractness in word production during the developmental transition in language from 11 to 24-months of age in the context of frames for mother-infant toy play and adopting a microgenetic research design. This key transition is of special relevance since one-year-olds are active word learners, with a mean receptive vocabulary of around 80 words37 and with at least some words denoting abstract concepts31. Still, they are not yet able to produce any words referring to abstract concepts. Observing this developmental window, we will investigate abstract and concrete concepts as they are conveyed and expressed by concrete and abstract words. Notably, here we focus on “abstractness,” which we distinguish from “abstraction”48; see also49. With “abstraction,” we refer to the process that leads to the emergence of hierarchically ordered categories. Category formation always involves abstraction, and abstraction is more substantial the more general a category is. Hence, the abstraction process is more pronounced when we abstract from the distinctive characteristics of animals to form the superordinate category of “animals” than when we abstract from the features of specific cats to form the category “cat.” Still, in both cases, the referent of these categories consists of single objects/entities. Although related to abstraction, abstractness differs from it and concerns the characteristics of concepts whose referents are not single, bounded objects and the process that leads us to go beyond what we perceive through our senses, as when we interpret the experience of running on the grass as indicating “freedom”.Adopting a grounded view on abstract concepts, i.e., the Words as Social ToolsConsidering the challenge to code abstractness in infancy we propose to operationalize it by looking at instances in which children use words that go beyond the ‘here and now’ context and moment, including therefore labels that refer either to abstract ideas or events displaced in space or time (past or future). References to internal states , relational words, verbs and pronouns are also included in our classification, as they can vary in their degree of distancing from the present moment and context, and therefore in the degree of abstractness. We propose a clear distinction between reference and abstractness. Reference, even reference for absent objects, is still a concrete cognitive task: objects have names and can potentially be pointed at. Abstractness requires a detachment from concreteness and context, and reflects a form of thought/mental processing that is more closely tied to pretend, imagination, etc., than to reference. Social interaction is important in establishing reference, as a child needs to follow the pointing gesture of another person in order to understand which object the person is referring to. To share an abstract meaning, a different and specific kind of social interaction and social cognition is necessary, one that implies ‘not knowing’ and going beyond the ‘here and now.’ This creates the conditions for abstract thinking, and will change and re-organize the way in which the child interacts with other communicative partners. As a preferential avenue for higher-order cognition and abstractness, it is therefore essential for researchers to pay attention to the social context in which abstract words are acquired.50—a methodology that may have a subjective component, as parents may be biased when reporting about their children’s knowledge51 or focus on the acquisition of words denoting single concepts . The choice to adopt an ecological, longitudinal and interactive method is in keeping with our theoretical stance, according to which linguistic and social interaction are critical for the acquisition of a vocabulary referring to abstract concepts54.Compared to previous studies, ours has an important novelty. We intend to investigate the emergence and use of types of words differing in abstractness level as they emerge in real time in language acquisition. Importantly, we will pursue this aim employing an ecological method, i.e., analyzing the word usage in an interactive mother–child situation, when parent and infant play with objects. To the best of our knowledge, this is the first study systematically addressing the acquisition of different kinds of words denoting abstractness in infancy with such an approach. The few papers investigating the acquisition of concrete and abstract words in infants rely on questionnaires submitted to parents58.Importantly, not only will we test the emergence of abstract words as a whole, but we provide a fine-grained analysis of different kinds of words denoting different level of abstractness, in line with recent trends in the literature on abstract conceptual knowledge50, relying on indirect measures of children's productive vocabulary, recently found evidence that knowing general, superordinate words facilitates faster vocabulary growth. Having the same vocabulary size but more superordinate words, such as ‘color’, ‘animal’, and ‘move’ may predict faster learning of words associated with those categories, rather than having less general words in one own’s vocabulary, such as ‘yellow’, ‘fox’, and ‘run’. According to Gentner59, words for relational concepts have a membership based on common relational structure; they include terms for spatial relations, and natural numbers and concepts like ‘friends’, ‘enemies’, and terms for kinship that have role slots. These terms can be learned via analogical comparison, which renders the common structure more salient, thus promoting abstraction and transfer60. Following previous research59, we expect that once children will develop the kind of cognition that allows for abstractness to which we referred above, they will also begin to utter and use some abstract words, and in particular relational terms, these labels will work as tools for learning other abstract words and concepts. Abstract words will help children retain and reuse relational structures, promoting future relational and abstract encoding and overall vocabulary growth. So, we expect an acceleration in the rate of acquisition of vocabulary once children begin to produce and use abstract words in conversation with their parents.An important issue we intend to test is whether the early development of words referring to abstract, relational concepts facilitates later vocabulary acquisition. Lewis and colleagues7 was used to investigate the emergence of abstractness in vocabulary acquisition in the context of parent-infant games with objects during the second year of life. The data collection was part of a larger study directed by Alan Fogel at Purdue University on the development of communicative behavior in infants61. All methods in the study were carried out in accordance with the Declaration of Helsinki. Observational protocols and parent Informed Consent documents were approved by the Institutional Review Board of Purdue University (USA). Informed consent of the parents was obtained after the nature of the procedures had been fully explained.A microgenetic research design with a multiple case study method and a combination of quantitative and qualitative analysesEight children, four boys  and four girls , were videotaped biweekly interacting with their mothers and a set of age-appropriate toys in a laboratory playroom. The observation started when infants were twelve months and continued until they were 24 months. All children were full-term and healthy at birth. The mothers came from middle-class families in a small midwestern community in the United States, and they were all older than 21 years. All mothers spoke English as their primary language. One mother and infant were African-American, and the others were Caucasian-American.Each session took place in a laboratory playroom. The mother and infant sat on small chairs at two adjacent sides of a low table, and the toys provided were two telephones, a doll bath and a crib set, a tea party set, and a wooden puzzle. Toys were selected to elicit both symbolic and functional play. The mothers were not informed of any research interest in abstract words. They were told: ‘Play and talk to your baby as you would at home’. This instruction was given only on the first visit to the lab. Thereafter, the mother was left to develop her own style of interaction with the infant. Attrition and missed visits were kept to a minimum by regular telephone contact with the staff, bi-monthly newsletter for the parents, and subject payments at the end of every 6-month period. One dyad completed all 30 possible sessions. The others completed between 26 and 29 sessions.62. To the best of our knowledge, English concreteness norms are only available for adults and not for children63. So, we developed a coding scheme that allowed us to account for the fact that—as we discuss later— while a concept might be relatively concrete for an adult, it might be considered as more abstract by a child . All proto-words and words used by the children in a play toy session with their mother were transcribed and coded from the tapes and further classified—for the current study—in terms of (a) grammatical category, (b) conceptual aspect and (c) level of abstractness. Only words that were uttered spontaneously were considered, not those that were produced as an immediate imitation of mother’s previous utterances. Below we describe more in detail the coding scheme adopted for the present study.Grammatical category. For each word uttered, we reported its corresponding grammatical category. For example, “dolly” was coded as a noun, “this” as a pronoun, “pretty” as an adjective, “take” as a verb.43, we assigned each word uttered by the child to one of the categories according to the CDI: Animals, Toys, Drink, Body parts, Furniture, Small household items, Outside things/places, common nouns, People, Games and routines, Action words, Time words, Descriptive words, Pronouns, Question words, Preposition and locations, Numerals and quantifiers, Classifiers.Conceptual level. Following the classification given in a widely used parent-report instrument to measure early language acquisition, the MacArthur-Bates Communicative Development Inventory (CDI) “Words and Sentences”64 and the developmental classification of decontextualized terms and of terms indexing social knowledge66 three levels of abstractness were proposed—(1) low: concrete; (2) intermediate: medium; and (3) high: abstract. We coded as concrete words referring to objects or people that were physically present, either manipulable or simply visible, in line with the idea that concrete concepts are highly imageable, score high in Body Object Interaction, and are strongly associated with a specific context68. We included into this classification greeting routines, because they are directly linked to the appearance of objects and people, and terms referring to colors, because directly linked with visual aspects. We coded words as having an intermediate level of abstractness when: they referred to objects and people physically absent (displaced in space from the here and now situation), complex communicative and action routines, evaluative words that refer to physical appearance, spatial, time and location terms, and labels for physiological inner states. We considered labels for locations as intermediate because they do not have a single, spatially bounded object as referent and coded spatial and time terms as intermediate in line with previous evidence showing that spatio-temporal elements are the most concrete among abstract concepts29. Labels for perceptual and physiological inner states were taken as intermediate, in line with the idea that bodily states, and at a higher level of abstractness emotions, represent the first concepts children acquire that do not have a concrete referent70. Finally, we coded as high in abstractness words that are considered as such according to the current literature26, as words referring to numbers, emotions, and mental states terms, together with verbs and pronouns, typically considered as more abstract than nouns73, and words for routines that are considered as abstract in recent studies31.Level of abstractness. Following the previous classification of abstract termsThe present work was based on a longitudinal database made available by Alan Fogel and on the transcription and coding of child’s vocabulary production from previously published studiesWe report below the coding schema enriched by specific examples. Level 1: concrete (low) was assigned to all names referring to objects that were perceptually present and that the child could manipulate , to visible parts of the body , to words referring to the mother , to colors , and to routines for greetings . Level 2: medium (intermediate) was assigned to names referring to absent relatives  and to parts of one’s body that were invisible . We considered concepts referring to invisible or absent elements in the intermediate category because these concepts do have a spatially bounded, concrete referent, like concrete concepts, but children recognize the current absence of that referent.31). Internal states referring to emotions , volitions , cognitions , and moral terms  were also assigned to level 3.Level 2 was also assigned to routines , to onomatopoeic sounds or protowords , to question words , to descriptive words , to references to space and time , to location words  and to perceptual and physiological internal states . Level 3: abstract (high) was assigned to personal pronouns, numbers and quantifiers , routines for affirming and negating , to verbs referring to actions and to the routines ‘all gone’ and ‘all done’  of the different categories of terms uttered by children at different ages. We will report descriptives of the occurrences of the different categories of concrete, medium in abstractness, and high in abstractness, to show which categories children mostly rely on during the developmental period examined. Finally, to further explore the relation between age groups and conceptual categories, we will present correspondence analyses based on the frequencies of use of the categories of concrete and abstract words occurring in all age groups.In this section, we will focus on a qualitative analysis of types of abstract words used by children while playing with their mother and the corresponding age of acquisition. Appendix These terms were used in spontaneous conversation with the mother during play with age-appropriate toys. Below we provide real examples of the exchanges occurring between child and mother. A child (77 weeks) says ‘Alldone’ while giving back a toy to mother, a child says ‘empty’ (86 weeks) while putting the lid on the top of a pot, a child says ‘round’ when he turns around a piece of a puzzle to make it fit, a child (98 weeks) says ‘turn’ when he turns the puzzle so that it spins around, a child (94 weeks) says ‘very good’ when he did fit the piece of a puzzle in the right spot, a child (97 weeks) says: ‘Mama take it’ while offering the doll to the mother, a child wants to put the blanket on the doll by herself (without mother help) and says ‘I do’ (97 weeks), a child offers an apple to the doll and says ‘Like that?’ (age 102 weeks), a child (104) says ‘more milk’ while mother is pretending to drink, as he wants her to pretend to drink more, a child (87 weeks) says ‘cry’ while holding a doll, in reply to the mother’s comment: ‘You better hold her nicely’, the mother than asks ‘is she crying?, and the girl responds ‘yes’. These excerpts show that the terms were used within a dialogical exchange, and were genuine and creative references to abstract aspects rather than contextualized occurrences.Appendix 44. However, when we look at the relation between the size of abstract vocabulary and overall productive vocabulary that the children reached by 24 months, we notice an interesting progression. The magnitude of abstract vocabulary was positively correlated with the overall magnitude of vocabulary size across children, r(6) = 0.94, p > 0.001. In fact, children reaching larger abstract vocabulary at 24 months tend to have larger overall vocabulary as well, and the group of children with a smaller abstract vocabulary at 24 months have smaller overall vocabulary as well. Remarkably, this is true independent of the child’s gender. We can more easily observe this progression by ordering children on the basis of their size of abstract vocabulary, as shown in Appendix 74. Further research is needed to untwine these two alternative hypotheses.There was a large interindividual difference in vocabulary sizes in our sample, well documented in the literature for early stages in language acquisitionTo explore the pattern of all kinds of words produced by children at different ages, we present percentages of words produced for each subcategory by children across all sessions. Subcategories are in different colors depending on their level of abstractness. Figure Concrete (green): names for toys , for visible body parts (e.g. ‘hand’), names referring to the mother (present), names for vehicles, beverages, clothing, furniture, familiar objects, places, routines for greeting , and colours. Figure Medium (orange): kinship , names of people, own’s body parts that cannot be directly seen (e.g. ‘nose’ or ‘eyes’), routines such as ‘thank’, onomatopoeic sounds (such as ‘roar’ for tiger), descriptive words, question words , references to space and time , and to perceptual and physiological internal states , alphabet and songs.Abstract (blue): personal and possessive pronouns, child’s own name, numbers, quantifiers, routines for affirming and negating, verbs for actions and verbs for routines ‘all gone,’ ‘all done,’ internal states referring to emotions, desires, volitions cognitions and moral states.Across all age groups, the more frequent concrete concepts are toys, familiar objects, references to their mommy, and greeting routines. The more frequent middle concepts are kinship and spatial terms. Finally, the more frequent abstract concepts are assertions, negations, verbs, and personal and possessive pronouns. Table To tackle the developmental pattern of abstractness, we now consider the production of children, breaking it down for each age group (see §Coding).Figures Considering the subcategories for each age group Figs. , 3 and 476. Correspondence Analysis is a data reduction technique allowing to extract the main dimensions along which information is grouped77. The input for the following correspondence analysis is a matrix composed of age groups (rows) and the sum of occurrences produced by each age group for each category (columns). We found a statistically significant dependency between rows and columns, p < 0.001. The first two dimensions explained 100% of the variance, with Dimension 1 explaining most of the variance (95.05%), followed by Dimension 2 (4.94%). The results can be seen in Fig. To further address the relation between age group and category, we conducted a correspondence analysis, implemented through the “FactoMineR” and “factoextra” R’s packagesariance 9.05%, folWe discuss only points that weigh more than 10% of the variance for each dimension.Dimension 1 captures the opposition between abstractness and concreteness, featuring a distinction between concrete and abstract concepts, the first characterizing the production of younger children and the second of the older age group. Thus, on Dimension 1 (which explains most of the variance), we find a strong opposition between age group 1  and age group 4 , while on Dimension 2, age group 2  is opposed to age group 3 .Dimension 1 features the traditional opposition between abstract (39.9%) and concrete (57.89%) concepts, while on Dimension 2, we find medium concepts (72.62%) opposed to abstract concepts (22.28%).Results from the correspondence analysis suggest that children in the first age group (12–15 months) produced more concrete concepts, whereas they produced more abstract concepts as they grew older . As for the middle-aged groups, we found children in the second age group (16–18 months) produced more abstract concepts, while children in the third age group (19–21 months) mainly produced concepts at an intermediate level of abstractness. The last result might not seem intuitive, but it accounts for a very small percentage of the variance (4%), and it can be considered marginal. It can, however, remind us that the process from concreteness to abstractness is not straightforward, but there might be fluctuations.Table A qualitative inspection of the data shows that, on average, children tended to produce more concrete terms in all age groups except from age group 4—in which the production of abstract terms increased, exceeding the production of both concrete and medium terms.Figure Despite large interindividual differences, there is a growing trend for both concrete words and for words with medium and high levels of abstractness across sessions. Concrete words are used proportionally more than abstract words.Relationship between age groups and subcategories. To further explore the pattern of our data, we performed another correspondence analysis using a matrix composed of age groups (rows) and the sum of occurrences produced by each age group for each subcategory (columns). We found a statistically significant dependency between rows and columns, p < 0.001. The first two dimensions explained 87% of the variance, with Dimension 1 explaining 56.31% of the variance, followed by Dimension 2 explaining 31.45% of the variance, and Dimension 3 explaining 12.2% of the variance.We discuss only points that weigh more than 10% of variance.On Dimension 1 age group 2  and age group 1  are opposed to age group 4 , while on Dimension 2 age group 1  is opposed to age group 2 . On Dimension 3 we found a strong opposition between group 2  and group 3 .On Dimension 1, we found no point contributed more than 10% to the variance. However, it might be worth mentioning three categories that contributed more than 8% to the variance: abstract routines allgone-alldone (9.15%) opposed to concrete toys (9.49%) and abstract assertions 8.27%). On Dimension 2, we found an opposition between medium invisible body parts (57.25%) and abstract negation (19.28%), while on Dimension 3 we found concrete beverages (19.14%) together with medium routines-time concepts (26.01%) are opposed to abstract routines allgone-alldone (10.48%) and abstract personal pronouns (11.66%). Figure %. On DimThe correspondence analysis results indicate that children in the first age group (12–15 months) produced more words referring to concepts with a medium level of abstractness, labels for body parts. In contrast, children in the second group of age (16–18 months) produced mainly abstract concepts referring to routines-negation. They also suggest that children in the first (12–15 months) and second (16–18 months) group of age produced the first words for abstract concepts, i.e., abstract routines allgone-alldone. Children in the second group of age (16–18 months) produced mostly words for abstract routines such as allgone-alldone and abstract personal pronouns; children in the third group of age (19–21 months) used mainly medium routines-time related terms and concrete terms referring to beverages; they also produced labels for concrete toys and abstract-assertions.The results of this analysis give us important information as to the development of a vocabulary for different kinds of abstract concepts. We first find a clear opposition between younger and older infants . Even if no point weighs more than 10%, an analysis of points contributing above 8% suggests that children of the first two age groups already produce the first abstract words , but that older children produce more sophisticated words for abstract concepts, i.e., abstract assertions, together with concrete toys. An increase in abstractness seems to occur early on: in the second dimension, we find that, whereas children of age group 1 (12–15 months) produce more labels for invisible body parts (medium), children of age group 2 (16–18 months) produce more abstract negations. Importantly, there might be shifts and fluctuations, especially between age groups 2 (16–18 months) and 3 (19–21 months), as revealed by Dimension 3: children of age group 2 (16–18 months) produce more abstract personal pronouns and routines alldone-allgone, children of age group 3 (19–21 months) more concrete beverages and routines-time (medium).78, suggests that 75% of the words most frequently produced by school‐age children (first to eighth grade) were concrete, while only 28% of the most used words by adults were concrete69.The results of the study are quite clear. They indicate that children during the course of the second year of life use progressively more abstract words when interacting with their mothers in a toy play context. The major shift seems to occur between the first and last phases, i.e., from 12–15 months to 22–24 months, but the qualitative data indicate an incremental growth of terms to denote abstract concepts. Our results confirm that the acquisition of words referring to abstract concepts occurs later compared to that of words referring to concrete ones. This evidence complements that of language production in children and adults. For example, Brown (1957), as reported in Schwanenflugel50. Parental reports have the advantage to acquire quick data collection on large samples, but at the expense of reliability. When asked to check from a list of words those ever used by their child, parents may overestimate or underestimate their children’s productive vocabulary and tend to respond on the basis of their memories, perceptions, and beliefs, as they do not have specific training on language development; they may also respond on the basis of what they think is more acceptable or expected, the well-known ‘social desirability’ effect. Laboratory and naturalistic observations, upon which our work relied, require transcription of speech and are labour intensive, but have the undeniable advantage of ecological validity and are considered direct, objective and reliable79. Our study is the first one, to our knowledge, focusing on the real time age of acquisition for abstract terms based on direct longitudinal observations  of the child in interaction with the mother during the second year of life. Parent-infant play can be considered a privileged situation that facilitates symbolic thinking and early language acquisition. The microgenetic design adopted, using multiple case studies and intensive observations across a key developmental transition, enabled us to document the composition and the age of acquisition of abstract terms in real-time for eight English-speaking children. Despite ample interindividual differences observed in our sample in abstract and overall vocabulary sizes, we found a relationship between the number of abstract words and overall vocabulary size for children, giving initial support to the idea that abstract vocabulary can be seen as a kit or a tool for improving the elaboration of abstract cognitive skills and the resulting production of abstract words in spoken language. Our results have several implications bridging research on abstract conceptual knowledge and developmental research. In the following, we will briefly summarize the main findings of our study.Previous work on the acquisition of concrete vs. abstract terms in productive vocabulary has relied on parental reports identifying the age of children’s first usage of specific termsFirst, we provide evidence of a significant shift from terms denoting concrete to abstract concepts between one and two-year-olds. Notably, terms denoting abstract concepts produced at this age are not like “fantasy” or “justice”. We offered a framework to operationalize and classify different kinds of abstract terms very early in development, and proposed that abstractness requires a detachment from concretness and context and a kind of social interaction and cognition that implies ‘not knowing’ and going beyond the here and now.80. Within terms denoting abstract concepts, abstract routines alldone-allgone are present early, and characterize mostly the first age group (12–15 months); abstract negations and abstract personal pronouns emerge in the second age group (16–18 months), whereas the more complex abstract assertions emerge later on. Interestingly, labels for numbers appear in the second age group and quantities in the third (19–21 months). This result supports the idea that labels for numbers might be less abstract than labels for other abstract concepts, like mental states ones81.Second, and crucially, we presented a detailed analysis of the pattern of categories that progressively emerge as more relevant with age. In accord with recent developments in the literature on abstractness, we show that categories of words used to refer to abstract concepts are not a unitary whole but are rather composed of different kinds58.Importantly, the analysis we performed on the emergence of the different subcategories of terms denoting abstract concepts can also contribute to very recent literature on abstract concepts in adults. It confirms that abstract concepts cannot be considered a unitary whole nor a dichotomy; they can be seen as a continuum’s extremes or, even better, as points in a multidimensional space defined by various dimensions, such as abstractness, imageability, age and modality of acquisition and that it is crucial to investigate fine-grained differencesThird, the qualitative analysis we performed allowed us to understand in detail the progression of abstract words acquisition in specific domains. Among the categories of abstract words analyzed in our work, two categories deserve special attention in our view, as they seem especially difficult to acquire: verbs and terms denoting mental states, which we will discuss next.84. It has been proposed that nouns are easier to learn than verbs because they refer to perceptually distinct units that are stable and consistent across time and context85. Nouns rely on the basic understanding of object permanence and of the physical properties of objects that are well established in the first year of life86. By contrast, to learn a verb, children have to determine which aspect of an ongoing event is being referred to, so they have to understand something of the intentional nature of actions87—an abstraction—and these abilities develop toward the end of the second year. Golinkoff & Hirsh-Pasek88 propose that toddlers must coordinate multiple cues  to learn verbs, the gateway to grammar. They propose an interesting continuum representing the fact that verbs that rely on perceptual cues will be learned before verbs that label perceptually less accessible referents. According to their model attention to perceptual cues for verb meaning precedes children’s attention to intentional and grammatical cues, that would not be in the service of word learning until 24 months of age.In relation to verbs, it is well established that verbs are acquired later than nouns in different languages and cultures—even in ‘verb-friendly’ languages such as Korean and Mandarin89. Consistently, in our data, all children begin to use verbs only after 18 months. The first verbs uttered are ‘push’, ‘drink’, ‘hang up’, ‘done’, ‘stir’, and ‘don’t’, and by the end of the second year they can rely on a wide range of verbs including ‘play’, ‘tickle’, ‘call’, ‘make’, ‘count’, ‘work’, ‘sleep’, ‘go’, ‘wait’, ‘eat’ and ‘sing’.Furthermore, verbs are more complex than nouns since they involve a relation between at least one agent and some activity, and action categories are not as well defined as object categories92. Internal state language is highly predictive of later Theory of Mind, as measured by the false belief task93. In our work, we classified these terms as abstract, as they refer to internal experiences that are not visible and that can only be inferred. The vocabulary for mental states collected from our sample is large and includes terms such as ‘pretend’, want’, ‘love’, ‘happy’, ‘feel’, ‘know’, ‘like’ and ‘worry’, showing that by 24 months children indeed have begun to reflect on themselves and on other’s behaviors in conversations with a parent in a somewhat abstract way.In relation to mental states, several authors have documented that language for labelling states or processes occurring in the mind emerges late in the second year of life and grows in the third, as children’s conversations gradually come to carry explicit reference to shared inner experiences74. Alternatively, we could say that children who developed early abstract, relational concepts later have a wider vocabulary50. In a similar perspective, Lewis, Colunga & Lupyan50, recently demonstrated that knowing general words facilitates faster vocabulary growth. Why should abstract terms facilitate language learning—and possibly higher-order cognition? Gentner59 has proposed that there is a special class of terms referring to relational concepts that are important and difficult to acquire, but that represent a cognitive ‘tool kit’ and a preferential avenue for higher-order cognition and abstractness. Relational words are slow to be acquired, but some of these words, such as terms for spatial relations  and ordinal numbers, are acquired early and, once acquired, are in constant use. Our results add to these studies a detailed and fine-grained documentation of the specific abstract terms used in conversation with parents by typical English-speaking children.Finally, our findings suggest a reason why learning progressively more abstract concepts might be crucial. In line with recent views, our results suggest that language, and particularly abstract language, promotes cognition. Specifically, we found that the frequency of the produced abstract terms corresponds to the vocabulary size—the larger the vocabulary size, the larger the number of produced abstract concepts. This finding might be interpreted in two different ways, both suggesting an important relationship between abstract concepts and language. First, we could say that children need to master many words to acquire hard words like abstract onesDespite its ecological and longitudinal approach, our study is not without limitations. The microgenetic design adopted, using multiple case studies and intensive observations across a key developmental transition, has the disadvantage to allow data collection for only small numbers of participants. The conclusions gained from our effort may be tested in larger samples of children speaking different languages and belonging to more diverse socio-cultural backgrounds, in order to establish typical versus delayed trajectories of the acquisition of abstract vocabulary. Moreover, investigating factors that may underlie typical versus delayed acquisition of abstract vocabulary may in the future be relevant and useful in designing interventions for children with atypical language development. On the other hand, our focus on productive language acquisition constrained our work and our conclusions as it cannot be excluded that infants younger than one year may possess some abstract concepts even before having learned any words that refer to these concepts.To conclude, our study provides insight into young children's progress in acquisition of abstract terms, combining qualitative examples with a quantitative analysis. We focused on how infants progressively acquire a detailed vocabulary to refer to abstract concepts with an ecological method, analyzing word usage in an interactive mother–child play situation. It documents when children start to use a wide range of abstract terms for the first time. Our results show that children acquire terms denoting abstract concepts later than terms denoting concrete ones, but not in a homogeneous manner since different sub kinds of abstract concepts emerge at different ages. It also suggests the exciting possibility that abstract concepts might prepare children to acquire more words and new sophisticated thinking abilities. Further research is needed to deepen this critical topic.Supplementary Information.


Factors such as gender, marital status, race and/or ethnicity, nationality, income, education, job status, or social relationships are known as social determinants of health. Recently, healthcare professionals have been required to consider patients’ social determinants and to address issues to improve the care of patients.Social backgrounds affect people’s health and health behaviour.et al, there are multiple barriers that people need to overcome to access primary care. The conceptual diagram which Levesque and colleagues previously summarised shows that the barriers include: ‘Approachability‘, ‘Acceptability‘, ‘Availability and accommodation‘, ’Affordability’, and ’Appropriateness’. To overcome the barriers, patients need to demonstrate their capabilities, which were summarised as ‘Ability to perceive‘, ‘Ability to seek‘, ‘Ability to reach‘, ‘Ability to pay‘, and ‘Ability to engage‘. Both barriers and capabilities are shown in These social determinants of health can also prevent patients’ access to primary care. According to Levesque strength to demonstrate their capabilities and overcome the barriers to healthcare access. This perspective, known as a ‘strength model‘, is well known and utilised in the field of social work.The conceptual diagram can also be considered from the perspective of social work: we can regard the patient before us, who has accessed primary care and received care, as having the  Once a patient is stigmatised by healthcare professionals, their power to overcome the barriers reduces due to discouragement, resulting in the state of ’powerlessness‘. Once the person became powerless due to stigma, they are being effectively excluded from the society. Consequently, the patients will be unable to access to primary care. This state is known as ’social withdrawal‘ and represents one of the coping skills of patients employ to avoid being stigmatised repeatedly. Such withdrawal may mean that the physician no longer sees the patient, leading to increased marginalisation.However, healthcare professionals sometimes stigmatise socially vulnerable patients in clinical settings, being prejudiced against those patients capable of reaching primary care because of an unconscious implicit bias that is embedded in our daily practice.individualisation, purposeful expression of feelings, controlled emotional involvement, acceptance, non-judgmental attitude, client self-determination, and confidentiality. As we have seen, patients who could attain access to primary care had the strength to demonstrate their capabilities to overcome multiple barriers. We, as healthcare professionals, do not have the authority to judge an individual patient’s background. It is important to accept the process that has led the person to seek medical care support. Healthcare professionals have been reported to be one of the sources of patients’ stigma. Because stigma is a known health risk that can arise from healthcare professionals’ prejudice embedded in everyday life, it is important for healthcare professionals to be aware of their own implicit biases. Approaches utilised in social work, introduced above, may reduce the barriers faced by patients needing primary healthcare access, and may strengthen their capabilities. In recognising these concepts and their applicability to primary care, healthcare professionals may be able to encounter, with ‘fresh eyes’, a marginalised patient who had been prevented access to primary care due to their social determinants.If we learn from the social work perspective, we may be able to prevent this unfavourable consequence of implicit bias in healthcare professionals. Biestek‘s basic principles of social work include