Caribbean small island developing states (SIDS) are vulnerable to climate change impacts including sea level rise, invasive species, ocean acidification, changes in rainfall patterns, increased temperatures and changing hazard regimes. Many livelihoods in the Caribbean SIDS are dependent on natural resources; therefore, a focus on ecosystems and their interaction with people is essential for climate change adaptation. This paper critically reviews ecosystem-based adaptation (EbA) approaches which encourage the use of local and external knowledge about ecosystems to identify climate change adaptation approaches. It provides an analysis of current EbA in the Caribbean alongside a review of methodologies used to integrate local and external expertise for EbA. The paper identifies key gaps and lessons learnt suggesting ways forward for EbA in the Caribbean SIDS.