Elsevier

Early Childhood Research Quarterly

Volume 42, 1st Quarter 2018, Pages 105-118
Early Childhood Research Quarterly

Associations between continuity of care in infant-toddler classrooms and child outcomes

https://doi.org/10.1016/j.ecresq.2017.08.002Get rights and content

Highlights

  • CoC associated with higher teacher ratings of child self-control, initiative, and attachment while in infant-toddler rooms.

  • CoC associated with fewer teacher-rated behavioral concerns while children were enrolled in infant-toddler classrooms.

  • No consistent relation of CoC with preschool teachers’ ratings of self-control, initiative, attachment or language at age 3.

  • Findings do not provide clear support for CoC, but suggest a need for additional research.

  • Future research needed to fully examine associations with child outcomes and impacts on teachers, families, and peers.

Abstract

Ensuring that young children, especially infants and toddlers, experience consistency in child care providers over time is a practice endorsed by multiple professional organizations. This practice, commonly referred to as continuity of care (CoC), is recommended for center-based group settings to provide infants and toddlers with the sensitive, responsive care needed to promote early development. Despite widespread endorsement, there has been limited empirical examination of CoC. This study examines the extent to which CoC experienced in infant-toddler center-based care is associated with social-emotional and language development. Associations of CoC with children’s social-emotional development during the infant-toddler period and with later social-emotional and language outcomes at age 3 were investigated in a large sample of children attending high-quality early childhood programs designed for young children growing up in poverty. During the infant-toddler years, CoC was related to higher teacher ratings of self-control, initiative, and attachment, and lower ratings of behavior concerns. In addition, a classroom quality × CoC interaction indicated that CoC differences were larger in higher, than lower, quality infant-toddler classrooms. In contrast, CoC in infant-toddler classrooms was not related to rates of change in teacher ratings of social skills during the infant-toddler years nor to children’s vocabulary development or ratings of social skills after they transitioned to preschool. Neither were there quality × CoC interactions at preschool. These findings do not provide clear support for the current widespread recommendations for CoC, but suggest a need for additional research. The need for future research to more fully understand associations with child outcomes as well as to examine potential impacts of CoC on teachers, families, and peers is highlighted.

Introduction

Infant-toddler care is the fastest growing and most sought-after form of child care in the U.S., according to the National Association of Child Care Resource and Referral Agencies (2008). Currently, approximately 50% of U.S. children birth to age 3 experience a regular child care arrangement, with the percentage enrolled in center-based care increasing with age from 9% of children under 12 months to 20% of 2- to 3-year-olds (NSECE Project Team, 2015). Based on developmental and attachment theories (e.g., Ainsworth, Blehar, Waters, & Wall, 1978; Sroufe, 1988, Thompson, 2000), multiple professional organizations have endorsed the provision of continuity in nonparental caregivers, commonly referred to as continuity of care (CoC), as a recommended practice with the intent to provide infants and toddlers with the sensitive, responsive care needed to promote early development (Sosinsky et al., 2016). Despite this widespread endorsement, there has been limited empirical examination of CoC (Sosinsky et al., 2016). For this reason, this study uses an existing dataset to examine the extent to which CoC experienced in infant-toddler group settings is associated with social-emotional and language outcomes in a network of programs that all endorsed the goal of providing CoC for young children. Specifically, the research focused on whether low-income children experiencing CoC during their infant-toddler center-based care show more advanced social-emotional development in the short- and longer-term than children without CoC, with an added examination of receptive vocabulary at age 3. Given the research relating early care to child outcomes in middle childhood and adolescence (e.g., NICHD ECCRN, 2005, NICHD ECCRN, 2006, Vandell et al., 2010), the growing number of infants and toddlers experiencing center-based care, and the emphasis on CoC in professional recommendations, careful examination of the relative and interactive contributions of CoC and quality in a large sample is crucial.

CoC is an intentional grouping and staffing pattern implemented in infant-toddler center-based care to enhance consistency in caregivers (Sosinsky et al., 2016). CoC for infants and toddlers occurs when the child remains with the same caregiver across multiple years (Cryer, Hurwitz, & Wolery, 2001), preferably until 36 months of age (Program for Infant/Toddler Care, n.d.). It can occur when a caregiver is assigned to a group of similarly-aged infants, and that group remains together until the children all move to preschool at the same time (McMullen, Yun, Mihai, & Kim, 2016; Sosinsky et al., 2016). This arrangement is referred to as looping. It can also occur in mixed-age infant-toddler classrooms when infants enter at various times and stay with the teacher until they reach the age to move to the preschool classrooms (Sosinsky et al., 2016, Theilheimer, 2006), and are replaced within their former classroom with young infants. As noted by McMullen et al. (2016), furnishings, equipment, materials, supplies, room location, and peers may change in CoC, but the central characteristic is that teachers/caregivers, and thus the relationship between an individual child and teacher, remain intact for a given child over an extended period of time. The premise, regardless of strategy, is that if the child and his/her caregiver stay together for an extended period of time, the caregiver’s knowledge and understanding about that child and his/her family will deepen, resulting in trust and security between and among all within the group – caregiver, child, and family members (Essa, Favre, Thweatt, & Waugh, 1999; Sosinsky et al., 2016, Theilheimer, 2006). Based on attachment theory, the infant should be able to develop a secure attachment with this caregiver if that person is responsive and sensitive, and that attachment serves as a secure basis for the development of subsequent social and cognitive skills (Sroufe, 1988).

CoC became more prevalent in the U.S. in the 1990s during a period when a number of factors converged: rates of maternal employment for mothers of infants and toddlers increased; debate about the potential effects of maternal employment and the associated increase in use of out-of-home care for infants and toddlers reached a high point; attachment principles and results of studies of secondary attachment became better known; and infant-toddler child care was of notably poor quality. Findings related to infant-toddler center-based child care and associations with attachment and caregiver consistency provide the rationale and justification for CoC (Sosinsky et al., 2016) and thus are discussed in more detail below.

Waldman (1983) reported that in 1970 participation in the labor force among married mothers whose youngest child was less than a year old was 24% and by 1983 that number had increased to 45%. In March 2012, the U.S. Department of Labor reported that 55% of all mothers with children under 3 years of age were in the labor force (Bureau of Labor Statistics, 2014). Increasing maternal employment has meant that increasing numbers of very young children experience out-of-home care. Increased use of out-of-home care attracted research attention (e.g., NICHD ECCRN, 1996, NICHD ECCRN, 2005), and questions were raised about potential harmful effects of nonmaternal care, particularly in regard to children’s early attachments to primary caregivers (Belsky & Eggebeen, 1991; Han, Waldfogel, & Brooks-Gunn, 2001). Concerns grew with studies documenting that over 40% of infant-toddler center-based care was of poor quality (Cost Quality and Child Outcomes Study Team, 1995); that the average annual teacher turnover rate in early childhood programs was 30% (Whitebook & Sakai, 2003); and that common infant-toddler classroom practices such as moving a child to a new classroom when a developmental milestone was attained resulted in transitions occurring as often as every 6 months for infants (Cryer et al., 2005).

Attachment theory (Ainsworth et al., 1978) posits that infants’ early development depends on frequent, warm, consistent interactions with their primary caregivers. Those interactions promote close, secure, and nurturing relationships between the caregiver and infant that serve as the foundation for children’s subsequent language and socio-emotional development (Sroufe, 1988). Applied to infant-toddler care, high rates of teacher turnover and frequent changes in caregivers were thought to place the early development of infants and toddlers in jeopardy (Thompson, 2000).

Research indicated that infants formed attachment relationships with their child care providers as well as their parents (Howes & Hamilton, 1992; Van IJzendoorn, Sagi, & Lambermon, 1992). Raikes (1993) reported that a higher percentage of children had secure attachments with teachers when they had been with the same teacher for more than one year. Howes and Spieker (2008) noted that extended interactions with a child may increase a caregiver’s emotional investment in the child and promote responsive caregiving. Additionally, more time and experience with a child may help a caregiver read and appropriately respond to a child’s unique cues and needs. Ahnert, Pinquart, and Lamb (2006) reported that children were more likely to receive sensitive and responsive care and to develop secure relationships with their caregivers when the dyads were together for a longer period of time. This responsive and individualized care, in turn, has been found to support children’s development in a variety of areas. For example, higher levels of language development and greater levels of peer play have been associated with sensitive and responsive caregiving experienced in group care (NICHD ECCRN, 2005).

Over the past several decades some infant-toddler group care in the U.S. implemented practices consistent with attachment theory and research, seeking to provide infants and toddlers with caregivers/teachers who offer children a secure base and a secondary attachment during their time away from primary caregivers. For example, the Program for Infant/Toddler Care (PITC, Lally & Mangione, 2009), a widely-used infant-toddler approach (Horm, Goble, & Branscomb, 2011), provides a philosophy and strategies for promoting responsive, relationship-based infant-toddler center-based care. PITC and similar programs advocate practices consistent with attachment research by keeping children and teachers together throughout the infant-toddler period until age 3 (Program for Infant/Toddler Care, n.d.). In fact, CoC is one of PITC’s anchor policies (Mangione, 2006).

Several professional organizations and groups including Zero to Three, the National Association for the Education of Young Children (NAEYC), the National Head Start Association (NHSA) and Early Head Start, and the Center for Law and Social Policy (CLASP) have also endorsed CoC as a recommended practice with infants and toddlers (Sosinsky et al., 2016). For some, maintaining the same caregiver during the infant-toddler period is viewed as a key indicator of high-quality infant care (Copple, Bredekamp, Koraleck, & Charner, 2013; Zero to Three, 2008). However, in early research infant-toddler teachers were reported to be less enthusiastic about the practice; for example, fewer than half of 273 early childhood teachers in one study agreed that infants and toddlers should have the same teacher until age 3 (Cryer et al., 2001). On the other hand, De-Souza (2012) in a dissertation study using in-depth interviews with 21 center directors, found that directors supported the concept but had concerns about whether it could be implemented in their own programs due to staff issues. Thus, philosophical support for CoC may be more wide-spread than the practice, although there is little research documenting the implementation of CoC.

Despite its plausible theoretical underpinnings and endorsement by professional associations and groups, there is relatively little empirical research on CoC (Owen, Klausli, Mata-Otero, & O’Brien-Caughy, 2008; Ruprecht, Elicker, & Choi, 2016; Sosinsky et al., 2016). As noted above, while research on caregiver attachment and instability strongly implies that CoC should have positive impacts on child outcomes, little research has examined CoC, per se, as an intentional care practice (Sosinsky et al., 2016). The emerging research has focused on different aspects of CoC, for example, the implementation of CoC including barriers and supports (e.g., Ackerman, 2008; Aguillard, Pierce, Benedict, & Burts, 2005; Cryer et al., 2001). Some studies have examined teacher behaviors and found that programs promoting CoC have teachers who are more responsive and engaged with the children (Owen et al., 2008: Raikes, 1993Owen et al., 2008: Raikes, 1993; Ruprecht et al., 2016). Other studies have examined CoC as a means to promote stronger parent-caregiver relationships and greater parental involvement (Owen et al., 2008).

Only a few studies have examined CoC and child outcomes, and the results of these few studies are inconclusive. Early studies documented positive relations between stability in caregivers and child outcomes through 30 months of age (Howes and Hamilton, 1992, Howes and Hamilton, 1993; Hamilton, 1992, 1993). In more recent research, toddlers who experienced CoC in their classrooms were rated as having fewer behavior problems, but not more social competence (Ruprecht et al., 2016). Preschool children in CoC classrooms were more engaged with their caregivers than similar children attending comparison centers, with reported effects greater for African-American than Latino children, in a study of preschool children attending programs serving low-income families (Owen et al., 2008). However, this study reported no consistent benefits of CoC for child receptive vocabulary development, school readiness, or problem behaviors.

In summary, to date no studies have examined a variety of child outcomes related to CoC during infancy, and mixed findings define the current research base. The goal of this study is to examine, with a larger sample than used in previous research, CoC and its association with a range of developmental outcomes in infants and toddlers—the age group the background literature on attachment and caregiver stability would predict may be most impacted by CoC. Based on the theory and research in this area, the logic model is that sensitive and responsive care is the mechanism through which teacher-child attachments are developed and undergird positive child outcomes. Thus, CoC effects could be large with sensitive and responsive caregivers due to their creation of the secure base necessary for infants and toddlers to develop social and cognitive skills. However, given the importance of classroom quality to child outcomes, it could be that CoC has a smaller impact when quality is high due to the protective role that classroom quality has been found to play in relation to child outcomes in center-based settings. This study examines these possibilities.

CoC is but one indicator of high-quality infant-toddler care practices. Other classroom indicators, such as regulatable (e.g., class size, child:staff ratio) and global quality (e.g., observational measures of the environment), have been addressed in past and recent empirical research investigating the impact of center-based programs on young children’s development, including infants and toddlers living in poverty (IOM and NRC, 2012, National Scientific Council on the Developing Child, 2004, NICHD ECCRN, 1996, Phillips and Lowenstein, 2011, Vandell et al., 2010). Whether global quality of care moderates associations between CoC and early development has not been examined. Quality of infant-toddler care is thought to be the mechanism through which early care impacts infant-toddler development (IOM & NRC, 2012), with considerable experimental and observational evidence linking quality to infant-toddler development (Burchinal, Roberts, Nabors, & Bryant, 1996; Campbell, Pungello, Miller-Johnson, Burchinal, & Ramey, 2001; NICHD ECCRN, 2006, NICHD ECCRN and Duncan, 2003).

Given the existing extensive quality literature, it is important to investigate the potential moderating effect of overall classroom quality when examining CoC and relations with child outcomes. In previous studies, researchers recognized the importance of classroom quality and accounted for it in their studies of CoC by attempting to hold quality constant through restricting their sample to NAEYC-accredited centers (Owen et al., 2008) or by investigating QRIS ratings and structural indicators of quality such as child:staff ratios, both of which were higher in CoC versus non-continuity classrooms (Ruprecht et al., 2016). Neither of these studies, however, asked whether higher quality classrooms might intensify the hypothesized positive impacts of CoC or could potentially buffer the hypothesized negative effects of discontinuity.

The current study takes advantage of a large database of independently collected child, parent, and classroom quality data to examine child outcomes at semester intervals during the infant-toddler period and at age 3 (after attendance in the infant-toddler program) for children who did or did not experience CoC in infant-toddler classrooms. The data were collected for the Implementation Study of the Educare Learning Network (ELN), an association of 21 schools that describe their programs as enhanced Early Head Start and Head Start programs. In a randomized clinical trial the ELN has documented that children enrolled in Educare classrooms experience moderately high to high-quality early care and education, and had better language and social skills at two years than a control group (Yazejian et al., 2017). An earlier observational study of all children enrolled in Educare through 2013 showed that children who entered earlier and stayed longer had higher language outcomes than those who entered later (Yazejian, Bryant, Freel, Burchinal, & the Educare Learning Network Investigative Team, 2015). To participate in the ELN, all schools committed to deliver high-quality early care and education, with CoC as an expected practice. Yet, data show that schools are differentially successful in achieving CoC in the staffing of their classrooms. Therefore, secondary analysis of the Educare data should provide much-needed empirical evidence regarding whether CoC during infancy is related to social and language development in programs with no pre-existing difference in terms of their commitment to using CoC.

Thus, the purpose of this study was to investigate associations between CoC and child outcomes over and above quality. Specifically, the research questions were:

  • 1.

    Does continuity of care experienced in infant-toddler center-based classrooms relate to:

    • a.)

      children’s social-emotional development during the infant-toddler period; and

    • b.)

      children’s social-emotional and language skills at entry to preschool?

  • 2.

    Is continuity of care more strongly (or weakly) related to early development when infants and toddlers experience higher quality classrooms?

Section snippets

Participants

Data from the first 11 Educare schools (Educare uses “school” to highlight the intentional learning opportunities provided in their program model) that joined the ELN were used in this study to ensure that enough years of data were available to assess continuity over a period of at least 4 years. The 11 Educare schools were located in Chicago, Denver, Kansas City, Miami, Milwaukee, Oklahoma City, Omaha (two schools), Seattle, and Tulsa (two schools). These center-based programs serve children

Results

These analyses examined relations between continuity of care (CoC) and children’s social-emotional development during the infant-toddler period while in EHS and child outcomes in social-emotional and receptive vocabulary development after the child transitioned from EHS classrooms and teachers to HS classrooms and teachers. Analyses focused on whether the child experienced continuity with the lead teacher in infant-toddler classrooms, but sensitivity analyses examined the other indices of CoC

Discussion

The extent to which CoC improved early social-emotional and language development among infants and toddlers in center-based care was examined in this secondary analysis of a program providing high-quality care to children from low-income families. Findings suggested that teachers’ ratings of self-control, initiative, and attachment were higher when CoC was maintained during the infant-toddler period. In fact, children in the CoC classrooms also received higher socio-emotional ratings from their

Acknowledgements

We gratefully acknowledge the funding support for this work provided by the Buffett Early Childhood Fund and the George Kaiser Family Foundation. The content of this publication does not necessarily reflect the views or policies of the Buffett Early Childhood Fund or the George Kaiser Family Foundation. We also thank Karen Taylor and John Cashwell for valuable assistance with the data for this paper. Finally, we thank the programs for providing the data, including the Educare staff, families,

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