Creative Education
2012. Vol.3, No.2, 263-268
Published Online April 2012 in SciRes (
Copyright © 2012 SciRe s . 263
Health of School-Aged Children in 11+ Hours of
Center-Based Care
Tokie Anme1, Ryoji Shinohara1, Yuka Sugisawa1, Lian Tong1, Emiko Tanaka1,
Etsuko Tomisaki1, Taeko Watanabe1, Kentaro T o kut ake1, Yukiko Mot i z u k i 1,
Hisako Matsumoto1, Chihiro Sugita1, Uma Segal2
1Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan
2School of Social Work, University of Missouri, St. Louis, USA
Received March 18th, 2012; revised April 12th, 2012; accepted April 28th, 2012
With increasing numbers of women joining the evening/nighttime and extended-hour workforce, there is
a need for quality childcare during these hours. This project, conducted in Japan, sought to compare the
effects of expanded child-care on the health of 271 school-aged children. Parents completed a survey on
the childrearing environment at home, their feelings of self-efficacy, and the presence of support for
childcare; and childcare professionals evaluated the development of these school-aged children. Children
responded to questions regarding their health. Results of the multiple regression analysis indicate that
factors in the home environment, not length of time in center-based care, explained health risks at school
Keywords: Health; Child-Care; Cohort Study
Demands for the expansion of center-based child night and
extended-hour care have dramatically increased with the rising
numbers of working mothers in Japan. High-quality center-
based night care is essential to provide a safe and comfortable
environment for children whose parents are employed in occu-
pations that require long hours including evening and night
shifts. Sixty-one authorized night care facilities, centers that are
licensed by the national government as meeting quality care
standards, have been established since 1981, after the several
highly publicized involuntary homicides (cases of neglectful
death) in the existing low-quality “Baby Hotels”. Baby Hotels
are facilities that continue to exist in Japan and that provide
childcare services 24 hours-a-day for children from birth to
seven years of age. With the continued shortage of authorized
facilities, over 120,000 children use non-authorized, sub-stan-
dard Baby Hotels (Anme & Segal, 2003, 2004). Governmental
authorization standards are high, including many criteria in-
cluding child-to-professional ratios (three babies to one nation-
ally licensed professional), credentialling (licensed child care
professionals and nurses), adequacy of physical environment
(space, facilities, safety assurance) and sound management
(budget, accountability, oversight).
The community health program that allows visiting nurses to
provide preventative care for children in the home ceases as
children enter the formal educational system, and primary
schools experience a growing problem with increasing numbers
of students with rising health concerns. Japanese children can
be in child care from the ages 4 months to six years, the period
during which they receive home visits from community nurses.
They attend primary school (grades one to six) from seven
years of age to twelve yeas. After six years in primary school,
all children proceed to junior high school for another three
years. Over 96% of these children go on to senior high shool
for three more years, and 2006 census reports indicate that 76%
children get higher education at a university or college follow-
ing high school. It is essential that the health of these children
be assessed to prevent health decline and to promote health for
children in the school system.
Longitudinal research from the United Kingdom (1958-2007),
and others, indicates the importance of the child environment
during the toddler years in predicting later development (Shoon,
2006; Shoon & Parson, 2002; Sacker, 2002; Salmela-Aro,
2005). The quality of care must be considered carefully if the
effects of early childcare are to be understood [National Insti-
tute of Child Health and Human Development (NICHD),
1999a]. Children from higher-quality centers have been found
to be less anxious and have less problematic transitions to
school. However, in another longitudinal study, such positive
effects of high quality center care facilities were not discernible
among all children sampled at age 13 years (Andersson, 1992).
NICHD (2001, 2002a) further found that the quality of maternal
caregiving was the strongest predictor of development but that
the quality of nonmaternal caregiving was also associated with
children’s development. Contrary to the NICHD’s expectations,
however, family risk factors were the strongest predictors of
behavior problems, prosocial behavior, and langauge skills in
another longitudinal study, but there was limited evidence that
child care experiences moderated the negative associations
between family risk and the child outcomes under investigation
(NICHD, 2002b).
The NICHD (2003) and Langlois and Liben (2003) arrived at
three conclusions: 1) the cumulative quantity of child care dur-
ing the first four years of life predicts some problematic beha-
viors of children between ages 4.5 and 5 years, but these be-
haviors were corroborated by reports of parents and teachers,
not with observed behaviors and were usually low to moderate,
not large; 2) maternal sensitivity and family income were
stronger predictors than quantity of care; and 3) the problem
behaviors indicated were not at clinical levels.
Watamura et al. (2003) reported on some physiological cor-
relates of child care, suggesting that toddlers in nonparental
care may experience more stress by the afternoon hours than do
those who are in maternal care. Effects of nonparental care may
be mitigated by the quality of peer interaction they experience.
Lamb (1996) reviewed the literature on the effects of nonpar-
ental care on children a decade ago and found that evidence
was inconclusive and that nonparental care does not necessarily
have either positive or detrimental effects on infants and chil-
dren. The quality of the relationship between the care provider
and the child substantially affects develoment. The findings of
three different studies, one in Australia, another in Israel, and a
third in the United States, were discussed by Love et al. (2003)
to highlight that quality of care, rather than quantity, was a
better predictor of children’s outcomes, and in fact, when chil-
dren are in non parental child care, parents compensate by in-
creasing the intensity and amount of attention they devote to
their children when they are together (Ahnert et al., 2003). On a
different note, Crockenberg (2003) suggests that is not only the
quality and quantity of care a child receives (either parental or
nonparental) but also a child’s temperatment and gender, in-
cluding its tolerance for stress, that influence its development.
As the literature citations indicate, much of the study of child
development in light of center-based child care has occurred in
Western countries. Less is known about it in other countries
such as Japan. Furthermore, traditionally, in Western countries,
children are placed in nonparental care for between eight and
ten hours during the workday. Despite the need for child care
for children after 6:00 pm, there are few, if any, facilities that
provide this service in most nations. Japan has responded to the
need of working mothers, many of whom work long hours or
during the nighttime hours, by establishing governmentally
authorized night care facilities. This formalization of center-
based night care is rare in nations outside Japan. Even in Japan,
few studies have assessed the influence of center-based night
care on child development (Anme, 1998). This study sought to
identify correlations between 1) extended-hour center-based,
including nighttime care and school children’s health; and 2)
the childrearing environment provided by parents and chil-
dren’s health at when they are at school age.
Setting and Sample
All authorized child-night-care centers and attached child-
day-care facilities across Japan participated in the study at
when the children were toddler-aged. Centers unauthorized by
the government were excluded as they often do not cooperate
with external investigators. The subjects were all parents and
service providers in the authorized facilities. Parents were sur-
veyed regarding the home environment, and service providers
evaluated the development of each child in the facility. The
baseline return rate was 74.6% (1957 between the ages of 0 - 6
years) both for parents and service providers. Of these, 271
children from 22 authorized child care, participated in the sur-
vey at school age. Several families had moved their children
from the 22 facilities that did participate; this is not unusual as
parents often move residences for a variety of reasons. Parents
and caregivers of children with disabilities were excluded from
this second analysis as the needs and outcome measures of
children with disabilities differed substantially from those of
children without disabilities. The final usable set of follow-up
responses was 271; children were between the ages of three to
six years old at the time of the first study and were currently
between the ages of seven and eleven. The usable responses
were substantially lower than would have been preferred, yet
sufficiently large to provide some meaningful findings.
Table 1 provides the gender and grade enrollment of the
subject population. The distribution of boys, 123 (45.4%), and
girls, 148 (54.6%), was fairly even. The largest number of chil-
dren was in first grade (35.0%), followed by those second
(28.4%) and third (17.0%) grades.
Table 1.
Demographic background.
Items N %
Male 123 45.4
Female 148 54.6
Grade in school
First 95 35.0
Second 77 28.4
Third 46 17.0
Forth 29 10.7
Fifth 24 8.9
Family type
Nuclear family
Parents 184 67.9
Mother only 43 15.9
Father only 2 0.7
Extended family
Parents, gra ndparents 25 9.2
Mother, grandparent 9 3.3
Father, gra ndparent 0 0.0
Other 8 3.0
Yes 176 64.9
No 95 35.1
Quantity of child care
11 hours or more 146 53.9
Less than 11 hours 125 46.1
Mother 254 93.7
Father 13 4.8
N.A. 4 1.5
Total 271 100.0
Copyright © 2012 SciRe s .
Overview of Measures
Indicators of child-care quantity (length of time in care ), sta-
bility (regularity of attendance), a nd type (normal vs long hours)
along with measures of family background [socioeconomic
status (determined by the requirement to pay income tax), fa-
mily composition], the child’s demographic characteristics, and
child adaptation to center-based care (willingness to go to cen-
ter-based care) were obtained from questionnaires completed
by the parents responsible for the children in the first six years
of their lives. Parents completed Japanese versions of ques-
tionnaires on the child-rearing environment (HOME, Caldwell
& Bradley, 1984, J-HOME, Anme, 1991, 1996) and on self-
efficacy and support for childcare (Anme, 1995). Self-efficacy
was evaluated by parental response on the item “I am con-
vinced my capability to provide quality childcare”. Support for
childcare was determined by whether the parent reported assis-
tance from a spouse or others.
Childcare professionals evaluated children’s social compe-
tence, communication, and development in vocabulary/motor/
intelligence for each child from 2000 to 2005 using develop-
mental scales (Anme, 2006). This scale was standardized in
Japan and revealed that 10% of children in the Japanese popu-
lation were below the normal range of age-appropriate cogni-
tive development.
The social competence subscale includes items such as,
“drinks from cup without assistance” at 11 months and, “able to
change clothes” at 56 months. The communication subscale
includes items such as, “smiles in response to caregiver’s
voice” at 4 months, “takes a particular role in playing ‘house’”
at 36 month, etc. The vocabulary subscale includes “is able to
say at least one word” at 12 months, and “follows story telling”
at 60 months, etc. The motor subscale includes “is able to walk
without assistance” at 14 months, “is able to draw an ‘X’” at 45
month, etc. The intelligence subscale includes “understands
‘eyes’, ‘mouth’, ‘nose’ etc.” at 21 month and can “count to
three” at 42 months.
All childcare professionals, already qualified in child deve-
lopment, were provided with a minimum of eight hours of
training to translate children’s development into the measures
indicated on the child development scale. These variables, se-
lected to be consistent with earlier studies by the NICHD
(1999a), were then used to explore the relationship between
length of care and child development.
The two categories of childcare were identified by the time at
which children left the center-based care: “normal care” (use of
center-based care for under 11 hours), and “extended care” (use
of center-based care for 11 hours or more). Of the subjects, 125
(46.1%) were enrolled in “normal care”, and 146 (53.9%) in
“extended care”.
Family and child variables included the child’s gender and
age, child development along the Anme (2006) scale, the child
rearing environment at home, the caregiver’s efficacy for care,
and the existence of childcare support. Professional caregivers
measured child development along six variables (gross and fine
motor, social competence, communication, vocabulary, and
intelligence development) that were categorized into 2-point
items [(normal, delayed) Anme, 2006]. These service providers
in the center-based childcare facilities also evaluated the health
and disabilities of the children based on descriptions by physi-
The child rearing environment was assessed based on re-
sponses (yes/no) to activities in the home environment (see
Table 2). For analysis, the 25th percentile point was used as a
cut-off for non-nominal items. Caregivers’ self reports on the
five-point scale, (where 1 = always, 2 = often, 3 = sometimes, 4
= rarely, 5 = never) measured parental efficacy for care (Anme,
1998). The items used to assess the child’s health at school age
are believed to be reliable and valid and are consistent with
those on the annual National School Health Survey by Japanese
Ministry of Education.
The difference between the two categories of care (“normal”
and “extended”) was examined by using items of child devel-
opment, positive qualities of parents’ behavior, parent efficacy
for care, and existence of care support. The Statistical Analysis
System (SAS) statistical package was used for analy sis. Multiple
Table 2.
Number and percentage in risk group.
items No. %
1) Child development
Gross motor 10 3.7
Fine motor 7 2.6
Social competence 6 2.2
Communication 3 1.1
Vocabulary 7 2.6
Intellectual 4 1.5
2) Parent be havior
a) Human stimulation
Play with child 8 3.0
Reading bo oks 43 15.9
Singing songs togeth er 18 6.6
At least one meal with parents 3 1.1
b) Avoidance of restriction
Appropriate respons e to mistakes 11 4.1
Punishment 95 35.1
c) Social stimulation
Going to groc ery store with p arent 7 2.6
Going to park with pare nt 63 23.3
Going to friends’ houses 121 44.7
d) Support
Support for child care 67 24.7
Having con s ultation 16 5.9
Support from spouse 33 12.2
Talking with spouse a bo ut child 30 11.1
3) View of child care
Confidenc e about chil d caring abil it ies 17 6.3
4) Adaptation for center based care
Adaptation for center based care 5 1.9
Copyright © 2012 SciRe s . 265
regression analysis was used to predict child health symptoms
at school age (yes or no) with independent variables such as
types of care (“extended care” or else), positive qualities of
parents’ behavior (13 items), parent efficacy for care, and exis-
tence of care support, child development (delayed or normal)
and child adaptation to center-based care (adapted or not) at
toddler age. An odds ratio was calculated to clarify the magni-
tude of effects. The odds ratio was calculated applying a multi-
ple logistic analysis to estimate the strength of relations. All
results were assessed significant at the p < .01 or p < .05 level,
however, the variable “types of care” was not always selected
as a related varia bl e in all analyses .
Table 2 reports the number of risks in parent behavior.
Table 3 shows correlations with the child’s health at school
age. The maximum percentage is 17.0% for “easy to fatigue”,
while the minimum percentage is 7.8% for poor physical
Table 4 reports the results of the Chi-square test between
factors at the toddler age and the child’s health at school age.
The delay of fine motor at the toddler age was significantly
related to anxiety at school age. Interestingly, being the only
child was related being easily fatigued at school age.
Table 4 also presents the relationship between the care-
giver’s factors expressed when the child was a toddler and the
child’s health at school age. Not singing songs together in the
early years was significa ntly related to poor physical strength at
school age. Not going to the park with parents was related to
headaches at school age.
As indicated in Table 5, a multiple regression analysis, that
input all factors and excluded the effects of gender and grade in
school, was employed to explain children’s health at school age.
Poor physical strength at school age was significantly related
not playing with the child at the toddler age (odds ratio 3.23).
Feelings of loneliness at school age was significantly related to
not being adapted to center-based care at the toddler age (9.40).
This is the first nation-wide study of center-based care that
Table 3.
Child’s health at school age.
Item Yes (%) No (%)
Feeling ove r whelmed 8.1 91.9
Anxious 11.4 88.6
Get irritated 15.1 84.9
Poor physical strength 7.8 92.2
Easy to fatig ue 17.0 83.0
Lonely 11.4 88.6
Displeasure and easy to get angry 14.0 86.0
Poor endura nce 13.7 86.3
Headache 10.7 89.3
Feel depressed 8.5 91.5
Want to attack someone 15.5 84.5
Lose interest in study 14.4 85.6
(n = 131)
focuses on the effects of extended-hour care, including night
care, and that assesses child health at school age based on the
complex relations among factors, including the quality of par-
ent behavior. Center-based extended-hour care through mid-
night is unique in Japan, reflecting the increase in the number
of parents who work late into the night. This investigation ex-
plored the influence of extended-hour center-based care (over
11 hours of care per day, including night care), in comparison
to normal care (11 hours or less). All night care centers in this
study had passed governmental standards and attempted to
ensure that the natural circadian rhythms for children, such as
sleeping, eating, and playing, were well maintained.
Several relatively recent large-scale, center-based childcare
studies conducted outside Japan have documented relations
between early and/or extensive childcare experience, noncom-
pliance, and problem-behavior, even after controlling for selec-
tion effects (Bates et al., 1994; Baydar & Brooks-Gunn, 1991;
Belsky & Eggebeen, 1991; Borge & Melhuish, 1995; Park &
Honig, 1991; Vandell & Corasaniti, 1990). Divergent results
emerged from the current investigation, which found little evi-
dence that the amount of time children spent in non-parental
care in the first 2 or 3 years of life is, in and of itself, system-
atically related to children’s self-control, compliance, or prob-
lem behavior by the time they reach the school-age years.
In light of prior studies and contemporary theory about the
complex ecology of child development, the general absence of
strong or consistent effects of the variable “type of care”, by
itself, may not be surprising. The compensatory-process, and
lost-resource perspectives outlined in the introduction led to the
anticipation of findings that highlight interactions between
quality and quantity of care and child development more than
main effects of the length of center-based care. Although qua-
lity was the most consistent predictor of child development, the
amount of explained variance was modest, and standardized
regression coefficients never exceeded .26 in the cumulative-
experience analysis and/or .16 in the lagged-and-concurrent
On the basis of analyses employed to identify selection-effect
variables, several of the caregivers’ and family characteristics
that distinguished between families that participated in this
study, and those who did not, may be systematically related to
childcare quality. Nevertheless, the high rate of return and the
highly homogeneous nature of Japanese society may minimize
these effects. That the home environment was more strongly
related to child development and adaptation than was length of
center-based care is consistent with results of prior examina-
tions of the effects of childcare on infant-mother attachment
(NICHD, 1998b) and child development (Langlois & Liben,
2003). The principal conclusion of this large-scale, multisite
research project is that child rearing behavior by the caregiver
may be more important in explaining children’s health at school
age than whether parents routinely use the services of high
quality center-based care facilities or the length of time children
spend in these facilities. Items strongly related to child health at
school age, such as “playing with child” in infancy, may serve
as a proxy items for a number of factors at home, because they
indicate the opportunity to engage in activities inside and out-
side home, with other children, and in proximity of their care-
Literature does suggest, however, that center-based care ex-
erts some influence upon children. Studies report that the qua-
lity of care is the most consistnt child-care predictor, with e
Copyright © 2012 SciRe s .
Copyright © 2012 SciRe s . 267
Table 4.
Factors related to child’s health at sch ool age.
Category Anxious %
Easy to fatigue
% Poor physical
strength % Headache %
Child’s factors at toddler age
Delay 42.9* .0 14.3 14.3
Fine motor Normal 10.6 17.4 13.6 10.6
No 14.7 26.3** 14.7 13.7
Siblings Yes 9.7 11.9 13.1 9.1
Caregiver’s factors at toddler age
No 16.7 16.7 33.3* 16.7
Singing songs together Yes 11.1 17.0 12.3 10.3
No 9.5 15.9 15.9 17.5*
Going to park with parents Yes 12.0 17.3 13.0 8.7
Note: **p < .01; *p < .05.
Table 5.
Odds ratio for child’s health at scho ol age.
Poor physical strength Lonely
Item Odds Range Odds Range
Gender 2.79** 1.29 - 6.01 3.03* 1.29 - 7.11
Grade in scho ol 1.09 .82 - 1.45 .99 .72 - 1.37
Play with child 3.23* 1.02 - 10.22
Adaptation for center-based care 9.40* 1.09 - 81.23
Intercept –2.6523 –2.6979
H-L test .6836 .8609
Note: **p < .01; *p < .05.
higher quality of care relating to greater social competence and
cooperation and less problem behavior at both two and three
years of age (NICHD, 1998a). More time in low-quality care
and more numerous care arrangements (i.e., less stable care) are
predictors of negative outcomes for children at 2 years of age
(NICHD, 1999b). Furthermore, greater experience in groups
with other children predicted more cooperation and fewer
problems at both 2 and 3 years of age.
While further follow-up research with the current sample will
investigate less obvious effects of child-care that may emerge
later in development, the findings of this study are believed to
be useful in parent education programs. Outcomes of this study
were integrated into practice as early childhood parent educa-
tion programs highlighted the importance not only of the
physical care of children but of increasing the quality of social
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