美國託兒所實施雙標準 幼兒安全難以保障

Deborah Stenseng had an unusual way of comforting infants in her home day care. When they got fussy or wouldn't take a bottle, the Duluth woman opened her shirt and had them suckle on her breast, even though she wasn't lactating or breast-feeding children of her own.

Worse, Stenseng deceived some parents about the practice and defied others who asked her not to do it with their children, regulators later concluded. Eventually, a complaint reached St. Louis County authorities, who shut down Stenseng's day care in January and revoked her license in April. "Serious personal boundaries ... were crossed," licensing officials concluded.

Though extreme, Stenseng's case reflects an inherent problem in licensed family child care -- a problem that may be linked to a recent increase in child care deaths in Minnesota. Operating with minimal training, spotty inspections and inconsistent rule enforcement from one county to another, home-based providers can engage in practices that range from inappropriate to dangerous as they care single-handedly for as many as a dozen children.

Minnesota has some of the leanest training requirements in the nation for in-home child care, according to a Star Tribune review of licensing data. Providers don't need high school diplomas or child development expertise to get licensed. Inspections are required only every two years, and one watchdog group estimates that Minnesota's ratio of inspectors to providers is aMong the nation's lowest.

The risk is that low standards result in low quality, said Amie Lapp Payne, who wrote an influential 2011 report for the National Association for Regulatory Administration on child-care safety. "If it isn't a regulatory requirement, they aren't going to do it," she said.

Even with lax standards, thousands of Minnesota day-care providers nurture children skillfully, with no deaths or safety violations. But a review of public records shows that the rules allow substandard operators to stay in business and place children at risk.

One former provider in Delano, for example, shoved a child's face into a pool of urine on her floor in early 2010 after discovering that the child had had a toileting accident. Documents show that the woman pressed hard enough to bruise the child's forehead.

Other providers dunked children in water, put hot sauce on their tongues, or grabbed or hit them hard enough to break bones. Altogether, the newspaper found 70 cases of corporal punishment since 2007 -- even though it is forbidden under state law.

In the last decade, the Legislature has considered raising training and safety standards for home child care several times. But lawmakers have repeatedly hedged, out of concern that higher standards would increase costs or represent government intrusion for these small businesses.

Even the Minnesota Licensed Family Child Care Association, which represents small, in-home providers, has encountered resistance when seeking more funding so that providers could be mentored by experienced colleagues.

"[It's] the idea that, 'Why do people who are taking care of little kids need this?' " said Katy Chase, the association's executive director. "There's just a feeling we're born able to properly care for children."

The result is a two-tier child-care system: Roughly 1,500 large child-care centers with more employees, higher training requirements and inspections by Minnesota regulators; and about 11,100 small in-home day cares, where providers often operate in isolation with little support and scrutiny.

'Adults get worn down'

Reviewing licensing documents and death records, the Star Tribune found that 82 of 85 deaths in licensed child care since 2002 have taken place in homes, not centers. The number of deaths has nearly doubled in the past five years.

One of the few researchers to examine the causes of child-care deaths nationally said the absence of oversight increases risks for children.

Julia Wrigley, a sociologist at the City University of New York, found a higher rate of deaths in the nation's licensed home day cares than in centers. She concluded that large child-care centers are safer because they have multiple workers on hand to monitor children and stop co-workers from making mistakes.

"Adults can get worn down. They can get distraught and frustrated and these all can be risk factors when caring for a lot of little kids," she said. "If you have other adults there ... they can ensure that safe standards are maintained."

A Star Tribune review of 1,100 disciplinary actions issued since 2007 against Minnesota licensed day-care homes showed that the isolation of providers can play a significant role. More than 300 sanctions resulted from lapses in child supervision -- often because providers were spread thin.

In Rochester in 2010, a provider confined two preschoolers to a basement for seven hours (keeping one in a 4-foot-square pen) to keep them away from a furnace repair man. At a Rose Creek day care last fall, a 1-year-old was left unattended and wandered two blocks away to a hardware store.

Tighter enforcement?

To aid providers who are struggling with safety and quality, advocates believe Minnesota needs tougher standards and enforcement.

Many child deaths reviewed by the Star Tribune involved providers who didn't follow even basic safe-sleeping rules. At least 10 deaths since 2007 involved infants placed to sleep on their stomachs -- a clear violation of guidelines -- or on unsafe surfaces. Several deaths involved napping infants who weren't checked for long periods of time -- in one case three hours.

The state requires that in-home providers and center workers be within sight or hearing of sleeping infants. But only at child-care centers are workers required, in most cases, to visually check sleeping infants every 15 minutes.

In Kansas, which overhauled its child-care rules in 2010, in-home caregivers must check on sleeping children every 15 minutes. It is one of at least six states that require in-home providers to observe children during their nap times.

In a May 3 letter to family providers, Minnesota Department of Human Services Inspector General Jerry Kerber said his agency would examine the "vast differences" in death figures between centers and licensed homes, and whether additional training or supervision is needed.

In addition, some advocates believe Minnesota needs better day-care inspections. Child Care Aware of America, a research and watchdog group, estimates that Minnesota has one county inspector for every 150 family child care homes -- 10th worst in the nation.

Actual rates vary widely by county. In Anoka County, three inspectors have caseloads of more than 200 providers and aren't able to spend as much time with individual providers as they would like.

"If we're really wanting to know what's going on in a home, the best way ... is to be there in person, eyeball to eyeball," said Evelyn Nelson, who supervises the Anoka office. "We don't have the people power to do that."

In 26 states, inspections occur at least once a year, with 14 states inspecting in-home providers twice a year or more, according to Child Care Aware of America's survey. Four states inspect at least quarterly, including Wyoming, where there is an inspector for every 66 home child care providers.

Better training?

Better training of child care providers also can improve the quality of care, according to several research studies.

Minnesota requires in-home providers to be trained in first aid and CPR before they are licensed, but no training in child development is required until after they open. The state's requirement of eight hours of annual training was 33rd lowest among 42 states that license small child care homes, according to Child Care Aware.

Wisconsin requires at least 40 hours of initial training, including child development, and then 18 hours annually.

"We think [training] increases the likelihood children will be safer in care," said Grace Reef, Child Care Aware's public policy director. "But it's also about healthy [child] development."

Responding to the Star Tribune's ongoing investigation, state regulators recently recommended increased training in safe sleep positioning and CPR.

Yet proposals to increase training can face political resistance. In 2006 Minnesota increased its annual training requirement from six hours to eight after lawmakers opposed increasing the total to 12.

"Conservatives railed against 'the nanny state,' " said John Hottinger, a former DFL state senator who sponsored the training bill.

Some legislators remain skeptical of more regulation. "It never ends. We add regulation on regulation, training on training," said Rep. Steve Gottwalt, R-St. Cloud. "Unless you've got real good evidence that six hours results in 'X' amount of better safety for kids, then why not 12 hours? Why not 36 hours? Why not require day-care providers to have a master's degree?"

Training isn't a cure-all, Wrigley said. Her deaths study concluded that the environment of family child care was more problematic than a lack of education. And Stenseng, the provider who lost her license because she used breast-suckling to control behavior, had college training in psychology and social work.

Stenseng said she created her own licensed child care because she was dissatisfied with options for her children and wanted to create a facility that supported alternatives such as cloth diapers, attachment parenting and extended breast-feeding. She disagreed with the state report, arguing that most parents were aware of her "comfort nursing" practice. "To them," she said, "it was a very natural fit" with their parenting philosophies.

Katy Chase of the Family Child Care Association believes providing more mentors would raise child-care quality. Public funding covers mentoring for only five providers a year, she noted.

Payne, the author of national child-care guidelines, said ultimately it's up to states to ensure safety at home-based day care.

"This is their house," she noted. "But is it safe enough for kids? That's the bottom-line question."在一個位於明尼蘇達州德盧斯的家庭託兒所中，德博拉·斯坦森用一種不尋常的方式來安慰嬰兒。每當嬰兒吵鬧或不喝奶時，她會解開衣服，讓嬰兒吮吸自己的乳房，但她並沒有分泌乳汁或在給自己的孩子餵奶。

監督機構後來發現，更糟的是，一些父母對斯坦森這種做法毫不知情，另一些父母要求她不要這樣帶他們的孩子，她卻公然違背了這些父母的要求。最後，有人向聖路易斯縣有關監督部門投訴，監督部門1月取締了斯坦森的託兒所，4月吊銷了她的執照。頒發執照的官員說：“她越過了身體接觸的界限，事態很嚴重。”

斯坦森的例子雖然很極端，但也反映出獲得營業執照的家庭託兒所中存在的固有問題——這個問題也許與近日明尼蘇達州託兒所死亡事件增加有關聯。缺乏培訓、定期檢查過少及各個縣法律執行力度不一，在這種情況下營業的家庭託兒所負責人獨自照料多達12個兒童時，可能會採取各種方法，包括不恰當或危險的方法。

《星論壇報》檢查執照的數據後發現，明尼蘇達州對家庭託兒所的培訓要求是全美最寬鬆的。家庭託兒所負責人無需有高中文憑或兒童發育的專門知識就可以獲得執照；每兩年才進行一次檢查。一個監察組織估計在明尼蘇達州，檢查員與託兒所負責人的比率是全美最低的。

“風險就在於低標準造成低質量，”阿米·拉普·佩恩說，“如果不是法規要求，那些負責人不會去做。”阿米曾在2011年爲“全美兒童保育安全監督管理協會”寫過一篇影響頗深的報告。

在明尼蘇達州，即使標準很鬆，成千上萬的託兒所熟練地照顧孩子，沒有兒童死亡或安全違規行爲。但是查看備案材料後發現，寬鬆的法規縱容不合格的託兒所經營者留在託兒所行業，將兒童置於危險中。比方說，2010年，德拉諾曾有個家庭託兒所負責人發現孩子在地上小便後，把那個孩子的臉按到那灘尿液中。材料顯示那個女人用力太大，擦傷了孩子的前額。

還有些負責人把孩子泡在水裏，給孩子喂辣椒醬，或者抓他們、打他們時用力過大，造成孩子骨折。《星論壇報》發現儘管明尼蘇達州法律禁止兒童體罰，從2007年起，共發生了70起這樣的事件。

明尼蘇達州獲得執照家庭託兒所協會曾試圖籌得資金，讓家庭託兒所負責人接受有經驗的同行的培訓，甚至是此舉都受到了阻力。這個協會代表着小型家庭託兒所。

“大家的想法是‘照顧小孩子的人爲什麼需要培訓？’”此協會的執行理事凱蒂·蔡斯說，“大家都覺得我們生來就會正確地照顧兒童。”

結果就是雙重託兒所繫統：一重是約1500家大型託兒所中心，僱員更多，培訓要求更高，由明尼蘇達州的監管部門定期檢查；另一重是約1.11萬家小型家庭託兒所，負責人往往獨立經營，沒有人幫忙，很少有人來檢查。

照看者筋疲力盡

通過查看執照文檔和死亡記錄，《星論壇報》發現，自2002年起，有85次兒童死亡事故，其中82起發生在家庭託兒所中，而不是托兒中心中。過去5年中，死亡數字將近增加了一倍。

有幾位研究者檢查了全美託兒所兒童死亡原因，其中一人表示缺乏監督增加了兒童死亡的風險。

紐約城市大學的社會學家茱莉亞·裏格麗發現獲得執照的家庭託兒所中兒童的死亡率比托兒中心要高。她的結論是大型托兒中心更安全，因爲托兒中心隨時有多位僱員照看小孩，並阻止同事犯錯。

“成年人會筋疲力盡。他們會變得心煩、受挫。照顧小孩時，這些都可能是風險因素，”茱莉亞說，“但是如果有其他成人在那，他們可以保證安全。”

過去十年中，明尼蘇達州的立法機關多次考慮增加家庭託兒所的培訓和提高對他們的標準，但由於擔心提高標準將增加成本，讓人覺得政府在干預小型企業，立法者對此多次閃爍其詞。

《星論壇報》查看了2007年以來針對明尼蘇達州有執照的家庭託兒所發佈的1100項懲戒性措施，結果發現隔離家庭託兒所負責人作用顯著。超過300項處罰措施是因爲負責人沒有照看好孩子，這往往是因爲她們無力同時照顧太多孩子。

2010年，羅切斯特有一名家庭託兒所負責人把兩個學齡前兒童關在地下室7小時（有一個孩子被關在約1.2米的籠子裏），以讓他們遠離修爐工。去年秋季，在羅斯克裏克的一家日託所裏，一個1歲的孩子無人照看，獨自遊蕩了兩個街區，到了一家五金店裏。

增強執行力度？

爲幫助那些盡力保證託兒所質量和安全的負責人，倡導者認爲明尼蘇達州需要設定更高的標準和增強執行力度。

《星論壇報》查看的衆多幼兒死亡事件中，很多都是由於負責人無法執行基本的安全睡眠法則。2007年以來，至少有10起幼兒死亡事件涉及到嬰兒背朝天睡覺——明顯違反了標準——或在不安全的表面睡覺。數起死亡事件涉及到嬰兒睡覺時，長時間無人查看——有一例中，三個小時內，無人查看嬰兒。

明尼蘇達州要求嬰兒睡覺時，家庭託兒所負責人和託兒所中心員工必須能看到或聽到孩子的動靜。但是往往只有託兒所中心要求員工每15分鐘檢查一下熟睡中的嬰兒。

2010年，堪薩斯州全面修訂了照看兒童的規定，要求家庭託兒所負責人每15分鐘查看一次熟睡中的幼兒。至少有六個州要求家庭託兒所在孩子小睡期間查看幼兒，堪薩斯州就是其中的一個。

5月3日，明尼蘇達州人類服務部監察長傑裏·科伯給家庭託兒所負責人寄了一封信，信中說道，人類服務部將查看託兒所中心和獲得許可的家庭託兒所之間幼兒死亡率差別如此之大的原因，看看是否需要給家庭託兒所負責人提供額外的培訓或監督。

另外，一些倡導者認爲明尼蘇達州需要更好的日託所視察。據研究與監督機構美國兒童看護意識估計，在明尼蘇達州，每150個家庭託兒所配有一名縣級視察員，這在全美倒數前十之列。

真實的比率根據不同的縣而不同。在安諾卡縣，超過200名負責人僅配有3名視察員，視察員無法給每個負責人那裏安排儘可能多的時間。

“如果我們真的想知道家庭託兒所的真實情況，最好的辦法是派個人在那裏看着，”伊芙琳·內爾遜說，“我們沒有那麼多人力。”內爾遜是安諾卡縣視察辦公室的負責人。

據美國兒童看護意識的調查，全美有26個州每年至少視察一次家庭託兒所，其中有14個州是每年2次以上，包括懷俄明州在內的4個州每個季度至少視察一次。在懷俄明州每68家家庭託兒所配有1名視察員。

改善培訓？

多項研究顯示，爲家庭託兒所負責人提供更好的培訓也能改善看護兒童的質量。

美國兒童看護意識的調查顯示，在明尼蘇達州，家庭託兒所負責人獲得執照前必須接受急救和心肺復甦術的培訓，但是要等到家庭託兒所開業後纔要求其負責人接受兒童發展的培訓。明尼蘇達州要求每年接受8小時的培訓，這在給小型家庭託兒所頒發執照的42個州中排名第33位。

威斯康星州要求最少要接受40小時的前期培訓，其中包括兒童發展方面的培訓，並且每年必須接受18小時培訓。

“我們覺得增加培訓可以提高孩子看護的安全度，”美國兒童看護意識的公共政策主管格蕾絲·麗芙說，“同時還關乎到兒童的健康成長。”

明尼蘇達州對《星論壇報》的調查做出了迴應，管理機構最近建議增加在安全睡眠姿勢和心肺復甦術方面的培訓。

但是增加培訓的提議可能會遇到政治上的阻力。2006年，明尼蘇達州的立法者反對將培訓時間增加到12小時，結果只從6小時增加到了8小時。

“保守派反對保姆式國家。”支持家庭託兒所培訓法案的前參議員約翰·豪廷傑說。

一些立法者對更多管控持懷疑的態度。“管控無止境。我們在管控上加新的管控，在培訓上加新的培訓，”共和黨員史蒂夫·哥特瓦特說，“除非你有鐵證證明六個小時爲孩子增加了多少安全度。爲何不增加到12小時？爲何不增加到36小時？爲什麼不要求家庭託兒所負責人獲得碩士學位？”

裏格勒說，培訓不是萬能鎖。她的幼兒死亡研究結果是家庭託兒所的環境比其負責人缺乏教育問題更大。斯坦森因爲用讓孩子吮吸乳房的方法控制他們的行爲而被吊銷執照，但她本人接受過心理和社會工作的大學培訓。

斯坦森說她辦了自己的託兒所是因爲她不滿意看護孩子方法的限制性，她想要辦個支持額外做法的託兒所，如布尿布、親密育兒和延長母奶餵養等。她不贊同明尼蘇達州的報告，反駁道大多數父母都知道她的安慰式撫養法。“大多數父母覺得，”她說，“我的做法很自然地吻合了”他們的育兒理念。

家庭託兒所協會的成員凱蒂·蔡斯認爲提供更多的培訓會提高育兒的質量。她還提到，公共資助每年只覆蓋5名家庭託兒所負責人。

《全美育兒指導》的作者佩恩說最終還是要靠各個州來保證家庭託兒所的安全。

“這是家庭託兒所的家，”她寫着“但是對孩子來說安全嗎？這是我們的底線。”