Child Care Usage

In the USA, about 11.3 million young children are regularly in care by someone other than their parents, largely due to the vast increase in employment of mothers of young children in recent decades. Fifty-eight percent of children 4 yr old and younger with employed parents are in regular child care. The largest increase in child care use is among infants and toddlers, with 53% of infants and 57% of toddlers in child care. Additionally, children are in care for long hours, with 42% of children age 4 yr or younger attending child care for 35 hr or more each week.

Child-Care Settings

These settings vary widely and fall into 4 broad categories, from the least to the most formal: relative care, in-home nonrelative care (e.g., nannies, au pairs), family daycare, and center-based care. Parents more often utilize home-based care for infants and toddlers, in part due to greater preference, flexibility, and availability, and sometimes due to lower cost. Almost 30% of infants and toddlers in care are in family daycare homes. Family daycare providers typically provide care in their home for up to 6 young children, often including children of mixed ages, siblings, or the provider’s own children. Use of center-based child care, provided in nonresidential facilities for typically 13 or more children, is greater among preschoolers (children 3-5 yr old). Early education settings for preschoolers (e.g., Head Start, prekindergarten) also may play an important role in child care. Although early education programs may have a greater focus on educational activities and often only provide limited hours of care per days, the health and safety issues involved with early education programs are similar to those presented by other group child-care settings. Child-care centers and early education programs are administered by a wide array of businesses and organizations, including for-profit independent companies and chains, religious organizations, public and private schools, community organizations, cooperatives, and public agencies.

Sick Children

When children are ill, they may be excluded from out-of-home arrangements, and settings under state licensure are required to exclude children with certain conditions. Guidelines for health and safety in out-of-home care from the American Academy of Pediatrics, the American Public Health Association, and the National Resource Center for Health and Safety in Child Care offer recommendations regarding the conditions under which sick children should and should not be excluded from group programs (Table 15-1). These include fever, vomiting, and diarrhea, as well as certain parasitic conditions. State laws typically mirror these guidelines but may be stricter in some states. Most families need to make arrangements to keep sick children at home (staying home from work). Alternative care arrangements outside the home for sick children are relatively rare but may include either (1) care in the child’s own center, if it offers special provisions designed for the care of ill children (sometimes called the infirmary model or sick daycare); or (2) care in a center that serves only children with illness or temporary conditions. Although it is important that such arrangements emphasize preventing further spread of disease, one study found no occurrence of additional transmission of communicable disease in children attending a sick center. The impact of group care of ill children on their subsequent health and on the health of their families and community is unknown.

Table 15-1 CONDITIONS THAT DO AND DO NOT REQUIRE EXCLUSION FROM GROUP CHILD CARE SETTINGS

Adapted from American Academy of Pediatrics, American Public Health Association, National Resource Center for Health and Safety in Child Care: Caring for our children: national health and safety performance standards: guidelines for out-of-home child care, ed 2, Elk Grove Village, IL, 2002, American Academy of Pediatrics, American Public Health Association, and National Resource Center for Health and Safety in Child Care, pp 124–129. http://nrc.uchsc.edu/CFOC/index.html.

Child Care Licensing, Regulation, and Accreditation

Most child-care centers and preschools and many family daycare providers are subject to state licensing and regulation. Licensing and regulatory requirements for the most part mandate basic health and safety standards, such as sanitary practices, child and provider vaccinations, access to a health care professional, and facilities and equipment safety, as well as basic structural and caregiver characteristics, such as the ratio of children to staff, group sizes, and minimum caregiver education and training requirements.

The types of facilities that are subject to licensure vary by state. As of 2010, most child-care centers in all 50 states are subject to state health and safety licensure. Most states license some types of family child-care homes, although some states only license specific types of family child-care homes, and 3 states do not license these providers at all (Idaho, Louisiana, and New Jersey). Seven states (Arizona, Idaho, Louisiana, New Jersey, Ohio, South Dakota, and Virginia) do not license small family child-care homes, and 11 states (Arkansas, Idaho, Kentucky, Louisiana, Maryland, Maine, North Carolina, New Jersey, Vermont, Washington, and Wisconsin) and the District of Columbia do not license large/group family child-care homes. Louisiana has a registration process for family child-care homes with no more than 6 children, but registration is only required when the provider cares for children subsidized by the federal Child Care and Development Fund (which assists low-income families receiving temporary public assistance, or those needing child care in order to work or receiving training to transition off of public assistance). New Jersey has a voluntary registration process for family child-care homes that is operated by child-care resource and referral agencies in the state.

Many providers are exempt from licensing requirements (often programs operated by a religious organization or a public school), many others are out of compliance, and an unknown proportion of family daycare homes are unregulated and unknown to the public licensure system. Health and safety conditions may be unsatisfactory in unlicensed settings. Furthermore, in most states, licensing and regulatory standards have been found to be inadequate to promote optimal child development, and in many states standards are so low as to endanger child health and safety. Therefore, even licensed providers may be providing care at quality levels far below professional recommendations. For example, the National Association for the Education of Young Children (NAEYC; www.naeyc.org) and the National Association for Family Child Care (NAFCC; www.nafcc.org) recommend infant-to-staff ratios of no more than 3 to 1. But in 2007, requirements were 3 or 3.5 to 1 in only 3 states, whereas the legally allowable ratio was 5 to 1 in 9 states and 6 to 1 in another 5 states.

A small portion of providers become accredited by NAEYC, NAFCC, or other organizations by voluntarily meeting high-quality, developmentally appropriate, professionally recommended standards. The accreditation process goes far beyond health and safety practices and structural and caregiver characteristics to examine the quality of child-caregiver interactions, which are crucial for child development, as described in the next section. Research indicates that child-care programs that complete voluntary accreditation through NAEYC improve in quality and provide an environment that better facilitates children’s overall development. Less than 8% of providers are accredited; this is due in part to a lack of knowledge, resources, and incentives for providers to improve quality, but it may also be due in part to expenses providers incur in the process of becoming accredited.

State child care licensing agencies are playing a larger role in various initiatives designed to improve the quality of child care working through the infrastructure of the early care and education system. Several states’ licensing agencies are part of quality initiatives, such as tiered quality strategies (e.g., tiered reimbursement systems for participating providers who achieve levels of quality beyond basic licensing requirements), public funding to facilitate accreditation, professional development systems, and program assessments and technical assistance.

Characteristics of Child Care and Associations with Child Developmental Outcomes

High-quality child care is characterized by warm, responsive, and stimulating interactions between children and caregivers. In high-quality interactions, caregivers express positive feelings toward their children; are emotionally involved, engaged, and aware of the child’s needs and sensitive and responsive to their initiations; speak directly with children in a manner that is elaborative and stimulating while being age-appropriate; and ask questions and encourage children’s ideas and verbalizations. Structural quality features of the setting, including ratio of children to adults, group size, and caregiver education and training, act indirectly on child outcomes by facilitating high-quality child-caregiver interactions. It would be difficult for even the most sensitive and stimulating provider to engage in high-quality interactions with each child, if she was the sole caregiver of 10 toddlers.

The quality, quantity, and type of child care experienced by young children contribute to child development. Child care use by itself does not affect maternal-child attachment. Only when combined with low maternal sensitivity and responsiveness does poor-quality child care, larger quantities of child care, or multiple child care arrangements predict greater likelihood of insecure attachment.

Adjusting for family factors (parental income, education, race/ethnicity, family structure, parental sensitivity) the quality of child care is a consistent and modest predictor of child outcomes across most domains of development, whereas the quantity of child care is a consistent and modest predictor of social behavior. The type of child care setting, however, is an inconsistent, modest predictor of cognitive and social outcomes. Specifically in regards to quality, children who experience higher-quality child care perform better than other children on cognitive, language, and academic skill tests and, at some points in early childhood, show more prosocial skills and fewer behavior problems and negative peer interactions. Parenting quality, however, matters far more. Compared to the effects for child care, which are relatively consistent and modest in magnitude, the effects of parenting quality on the same outcomes are very consistent and strong, being about twice as strong as the effects of child care quality.

The effects of quantity and type of child care on child development are less strong and less consistent. Quantity of child care is related only to social outcomes. Children who spend more time in any kind of child care are rated or observed at some points in the preschool period to display more problem behaviors, more teacher-child conflict, and more negative behaviors in interactions with friends. The magnitudes of these effects of child care hours on social outcomes are modest. Type of care shows mixed associations with child outcomes. Although findings vary across age, children who experience more center care have stronger cognitive, language, and memory skills and display more positive behaviors in interactions with a friend, but also show fewer prosocial skills and more behavior problems. These effects of center-based care on child outcomes are less consistent and more modest in magnitude compared to other reported effects.

Despite the importance of high-quality child care for child development, several large studies have found that most U.S. child care is of “poor to mediocre” quality. In one study, only 14% of centers (8% of center-based infant care) were found to provide developmentally appropriate care, while 12% scored at minimal levels that compromised health and safety (40% for infant care). In another study, 58% of family daycare homes provided adequate or custodial care, and only 8% provided good care. Children with the greatest amount of family risk may be the most likely to receive child care that is substandard in quality. Many children from lower-risk families also receive lower-quality care, and despite their advantages at home, these children may not be protected from the negative effects of poor-quality care.

Affordable, accessible, high-quality child care is hard to find. Middle-class families spend about 6% of their annual income on child care expenses, while poor families spend about 33% (on par with housing expenses). Infant and toddler care is particularly expensive with fewer available slots. In addition to the stress of meeting such a high expense, many parents worry that their child will feel unhappy in group settings, will suffer from separation from the parents, or will be subjected to neglect or abuse. This worry is especially likely among low-income parents with more risk factors, fewer resources, and fewer high-quality options available. Parents are the purchasers but not the recipients of care, and are not in the best position to judge its quality. Many parents are first-time purchasers of child care with little experience and very immediate needs, selecting care in a market that does little to provide them with useful information about child care arrangements. In many states, efforts are underway to improve quality and provide parents with quality information, but most states do not have a quality rating and information system, and programs in states that do are still emerging, and testing of effectiveness is still underway. To inform their care decisions, parents may turn to their child’s pediatrician as the only professional with expertise in child development with whom they have regular and convenient contact.

Child Care and Child Health

A disproportionate number of sudden infant death syndrome (SIDS) deaths occur in child-care centers or family-based child-care homes (approximately 20%). Infants who are back-sleepers at home, but are put to sleep on their fronts in child-care settings, have a higher risk of SIDS. Providers and parents should be made aware of the importance of placing infants on their backs to sleep (Chapter 367).

Children enrolled in child care are also of an age that places them at increased risk for acquiring infectious diseases. Participation in group settings elevates exposure. Children enrolled in such settings have a higher incidence of illness (e.g., upper respiratory tract infections, otitis media, diarrhea, hepatitis A infections, skin conditions, and asthma) than those cared for at home, especially in the preschool years. However, a review of correlational and experimental research found that these illnesses had no long-term adverse consequences. Child-care providers that follow child care licensure guidelines for handwashing, diapering, food handling, and manage child illness appropriately can reduce communicable illnesses.

There is debate about whether child care exposure serves as a risk or protective factor for asthma. One cross-sectional study found that preschoolers in child care had increased risk of the common cold and otitis media, and children who began child care before the age of 2 yr had increased risk of developing recurrent otitis media and asthma. However, a longitudinal study found that children who were exposed to older children at home or to other children at child care during the first 6 mo of life were less likely to have frequent wheezing from age 6-13 yr, suggesting that child care exposure may protect against the development of asthma and frequent wheezing later in childhood. A 10-yr follow up of a birth cohort found no association between child care attendance and respiratory infections, asthma, allergic rhinitis, or skin prick test reactivity. Another study found that in the first year of elementary school, children who had attended child care had fewer absences from school, half as many episodes of asthma, and less acute respiratory illness than their peers who had never attended child care. These results are perhaps related to protection against respiratory illness as a result of early exposure or a shift in the age-related peak of illness, though selection of illness-prone children into home care may play a role. Other factors may also be relevant to this issue, such as children in child care potentially being less exposed to passive smoking than children at home.

Child Care and Children with Special Needs

The needs of children with mental, physical, or emotional disabilities who, because of their chronic illness, require special care and instruction may require particular attention when it comes to their participation in most child-care settings. Guiding principles of services for children with disabilities advocate supporting children in natural environments, including child care. Furthermore, the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973 prohibit discrimination against children and adults with disabilities by requiring equal access to offered programs and services.

Although many child-care providers and settings are unprepared to identify or administer services for children with special needs, child care could be utilized for delivery of support services to these children and/or for linking families to services, such as early intervention and doctor referrals. Further, pediatricians can draw upon child-care providers to help provide important evaluative data regarding a child’s well-being, since these providers have extensive daily contact with the child and may have broad, professional understanding of normative child development. A child-care provider may be the first to identify a child’s potential language delay. Child-care providers are also necessary and valuable partners in the development and administration of early intervention service plans.

Children with special needs may be eligible for services under the Individuals with Disabilities Education Act (IDEA). (See also Chapter 14.) The purpose of this law is to provide “free appropriate public education,” regardless of disability or chronic illness to all eligible children birth to 21 yr in a natural and/or least restrictive environment. Eligible children include those with mental, physical, or emotional disabilities who, because of their disability or chronic illness, require special instruction in order to learn. As a part of these services, a formal plan of intervention is to be developed by the service providers, families, and the children’s health care providers. Federal funds are available to implement a collaborative early intervention system of services for eligible infants and toddlers between the ages of birth and 3 yr and their families. These services include screening, assessment, service coordination, and collaborative development of an individualized family service plan (IFSP). The IFSP describes early intervention services for the infant or toddler and family including family support and the child’s health, therapeutic, and educational needs. An understanding of the child’s routines and real-life opportunities and activities, such as eating, playing, interacting with others, and working on developmental skills, is crucial to enhancing a child’s ability to achieve the functional goals of the IFSP. Therefore, it is critical that child-care providers be involved in IFSP development or revision, with parental consent. Child-care providers should also become familiar with the child’s IFSP and understand the providers’ role and the resources available to support the family and child-care provider.

Additionally, IDEA provides support for eligible preschool age children to receive services through the local school district. This includes development of a written individualized education program (IEP), with implementation being the responsibility of the local education agency in either a public or private preschool setting. As with IFSPs, child-care providers should become familiar with the preschooler’s special needs as identified in the IEP and may become involved, with parental consent, in IEP development and review meetings. In cases where children may have or be at risk of developmental delays, a diagnosis is important for obtaining and coordinating services and further evaluation. To this end, pediatricians can partner with child-care providers to screen and monitor children’s behavior and development.

Advising Parents on Child Care Selection

Organized professional guidance in choosing child care is insufficient. Pediatricians can help parents understand the importance for their child’s development of selecting high-quality care by describing how it looks and providing referrals and tips on how to find and select high-quality child care (Table 15-2). In addition, pediatricians can help parents determine how to adjust child care arrangements to best meet their child’s specific needs (e.g., allergies, eating and sleeping habits). For most parents, finding child care that they can afford, access, manage, and accept as a good environment for their child is a very difficult process and one many parents find distressing. Many parents are also worried about how their child will fare in child care (e.g., Will their child feel distressed by group settings, suffer from separation from the parents, or even be subjected to neglect or abuse?). These worries are especially likely among low-income parents with fewer family and community resources to draw upon. A few parents may think of child care only as babysitting, and may not consider the consequences for their child’s cognitive, linguistic, and social development, focusing solely on whether the child is safe and warm. These parents may be less likely to select a high-quality child care arrangement, which is especially problematic if the family is facing socioeconomic challenges that already place them at risk of receiving lower-quality care for their children. For these parents, it is vital to stress the importance of quality and its implications for their child’s cognitive, language, and behavioral development and school readiness.

Table 15-2 CHILD CARE INFORMATION RESOURCES

Advising Parents on Child Care Health Issues

Parents of infants should be advised to ensure that child-care providers put infants on their back to sleep to prevent SIDS. Further, when children are ill, parents should be advised to follow guidelines for inclusion and exclusion (see Table 15-1). Parents may disagree with child-care staff about whether a child meets or does not meet the exclusion criteria. However, professional guidelines state that “if the reason for exclusion relates to the child’s ability to participate or the caregiver’s ability to provide care for the other children, the child-care provider is entitled to make this decision and cannot be forced by a parent to accept responsibility for the care of an ill child. If the reason for exclusion relates to a decision about whether the child has a communicable disease that poses a risk to the other children in the group, different health care professionals in the community might give conflicting opinions. In these cases, the health department has the legal authority to make a determination.” Pediatricians should emphasize the importance of following vaccination schedules; most states require compliance for children to participate in licensed group child-care settings.

Helping Children with Special Needs

Pediatricians should work with parents and communicate with other service providers and early intervention staff to identify problems, remove access barriers, and coordinate service delivery for children with special needs. They should also encourage involvement of parents and child-care providers in IFSP or IEP plan development.

Consulting and Partnering with Child-Care Providers

Most state regulations mandate that licensed programs have a formal relationship with a health care provider. Pediatricians can provide consultation to child-care providers about measures to protect and maintain the health and safety of children and staff. This may include consultation regarding promoting practices to prevent SIDS; preventing and reducing the spread of communicable disease; reducing allergen, toxin, and parasite exposure; ensuring vaccinations for children and staff; removing environmental hazards; and preventing injuries.