Is day care good enough?

Every morning, Kathy Duncan drops off her baby and toddler at day care. Like any parent, she worries.

“At work, I’m surrounded by pictures of my children,” says Duncan, a purchasing officer for the town of Carrboro. “There’s always guilt, and I wish I had more time with them. But I have to put some things in perspective. We’ve even thought about my husband quitting his job and staying home. But we both need the income and personal development that we get from work.”

Day care or preschool is fast becoming a necessity for parents of young children-62 percent of all women with children under age six work at least part time. Studies from Carolina researchers bring mixed news for those parents. One suggests that if child care is high quality, kids won’t suffer. But another shows that high-quality care is hard to find. Not to mention expensive.

The first of these studies may ease some worries. Led by Martha Cox, a senior investigator at Carolina’s Frank Porter Graham Child Development Center (FPG), researchers observed kids at home and in day care from birth to three years. They found that child care is not as closely related to children’s language skills and attachment to their mothers as income, education of parents, and home environment.

Child care did have a small, but consistent, effect. When the care was high quality, children’s language and cognitive skills were slightly higher. The caregivers who had the most positive effect on children’s skills were those who talked to the children, asked them questions, and responded to the children’s vocalizations.

Researchers also observed how child care affected the relationship between mother and child. The child’s attachment to the mother-how much the child used the mother as a source of security-was no weaker for children in child care than for those who stayed at home.

But children who spent more hours in the care of someone other than their mother did have slightly less warm and responsive interactions with their mothers, and these mothers showed slightly less sensitive play with their children. “Even so, these children were just as securely attached to their mothers,” Cox says.

These findings suggest that if parents use high-quality day care, they don’t need to worry about their children. But there is one catch. A study conducted by Ellen Peisner-Feinberg, investigator at FPG, and other Carolina researchers, showed that the average quality of day-care centers was only mediocre. Of 400 centers observed in North Carolina, Connecticut, California, and Colorado, just 14 percent were rated high quality. The rest were mediocre to poor, with 12 percent earning a poor rating.

In centers rated poor, children’s needs for health and safety frequently weren’t met, and often caregivers didn’t encourage learning or show warmth or support. Mediocre classrooms were more likely to meet children’s routine care needs. But they provided only limited opportunities for learning, individual attention, or warm relationships.

“Mediocre just isn’t good enough,” Peisner-Feinberg says. “In those early years, children really are learning and developing, and they’re setting a stage for how they’re going to do in school.”

The results were more disturbing when the quality of care for infants and toddlers was measured separately. For these younger children, 40 percent of the centers gave poor care.

“Babies in poor-quality centers are more vulnerable to illness because basic sanitary conditions are not met for diapering and feeding, and they aren’t likely to have warm relationships with their caregivers. There may be too many children in the classroom for that,” Peisner-Feinberg says.

More poor-quality centers were found in North Carolina than in the other three states. That makes sense, since of the states studied, North Carolina had the least stringent child-care standards and the poorest economic climate. North Carolina allows centers to have one adult supervising as many as 10 two-year-olds, while the National Association for the Education of Young Children recommends one adult for every six two-year-olds.

“I don’t want results like this to scare parents and make them feel that they need to pull their children out of child-care centers. There aren’t a lot of alternatives,” Peisner-Feinberg says. Instead, she’d like the findings to spur policy makers to enact more stringent licensing regulations for day cares and allot more funds to improving care.

The study found that the better day cares had higher staff-to-child ratios, paid teachers higher wages, hired teachers with more training, and had less staff turnover. But all of that takes money. “Where are all these funds going to come from?” Peisner-Feinberg says. “Parents can’t bear the cost of that completely.”

Center-based child care is costly, Peisner-Feinberg says. In the centers studied, even mediocre care cost an average of $95 per week per child. That figure would be much higher if workers were paid competitive wages. On average, child-care workers in the study, who were mostly female, earned about $5,200 less each year than they could in other female-dominated jobs. Making up these discrepancies will take a mix of public and private money, Peisner-Feinberg says.

One such effort to improve child care has been effective, says Donna Bryant, another researcher at FPG. Bryant is leading an evaluation of Smart Start, North Carolina’s effort to ensure that all children start school healthy and ready to learn.

“Smart Start is hard to evaluate because it’s not a program you go enroll in,” Bryant says. “It’s a collaborative process that channels money to counties to use as they see fit.” Counties might use funds for beefing up health-care services, providing day-care subsidies for families, or funding training programs for preschool teachers. For example, one county had not a single practicing pediatrician, so they used part of their money to have one visit each week.

About 40 percent of Smart Start dollars are currently used to improve child care, Bryant says. After visiting more than 360 child-care centers and interviewing families, Bryant’s team found that the money is doing some good. Between 1994 and 1996, child care in the first 12 counties to receive Smart Start money improved significantly. Overall, evaluation scores rose about 7 percent over the two years. The number of centers meeting or exceeding the score of “good” rose from 14 percent to 25 percent.

Bryant believes that the improvements are due to Smart Start because the day cares got better in proportion to the amount of Smart Start money that was spent on child care as opposed to other services. “It looks like this broad-based approach-letting counties decide-is working,” she says.

All North Carolina counties have some Smart Start dollars. Forty-five have funds to actually use for services, while 55 have only planning money, Bryant says. Those counties should get service money soon.

Until such programs improve the quality of care for all families, the best thing parents can do is ask lots of questions and make the most of any chance they have to observe their day-care center. Peisner-Feinberg says, “If you want to get a real sense of what the day looks like for your child, don’t watch how the staff interact with your child, watch how they interact with the other kids.” Staff may act differently when a child’s parent is around.

That’s what Duncan has done. She feels confident about the day care she uses, but it took some legwork to find it. After visiting several other centers, Duncan tried one out for a year, in part because it was convenient to her workplace. But she left it after she saw practices she didn’t like-children weren’t given much structured instruction, staff were sometimes rude to children, things often weren’t clean.

Duncan says, “I wanted a center that was more than just a child warehouse-a place where you drop them off to be put into a big group and watched.”

Finding Their Way in a Visual World

We live in a visual world. We can tell how people are feeling by the expressions on their faces. With a glance at our surroundings, we can see if we’re safe or in danger.

Taking our sight for granted comes naturally to those of us who can see. But what about those who are born without this innate ability? How do they learn to find their way in a visual world?

Deborah Hatton, an investigator at UNC-CH’s Frank Porter Graham Child Development Center who studies the development of children with visual impairments, says, “If you’re not exposed to children who are visually impaired, it doesn’t occur to you that development would be all that different for children who can’t see.”

But a recent study led by Hatton found that the amount of a vision a child has does make a difference, even when the child has another disability in addition to the visual impairment.

Hatton conducted a comprehensive, long-term study to determine the level of vision impairment that really begins to affect a child’s development. Because there are so few children with disabilities in any one area, Hatton had to do some clever maneuvering to acquire the data she needed. Fortunately, she could draw on data she had collected while working with the Governor Morehead Preschool, which serves North Carolina children who are blind. She further tapped into a long-term study already under way at the University of Northern Colorado. Over time, she acquired multiple assessments of 186 children with visual impairments between the ages of 12 and 73 months. Of these children, 40 percent also had mental retardation or developmental delay. The children were measured in terms of several skills-personal-social, adaptive, motor, communication, and cognitive. Their levels of vision were also measured.

The study found that development for children whose vision was worse than 20/800 (they have to be 20 feet away to see what a normal eye can see from 800 feet) was very different from children with higher vision levels. Hatton discovered that amount of vision had a similar affect on children with and without mental retardation or developmental delay, showing that both visual acuity and mental retardation make unique contributions to development.

Motor and personal-social skills appeared to be most affected by amount of vision. Children without vision are probably not as aware of their environment as other children. Hatton says, “If a child can’t see interesting things, there is not much motivation to move or reach toward them.”

And, since they can’t establish eye contact, these children often don’t bond as well with their parents, causing them to feel less secure in exploring their environment. This is important because when children with sight first start to investigate their surroundings, they tend to move out a little, look back at their mother for approval, and then continue moving. “Children who cannot see,” Hatton says, “may lack that kind of security and relationship with the parent.”

Another critical factor that affects motor skills as well as personal-social skills is the inability for children without sight to imitate those around them. Children learn by watching others, so those who cannot see are definitely at a disadvantage from the start. “This is why,” Hatton says, “it’s important to have intervention early on with babies who have disabilities, especially blindness.”

As they get older and begin to associate with peers who can see, they can’t hang around a group of children, watching for an opportunity to join the action, Hatton says. They have to ask, “What are you doing and can I play?” As a result, Hatton says, “They just don’t jive with what’s happening with children who have vision.”

Considering the obstacles children with visual impairments must overcome, Hatton says, “It is amazing that some children do so well developmentally without sight.”

In the right environment, however, children without sight can and do learn to get along in a visual world. An insightful teacher, for example, can make all the difference. Let’s say there is a group of children playing with blocks in one corner of the classroom, and not far off a child without vision trying to work his way into the group. The teacher could take the boy by the hand and say, “Stephen, they are building blocks, why don’t you come on over,” and then find someone in the group to get Stephen started. Unless the teacher makes a conscious effort to help children interact, it probably won’t happen, Hatton says.

The next step for Hatton is to design some intervention studies to test possible methods of enhancing development. First, Hatton wants to talk to teachers and parents of the children, as well as adults who have been blind from birth, to find out what they think helps. As Hatton says, “The bottom line is to try to figure out what’s affecting development, so that we can decide what we can do to make it more optimal.”

Open Classrooms, Open Minds

Not so long ago, it was thought that a child born with a disability should be placed in a special school or even an institution. Blind children in North Carolina were automatically sent to the Governor Morehead’s School for the Blind. Children with other disabilities, such as mental retardation, were often labeled unfit for society and locked up in an institution.

In the 1970s, however, the federal government declared that children with disabilities have a right to be educated in the least restrictive environment-generally considered to be the child’s home school.

Researchers today believe that inclusion-the integration of children with disabilities into regular classrooms-benefits not only the children with disabilities but also those without. According to Sam Odom, professor of special education, inclusion is gaining popularity across the country. “It follows a broader national trend of deciding to become more accepting of children and other individuals with disabilities,” he says.

Led by Odom, a team of Carolina researchers is part of a five-year, five-university research consortium called the Early Childhood Research Institute on Inclusion (ECRII) whose goals are to examine inclusive settings, determine barriers and policies affecting inclusion, and develop strategies for addressing those barriers. After four years of research, Odom and his colleagues believe children with disabilities get some benefits from an inclusive setting that they may not get from nonintegrated special-education settings.

“Inclusive settings allow kids with disabilities to engage in social-cognitive tasks with other kids who are doing things at their typical age level,” Odom says. “In special-education classrooms, it’s more likely that the peers with whom they would be playing would have developmental delays, so there would be no real indication of where they should be developmentally.”

For example, preschoolers with disabilities have a harder time following routines. But by watching their classmates, children with disabilities can learn when it is time to move from one activity to another.

Unfortunately, an inclusive setting does not always guarantee a better learning environment. “A lot of it has to do with the quality of the early-childhood setting,” Odom says. “Many families may not have access to high-quality child-care facilities.”

That’s because there are many barriers such as social and public policies, economic difficulties, and cultural issues, that stand in the way of school systems being able to implement inclusive programs. Public policy, for example, may prevent the use of special-education funds for services involving children who do not have disabilities, making it difficult to integrate classrooms. And even if policy allows integration, a barrier may occur at the classroom level when there is a large number of children with disabilities enrolled in one class and only one teacher to plan and carry out individual learning opportunities.

For the final year of the project, Odom says, “We’ll be developing products teachers could use in their classrooms that would support inclusion, and we’ll be testing how useful those products are-things like curriculum guides and strategies for supporting community integration for families.”

Even with limited resources, Odom says, teachers can help their students who have disabilities acquire the skills they need to move on to the next level. Teachers can use “embedded individual learning opportunities” in activities they plan for a whole class, so that a single child may get needed practice in a specific area. For instance, a child may not easily pick up on the concept of sharing, so while setting up an art activity, the teacher could place only one tube of paste at each table of three or four students. This way, when the child needs to use the paste and another student has it, he will have to use his verbal skills to get it. Likewise, when another student asks for the paste, he will have to learn to give it up-to share.

Despite the obstacles, researchers feel the onus of providing inclusive environments for children with disabilities is worth the effort. There’s even evidence that children who do not have disabilities gain a better appreciation of what it’s like to have one if they are placed in preschool settings with children with disabilities. “They may well be more accepting of differences with children who have disabilities,” Odom says. “And this acceptance can extend beyond the preschool to their attitudes at home and later on after they grow older.”

For Children at Risk, Doors Can Open

Don’t expect to catch Mary Linker behind a desk. As a supervisor of family-and-child social work in the Chatham County Health Department, she’s lucky if she has time to slip into her office to retrieve messages. She’s more likely to be driving her station wagon around the county to visit a family, teach a parenting class, or train members of “The Coalition for Family Peace” to counsel families facing domestic violence.

Linker, who has master’s degrees in social work and public health from Carolina, directs programs for children who are “at risk” because of poverty, developmental abnormalities, or medical conditions such as low birth weight. One of the biggest problems she sees is isolation-parents who have no one they can go to for help or advice.

So Linker gets involved with her clients. She attends their weddings, takes their emergency phone calls. For these parents, she’s a source of information rather than someone who comes to check up on them.

“One of our goals is to help teach people how to reach out and find what they and their children need-how to pick up the phone and arrange transportation to get your child to the doctor, for instance,” Linker says. Chatham County has the beginnings of a public transportation system, but many parents might not be aware of it. She also helps parents get information about education and job opportunities, parenting-education classes, and subsidy programs such as food stamps.

Day to day, Linker advises parents and children who face problems that many of us only read about-poor health care, violence, isolation. At Carolina, researchers are studying how to combat some of those problems, and maybe make Linker’s job a little easier.

Lack of preventive health care hampers many children. Almost 223,000 North Carolina children have no health insurance, and as a result some of them might never see a doctor outside of an emergency room. There are other places uninsured patients can go, such as the health department or primary-care clinics, Linker says. But many families don’t know about them.

Even if people know where to get preventive care, other hassles can interfere. Immunizations, for example, are free at health departments, but if a parent has to take a child to the doctor’s office for regular care, then to the health department for a free vaccine, that means scheduling another visit and taking more time off work, says Gary Freed, associate professor of pediatrics. And when kids are shuttled from one place to another for care, something might get overlooked.

In 1994, North Carolina started a “universal purchase” program, in which the government buys vaccines to be distributed for free in doctors’ offices. This program was designed to avoid the “fragmentation of care” that occurs when families must visit several different providers. But Freed doubted whether the program would do much good.

His biggest concern was the potential for “cost shifting.” Under universal purchase, not only do doctors give out vaccines for free, but the administrative fee they usually charge for vaccines is limited. To make up for the lost revenue, doctors might charge more for other services.

What also worried Freed was the “shocking” fact that several other states had used universal purchase for years, but none had ever evaluated its success. So he proposed that he find out if universal purchase was really improving immunization rates for kids in North Carolina. He says, “I have to take my hat off to the state. It was very courageous for them to fund this study. Other states had spent millions of dollars on universal purchase, without once evaluating whether the money was really doing any good. But less than two years into their program, North Carolina decided to see whether or not they were really making a difference.

“I went into it thinking that universal purchase wouldn’t have a significant impact,” Freed says. “But I was proved wrong.”

His study of more than 2,700 children under age two found that since universal purchase began, the number of children receiving recommended immunizations increased from 86 percent in 1996 to 89 percent in 1997. And the biggest increases were for children in “at-risk” groups-those without insurance, those enrolled in Medicaid, and children whose insurance doesn’t cover vaccines.

The study also found that cost shifting was “minimal,” Freed says, and that the number of immunizations given to children in health departments was cut in half.

“More and more children were able to get their care at a doctor’s office,” Freed says. “That’s good news for the state.”

Though immunization rates look good, child abuse cases are on the rise. They have been since 1984, says Marcia Herman-Giddens, adjunct professor of maternal and child health and medical director of the N.C. Child Fatality Prevention team. There were 45 deaths due to child abuse in 1996, up from an average of 22 in the 10 years before that.

Stress, caused by poverty, single parenthood, and other factors, is one contributor to this increase, Herman-Giddens says. Linker adds that marital disputes can also aggravate parents’ irritation with children. And often parents never learned from their own families how to let their anger boil down before taking it out on someone. “When children see violence at home, it’s ingrained in them,” Linker says. They think, `that’s what a loving relationship looks like-dad hitting mom.’”

Such stresses weigh more heavily when a family has nowhere to turn for help. A continuing 20-year study led by Desmond Runyan, professor of social medicine, found that the more sources of support a family had, the less likely children were to have trouble with emotional, behavioral, or developmental problems. This was true even for children who were considered at risk because of poverty or prior reports of abuse.

Three support mechanisms-examples of what the researchers call “social capital”-had direct correlation with kids doing well. One was perception of personal support-if a single mother, for example, felt there was someone whom she could ask to give her a ride to the doctor. Other important support mechanisms were neighborhood ties and church membership. Church attendance is important, Runyan says, because it’s one of the few activities that involves both kids and parents and allows children to form relationships with adults outside their family.

We can increase social capital by building smaller apartment complexes and schools so that families don’t feel anonymous. Runyan says, “In a smaller school, teachers know the kids, so they can cheer them on. And someone will tell parents when their kids step out of line.”

Supporting kids and families who have no one else isn’t easy. In the programs Linker supervises, five social workers and one public-health nurse serve 350 families. But at least someone knows those children are out there.

“Part of the reason more children are referred for help these days is that there’s a better understanding of what puts children at risk,” Linker says.

To help more children get the attention they need, Linker puts much of her effort into planning and starting new programs. That takes time. Her work day technically runs from 8 to 5, but she rarely breaks for lunch and usually works late. You won’t hear her complain, though.

“I really love my job,” she says. “I love working with folks to help them create a better life for themselves.”

What’s wrong with this picture?

A child sits on a crowded bus, swinging her legs as she watches the people. Bored, she glances up at the ads posted on the bus walls. Most don’t concern her, but one catches her eye. A little girl about her age, maybe eight or nine, clutches a teddy bear. But the girl in the picture is in a provocative sundress and she’s painted in makeup. She’s posing for a perfume ad. The caption reads: “Because innocence is sexier than you think.”

What is the little girl supposed to think when she sees this ad? Unfortunately, such ads are not uncommon. They show up in magazines, TV commercials, billboards-even on the bus. According to the Committee on Child Abuse & Neglect, part of the North Carolina Pediatric Society, these ads may not be considered pornography, but they are still a type of abuse. To bring attention to this issue, the committee has launched a statewide publicity campaign called “Let Kids be Kids: Taking a Stand Against the Sexual Exploitation of Kids in Advertising.”

Marcia Herman-Giddens, adjunct professor of maternal and child health and a member of the committee, says she and her colleagues began the project because they were concerned about the messages these ads were giving. She says, “Nobody else really seemed to be taking notice. There was some concern over the Calvin Klein ads, but not much else.”

Researchers worry that when children are exposed to images of age-inappropriate sexualization, their development could be affected. V. Denise Everett, a pediatrician who directs the child sexual abuse team at Wake Medical Center and chairs the committee, says, “When children are exploited in advertising, kids, as well as adults, may begin to think and act as if children are sexual objects.”

Everett feels there is a strong connection between child sexual abuse and sexually suggestive advertising involving children. She says, “When you start to blur the boundaries between children and adults, it becomes confusing as to what is and what is not appropriate behavior. Children become vulnerable.”

In addition to motivating people to take a stand against the sexual use of children in advertising, another goal of the campaign is to provide teachers and parents with resources for discussing these ads with children. Campaign members have assembled brochures that have been distributed to pediatricians across North Carolina, produced a videotape, and created an informational web page.

Inspired by North Carolina’s efforts, the American Academy of Pediatrics has begun a national effort to increase the awareness of the sexual exploitation of children, Everett says. In addition, the American Medical Association has recently endorsed advertising campaigns that depict youth in positive, healthy settings.