I have promised to discuss interventions for childhood constipation and soiling, but I received a great comment that I would like to address first.

A reader of the blog commented:

As the director of a Montessori school in Colorado, I have a few questions:
1) What are your thoughts about early child care and its effects on attachment? I am aware of Belsky’s study and the NIHCD studies. Do you believe that early child care (before 3) undermines security of attachment? Do you believe this is irrespective of the type or quality of care? Is there other research on this issue that you would recommend?

2) I know there have been a lot of studies (some even specific to child care) which show that infants/young children separated from their parents show abnormally high cortisol levels and lower growth hormone levels. Given these studies, do you have a recommendation as to an optimal way to transition a young child into a child care setting (to minimize their distress)? Is there an optimal way for children to separate from their parents each day (we have tried many things over the years- parents walking their child into the school, children leaving their parents in a car line- a teacher comes out to get the child, etc)? If a child appeared to be highly stressed (how would you quantify this?), what would you recommend? Is there any research as to how specific practices might increase or decrease a child’s experience of separation?

In response to this important comment, I contacted recent graduates of the Infant Parent Mental Health course in Boston and Napa, of which I am on the faculty – https://www.umb.edu/academics/cla/psychology/professional_development/infant-parent-mental-health. I value the knowledge and expertise of this group of clinicians and wanted to start a discussion about the issues of childcare, security of attachment, and separation from parents. I will also request comments from another group of valued colleagues – preschool teachers.

My first response came from an IPMH graduate who also has extensive experience directing and administrating early child care programs, Alayne Stieglitz. Here is her thoughtful response:

When I read these questions I thought of Ed Tronick on the first day of the IPMH Program introducing us to the caregiving practices of several cultures around the world: The village in the Andes where infants are bundled in blankets and strapped upside down on their mothers backs for the first year of their lives and the tribal group in Africa where children have an average of seven caregivers before their first birthday. These are not what we would consider ” best practices” but the children there are reaching their developmental milestones, forming healthy, robust attachments, and thriving in their societies. He said, “Different patterns of care taking and parenting may violate norms we hold as vital, yet children are still developing and learning. Those differences work for their culture. The point is to raise a child who can be competent and successful in the culture they live in.”

In this day and age, the culture that an increasing number of families are living in includes childcare. Single parent households and households where both parents work in order to provide what’s needed for their family do not have the option of whether or not to put their children in someone else’s care. There are many choices; in home care by a relative, in home care by a nanny, small family day care, and center based care. I think the question to ask is not, “Which type of care is best?” But, “Which type of care will be best for my child and my family?” And, of course, “Which is the highest quality of care that I can afford?” This last question limits the options for many families.

I think the most important thing to look for in a child care setting, beyond safety and supervision, is the quality of the relationships; between adults and children, between adults and other adults, and between children and other children. Ask, “Is there a feeling of partnership?” “Are people working together and respecting one another?” “Would I be comfortable here?” “Given what I know about my child, will this situation acknowledge and meet his/her needs?” This idea of partnership is key for me as a parent and a caregiver. Parents need to be recognized as the experts on their child. At the same time, the education and experience of the caregiver must also be respected. Working together and seeing each other as caring, knowledgeable resources makes for quality care.

In a workshop that I attended last year, Kadija Johnston of the Infant Parent Program at UCSF emphasized that the quality of infant’s relationships contribute to the trajectory of their development. In addition, the quality of the relationships between the significant adults in their lives contributes just as significantly to the child’s optimal development.

The second thing I would look at to gage the quality of care is the establishment and consistent implementation of continuity of care practices. The first of these practices is low child to caregiver ratios and small group size. The second is the formation of “primary care” relationships between children and caregivers especially for infants and especially for feeding, toileting and sleep routines. And, third, the practice of keeping children with the same caregivers and peers over their first three years either by keeping adults and children together as they move to new, developmentally appropriate environments or by modifying the same environment as children develop. These practices contribute significantly to the establishment of the deep, meaningful relationships that optimize development and learning; they give children the secure base they need to explore and discover their world.

I have never assumed that attachment theory limits the number of significant relationships an infant can have to one. In all my years as a teacher, administrator and parent I have never come across a healthy, typically developing child who didn’t have secondary attachments before their first year or earlier. Even in what might be considered the western “ideal” of a nuclear family, attachments to the other parent, grandparents, older siblings can form without compromising the primary attachment. I do agree, however, that the quality of childcare and the “fit” of that care for any particular child, would impact their optimal learning and development. Even so, in the NIHCD study mentioned in the question found that the sensitivity of the mother to their child’s needs and feelings was more impactful to a child’s social development than the number of hours spent in childcare. Also, it’s worth mentioning that the study found that there was no difference at four years old in the amount of negative and aggressive behavior of children who began childcare as infants compared with those that began childcare after their third year.

Recently I have been reading “The Infant’s World” by Philippe Rochat and have been reminded that even very young children are intensely attuned and affected by the feelings, emotions and affects of the people they are attached to. It is with this in mind that I have talked about the issue of separation with families. I have found that, because it is often the adult’s feelings of guilt, sadness, and worry that are exacerbating separation challenges, sitting down with the families and talking about their experience in leaving their child is the first step towards a smooth separation. Acknowledging their feelings, wondering about how their child is feeling and what he/she might be thinking, asking what they imagine separation would look like and offering what I have learned through education and experience have led to individual separation plans that have been remarkably effective in easing the entrance into care for children, families and teachers.