Today's practicing pediatrician is likely to encounter an enormous variety of parenting styles and a diverse use of child-care arrangements. Therefore, this article will discuss both parenting and day care, broadly and empirically, in light of the realities encountered in pediatrie practice. "Day care" is defined here as an arrangement by which parents delegate the care of a child to a person outside the immediate family for more than 10 hours a week. Ten hours a week is selected as a boundary because the most recent national child-care survey has demonstrated that this figure represents a point that differentiates quite casual baby-sitting from more substantial use of child care.1
"Parenting" is defined here as the process of socializing a child into the dominant values of the parents' culture while supporting the child's physical development. An essential task of parenting is the reconciliation of parent (adult) interests with child interests.2 Contemporary parenting is experienced by many parents, especially mothers, as ultimately rewarding but demanding, isolating work fraught with tension and uncertainty,3"9 American parenting is a process characterized, among other things, by stress. Sources of stress on American parenting range from poverty, discrimination, handicapping conditions or chronic illness of a family member, geographic mobility, increasing industrialization of rural areas, and rising divorce rates and numbers of single-parent families to a fragmenting of more monochromatic, predictable cultural values into ever-changing swirls of "right" and "wrong" ways to raise children, frightening (and apparently uncontrollable) developmental outcomes among adolescents, and a new diversity of acceptable (but sometimes conflicting) roles for women.10,16 Nearly all observers agree that widespread stress derives from the increasing economic, social, and philosophic isolation of parents, especially mothers, into "lonely nuclear families" within a society whose economic and occupational system denigrates the value of child care.7,17 The clinician is likely to see these stresses reflected in the telephone calls and patient visits prompted by parent anxiety and in the demand for physician involvement in family problems.
Seen in the context of the economic, social, and psychologic forces that stress parenting, the relationship between day care and parenting is a simple one. Properly selected and used without a negative emotional experience, day care helps to relieve stress. In some cases, contemporary parents are still able to rely on extended- family members for child care.1 But in an age when the extended family is no longer accessible to increasing numbers of young families because of divergence in child-rearing philosophies, geographic mobility, or employment patterns, day care assumes one function traditionally carried out by the extended family - help with the children.
WHO USES DAY CARE AND WHY?
Over 14 million children under the age of 14 are in some form of day-care arrangement for more than 10 hours a week.1 When the National Child Care Consumer Survey asked parents their reasons for using child care, a diversity of responses was obtained (Table 1).* Maternal employment, promotion of child development, and relief from full-time responsibility for child care motivated arrangements for day care.
MATERNAL EMPLOYMENT AND PARENTING
An ever-increasing number of mothers now combine employment with parenting: 47.4 per cent of married or once married mothers, 44.8 per cent of married mothers with husbands present, and 64.7 per cent of divorced and separated mothers with children under 18 now work outside the home. Thirty-four per cent of employed married mothers work part-time; of the full-time workers, many are employed for less than 50 weeks a year. About 16 per cent of divorced and separated mothers work part-time.
Relief from economic stresses impeding parenting motivates many mothers seeking employment. That need is most obvious in the almost four million female-headed families now in the labor force. Economic need also prompts mothers with husbands into the labor force. However, employed mothers are compensated at low rates for their labors outside the home. The National Child Care Consumer Survey found that approximately 85 per cent of the mothers earning income were paid less than $10,000 a year, and 45 per cent earned less than $5,000 a year. Despite discrimination and denial of equal pay for equal work, the earnings of employed wives accounted on the average for onefourth of family income in 1974 - from about 12 per cent, when the wife works fulltime for six months or less or works parttime, to 38 per cent, when the wife works full-time year-round.18
REASONS FOR USING CHILD CARE
Given the oppressive economic conditions prompting millions of mothers to seek employment and the meager salaries earned once they are in the paid labor force, we might assume that most mothers are employed against their wishes to be at home with their children. In that case, maternal employment per se could be construed as a stress on parenting. This may be so for mothers in particularly unrewarding jobs who must come home to face all the household maintenance chores by themselves. For the low-income working mother, however, this country's contemporary version of a "mother's allowance" - the welfare system - is so unpalatable that the stresses incurred in pursuing even low-paying, tedious jobs are apparently (and understandably) preferred to the enormous stresses entailed in dependence on welfare.
Moreover, the evidence does not support the assumption that most working mothers are dissatisfied with their employment status. When the National Child Care Consumer Survey asked employed mothers their reasons for working, 60.1 per cent said that it was necessary for economic survival. However, 49.5 per cent responded, "I like what I do on my job"; 42.4 per cent responded, "It gives me a feeling of independence and selfsatisfaction"; and 29.9 per cent said, "To have contact with other adults and their ideas."
Entry into the paid labor force - with its opportunities for productivity, greater economic independence, and rewarding social contact - apparently bolsters self-esteem among mothers whose job experience is not demeaning or onerous. In an earlier, exhaustive review of the literature on the effects of maternal employment, Howell19-21 concluded:
Studies of both employed and nonemployed mothers permit a single broad generalization: women who enjoy their work also enjoy the role of parent, and mothers who are dissatisfied with their work are more Ukely to be unhappy, unsure or dissatisfied with parenting.19
The National Child Care Consumer Survey found that nearly two-thirds of all households with children under 14 that were using day care for more than 10 hours a week had mothers who were not employed outside the home. As Table 1 demonstrates, substantial percentages of mothers use child care to "go out" and to "get away from children for a while sometimes." Additionally, the desire to promote greater sociability and independence in the child motivates many mothers to use child care.
HOUSEHOLDS USING MAIN METHODS OF CARE 10 OR MORE HOURS PER WEEK
Whether to produce the income needed for healthy child rearing, to enhance self-esteem, to seek some respite from unremitting availability to children, or to offer children the opportunity for learning how to separate from and return to parents, the use of day care in the United States can be construed as a support to parenting. The decision about the use of day care is one of the many involving the accommodation between adult interests and child interests that characterizes parenting.
KINDS OF CHILD-CARE ARRANGEMENTS MADE
The great majority of American parents use home-based child care (Table 2). Either someone comes into their home or the child goes to another home. As we can see by the preponderance of care by relatives in Table 2, the extended family still functions for a great many parents. The National Child Care Consumer Survey estimates that 3,342,300 households using 10 or more hours of child care per week depend for their main method of care on relatives. The remaining households using substantial day care - projected at 4,113,500 by the National Child Care Consumer Survey - use nonrelatives, primarily at home or in another's home. Those figures are tot households - they are different when the numbers of children in various daycare arrangements are considered. Thus, 1.8 million children are looked after by a caregiver in their own homes for more than 10 hours a week, 2.3 million children are cared for in the home of the caregiver, 1.8 million children are in nursery school and day-care centers, 1 00,000 children are in parent cooperative programs, and 300,000 children are in before- or afterschool day-care programs.
Why do parents choose the specific daycare arrangements they do? The parents surveyed in the consumer study ranked caregiver reliability or training and caregiver responsiveness as the most important factors. This probably represents the parents' need to find someone who can be trusted to meet basic child needs,22,23 as well as parent needs for promptness and continuity, freedom from anxiety about the child's safety and wellbeing, and reciprocity in communications about the child. Trust development is a significant consideration when care by someone other than relatives or family friends is used.24
For some parents, it may be easier to develop trust in caregivers who come from and operate within envionments similar to their own; thus the appeal of home-based or family day care.25 For other parents, knowledge of specialized training and supervision of caregivers in day-care centers and nursery schools may inspire confidence. Still others may see a greater opportunity for trust to develop when parents "help themselves" and avoid reliance on strangers or professionals by developing their own cooperative forms of child care.21
Another important factor is cost. About one-fourth of the users of principal methods of child care in the National Child Care Consumer Survey had considered methods other than their current day-care arrangement - principally nursery schools, day-care centers, and care by someone coming into the child's home - and had rejected that type of care as too expensive.
The task, then, for many parents attempting to make child-care arrangements is to find someone whom they can trust and whose child-care fees are affordable. For mobile parents, particularly those with limited incomes, this task can be extremely difficult.
ATTITUDES OF PARENTS TOWARD CHILD CARE
The use of child care, even for a few hours a week, may be accompanied by parental guilt and worry. About 35 per cent of the consumer survey respondents, for example, agreed with the statement "I sometimes feel guilty when I have to leave my child with someone else." One-third also agreed with the statement "I would worry about my child being treated badly while someone else is taking care of him/her." Low-income minority parents were especially likely to agree - and agree strongly - with this statement. Not all attitudes surveyed were negative toward child care. Fiftyone per cent of the parents surveyed, for example, agreed that "taking children out of the home to someone else is good for children, since it makes them more independent." And it is important to understand the guilt associated with day-care usage in relation to the general phenomenon of parental guilt, a pervasive emotion experienced by parents in many aspects of child rearing.26
THE ACTUAL IMPACT OF DAY CARE ON THE CHILD
Are the guilty feelings of American parents justified? What happens to young children who spend considerable amounts of time in the care of persons other than their parents?
Arguments against day care are made by citing the risk of impairment in the parentchild bond, the child's emotional or intellectual development, and even the child's health.27 Some have warned that the extremely apathetic and deprived behavior characteristic of "hospitalism," found in institutionalized children, might occur among children in day-care centers; others have worried that the dramatic effects of hospitalization in young children, described as a well-defined pattern of initial frightened protest and then withdrawal into passive rejection of human interaction,28,30 would be found in children using day care.
Since both federal funding and research interest in day care were revived about 10 years ago amid much public anxiety, it seems reasonable to assume that the prevalence of hospitalism in day care would have been reported by now. There have been no such reports. This, of course, is not surprising, since the experience of daily separation from parents into a familiar day-care environment where the children are encouraged to play, explore, and enjoy themselves is quite different from (1) loss of the parent through death or complete separation induced by family crisis, with subsequent total immersion into an institution, or from (2) forced separation of the parent and child, frequently against the parent's wishes, and the child's subsequent experience of abandonment in a hospital environment replete with painful encounters and overwhelming evidence of bodily damage among other children.
Given that there is no evidence of widespread, severe psychologic damage in children using day care, what can be said about the more subtle effects of day care on young children?
Recent reviews of carefully designed studies focused on the effects of formalized day care support the following conclusion: The use of day care does not alter the paramount influence of the family and home environment on children except in situations where the extreme family stress of poverty, oppressive living conditions, malnutrition, or child abuse has limited or interfered with what might have been the child's normal development. In these situations, the provision of carefully designed, formalized day-care programs aids the child's development while the day care is being offered and particularly when parents are involved.
That conclusion can be based on several statements about formalized day care's effect on children:
1. Formalized day-care programs do not impair the child's attachment to his mother. The classic study in this area by Caldwell et al. in 1970(31) reported that 30-month-old infants who had been in a day-care center since six months of age showed very little difference in attachment behaviors from a control group of infants who had been cared for exclusively at home by their mothers. Since then, Kagan32 has reported from extensive studies of 29month-old children enrolled in a day-care center from three and a half to five and a half months of age, carefully matched with control children, that day-care and home-control children were equally likely to approach their mothers in moments of uncertainty, boredom, or fatigue and that the day-care child did not prefer the day-care teacher to the mother. In the same article, Kagan reviewed other studies assessing day-care children's attachment to their mothers and concluded that there is no evidence that high-quality day care, which has an adequate ratio of adults to children and consistent caregivers, dilutes the child's attachment at all. Bronfenbrenner, Belsky, and Steinberg,33 after conducting an equally exhaustive review of the recent literature, reached the same conclusion. Kagan32 in fact reports a study in which kibbutz-reared children, who from infancy had spent over 20 hours daily away from their mothers in the care of a metapelet, were more likely at 12 to 15 months to approach their mother than their metapelet when a female stranger was in the room with both the mother and the metapelet. Kagan concludes that "the effects of the home appear to have a salience that is not easily altered by the group care context. The family has a mysterious power, which is perhaps one reason why it has been the basic and most stable social unit in this and other societies for so long a time."
Research into the impact of day care has been conducted from a defensive posture. No studies have been undertaken, for example, to determine whether day-care use improves parent-child attachment.
2. Formalized day-care programs do not impair the young child's ability to cope with unfamiliar social situations. Most of the relevant studies have involved separating the child from the mother in an unfamiliar setting, sometimes with the additional stress of introducing a stranger into this setting. Several investigators33-36 point out that since most of these studies examine children's responses to separation in laboratory settings, which in themselves are anxiety-producing environments for mothers and children, they could be expected to intensify anxious reactions. Carefully controlled studies of separation protest in laboratory situations do not show differences between children using substantial amounts of formalized day care and children spending their full days at home with their mothers.
One study by Blehar37 did report more anxious separation reactions in day-care children. However, this study's findings have been challenged on méthodologie grounds. Specifically, Kagan32 points out that the day-care children had been in day care for only four to five months and so were possibly still adjusting. Also, 80 per cent of the day-care children were firstborn, in contrast to only 60 per cent of home controls. Finally, it is noteworthy that in this study, which assessed separation behavior in 20 children aged 39 months and 20 children aged 30 months, the older children were more likely to cry than the younger ones.
3. Formalized day care has mildly benefi ficial effects on cognitive development for children whose intellectual development may have been impaired by severe environmental stress.38 For other children, formalized day care has a "neutral effect." It neither retards nor accelerates cognitive development.32,33
It must be noted also that results have been obtained primarily with day care that is of high quality, with an adequate staff-child ratio such as that recommended by the American Academy of Pediatrics. One study,36 of children in day-care centers where the ratio of children to staff was more than 12 to 1, described developmental retardation in the day-care children. Although no systematic studies have been completed of day-care conditions nationally, there has been substantial documentation40·42 of conditions in some day-care settings that threaten healthy development (and sometimes border on abuse). A broad review of the literature relevant to child health and day-care by Pizzo and Aronson43 concluded that while there is evidence that good day care improves the overall health of children, there are also some programs - even federally funded day-care programs - in which children are at risk of injury, infectious disease, and impaired health. These substandard conditions exist for reasons ranging from ineffective licensing and federal oversight to inadequate funding and public disinterest or even antipathy towards day-care programs. The exacerbated guilt, anger, and sense of impotence among parents who feel trapped in substandard day-care arrangements have been described in interviews with parents using several different kinds of child care.41,44
HOW CAN THE CLINICIAN HELP?
The physician to whom parents turn for advice about the use of day care can help make sure that the use of day care is a supportive experience for parents and children by (1) helping parents decide on the day-care arrangement(s) best suited to themselves and their children, (2) helping anxious or guilty parents understand and deal with their painful emotions, and (3) supporting public efforts to ensure adequate supply of good caregivers and quality day-care environments that meet diverse family needs. Physicians can obtain copies of guides to day-care selection45-49 and distribute them to parents or inform parents where they can obtain these pamphlets for themselves. Encouraging parents to interview several caregivers and examine several daycare environments using these guides will help particularly the young, inexperienced parent maintain the self-confidence necessary to question apparently experienced caregivers and inspect homes and centers for safety features, warmth of relationships, preventive health measures, etc. Physicians who maintain records on patients that note use of day care can perform a simple but very useful service for parents (when clients agree) by referring the parent who is trying to evaluate day-care arrangements to other parents who have used similar arrangements. Even a bulletin board set up in a physician's office or clinic can allow parents to inquire if other parents would inform them of their experiences with a day-care center or with using a baby-sitter. This is particularly helpful for highly mobile parents.
Physicians might also explore whether there are child-care information and referral centers in their communities, such as the ones in Boston-Cambridge, San Francisco, and New York City. These centers maintain lists of all kinds of day-care settings and caregivers and will help parents identify, evaluate, and choose the day-care arrangement that meets their needs. Friendly support at the time of selection can contribute not only to a choice well suited to the child's temperament and developmental stage but also to the prevention of overanxiety, particularly among inexperienced parents.
When parents who are guilty about using day care confide their concerns, some physicians, particularly if they themselves are ambivalent about day care, may experience an impulse to flee. Even the ambivalent physician, however, can refer parents to the studies mentioned in previous paragraphs or to books that are helpful to guilt-ridden parents, usually mothers,50 or to experienced day-care providers who can help the parents determine whether their concerns are reasonable. The physician who feels fairly comfortable that his own biases will not intensify parental guilt can help the parents discover the source of the concern, determine whether there is a reasonable basis for it, and develop some options. A useful approach might be to help the parents assess their current level of trust in the daycare provider and the potential for the growth of trust and to determine what obstructs the development of trust.
Finally, the physician can contribute to a reduction of parent stress by lending his voice to advocacy for good state and federal standards for day care, effective regulating mechanisms, and adequate funding of daycare programs so that parents can exercise a real choice among different kinds of day-care arrangements. Consultation services to daycare programs can also be proffered. The Infant and Preschool Committee of the American Academy of Pediatrics has developed statements and publications about day care.
The concerned physician can make significant contributions to the enhancement of parenting by awareness and acceptance of the relationship between parenting and day care.
1. Rodes, T., and Moore, J. National Childcare Consumer Survey, Volumes MIL Washington, D.C.: Office of Child Development, 1975.
2. Markun, P. M. (ed.) Parenting. Washington, O.G.: Association for Childhood Education International, 1973.
3. Barber, V., and Skaggs, M. M. The Mother Person. Indianapolis: Bobbs-Merrill, 1975.
4. Boocock. S. S. The rote of the parent: Problems and prospects. In Vaughnand Brazetton, T. B. (eds.). The Family - Can ItBe Saved? Chicago: Year Book Medical Publishers, 1976.
5. Brazelton, T. B. Infants and Mothers. New York: Delacorte Press, 1969.
6. Callahan, S. C. Parent: Principles and Politics of Parenthood. Baltimore: Penguin Books, 1974.
7. Levine, J. Who Will Raise the Children? Philadelphia: J. B. Lippincott Company, 1976.
8. McBride, A. B. The Growth and Development of Mothers. New York: Harper & Row, Publishers. 1974.
9. Slater, P. The Pursuit of Loneliness. Boston: Beacon Press. 1970.
10. Howe, L. Future of the Family. New York: Simon and Schuster, 1972.
11. Joint hearings before the Senate Subcommittee on Children and Youth. American Families: Trends and Pressures. Washington. D.C.: U.S. Government Printing Office, 1973.
12. Towards a National Policy for Children and Families. Washington, D.C.: National Academy of Sciences, 1976.
13. America's Children. Washington, D.C.: National Council of Organizations for Children and Youth, 1976.
14. Bicentennial Conference on Children. Washington, D.C.: National Council of Organizations for Childten and Youth, 1976.
15. Packard. V. A Nation of Strangers. New York: David McKay Company, 1972.
16. Talbot, N. (ed). Raising Children in Modem America. Boston: Little, Brown and Company, 1976.
17. Brazelton, T. B. Toddlers and Parents. New York: Delacorte Press, 1974.
18. Marital and Famäy Characteristics of the Labor Force. Washington, D.C.: United States Department of Labor, Bureau of Labor Statistics. March, 1975.
19. He-well. M. C. Employed mothers and their families. Pediatrics 52(1973). 252-263.
20. Howell, M. C. Effects of maternal employment on the child. Pediatrics 52 (1973), 327-343.
21. Howell. M. C, Helping Ourselves: Families and the Human Network. Boston: Beacon Press. 1975.
22. Pizzo, P. D. The Infant Day Care Debate: Not Whether but How. Washington, D.C.: The Day Care and Child Development Council.
23. Pizzo, P. D. Interview for Day Care, a radio show produced by Options in Education. National PubSc Radio. September, 1976.
24. Sussman, M. Family systems in the 1970' s: Analysis of policies and programs, (n Skofntck, A., and Skofnick, J. (eds.). Intimacy, Family and Society. Boston: Little. Brown and Company, 1974.
25. Collins, A., and Watson. E. Family Day Care: A Practical Guide for Parents. Caregivers and Professionals. Boston: Beacon Press, 1976.
26. Storr, C- Freud and the concept of parental guilt. In Skolnick. A., and Skolnick. J. (eds.). Intimacy, Famity and Society. Boston: Little, Brown and Company. 1974.
27. Joint hearings before the Senate Subcommittee on Children and Youth, the House Select Subcommittee on Education and the Senate Subcommittee on Employment, Poverty and Migratory Labor on the Child and Family Services Act, Feb. 20-21. June 20-23, 1975.
28. Petrillo, M., and Sanger, S. Emotional Care of Hospitalized Children: An Environmental Approach. Philadelphia: J. B. Lippincott Company, 1972.
29. Plank, E. N. Working with Children in Hospitals. Cleveland: Western Reserve Press. 1970.
30. Robertson, J. Young Children in Hospitals, Second Edition. New York: Barnes & Noble, 1970.
31. Caldwell, B., Wright, C., Honig, ?., and Tannenbaum, J, Infant day care and attachment. Am. J. Orthopsychiatry 40 (1970), 397-412.
32. Kagan, J. The effect of day care on the infant. Report prepared for the HEW Federal lnteragency Day Care Requirements Appropriateness Study, 1976.
33. Bronfen brenne r, U., Belsky, J., and Steinberg, L Day care in context: An ecological perspective on research and public policy, Report prepared for the HEW Federal lnteragency Day Care Requirements Appropriateness Study, December, 1976.
34. Brookhart, J., and Hock, E. The effects of experimental context and experiential background on infants' behavior toward their mothers and a stranger. Child Dev. 47 (1976), 333-340.
35. Doyle, A. B. Infant development in day care. Dev. Psychology 11 (1975),655-656.
36. Kearsley, R. B., Zelazo, P. R., Kagan, J., and Hartmann, R. Separation protest in day-care and home-reared infants. Pediatrics 55 (1975), 174-175.
37. Blehar, M. C. Anxious attachment and defensive reactions associated with day care. Child Dev. 45 (1974), 683-692.
38. Robinson, H. B-, and Robinson, N. M. Longitudinal development in very young children in a comprehensive day care program: The first two years. CMd Dev. 42 (1971), 1673-1683.
39. Ricciuti. H. Effects of infant day care experience on behavior and development: Research and implications for social policy. Report prepared for the HEW Federal lnteragency Day Care Requirements Appropriateness Study, October, 1976.
40. District of Columbia. Department of Environmental Services. Environmental Health Evaluation of the District of Columbia Day Care Centers. Washington, D.C., 1975.
41. Keyserling. M. D. Windows on Day Care. New York: National Council of Jewish Women, 1972.
42. A Baseline for Improving Day Care Services in Region X, Volume 2. UNCO, Inc.. Contract No. OEC-X-72-0055, 1972.
43. Pizzo, P. D., and Aronson, S. Concept paper on health and safety issues in day care. Report prepared for the HEW Federal lnteragency Day Care Requirements Study, September, 1976.
44. Auerbach-Fink. S. Parents and Child Care: A Report on Child Care Consumers in San Francisco. San Francisco: West Laboratory for Educational Research and Development, 1974.
45. Auerbach-Fink, S., and Freeman, L. Choosing Child Care: A Guide for Parents. San Francisco: Parents and Child Care Resources. 1976.
46. Playgroups: How to Grow Your Own from Infancy Onward. Cambridge, Mass.: Child Care Resource Center. 1976.
47. Gold, J., and Bergstfom, J. Checking Out Child Care: A Parent Guide (also available h Spanish). Washington, DC.: Day Care and Child Development Council, 1976.
48. Selecting and Instructing Babysitters. Evansville. Ind.: Mead Johnson and Company, 1968
49 Some Ways of Distinguishing a Good School or Center for Young Children. Washington, D.C .: National Association for the Education of Young Children. 1972.
50. Curtis, J. Working Mothers. New York: Doubteday and Company, 1976.
REASONS FOR USING CHILD CARE
HOUSEHOLDS USING MAIN METHODS OF CARE 10 OR MORE HOURS PER WEEK