Child Care
Margot Kaplan-Sanoff
Wilhelmina Hernandez
I. Description. For a majority of today’s young children, spending time in the care of someone other than a parent is now part of their daily life experience. Second only to the immediate family, child care has become the context in which early development unfolds. Coupled with the growing body of research suggesting that early childhood experiences play a significant role in shaping future life outcomes, child care serves as an important arena for addressing the diverse needs of children and parents and for promulgating public policy and advocacy initiatives. Given the diverse work hours and shift patterns of working parents, child care is not just “day” care, and it is not just “care.” Quality child care provides nurturance and support for enhancing child development and learning, in addition to offering services for families, including parent support and education, poverty reduction through vouchers allowing families to return to school or work, and respite care for child welfare cases. While state child care regulations often mandate minimal involvement from pediatrics, the opportunity for powerful and meaningful collaboration between child care and pediatric care is enormous.
A. Epidemiology.
More than 20 million families in the United States have either a single working parent or two working parents and, as a result, rely on some form of nonparental child care; 11.3 million children younger than 5 years need care while their parents are at work. Yet, child care costs continue to rise and, for many families, child care has become their second largest expense, surpassed only by housing.
Sixty-one percent of children younger than 6 years have parents in the labor force, and 73% of these children are cared for by someone other than a parent.
Children are enrolled in child care very early in life; the average age of entry into care is 3.31 years for an average of 30 hours a week of care and 1.7 million infants younger than 1 years are currently in child care.
B. Types of care. The term child care has come to represent a wide variety of options from a quality developmental program for children to a basic support service for working parents. Within this spectrum, child care programs can be for-profit or nonprofit, faith-based or nondenominational, company-based or employer-supported/affiliated, private or public. Most child care options fall into the following major categories:
1. Home-based care. This category includes care either in the home of the child or in the home of the caregiver, where the care is provided by relatives or nonrelatives.
a. In-home care. This type of care involves a caregiver, such as a relative, babysitter, or nanny, coming to or living in the child’s home. Such an arrangement can be costly but does offer children the familiarity of their home environment, as well as added convenience and flexibility for parents, especially those working long hours or variable workday schedules. Approximately 4% of children younger than 5 years are currently in-home child care while their parents work.
b. Family child care. Family child care is care provided in someone else’s home. According to the National Association for Family Child Care (NAFCC), there are approximately 1 million family child care providers providing care for 4 million children in the United States. For regulation purposes, family-based care is subcategorized into small (less than seven children) and large (seven or more children). Many parents are attracted to the home-like atmosphere and the potential for close bonding with a single child care provider that family-based care offers. Family-based care may offer greater flexibility in hours and be less expensive than center-based care but can also be less reliable when the caregiver becomes ill or goes on vacation. Provider training and credentials/certification, as well as program quality, is regulated by individual states and thus tends to be far more variable than center-based care. While most family child care homes are licensed by the state, there exists an “underground” network of unlicensed family child care homes that do not comply with any state health, safety, or educational standards.
Approximately 7% of children younger than 5 years are currently in family child care while their parents work.
2. Center-based care. Center-based child care refers to care provided in a nonresidential facility. For regulation purposes, it also includes residential-based, family child care facilities that serve more than 12 children. Center-based programs include nursery/preschools, child care centers, prekindergarten programs, church-based centers, and Early Head Start/Head Start programs. While most programs are open year-round and are licensed by the state, center-based child care offers less flexible hours, is more expensive than family child care, and may provide less opportunity for close bonding with caregivers because of large class sizes, changing classrooms, and high staff turnover. On the positive side, centers often attract high-quality, well-trained teachers who provide a stimulating curriculum and learning environment for young children, allowing children the opportunity to interact with a greater number of peers. Finally, center-based programs have many adults and parents who can observe the program and individual interactions between children and between children and staff, offering parents additional sets of eyes on their child’s safety and well-being. A majority (60%) of the 3- to 5-year-olds in child care are enrolled in some form of center-based care.
3. School-aged care. Included in this category are before- and after-school programs and vacation programs. School-aged child care settings include both school-based facilities and other community locations. They offer an alternative to unsupervised after-school time and provide children with the opportunity to interact with peers, but they introduce added cost, their structure can be quite variable, and not all programs are regulated.
C. Ratios, licensure, and accreditation
1. Ratios. Although not a guarantee of quality, lower child to staff ratios, as well as total group size, have been deemed to be very important indicators in the setting of national standards for quality child care. Research indicates that child-provider ratio is the most sensitive indicator of quality care. (See Table 92-1 for child-provider ratios.)
2. Licensure. Regulated by state agencies, licensure of child care programs and certification of child care providers can vary significantly from state to state. Criteria for licensure typically include standards relating to child to staff ratios, staff qualifications and training, supervision and discipline, administration of medication, emergency planning, and hand-washing and diapering procedures. In some states, certain types of care (such as faith-based, school-aged, or summer programs) may be exempt.
3. Accreditation. Some child care programs voluntarily undergo a process of accreditation to demonstrate their commitment to and delivery of quality child care above and beyond what is required for licensure. Accreditation offers parents and caregivers a useful way to assess quality, and the process of attaining and maintaining accreditation may actually improve quality of care and increase professionalism. There are 7170 programs serving 667,728 children currently accredited by the National Association for Early Childhood Education. Once approved, accreditation is granted for 5 years. Organizations such as the NAFCC have also developed quality standards for family care accreditation.
II. Role of the clinician.
A. Parental support and guidance. Although 79% of pediatric clinicians have reported that they want to be involved in child care decisions made by the families in their care, only 32%
actually offered parents resources and information on the subject. Pediatric clinicians should be willing and able to discuss a family’s child care options and arrangements, address any concerns that might arise, and offer guidance on how to find safe, affordable, child care that is developmentally, educationally, and nutritionally sound. Table 92-2 offers a list of potential factors that parents should consider when deciding on the best child care option for their family. The following is a sample list of some of the key questions that pediatric clinicians can discuss with parents to guide them in their search for quality child care:
Table 92-1. Recommended child to adult ratio and group size for large family child home care and centers
Age
Child to staff ratio
Maximum group size
Birth-12 mo
3:1
6
13-30 mo
4:1
8
31-35 mo
5:1
10
3 years olds
7:1
14
4-5 years olds
8:1
16
6-8 years olds
10:1
20
9-12 years olds
12:1
24
American Public Health Association and American Academy of Pediatrics. Caring for Our Children: Guidelines for Out-of-Home Child Care Programs, a Collaborative Project. Copyright 2002 by the American Public Health Association, the American Academy of Pediatrics, and The National Resource Center for Health and Safety in Child Care.
Note: Group size refers to number of children in a room or other well-defined space.
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