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Quality Matters

Barriers to high-quality ece, steps to improve quality ece, recommendations for pediatricians, recommendations for community-level actions, recommendations for national- and state-level actions, lead author, council on early childhood executive committee, 2015–2016, quality early education and child care from birth to kindergarten.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Elaine A. Donoghue , COUNCIL ON EARLY CHILDHOOD , Dina Lieser , Beth DelConte , Elaine Donoghue , Marian Earls , Danette Glassy , Alan Mendelsohn , Terri McFadden , Seth Scholer , Jennifer Takagishi , Douglas Vanderbilt , P. Gail Williams; Quality Early Education and Child Care From Birth to Kindergarten. Pediatrics August 2017; 140 (2): e20171488. 10.1542/peds.2017-1488

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High-quality early education and child care for young children improves physical and cognitive outcomes for the children and can result in enhanced school readiness. Preschool education can be viewed as an investment (especially for at-risk children), and studies show a positive return on that investment. Barriers to high-quality early childhood education include inadequate funding and staff education as well as variable regulation and enforcement. Steps that have been taken to improve the quality of early education and child care include creating multidisciplinary, evidence-based child care practice standards; establishing state quality rating and improvement systems; improving federal and state regulations; providing child care health consultation; as well as initiating other innovative partnerships. Pediatricians have a role in promoting quality early education and child care for all children not only in the medical home but also at the community, state, and national levels.

Children’s early experiences are all educational, whether they are at home, with extended family and friends, or in early education and child care settings. Those educational experiences can be positive or negative. At present, more than half of children less than 5 years old regularly attend some type of out-of-home child care or early childhood program, 1 and their experiences in these settings will affect their future lives. 1 The arrangements families make for their children can vary dramatically, including care by parents and relatives, center-based child care, family child care provided in a caregiver’s home, care provided in a child’s own home by nannies or baby-sitters, or a combination of these types of care. 1 , – 3 How a family chooses this care is influenced by family values, affordability, and availability. 2 , 4 For many families, high-quality child care is not available or affordable. 2 , 4 This policy statement outlines the importance of quality child care and what pediatricians can do to help children get care in high-quality early childhood education (ECE) settings.

When care is consistent, developmentally appropriate, and emotionally supportive, and the environment is healthy and safe, there is a positive effect on children and their families. 5 , – 14 Children who are exposed to poor-quality environments (whether at home or outside the home) are more likely to have unmet socioemotional needs and be less prepared for school demands. 5 , – 14 Behavioral problems in ECE can lead to preschool expulsion with cascading negative consequences. Each year, 5000 children are expelled from ECE settings, which is a rate 3 times higher than that of their school-aged counterparts. 15 When behavioral health consultation is available to preschool teachers, the rate of reported expulsions is half that of the control population. 15 , 16  

Early education does not exist in a silo; learning begins at birth and occurs in all environments. Early brain and child development research unequivocally demonstrates that human development is powerfully affected by contextual surroundings and experiences. 17 , – 19 A child’s day-to-day experiences affect the structural and functional development of his or her brain, including his or her intelligence and personality. 17 , – 19 Children begin to learn to regulate their emotions, solve problems, express their feelings, and organize their experiences at an early age and then use those skills when they arrive at school. 19 The American Academy of Pediatrics (AAP) has recognized the importance of early brain and child development by making it a strategic priority.

Research of high-quality, intensive ECE programs for low-income children confirm lasting positive effects such as improved cognitive and social abilities (including better math and language skills than control groups). 5 , – 14 The indicators of high-quality ECE have been studied and are summarized in Table 1 .

Domains of Health and Safety Quality in ECE

Adapted from Stepping Stones 20  

There are different staff-to-child ratios for small-family homes, large-family homes, and centers. Ratios are also based on the ages of the children. Specific staff-to-child ratios are described in standard (1.1.1.2). 21  

Many families have no quality child care options in their immediate communities. 2 The positive effects from high-quality programs and the negative effects from poor-quality programs are magnified in children from disadvantaged situations or with special needs, and yet, these children are least likely to have access to quality early education and child care. 2 , 4 , 22 , 23 Barriers to high-quality ECE include inadequate funding and staff education as well as inconsistent regulation and enforcement. 15 Funding on the federal, state, and local levels (even when combined with parental fees) often does not provide adequate financial support to ensure proper training, reasonable compensation, or career advancement opportunities for the early education workforce. 2 , – 4 , 22 , – 25 Adequate compensation of early education providers promotes quality by recruiting and retaining trained staff and their directors. Young children, especially infants and toddlers, need stable, positive relationships with their caregivers to thrive, and staff retention helps maintain those strong relationships. 19 Budget restrictions also limit the number of children who can be served. 22 As of 2012, 23 states had wait lists for their child care subsidy programs, and many areas have wait lists for Head Start programs. 4 Finally, budget restrictions may limit a program’s ability to hire child care health consultants. ECE settings rarely have health professionals like school nurses despite the fact that the children served are younger, less able to express their symptoms, and are prone to more frequent infectious illnesses. 26 Some states require child care health consultants to visit infant and toddler programs regularly.

State regulations of ECE programs vary dramatically because of an absence of national regulation, and this contributes to variation in ECE quality. Family child care settings have different regulations than center-based care, and some forms of child care are exempt from regulation. 23 , 25 , 27 The variability in regulation, staff screening, staff training, and the availability of supports such as child care health consultation contribute to a wide variation in quality. Even when regulations are present, enforcement varies, and only 44 states conduct annual health and safety inspections. 23 , 25  

The definition of quality in ECE is becoming more evidence based as newer, validated measures become available. State licensing standards have been the traditional benchmarks, but they set a minimum standard that is typically considerably less than the recommendations of health and safety experts. 20 , 21 , 23 , 25 , 27 , 28 National organizations including the AAP, the American Public Health Association, and the National Association for the Education of Young Children have developed standards and voluntary systems of accreditation that are often more robust than state licensing regulations. The publication Caring for Our Children, Third Edition 21 includes evidence-based practice standards for nutrition, safety, hygiene, staff-to-child ratios, and numerous other subjects that have been shown to improve the quality of child care. 29 , 30  

The quality rating and improvement system (QRIS) is a method of quality improvement that is being implemented in >75% of states. 25 QRISs use research-based, measurable standards to define quality levels, which are often denoted by a star rating system. QRISs often use incentives (such as staff scholarships, tiered reimbursement for child care subsidies, and technical assistance and/or professional development) as strategies to improve ECE quality. Unfortunately, the QRIS does not always include key health and safety standards. Those who are responsible for implementing QRISs would benefit from input from pediatricians, who are familiar with health issues and with the challenges of translating research into practice. Child care resource and referral agencies are available nationwide, and they serve as regional resources for information about quality child care. They often also serve as a resource for QRIS implementation; however, most child care resource and referral agencies do not have adequate funding to hire early childhood health consultants as part of that technical assistance.

Improving access to child care health consultation is another way to positively affect the health and safety of children in ECE. Child care health consultants are health professionals who are trained to provide technical assistance and develop policies about health issues, such as medication administration, infection control, immunization, and injury prevention. 31 Child care health consultants also can provide developmental, hearing, oral health, and vision screenings and provide assistance with integrating children with special health care needs into ECE settings. 29 , 32 , 33  

The opportunities to use ECE programs to teach healthy habits (including healthy food choices, increased physical activity, and oral health practices) should not be overlooked. These messages can then be shared with families. Health screening services (such as vision and dental testing) also can be provided.

Innovative strategies to promote access to quality care and education also include state initiatives to promote cross-disciplinary teams (such as Early Childhood Advisory Councils), public-private funding partnerships, and universal preschool programs.

Ask families what child care arrangements they have made for their children, and educate them about the importance of high-quality child care. Resources include brochures (listed in Resources); checklists of quality, which can be accessed at www.aap.org/healthychildcare ; and referrals to local child care resources and referral agencies, which can be found at www.childcareaware.org .

Become educated about high-quality child care through the resources on the Healthy Child Care America Web site ( www.healthychildcare.org ), in Caring for Our Children , 21 and others (see Resources).

Be a medical home by participating in the 3-way collaboration with families and ECE professionals. The medical home concept of comprehensive, coordinated care is particularly critical for children with special health care needs. Three-way communication among the pediatricians, families, and ECEs can facilitate shared knowledge of the unique child care needs of children with special needs and foster implementation of child care policies and practices to meet those needs. 32 , 33 These activities are likely to improve access to ECE for these patients. Detailed care plans written in lay language assist in this collaboration. Medical team-based or time-based coding and billing may provide support for these efforts.

Advise families and early educators when children are having behavioral problems in ECE and are at risk for expulsion. Explain the triggers for behavior problems and recommend behavioral health resources as needed. 16 Some states have behavioral health resources available for young children through an Early Childhood Mental Health Consultation program. Read the AAP policy statement and technical report on toxic stress 19 and learn about the resources that are available through each state’s early care and education system.

Discuss the importance of guidelines on safe sleep, immunization, safe medication administration, infection control, healthy diet and physical activity, oral health, medical home access, and other health topics with local child care centers. Share resources such as Caring for Our Children , 21   Bright Futures , and the Healthy Child Care Web site ( www.healthychildcare.org ).

Become a child care health consultant or support your local child care health consultant nurses. Consider conducting a health and safety assessment in a local child care program by using a national health and safety checklist ( www.ucsfchildcarehealth.org ).

Educate policy makers about the science that supports the benefits of quality early child care and education and, conversely, the lost opportunities and setbacks that result from poor-quality care. 15 , 24  

Close the gaps between state regulations and the quality standards outlined in Caring for Our Children by encouraging strong state regulation and enforcement. Each AAP chapter has a legislative group that can help target these public policy makers with visits and letters. Nearly every AAP chapter also has an Early Childhood Champion, a pediatrician who is familiar with the early education and child care needs in that chapter and has knowledge about local resources to assist your efforts. Find your Early Childhood Champion at www.aap.org/coec .

Support a QRIS in your state if one is being implemented, and encourage robust child health and safety standards based on Caring for Our Children .

Advocate for improved funding for child care health consultation.

Encourage training of ECE professionals on health and safety topics, such as medication administration and safe sleep practices for infants. Consider providing training that uses the Healthy Futures curriculum provided on the Healthy Child Care Web site ( www.healthychildcare.org ).

Advocate and encourage expanded access to high-quality ECE through funding, such as expanded Child Care Developmental Block grants or Head Start funding. Reach out to legislators on the national and state levels to make the case for investing in quality early education as a good business, education, and social investment that has shown a strong return on investment. Encourage pediatric representation on state Early Childhood Advisory Councils or similar state groups to make the case to state officials personally.

American Academy of Pediatrics. Choosing Child Care: What’s Best for Your Family [Pamphlet]. Elk Grove Village, IL: American Academy of Pediatrics; 2002. Available through the AAP publications department: 800/433-9016 or at www.aap.org

American Academy of Pediatrics. The Pediatrician’s Role in Promoting Health and Safety in Child Care. Elk Grove Village, IL: American Academy of Pediatrics; 2001. Available at: www.healthychildcare.org

Child Care Aware, National Association of Child Care Resource and Referral Agencies (NACCRRA). Is this the right place for my child? 38 research-based indicators of quality child care. Available at: http://childcareaware.org/resources/printable-materials/

Child Care Aware, National Association of Child Care Resource and Referral Agencies (NACCRRA). Quality child care matters for infants and toddlers. Available at: http://childcareaware.org/families/choosing-quality-child-care

Child Care Resource and Referral Agencies, local referral agencies that can assist families in finding quality, affordable programs. Available at: http://childcareaware.org/families/choosing-quality-child-care/selecting-a-child-care-program/

Head Start. Early childhood learning and knowledge center. Available at: http://eclkc.ohs.acf.hhs.gov/hslc/tta-system/health

Healthy Child Care America. Federally funded and housed at the AAP, this Web site has many resources for health and ECE professionals. Available at: www.healthychildcare.org

National Association for the Education of Young Children. Developmentally Appropriate Practice in Early Childhood Programs Serving Children from Birth through Age 8. 3rd ed. Washington, DC: National Association for the Education of Young Children (NAEYC); 2009. Available at: www.naeyc.org/files/naeyc/file/positions/PSDAP.pdf

National Resource Center for Health and Safety in Child Care and Early Education. Available at: www.nrckids.org

Zero to Three. Early Experiences Matter Policy Guide. Washington, DC: Zero to Three; 2009. Available at: https://www.zerotothree.org/resources/119-early-experiences-matter-policy-guide

Zero to Three. Matching Your Infant’s and Toddler’s Style to the Right Child Care Setting. Washington, DC: Zero to Three; 2001. Available at: https://www.zerotothree.org/resources/86-matching-your-infant-s-or-toddler-s-style-to-the-right-child-care-setting

American Academy of Pediatrics

early childhood education

quality rating and improvement system

Dr Donoghue updated the previous policy statement and revised that original document by adding references, updating the wording, and adding new sections based on updates from the field. The document went through several layers of review, and Dr Donoghue was responsible for responding to those comments.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, policy statements from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

FUNDING: No external funding.

Elaine A. Donoghue, MD, FAAP

Jill Sells, MD, FAAP, Chairperson

Beth DelConte, MD, FAAP

Elaine Donoghue, MD, FAAP

Marian Earls, MD, FAAP

Danette Glassy, MD, FAAP

Alan Mendelsohn, MD, FAAP

Terri McFadden, MD, FAAP

Seth Scholer, MD, FAAP

Jennifer Takagishi, MD, FAAP

Douglas Vanderbilt, MD, FAAP

P. Gail Williams, MD, FAAP

Claire Lerner, LCSW, Zero to Three

Barbara U. Hamilton, MA, Maternal and Child Health Bureau

David Willis, MD, FAAP, Maternal and Child Health Bureau

Lynette Fraga, PhD, Child Care Aware

Abbey Alkon, RN, PNP, PhD, National Association of Pediatric Nurse Practitioners

Laurel Hoffmann, MD, AAP Section on Medical Students, Residents, and Fellows in Training

Charlotte O. Zia, MPH, CHES

Competing Interests

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Family Child Care Research & Data

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Family Child Care Research & Data Fact Sheet

This fact sheet, created by NAFCC, draws on various sources to provide important data on family child care programs around the nation. It provides insights on children’s enrollment in family child care, the availability of family child care, and challenges/opportunities for family child care programs. This data should be used to inform family child care policy and advocacy.

You can download and share it in PDF form or via our website on your own digital platforms (social media, email, etc.). If you share via social media, please tag @NAFCC.

Enrollment in Family Child Care:

Out of nearly 11 million young children with working mothers, 40% spent more time in family child care than in any other child care setting. [i] Here’s a look at the details:

• 94.2% of listed, home-based providers were caring for at least one child under three years of age, while 85.5% were caring for at least one preschooler (ages 3 through 5 years). [ii] Almost two-thirds (63.2%) reported serving at least one school-age child. [iii]
• Nationally, about one in four children (24%) receiving child care funded by the Child Care and Development Fund (CCDF) program are cared for in family child care. [iv]
• Family child care providers care for 27% of infants younger than age 1, and 24% of toddlers ages 1-3, in CCDF-supported child care. [v]

Availability of Family Child Care:

According to the National Survey of Early Care and Education (NSECE), there are one million paid providers caring for children in a home of the provider, caring for three million children from birth to age five in these settings [vii]. NSECE classified about 118,000 of the one million paid providers as licensed, regulated, exempt from licensure, or registered – the states use different terms with different definitions. As a group, these 118,000 paid providers are referred to as “listed” by the NSECE, who also categorized 919,000 as unlisted, paid home-based providers.

ACF data from 2017 shows 123,816 licensed family child care. That includes 86,309 small family child care programs, which ACF defines as a solo person/no other workers. And it includes 37,507 large family child care programs (not a term or a category used in every state) which ACF defines as having two or more people providing child care there.

The number of licensed family child care homes fell by 52% from 2005 to 2017 [viii]. From 2014 to 2017, the drop was 22% and family child care educators share that it’s a challenging job to navigate and carry out standards without sufficient dollars/resources, as well as difficulty with economics, the costs, and aging/retirement.

Commitment to the Practice and the Profession:

• 61% of listed, paid home-based providers have more than 10 years of experience and 42% intend to continue for 10 or more years [ix]. 47% say this work is a personal career or a calling [x].
• Predictors of quality in family child care include licensing, professional support, training, financial resources, and provider experience. [xi]
• One-third of listed providers have a degree in ECE or an ECE-related major. [xii] Among listed, paid home-based providers who cared for at least one child under age 3 [xiii], 43% had a Child Development Associate (CDA) or a state certification.
• Three-quarters of listed providers have participated in a workshop in the previous 12 months and among those providers, one-third of them reported participating in a series. [xiv] 30% are taking a college course and 34% are receiving coaching. [xv]
• Family child care programs can be a learning environment with activities and experiences that are safe, healthy, and allow for children to work at their own pace. More than half (54.9%) of listed, home-based providers are using a curriculum or prepared set of learning and play activities.
• 30% of listed, paid home-based providers note their main responsibility is to provide for children’s basic needs. 44% of listed, paid home-based providers have helped at least one family to find services.

Opportunities Right in Our Own Neighborhoods:

• The opportunity for one-on-one relationships and responsive and nurturing care in a family setting has the potential for positive outcomes for children. [xvi]
• High-quality family child care has been linked to improvements in children’s cognitive, social-emotional, and physical development. [xvii]
• 70% of poor children in regular, non-parental care receive that care within three miles of their home. [xviii] In communities where price, location and transportation barriers limit child care options, family child care is a critical need for families.

Relationships and Continuity:

• There is evidence that consistent and reliable caregiving supports early neurological development. [xix]
• Having the same family child care provider for several years provides the opportunity for a responsive relationship between the infant or toddler and the adult caregiver. [xx]
• Family child care provides children an opportunity to be cared for in smaller groups and to be cared for by a provider who is responsible for fewer children than in a center setting. [xxi] These small group sizes facilitate the strengths of relationships and interactions.

[i] Laughlin, L., 2013, Table 3. Primary Child Care Arrangements of Preschoolers with Employed Mothers: Selected Years, 1985 to 2011, Who’s Minding the Kids? Child Care Arrangements: Spring 2011, Current Population Reports, P70-135, U.S. Census Bureau, Washington, DC. The 40-percent figure includes relative and nonrelative care given in the provider’s home or child’s home. A primary child care arrangement is defined as the arrangement used for the most hours per week.

[ii] National Survey of Early Care and Education Project Team (2016). Characteristics of Home-based Early Care and Education Providers: Initial Findings from the National Survey of Early Care and Education. OPRE Report #2016-13, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

[iii] Ibid.

[iv] U.S. Department of Health and Human Services, Administration for Children and Families, Office of Child Care. (2016). FY 2015 Preliminary Data Table 3 – Average Monthly Percentages of Children Served by Types of Care. Retrieved from https://www.acf.hhs.gov/occ/resource/fy-2015-preliminary-data-table-3 .

[v] U.S. Department of Health and Human Services, Administration for Children and Families, Office of Child Care. (2016). FY 2015 Preliminary Data Table 13 – Average Monthly Percentages of Children in Child Care by Age Category and Care Type. Retrieved from https://www.acf.hhs.gov/occ/resource/fy-2015-preliminary-data-table-13 .

[vi] National Survey of Early Care and Education Project Team (2015). Fact Sheet: Provision of Early Care and Education during Non-Standard Hours. (OPRE Report No. 2015-44). Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Available at http://www.acf.hhs.gov/programs/opre/research/project/national-survey-of-early-care-andeducation-nsece-2010-2014

[vii] National Survey of Early Care and Education Project Team (2016). Characteristics of Home-based Early Care and Education Providers: Initial Findings from the National Survey of Early Care and Education. OPRE Report #2016-13, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

[viii] https://childcareta.acf.hhs.gov/sites/default/files/public/addressing_decreasing_fcc_providers_revised_march2020_final.pdf

I[x] National Survey of Early Care and Education Project Team (2016). Characteristics of Home-based Early Care and Education Providers: Initial Findings from the National Survey of Early Care and Education. OPRE Report #2016-13, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

[xi] Raikes, H., Torquati, J., Jung, E., Peterson, C., Atwater, J., Scott, J., and Messner, L. (2013). Family child care in four Midwestern states: Multiple measures of quality and relations to outcomes by licensed status and subsidy participation. Early Childhood Research Quarterly, 28(4), 879–892; Forry, N., Iruka, I., Tout, K., Torquati, J., Susman-Stillman, A., Bryant, D., and Daneri, M.P. (2013). Predictors of quality and child outcomes in family child care settings. Early Childhood Research Quarterly, 28(4), 893–904.

[xii] National Survey of Early Care and Education Project Team. (2013). Number and Characteristics of Early Care and Education (ECE) Teachers and Caregivers: Initial Findings from the National Survey of Early Care and Education (NSECE). OPRE Report #2013-38, Washington DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

[xiii] Madill, R., Blasberg, A., Halle, T., Zaslow, M., & Epstein, D. (2016). Describing the preparation and ongoing professional development of the infant/toddler workforce: An analysis of the National Survey for Early Care and Education data. OPRE Report #2016-16, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

[xiv] National Survey of Early Care and Education Project Team (2016). Characteristics of Home-based Early Care and Education Providers: Initial Findings from the National Survey of Early Care and Education. OPRE Report #2016-13, Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services.

[xvi] NICHD Early Child Care Research Network. (2004). Type of child care and children’s development at 54 months. Early Childhood Research Quarterly, 19 (2). Retrieved June 13, 2017 from http://www.sciencedirect.com/science/article/pii/S0885200604000389 .

[xvii] U.S. Department of Health and Human Services, Commissioner’s Office of Research and Evaluation, and the Head Start Bureau, Administration on Children, Youth and Families, Evaluation of Head Start Family Child Care Demonstration, Final Report, 2000. Retrieved June 11, 2017 from  http://www.acf.hhs.gov/progrms/opre/resource/evaluation-of-head-start-family-child-care-demonstration-final-report .

[xviii] National Survey of Early Care and Education Project Team (2016). Fact Sheet: How Far Are Early Care and Education Arrangements from Children’s Homes? OPRE Report No. 2016-10, Washington DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Available at: http://www.acf.hhs.gov/programs/opre/research/project/national-survey-of-early-care-and-education-nsece-2010-2014 .

[xix] Center on the Developing Child. (2012). Executive function: Skills for life and learning (In Brief). Retrieved June 13, 2017 from http://developingchild.harvard.edu/resources/inbrief-executive-function/ .

[xx] Ruprecht, K., Elicker, J., & Choi, J. (2016). Continuity of care, caregiver–child interactions, and toddler social competence and problem behaviors. Early Education and Development, 27(2), 221–239. Retrieved June 11, 2017 from http://www.tandfonline.com/doi/full/10.1080/10409289.2016.1102034?scroll=top&needAccess=true via https://childcareta.acf.hhs.gov/sites/default/files/public/itrg/pitc_rationale_-_primary_care_508_1.pdf .

[xxi] Buell, M.J., Pfister, I., & Gamel-McCormick, M. (2002). Caring for the caregiver: Early Head Start/family child care partnerships. Infant Mental Health Journal , 23(1-2), 213-230.; Krauss, J. (1998). Brief Report: Safe at home base: Working parents’ reasons for choice of home-based child care. Journal of Adult Development . 5:59–66; Leu, C.R. & Osborne, S. (1990). Selecting child care. Early Child Development and Care . 54:95–98.

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Child Care Centers Licensing Standards in the United States from 1981 to 2023

• Published: 04 September 2023

Cite this article

• Clara Puni-Nyamesem   ORCID: orcid.org/0009-0002-7124-0290 1 ,
• Amie A. Perry   ORCID: orcid.org/0009-0000-4661-7960 1 &
• Julia T. Atiles   ORCID: orcid.org/0000-0001-6893-1942 1  

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Over the past thirty years, there have been notable changes in child care ratios and group sizes. Child care ratios refer to the number of children one caregiver is responsible for, while group size refers to the total number of children in a classroom at an early care and education setting. The current analysis examines the current licensing requirements in every state and the District of Columbia and compares those requirements to the numbers from 1981 and 1995. Furthermore, the manuscript examines the progress made by different states regarding states’ compliance with NAEYC’s recommended child-to-staff ratio and maximum group size. In the 1990s, child care ratios were less regulated, resulting in higher group sizes and fewer caregivers per child. However, research on child development and safety concerns led to increased regulations and lower childcare ratios. As a result, group sizes have decreased, and there are now more caregivers per child in early care and education settings. These changes have been beneficial for children, as they allow for more individual attention and care. Additionally, they have led to safer environments for children and reduced the risk of accidents and injuries. Despite these improvements, there is still room for further progress in ensuring high-quality childcare for all children, especially in the remaining states that continue to allow high ratios and large group sizes.

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Puni-Nyamesem, C., Perry, A.A. & Atiles, J.T. Child Care Centers Licensing Standards in the United States from 1981 to 2023. Early Childhood Educ J (2023). https://doi.org/10.1007/s10643-023-01569-6

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Child Care and the Development of Behavior Problems among Economically Disadvantaged Children in Middle Childhood

Elizabeth votruba-drzal.

Department of Psychology, University of Pittsburgh

Rebekah Levine Coley

Applied Developmental and Educational Psychology, Lynch School of Education, Boston College

Carolina Maldonado-Carreño

Department of Psychology, Universidad de Los Andes, Bogotá-Colombia

Christine Li-Grining

Department of Psychology, Loyola University of Chicago

P. Lindsay Chase-Lansdale

Human Development and Social Policy Program, Northwestern University

Research examining the longer term influences of child care on children’s development has expanded in recent years, but few studies have considered low-income children’s experiences in community care arrangements. Using data from the Three-City Study (N = 349), this study examines the influences of child care quality, extent and type on low-income children’s development of behavior problems during middle childhood (7–11 years old). Higher levels of child care quality were linked to moderate reductions in externalizing behavior problems. High quality child care was especially protective against the development of behavior problems for boys and African American children. Child care type and the extent of care that children experienced were generally unrelated to behavior problems in middle childhood.

Nonparental child care arrangements have become important contexts for early child development in the U.S., with recent national estimates showing that approximately 12.2 million children under age 6 attend child care or preschool programs ( Mulligan, Brimhall, & West, 2005 ). Economically disadvantaged children are slightly less likely than their advantaged counterparts to experience nonparental care during their preschool years, with 65% of children from poor families and 75% of children from non-poor families regularly cared for in child care settings ( Mulligan et al., 2005 ). Yet child care experiences may be particularly salient for low-income children’s health and development. Faced with limited resources in their home environments, low-income children may be especially responsive either to the added supports of stimulating and responsive nonparental care, or to the added risks of poor quality or extensive child care ( Dearing, McCartney, & Taylor, 2009 ; Loeb, Bridges, Bassok, Fuller, & Rumberger, 2007 ; Magnuson, Ruhm, & Waldfogel, 2007 ).

Beyond a few model early intervention programs and a handful of short-term longitudinal studies, our knowledge is limited concerning the implications of child care experiences for low-income children’s later development. Whether child care experiences have long-term effects on low-income children’s socioemotional functioning, such as their skills in regulating their emotions and behaviors, getting along with peers, and refraining from inappropriate behaviors, is understudied. Behavioral and emotional skills are essential for early school success and also have long-term implications for children’s mental health and behavioral functioning ( Raver, 2002 ). As children transition into formal schooling and traverse middle childhood, lower problem behaviors and better behavioral skills are central indicators of developmental success with long-term repercussions for healthy functioning ( Huston & Ripke, 2006 ). Indeed, problem behaviors and behavioral/emotional skills that are established in middle childhood exhibit significant continuity across adolescence and even into adulthood ( Huston & Ripke, 2006 ).

Grounded in bioecological models of development ( Bronfenbrenner & Morris, 1998 ; Sameroff, 1994 ), this study seeks to enhance our understanding of how experiences in early education and care settings shape the development of behavior problems among economically disadvantaged children into middle childhood. Bioecological theory describes human development as the result of proximal processes and reciprocal interactions between individuals and their environments. Driving future development are proximal processes that occur in microsystems, along with the characteristics of individuals that affect the contexts that they select into as well as the experiences that they elicit in these contexts. Within the child care microsystem, this model argues that caregiving experiences as well as children’s individual characteristics together influence future developmental trajectories, with potentially divergent influences for children with different characteristics ( Bronfenbrenner & Ceci, 1994 ; Bronfenbrenner & Morris, 1998 ).

Effects of Child Care Quality on Children’s Behavior Problems and Socioemotional Functioning

Research to date has identified three aspects of child care experiences that are important potential influences on children’s well-being: quality of care, extent of care, and type of care setting. High quality child care is characterized by caregivers who are warm and responsive, who provide materials and experiences that stimulate learning and emotional support, and who afford consistency and structure. Experiences in high quality care settings promote socioemotional development by helping children learn to regulate their emotions, behaviors and attention, to get along with peers, and to comply with rules and requests. Indeed, research has proliferated documenting the associations between early education and care experiences and children’s socioemotional development. In concurrent and short-term longitudinal studies with large, socioeconomically diverse samples, high quality child care has been found to predict modestly lower behavior problems and negative affect as well as enhanced peer relations, sociability, and compliance (e.g., Love et al., 2003 ; NICHD Early Child Care Research Network (ECCRN), 1998 ; 2001 ). If children show improved regulation, affect, and peer skills in early childhood in relation to child care experiences, it is hypothesized that these skills will carry forward, promoting an easier transition into formal schooling and in turn leading to better social functioning later in childhood ( National Research Council and Institute of Medicine, 2000 ). There is little existing evidence, however, that links between child care quality and early socioemotional functioning endure into middle childhood. Findings from the NICHD ECCRN (2005 ; Belsky et al., 2007 ) suggest that child care quality from birth through preschool does not predict behavior problems or other measures of social functioning in middle childhood. Similarly, results from the Cost, Quality, and Outcomes Study found no links between quality of child care during preschool and socioemotional functioning in 2 nd grade, although significant links were identified between teacher-child closeness during early child care and lower behavior problems during middle childhood ( Peisner-Feinberg et al., 2001 ).

There is a notable paucity of research assessing the effects of child care quality on economically disadvantaged long-term behavioral functioning. Though the studies discussed above include children from a range of socioeconomic backgrounds, most children were from middle-class families. In contrast to the experiences of more affluent children, economically disadvantaged families tend to face high levels of stress and have limited resources to invest in children, leading to less stimulating, responsive, and emotionally supportive home environments ( Magnuson & Votruba-Drzal, 2009 ). Such economic disparities have implications for children’s development of behavior problems ( Duncan & Brooks-Gunn, 1997 ; Votruba-Drzal, 2006 ). High quality nonparental care settings may protect economically disadvantaged children by providing them with opportunities and experiences that facilitate the mastery of central developmental challenges in early and middle childhood ( Dearing al., 2009 ).

Model early intervention programs, such as the Perry Preschool Project and the Abecedarian Program, show that high quality early child care experiences, combined with comprehensive services for children and families, protect low-income children against significant behavioral problems later in life such as juvenile delinquency and incarceration ( Campbell, Ramey, Pungello, Sparling, Miller-Johnson, 2002 ; Schweinhart, et al., 2005 ). These interventions were administered by highly trained professionals and provided multifaceted services to low-income children and families. In contrast, recent research indicates that the quality of child care typically experienced by economically disadvantaged children is highly variable and indeed, often rated as inadequate in meeting children’s developmental needs ( Li-Grining & Coley, 2006 ; Fuller, Kagan, Loeb, & Chang, 2004 ), questioning the generalizability of results from such model intervention programs.

Virtually no studies have considered whether the quality of child care available in low-income communities provides long-term protection against behavior problems for economically disadvantaged children. The Peisner-Feinberg et al. study (2001) found the protective effects of teacher-child closeness on behavior problems to be sustained more strongly among children of mothers with low education, which was used as a proxy for low-income. Assessing low-income children from the Three-City Study, Votruba-Drzal, Coley and Chase-Lansdale (2004) found that the quality of child care experienced by preschool-age children (average age of 3 years) predicted improvements in socioemotional functioning over a 1 ½ year period, with higher quality care reducing internalizing and serious externalizing behavior problems and enhancing positive behaviors. Similar results were reported by Loeb, Fuller, Kagan and Carrol (2004) using a different sample of low-income children. It is unknown whether such short-term protective effects of child care quality on low-income children’s behavioral functioning extend to middle childhood.

Extent of Child Care Use and Children’s Behavior Problems and Socioemotional Functioning

Along with child care quality, the extent of nonparental care that children are exposed to is a salient dimension of early experiences in child care. Increasing evidence suggests that extensive experience in nonparental care during the early years may be harmful for behavioral functioning. Early, extensive nonparental care may threaten behavioral development by undermining maternal sensitivity, as mothers have less time to spend with young children and become familiar with their signals ( NICHD ECCRN, 1999 ), or by imposing high levels of stress on young children associated with extended peer exposure that taxes their nascent self-regulatory and social skills. In a series of studies using data from the NICHD Study of Early Child Care, the NICHD ECCRN (1998 ; 2003 ; 2005 ) and Belsky and colleagues (2007) found positive links between the quantity of care children experienced and externalizing behavior problems during early childhood, although these effects faded out by middle childhood. Negative links also emerged between the hours children were in care and their social competence; these results remained through the transition to middle childhood (age 8), but faded thereafter becoming nonsignificant by the end of middle childhood (age 12). It is important to note that in the NICHD study, child care characteristics were measured from age 3 months through 54 months. The extent of care that children experienced across early childhood was quite stable, such that children who experienced extensive care during infancy tended to do so consistently throughout early childhood ( NICHD ECCRN, 2003 ). Thus, NICHD measures of the quantity of care tap into both early entry and extensive hours of child care, and research with this sample has not been able to determine whether negative effects are due to early entry, to extensive hours of care, or to some combination of these two factors.

It is unknown whether a detrimental effect of extensive nonparental care will emerge among low-income children. Recent work assessing extent of child care during preschool years (e.g., after infancy but prior to kindergarten) has found no negative effects for low-income children. A recent study using a nationally representative sample found no detrimental effects of high hours in center care for low-income children’s behavioral functioning in kindergarten, although negative effects were apparent among middle and high-income children ( Loeb, et al., 2007 ). Similarly, longitudinal studies with low-income samples suggest no effects of extent of care ( Love et al., 2003 ; Votruba-Drzal, et al., 2004 ). One recent study of Canadian children found that an earlier age of onset of nonparental care (prior to 9 months) was protective against the development of externalizing behavior problems for children of mothers with low education, although the extent of care per week was not a significant predictor of behavior problems ( Côté, Boivin, Nagin, Japel, Xu, Zoccolillo, & Tremblay, 2007 ).

Type of Care and Children’s Behavior Problems and Socioemotional Functioning

A third important aspect of early care experiences are captured by the type of care they experience, that is care provided in child care centers or prekindergarten programs versus daycare homes or informal care arrangements with relatives or babysitters. Formal child care centers typically have more educated care providers and higher developmental quality. Home arrangements, on the other hand, on average have notably smaller group size and lower child-adult ratios, often include relatives of the child as the care provider, and provide more flexible and accessible care to families (Coley, et al., 2006; Li-Grining & Coley, 2006 ). Though beneficial for academic development, recent evidence with large and nationally representative samples suggests that center-based care is linked to elevated levels of externalizing problems in early childhood and that these associations are evident through middle childhood ( Belsky et al., 2007 ; Magnuson, et al., 2007 ). Although some argue that center-based care is less developmentally appropriate for infants in particular in comparison to home-based arrangements ( Loeb et al., 2007 ), negative effects of center care on behavioral functioning have emerged when considering center care use in the preschool years (e.g., Magnuson et al., 2007 ) or including both infancy and preschool (e.g., Belsky at al., 2007 ). Although there is little research specifying the mechanisms of these effects, center-based care arrangements, with larger group sizes, fewer adults, and frequent staff changes, may challenge young children’s self regulatory skills and provide greater opportunities for negative peer interactions ( Dowsett, Huston, Imes, & Gennetian, 2008 ). Recent studies have further argued that these harmful effects of center care on children’s behaviors are stronger among poor children in comparison to their more advantaged counterparts ( Loeb et al., 2007 ; Magnuson et al., 2007 ). It is interesting to note, however, that when studies are able to separate effects of child care quality, extent, and type, no detrimental effects of center care have been found for low-income preschoolers’ behavioral functioning ( Loeb et al., 2004 ; Votruba-Drzal et al., 2004 ). It is unclear whether such effects might emerge later during middle childhood.

Does Child Care Quality Matter More for Certain Children?

Bioecological theories of development suggest that individual characteristics may interact with environmental experiences to influence future development ( Bronfenbrenner & Morris, 1998 ; Sameroff, 1994 ). In the realm of child care, we hypothesize that the effects of early experiences in nonparental care settings may differ based on characteristics of the developing child, such as gender and race/ethnicity. A variety of factors may lead to differential effects of early child care experiences on behavior problems related to child gender. These factors include gender differences in the development of inhibitory control ( Kochanska, Murray, Jacques, Koenig, & Vandegeest, 1996 ) and in the nature of children’s social interactions in same-sex peer groups ( Fabes, Hanish, & Martin, 2003 ; Maccoby 1998 ), as well as boys’ overall greater vulnerability and reactivity to psychosocial stress ( Zaslow & Hayes, 1986 ). If boys exhibit lower inhibitory control or greater peer conflict or show greater reactivity to stress, then the environmental challenges and opportunities imposed by nonmaternal care may have elevated effects on boys’ psychosocial functioning.

A handful of recent studies have considered whether characteristics of nonpaternal care settings (e.g., quality, quantity, and type) are differentially related to children’s behavioral functioning for girls versus boys. Most recent research has found no evidence of gender moderation in either the short or long term ( Belsky et al., 2007 ; Burchinal, Peisner-Feinberg, Bryant, & Clifford, 2000 ; Peisner-Feinberg et al., 2001 ). On the other hand, recent research with low-income children from the Three-City Study found that high quality child care appeared more protective for boys than girls when it came to the development of externalizing behavior problems, and low-quality care seemed to be especially risky for boys’ development of serious internalizing behavior problems ( Votruba-Drzal et al., 2004 ).

Another child characteristic that may moderate associations between early nonmaternal care experiences and the development of behavior problems in middle childhood is child race/ethnicity. Conceptual models highlight the importance of considering child care settings within the context of children’s ethnic and cultural backgrounds, taking into account the ecological contexts of home and care settings ( Johnson et al., 2003 ). A number of studies have reported race/ethnicity differences in the use of child care, with African American families more likely to access center-based care, and Hispanics more likely to use informal kin care ( Fuller, Holloway, & Liang, 1996 ; Radey & Brewster, 2007 ). Only recently has research begun to ask explicitly whether characteristics of child care settings (e.g., quality, type, and quantity) have differential effects on children’s development across sociocultural contexts.

Two contrasting hypotheses have been proposed regarding child care effects across children from socioculturally diverse backgrounds. One argument is that high quality child care can have an enhanced protective role for children experiencing risks from factors such as poverty, racial discrimination, or immigrant/non-English-speaking status which might limit children’s and families’ access to economic and social resources. Similarly, poor quality child care may be particularly detrimental for such children. A contrasting argument suggests that child care settings may not meet the culturally-specific needs of children from ethnic minority families ( Burchinal & Cryer, 2003 ). Or, our current measures of child care quality may not be valid for ethnic minority children. These arguments would suggest that links between child care quality and child well-being would be attenuated among specific groups of ethnic minority children ( Burchinal & Cryer, 2003 ).

Assessing two large, longitudinal studies of child care quality (the NICHD study and the Cost, Quality, and Child Outcomes Study), Burchinal and Cryer (2003) found support for neither argument. Rather, their results suggest that highly-used measures of child care quality are equally valid and reliable across African American, Hispanic, and White samples, and further that quality is similarly predictive of children’s cognitive and socioemotional skills during the preschool years (see also Burchinal et al., 2000 ). It is important to note, however, that their samples had numerous limitations, particularly in regards to the percentage of Hispanic families, leading to questions concerning generalizability. In contrast, a recent study using data from the ECLS-K found that center-based care was not related to heightened behavior problems among English-proficient Hispanic children but was a particularly strong predictor of behavior problems for African American children in kindergarten ( Loeb et al., 2007 ). Furthermore, a third recent study found a particular aspect of child care quality, relationship-focused care, to be predictive of less adaptive functioning for Hispanic children, but not related to functioning among African American children ( Owen, Klausli, Mata-Otero, & Caughy, 2008 ). Together, these results suggest that the interactions between child care characteristics and children’s ethnic backgrounds are complex and deserving of continued careful attention.

Research Aims

The current investigation aims to strengthen understanding of how low-income children’s early education and care experiences shape their development into middle childhood. First, we will examine whether there are long-lasting associations between the developmental quality, extent, and type of child care settings low-income children experience and the development of their behavior problems into middle childhood. Second, consistent with the bioecological model of child development, we will explore whether associations between dimensions of child care settings and low-income children’s development vary according to two key child characteristics-gender and race/ethnicity.

Data for this paper were drawn from the Three-City Study , a longitudinal, multi-method study of the well-being of low-income children and families in the wake of welfare reform. Two components of the Three-City Study were used, the main survey and the Embedded Developmental Study (EDS). The main survey was conducted with a household-based, stratified random sample of about 2,400 low-income children (aged 0 to 4 or 10 to 14 years) and their primary female caregivers in low-income neighborhoods in Boston, Chicago, and San Antonio. Three survey waves were conducted, in 1999 (90% screening rate and 83% interview completion rate), 2000–2001 (88% retention rate), and 2005 (80% retention rate from wave 1). During each wave of the main survey, mothers participated in an in-home interview and children aged two and older completed individualized cognitive achievement assessments. The Embedded Developmental Study (EDS) portion of the Three-City Study provided a more intensive view into the lives of the preschool-aged children (2 to 4 years) from the main survey. The goal of the EDS was to capture rich detail about children’s primary caregivers and early environments, assessed through additional mother interviews and videotaped assessments of mother-child interactions, biological father interviews, and observations of child care settings and interviews with child care providers. Children were eligible for the child care component of the EDS if they were in child care for 10 hours or more per week: 49% of 737 EDS children in wave 1 and 40% of 670 children in wave 2 were eligible. After obtaining permission from the mother and the child care provider, children were observed in their primary child care setting for at least 2 hours, and the child care providers were interviewed. The response rate for the child care component of the EDS was 70% in wave 1 and 73% in wave 2.

The current paper is based on 349 families who participated in a child care observation at either wave 1 or wave 2. Comparisons of the children in our sample to the broader sample of 2–4 year olds in the Three-City Study revealed few significant differences, with the exception that the children in our sample were more likely to be African American and less likely to have parents who were employed and had slightly higher levels of education. Among the 349 children in the analytic sample, 5% were missing wave 1 child behavior problems measures, 19% were missing a child care observation at one wave, 16% were missing data on at least one covariate, and 21% were missing wave 3 child behavior problems measures. Our analysis of missing data suggested that the data were missing at random. Missing data were imputed using multiple imputation by chained equations (MICE) implemented in Stata 10 to create ten complete data sets ( Royston, 2004 , 2005 ), which were then analyzed using mim commands in Stata. Based on the relative efficiency calculation by Rubin (1987) , ten imputations were deemed sufficient for the level of missing data in our study.

Analytic Approach

A major challenge when considering child care’s influence on children’s development involves disentangling whether child care characteristics truly enhance development or whether it is simply the case that more advantaged parents have children who are more developmentally advanced and also choose higher quality child care. Certain characteristics of children and families, such as race/ethnicity, income, parental education and employment, social support, and children’s age and gender, influence parents’ decisions regarding child care ( Fuller et al., 1996 ; Singer, Fuller, Keiley, & Wolf, 1998 ). Most studies have controlled for a variety of family differences that might influence both family decision-making and children’s development in order to isolate less-biased estimates of child care’s influence. Since it is impossible to measure all important family characteristics, an additional strategy is to limit the influence of unmeasured variables statistically.

In the current analyses, associations between child care characteristics and the development of behavior problems in middle childhood were modeled using a longitudinal lagged regression model that is based on an accumulation of inputs framework, which has been articulated most clearly in the work of NICHD Early Child Care Research Network and Duncan (2003) and Blau (1999) . This model suggests that child i ’s development at time t is an additive function of all child care, maternal, child, and household inputs to a child’s development prior to that point in time. So, for example, as shown in Equation 1 , behavior problems during middle childhood (wave 3) are expressed as a function of child care characteristics, including the type of care arrangement, number of hours spent in care, and the quality of the care that children have experienced across wave 1 and wave 2 of the study.

To reduce the threat of selection bias posed by measured characteristics of children and families, a series of child, maternal, and household factors aggregated over waves 1 and 2 of the survey were included in the models as covariates. Covariates included child age, gender, and race/ethnicity as well as maternal education, employment, and marital status. Each of these factors has been associated with characteristics of early care experiences and behavior problems in prior research. Thus, the failure to include these variables in our analysis may result in omitted variable bias. A time 1 measure of the same child outcome that was being modeled as the dependent variable at time 3 was included as an additional covariate in the model to reduce omitted variable bias further. The regression coefficients are thus interpreted as the effects of each independent variable on changes in behavior problems over time ( Kessler & Greenberg, 1981 ). Including the time 1 child outcome as a covariate allows us to control for unmeasured, time-invariant differences in children that were present at the first interview ( Cain, 1975 ; Chase-Lansdale et al., 2003 ). In this model, unmeasured, time-varying characteristics of children that may be related to child care selection at time 1 or time 2 and children’s development over time may continue to bias estimates of the relation between child care characteristics and children’s development.

In addition to considering main effects of child care experiences, we explored whether or not the effects of child care type, extent and quality vary as a function of a child’s gender and race. This was done by adding interactions between child care characteristics and both child gender and race/ethnicity to our model followed by a series of post-hoc regression analyses to compare the non-reference race/ethnic groups. All analyses were weighted with probability weights, which strengthen our ability to make inferences to our population of interest, which includes all children living in low-income neighborhoods in Boston, Chicago, or San Antonio in households with incomes less than 200 percent of the poverty line.

Child Care Characteristics

The global developmental quality of each child’s care arrangement was measured during child care observations at wave 1 and wave 2 using widely-used and well-validated instruments. Center-based care arrangements were rated using the Early Childhood Environment Rating Scale – Revised (ECERS, Harms, Clifford & Cryer, 1998 ). The quality of day care homes and informal home care arrangements was measured using the Family Day Care Rating Scale (FDCRS, Harms & Clifford, 1989 ). Fifteen percent of the observations were independently double-coded, with average intraclass correlations (ICC) at the subscale level of .90 in wave 1 and .89 in wave 2 for the ECERS-R and .98 and .99 for the FDCRS. The Arnett Scale of Provider Sensitivity ( Arnett, 1989 ) was used to measure the emotional and behavioral relationships between the care providers and children in both center- and home-based care arrangements. The Arnett Scale (α T1 = .94 and α T2 = .92) supplemented items related to the teacher-child relationships on the ECERS and FDCRS which focus more on supervision and discipline. Composite scores had average ICCs of .81 and .82 at waves 1 and 2. A global child care quality composite (α T1 = .94 and α T2 = .91) was created at each wave by combining subscales from the ECERS or FDCRS with the composite score from the Arnett ( Growing Up in Poverty Project, 2000 ; Votruba-Drzal et al.,2004 ). The total quality scores from wave 1 and wave 2 were then averaged to reflect the average level of child care quality that children experienced across the first two waves of the study.

The extent of child care children experienced was measured using maternal reports of the number of hours per week that children were in child care at wave 1 and wave 2 of the survey. These numbers were then averaged to create a composite measure of the extent of care that children experienced across wave 1 and wave 2 of the survey. Child care type was coded with dummy variables indicating whether children experienced consistent center care across both waves of the survey, center care at one wave only, or consistent home-based care across waves 1 and 2 (omitted).

Behavior Problems

Behavior problems were measured using mothers’ reports on the age-appropriate version of the Child Behavior Checklist (CBCL) ( Achenbach, 1991 , 1992 ; Achenbach & Rescorla, 2001 ). Analyses focused on the internalizing and externalizing behavior problems subscales. The CBCL internalizing scale (α = .83 to .87) focuses on anxiety, depression, withdrawal, and somatic complaints, whereas the externalizing scale (α T3 = .90 to .91) includes items related to aggression and rule breaking. Standardized (t-scores) subscale scores from wave 3 were used as dependent variables, with scores from wave 1 included as covariates to reduce bias related to unobserved heterogeneity. We also included an indicator for whether the 2–3 year old version or the 4–18 year old version of the CBCL was used in wave 1, to control for differences in instrumentation.

Child Characteristics

Child characteristics included as covariates included child age at wave 3 represented in months, and gender. Child race was represented with a series of dummy variables indicating whether the child is of Hispanic (omitted), non-Hispanic African American, or White/other non-Hispanic origin. Child characteristics were obtained via mother report.

Maternal and Household Characteristics

Several maternal and household characteristics averaged across wave 1 and wave 2 also were included as covariates. Covariates included maternal education (greater than a high school education versus a high school degree or less), employment (employed at least 10 hours per week versus not), and marital status (married versus not). Characteristics of children and mothers are presented in Table 1 along with descriptive information about their child care arrangements. Children in the analytic sample averaged 3 years in the first wave (range 2 to 5 years) and averaged 9 years in the third wave (range 7 to 11). They were primarily African American (55%) and Hispanic (37%) and most lived with single mothers (84%) with relatively low education. Bivariate correlations of the child care and behavior problems variables are available from the first author by request.

Child Care and Demographic Characteristics of the Sample (N = 349)

Child Care Characteristics and Low-Income Children’s Development in Middle Childhood

Results from lagged Ordinary Least Squares (OLS) regressions on children’s behavior problems in middle childhood (i.e. at wave 3) are presented in Table 2 . Child care quality was linked to significant reductions in externalizing behavior problems over time. The magnitude of this association was modest in size. A one standard deviation increase in the child care quality composite was linked to .26 of a standard deviation decline in externalizing behavior problems. The association between child care quality and internalizing behavior problems in middle childhood was also negative and of a relatively similar size (.15 of a standard deviation), but failed to reach conventional levels of statistical significance ( p =.10). Controlling for the quality of care, neither the type of child care that children experienced nor the extent of care were significantly related to the development of behavior problems in middle childhood.

Main Effects Models Examining the Influence of Child Care Characteristics on the Development of Behavior Problems in Middle Childhood

t< .10

The relatively high correlation between stable center care and average quality in our data (r = .47) is consistent with the literature on child care for low income families, but raises concerns when the measures are analyzed simultaneously in a regression model. Thus, we ran an additional set of model specifications to consider whether the quality findings hold when the measure of child care type is excluded from the models and to confirm that we do not detect a significant effect of center care when child care quality is dropped from the model. When the measure of child care type was dropped from the regression models presented in Table 2 , the negative effects of child care quality on both internalizing ( B = −1.62, t = −2.31, p < .05) and externalizing ( B = −2.15, t = −2.81, p < .01) behavior problems strengthened slightly. When child care quality was excluded from the models presented in Table 2 , associations between child care type and both internalizing and externalizing problems remained nonsignificant at conventional levels, although stable center care did predict declines in internalizing problems at a level bordering significance ( B = −4.07, t = −2.08, p = .05). This set of specifications helps strengthen our certainty that child care quality is the predominate factor in our models protecting against the development of behavior problems during middle childhood.

Child Characteristics as Moderators

The second set of analyses considered whether associations between child care characteristics and children’s development varied as a function of child gender and race/ethnicity. Before delving into the results of these analyses it is important to consider whether there are significant differences related to child gender and race/ethnicity when it comes to our primary variables of interest. There were no significant differences in average levels of behavior problems by gender or race/ethnicity at wave 1 or wave 3. Nor were there significant differences in average child care characteristics by child gender. Characteristics of child care experiences were similar by race/ethnicity as well, with the exception that the average level of child care quality of children falling into the White/Other race/ethnic category was significantly higher than the average level of quality for both African American and Hispanic children.

Child Care Characteristics and Gender

Regression results indicated that child gender moderated the link between child care quality and children’s functioning (see Table 3 ). Specifically, high-quality child care appeared to be especially protective for boys’ development of internalizing behavior problems. The results for externalizing behavior problems suggest a similar pattern, but the interaction term did not reach statistical significance. A standard deviation increase in the child care quality composite was associated with .37 more of a standard deviation decline in internalizing behavior problems for boys when compared to girls. There was also some evidence to suggest that child care type showed different patterned links with boys’ and girls’ behavior problems, with a tendency for center care (i.e., one wave of center care and two waves of consistent center care) to be more protective for girls than boys when it came to the development of internalizing problems, when comparing center care to home-based care. This same pattern emerged for externalizing behavior problems, but this interaction was not statistically significant. Finally, consistent with the results of the main effects models, no significant associations were observed between the extent of child care and the development of behavior problems for boys or girls.

Interaction Models Examining the Influence of Child Care Characteristics on the Development of Behavior Problems in Middle Childhood

t < .10

Child Care Characteristics and Race/Ethnicity

The association between child care quality and behavior problems in middle childhood also varied as a function of race/ethnicity. The results presented in Table 3 show that child care quality seemed to be especially protective against the development of behavior problems among African American children. Greater child care quality was related to significantly greater reductions in externalizing behavior problems for African American children than for both Hispanic and White/other children. Although this interaction between child care quality and child race/ethnicity did not reach statistical significance for internalizing behavior problems, the same pattern of results emerged.

Utilizing multi-method data from a representative sample of young children in low-income neighborhoods, this study extends existing research by assessing longer term effects of child care characteristics on the development of behavior problems through middle childhood. In this analysis, we asked whether three aspects of child care experiences predicted behavior problems: the global developmental quality of care, the extent of care, and care type. It is important to note that in this study, we assessed children’s experiences in child care during their preschool years; the data did not include information on nonparental care during infancy.

The Importance of Child Care Quality

The most consistent results from this analysis highlight the importance of the quality of care in the reduction of problem behaviors. Using well-validated, standardized observational measures of the global developmental quality of the care provided by child care settings and controlling for the type and extent of care, we found that higher quality care was protective against the development of behavior problems in middle childhood. Children who attended more responsive, stimulating, and well-structured care settings than their peers during their preschool years showed reductions in externalizing behavior problems by mid-elementary school. The pattern of results was similar for internalizing behavior problems, though insufficiently precise to reach statistical significance. This means, of course, that the reverse was true as well: children attending lower quality child care showed more elevated behavior problems than their peers by mid-elementary school.

These results extend a very limited and contradictory base of research concerning whether child care quality shows longer-term links with socioemotional functioning into middle childhood. Peisner-Feinberg and colleagues (2001) , for instance, found positive effects of close teacher-child relationships but not global developmental quality on 2 nd graders’ social functioning, whereas other research has unearthed longer-term benefits of high quality care on cognitive skills but not socioemotional functioning into middle childhood. For example, the NICHD study found that high quality care from birth through age 5 predicted higher cognitive scores in third and fifth grades ( NICHD ECCRN, 2005 ; Belsky et al., 2007 ), but found no effects on behavior problems or socioemotional functioning among their notably more advantaged sample.

Why might our results differ so substantially from those derived from more economically advantaged samples? A risk and resilience framework may be useful in reconciling these differences ( Masten, Best, & Garmezy, 1990 ). Children in our sample, primarily from ethnic minority, single-parent families with extremely limited economic resources and residing in high poverty urban neighborhoods, likely faced an accumulation of risks across multiple contexts. While most children have the resources to cope with one risk without serious developmental consequences, the cumulative risk perspective suggests that the accumulation of risk across settings leaves children vulnerable to maladaptive psychosocial functioning ( Friedman & Chase-Lansdale, 2002 ). Faced with contextual risks from multiple sources, high quality, responsive, and stimulating child care settings may serve as a protective factor, or source of resilience, for young children to avoid problematic behavior and to develop nascent emotional and behavioral skills in self-regulation, peer interactions, and conflict management during their early school years. Similarly, low quality child care may exacerbate the existing risks children experience. Indeed, it is interesting to note that the current results show stronger and more consistent effects of child care quality on behavior problems than found by Votruba-Drzal and colleagues (2004) looking at short-term effects predicting children’s well-being during early childhood.

A second set of core findings from this study indicated that particular subgroups of children were driving our findings related to child care quality. Based upon bioecological theory which suggests that the effects of contextual experiences may differ in response to characteristics of the individual, we hypothesized that child gender and race/ethnicity may moderate links between child care and children’s development of behavior problems. Our results supported this hypothesis. Regarding gender, our findings suggest that higher quality early education and care experiences were particularly important for boys. Child care quality more strongly predicted a decline in boys’ than girls’ internalizing behavior problems and a similar pattern of results was evident for externalizing problems though it was not statistically significant. The behavior problems of boys may be more responsive to the quality of their early nonmaternal care arrangements due to their greater challenges with self-regulation, wherein boys tend to have lower levels of inhibitory control and physiological regulation than girls ( Kochanska, et al., 1996 ; Dettling, Parker, Lane, Sebanc, & Gunnar, 2000 ). Moreover, during preschool, boys’ peer interactions appear to incorporate more conflict and roughness than girls’ play, with the latter involving more verbal interactions and cooperation ( Fabes, et al., 2003 ; Maccoby, 1998 ). Thus, as noted by Votruba-Drzal and colleagues (2004) , more responsive and well structured child care settings may provide an important support to boys in helping to regulate their behaviors and emotions and supervise their play in a productive manner.

In addition to this gender moderation, results also found that race/ethnicity was important. More specifically, child care quality was particularly protective against the development of behavior problems for African American children when compared to Hispanic and White/other children. When they were cared for in high quality settings, African American children experienced greater declines in externalizing behavior problems than both Hispanic and White/other children. The same pattern of results emerged for internalizing problems, though the interactions were not statistically significant. These results may be related to the greater acceptance and wider use of formal child care and maternal employment among African American children, resulting in a better match between families’ goals and expectations and child care settings. As noted by Johnson and colleagues (2003) , in understanding ethnic minority families’ experiences in child care we must attend to their broader cultural and ecological contexts. Based upon theories of person-environment fit and models of competency in children of color ( Garcia Coll et al., 1996 ; Johnson et al., 2003 ), this conceptualization argues that children’s development must be understood in context, with minority children’s contexts affected by their social and cultural location. Hispanic families may have fewer social norms concerning maternal employment and nonmaternal care provision; they also may experience greater disconnects between the language environment of child care settings and home settings ( Magnuson & Waldfogel, 2005 ). Indeed, other research has found that Hispanic parents, particularly in immigrant families, are less likely to access a broad range of social services in addition to formal child care and these restrictions are linked with poorer outcomes for children ( Kalil & Chen, in press ).

If the context of the care setting provides a stronger fit with the family preferences and cultural norms of African American children, whereas language or cultural disconnects between home and care settings inhibit person-environment fit for Hispanic children, we would expect that supportive characteristics of care settings such as high quality, structured, responsive care giving would have a stronger beneficial effect on African American children’s development. Supporting the tenets of bioecological theory, this proposition argues that environmental experiences (e.g., child care) are both affected by and interact with individual characteristics of the child and family. Indeed, other research with the Three-City Study child care sample found that African American mothers reported greater satisfaction with their child’s care setting than did Hispanic and White mothers, and also reported (nonsignificantly) higher levels of communication and comfort with the care provider (Coley et al., 2006). Future research should seek to explore these interactions more closely, for example assessing whether a match between the language or ethnicity of the care provider and the child improves the quality of the child’s care experiences and enhances the beneficial effects of high quality care or the detrimental effects of early entry or long hours in nonparental care settings on children’s development.

It is interesting to note that the stronger beneficial effects of child care quality for African American than for Hispanic children found in the current research contrast with a lack of ethnic moderation found in larger-scale studies assessed by Burchinal and Cryer (2003) . As the authors remind us, those larger-scale studies included extremely small samples of Latino families and excluded families who were not fluent in English. They also had small groups of low-income families. Though our sample is smaller, it is representative of low-income families in our three cities, and includes both English and Spanish speaking Hispanic children, with approximately 20% of children residing in immigrant families. It is possible that this more representative sample of low-income, ethnic minority children was better poised to unearth important ethnic differences in the effects of child care on children, over a longer time period. Given the paucity of research in this arena and the continuing notable expansion of ethnic diversity in the U.S., continued assessment of ethnic and cultural variation in child care effects on child well-being is clearly warranted.

Limited Results for Child Care Type and Extent

In addition to the quality of child care, this study also assessed the effect of child care type and the extent of use. As mentioned previously, studies using data from the NICHD SECCYD and the ECLS-K have uncovered harmful effects of extensive or early-initiated child care on behavior problems, some of which endure in middle childhood ( Belsky et al., 2007 ; Loeb et al., 2007 ). Similarly, these studies have found that the use of center-based care is linked with heightened behavior problems continuing into elementary school, albeit also with enhanced cognitive skills ( Belsky et al., 2007 ; Loeb et al., 2007 ; Magnuson et al., 2007 ; NICHD ECCRN & Duncan 2003 ). These patterns were not replicated in this study. Categorizing children’s preschool experiences over two waves as being housed consistently in home care settings, consistently in formal center care, or inconsistently in center care, and measuring the hours per week children experienced child care, we found that neither care type nor extent were linked to behavior problems in middle childhood. One exception to this pattern was a trend finding which suggested that center care in comparison to home-based care may be beneficial for girls but not boys when it comes to the development of internalizing problems.

In comparing these results to other longitudinal studies, it is important to note that we did not assess hours of care or center care starting in infancy, but focused only on the preschool years. Extensive and large-group care settings may be more taxing for infants and toddlers than preschool-age children. Moreover, returning to the risk and resilience perspective noted above, it is possible that for children in high poverty neighborhoods and families, the challenges of center care or extensive child care may not pose a measurable burden in isolation. Facing enhanced rates of residential moves and relationship transitions in comparison to advantaged families, poor children may react in a less discernable fashion to the extent and type of child care, with process variables like quality holding greater importance. Indeed, a previous shorter-term study with the Three-City Study sample found that extent of care was linked with behavior problems only in interaction with the quality of care: more extensive experience in high quality care predicted decreased behavior problems, whereas extensive experience in low-quality care predicted increases in behavior problems ( Votruba-Drzal et al., 2004 ).

Conclusions

This study provides an important addition to existing research on child care arrangements and children’s developmental trajectories. Overall, our results highlight the importance of the developmental quality of care experiences for disadvantaged young children, arguing that high quality child care experiences can have a sustained influence on children’s behavioral functioning, through their transition to formal schooling and into middle childhood. Early child care quality is important for understanding low-income children’s ability to function effectively in school, get along with their peers, and control their impulses. Future research should seek to assess a broader array of behavioral and emotional functioning measures, for example assessing prosocial behaviors and social skills.

This study has several strengths. One is the sampling of the Three-City Study, which provides an in-depth look at a representative sample of young children and their families living in economic disadvantage, at both the family and community levels, in three cities. As such, this sample, whose experiences of urban poverty place children at notable risk for maladaptive social functioning, represents a population of significant concern to policy makers and practitioners. Increasing understanding of what types of supportive services can enhance the well-being of such children is of paramount importance for practitioners and policy makers. Moreover, our study focuses on children and families’ experiences in community care, which are the care settings that disadvantaged parents have been able to access in their communities. Although model early intervention studies have provided centrally important information on how to productively intervene and provide bundles of high-quality services to disadvantaged families, such studies cannot tell us whether their findings can be generalized to the types of services to which disadvantaged families actually have access.

It is also important to point out limitations of the current study. As in all nonexperimental work, we cannot draw causal conclusions from the results, and remain cognizant that the links detected here, between child care environments and children’s developmental trajectories, could be due to selection or other unmeasured variables. The inclusion of child and family characteristics as well as earlier child functioning lessens the likelihood of such alternative explanations. Still, we were not able to control for characteristics of important contexts, such as schools and homes, in the years between preschool and middle childhood. If these were correlated with child care characteristics, this would threaten the validity of our results. The analytic sample was also relatively small, and representative of a particular population of disadvantaged urban families. Although attention was paid to carefully measuring characteristics of both child care centers and more informal home arrangements, this study was not able to compare children’s experiences in maternal care to those of their peers in child care settings. Continued careful analysis of early child care environments and children’s development using diverse samples and multiple methods that include measures of both behavior problems and social competence will help the field to triangulate evidence of how child care can support low-income children’s healthy development. Further studies can also more carefully assess individual children’s experiences in child care settings (rather than a more global classroom and group-level assessments obtained through measures such as the ECERS, FDCRS and Arnett). Such research might shed light on the differential patterns related to child gender and ethnicity unearthed here.

Finally, studies have raised questions about the validity of the CBCL for high poverty or ethnic minority children and the results of these studies are mixed. Some have validated the CBCL with low-income, African-American, and Latino families ( Gross, Young, Fogg, Ridge, Cowell, Richardson, & Sivan 2006 ; Sivan, Ridge, Gross, Richardson, & Cowell, 2008 ), whereas others have uncovered problems with using CBCL norms for these populations ( Raadal, Milgrom, Cauce, Mancl, 1994 ; Sandberg, Meyer-Bahlburg, & Yager, 1991 ). Thus, it is important for our findings to be replicated using alternative measures of behavior problems. In sum, this paper is part of a new generation of child care research that is taking a more nuanced approached to multiple dimensions of children’s experiences in child care. With a sizable sample, valid, reliable, and longitudinal measures and rigorous statistical methodology, we have increasing confidence that child care quality is an important factor in the developmental trajectories of young children in poverty. The results of the present study add to a growing body of empirical evidence suggesting the need for policy and programmatic efforts to increase low-income families’ access to high quality child care.

Acknowledgments

We gratefully acknowledge the support of the following organizations. University of Pittsburgh’s Central Research Development Fund’s Small Grants Program. Government agencies: National Institute of Child Health and Human Development (R03 HD057294 “Child Care Resources in Low-Income Communities” & RO1 HD36093 “Welfare Reform and the Well-Being of Children”), Office of the Assistant Secretary of Planning and Evaluation, Administration on Developmental Disabilities, Administration for Children and Families, Social Security Administration, and National Institute of Mental Health. Foundations: The Boston Foundation, The Annie E. Casey Foundation, The Edna McConnell Clark Foundation, The Lloyd A. Fry Foundation, The Hogg Foundation for Mental Health, The Robert Wood Johnson Foundation, The Joyce Foundation, The Henry J. Kaiser Family Foundation, The W.K. Kellogg Foundation, The Kronkosky Charitable Foundation, The John D. and Catherine T. MacArthur Foundation, The Charles Stewart Mott Foundation, The David and Lucile Packard Foundation, The Searle Fund for Policy Research, and The Woods Fund of Chicago. A special thank you is also extended to the families who participated in the Three-City Study.

Contributor Information

Elizabeth Votruba-Drzal, Department of Psychology, University of Pittsburgh.

Rebekah Levine Coley, Applied Developmental and Educational Psychology, Lynch School of Education, Boston College.

Carolina Maldonado-Carreño, Department of Psychology, Universidad de Los Andes, Bogotá-Colombia.

Christine Li-Grining, Department of Psychology, Loyola University of Chicago.

P. Lindsay Chase-Lansdale, Human Development and Social Policy Program, Northwestern University.

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New study: Spending more time in a child care center does not lead to problem behavior for kids

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Parents have a lot on their minds when they send their children to child care. Will the child cry during drop-off, eat or skip a nap? 

But a new study shows there is one thing parents may not need to be concerned about: whether kids’ time spent in a child care center will lead to problem behavior. 

The study, written by researchers in North America and Europe and published in Child Development last month, looked at data from seven studies on more than 10,000 toddlers and preschoolers in Germany, the Netherlands, Norway, Canada and the United States. The report found “little evidence” that behavior problems, including hitting, kicking, biting, fighting or bullying other children, increase as children spend more time in a child care center. 

“Finding there is not this causal link between children spending time in child care and having more externalizing problems is very reassuring for parents,” said Catalina Rey-Guerra, the lead researcher, a doctoral candidate at Boston College and a fellow at the college’s Institute of Early Childhood Policy. The results also bolster findings showing that early childhood education can have a positive effect on children, she added.

The report adds to a growing body of research on the link between time spent in child care and negative behaviors, much of which has yielded mixed results. A 2019 report on Quebec’s universal preschool program, for example, found children who were placed in participating child care programs had higher rates of aggression and illness, as reported by parents, than their peers living elsewhere in Canada. Those negative effects also persisted into adulthood. (Some suggested that program quality was the issue, as many children enrolled in participating child care centers may have had higher-quality environments at home compared to the care environments.) Similarly, a 2007 study of children in the United States found more time in center-based care was linked to teacher-reported problem behavior later in elementary school.  

However, other studies have found no relation between child care enrollment and problem behavior or even the opposite effect, with children cared for primarily by their mothers — especially in high-risk families — showing more physical aggression than those attending group care. 

Over the years, researchers have suggested theories for why some studies have found negative impacts on behavior that seem to be linked with time spent in child care centers. These include the ideas that child care may diminish a child’s attachment to a parent or children may learn bad behavior from peers. These theories have not been proven, Rey-Guerra said. The findings are more likely due to poor caregiver-child relationships and negative peer interactions, according to a 2015 study. That study also found behavior problems were reduced in high quality care. 

The new report did not look at the quality of centers, an aspect other research has shown can impact child outcomes beyond behavior. However, Rey-Guerra said researchers tried to go beyond previous research on the issue of child care quantity and behavior to examine potential factors that could impact a child’s behavior, including family income and maternal education. Even when considering these factors, the results showing no link between time in child care and poor behavior still held up, she said, making the researchers’ findings “more robust.” These results were consistent across different age groups, a finding that “strengthens the argument that time in child care is not detrimental for children in different developmental periods,” the authors concluded. Researchers also found no correlation between a change in hours spent in center-based care and a change in the amount of problem behavior. 

Still, Rey-Guerra noted the study was constrained to short-term effects. She cautioned against applying the findings to countries outside of the study, since the included countries are industrialized, wealthy nations. While this study expanded the scope of previous research by looking at countries outside of the United States and Canada, she said there’s “still this lingering question of, ‘Would this then be also generalizable to other types of societies, to other political contexts?” 

This story about center-based care was produced by The Hechinger Report , a nonprofit, independent news organization focused on inequality and innovation in education. Sign up for Hechinger’s newsletter .

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CapMetro daycare center to stay open for another year, previously at risk of closure

AUSTIN (KXAN) — Parents using CapMetro’s child care center are breathing a sigh of relief.

The CapMetro’s Board of Directors considered closing the center, but instead voted to extend the daycare program for another year.

It’s a temporary fix while they figure out a more permanent solution that addresses the cost of running it.

CapMetro is considering other options like childcare assistance stipends for employees and discounted rates for CapMetro families at alternative childcare providers.

The resolution directed staff to research different options and report back to the board in July with their findings.

Background of child center

CapMetro said it first opened the Capital Metro Child Care & Early Learning Center in 2006 to support its staff and their families.

It was income-based tuition subsidized by CapMetro. They contracted with Bright Horizons to operate the center since it opened.

According to the organization, it opened up the center to the community at large in 2012 to help offset increasing costs to keep the center open.

Since then, employee enrollment has gone down and the cost to keep the center running has gone up.

CapMetro families using the center:

• December 2018: 13
• December 2019: 6
• December 2020: 10
• December 2021: 8
• December 2022: 7
• December 2023: 6
• January 2024: 8

Community families using the center:

• December 2018: 51
• December 2019: 47
• December 2020: 44
• December 2021: 48
• December 2022: 42
• December 2023: 43
• January 2024: 44

On Monday, board member Dianne Bangle said the few families enrolled are costing thousands of dollars.

“Authorizing a contract that provides almost $85,000 in subsidy for each of the eight families,” Bangle. “It just doesn’t make sense.”

Board member Chito Vela said the center’s hours of operations could be contributing to the low enrollment numbers.

“It’s really not a good match, especially for the really tough bus operator, bus driver hours,” Vela said. “My concern is that it doesn’t serve our blue collar employees very well. That’s who needs the most help.”

Ultimately, a majority of the board agreed it was important to extend the contract so it could allow for more time to consider other childcare options for employees.

‘These are my families’

Before the vote, families packed the board room and expressed their outrage.

“East Austin is a childcare desert,” said parent Christina Ly.

One parent emotionally told the board that many of the teachers have been caring for their kids since 2006.

A teacher at the daycare was among those who spoke out against the potential closure.

While the long-term future of the center is unknown, parents like Ian Dorish are grateful his daughter will have more time there.

“Every single day you go in there, there’s such smiles on everybody’s face,” Dorish said. “The actual progress of my daughter as a toddler has been very impressive.”

Not enough supply

This discussion comes at a time when there aren’t enough childcare centers available for families.

“We struggled looking for daycare,” Dorish said. “We had no idea how long the waitlists and the problems were.”

Senior Research Fellow at Urban Institute Diane Schilder said she found that both nationally and in Austin, the demand far outpaces the supply of available care.

“Potentially about 56,000 young children in need of childcare,” Schilder said. “The number of licensed slots is woefully insufficient to meet that demand.”

Schilder said not only are there waitlists, but the cost of childcare is a barrier as well.

For the latest news, weather, sports, and streaming video, head to KXAN Austin.

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What the data says about abortion in the U.S.

Pew Research Center has conducted many surveys about abortion over the years, providing a lens into Americans’ views on whether the procedure should be legal, among a host of other questions.

In a  Center survey  conducted nearly a year after the Supreme Court’s June 2022 decision that  ended the constitutional right to abortion , 62% of U.S. adults said the practice should be legal in all or most cases, while 36% said it should be illegal in all or most cases. Another survey conducted a few months before the decision showed that relatively few Americans take an absolutist view on the issue .

Find answers to common questions about abortion in America, based on data from the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, which have tracked these patterns for several decades:

How many abortions are there in the U.S. each year?

How has the number of abortions in the u.s. changed over time, what is the abortion rate among women in the u.s. how has it changed over time, what are the most common types of abortion, how many abortion providers are there in the u.s., and how has that number changed, what percentage of abortions are for women who live in a different state from the abortion provider, what are the demographics of women who have had abortions, when during pregnancy do most abortions occur, how often are there medical complications from abortion.

This compilation of data on abortion in the United States draws mainly from two sources: the Centers for Disease Control and Prevention (CDC) and the Guttmacher Institute, both of which have regularly compiled national abortion data for approximately half a century, and which collect their data in different ways.

The CDC data that is highlighted in this post comes from the agency’s “abortion surveillance” reports, which have been published annually since 1974 (and which have included data from 1969). Its figures from 1973 through 1996 include data from all 50 states, the District of Columbia and New York City – 52 “reporting areas” in all. Since 1997, the CDC’s totals have lacked data from some states (most notably California) for the years that those states did not report data to the agency. The four reporting areas that did not submit data to the CDC in 2021 – California, Maryland, New Hampshire and New Jersey – accounted for approximately 25% of all legal induced abortions in the U.S. in 2020, according to Guttmacher’s data. Most states, though,  do  have data in the reports, and the figures for the vast majority of them came from each state’s central health agency, while for some states, the figures came from hospitals and other medical facilities.

Discussion of CDC abortion data involving women’s state of residence, marital status, race, ethnicity, age, abortion history and the number of previous live births excludes the low share of abortions where that information was not supplied. Read the methodology for the CDC’s latest abortion surveillance report , which includes data from 2021, for more details. Previous reports can be found at  stacks.cdc.gov  by entering “abortion surveillance” into the search box.

For the numbers of deaths caused by induced abortions in 1963 and 1965, this analysis looks at reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. In computing those figures, we excluded abortions listed in the report under the categories “spontaneous or unspecified” or as “other.” (“Spontaneous abortion” is another way of referring to miscarriages.)

Guttmacher data in this post comes from national surveys of abortion providers that Guttmacher has conducted 19 times since 1973. Guttmacher compiles its figures after contacting every known provider of abortions – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, and it provides estimates for abortion providers that don’t respond to its inquiries. (In 2020, the last year for which it has released data on the number of abortions in the U.S., it used estimates for 12% of abortions.) For most of the 2000s, Guttmacher has conducted these national surveys every three years, each time getting abortion data for the prior two years. For each interim year, Guttmacher has calculated estimates based on trends from its own figures and from other data.

The latest full summary of Guttmacher data came in the institute’s report titled “Abortion Incidence and Service Availability in the United States, 2020.” It includes figures for 2020 and 2019 and estimates for 2018. The report includes a methods section.

In addition, this post uses data from StatPearls, an online health care resource, on complications from abortion.

An exact answer is hard to come by. The CDC and the Guttmacher Institute have each tried to measure this for around half a century, but they use different methods and publish different figures.

The last year for which the CDC reported a yearly national total for abortions is 2021. It found there were 625,978 abortions in the District of Columbia and the 46 states with available data that year, up from 597,355 in those states and D.C. in 2020. The corresponding figure for 2019 was 607,720.

The last year for which Guttmacher reported a yearly national total was 2020. It said there were 930,160 abortions that year in all 50 states and the District of Columbia, compared with 916,460 in 2019.

• How the CDC gets its data: It compiles figures that are voluntarily reported by states’ central health agencies, including separate figures for New York City and the District of Columbia. Its latest totals do not include figures from California, Maryland, New Hampshire or New Jersey, which did not report data to the CDC. ( Read the methodology from the latest CDC report .)
• How Guttmacher gets its data: It compiles its figures after contacting every known abortion provider – clinics, hospitals and physicians’ offices – in the country. It uses questionnaires and health department data, then provides estimates for abortion providers that don’t respond. Guttmacher’s figures are higher than the CDC’s in part because they include data (and in some instances, estimates) from all 50 states. ( Read the institute’s latest full report and methodology .)

While the Guttmacher Institute supports abortion rights, its empirical data on abortions in the U.S. has been widely cited by  groups  and  publications  across the political spectrum, including by a  number of those  that  disagree with its positions .

These estimates from Guttmacher and the CDC are results of multiyear efforts to collect data on abortion across the U.S. Last year, Guttmacher also began publishing less precise estimates every few months , based on a much smaller sample of providers.

The figures reported by these organizations include only legal induced abortions conducted by clinics, hospitals or physicians’ offices, or those that make use of abortion pills dispensed from certified facilities such as clinics or physicians’ offices. They do not account for the use of abortion pills that were obtained  outside of clinical settings .

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The annual number of U.S. abortions rose for years after Roe v. Wade legalized the procedure in 1973, reaching its highest levels around the late 1980s and early 1990s, according to both the CDC and Guttmacher. Since then, abortions have generally decreased at what a CDC analysis called  “a slow yet steady pace.”

Guttmacher says the number of abortions occurring in the U.S. in 2020 was 40% lower than it was in 1991. According to the CDC, the number was 36% lower in 2021 than in 1991, looking just at the District of Columbia and the 46 states that reported both of those years.

(The corresponding line graph shows the long-term trend in the number of legal abortions reported by both organizations. To allow for consistent comparisons over time, the CDC figures in the chart have been adjusted to ensure that the same states are counted from one year to the next. Using that approach, the CDC figure for 2021 is 622,108 legal abortions.)

There have been occasional breaks in this long-term pattern of decline – during the middle of the first decade of the 2000s, and then again in the late 2010s. The CDC reported modest 1% and 2% increases in abortions in 2018 and 2019, and then, after a 2% decrease in 2020, a 5% increase in 2021. Guttmacher reported an 8% increase over the three-year period from 2017 to 2020.

As noted above, these figures do not include abortions that use pills obtained outside of clinical settings.

Guttmacher says that in 2020 there were 14.4 abortions in the U.S. per 1,000 women ages 15 to 44. Its data shows that the rate of abortions among women has generally been declining in the U.S. since 1981, when it reported there were 29.3 abortions per 1,000 women in that age range.

The CDC says that in 2021, there were 11.6 abortions in the U.S. per 1,000 women ages 15 to 44. (That figure excludes data from California, the District of Columbia, Maryland, New Hampshire and New Jersey.) Like Guttmacher’s data, the CDC’s figures also suggest a general decline in the abortion rate over time. In 1980, when the CDC reported on all 50 states and D.C., it said there were 25 abortions per 1,000 women ages 15 to 44.

That said, both Guttmacher and the CDC say there were slight increases in the rate of abortions during the late 2010s and early 2020s. Guttmacher says the abortion rate per 1,000 women ages 15 to 44 rose from 13.5 in 2017 to 14.4 in 2020. The CDC says it rose from 11.2 per 1,000 in 2017 to 11.4 in 2019, before falling back to 11.1 in 2020 and then rising again to 11.6 in 2021. (The CDC’s figures for those years exclude data from California, D.C., Maryland, New Hampshire and New Jersey.)

The CDC broadly divides abortions into two categories: surgical abortions and medication abortions, which involve pills. Since the Food and Drug Administration first approved abortion pills in 2000, their use has increased over time as a share of abortions nationally, according to both the CDC and Guttmacher.

The majority of abortions in the U.S. now involve pills, according to both the CDC and Guttmacher. The CDC says 56% of U.S. abortions in 2021 involved pills, up from 53% in 2020 and 44% in 2019. Its figures for 2021 include the District of Columbia and 44 states that provided this data; its figures for 2020 include D.C. and 44 states (though not all of the same states as in 2021), and its figures for 2019 include D.C. and 45 states.

Guttmacher, which measures this every three years, says 53% of U.S. abortions involved pills in 2020, up from 39% in 2017.

Two pills commonly used together for medication abortions are mifepristone, which, taken first, blocks hormones that support a pregnancy, and misoprostol, which then causes the uterus to empty. According to the FDA, medication abortions are safe  until 10 weeks into pregnancy.

Surgical abortions conducted  during the first trimester  of pregnancy typically use a suction process, while the relatively few surgical abortions that occur  during the second trimester  of a pregnancy typically use a process called dilation and evacuation, according to the UCLA School of Medicine.

In 2020, there were 1,603 facilities in the U.S. that provided abortions,  according to Guttmacher . This included 807 clinics, 530 hospitals and 266 physicians’ offices.

While clinics make up half of the facilities that provide abortions, they are the sites where the vast majority (96%) of abortions are administered, either through procedures or the distribution of pills, according to Guttmacher’s 2020 data. (This includes 54% of abortions that are administered at specialized abortion clinics and 43% at nonspecialized clinics.) Hospitals made up 33% of the facilities that provided abortions in 2020 but accounted for only 3% of abortions that year, while just 1% of abortions were conducted by physicians’ offices.

Looking just at clinics – that is, the total number of specialized abortion clinics and nonspecialized clinics in the U.S. – Guttmacher found the total virtually unchanged between 2017 (808 clinics) and 2020 (807 clinics). However, there were regional differences. In the Midwest, the number of clinics that provide abortions increased by 11% during those years, and in the West by 6%. The number of clinics  decreased  during those years by 9% in the Northeast and 3% in the South.

The total number of abortion providers has declined dramatically since the 1980s. In 1982, according to Guttmacher, there were 2,908 facilities providing abortions in the U.S., including 789 clinics, 1,405 hospitals and 714 physicians’ offices.

The CDC does not track the number of abortion providers.

In the District of Columbia and the 46 states that provided abortion and residency information to the CDC in 2021, 10.9% of all abortions were performed on women known to live outside the state where the abortion occurred – slightly higher than the percentage in 2020 (9.7%). That year, D.C. and 46 states (though not the same ones as in 2021) reported abortion and residency data. (The total number of abortions used in these calculations included figures for women with both known and unknown residential status.)

The share of reported abortions performed on women outside their state of residence was much higher before the 1973 Roe decision that stopped states from banning abortion. In 1972, 41% of all abortions in D.C. and the 20 states that provided this information to the CDC that year were performed on women outside their state of residence. In 1973, the corresponding figure was 21% in the District of Columbia and the 41 states that provided this information, and in 1974 it was 11% in D.C. and the 43 states that provided data.

In the District of Columbia and the 46 states that reported age data to  the CDC in 2021, the majority of women who had abortions (57%) were in their 20s, while about three-in-ten (31%) were in their 30s. Teens ages 13 to 19 accounted for 8% of those who had abortions, while women ages 40 to 44 accounted for about 4%.

The vast majority of women who had abortions in 2021 were unmarried (87%), while married women accounted for 13%, according to  the CDC , which had data on this from 37 states.

In the District of Columbia, New York City (but not the rest of New York) and the 31 states that reported racial and ethnic data on abortion to  the CDC , 42% of all women who had abortions in 2021 were non-Hispanic Black, while 30% were non-Hispanic White, 22% were Hispanic and 6% were of other races.

Looking at abortion rates among those ages 15 to 44, there were 28.6 abortions per 1,000 non-Hispanic Black women in 2021; 12.3 abortions per 1,000 Hispanic women; 6.4 abortions per 1,000 non-Hispanic White women; and 9.2 abortions per 1,000 women of other races, the  CDC reported  from those same 31 states, D.C. and New York City.

For 57% of U.S. women who had induced abortions in 2021, it was the first time they had ever had one,  according to the CDC.  For nearly a quarter (24%), it was their second abortion. For 11% of women who had an abortion that year, it was their third, and for 8% it was their fourth or more. These CDC figures include data from 41 states and New York City, but not the rest of New York.

Nearly four-in-ten women who had abortions in 2021 (39%) had no previous live births at the time they had an abortion,  according to the CDC . Almost a quarter (24%) of women who had abortions in 2021 had one previous live birth, 20% had two previous live births, 10% had three, and 7% had four or more previous live births. These CDC figures include data from 41 states and New York City, but not the rest of New York.

The vast majority of abortions occur during the first trimester of a pregnancy. In 2021, 93% of abortions occurred during the first trimester – that is, at or before 13 weeks of gestation,  according to the CDC . An additional 6% occurred between 14 and 20 weeks of pregnancy, and about 1% were performed at 21 weeks or more of gestation. These CDC figures include data from 40 states and New York City, but not the rest of New York.

About 2% of all abortions in the U.S. involve some type of complication for the woman , according to an article in StatPearls, an online health care resource. “Most complications are considered minor such as pain, bleeding, infection and post-anesthesia complications,” according to the article.

The CDC calculates  case-fatality rates for women from induced abortions – that is, how many women die from abortion-related complications, for every 100,000 legal abortions that occur in the U.S .  The rate was lowest during the most recent period examined by the agency (2013 to 2020), when there were 0.45 deaths to women per 100,000 legal induced abortions. The case-fatality rate reported by the CDC was highest during the first period examined by the agency (1973 to 1977), when it was 2.09 deaths to women per 100,000 legal induced abortions. During the five-year periods in between, the figure ranged from 0.52 (from 1993 to 1997) to 0.78 (from 1978 to 1982).

The CDC calculates death rates by five-year and seven-year periods because of year-to-year fluctuation in the numbers and due to the relatively low number of women who die from legal induced abortions.

In 2020, the last year for which the CDC has information , six women in the U.S. died due to complications from induced abortions. Four women died in this way in 2019, two in 2018, and three in 2017. (These deaths all followed legal abortions.) Since 1990, the annual number of deaths among women due to legal induced abortion has ranged from two to 12.

The annual number of reported deaths from induced abortions (legal and illegal) tended to be higher in the 1980s, when it ranged from nine to 16, and from 1972 to 1979, when it ranged from 13 to 63. One driver of the decline was the drop in deaths from illegal abortions. There were 39 deaths from illegal abortions in 1972, the last full year before Roe v. Wade. The total fell to 19 in 1973 and to single digits or zero every year after that. (The number of deaths from legal abortions has also declined since then, though with some slight variation over time.)

The number of deaths from induced abortions was considerably higher in the 1960s than afterward. For instance, there were 119 deaths from induced abortions in  1963  and 99 in  1965 , according to reports by the then-U.S. Department of Health, Education and Welfare, a precursor to the Department of Health and Human Services. The CDC is a division of Health and Human Services.

Note: This is an update of a post originally published May 27, 2022, and first updated June 24, 2022.

Support for legal abortion is widespread in many countries, especially in Europe

Nearly a year after roe’s demise, americans’ views of abortion access increasingly vary by where they live, by more than two-to-one, americans say medication abortion should be legal in their state, most latinos say democrats care about them and work hard for their vote, far fewer say so of gop, positive views of supreme court decline sharply following abortion ruling, most popular.

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Healthy Living with Diabetes

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How can I plan what to eat or drink when I have diabetes?

How can physical activity help manage my diabetes, what can i do to reach or maintain a healthy weight, should i quit smoking, how can i take care of my mental health, clinical trials for healthy living with diabetes.

Healthy living is a way to manage diabetes . To have a healthy lifestyle, take steps now to plan healthy meals and snacks, do physical activities, get enough sleep, and quit smoking or using tobacco products.

Healthy living may help keep your body’s blood pressure , cholesterol , and blood glucose level, also called blood sugar level, in the range your primary health care professional recommends. Your primary health care professional may be a doctor, a physician assistant, or a nurse practitioner. Healthy living may also help prevent or delay health problems  from diabetes that can affect your heart, kidneys, eyes, brain, and other parts of your body.

Making lifestyle changes can be hard, but starting with small changes and building from there may benefit your health. You may want to get help from family, loved ones, friends, and other trusted people in your community. You can also get information from your health care professionals.

What you choose to eat, how much you eat, and when you eat are parts of a meal plan. Having healthy foods and drinks can help keep your blood glucose, blood pressure, and cholesterol levels in the ranges your health care professional recommends. If you have overweight or obesity, a healthy meal plan—along with regular physical activity, getting enough sleep, and other healthy behaviors—may help you reach and maintain a healthy weight. In some cases, health care professionals may also recommend diabetes medicines that may help you lose weight, or weight-loss surgery, also called metabolic and bariatric surgery.

Choose healthy foods and drinks

There is no right or wrong way to choose healthy foods and drinks that may help manage your diabetes. Healthy meal plans for people who have diabetes may include

• dairy or plant-based dairy products
• nonstarchy vegetables
• protein foods
• whole grains

Try to choose foods that include nutrients such as vitamins, calcium , fiber , and healthy fats . Also try to choose drinks with little or no added sugar , such as tap or bottled water, low-fat or non-fat milk, and unsweetened tea, coffee, or sparkling water.

Try to plan meals and snacks that have fewer

• foods high in saturated fat
• foods high in sodium, a mineral found in salt
• sugary foods , such as cookies and cakes, and sweet drinks, such as soda, juice, flavored coffee, and sports drinks

Your body turns carbohydrates , or carbs, from food into glucose, which can raise your blood glucose level. Some fruits, beans, and starchy vegetables—such as potatoes and corn—have more carbs than other foods. Keep carbs in mind when planning your meals.

You should also limit how much alcohol you drink. If you take insulin  or certain diabetes medicines , drinking alcohol can make your blood glucose level drop too low, which is called hypoglycemia . If you do drink alcohol, be sure to eat food when you drink and remember to check your blood glucose level after drinking. Talk with your health care team about your alcohol-drinking habits.

Find the best times to eat or drink

Talk with your health care professional or health care team about when you should eat or drink. The best time to have meals and snacks may depend on

• what medicines you take for diabetes
• what your level of physical activity or your work schedule is
• whether you have other health conditions or diseases

Ask your health care team if you should eat before, during, or after physical activity. Some diabetes medicines, such as sulfonylureas  or insulin, may make your blood glucose level drop too low during exercise or if you skip or delay a meal.

Plan how much to eat or drink

You may worry that having diabetes means giving up foods and drinks you enjoy. The good news is you can still have your favorite foods and drinks, but you might need to have them in smaller portions  or enjoy them less often.

For people who have diabetes, carb counting and the plate method are two common ways to plan how much to eat or drink. Talk with your health care professional or health care team to find a method that works for you.

Carb counting

Carbohydrate counting , or carb counting, means planning and keeping track of the amount of carbs you eat and drink in each meal or snack. Not all people with diabetes need to count carbs. However, if you take insulin, counting carbs can help you know how much insulin to take.

Plate method

The plate method helps you control portion sizes  without counting and measuring. This method divides a 9-inch plate into the following three sections to help you choose the types and amounts of foods to eat for each meal.

• Nonstarchy vegetables—such as leafy greens, peppers, carrots, or green beans—should make up half of your plate.
• Carb foods that are high in fiber—such as brown rice, whole grains, beans, or fruits—should make up one-quarter of your plate.
• Protein foods—such as lean meats, fish, dairy, or tofu or other soy products—should make up one quarter of your plate.

If you are not taking insulin, you may not need to count carbs when using the plate method.

Work with your health care team to create a meal plan that works for you. You may want to have a diabetes educator  or a registered dietitian  on your team. A registered dietitian can provide medical nutrition therapy , which includes counseling to help you create and follow a meal plan. Your health care team may be able to recommend other resources, such as a healthy lifestyle coach, to help you with making changes. Ask your health care team or your insurance company if your benefits include medical nutrition therapy or other diabetes care resources.

Talk with your health care professional before taking dietary supplements

There is no clear proof that specific foods, herbs, spices, or dietary supplements —such as vitamins or minerals—can help manage diabetes. Your health care professional may ask you to take vitamins or minerals if you can’t get enough from foods. Talk with your health care professional before you take any supplements, because some may cause side effects or affect how well your diabetes medicines work.

Research shows that regular physical activity helps people manage their diabetes and stay healthy. Benefits of physical activity may include

• lower blood glucose, blood pressure, and cholesterol levels
• better heart health
• healthier weight
• better mood and sleep
• better balance and memory

Talk with your health care professional before starting a new physical activity or changing how much physical activity you do. They may suggest types of activities based on your ability, schedule, meal plan, interests, and diabetes medicines. Your health care professional may also tell you the best times of day to be active or what to do if your blood glucose level goes out of the range recommended for you.

Do different types of physical activity

People with diabetes can be active, even if they take insulin or use technology such as insulin pumps .

Try to do different kinds of activities . While being more active may have more health benefits, any physical activity is better than none. Start slowly with activities you enjoy. You may be able to change your level of effort and try other activities over time. Having a friend or family member join you may help you stick to your routine.

The physical activities you do may need to be different if you are age 65 or older , are pregnant , or have a disability or health condition . Physical activities may also need to be different for children and teens . Ask your health care professional or health care team about activities that are safe for you.

Aerobic activities

Aerobic activities make you breathe harder and make your heart beat faster. You can try walking, dancing, wheelchair rolling, or swimming. Most adults should try to get at least 150 minutes of moderate-intensity physical activity each week. Aim to do 30 minutes a day on most days of the week. You don’t have to do all 30 minutes at one time. You can break up physical activity into small amounts during your day and still get the benefit. 1

Strength training or resistance training

Strength training or resistance training may make your muscles and bones stronger. You can try lifting weights or doing other exercises such as wall pushups or arm raises. Try to do this kind of training two times a week. 1

Balance and stretching activities

Balance and stretching activities may help you move better and have stronger muscles and bones. You may want to try standing on one leg or stretching your legs when sitting on the floor. Try to do these kinds of activities two or three times a week. 1

Some activities that need balance may be unsafe for people with nerve damage or vision problems caused by diabetes. Ask your health care professional or health care team about activities that are safe for you.

Stay safe during physical activity

Staying safe during physical activity is important. Here are some tips to keep in mind.

Drink liquids

Drinking liquids helps prevent dehydration , or the loss of too much water in your body. Drinking water is a way to stay hydrated. Sports drinks often have a lot of sugar and calories , and you don’t need them for most moderate physical activities.

Avoid low blood glucose

Check your blood glucose level before, during, and right after physical activity. Physical activity often lowers the level of glucose in your blood. Low blood glucose levels may last for hours or days after physical activity. You are most likely to have low blood glucose if you take insulin or some other diabetes medicines, such as sulfonylureas.

Ask your health care professional if you should take less insulin or eat carbs before, during, or after physical activity. Low blood glucose can be a serious medical emergency that must be treated right away. Take steps to protect yourself. You can learn how to treat low blood glucose , let other people know what to do if you need help, and use a medical alert bracelet.

Avoid high blood glucose and ketoacidosis

Taking less insulin before physical activity may help prevent low blood glucose, but it may also make you more likely to have high blood glucose. If your body does not have enough insulin, it can’t use glucose as a source of energy and will use fat instead. When your body uses fat for energy, your body makes chemicals called ketones .

High levels of ketones in your blood can lead to a condition called diabetic ketoacidosis (DKA) . DKA is a medical emergency that should be treated right away. DKA is most common in people with type 1 diabetes . Occasionally, DKA may affect people with type 2 diabetes  who have lost their ability to produce insulin. Ask your health care professional how much insulin you should take before physical activity, whether you need to test your urine for ketones, and what level of ketones is dangerous for you.

Take care of your feet

People with diabetes may have problems with their feet because high blood glucose levels can damage blood vessels and nerves. To help prevent foot problems, wear comfortable and supportive shoes and take care of your feet  before, during, and after physical activity.

If you have diabetes, managing your weight  may bring you several health benefits. Ask your health care professional or health care team if you are at a healthy weight  or if you should try to lose weight.

If you are an adult with overweight or obesity, work with your health care team to create a weight-loss plan. Losing 5% to 7% of your current weight may help you prevent or improve some health problems  and manage your blood glucose, cholesterol, and blood pressure levels. 2 If you are worried about your child’s weight  and they have diabetes, talk with their health care professional before your child starts a new weight-loss plan.

You may be able to reach and maintain a healthy weight by

• following a healthy meal plan
• consuming fewer calories
• being physically active
• getting 7 to 8 hours of sleep each night 3

If you have type 2 diabetes, your health care professional may recommend diabetes medicines that may help you lose weight.

Online tools such as the Body Weight Planner  may help you create eating and physical activity plans. You may want to talk with your health care professional about other options for managing your weight, including joining a weight-loss program  that can provide helpful information, support, and behavioral or lifestyle counseling. These options may have a cost, so make sure to check the details of the programs.

Your health care professional may recommend weight-loss surgery  if you aren’t able to reach a healthy weight with meal planning, physical activity, and taking diabetes medicines that help with weight loss.

If you are pregnant , trying to lose weight may not be healthy. However, you should ask your health care professional whether it makes sense to monitor or limit your weight gain during pregnancy.

Both diabetes and smoking —including using tobacco products and e-cigarettes—cause your blood vessels to narrow. Both diabetes and smoking increase your risk of having a heart attack or stroke , nerve damage , kidney disease , eye disease , or amputation . Secondhand smoke can also affect the health of your family or others who live with you.

If you smoke or use other tobacco products, stop. Ask for help . You don’t have to do it alone.

Feeling stressed, sad, or angry can be common for people with diabetes. Managing diabetes or learning to cope with new information about your health can be hard. People with chronic illnesses such as diabetes may develop anxiety or other mental health conditions .

Learn healthy ways to lower your stress , and ask for help from your health care team or a mental health professional. While it may be uncomfortable to talk about your feelings, finding a health care professional whom you trust and want to talk with may help you

• lower your feelings of stress, depression, or anxiety
• manage problems sleeping or remembering things
• see how diabetes affects your family, school, work, or financial situation

Ask your health care team for mental health resources for people with diabetes.

Sleeping too much or too little may raise your blood glucose levels. Your sleep habits may also affect your mental health and vice versa. People with diabetes and overweight or obesity can also have other health conditions that affect sleep, such as sleep apnea , which can raise your blood pressure and risk of heart disease.

NIDDK conducts and supports clinical trials in many diseases and conditions, including diabetes. The trials look to find new ways to prevent, detect, or treat disease and improve quality of life.

What are clinical trials for healthy living with diabetes?

Clinical trials—and other types of clinical studies —are part of medical research and involve people like you. When you volunteer to take part in a clinical study, you help health care professionals and researchers learn more about disease and improve health care for people in the future.

Researchers are studying many aspects of healthy living for people with diabetes, such as

• how changing when you eat may affect body weight and metabolism
• how less access to healthy foods may affect diabetes management, other health problems, and risk of dying
• whether low-carbohydrate meal plans can help lower blood glucose levels
• which diabetes medicines are more likely to help people lose weight

Find out if clinical trials are right for you .

Watch a video of NIDDK Director Dr. Griffin P. Rodgers explaining the importance of participating in clinical trials.

What clinical trials for healthy living with diabetes are looking for participants?

You can view a filtered list of clinical studies on healthy living with diabetes that are federally funded, open, and recruiting at www.ClinicalTrials.gov . You can expand or narrow the list to include clinical studies from industry, universities, and individuals; however, the National Institutes of Health does not review these studies and cannot ensure they are safe for you. Always talk with your primary health care professional before you participate in a clinical study.

This content is provided as a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), part of the National Institutes of Health. NIDDK translates and disseminates research findings to increase knowledge and understanding about health and disease among patients, health professionals, and the public. Content produced by NIDDK is carefully reviewed by NIDDK scientists and other experts.

NIDDK would like to thank: Elizabeth M. Venditti, Ph.D., University of Pittsburgh School of Medicine.

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Attractions and entertainment in Togliatti - what to see on your own

This article has been translated from Russian language using an artificial intelligence-based translation algorithm. We apologize for any inconvenience caused by the quality of the translation. You can read the original of this article in Russian here , and ask questions on the topic of our travel forum in English here .

Unfortunately, there are no significant historical or architectural attractions in Togliatti. Tourists here can visit several museums, including a very worthy Local History Museum, The Museum of the history of the city "heritage", the art and Museum of Modern Art, and the real tourist pride of the city - the Technical Museum. Sakharov, which comes even from other regions. In addition to these museums, there are several small departmental ones operating at enterprises, educational institutions or organizations, but they do not work stably on a schedule, and open their doors to visitors only after a preliminary call.

But Togliatti is convenient to use as a starting point for excursions and hikes in Samara Luka National Park and Zhigulevsky reserve , because you can get to it from here faster, and it is closer than Samara. Other attractions of the Samara region are also available from Togliatti, but most of them can only be accessed by their own transport. See more:

• Sights of Samara
• Sights of the Samara region

As for entertainment in Togliatti for tourists,the city has nothing to surprise. There is everything the same as in any major Russian city: cinemas, nightclubs, large shopping centers, there is a theater, a philharmonic, entertainment parks for children and adults. There is even a diving center that organizes training and diving in the Volga waters, especially interesting places of the flooded Old Town. Sometimes car races are held on the dirt Circuit of the ECC, as well as Christmas races on ice in the vicinity of the city. But there are no special entertainment specifically for tourists here, they are all standard, mainly focused on local residents. There is entertainment for children, but nothing special: there are amusement parks in shopping centers, a city amusement park (carousels, slides, a summer children's water park, etc.), a cart track. In summer there is a mobile zoo, circus Chapiteau.

And we also advise you to see ready-made excursions around Togliatti, with which it will be much more interesting to get acquainted with the city. You can find and Book Group or individual excursions to Togliatti with reviews on these trusted sites:

• 📷 search for excursions in Togliatti on Tripster.ru
• 📷 search for excursions in Togliatti on Sputnik8.com

Below is a list of attractions in Togliatti, as well as places that can be visited from the city, indicating the time of their work, cost and ways to get to them:

You can download ⤓ points of interest, important transport points (bus stations, airports, etc.), districts and beaches from our map in KMZ/KML format. These files can be downloaded to the navigator or smartphone for use with offline or online Google Maps applications, Organic Maps and others that support this format, and use them to navigate and explore resorts.

Attractions in Togliatti

Museum of technology.

Completely this museum is called Park Complex of the history of Technology named after K. G. Sakharov , and the people call it simply "AvtoVAZ Technical Museum" (the old name). This is the most interesting Museum of the city and the real pride of Togliatti, and for good reason, because it is the largest Technical Museum in Europe. Here, on an open-air site on an area of 38 hectares, military and other equipment of the period of the USSR and Russia were placed, in total more than 450 exhibits. There are automobiles, locomotives, space vehicles, armored vehicles, airplanes, artillery, missiles, and even the world's largest diesel-electric submarine, the B-307. Exhibits can be touched, some of them climb and even climb inside, although theoretically the rules of the museum are prohibited. Of course, this museum is mandatory to visit during trips to Togliatti do not spare time and money on it. Learn more about the Technical Museum here...

🕐 Working hours : daily from 08:00 to 17:00, seven days a week; the experimental vehicle hangar is open from April to September from 10:00 to 17:00; submarine excursions are held on Tuesday, Wednesday, Thursday, Friday from 13:00, 15:00; Saturday, Sunday– 11:00, 11:45, 12:30, 14:00, 14:45, 15:30.

💵 Entrance fee / tickets price : adult-200 rubles / children – 100. Visit with excursion accompaniment adult-250 rubles / children – 150. Excursion to the submarine B-307-250 rubles. Hangar of experimental cars – 50 rubles.

🚶 How to get there : the museum is located on the outskirts of the automobile plant district at 137 Yuzhnoye Shosse, opposite the Avtovaz plant ( Museum on the map ).

Local History Museum

This is the main museum of the city, telling about the history of the region from prehistoric times to the Soviet period. The museum exhibits ancient artifacts found in the Volga land, including mammoth bones, tools of the bronze and pre-bronze period. But the main part of the exhibition is a later period. Much is told about the life of peasants and wealthy residents, about the period of formation of the city of Stavropol, its transfer to a new place, and the subsequent renaming to Togliatti. What is good, the museum does not stand still, and new interactive exhibits appear: you can watch a film about the history of the city, create a photo postcard on the screen with old views of the city and your photo, listen and try to guess the singing of birds living in local areas, do archaeological excavations. In general, the museum is not even bad, and worth a visit. A cursory inspection without a tour will take at least an hour. Learn more about the museum here...

🕐 Working hours : Tuesday-Sunday from 10:00 to 18:00, Wednesday from 10:00 to 21:00, Monday – closed. Last Friday of the month-sanitary day.

💵 Entrance fee / tickets price : the museum has several permanent exhibitions, which can be paid separately or a single ticket is purchased. The cost of expositions - from 50 to 100 rubles, a single ticket-200 rubles / schoolchildren, students, pensioners-130 rubles. Excursion service-300 rubles. Audio guide-150 rubles. Videography – 50 rubles, photography-25 rubles.

🚶 How to get there : the museum is located in the Central District of Togliatti at 22 Lenin Boulevard ( Museum on the map . You can get here by minibus 93K, 126, 326 to the stop "Museum of local lore", or to the stop "City Garden", better known as DC Togliatti or DC Sintezkauchuk (old name), almost any bus or minibus, and 10 minutes walk.

City Museum complex "Heritage"

This museum is a real find for the dull tourist face of the city, and guests of Togliatti simply have to visit it. This was based on a log house built at the beginning of the last century, once owned by the family of shoemaker Starikov, and moved from the site of the old flooded city of Stavropol on the Volga, later renamed Togliatti. Inside, the atmosphere of that time is recreated, many of the exhibits are original, belonged to the Starikov family. The exposition itself is not very large, but with excursion accompaniment, a visit to the museum becomes interesting and informative. Learn more about the museum "Legacy" here...

🕐 Working hours : Tuesday-Sunday from 10:00 to 18:00, Wednesday from 10:00 to 21:00, Monday – closed. The last Friday of the month is a sanitary day. It is better to make an appointment in advance by Phone +7 (8482) 487302, since the visit involves a tour.

💵 Entrance fee / tickets price : with excursion accompaniment adults 85 rubles; schoolchildren 70; students, pensioners – 65. Without excursion accompaniment adults 50 rubles; schoolchildren-35; students, pensioners-30.

🚶 How to get there : the museum is located in the Central District, Sovetskaya St., 39 ( Museum on the map ). This is a private sector area, and public transport does not go here, so you need to get there by your own transport, taxi, or get to the Stop "Shop Rubin" on buses No. 22, 73 or minibus № 91, 96, 108, 137, 142, and then 15 minutes on foot.

AvtoVAZ Museum

To visit Togliatti, and not to visit the Museum of Avtovaz is impossible, because it is, after all, the automotive capital of Russia. The museum presents the entire model range of serial Vaz cars, some experimental models, as well as cars with their own history. For example, there is a "Kalina", on which the president of the Russian Federation drove to the Far East and then left his autograph on it; there are auto – winners of races; Niva, who visited the north pole, etc.Also there is a collection of cups, medals and other awards of the plant and cars, documents, photos about the history of the plant. Learn more about the Avtovaz Museum here...

🕐 Working hours : from 10:00 to 12:15 and from 13:00 to 17:00; Saturday from 09:00 to 17:00; Saturday, Sunday – closed.

💵 Entrance fee / tickets price : free.

🚶 How to get there : the museum is located in the building of the Vaz Training Center at 121 Yuzhnoye Shosse ( Museum on the map . If you go by taxi, you need to tell the taxi driver that you need to go to the Vaz training center, and not to the museum, otherwise you will be taken to the Technical Museum. You can get there by bus number 5T, 12, 14, 36, 37, 72, 76, 171, 172, 190 to the stop "personnel department" ; by bus No. 28, 115, 305 or trolleybuses No. 13, 14 to the stop "training center".

Togliatti Art Museum

The only art museum in the city. Here you can get acquainted with the collection of Contemporary Art of the XX-XXI centuries, temporary exhibitions are also held. The main collection includes works of painting, decorative and Applied Arts, graphics, sculpture, children's drawing, glass, mainly by Soviet and Russian artists such as M. P. Konchalovsky, M. K. Kantor, N. N. Brandt, D. A. Nalbandian, L. I. Tabenkin, E. A. Aslamazyan and others. Information about the exhibitions can be found on the official website. Creative workshops and master classes are also held.

🌐 Website: thm-museum.ru

🕐 Working hours : from 10:00 to 18:00; Friday from 10:00 to 21:00; Monday - closed.

💵 Entrance fee / tickets price : with excursion support adults 215 rubles; schoolchildren 140; students, pensioners – 165. Without excursion accompaniment adults 150 rubles; schoolchildren – 75; students, pensioners – 100. During thematic exhibitions, the price may be several times higher, check the schedule of exhibitions on the website.

🚶 How to get there : the museum is located in the Central District of Togliatti at 22 Lenin Boulevard ( Museum on the map ). This is the building of the Local History Museum, the entrance from the end of the building. You can get here by minibus 93K, 126, 326 to the stop "Museum of local lore", or to the stop" City Garden", better known as DC Togliatti or DC Sintezkauchuk (old name), almost any bus or minibus, and 10 minutes walk.

Museum of Modern Art

This is a branch of the Main Art Museum, where exhibitions of contemporary art, master classes, creative workshops are held. This is the only place in the city where you can get acquainted with modern art.

🕐 Working hours : Monday from 10:00 to 18:00; Tuesday-Saturday from 12:00 to 20:00; Sunday – closed.

💵 Entrance fee / tickets price : adults-150 rubles; students, pensioners-100; schoolchildren-75; preschoolers-free of charge. Excursion – 65 rubles.

🚶 How to get there : The museum is located in the avtozavodsky district, Sverdlov STR., 3 ( Museum on the map ). This is a residential building, the museum is located on the first floor. Phone 8(8482) 30-20-95.

Museum of the Institute of ecology of the Volga Basin of the Russian Academy of Sciences

If you ask the locals if they know about the existence of this museum, they will say that this is the first time they have heard about it. Meanwhile, this museum is quite interesting and worthy of visiting, and it will be interesting for children here. Among the exhibits are samples of the oldest rocks from the region, minerals, samples of oil from Devonian deposits, which was mined in the Samara region, fossilized prints of plants and animals, and much more. The only bad thing is that this museum is located at the Institute and therefore works only during working hours, besides it is difficult to get to it. But if you do, you won't regret it. Excursions in the museum are not held, but the museum staff are happy to talk about the exhibits.

🕐 Working hours : Monday, Wednesday and Friday from 09:00 to 15:00, but sometimes closed. Before visiting, it is better to clarify by Phone +7 848 248-97-56.

🚶 How to get there : the museum is located in the forest park zone of the city between the districts in the building of the Institute of ecology of the Volga Basin, Komzina STR., 10 ( Museum on the map . You can get here by trolleybus No. 7 from the Central and Komsomol districts (goes very rarely), route taxis No. 91, 93 (from the automobile and Central Districts), No. 102 (from the automobile and Komsomol districts), No. 310 (from all districts). You need to go to the Park Hotel stop, it's useless to ask the drivers about the museum, no one knows. To find the right transport/bus, local residents and drivers need to ask how to get to the "green zone".

Bayram Art Gallery

"Bayram Art Gallery" is a unique place where guests of the city who are interested in art and culture should get. This is the Creative Studio of the artist Bayram, where he has been creating his works for many years. To visit the gallery, it is best to agree in advance on the time of visit by phone +79178200324 or +79272687149. The call is needed in order to be waited for, MET and answered the questions that you will definitely have while viewing the works and getting acquainted with the artist's workplace. Learn more about Bayram art gallery here...

🌐 Website: art-bairam.ru

🕐 Working hours : from Monday to Friday from 13:00 to 19:00 (with prior arrangement by call), on Saturday and Sunday also by appointment by prior call. Phone numbers: +79178200324 and +79272687149.

🚶 How to get there : the gallery is located in the Avtozavodsky District of Moscow.Togliatti, 16 Block, Tsvetnoy Boulevard, 29A, on the second floor of the building ( gallery on the map ).

Victory Park

Victory Park is one of the few places in Togliatti where tourists can just walk in their free time. In the center is a monument erected on the day of the 40th anniversary of the victory in the Great Patriotic War, and nearby is the alley of memory with several more monuments. There are alleys for walks in the park, there are shops and green spaces, a tank, a self-propelled gun and a gun from the Second World War are placed on the site. In the summer there are inflatable trampolines and trays with fast food, cotton candy and the like.

🕐 Working hours : around the clock.

🚶 How to get there : the park is located in Avtozavodsky district ( Park on the map ).

Monument To Tatischev

Vasily Tatischev is the founder of the city of Stavropol. He was a statesman of the era of Peter I, and founded cities in order to protect the Russian land from nomadic tribes. In the middle of the XX century, Stavropol was moved to a new place, and the old one was flooded by the Zhiguli reservoir, which was required for the construction and operation of the Zhiguli hydroelectric power station. The monument to the founder of the city was erected in 1998 on the banks of the Volga River in the area of the flooded city. Nearby there is also a memorial to the soldiers of the Second World War. Today it is another of the places that must attend wedding ceremonies.

🚶 How to get there : the monument is located in the park zone separating Avtozavodsky and Central Districts ( monument on the map ).

Spaso-Preobrazhensky Cathedral

The Transfiguration Cathedral is the main and largest church in Togliatti. It was built in the period from 1992 to 1994, one of the sponsors of the construction was the Avtovaz plant. The cathedral is built in the style of old Russian architecture on the basis of modern technologies, accommodates from 3 to 5 thousand people. It is one of the architectural visiting cards of the city.

🕐 Working hours : during daytime.

🚶 How to get there : the cathedral is located in the Avtozavodsky district, Revolutsionnaya STR., 19 ( Cathedral on the map ).

Sculptures "history of transport"

Several funny sculptural compositions were built in Soviet times in an attempt to create at least something attractive in Togliatti. There are three sculptures in total, located along the alley opposite a number of old shopping centers. Depict the technique of the early XX century: a locomotive, a steamship and a balloon. In fact, nothing special and outstanding of themselves do not represent, but if you walk here, you can pay attention to them, as they look very monumental.

🚶 How to get there : the sculptures are located in a park along Revolutsionnaya Street in the Avtozavodsk district ( sculptures on the map ).

Monument of devotion

Monument of devotion – one of the iconic monuments of the city of modern times. He appeared here after the tragic events that occurred in 1995. In the summer of that year, a car accident occurred on a busy road near this place, as a result of which the owners of the dog died, only the dog himself survived. And after these events, he lived on the street in this place. Patiently waiting for their dead Masters. The dog received the nickname "faithful" among the people, and waited for them for another 7 years. In memory of this event, and as a symbol of loyalty, the townspeople arranged a monument and an alley here. Based on the story, the feature film "Kostya" was shot. Now this place is necessarily visited during wedding ceremonies, in order to symbolically consolidate marriage with Fidelity and devotion.

🚶 How to get there : the monument is located near the intersection of Yuzhnoye Shosse and Lev Yashin streets in Avtozavodsky district ( monument on the map ).

Entertainment in Togliatti

Einstein museum of entertaining sciences.

This is an entertaining science museum for children and adults, and in our opinion one of the most interesting attractions and entertainment for the family, if you have not been to such places before. This, of course, is not a real museum, but rather an entertainment park, where visitors are introduced to physical phenomena in an entertaining and funny way, while explaining the principle of the origin of certain phenomena. Deception of vision, magic electric ball, giant furniture, experiments with magnets, bottomless well, shadow theater, experiments with pendulums, etc., in total more than 70 exhibits. Consultants-guides help to understand this or that exhibit, explain the essence of the phenomena. A standard visit includes an excursion lasting one hour, and then free time, during which you can once again proytit and try the exhibits. Everything is allowed to touch, twist, pull, etc. Additionally, the museum holds entertaining master classes with children by appointment (Tel. +7(8482)280444 or +79277725464), the cost of 300 rubles/hour.

🌐 Website: https://vk.com/club79218514

🕐 Working hours : from 10:00 to 20:00 seven days a week; sometimes the start of the tour has to wait a little until the group is recruited.

💵 Entrance fee / tickets price : 360 rubles (adult ticket from 3 years); pensioners, students, large families, disabled people - discounts; master classes-from 300 rubles/hour.

🚶 How to get there : "Einstein" is located in the 6th quarter of the Automobile Plant District on Korolev Boulevard, 13 ( Einstein on the map ).

Embankment and beach of the Avtozavodsky district

In the Avtozavodsky district there is a long sandy and Pebble Beach with an embankment. It stretches along the entire coast of the district, interrupted in the middle by boat stations. This is a favorite place for citizens to relax in the summer, so in good hot weather it is always fun and noisy, and there are many beautiful girls on the beach. The embankment itself does not represent anything outstanding: there are no architectural attractions, amenities, and beauties. There is only a series of cafes, stalls with ice cream and fast food, and old shops. Oh yes, the embankment on summer evenings is a favorite place for local youth.

🕐 Working hours : summer, daytime.

🚶 How to get there : the beach stretches along the entire Automobile Plant District ( Beach on the map ).

Cartodrome on the embankment

On the embankment of the Avtozavodsky district there is a cartodrome, it operates only in the summer. On Sundays there are competitions among amateurs.

🕐 Working hours : during the daytime (did not work in the 2020 season, there is no information about the resumption of work).

💵 Entrance fee / tickets price : 400 rubles 7 minutes.

🚶 How to get there : located on the embankment of the Avtozavodsky district ( cartodrome on the map ).

Fanny children's Park

The main children's amusement park with carousels, swings, trampolines, Ferris wheel, children's summer water slides, and other children's and adult entertainment. Also in the park there are two bars selling alcohol.

🌐 Website: http://funny-park.ru/

🕐 Working hours : 10:00 – 22:00.

💵 Entrance fee / tickets price : attractions from 100 rubles.

🚶 How to get there : In the center of the Avtozavodsk district, 16A Frunze street behind the Rus shopping center ( Park on the map ).

Garibaldi Castle and Park

Garibaldi Castle and park is a hotel and tourist complex in the village of Khryashchevka, 40 kilometers from Togliatti and 125 kilometers from Samara. The building of a beautiful castle in the Gothic style, as if transferred from somewhere in old England, is surrounded by a beautiful manicured park, statues. There is a fountain and a restaurant, and in summer there is a tent cafe. In winter, of course, there is no park with its beauties and a fountain.

So far, the hotel itself is not open, as the complex continues to be completed for many years, but anyone can inspect the outside and walk around the park today. Learn more about Castle Garibaldi here...

🕐 Working hours : around the clock, it is better to come during the day and on weekends in the summer.

🚶 How to get there : the complex is located in the center of the village of Khryashchevka, 40 kilometers from Togliatti and 125 kilometers from Samara ( Castle on the map . To the village of Khryashchevka there is a single suburban bus (minibus) from Togliatti No. 320 (in the daytime approximately every 30 minutes, the cost is 60 rubles). It is best to get here by your own transport or taxi.

Just in case, we once again remind you that the best way to get acquainted with Togliatti is excursions. And even better, if they are held by local residents who know and love their city well. Find and Book Group or individual excursions from locals with reviews on these trusted sites: