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Continuity of care with infants & toddlers: Identifying benefits and addressing common concerns

Authors:
Continuity of Care with Infants and Toddlers
by Mary Benson McMullen
“Human babies are not like us.
Jean-Jacques Rousseau
Rousseau’s words remind us how truly special babies are
and about the uniqueness of very early childhood. Children
grow, develop and learn more rapidly during the rst three
years of life than at any other time (Shonko & Phillips,
2000). The remarkable changes they undergo impact who
they are now and who they will become in the future.
Whether positive or negative, big, small, or in between,
everything that happens to infants or toddlers impacts
their health and well-being for a lifetime.
Psychologists, sociologists, neurobiologists, health care
professionals, philosophers, and educators have published
mountains of research about the importance of these
rst three years. Additionally, babies and everything for
and about them are a hot topic in popular literature and
social media. Books, magazine articles, websites, videos,
blogs, and discussion forums are found alongside research
publications. Underlying all of this work — scholarly as well
as popular — is the understanding that the rst three years
matter!
New information and continuing discoveries about the rst
three years give parents and professionals new ways to
think about how very young children can and should spend
their days in child care. Most importantly, we’ve learned
to support healthy growth, development, and learning by
surrounding infants and toddlers with positive, sensitive,
and nurturing relationships. Creating and maintaining
these relationships is up to the professional infant/toddler
caregiver. In earlier writings (McMullen, 2013; McMullen,
Yun, Mihai, & Kim, 2015), I described the highly qualied
infant/toddler professional caregiver as someone who:
has in-depth knowledge of typical child growth,
development, and learning that spans prenatal to age 3.
is skilled at responding sensitively to the verbal and
nonverbal communications of individual infants and
toddlers.
comes to know each infant or toddler in his or her
care in the context of his or her family and home life,
community, and culture.
commits to forming respectful partnerships with families
in making caregiving decisions and goal setting for his or
her infants and toddlers.
Being able to accomplish all of this involves more than
having specialized knowledge and skills; it requires
individuals willing to invest time and energy toward
building and maintaining strong inter-personal
relationships between and among all of those in the child
care environment — babies, professionals, and family
members. It also requires policies and practices that
support caring relationships, which are the heart and soul
of recommended practices with infants and toddlers cared
for outside of the home (Elicker, Ruprecht, & Anderson,
2014; Lally & Mangione, 2008). Ideally, supportive structures
ensure these relationships will be long-term, existing over
years, rather than a few weeks or months (Zero to Three,
2008).
The characteristics listed above for highly qualied infant/
toddler professionals are, of course, important for those
working with preschool, kindergarten, and primary-grade
children; their emphasis in the rst three years, however,
is much greater. Individualized, sensitively responsive,
relationship-based care is critical, not just important,
when caring for very young children, if we are to ensure
Mary Benson McMullen, Ph.D., is Professor of Early Childhood
Education at Indiana University, Bloomington, Indiana, where she
has been on faculty for 22 years. Prior to this she was an infant
caregiver and preschool teacher, and then early childhood program
director. Currently, her primary research and teaching interests
involve studying factors that influence the healthy overall growth,
development, learning, and well-being of infants, toddlers, and preschoolers; and
looking at factors that influence and ensure the well-being of the parents and
professionals who care for our youngest citizens. She and her husband have raised
three sons.
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their health and well-being at this highly vulnerable and
dependent time of life. Also, caregiving relationships
that form between parents and professionals — and
professionals with the babies themselves — involve a level
of physical and emotional intimacy that is deeper and more
sensitive than at later periods of childhood.
Infant/Toddler Continuity of Care
The practice of continuity of care (COC) is designed to
keep very young children together with their caregiving
team over a long period of time, typically two to three
years. There are two popular models for achieving COC:
one involves multi-age (or mixed-age) grouping and the
other is the ‘looping’ method. The multi-age model, like
it sounds, involves mixed-age groups that might include
young infants, toddlers, and two-year-olds, all together in
one room. At some designated time, often during summer
or early fall, children who have ‘aged out’ (typically age 3)
move out, and new, younger infants or toddlers move in.
In the looping model, a group of caregivers starts with
infants, sometimes as young as six weeks old. The group
remains together until, typically, all of the children turn
three and move on to preschool. The caregivers then
‘loop’ back to begin with a new group of infants for a new
three-year cycle. Whether in a setting that uses multi-
age grouping or looping, in a COC model, a child who
begins a program as a young infant remains with the same
caregivers and most of the same peers for up to three years.
‘Discontinuous’ models are much more common for
stang and grouping in infant toddler child care, despite
being known to contribute to stress in very young children
(Cryer et al., 2005). One such model follows a traditional
school calendar, meaning during summer or early fall,
children begin each ‘school’ year in a new room with new
caregiving professionals. In a second form of discontinuous
care, children are constantly transitioning in and out of a
group; old ‘friends’ leave as they celebrate their birthday
or acquire a new skill (e.g. crawling, walking, being potty-
trained,) while new ones enter, creating a revolving door of
comings and goings.
Neither form of discontinuous care prioritizes the
long-lasting, trusting relationships among caregiving
professionals, children, and families that are known to
facilitate attachment security. The frequent ‘hellos’ and
‘good-byes’ in discontinuous child care mean everyone
spends much time and energy adjusting to new faces,
establishing new relationships, and redening their
communities. Contrast that with a COC group, in which
children, families, and professional caregivers enjoy stability
created by an extended period of time together, time that
allows knowledge of one another to grow and trusting
relationships to ourish.
COC recognizes that secure attachments between babies
and caregivers and trusting relationships among all
involved take time to develop and should last as long as
possible (Bernhardt, 2000; Elfer, Goldschmied, & Selleck,
2003; Lally & Mangione, 2008; Raikes & Edwards, 2009). COC
is strongly recommended as a practice for ensuring groups
of individuals in child care stay together as long as possible
to facilitate quality relationship-based experiences during
these important rst three years. It has been recommended
by nearly all major professional organizations that address
infant toddler practices (see box below), and it is based
upon attachment research that demonstrates the lifelong
impact of supportive, stable relationships that begin in
infancy (Sroufe, 2005).
Organizations Recommending
Infant Toddler Continuity of Care
Center for Law and Social Policy (CLASP)
www.clasp.org/issues/child-care-and-early-education
Childcare Aware of America
http://usa.childcareaware.org/
EDUCARE
www.educareschools.org/
HighScope
www.highscope.org/
Program for Infant Toddler Care (PITC)
www.pitc.org/pub/pitc_docs/home.csp
National Association for the Education of Young
Children (NAEYC)
www.naeyc.org/
National Head Start Association (NHSA)
www.nhsa.org/
Ounce of Prevention Fund
www.theounce.org/
Zero to Three
www.zerotothree.org/
…among others
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Benets of Continuity of Care
Although many organizations, scholars, and leaders in
the eld promote infant/toddler COC, only recently have
researchers examined it closely. Below, unless otherwise
noted, I list benets found in my study of successful infant/
toddler COC (McMullen, Yun, Mihai, & Kim, 2015):
Increased knowledge of child development
Caregivers develop a more complete understanding of
how children grow, develop and learn from infancy to age
3.
Stronger knowledge of individual children
Caregivers develop more in-depth knowledge of each
individual child and their families, allowing them to better
individualize care.
Decreased stress — Parents, caregivers (McMullen et al.,
2015), and children (Cryer et al., 2005) feel less stressed
in COC as compared to discontinuous care where they
experience multiple transitions and the more frequent
breaking and reforming of important relationships.
Smoother developmental progress — Because there is
less starting, stopping, and starting over again, children
make more steady, even developmental progress,
experiencing less regression.
Easier adaptation to preschool — Children transitioning
to preschool after infant/toddler COC ‘hit the ground
running’ in terms of knowing how to use the environment
and socialize with friends.
Stronger family-caregiver partnerships — Parents
and caregivers in COC build stronger partnerships that
value each other’s expertise in decision-making and goal
setting.
Parents empowered — COC parents become
empowered to be strong advocates for their children, an
empowerment that carries through to formal schooling.
Family-like atmosphere — Parents and caregivers
develop a closeness that mirrors feelings they have for
extended family members and close friends.
Increased sensitive-responsiveness — Caregivers are
more likely to respond in sensitively responsive ways to
infants and toddlers (Ruprecht, Elicker, & Choi, 2015).
Improved behavior of children — Caregivers in COC
identify fewer behavioral concerns for infants and toddlers
than those in discontinuous care (Ruprecht, Elicker, &
Choi).
More secure attachments — Infants and toddlers in COC
with the same caregivers for at least 12 months develop
stronger, more secure attachments (Raikes, 1993).
Confronting Old Fears
Despite its many benets and strong endorsements, infant/
toddler COC is still not a widely adopted practice (Aguillard
et al., 2005; Cryer et al., 2000; Essa, Favre, Thweatt, & Waugh,
1999). Caregivers and administrators express many reasons
for their reluctance to engage in COC.
“It’s too difficult.” Some administrators fear the initial
change to COC will be too dicult or too costly, believing
their programs would need expensive changes to existing
physical structures and materials. In reality, although
transitioning to COC from discontinuous care does take
careful planning, it should be possible within most settings
with limited disruption and it should not cost anything
beyond normal operating expenses. Typically, programs
move existing furnishings and materials around to
accommodate the needs of a group, or they rotate an entire
group to a more appropriate room as needed.
“Families won’t like it. An often-expressed fear is that
families will not like COC because they might feel ‘stuck’
with the same caregivers over a two- to three-year period.
Professionals and parents in my study believed this does
not happen if all involved are willing to invest in the long-
term relationships. If you know that you will be together
with other people for two to three years, rather than a few
months, you work hard to build and maintain positive,
supportive relationships, and are more likely to address
issues that arise, rather than just let them go.
“Caregivers won’t like it.” “I’m only good with babies
(toddlers).” Sometimes caregivers feel very competent with
one age group and worry their expertise would not extend
to another. Some caregivers in my study admitted having
similar concerns as they began COC, but said those fears
quickly vanished. They enjoyed the benets of watching
the children in their care develop and took pride in being
a part of that growth and change. They also appreciated
the opportunity to grow, themselves, as professionals with
increased knowledge and skills throughout birth to age 3.
In addition, they grew very close to the children and their
families, coming to truly value those relationships.
“Life is change.” “They better get used to it.” Some
parents in my study told us that they had initially been
against the idea of COC because they believed children
need to start preparing for the realities of school — even
as infants! “They better get used to it,” I was told, referring
to the multiple transitions and constantly changing
relationships they’ll experience in formal schooling. A
colleague of mine responds to this attitude by reminding
us that to prepare for a hurricane, we don’t actually practice
going through a hurricane; rather, we stock up on non-
perishable foods and bottles of water, cover windows with
plywood, and similar measures. In other words, we stockpile
resources and prepare. Similarly, a strong, relationship-based
beginning with the rst three years buttresses children for
the multiple transitions they will face in the future.
Considering Real Challenges
Most of the concerns presented above are based upon
fear of the unknown. This is not to say, however, that COC
is without its diculties. Caregivers in my study reported
their most challenging time is when children transition to
preschool from the infant toddler program. As caregivers
say goodbye to children and families they have grown
to love, they must open their hearts to make room for
new relationships and change the physical space to
accommodate the new group of infants.
Final oughts on Continuity
So true are Rousseau’s words, written so long ago: Human
babies are not like us. Infants and toddlers have needs,
interests, preferences, and capabilities that are dierent
from those of older children and adults, and thus they need
to be supported dierently. Increased understanding of the
importance and life-long impact of the rst three years of
life, along with new understandings of the role of babies’
attachment to secure adult caregivers have resulted in
support for COC.
A word of caution is needed, however; programs should not
simply launch into doing COC if other elements of quality do
not exist: proper ratios and group sizes, a healthy and safe
environment, stable qualied professional sta, consistent
program philosophy, strong leadership and supportive
administrative structures (Ackerman, 2009; Garrity,
Longstreth, & Alwashmi, 2015; Norris, 2010). COC is the icing
on the cake for an already strong, quality setting, serving
to increase the overall quality and ensure the best possible
experiences for children as they live, love, work, and play
through their days in infant toddler child care settings.
References
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(2005). Barriers to the implementation of continuity of care
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Benets of Infant Toddler Continuity of Care
Increased caregiver knowledge of child development
• Stronger caregiver knowledge of individual children
Decreased stress for children, parents, and caregivers
• Smoother developmental progress of children
Stronger family-caregiver partnerships
• Parents empowered as advocates for their children
Family-like atmosphere
• Children adapt more easily to preschool
Increased sensitive-responsiveness of caregivers
• Improved behavior of children
• More secure attachments of babies to adults
Garrity, S., Lonstreth, S., & Atwashmi, M. (2015). A qualitative
examination of the implementation of continuity of care: An
organizational learning perspective. Early Childhood Research
Quarterly, 36, 64–78.
Lally, J. R., & Mangione, P. L. (2008). The program for infant
toddler care. In J. P. Roopnarine & J. E. Johnson (Eds.),
Approaches to early childhood education (5th ed., pp. 25–47).
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Research Findings: Continuity of care is a recommended practice in child care intended to promote secure and supportive relationships between infants and toddlers and their caregivers. Toddlers (N = 115) between 12 and 24 months were observed in 30 continuity and 29 noncontinuity classrooms. The average duration of care for toddlers with caregivers was 14 months in the continuity rooms and 5 months in noncontinuity rooms. Toddlers observed in continuity rooms experienced higher levels of interactive involvement with their caregivers and were rated by their caregivers as having fewer problem behaviors compared with the toddlers in noncontinuity rooms. Toddlers in rooms with higher staff–child ratios also experienced more involved caregiving. We did not find evidence that the level of involved caregiving mediated the association between continuity of care and toddlers’ social competence or problem behaviors. Practice or Policy: Continuity of care may be a promising practice for programs that strive to provide high-quality care for infants and toddlers.
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Research Findings: A qualitative descriptive study was conducted to look at the nature of continuity of care by examining the perspectives of those who lived it in 2 programs in which it was a well-established practice. The 35 participants included infant toddler caregivers, parents, preschool teachers, and administrators. Findings are organized around 8 features of continuity of care revealed in the study: increased knowledge (increased understanding of child development and individual children), stable relationships (decreased disruption associated with frequent transitions), a family-type atmosphere (trust, warmth, and affection promoted), primary caregiving (changing nature of roles over time), family-centeredness (mutual empowerment of parents and caregivers), effective caregiver partnerships (caregiving relationships among caregivers), the transition to preschool (higher levels of ability in social and self-help skills among children), and recommendations for improvement. Practice or Policy: We discuss implications for practitioners, teacher educators and policymakers, including further consideration of parental/caregiver empowerment, the maintenance of continuity across members of caregiving teams, and keeping children ages birth to 5 together in 1 setting. Also, findings suggest differences in the nature of primary caregiving in continuous versus discontinuous care settings. Finally, we conclude that continuity is beneficial, but complex, and more likely to succeed in programs already committed to engagement in strong, relationship-based practice.
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Practice or Policy: Continuity of care (COC) has many benefits for young children's development but is not the norm in infant/toddler classrooms. As a consequence, policymakers might not realize how such an approach might also benefit the professional development of infant and toddler teachers, particularly if they come to the field with little formal training. Although the supports and policies available to military child development centers may not be possible to implement at present in much of the civilian sector, this study suggests that their potential benefit for infant/toddler teachers' learning and practice may be worthy of further inquiry. Research Findings: This study shares the results of an exploratory study of the benefits of COC, professional community, and the larger policy context for staff working in a military child development center serving children aged 0 to 2. COC-related professional development also seems to enhance professional community, which along with the policy context is viewed as an essential aspect of improving teacher learning and practice in the K–12 literature.
Repeated calls have recently arisen for increasing the educational level of early childhood teachers in all early care and education settings including classrooms for infants and toddlers. Since the majority of teachers in early child settings do not have a college degree, higher educational expectations could place a strain on early childhood teacher preparation programs. Implications of increasing educational expectations of teachers for the higher education institutions that prepare early childhood educators are presented. Challenges related to both the needs of the institutions as well as the needs of the students are addressed. The successful utilization of online courses is explored as one solution to meeting some of the challenges. Recommendations are summarized for policy makers, institutions of higher education, teacher education programs, and faculty.
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This study examined barriers to the implementation of continuity-of-care practices in child care centers. We collected qualitative and quantitative data for 52 children at four centers that advertise their programs as continuity programs. Of the 52 children, only 7 of the children had been cared for in a single child–caregiver dyad between the time of their entry into child care and either their third birthday or the time of data collection. During their infant–toddler period, the remaining 45 children had experienced 71 cumulative transitions to new child–caregiver dyads. We found that the barrier frequently suggested in the literature and by practitioners, caregiver turnover, was not a significant cause for the non-continuity transitions. The primary barrier that we found was infant caregiver unwillingness or inability to care for children who had developed toddler abilities. A secondary barrier was directors’ reluctance to replace unwilling or unable caregivers with willing and able ones.
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Theory and research support the need for continuity of caregiving for infants and toddlers, yet current practice often ignores that need. In many child care centers, children are promoted to a new class when they reach a specific milestone, such as a birthday. In other cases, frequent teacher turnover and parental choice add to very young children's discontinuity of care. At the Child and Family Research Center of the University of Nevada, Reno, Infants and toddlers stay with the same teacher for the first 3 years of life. Many benefits are seen from this practice, particularly in the close relationship between children and teachers. Children's attachment to their teachers is evident in the security with which they explore their environment. Another major benefit of this 3‐year continuity of children with teachers is the close relationship that develops between the parents and the teachers. Close bonds are forged between the adults who have nurtured and watched their babies develop over a 3 year period Into competent preschoolers. In addition, yearly transitions to new classrooms, which better match the children's growing developmental skills, are eased when the entire group of children and adults move together. In some classes, there is a relatively wide range In ages of children, yet this age span has not proven to be a concern; children become very dose to and protective of members of their cohort and adapt to the varying developmental abilities of peers. The practice of keeping a group of infants with their primary teacher for a 3 year period is highly recommended by the staff of the Child and Family Research Center for other infant programs because it is developmentally important for very young children.
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The purposes of this mail survey were to describe the extent to which child care programs use continuity of caregivers with infants and toddlers, the factors influencing decisions to move infants and toddlers to new classes, the practices used to prepare them for such moves, and the extent to which respondents agreed with the concept of providing continuity of caregivers. Child care programs accredited by the National Association for the Education of Young Children and those that were not accredited were selected randomly from existing data bases. Results indicate that (a) relatively few programs use continuity of caregivers for infants and even fewer use it for toddlers; (b) the majority of programs consider children’s attainment of developmental milestones, their age, and the space available in the next class when deciding when to transition infants and toddlers to new classes; (c) most centers used a number of practices to prepare infants and toddlers to move to new classes; and (d) more respondents report agreement with using continuity of caregivers than practice it. Relatively few differences were noted across accredited and nonaccredited centers on these issues.