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Child Care and Common Communicable Illnesses
Results From the National Institute of Child Health and Human Development Study of Early Child Care
The National Institute of Child Health and Human Development Early Child
Care Research Network
Arch Pediatr Adolesc Med. 2001;155:481-488.
ABSTRACT
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Objectives To examine the relationship between experiences in child care and communicable
illnesses (gastrointestinal tract illness, upper respiratory tract infection,
and ear infections or otitis media) throughout the first 3 years of life and
to investigate whether increased frequency of these illnesses is related to
language development, school readiness, and behavior problems.
Design Health, child care, family, and child developmental data were obtained
from more than 1200 participants in the National Institute of Child Health
and Human Development Study of Early Child Care, a 10-site prospective study
that began at the participants' birth. Longitudinal logistic regression analyses
were performed using each type of communicable illness as the outcome variable,
with family, child, and child care variables as predictors in the model, and
followed by a series of regression analyses with developmental measures as
the outcome variables.
Results Rates of illness were higher in children in child care than for children
reared exclusively at home during the first 2 years of life, but the differences
were nonsignificant by age 3 years. Number of hours in child care per week
during the first year and number of other children in the child care arrangement
were related to the rates of illness. There was no evidence that increased
rates of illness have a negative effect on school readiness or language competence.
However, there was some evidence that increased illness was associated with
behavior problems as reported by mothers, but not by child care providers.
Conclusions Children in child care experience more bouts of illness in the first
2 years of life, but differences are negligible by age 3 years. The increased
rates of illness bear little relation to other aspects of children's development,
except, perhaps, for a small increase in behavior problems.
INTRODUCTION
AS THE NUMBER of infants who are cared for by someone other than their
parents has increased, so too has concern about the effect of nonparental
child care on childhood illness. Children who attend child care arrangements,
especially those enrolled in child care centers, are exposed more often to
common communicable illnesses. Previous research indicates that they experience
more bouts of respiratory illness, otitis media, and diarrhea than children
reared exclusively at home.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17
The explanations most commonly offered for increased rates of illness
among children in child care point to elevated levels of exposure to pathogens
carried by other children in child care settings. For example, the primary
factor connected with enteric tract illness seems to be the number of other
young children present in the child care arrangement. The most vulnerable
time for transmitted infections is immediately after entry into a new child
care arrangement.4, 18 Studies
of upper and lower respiratory tract infections also point to increased exposure
to other children (and the viruses they carry) as the primary risk factor
for elevated rates of illness among children in child care settings.3, 5, 14, 19
To our knowledge, there have been few prospective studies of communicable
illness in children in relation to the many types of child care arrangements
children now attend. Most studies have been cross-sectional, have examined
only a single category of illness, have focused on only 1 or 2 types of child
care arrangements, and have failed to control for other family and community
factors known to be related to illness. A critical issue yet unresolved is
whether the elevated rate of illness associated with child care is related
to children's cognitive, language, and social development.
We reexamine associations between child care and common childhood infections,
using data from approximately 1200 children living in 10 different sites in
the United States who are participating in the National Institute of Child
Health and Human Development (NICHD) Study of Early Child Care.20
We investigate 3 key issues concerning the relationship between child care
arrangements and 3 common childhood infections: enteric tract illness (GI),
upper respiratory tract infection (URI), and ear infections or otitis media
(OM). This study addresses (1) the pattern of these 3 common illnesses during
the first 3 years of life for children in different types of nonmaternal care;
(2) possible effects of child care experiences on the frequency of illnesses;
and (3) the possible effect on later development in such areas as language,
achievement, and social behavior. We hypothesize that rates of illness will
be higher for children who have contact with large numbers of other children
in child care. We also hypothesize that these increased rates of illness will
not negatively affect other areas of children's development.
PARTICIPANTS AND METHODS
PARTICIPANTS
Families participating in this study were recruited through mothers'
hospital visits that were made shortly after the birth of a child during the
calendar year 1991. Families lived in the vicinity of Little Rock, Ark; Irvine,
Calif; Lawrence, Kan; Boston, Mass; Philadelphia, Pa; Pittsburgh, Pa; Charlottesville,
Va; Morganton, NC; Seattle, Wash; or Madison, Wis. Of the 8986 mothers who
gave birth during the sampling period, 5416 (60%) met the eligibility criteria.
The criteria were as follows: a healthy mother older than 18 years and conversant
in English, a singleton child whose birth was normal and uncomplicated, a
family living in a neighborhood not considered extremely unsafe and located
less than 1 hour from the research site, and a family not planning to move.
One hundred thirty mothers refused to be interviewed (1%) and 308 refused
to be contacted again (3%). Of the 5416 eligible families, 3015 (56%) were
selected using a conditional random sampling plan that ensured the recruited
families reflected economic, educational, and ethnic diversity. Of the 3015
selected for participation, 1526 (51%) agreed to participate. The remaining
1489 families could not participate for a variety of reasons (60 babies remained
hospitalized for 7 days postpartum, 91 families planned to move, 512 could
not be contacted, 641 refused, and 185 had other reasons [most said that they
just didn't have the time]). Of the 1526 families who agreed to participate,
1364 (89%) completed the initial data collection visit and gave signed consent
when the child was 1 month old. Comparisons were made between the 51% of eligible
families who agreed to participate and the 49% who did not on several key
demographic and child variables. There were a number of small (effect sizes
were always <0.25) but statistically significant differences. Mothers who
agreed to participate were approximately a year older on average (28.0 years
vs 27.0 years), slightly better educated (65% with more than a high school
degree vs 50%), and less likely to be minority (19% vs 24%); however, the
participating mothers were no more likely to be married. On average, the children
were a little heavier at birth (3490 g vs 3393 g).
Of the 1364 families who participated in the study, 16.7% were living
in poverty (defined as a family income-to-needs ratio of 1.0 or less), 10.2%
had mothers with less than a high school education (68.7% had some education
beyond high school), and 76.5% were 2-parent households. White, non-Hispanic
children constituted 76.4% of the cohort, 12.7% were black non-Hispanic, and
6.1% were Hispanic.
PROCEDURES
We obtained information from the mother about the parents and the child
using face-to-face interviews when the child was 1, 6, 15, 24, and 36 months
of age and from telephone interviews done when the child was 3, 9, 12, 18,
21, 27, 30, and 33 months of age. Specifically, we obtained information about
the family context, the type of child care used, changes in child care arrangements,
the number of children in the child care arrangement, the amount of time the
child spent in child care, and the child's health status and illnesses. All
participating children came to the study site when they were 15, 24, and 36
months of age so that they could be observed in a variety of structured and
unstructured settings and be given a battery of developmental tests.
MEASURES
Family Background and Child Characteristics
Four pieces of demographic information were used: mother's level of
education, family size, presence of the father or another adult partner in
the home, and family income (the income-needs ratio).21
Child characteristics included ethnicity and sex. The Home Observation for
Measurement of the Environment (HOME) Inventory was administered during a
home visit when the child was 15 months of age (infant-toddler version); the
early childhood version, at 36 months. HOME assesses the quantity and quality
of stimulation and support available to the child in the home environment.22
Child Illness Histories
During the interviews held every 3 months, mothers were asked: "Since
the last interview, has [child] had an ear infection? . . . a respiratory
illness? . . . a gastrointestinal illness?"
Child Care Experiences
Child care information includes (1) type of care (center care, a child
care home, care by a relative, or care in the child's own home by a nonrelative);
(2) the total number of other children in all the child's nonmaternal care
arrangements during a particular 3-month interval; (3) stability of care (the
number of child care arrangements started during each 3-month interval); and
(4) hours in care (how many hours the child spent on average each week in
all forms of child care).
Child Developmental and Behavioral Outcomes
Children aged 3 years were assessed with the Bracken Basic Concept Scales
(BBCS) and the Reynell Developmental Language Scales (RDLS). The BBCS23 consists of the diagnostic scale and 2 screening
tests, and is designed to assess a child's knowledge of basic concepts necessary
for school readiness. The RDLS24 is composed
of two 67-item scales: verbal comprehension and expressive language. When
the children were aged 3 years, mothers completed the 99-item Child Behavioral
Checklist (CBCL).25 For the children in nonmaternal
care, child care providers also completed the CBCL when the children were
3 years of age.
STATISTICAL ANALYSIS
To determine whether the prevalence of each illness varied throughout
time and whether the illness varied as a function of background characteristics,
family circumstances, and child care experiences, longitudinal logistic regression
analyses were conducted using the generalized estimating equation approach.26 To adjust for the dependency in the data caused by
repeated measures, separate intercepts were estimated for each child. Time-invariant
predictors (between-subject variables) included site, mother's education,
ethnicity, and sex. Time-varying predictors included several measures of family,
child, or child care experiences that were obtained at each of the 12 assessment
points. These include child's age, child's age squared, type of interview
(telephone or in-person), whether mother had a spouse or other adult partner
present in the household, household size, average hours of all forms of child
care during that 3-month assessment, whether the child changed child care
arrangements during that period, whether the child attended a child care center
during that period, whether the child attended a child care home during that
period, whether the child was cared for by the father or grandparents or in
the child's own home during that period, and the total number of children
and adults summed across the various arrangements. The other 2 time-varying
predictors were income (for children aged 1, 6, 15, 24, and 36 months) and
HOME scores (children aged 15 and 36 months). Logistic regression models also
included several interaction terms: age x each child care variable,
and age x household size.
A multiple regression analysis was used to determine the relationship
between child care experiences and rates of illness during the first 3 years
of life and the child's developmental status at age 3 years. For each illness,
a series of 5 regression analyses was run, 1 for each of the five 3-year child
outcomes: Bracken23 school readiness, Reynell24 verbal comprehension, Reynell24
expressive language, CBCL25 externalizing problems,
and CBCL internalizing problems.25 Each regression
model included background, family, and child care factors as predictors. The
time-invariant predictors included site, mother's education, ethnicity, and
sex. The time-varying predictors were represented by the mean score for each
family on each measure. Similarly, child care hours was represented as the
average number of hours a child spent in all types of nonmaternal child care
per week from birth through 3 years based on all 12 data collection points.
There were 3 types of care variables: (1) number of assessment periods the
child was in center care; (2) number of periods the child was in a child care
home; and (3) number of periods the child was cared for by relatives or at
home by nonrelatives.
To determine whether a child's history of illness in child care effects
the relation between experiences in care and developmental outcomes, we conducted
a second series of regression analyses. Specifically, we added several statistical
interaction terms involving the proportion of time a child had a particular
illness and each child care experience factor.
RESULTS
RATES OF ILLNESS
The proportions of children who experienced episodes of OM, URI, and
GI during each 3-month period through age 3 years were examined for the following
4 groups of children: (1) those receiving exclusive maternal care; (2) those
in child care centers; (3) those in family child care homes; and (4) those
cared for by a relative or by a nonrelative in the child's own home. Longitudinal
logistic regression analyses indicated that the incidence of ear infections
rises in the first year of life and peaks by age 1 year, then gradually declines
during the next 2 years (Figure 1).
Respiratory tract illness follows the same basic pattern, although the decline
after age 1 year is much less pronounced (Figure 2). The rate of GI also rises in the first year of life,
followed by a slow decline (Figure 3).
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Figure 1. Predicted rate of gastrointestinal
tract illness for each 3-month interval, with 95% confidence intervals.
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Figure 2. Predicted rate of respiratory
tract illness for each 3-month interval, with 95% confidence intervals.
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Figure 3. Predicted rate of ear infection
for each 3-month interval, with 95% confidence intervals.
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CHILD CARE EXPERIENCE AND ILLNESS HISTORY
Table 1 displays results
from the longitudinal logistic regression analyses of each illness, as performed
on the whole sample. The table displays odds ratios with accompanying 95%
confidence limits for each aspect of child care experience examined, controlling
for the family background and child characteristics described above.
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Results of Longitudinal Logistic Regression Analyses for Otitis Media,
Gastrointestinal Illness, and Respiratory Illness*
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Hours per Week in Care
With 2 marginal exceptions, the number of hours per week children spent
in child care had little to do with their likelihood of contracting a communicable
illness. For OM, hours per week in care during the first year of life was
related to the likelihood of acquiring the illness. For GI, hours per week
during the third year of life increased the likelihood of contracting the
illness.
Changes in Child Care Settings
Starting a new child care arrangement during an assessment period was
associated with lower rates of OM and URI.
Number of Children in Child Care
The number of children present in nonmaternal child care arrangements
was related to the frequency of URIs. The number of children was a significant
predictor of both GIs and URIs. However, because the type of child care arrangement
was controlled in the analysis, the findings may offer conservative estimates
of the effect of number of children present in child care on the probability
of acquiring an illness. Children in center care were exposed to an average
of 10.3 other children at age 3 months, and 16.4 children at age 36 months.
This contrasts with the average number of other children present in a child
care home (2.3 children at age 3 months, and 3.8 children at age 36 months).
Type of Care
Compared with children in exclusive maternal care, those attending child
care centers and family child care homes were more likely to acquire OM and
URI (Figure 2 and Figure 3). When examining rates of OM in these 2 settings, the effect
of attending child care arrangements on rates of OM was much more pronounced
during the child's first and second years of life than during the third year.
Results showed higher rates of OM in center care during the first year of
life followed by a gradual decline, so that by age 3 years, the rate among
children in the 4 types of care were no longer different. The pattern for
URI was similar, but the findings were not quite as strong. Results also showed
that when children were being cared for by a relative, the risk of GI was
lower in the first year of life but higher in the third year of life.
As Table 1 presents, we
also computed the relative odds (odds of illness if the child was in particular
type of care divided by the odds of illness if the child was not in that type
of care) for the 3 illnesses at 3 ages: 12, 24, and 36 months. For OM, the
odds ratio associated with center care at age 12 months was 2.37, but that
declined to 1.22 by age 36 months (children in center care were more than
twice as likely as home-reared children to contract an ear infection at age
1 year, but only 22% more likely by age 3 years). Likewise, for URI, the odds
ratio associated with center care was 1.92 at 12 months, declining to 1.36
at 36 months. For GI, none of the odds ratios was greater than 1.20.
ILLNESS AND CHILD DEVELOPMENTAL OUTCOMES
The final issue addressed by this study was whether the increased illness
rate of children in child care settings is associated with poorer developmental
and behavioral outcomes at age 36 months. Results from the 15 regression analyses
run on the whole sample (3 illness categories x 5 outcome variables)
provide no evidence of an association between the frequency of acquiring a
communicable illness and either language competence (not significant) or school
readiness (not significant). By contrast, children who experienced higher
rates of URI (ß = 2.64, SE = 0.81, P<.001)
and GI (ß = 4.64, SE = 0.81. P<.001) were
described by their mothers as having a modestly higher rate of internalizing
problems. Similarly, children who experienced higher rates of OM (ß =
3.11, SE = 1.13, P<.006), URI (ß = 4.73,
SE = 1.14, P<.001), and GI (ß = 6.04, SE
= 1.15, P<.001) were reported by their mothers
as developing slightly more externalizing problems. For children in child
care, we reran the analyses using teacher reports of behavior problems. Results
showed no relationship between children's rates of illness and teacher reports
of behavior problems. The difference in results, depending on whether mothers
or teachers reported on behavior problems, may reflect a common reporter bias
on the part of mothers, since mothers were the only reporters on childhood
illness.
There was little evidence that child care factors interact with illness
histories to affect the course of a child's development. For each type of
illness, the regression analyses were rerun, adding a block of 4 statistical
interaction terms (the proportion of 3-month assessment periods during which
the illness occurred x [1] the average number of hours spent in child
care, [2] the proportion of assessment periods spent in a child care center,
[3] the proportion of periods spent in a child care home, and [4] the proportion
of periods spent in relatives' care or in-home care). The only significant
interaction involved mother-reported internalizing problems (hours in child
care x the illness rate for URI); even this interaction was not significant
when the child care provider's report of internalizing problems was analyzed.
Finally, because approximately 10% of the sample had ear ventilation
tube placements prior to age 3 years, the analyses relating a child's history
of ear infections to developmental outcomes were rerun adding 2 variables
to the model: (1) whether the child had ear tube placement, and (2) the interaction
between ear tube placement and the number of assessment periods during which
a child had an ear infection. Neither of these variables was significant for
any of the 5 outcomes examined.
COMMENT
Findings from the NICHD Study of Early Child Care provide significant
new details about how children's experience in nonmaternal care relates to
common childhood infections during the course of the first 3 years of life.
Children who were in nonmaternal care experienced a higher incidence of ear
infections, URI, and GI illnesses during the first 2 years of life. However,
by age 3, illness rates for children in child care were no different than
those reported for children reared exclusively at home. Despite the increased
rates of illness for children in nonmaternal care in the first 2 years of
life, there was no evidence that elevated rates of illness were associated
with poorer language or school readiness skills or elevated rates of behavior
problems in child care at age 36 months. However, children who experienced
more bouts of GI and URI illnesses were described by their mothers as having
more internalizing problems.
Results of this comprehensive, longitudinal study confirm findings from
cross-sectional studies with respect to the prevalence of ear infections,
GI illnesses, and upper respiratory illnesses.27, 28
For example, males were slightly more likely to manifest an ear infection
in early infancy, and African Americans reported fewer ear infections than
did members of other ethnic groups.1, 4, 5, 12, 28, 29, 30, 31
The NICHD study also confirms that the likelihood of children acquiring common
communicable illnesses during infancy is related to the type of child care
they receive and to the number of other children in that care environment.
This confirms findings from other studies of GI and diarrheal illnesses4, 29, 32 and otitis media.2, 5, 6, 11, 12, 15, 33, 34, 35, 36, 37
In contrast to reports stating that the likelihood of acquiring communicable
illnesses increases with the amount of time spent in child care,29
we found little evidence that the number of hours of care per week resulted
in increased illness rates for any of the 3 diseases examined. This finding,
which contradicts results from some earlier studies, may have emerged because
most of the children in this study spent more than 20 hours per week on average
in nonmaternal care throughout the first 3 years of life. That is, most were
in care for a sufficient amount of time to permit exposure to the other children
in the setting.
Rates of infection for each illness studied rose during the first year
of life, peaked in the second year, and then gradually declined. These data
suggest that spending time in nonmaternal care may accelerate immunological
responses to the pathogens that cause these illnesses. Although this study
does not provide specific evidence of increased resistance to communicable
illnesses by age 3 years because of early entry into child care, it may be
that the children with more extensive early child care experience will show
lower rates of communicable illnesses during kindergarten and first grade
than children with no prior child care experience.38
Many home-reared children may be exposed to the pathogens that cause common
communicable illnesses for the first time when they enter preschool or kindergarten,
and they will not yet have developed an immumological resistance to such pathogens.
It would be recommended to follow up the NICHD cohort until school entry.
Results clearly point to increased contagion as the primary reason for
the frequency of each of the illnesses studied. Exposure to other children
in nonmaternal child care arrangements increases the likelihood of contracting
communicable illnesses, especially during infancy. Up to a threshold of perhaps
8 to 10 children, the greater the number of other children and the greater
the amount of exposure, the greater the likelihood of contracting an illness.
The one anomaly in our results pertains to the finding that children who changed
child care more often did not manifest higher rates of illness.
When analyses were done within specific types of child care arrangements,
the number of children present was significant only for URI and only for child
care homes and care by relatives. This suggests that the pathogens connected
to GI are so common and so virulent that exposure to even a very small number
of other children is sufficient to increase the probability of contracting
GI illnesses. This corresponds to findings from other studies that suggest
that the risk for contracting a GI infection is greatest immediately after
entering a new child care arrangement.4 Our
findings regarding the relationship between number of children in child care
and URI are reminiscent of findings by Paradise et al.12
They found a "strong positive relationship (for days with middle ear effusion)
to the degree of exposure to other children"12(p323)
in arrangements with more than 5 children. The fact that the number of children
present within each type of child care arrangement was not a factor associated
with the rate of ear infections suggests that the number of children typically
found in child care homes and relative care is too low to make a difference,
and that the number of children typically found in child care centers is higher
than the threshold (in effect, more in the range of 8-10 children). For children
in child care, the number of children present in the child care arrangement
seems to contribute less to the risk of GI infection with time. By contrast,
the association between family size and rate of GI illness increased with
age for children reared exclusively at home perhaps because older siblings
bring GI infections into the household from exposures at school or elsewhere.
This study was the first to prospectively examine the question of whether
increased rates of illness for children who attend child care has a negative
effect on children's later developmental status. This issue was examined for
a range of developmental outcomes in a large, highly diverse sample. In this
sample, there was limited evidence that higher rates of illness were associated
with poorer developmental outcomes. The only significant associations found
were between rates of illness and mothers' reports of behavior problems. However,
higher rates of illness were not associated with child care providers' reports
of behavior problems for children in child care. This discrepancy may reflect
increases in parenting stress associated with caring for sick children and
perhaps greater fussiness or sullenness on the part of children while they
are at home sick. Because many child care providers have policies restricting
attendance for sick children, child care providers may be spared some of the
brunt of children's illnesses. Although our results showed several small relationships
between rates of illness and behavior problems, the absence of significant
interaction effects between amount and type of child care and illness histories
on child outcomes indicates that the effect of child care experience per se
on infection is largely unrelated to children's behavior, to their language
development, or to their school readiness. In effect, for children who attend
child care there is little evidence that having a greater number of common
communicable illnesses such as URI, GI, and OM during infancy significantly
alters the normal progression of behavioral development.
Results from this study clarify the relationship among children's experience
with nonmaternal care, children's history of communicable illness, and later
developmental outcomes. The study points to a single mechanism, contagion,
as the primary reason for the increased rate of illness for children in child
care. Furthermore, the results indicate that a single period of life, the
first 2 years, is the only developmental period for which increased exposure
leads to greater illness among children who enter care early in life. Finally,
the study indicates that increased early rates of illness for children who
attend child care arrangements do not seem to have any other adverse developmental
consequences. Continued analysis of the illness rates of children in this
sample as they enter school will provide useful information regarding whether
early exposure to the pathogens that cause common communicable illnesses leads
to a lower risk for illness after school entry.
Some caution should be exercised in applying the results from this study
to children from high-risk families. The exclusion criteria used to select
families for the study, coupled with slightly higher rates of participation
among children from high socioeconomic backgrounds, limits the generalizability
of the findings. Previous studies have shown that children from low SES families
are more likely to receive lower-quality child care and child care that is
more sporadic, factors that may increase their risk of exposure to communicable
illnesses.39
AUTHOR INFORMATION
Accepted for publication November 17, 2000.
This study was directed by a Steering Committee and supported by the
NICHD through cooperative agreement U10, which calls for a scientific collaboration
between the grantees and the NICHD staff.
| The NICHD Early Child Care Research Network
University of California, San Diego: Mark Appelbaum,
PhD. University of London, London, England: Jay Belsky,
PhD. University of Washington, Seattle: Cathryn Booth,
PhD. University of Arkansas, Little Rock: Robert
Bradley, PhD. University of Pittsburgh, Pittsburgh, Pa:
Celia Brownell, PhD. University of North Carolina, Chapel
Hill: Margaret Burchinal, PhD. University of Arkansas
for Medical Sciences, Little Rock: Bettye Caldwell, PhD. University of Pittsburgh: Susan Campbell, PhD. University
of California, Irvine: Allison Clarke-Stewart, PhD. University of North Carolina: Martha Cox, PhD. NICHD,
Bethesda, Md: Sarah Friedman, PhD. Temple University,
Philadelphia, Pa: Kathryn Hirsh-Pasek, PhD. University
of Texas, Austin: Aletha Huston, PhD. Research Triangle
Institute, Cary, NC: Bonnie Knoke, MS. Wellesley
College, Wellesley, Mass: Nancy Marshall, PhD. Harvard
University, Cambridge, Mass: Kathleen McCartney, PhD. University of Kansas, Kansas City: Marion O'Brien, PhD. NICHD: Mary Overpeck, DrPH. University of Texas at
Dallas: Margaret Tresh Owen, PhD. University of Virginia,
Charlottesville: Robert Pianta, PhD. Georgetown University,
Washington, DC: Deborah Phillips, PhD. Children's
National Medical Center, Washington, DC: Peter Scheidt, MD. University of Washington, Seattle: Susan Spieker, PhD. University of Wisconsin, Madison: Deborah Lowe Vandell, PhD. Research Triangle Institute: Kathleen Wallner-Allen, PhD. Temple University: Marsha Weinraub, PhD.
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From the National Institute of Child Health and Human Development Early
Child Care Research Network.
Corresponding author and reprints: Robert H. Bradley, PhD, Center
for Applied Studies in Education, University of Arkansas at Little Rock, 2801
S University Ave, Little Rock, AR 72204 (e-mail: rhbradley{at}ualr.edu).
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