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Developmental Aspects of Child Care
Development and Behavior: The Very Young Child
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Developmental Aspects of Child Care
Susan A. Dilks, MD*
THE NEED FOR CHILD CARE Child care is now the normative experience for most American infants and preschoolers. In 1987, the most recent year for which census data are available, 52.1 million children under the age of 15 years were living in the United States. Fifty-nine percent of these children (30.6 million) had mothers who were employed, and an additional 3% (1.4 million) had mothers who were enrolled in school. 45 Therefore, 62% of all American children under the age of 15 had mothers who were employed or in school. American women are employed for the same reasons that American men are employed-economic necessity and personal choice. Maternal employment is not a luxury for the vast majority of American families. The decline of the real median family income between 1973 and the mid-1980s necessitated women's entry into the labor force. 44 The fastest growing subgroup of working mothers are those from twoparent households with infants less than 1 year of age; most of these women are employed full time. 5 • 46 In 1988, 51% of women aged 18 to 44 with newborn children less than 1 year of age were in the active labor force, an increase from 38% in 1980 and 31% in 1976. 46 Nearly 3.7 million infants less than 12 months of age in the United States have mothers working outside the home. In the United States there have been absolute increases of both the proportion of children who have employed mothers and the actual number of children in child care. 45, 46 The impact of maternal employment and the need for adequate child care is widely debated. The question is no longer simply whether child care is good or bad for children. What are the current issues? Many families perceive a nonavailability of adequate options to meet the goals of both family rearing and economic stability. The economic climate has necessitated the availability of child care as an option for working parents. Federal *Assistant Professor of Pediatrics, Division of Developmental Pediatrics, Kluge Children's Rehabilitation Center, Children's Medical Center, University of Virginia, Charlottesville, Virginia
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standards for the licensing of child care facilities are lacking, although standards of good quality child care have been well defined by research. 32 • 39 The availability of and the access to quality care is inadequate for the numbers of children needing care. The impact of child care continues to be examined with regard to the emotional, social, and cognitive development of children. Knowledge regarding quality of child care and its developmental effect must be valued by society and government, with appropriate legislative action taken. Such knowledge must be incorporated into all child care settings, ensuring that care of good quality is available to all children. The focus of this article is a discussion of the effect of early child care on the emotional, social, and cognitive development of the young child. High-quality child care is associated with better child outcome; various characteristics of child care as related to quality of care are presented. Lastly, the role of the pediatrician in ensuring quality care to all young children and their families is discussed.
THE SPECTRUM OF CHILD CARE SETTINGS Child care is defined as care provided by an individual outside the nuclear family or in a setting separate from the child's home. Historically, families have creatively sought multiple solutions to the child care dilemma. Parents may work alternate shifts so that the child receives care from each parent in the home setting. One or both parents may work out of the home, combining employment with child care. The child may receive care in the home from either a relative or a nonrelative such as a nanny. The child may receive care in the home of a babysitter, either individually or in a small day-care home with one to three additional children. Care in a family day-care home may be licensed or unlicensed and may provide care for anywhere from two to more than ten children. Center-based child care may be proprietary or nonprofit. Proprietary child care includes independent centers and nationally based chains (e.g., Kindercare, La Petite Academy). Nonprofit child care may be either government sponsored (e.g., Head Start) or run by a church or an independent nonprofit group. Families may use one or multiple forms of alternative child care. Families often have strong preferences for choosing one form of child care over another. Their preferences are individual to the family, their child, and their situation. There are advantages and disadvantages to each form of child care (Table 1). Licensing, regulation, and concerns regarding health and child development vary with the type of child care. The families of children receiving child care differ in terms of family structure (single-parent, dual-parent, extended family), economic status, and coexisting stressors such as a mother's attitude toward both employment and child care. All families and home environments are not the same. Similarly, some child care environments are better for certain children than others.
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Table 1. Advantages and Disadvantages of Various Types of Child Care ADVANTAGES
DISADVANTAGES
Care in home by relative
Familiar environment Familiar (family) care provider Usually inexpensive
Stress in family relationships Lack of availability of extended family
Care in home by sitter
Familiar environment No transit time
Cost (usually expensive) Difficulty in locating an excellent caregiver No back-up if caretaker absent Lack of supervision of care provider
Family day care
Availability Cost (usually inexpensive) Flexibility in scheduling
Majority unlicensed, unregulated No back-up if caretaker absent Lack of supervision of care provider
Center-based child care
Cost (usually inexpensive) Reliable Well equipped with materials Peer availability Supervision of care provider
Individual needs of child may not be met Lack of flexibility in hours No arrangements for ill child Exposure to illness
CHILD CARE REGULATION AND ACCREDITATION The United States has no federal standards for the regulation of child care. The regulation of child care has been allocated to the individual states, resulting in specific standards and degrees of regulation that vary from state to state. Most states with regulation of standards monitor physical setting and health and safety factors, with limited or no standards related to quality of child care. Those states that monitor safety do not do so in a uniform manner; model health and safety standards jointly developed by the American Academy of Pediatrics and the American Public Health Association will be released in the summer of 1991. The National Daycare Study of 1977 noted that enhanced child development was correlated with low staff-to-child ratios in child care settings. The Federal Interagency Day Care Regulations were proposed that same year. Those regulations mandated a minimal staff-to-child ratio of one to three during infancy, one to four in toddlerhood, and one to five in a family day care setting. Additionally, the regulations proposed established group sizes and specialized training for care providers. Training commensurate with their responsibilities was required for caregivers and directors of child care facilities. Standards for program content and curricula were proposed; however, these regulations were suspended by Congress in 1980. 25 Following this, Public Law 98-473, The Model Child Care Standards Act, mandated that states determine specific child-to-staff ratio recommendations. Currently, 16% of all states have no established staff-to-child ratio for infants, and 62% have no set limitations for group size. The Model
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Child Care Standards Act addresses the training of care providers; however, the only specified training is for the recognition and prevention of child abuse among children in child care settings. Unlike most industrialized countries in the world, the United States has no system of paid parental leave at the federal level. 39 Past public policy has been reviewed by Martinez,25 and the proposed federal role in child care has been outlined by Senator Orrin Hatch22 in articles published after a national interagency conference on the future of child care. No significant action on comprehensive child care legislation has yet been taken on a federal level. ATTACHMENT IN NORMAL EMOTIONAL DEVELOPMENT The emotional, social, and cognitive development of a child follows an anticipated sequence of milestones. An understanding of normal child development is necessary before conjecture regarding the implications of child care for early development. The effect of child care on the development of an individual child depends on interrelated characteristics of the child, the child care setting, and the family. The needs of an infant differ greatly from the needs of a preschooler. The important qualities required of child care vary with the age and temperament of a particular child. Young infants have intense physical needs. They depend on others for basic care, including feeding, dressing, hygiene, and mobility. A great amount of time, both at home and in child care, is spent meeting these needs. In addition to major developmental changes in motor and cognitive areas, the infant makes dramatic changes emotionally during the first 2 years of life. Infant attachment is central to an infant's early emotional development. Attachment is the propensity of one individual to form a strong emotional bond with another individual. The infant becomes attached to a caregiver who provides comfort and consistency in addition to meeting varied physical needs. The quality of the attachment (secure or insecure) depends on the responsiveness of the caregiver in a consistent, timely, caring, and predictable manner and the infant's ability to perceive this responsiveness. Attachment theory maintains that the secure attachment of an infant to a primary caretaker (presumably the mother) is crucial not only for infant emotional development but also for determining the pattern of future relationships for that individual. 10, 13 An infant forms a secure attachment to a caregiver who has consistently responded to communication in a predictable manner. Securely attached infants use the caregiver as a secure base for exploration of the world around them. An infant may form an insecure attachment to a caregiver who has responded inconsistently, unpredictably, or in a detached or indifferent manner. Without security or predictability, infant exploration may be frightening and the development of future relationships may be anxiety-provoking. Normal emotional development is a spectrum of overlapping stages. 20 Emotional development begins with the attainment of self-regulation (the ability to calm oneself) during the first 3 months and progresses to
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"reciprocal wooing" during the second half of the first year of life. The infant learns much about and falls in love with the human world. By the beginning of the second year, children have reached the stage of communicative intent; by 2 years of age, children are capable of expressing needs and desires both verbally and nonverbally.20 Smooth transitions between these stages depend on the consistency and responsiveness of both primary and auxiliary caregivers. Preschool children increase their independence in communication, feeding, dreSSing, hygiene (toileting), and individual play. Caretakers supervise, encourage, and provide the appropriate setting and materials to achieve autonomy in these activities. Emotionally, preschoolers are beginning to create unique ideas. The attainment of this milestone can best be judged by the dramatic increase in language and the appearance of pretend play.20 Preschoolers need a stable setting with developmentally appropriate materials, which is both comforting and enriching in addition to providing a supportive, affective environment.
CHILD CARE AND EMOTIONAL DEVELOPMENT The relationship between child care and infant attachment has been well reviewed in the recent literature. 8. 11. 18.30.49 There is perhaps no topic more greatly debated in the fields of infant development and psychology than the effect of child care on infant attachment and emotional development. Various studies have arrived at different conclusions. Various reviews have differed in the interpretation of the data. Does child care during the first year of life decrease the likelihood of attachment to the mother? Attachment theory states that infants may form multiple attachments. A single primary attachment is formed with the mother. Several aspects of caretaking or mothering may be provided by other individuals if the relationship between infant and other adult caretaker is stable and of high quality. Although an infant may form an attachment to an alternative care provider, there is no evidence that child care can replace the primary attachment between infant and parent. 8. 18. 26 Does child care in the first year of life increase the probability of an insecure attachment to the mother? The quality of attachment depends on maternal sensitivity and responsiveness to infant cues, the stability of caregiving, and the child's ability to predict the availability and responsiveness of the caregiver. Other factors that may affect infant emotional development include physical qualities of the home and child care center, the number and responsiveness of nonprimary caregivers, the frequency of staff changes or changes in the child care setting, the identification of a primary care provider, the group size in the child care setting, and family stability.4 It is difficult to control for all variables when attempting to correlate quality of attachment with child care experience. Earlier research tended to be from the perspective of the impact of maternal employment on infant attachment; however, many of these studies failed to control for family or child care setting characteristics of child care setting or family stability. 4
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Although infants of middle class families with a mother at home full time are considered to be at low risk for insecure attachment, approximately 30% of such infants are insecurely attached to their mothers.6 Infants from families of lower socioeconomic classes are at somewhat greater risk of insecure attachment, most likely related to increased life stressors in these families. 47 Although infants in child care are at greater risk of insecure attachments to their mothers (even in low-risk middle or upper socioeconomic groups), most infants (approximately 60%) in child care are securely attached to their mother.6, 12, 15, 29, 33, 34 Therefore, although infants in child care may be at greater risk of insecure attachment formation, there is not a significant difference in the numbers of securely attached infants in child care as compared to the number of securely attached infants raised at home. Are there qualities of maternal employment that affect infant attachment? Some studies have found no difference in quality of infant attachment among infants whose mothers work full-time as compared to infants whose mothers work part-time,6, 29 whereas other studies have indicated that there is a greater risk for insecure attachment in the children of full-time working mothers as compared to part-time working mothers.lO, 40 There is also disagreement regarding the risk of insecure attachment and the timing of maternal return to work. One study47 has indicated that there is a greater risk of insecure attachment among those infants younger than 12 months of age whose mothers returned to work. Another study has noted, however, that there is a greater risk of insecure attachment among those infants whose mothers returned to work when the infant was between 6 and 12 months of age, than among infants whose mothers returned to work before the infant was 6 months of age. 12 Several authorslO, 15 have described the risk of insecure attachment being greater for male infants of working mothers as compared to female infants, but others have noted no sexrelated difference. 27 For those infants in child care, the risk of insecure attachment appears to be greater for infant-father attachments than for infant-mother attachments. 10 Do specific characteristics of child care affect the quality of attachment? Child care should not alter a mother's responsivity to her infant. It is reasonable to suggest that insecure attachment formation could be reinforced by child care that frequently changes, is unpredictable or unresponsive, or in which there are multiple caretakers. Child care that is consistently provided by a primary caregiver who is responsive and predictable may enhance secure attachment to both parent and caregiver, however. Future research may better delineate specific qualities of child care associated with greater or lesser risk of insecure attachment.
CHILD CARE AND SOCIAL DEVELOPMENT The social development of a child describes the child's style of interaction with others in his or her environment. A review of the current research reveals conflicting evidence regarding the impact of child care on the social development of infants and toddlers.38 Unlike emotional or
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cognitive development, there are no assessment tools that offer objective information regarding social development. Many studies either rely on historical information regarding early child care experience when assessing the present social development of school age children, or fail to control for such factors as quality and stability of child care, child temperament, family demographic information, or family stress. In assessing social development, it is difficult to draw a line between positive and negative characteristics. When does assertiveness, usually appreciated as a positive characteristic, become aggressiveness, which is usually identified as a negative characteristic? Without uniform criteria and stated definitions, it is difficult for studies to be objective in assessing qualities such as aggression. Studies that have associated early infant child care with positive outcomes note that children who have been in child care are more socially competent. Children who have had child care experience have been noted to be more sociable, compliant, more involved in activities, and better able to self-regulate. 36 Children who have had experience in early child care have been noted to be more peer involved and less adult-oriented. This may have either positive or negative connotations, depending on the context. 37• 38 Certain studies have noted that children in child care have more positive interaction with teachers and more openly accept the approach of an adult stranger; however, other studies have noted homereared children to be more responsive to teachers and adult strangers than children in child care. 27 Children in child care have been noted to be more aggressive when compared to home-care children. 21 The tendency for children in child care to be more aggressive does not clearly appear to be age- or sex-related; however, a review of the literature suggests that this difference may be more pronounced for male children. 21 In a classic study of low-income children in high-quality child care, grade school children who attended cognitively based child care were more aggressive than children in other forms of child care. 21 Despite being rated as more aggressive (and more intelligent) by their teachers, children in cognitively based child care were as easily managed and were as well liked by their teachers as their peers. Additionally, the aggression noted in public school tended to decrease over time. Possible explanations of these seemingly conflicting positive and negative social consequences could include differences in the structure or quality of the child care program and the earlier acquisition of social maturity for those children in child care. 21. 38 Contributing factors may also include family characteristics or consistency and amount of time spent in child care. 31 The quality of the child care setting is related to social development. 24. 31 Children in child care settings that emphasize child-caregiver verbal interaction tend to be more socially competent, more considerate, more sociable, more task-oriented, and less anxious than children from a child care setting that emphasizes peer verbal interaction. Children in programs with experienced directors tend to be less aggressive, less hyperactive, and less anxious than children in programs with less experienced directors; however, they also tend to be less considerate and sociable. 31 Children in child care
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settings that are interactive and responsive tend to have well-developed problem-solving skills. 24 The longitudinal multicenter study of children in various forms of child care better delineates the relationship between specific child care and family characteristics and long-term emotional and social development.
CHILD CARE AND COGNITIVE DEVELOPMENT There have been no significant differences observed when comparing the cognitive development of children in child care to that of children in home care. It has been clear from large studies of children from disadvantaged populations placed in high-quality university-affiliated child care settings that these children benefit cognitively from time spent in child care in terms of performance on standardized testing. The persistence of improved cognitive performance depends on these disadvantaged children continuing to receive supplemental resources throughout school-aged years. 35
DETERMINANTS OF QUALITY OF CARE The quality of available child care varies. Quality may be the most important determinant of the impact of child care on individual child development. Objective characteristics have clearly been described as discrete indicators of quality of child care. 32 These variables tend to exert influence on child development by enabling positive interaction between child and adult caregivers, thus promoting cognitive and social development. A low adultto-child ratio provides increased one-to-one interaction between caregiver and child, promotion of a language-rich environment, and decreased risk of danger to the child. 5. 32, 39, 49 Small group size has been associated with good quality child care. 5 , 31, 32, 49 A smaller group allows for more interaction between children within the group and between adult caregiver and child; a larger group requires an adult caregiver to spend greater amounts of time in management and observation. Specific caregiver training in child development is associated with good quality child care. 5, 32, 49 Caregivers who have received training in normal child development are more responsive to children, have a more positive affect, and are better able to provide a socially and intellectually stimulating experience. 32 Experience in child care provision may be important, but the research has demonstrated that this does not take the place of caregiver training or education in normal child development. The most consistently agreed upon characteristics associated with good quality child care are the adult-to-child ratio, group size, and caregiver training. Other variables or characteristics related to the individual child care setting are associated with quality. The physical setting32 should be developmentally appropriate and provide enough space (both quiet and active space) for each child. Staff stability and consistency are important, partic-
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ularly in relationship to attachment and emotional development in young children. 5, 32 The curriculum should include activities that are familiar and comforting as well as activities that are challenging and stimulating for the child's cognitive development. 5 Those factors that have a direct positive affect on caregivers provide secondary benefit to the child. 32 Education of caregivers regarding normal child development is of primary benefit to the caregiver but of secondary benefit to those children in child care. Child care providers who are able to observe the impact of their developmental understanding will be reinforced to continue to approach children from a developmentally appropriate perspective. The self-esteem and competence of child care providers is reinforced by improvement of employment status and a deserved increase in wages; children benefit from a resulting decrease in staff turnover. Family environment and the relationship between the caregiver and the family are crucial to the evaluation of impact of child care on child development. 31 , 39 Families certainly differ in terms of background, beliefs, and stresses. The impact of child care on child development cannot be evaluated in isolation from these family characteristics. No child benefits from poor quality child care. There has certainly been evidence presented that poor home environments can be compensated for in part by good quality child care. 35 It has been noted, however, that low-income or disorganized families often tend to receive the lowest quality child care because of financial constraints.
WHAT IS THE GREAT DEBATE? Why is the issue of infant day care debated so heatedly? The emotions that this issue raises are personal, professional, and, at times, palpable. The extraordinary number of infants in child care is a relatively new development. Although there have been working mothers throughout history, during the past 15 years the number of working mothers has reached "epidemic" proportions. The 1987 Census data clearly indicate that most infants less than 1 year of age have a working mother; child care has now become the normative experience. The children who have had ongoing child care experience from an early age are still a relatively young population. Research describing the short-term effects of child care on development is contradictory. Because this population is young, there is little information available regarding the long-term effects of early child care. This information will be unavailable until the present preschool population reaches young adulthood. Attachment theory describes infant attachment to the parent as being the model for all future relationships. Will the population with early child care experience be less secure as adults, with a higher incidence of divorce and single parenthood and form less secure attachments to their own children? Or will children who have had early child care experience be more independent, socially competent, successful, and adaptable as young adults? Most infants in child care are securely attached to their parents.
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The long-term effects of early child care on emotional development have not yet been consistently demonstrated. Many parents are clearly ambivalent about having their children in child care. Many parents would prefer to remain at home but cannot, given the economic reality of the world today. Working mothers feel conflicting pressures and feel unsupported. Most working women were brought up by mothers who stayed at home; many women ideally want to replicate that upbringing in their own families. At the same time, families need to survive economically and be secure. There has been a lack of societal support for working mothers, contributing to both ambivalence and guilt. Industry has not globally responded to the influx of working mothers with child care needs. There has been no federal response to the economic changes that have necessitated entry of record numbers of women into the work force. Despite the emphasis on family and children in recent federal campaigns, there has been no recent significant legislation approved that offers potential solutions to families with young children. As a group, physicians have not been supportive of maternal employment; in the not-so-distant past, influential pediatricians 14 warned parents that child care was harmful and cautioned mothers against working unless absolutely necessary. Recently, pediatricians have become more supportive of the working mother. It is the role of the physician to be an advocate for both children and parents. It is not helpful for issues of guilt to be raised in a young family in which there is no economic alternative to maternal employment. It is helpful to provide advice to parents regarding quality of child care so that the child is assured of the best quality care available. Physicians need to be sensitive to the fact that all children who spend a portion of their time in alternative forms of child care continue to have parents. Working mothers do not stop being mothers solely because of their employment. Most working mothers are with their children for at least one half of their waking hours. It has been noted that there is very little difference in the amount of time spent in direct parent-child interaction when comparing families with working mothers to families who have a mother at home. Working mothers more commonly neglect housework and personal time, tend to make a second career out of mothering, and should be credited for the good job they are doing. 23
WHAT ARE THE POSSIBLE SOLUTIONS? The nation as a whole must demonstrate that children and family are a national priority. On the federal level, standards for child care must be established that regulate not only health and safety but also characteristics that determine quality of child care. Guidelines for staff-to-child ratios, the group size, and the training of caregivers and directors of child care facilities in normal child development need to be specified on a national level and enforced on a state and local level. All child care, including family day care and church-operated nonprofit day care, should be uniformly regulated. On the federal, state, and community level, adequate resources must be made available to ensure that the standards for quality care are applied
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uniformly to subsidized programs and that adequate space is available in these programs to serve all children in need of care. As a nation, the United States must provide families with options that are equally attractive. Children are our nation's most valuable resource and are the leaders of tomorrow. The United States must join all other industrialized nations and establish a national policy of protected parental leave after the birth or adoption of an infant. The establishment of increased tax credits for all families with young children would allow parents the economic flexibility to remain at home with the child or to place the child in high-quality child care. Industry must better meet the needs of working parents. Flexible time work opportunities should be available and should be compensated adequately without loss of benefits. Industry with on-site child care available has found that employee turnover is decreased and employee productivity is increased. 44 Child care should be included as an option in benefit packages. Good quality child care is not inexpensive. The salaries of child care providers should be increased in proportion to the responsibility of providing high-quality consistent care to future generations. The cost of quality care should be shared by government, industry, and parents. Parents must make choices with which they are comfortable. Parents should be encouraged to consider the option of one parent staying at home with the child for a period of time, preferably 3 to 6 months, if that is an economic possibility for the family. Parents who work because of economic necessity could utilize flexible schedules to allow family time without loss of job status or benefits.
THE ROLE OF THE PEDIATRICIAN IN CHILD CARE The need for maternal employment and alternative child care will not disappear. Because there are no established federal standards for quality child care, families currently must make well-informed and individual choices while lobbying for quality care. Pediatricians and family physicians can serve as useful resources to families making important decisions regarding child care. Pediatricians can educate parents to become informed consumers of child care by providing accurate and objective information regarding the health and developmental implications of various child care choices. 5 Parental anxiety about employment may be reduced by such information. Physicians may introduce a discussion of the advantages and disadvantages of various child care options during prenatal visits or soon after the infant's birth. In a recent survey, 75% of practicing pediatricians provide counseling to families regarding child care; 58% provide counseling about child care before or at 2 weeks of age. All pediatricians should be aware of child care issues and should provide early counseling. Pediatricians should discuss with families those important characteristics that must be evaluated when choosing a child care environment such as staff-to-child ratio, group size, caregiver training, and consistency of caregiver. The pediatrician may
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provide literature or checklists to assist families with evaluation of various settings (Table 2).3,28 Good quality child care is expensive. Physicians can assist families in understanding the cost for this care. 5 As part of regular healthcare maintenance, pediatricians can provide advice pertinent to child care settings. New immunization recommendations should rapidly become incorporated into practice. The pediatrician can provide guidance to parents regarding a sick child's participation in child care. 16, 17 Physicians may help the family with ascertaining that nutrition and health practices in the child care environment and home environment complement each other. Pediatricians should be sensitive to the range of feelings that parents may experience regarding both employment and the necessity of child care. 49 They may help families recognize the need for shared child rearing and household responsibilities as mothers assume greater wage-earning roles within families. 5, 42 Additionally, pediatricians may accommodate working parents with provision of alternative office hours for both sick and well child visits. Lastly, pediatricians may serve as consultants or advisors to child care providers in the community, with liability clearly established from the onset of the relationship. Pediatricians, both individually and through
Table 2. Parental Checklist of Questions About Child Care Is the setting safe and developmentally appropriate? Inside play areas/rest areas Outside playground and surfaces Equipment Bathrooms, food preparation areas What policies are followed with regard to health and illness? Routine screening of children and caretakers Emergency policies for illness and injury Policies for participation of ill children in child care Is there a primary caregiver for my child? How many primary caregivers will care for What is the staff to child ratio? Infants « 18 months of age) Toddler (18-36 months of age) Preschool (3-5 years of age) What is the group size?
my child? No greater than 1:4 No greater than 1:5 No greater than 1:8, depending on group size
Questions about staff: What is the training of the director and individual caregivers? What is the rate of staff turnover? How are the caregivers supervised? Questions about program: Are materials available which are developmentally appropriate? Is there an established curriculum? Are there opportunities for active and quiet times? How are children disciplined? How is feedback proVided to the parents? How are parents encouraged to participate?
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professional organizations, can and should become advocates for the availability of good quality child care for all children.
SUMMARY As increasing numbers of women have entered the labor force, increasing numbers of children, particularly infants and toddlers, have become active participants in child care. Research and opinion regarding the effect of child care on infant emotional and social development is conflicting. Most infants in child care are securely attached to their parents; however, there is an increased risk of insecure attachment in infants in child care when compared to infants in home care. Participation in child care has been associated with both positive and negative outcomes in relation to social development. High-quality child care is associated with improved child outcome. The quality of child care can be assessed by characteristics such as low child-to-staff ratio, small group size, and training of child care providers. Families are in need of a greater variety of options to meet goals of economic stability and child rearing. It is the role of the pediatrician to monitor child well-being, to objectively advise parents as consumers of child care, and to encourage the availability of high-quality care to all children.
REFERENCES 1. Ainsworth MD, Wittig BA: Attachment and exploratory behavior of one year olds in a strange situation. In Foss BM (ed): Determinants ofInfant Behavior. London, Methuen, 1969 2. Ainsworth MD, Blehar MC, Waters E, et al: Patterns of Attachment. Hillsdale, Erlbaum, 1978 3. American Academy of Pediatrics: Tips on selecting the "right" day care facility. Elk Grove Village, American Academy of Pediatrics, 1985 4. Anderson CWo Attachment in daily separations: Reconceptualizing day care and maternal employment issues. Child Dev 51:242-245, 1980 5. Aronson S: Child care and the pediatrician. Pediatr Rev 10:277-286, 1989 6. Barglow P, Vaughn BE, Molitor N: Effects of maternal absence due to employment on the quality of infant-mother attachment in a low-risk sample. Child Dev 58:945-954, 1987 7. Bartlett AV, Reves RR, Pickering LK: Rotavirus in infant-toddler day care centers: Epidemiology relevant to disease control strategies. J Pediatr 113:435-441, 1988 8. Belsky J, Steinberg L: The effects of day care: A critical review. Child Dev 49:924-949, 1978 9. Belsky J: Infant-parent attachment and day care: In defense of the strange situation. In Lande JS, Scarr S, Gunzenhauser N (eds): Caring for Children: Challenge to America. Hillsdale, Erlbaum Associates, 1989 10. Belsky J, Rovine MJ: Nonmaternal care in the first year of life and the security of infantparent attachment. Journal of Child Development 59:157-167, 1988 11. Belsky J: Infant day care: A cause for concern? Zero to Three 6:1-9, 1986 12. Benn RK: Factors promoting secure attachment relationships between employed mothers and their sons. Child Dev 57:1224-1231, 1986 13. Bowlby J: Developmental psychiatry comes of age. Am J Psychiatry 145:1-10, 1988
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14. Brazelton TB: Issues for working parents. Am J Orthopsychiatry 56:14-25, 1986 15. Chase-Lansdale PL, Owen MT: Maternal employment in a family context: Effects on infant-mother and infant-father attachments. Child Dev 58:1505-1512, 1987 16. Committee on Early Childhood, Adoption and Dependent Care, American Academy of Pediatrics: Health in day care: A manual for health professionals. Elk Grove Village, American Academy of Pediatrics, 1987 17. Donowitz LG: Infection Control in the Child Care Center and Preschool. Baltimore, Williams & Wilkins, 1991, p 55 18. Gamble T, Zigler E: Effects of infant day care: Another look at the evidence. Am J Orthopsychiatry 56:26--42, 1986 19. Green M: Help parents make the right child-care choice. Contemporary Pediatrics 3:4049,1986 20. Greenspan S, Greenspan NT: First Feelings: Milestones in the Emotional Development of Your Baby and Child. New York, Viking Penguin, Inc, 1985 21. Haskins R: Public school aggression among children with varying day-care experience. Child Dev 56:689-703, 1985 22. Hatch 0: The federal role in child care. In Lande JS, Scarr S, Gunzenhauser N (eds): Caring for Children: Challenge to America. Hillsdale, Erlbaum Associates, 1989, p 125 23. Heins M: Who will speak for working mothers? Am J Dis Child 144:755-756, 1990 24. Holloway SD, Reichhrt-Erickson M: The relationship of day care quality to children's free-play behavior and social problem-solving skills. Early Childhood Research Quarterly 3:39-53, 1988 25. Martinez S: Child care and federal policy. In Lande JS, Scarr S, Gunzenhauser N (eds): Caring for Children: Challenge to America. Hillsdale, Erlbaum Associates, 1989, pIli 26. McCartney K, Galanopoulos A: Child care and attachment: A new frontier the second time around. Am J Orthopsychiatry 58:16-24, 1988 27. Melhuish EC: Socio-emotional behavior at 18 months as a function of daycare experience, temperament, and gender. Infant Mental Health Journal 8:364-373, 1987 28. National Association for the Education of Young Children: How to choose a good early childhood program, 1983 29. Owen MT, Easterbrooks MA, Chase-Lansdale L, et al: The relation between maternal employment status and the stability of attachments to mother and to father. Child Dev 55:1894-1901, 1984 30. Phillips D, McCartney K, Scarr S, et al: Selective review of infant day care research: A cause for concern! Zero to Three 7:18-25, 1987 31. Phillips D, McCartney K, Scarr S: Child-care quality and children's social development. Developmental Psychology 4:537-543, 1987 32. Phillips D: Quality in child care: What does research tell us? Washington, DC, National Association for the Education of Young Children, 1986 33. Portnoy FC, Simmons CH: Day care and attachment. Child Dev 49:239-242, 1978 34. Ragozin AS: Attachment behavior of day-care children: Naturalistic and laboratory observations. Child Dev 51:409-415, 1980 35. Ramey CT, Haskins R: The modification of intelligence through early experience. Intelligence 5:5-19, 1981 36. Rubenstein JL, Howes C: Caregiving and infant behavior in day care and in homes. Developmental Psychology 15:1-24, 1979 37. Rubenstein JL, Howes C, Boyle P: A two-year follow-up of infants in community-based day care. J Child Psychol Psychiatry 22:209-218, 1981 38. Rutter M: Social-emotional consequences of day care for preschool children. Am J Orthopsychiatry 51:4-28, 1981 39. Scarr S, Phillips D, McCartney J: Facts, fantasies and the future of child care in the United States. Psychological Science 1:1, 1990 40. Schw&rtz P: Length of day-care attendance and attachment behavior in eighteen-month old infants. Child Dev 54:1073-1078, 1983 41. St. Gemme JW, Pickering LK, Granoff DM, et al: Day-care diseases: Does day care make respiratory illness worse? Contemporary Pediatrics 3:22-42, 1986 42. Szanton ES: National center notes. Zero to Three 2:27, 1987
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43. Takala AK, Eskola J, Palmgran J, et al: Risk factors of invasive Haemophilus inJluenzae type b disease among children in Finland. J Pediatrics 115:694-701, 1989 44. The Child-Care Dilemma: Time June 22, 1987 45. US Department of Commerce Bureau of the Census: Who's minding the kids? Series P70, No 20, 1986-1987 46. US Department of Commerce Bureau of the Census: Fertility of American women. Series P-20, No 436, 1988 47. Vaughn BE, Cove FL, Egeland B: The relationship between out-of-home care and the quality of infant-mother attachment in an economically disadvantaged population. Child Dev 51:1203-1214, 1980 48. Wasserman RC, Dameron DO, Brozicevic MM, et al: Injury hazards in home day care. J Pediatrics 114:591-593, 1989 49. Zigler E, Hall NW: Day care and its effect on children: An overview for pediatric health professionals. J Dev Behav Pediatr 9:38-46, 1988
Address reprint requests to Susan A. Dilks, MD Department of Pediatrics Kluge Children's Rehabilitation Center Children's Medical Center University of Virginia 2270 Ivy Road Charlottesville, VA 22901
0031-3955/91 $0.00
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Developmental Aspects of Child Care
Susan A. Dilks, MD*
THE NEED FOR CHILD CARE Child care is now the normative experience for most American infants and preschoolers. In 1987, the most recent year for which census data are available, 52.1 million children under the age of 15 years were living in the United States. Fifty-nine percent of these children (30.6 million) had mothers who were employed, and an additional 3% (1.4 million) had mothers who were enrolled in school. 45 Therefore, 62% of all American children under the age of 15 had mothers who were employed or in school. American women are employed for the same reasons that American men are employed-economic necessity and personal choice. Maternal employment is not a luxury for the vast majority of American families. The decline of the real median family income between 1973 and the mid-1980s necessitated women's entry into the labor force. 44 The fastest growing subgroup of working mothers are those from twoparent households with infants less than 1 year of age; most of these women are employed full time. 5 • 46 In 1988, 51% of women aged 18 to 44 with newborn children less than 1 year of age were in the active labor force, an increase from 38% in 1980 and 31% in 1976. 46 Nearly 3.7 million infants less than 12 months of age in the United States have mothers working outside the home. In the United States there have been absolute increases of both the proportion of children who have employed mothers and the actual number of children in child care. 45, 46 The impact of maternal employment and the need for adequate child care is widely debated. The question is no longer simply whether child care is good or bad for children. What are the current issues? Many families perceive a nonavailability of adequate options to meet the goals of both family rearing and economic stability. The economic climate has necessitated the availability of child care as an option for working parents. Federal *Assistant Professor of Pediatrics, Division of Developmental Pediatrics, Kluge Children's Rehabilitation Center, Children's Medical Center, University of Virginia, Charlottesville, Virginia
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standards for the licensing of child care facilities are lacking, although standards of good quality child care have been well defined by research. 32 • 39 The availability of and the access to quality care is inadequate for the numbers of children needing care. The impact of child care continues to be examined with regard to the emotional, social, and cognitive development of children. Knowledge regarding quality of child care and its developmental effect must be valued by society and government, with appropriate legislative action taken. Such knowledge must be incorporated into all child care settings, ensuring that care of good quality is available to all children. The focus of this article is a discussion of the effect of early child care on the emotional, social, and cognitive development of the young child. High-quality child care is associated with better child outcome; various characteristics of child care as related to quality of care are presented. Lastly, the role of the pediatrician in ensuring quality care to all young children and their families is discussed.
THE SPECTRUM OF CHILD CARE SETTINGS Child care is defined as care provided by an individual outside the nuclear family or in a setting separate from the child's home. Historically, families have creatively sought multiple solutions to the child care dilemma. Parents may work alternate shifts so that the child receives care from each parent in the home setting. One or both parents may work out of the home, combining employment with child care. The child may receive care in the home from either a relative or a nonrelative such as a nanny. The child may receive care in the home of a babysitter, either individually or in a small day-care home with one to three additional children. Care in a family day-care home may be licensed or unlicensed and may provide care for anywhere from two to more than ten children. Center-based child care may be proprietary or nonprofit. Proprietary child care includes independent centers and nationally based chains (e.g., Kindercare, La Petite Academy). Nonprofit child care may be either government sponsored (e.g., Head Start) or run by a church or an independent nonprofit group. Families may use one or multiple forms of alternative child care. Families often have strong preferences for choosing one form of child care over another. Their preferences are individual to the family, their child, and their situation. There are advantages and disadvantages to each form of child care (Table 1). Licensing, regulation, and concerns regarding health and child development vary with the type of child care. The families of children receiving child care differ in terms of family structure (single-parent, dual-parent, extended family), economic status, and coexisting stressors such as a mother's attitude toward both employment and child care. All families and home environments are not the same. Similarly, some child care environments are better for certain children than others.
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Table 1. Advantages and Disadvantages of Various Types of Child Care ADVANTAGES
DISADVANTAGES
Care in home by relative
Familiar environment Familiar (family) care provider Usually inexpensive
Stress in family relationships Lack of availability of extended family
Care in home by sitter
Familiar environment No transit time
Cost (usually expensive) Difficulty in locating an excellent caregiver No back-up if caretaker absent Lack of supervision of care provider
Family day care
Availability Cost (usually inexpensive) Flexibility in scheduling
Majority unlicensed, unregulated No back-up if caretaker absent Lack of supervision of care provider
Center-based child care
Cost (usually inexpensive) Reliable Well equipped with materials Peer availability Supervision of care provider
Individual needs of child may not be met Lack of flexibility in hours No arrangements for ill child Exposure to illness
CHILD CARE REGULATION AND ACCREDITATION The United States has no federal standards for the regulation of child care. The regulation of child care has been allocated to the individual states, resulting in specific standards and degrees of regulation that vary from state to state. Most states with regulation of standards monitor physical setting and health and safety factors, with limited or no standards related to quality of child care. Those states that monitor safety do not do so in a uniform manner; model health and safety standards jointly developed by the American Academy of Pediatrics and the American Public Health Association will be released in the summer of 1991. The National Daycare Study of 1977 noted that enhanced child development was correlated with low staff-to-child ratios in child care settings. The Federal Interagency Day Care Regulations were proposed that same year. Those regulations mandated a minimal staff-to-child ratio of one to three during infancy, one to four in toddlerhood, and one to five in a family day care setting. Additionally, the regulations proposed established group sizes and specialized training for care providers. Training commensurate with their responsibilities was required for caregivers and directors of child care facilities. Standards for program content and curricula were proposed; however, these regulations were suspended by Congress in 1980. 25 Following this, Public Law 98-473, The Model Child Care Standards Act, mandated that states determine specific child-to-staff ratio recommendations. Currently, 16% of all states have no established staff-to-child ratio for infants, and 62% have no set limitations for group size. The Model
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Child Care Standards Act addresses the training of care providers; however, the only specified training is for the recognition and prevention of child abuse among children in child care settings. Unlike most industrialized countries in the world, the United States has no system of paid parental leave at the federal level. 39 Past public policy has been reviewed by Martinez,25 and the proposed federal role in child care has been outlined by Senator Orrin Hatch22 in articles published after a national interagency conference on the future of child care. No significant action on comprehensive child care legislation has yet been taken on a federal level. ATTACHMENT IN NORMAL EMOTIONAL DEVELOPMENT The emotional, social, and cognitive development of a child follows an anticipated sequence of milestones. An understanding of normal child development is necessary before conjecture regarding the implications of child care for early development. The effect of child care on the development of an individual child depends on interrelated characteristics of the child, the child care setting, and the family. The needs of an infant differ greatly from the needs of a preschooler. The important qualities required of child care vary with the age and temperament of a particular child. Young infants have intense physical needs. They depend on others for basic care, including feeding, dressing, hygiene, and mobility. A great amount of time, both at home and in child care, is spent meeting these needs. In addition to major developmental changes in motor and cognitive areas, the infant makes dramatic changes emotionally during the first 2 years of life. Infant attachment is central to an infant's early emotional development. Attachment is the propensity of one individual to form a strong emotional bond with another individual. The infant becomes attached to a caregiver who provides comfort and consistency in addition to meeting varied physical needs. The quality of the attachment (secure or insecure) depends on the responsiveness of the caregiver in a consistent, timely, caring, and predictable manner and the infant's ability to perceive this responsiveness. Attachment theory maintains that the secure attachment of an infant to a primary caretaker (presumably the mother) is crucial not only for infant emotional development but also for determining the pattern of future relationships for that individual. 10, 13 An infant forms a secure attachment to a caregiver who has consistently responded to communication in a predictable manner. Securely attached infants use the caregiver as a secure base for exploration of the world around them. An infant may form an insecure attachment to a caregiver who has responded inconsistently, unpredictably, or in a detached or indifferent manner. Without security or predictability, infant exploration may be frightening and the development of future relationships may be anxiety-provoking. Normal emotional development is a spectrum of overlapping stages. 20 Emotional development begins with the attainment of self-regulation (the ability to calm oneself) during the first 3 months and progresses to
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"reciprocal wooing" during the second half of the first year of life. The infant learns much about and falls in love with the human world. By the beginning of the second year, children have reached the stage of communicative intent; by 2 years of age, children are capable of expressing needs and desires both verbally and nonverbally.20 Smooth transitions between these stages depend on the consistency and responsiveness of both primary and auxiliary caregivers. Preschool children increase their independence in communication, feeding, dreSSing, hygiene (toileting), and individual play. Caretakers supervise, encourage, and provide the appropriate setting and materials to achieve autonomy in these activities. Emotionally, preschoolers are beginning to create unique ideas. The attainment of this milestone can best be judged by the dramatic increase in language and the appearance of pretend play.20 Preschoolers need a stable setting with developmentally appropriate materials, which is both comforting and enriching in addition to providing a supportive, affective environment.
CHILD CARE AND EMOTIONAL DEVELOPMENT The relationship between child care and infant attachment has been well reviewed in the recent literature. 8. 11. 18.30.49 There is perhaps no topic more greatly debated in the fields of infant development and psychology than the effect of child care on infant attachment and emotional development. Various studies have arrived at different conclusions. Various reviews have differed in the interpretation of the data. Does child care during the first year of life decrease the likelihood of attachment to the mother? Attachment theory states that infants may form multiple attachments. A single primary attachment is formed with the mother. Several aspects of caretaking or mothering may be provided by other individuals if the relationship between infant and other adult caretaker is stable and of high quality. Although an infant may form an attachment to an alternative care provider, there is no evidence that child care can replace the primary attachment between infant and parent. 8. 18. 26 Does child care in the first year of life increase the probability of an insecure attachment to the mother? The quality of attachment depends on maternal sensitivity and responsiveness to infant cues, the stability of caregiving, and the child's ability to predict the availability and responsiveness of the caregiver. Other factors that may affect infant emotional development include physical qualities of the home and child care center, the number and responsiveness of nonprimary caregivers, the frequency of staff changes or changes in the child care setting, the identification of a primary care provider, the group size in the child care setting, and family stability.4 It is difficult to control for all variables when attempting to correlate quality of attachment with child care experience. Earlier research tended to be from the perspective of the impact of maternal employment on infant attachment; however, many of these studies failed to control for family or child care setting characteristics of child care setting or family stability. 4
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Although infants of middle class families with a mother at home full time are considered to be at low risk for insecure attachment, approximately 30% of such infants are insecurely attached to their mothers.6 Infants from families of lower socioeconomic classes are at somewhat greater risk of insecure attachment, most likely related to increased life stressors in these families. 47 Although infants in child care are at greater risk of insecure attachments to their mothers (even in low-risk middle or upper socioeconomic groups), most infants (approximately 60%) in child care are securely attached to their mother.6, 12, 15, 29, 33, 34 Therefore, although infants in child care may be at greater risk of insecure attachment formation, there is not a significant difference in the numbers of securely attached infants in child care as compared to the number of securely attached infants raised at home. Are there qualities of maternal employment that affect infant attachment? Some studies have found no difference in quality of infant attachment among infants whose mothers work full-time as compared to infants whose mothers work part-time,6, 29 whereas other studies have indicated that there is a greater risk for insecure attachment in the children of full-time working mothers as compared to part-time working mothers.lO, 40 There is also disagreement regarding the risk of insecure attachment and the timing of maternal return to work. One study47 has indicated that there is a greater risk of insecure attachment among those infants younger than 12 months of age whose mothers returned to work. Another study has noted, however, that there is a greater risk of insecure attachment among those infants whose mothers returned to work when the infant was between 6 and 12 months of age, than among infants whose mothers returned to work before the infant was 6 months of age. 12 Several authorslO, 15 have described the risk of insecure attachment being greater for male infants of working mothers as compared to female infants, but others have noted no sexrelated difference. 27 For those infants in child care, the risk of insecure attachment appears to be greater for infant-father attachments than for infant-mother attachments. 10 Do specific characteristics of child care affect the quality of attachment? Child care should not alter a mother's responsivity to her infant. It is reasonable to suggest that insecure attachment formation could be reinforced by child care that frequently changes, is unpredictable or unresponsive, or in which there are multiple caretakers. Child care that is consistently provided by a primary caregiver who is responsive and predictable may enhance secure attachment to both parent and caregiver, however. Future research may better delineate specific qualities of child care associated with greater or lesser risk of insecure attachment.
CHILD CARE AND SOCIAL DEVELOPMENT The social development of a child describes the child's style of interaction with others in his or her environment. A review of the current research reveals conflicting evidence regarding the impact of child care on the social development of infants and toddlers.38 Unlike emotional or
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cognitive development, there are no assessment tools that offer objective information regarding social development. Many studies either rely on historical information regarding early child care experience when assessing the present social development of school age children, or fail to control for such factors as quality and stability of child care, child temperament, family demographic information, or family stress. In assessing social development, it is difficult to draw a line between positive and negative characteristics. When does assertiveness, usually appreciated as a positive characteristic, become aggressiveness, which is usually identified as a negative characteristic? Without uniform criteria and stated definitions, it is difficult for studies to be objective in assessing qualities such as aggression. Studies that have associated early infant child care with positive outcomes note that children who have been in child care are more socially competent. Children who have had child care experience have been noted to be more sociable, compliant, more involved in activities, and better able to self-regulate. 36 Children who have had experience in early child care have been noted to be more peer involved and less adult-oriented. This may have either positive or negative connotations, depending on the context. 37• 38 Certain studies have noted that children in child care have more positive interaction with teachers and more openly accept the approach of an adult stranger; however, other studies have noted homereared children to be more responsive to teachers and adult strangers than children in child care. 27 Children in child care have been noted to be more aggressive when compared to home-care children. 21 The tendency for children in child care to be more aggressive does not clearly appear to be age- or sex-related; however, a review of the literature suggests that this difference may be more pronounced for male children. 21 In a classic study of low-income children in high-quality child care, grade school children who attended cognitively based child care were more aggressive than children in other forms of child care. 21 Despite being rated as more aggressive (and more intelligent) by their teachers, children in cognitively based child care were as easily managed and were as well liked by their teachers as their peers. Additionally, the aggression noted in public school tended to decrease over time. Possible explanations of these seemingly conflicting positive and negative social consequences could include differences in the structure or quality of the child care program and the earlier acquisition of social maturity for those children in child care. 21. 38 Contributing factors may also include family characteristics or consistency and amount of time spent in child care. 31 The quality of the child care setting is related to social development. 24. 31 Children in child care settings that emphasize child-caregiver verbal interaction tend to be more socially competent, more considerate, more sociable, more task-oriented, and less anxious than children from a child care setting that emphasizes peer verbal interaction. Children in programs with experienced directors tend to be less aggressive, less hyperactive, and less anxious than children in programs with less experienced directors; however, they also tend to be less considerate and sociable. 31 Children in child care
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settings that are interactive and responsive tend to have well-developed problem-solving skills. 24 The longitudinal multicenter study of children in various forms of child care better delineates the relationship between specific child care and family characteristics and long-term emotional and social development.
CHILD CARE AND COGNITIVE DEVELOPMENT There have been no significant differences observed when comparing the cognitive development of children in child care to that of children in home care. It has been clear from large studies of children from disadvantaged populations placed in high-quality university-affiliated child care settings that these children benefit cognitively from time spent in child care in terms of performance on standardized testing. The persistence of improved cognitive performance depends on these disadvantaged children continuing to receive supplemental resources throughout school-aged years. 35
DETERMINANTS OF QUALITY OF CARE The quality of available child care varies. Quality may be the most important determinant of the impact of child care on individual child development. Objective characteristics have clearly been described as discrete indicators of quality of child care. 32 These variables tend to exert influence on child development by enabling positive interaction between child and adult caregivers, thus promoting cognitive and social development. A low adultto-child ratio provides increased one-to-one interaction between caregiver and child, promotion of a language-rich environment, and decreased risk of danger to the child. 5. 32, 39, 49 Small group size has been associated with good quality child care. 5 , 31, 32, 49 A smaller group allows for more interaction between children within the group and between adult caregiver and child; a larger group requires an adult caregiver to spend greater amounts of time in management and observation. Specific caregiver training in child development is associated with good quality child care. 5, 32, 49 Caregivers who have received training in normal child development are more responsive to children, have a more positive affect, and are better able to provide a socially and intellectually stimulating experience. 32 Experience in child care provision may be important, but the research has demonstrated that this does not take the place of caregiver training or education in normal child development. The most consistently agreed upon characteristics associated with good quality child care are the adult-to-child ratio, group size, and caregiver training. Other variables or characteristics related to the individual child care setting are associated with quality. The physical setting32 should be developmentally appropriate and provide enough space (both quiet and active space) for each child. Staff stability and consistency are important, partic-
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ularly in relationship to attachment and emotional development in young children. 5, 32 The curriculum should include activities that are familiar and comforting as well as activities that are challenging and stimulating for the child's cognitive development. 5 Those factors that have a direct positive affect on caregivers provide secondary benefit to the child. 32 Education of caregivers regarding normal child development is of primary benefit to the caregiver but of secondary benefit to those children in child care. Child care providers who are able to observe the impact of their developmental understanding will be reinforced to continue to approach children from a developmentally appropriate perspective. The self-esteem and competence of child care providers is reinforced by improvement of employment status and a deserved increase in wages; children benefit from a resulting decrease in staff turnover. Family environment and the relationship between the caregiver and the family are crucial to the evaluation of impact of child care on child development. 31 , 39 Families certainly differ in terms of background, beliefs, and stresses. The impact of child care on child development cannot be evaluated in isolation from these family characteristics. No child benefits from poor quality child care. There has certainly been evidence presented that poor home environments can be compensated for in part by good quality child care. 35 It has been noted, however, that low-income or disorganized families often tend to receive the lowest quality child care because of financial constraints.
WHAT IS THE GREAT DEBATE? Why is the issue of infant day care debated so heatedly? The emotions that this issue raises are personal, professional, and, at times, palpable. The extraordinary number of infants in child care is a relatively new development. Although there have been working mothers throughout history, during the past 15 years the number of working mothers has reached "epidemic" proportions. The 1987 Census data clearly indicate that most infants less than 1 year of age have a working mother; child care has now become the normative experience. The children who have had ongoing child care experience from an early age are still a relatively young population. Research describing the short-term effects of child care on development is contradictory. Because this population is young, there is little information available regarding the long-term effects of early child care. This information will be unavailable until the present preschool population reaches young adulthood. Attachment theory describes infant attachment to the parent as being the model for all future relationships. Will the population with early child care experience be less secure as adults, with a higher incidence of divorce and single parenthood and form less secure attachments to their own children? Or will children who have had early child care experience be more independent, socially competent, successful, and adaptable as young adults? Most infants in child care are securely attached to their parents.
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The long-term effects of early child care on emotional development have not yet been consistently demonstrated. Many parents are clearly ambivalent about having their children in child care. Many parents would prefer to remain at home but cannot, given the economic reality of the world today. Working mothers feel conflicting pressures and feel unsupported. Most working women were brought up by mothers who stayed at home; many women ideally want to replicate that upbringing in their own families. At the same time, families need to survive economically and be secure. There has been a lack of societal support for working mothers, contributing to both ambivalence and guilt. Industry has not globally responded to the influx of working mothers with child care needs. There has been no federal response to the economic changes that have necessitated entry of record numbers of women into the work force. Despite the emphasis on family and children in recent federal campaigns, there has been no recent significant legislation approved that offers potential solutions to families with young children. As a group, physicians have not been supportive of maternal employment; in the not-so-distant past, influential pediatricians 14 warned parents that child care was harmful and cautioned mothers against working unless absolutely necessary. Recently, pediatricians have become more supportive of the working mother. It is the role of the physician to be an advocate for both children and parents. It is not helpful for issues of guilt to be raised in a young family in which there is no economic alternative to maternal employment. It is helpful to provide advice to parents regarding quality of child care so that the child is assured of the best quality care available. Physicians need to be sensitive to the fact that all children who spend a portion of their time in alternative forms of child care continue to have parents. Working mothers do not stop being mothers solely because of their employment. Most working mothers are with their children for at least one half of their waking hours. It has been noted that there is very little difference in the amount of time spent in direct parent-child interaction when comparing families with working mothers to families who have a mother at home. Working mothers more commonly neglect housework and personal time, tend to make a second career out of mothering, and should be credited for the good job they are doing. 23
WHAT ARE THE POSSIBLE SOLUTIONS? The nation as a whole must demonstrate that children and family are a national priority. On the federal level, standards for child care must be established that regulate not only health and safety but also characteristics that determine quality of child care. Guidelines for staff-to-child ratios, the group size, and the training of caregivers and directors of child care facilities in normal child development need to be specified on a national level and enforced on a state and local level. All child care, including family day care and church-operated nonprofit day care, should be uniformly regulated. On the federal, state, and community level, adequate resources must be made available to ensure that the standards for quality care are applied
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uniformly to subsidized programs and that adequate space is available in these programs to serve all children in need of care. As a nation, the United States must provide families with options that are equally attractive. Children are our nation's most valuable resource and are the leaders of tomorrow. The United States must join all other industrialized nations and establish a national policy of protected parental leave after the birth or adoption of an infant. The establishment of increased tax credits for all families with young children would allow parents the economic flexibility to remain at home with the child or to place the child in high-quality child care. Industry must better meet the needs of working parents. Flexible time work opportunities should be available and should be compensated adequately without loss of benefits. Industry with on-site child care available has found that employee turnover is decreased and employee productivity is increased. 44 Child care should be included as an option in benefit packages. Good quality child care is not inexpensive. The salaries of child care providers should be increased in proportion to the responsibility of providing high-quality consistent care to future generations. The cost of quality care should be shared by government, industry, and parents. Parents must make choices with which they are comfortable. Parents should be encouraged to consider the option of one parent staying at home with the child for a period of time, preferably 3 to 6 months, if that is an economic possibility for the family. Parents who work because of economic necessity could utilize flexible schedules to allow family time without loss of job status or benefits.
THE ROLE OF THE PEDIATRICIAN IN CHILD CARE The need for maternal employment and alternative child care will not disappear. Because there are no established federal standards for quality child care, families currently must make well-informed and individual choices while lobbying for quality care. Pediatricians and family physicians can serve as useful resources to families making important decisions regarding child care. Pediatricians can educate parents to become informed consumers of child care by providing accurate and objective information regarding the health and developmental implications of various child care choices. 5 Parental anxiety about employment may be reduced by such information. Physicians may introduce a discussion of the advantages and disadvantages of various child care options during prenatal visits or soon after the infant's birth. In a recent survey, 75% of practicing pediatricians provide counseling to families regarding child care; 58% provide counseling about child care before or at 2 weeks of age. All pediatricians should be aware of child care issues and should provide early counseling. Pediatricians should discuss with families those important characteristics that must be evaluated when choosing a child care environment such as staff-to-child ratio, group size, caregiver training, and consistency of caregiver. The pediatrician may
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provide literature or checklists to assist families with evaluation of various settings (Table 2).3,28 Good quality child care is expensive. Physicians can assist families in understanding the cost for this care. 5 As part of regular healthcare maintenance, pediatricians can provide advice pertinent to child care settings. New immunization recommendations should rapidly become incorporated into practice. The pediatrician can provide guidance to parents regarding a sick child's participation in child care. 16, 17 Physicians may help the family with ascertaining that nutrition and health practices in the child care environment and home environment complement each other. Pediatricians should be sensitive to the range of feelings that parents may experience regarding both employment and the necessity of child care. 49 They may help families recognize the need for shared child rearing and household responsibilities as mothers assume greater wage-earning roles within families. 5, 42 Additionally, pediatricians may accommodate working parents with provision of alternative office hours for both sick and well child visits. Lastly, pediatricians may serve as consultants or advisors to child care providers in the community, with liability clearly established from the onset of the relationship. Pediatricians, both individually and through
Table 2. Parental Checklist of Questions About Child Care Is the setting safe and developmentally appropriate? Inside play areas/rest areas Outside playground and surfaces Equipment Bathrooms, food preparation areas What policies are followed with regard to health and illness? Routine screening of children and caretakers Emergency policies for illness and injury Policies for participation of ill children in child care Is there a primary caregiver for my child? How many primary caregivers will care for What is the staff to child ratio? Infants « 18 months of age) Toddler (18-36 months of age) Preschool (3-5 years of age) What is the group size?
my child? No greater than 1:4 No greater than 1:5 No greater than 1:8, depending on group size
Questions about staff: What is the training of the director and individual caregivers? What is the rate of staff turnover? How are the caregivers supervised? Questions about program: Are materials available which are developmentally appropriate? Is there an established curriculum? Are there opportunities for active and quiet times? How are children disciplined? How is feedback proVided to the parents? How are parents encouraged to participate?
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professional organizations, can and should become advocates for the availability of good quality child care for all children.
SUMMARY As increasing numbers of women have entered the labor force, increasing numbers of children, particularly infants and toddlers, have become active participants in child care. Research and opinion regarding the effect of child care on infant emotional and social development is conflicting. Most infants in child care are securely attached to their parents; however, there is an increased risk of insecure attachment in infants in child care when compared to infants in home care. Participation in child care has been associated with both positive and negative outcomes in relation to social development. High-quality child care is associated with improved child outcome. The quality of child care can be assessed by characteristics such as low child-to-staff ratio, small group size, and training of child care providers. Families are in need of a greater variety of options to meet goals of economic stability and child rearing. It is the role of the pediatrician to monitor child well-being, to objectively advise parents as consumers of child care, and to encourage the availability of high-quality care to all children.
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Address reprint requests to Susan A. Dilks, MD Department of Pediatrics Kluge Children's Rehabilitation Center Children's Medical Center University of Virginia 2270 Ivy Road Charlottesville, VA 22901