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Eager to Learn: Educating our Preschoolers 8 Program and Practice Standards AS THE UPBRINGING OF AMERICA’S CHILDREN, and therefore the transmission of its culture, relies more and more on out-of-home providers of early education and care, there is a growing public interest in ensuring that this happens well and safely. In this vein, this report recommends the adoption of program standards and professional requirements. Still, it is important to note at the outset that establishing standards of quality for early education in a country as large, diverse, and rapidly changing as the United States is challenging. There is the danger that attempts to set common standards, or even to formulate what children need, may reflect the preferences of a particular group rather than the American population as a whole. At their best, the promise of standards is that they provide a floor for program quality; they ensure that what we know children are capable of mastering in the early years they indeed have the opportunity to master in all state-approved programs. At their worst, standards put a ceiling on quality; they become an end rather than a departure point for the design and aspirations embodied in a program. Standards that are too low encourage mediocrity. Standards that are too high can be stressful and demoralizing. Standards that are too specific can undermine creativity and diversity; standards that are too broad can encourage compliance with the letter, but not the spirit of accountability.
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Eager to Learn: Educating our Preschoolers Any effort to use standards to ensure quality must therefore be a dynamic one that involves continual evaluation, and that allows for revision when the outcomes are counterproductive. PROGRAM STANDARDS The more we emphasize instructional assessment, the more necessary it becomes to confront the issue of the standards against which children’s learning should be assessed. Standards consist of the values, expectations, and outcomes of education. Various national curricular organizations (e.g., the National Council of Teachers of Mathematics, the American Association for the Advancement of Science, the National Council for Teachers of English, the International Reading Association) and nearly all states have proposed standards of achievement. However, very few of the content area standards apply meaningfully to very young children. Instructional or performance assessments that relate to children ages 2 to 5 articulate standards that are consistent with developmentally appropriate practice, child development research, and Head Start performance standards, but specific standards of learning for the early childhood years are not well developed in all curriculum areas. Table 8–1 presents the standards for mathematics developed by the National Council of Teachers of Mathematics and those for reading and writing developed by the National Association for the Education of Young Children (NAEYC) and the International Reading Association. It is important to deal with the issue of standards in early childhood, because standards provide a baseline of expectations to which pedagogy and assessment can be aimed. Standards also help us understand and define the goals of early childhood pedagogy. Currently, more than 30 states sponsor some type of prekindergarten program for at least some of the children in their boundaries (only Georgia has a universal pre-K program). Most of these states have published standards for what should be taught and what should be learned. Table 8–2 summarizes these standards as of 1996. A national survey of state-funded preschool initiatives was conducted in 1997–1998 (Ripple et al., 1999). Data collected for
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Eager to Learn: Educating our Preschoolers TABLE 8–1 Examples of Children’s Development in Early Reading and Writing and in Mathematics Continuum of Children’s Development in Early Reading and Writinga Goals for preschool: Children explore their environment and build the foundations for learning to read and write. Children can: enjoy listening to and discussing storybooks; understand that print carries a message; engage in reading and writing attempts; identify labels and signs in their environment; participate in rhyming games; identify some letters and make some letter-sound matches; use known letters or approximations of letters to represent written language (especially meaningful words like their name and phrases such as “I love you”) Standards for Children: Grades PreK-2b Standards: Grades (PreK-2 Selected items): Understand numbers, ways of representing numbers, relationships among numbers, and number systems Students should: count fluently with understanding and recognize “how many” in small sets of objects; understand the cardinal and ordinal meaning of numbers in quantifying, measuring, and identifying the order of objects; connect number words, the quantities they represent, numerals, and written words and represent numerical situations with each of these; develop an understanding of the relative magnitude of numbers and make connections between the size of cardinal numbers and the counting sequence; use computational tools and strategies fluently and estimate appropriately; develop and use strategies and algorithms to solve number problems; understand various types of patterns and functional relationships; sort and classify objects by different properties; order objects by size or other numerical property (seriation); identify, analyze, and extend patterns and recognize the same pattern in different manifestations; use mathematical models and analyze change in both real and abstract contexts; make comparisons and describe change qualitatively (e.g., taller than) aThis list is intended to be illustrative, not exhaustive. Children at any grade level will function at a variety of phases along the reading/writing continuum. b0nly a few of the items listed in this section in order to give a sense of the standards for the younger children. SOURCES: For reading and writing, information from Newman et al. (1999); for mathematics, information from National Council of Teachers of Mathematics 2000).
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Eager to Learn: Educating our Preschoolers TABLE 8–2 Summary of State Content Standards for Teaching Children in Prekindergarten Programs State Program Name Standards Motor Health, Safety, and Nutrition AR Arkansas Better Chance NAEYC guidelines used as basis for state child care accreditation, and program appropriateness Indoor, outdoor play that encourages development of habits; gross and fine motor skills Encourage good health and safety AZ At-Risk Preschool Program State guidelines for comprehensive early childhood programs Opportunity to acquire and refine fundamental movements Encourage appreciation for health and safety CA State preschool State Preschool Program Quality Requirements Facilitate physical and motor competence Provide a developmentally appropriate nutrition component and a healthy environment that refers children to appropriate agencies based on their health needs
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Eager to Learn: Educating our Preschoolers Cognitive (General) Numeracy Language Social-Emotional Aesthetics Support cognitive development Not specified Promote language development by means of reading materials Foster communication skills, social skills, positive self-esteem, and an appreciation for cultural diversity Creative expression, art, music, dramatic play Learning, using strategies such as experimentation, thinking games, play, self-directed learning, investigation; children encouraged to explore, question, participate in group discussions, give responses Encourage math vocabulary, concepts, and math-directed activities Library (reading-listening); reading/writing, curriculum materials multilingual as appropriate; day structured to facilitate child-to-child talk Encourage growth of social skills, communication, self-confidence, independence, respect, manners; appreciation for cultural diversity and current events Become competent artistically and musically; encourage child-initiated play Developmentally appropriate activities that facilitate a child’s cognitive development — — Foster social and emotional development —
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Eager to Learn: Educating our Preschoolers State Program Name Standards Motor Health, Safety, and Nutrition CO Colorado Preschool Program Standards based on NAEYC, cross-referenced to Head Start and state licensing — Nutrition and health services by local decision DE Early Childhood Assistance Program Head Start — — FL Pre-K Early Intervention Program NAEYC encouraged but not required Developmentally appropriate practices (DAP) DAP GA Georgia Prekindergarten Program Move with balance and coordination; indoor/outdoor activity; facilitate development of large and small muscle skills Make health referrals; provide breakfast, snack, and lunch IA Child Development Coordinating Council NAEYC, Head Start — —
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Eager to Learn: Educating our Preschoolers Cognitive (General) Numeracy Language Social-Emotional Aesthetics — — — — — — — — — — DAP DAP DAP Enhance emotional maturity and social confidence DAP Encourage exploration, observation, and communication of knowledge Activities dealing with counting concepts and resorting objects; shape and size comparison Recognition of pictures words, ABCs, and stories; understand and tell stories; understand that writing is communication Encourage cooperative play and work; positive interaction with other children, self-help skills; pride; care and self-control Express ideas and thoughts in creative ways, including crafts, drawing, and music — — — — —
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Eager to Learn: Educating our Preschoolers State Program Name Standards Motor Health, Safety, and Nutrition KY State Preschool Program State regulations reflect NAEYC, Head Start standards Indoor/outdoor activities; play areas with safe and appropriate equipment Assist understanding of nutrition LA Preschool Block Grant Local school district policies Indoor/outdoor play
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Eager to Learn: Educating our Preschoolers Cognitive (General) Numeracy Language Social-Emotional Aesthetics Encourage exploration; concrete experiential learning; integrate skills across content areas (integrative learning) Materials for math and problem solving Language experience approach (language understanding and use among children and adults, language arts, library area) Assist development of interpersonal skills, self-management and independence; positive self-esteem, self-regulation of behavior; multicultural curriculum Space and material for dramatic play, art, block building, cooking, house-keeping; opportunities for self-expression Activities including active exploration; problem solving; experimentation with hands-on, real-life materials; integrated learning through all developmental areas; learning through themes Language stimulation through varied opportunities of self-expression Child-initiated play, child-to-child and child-to-adult; positive guidance and encouraging of expected behavior Development of creativity and imagination
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Eager to Learn: Educating our Preschoolers State Program Name Standards Motor Health, Safety, and Nutrition MA Community Partnerships for Children NAEYC and state-established Early Childhood Standards Indoor/outdoor play; enhance physical development and skills by use of developmentally appropriate equipment, materials, and activities Routine tasks (eating, toileting, and dressing) incorporated into the program to further children’s learning; access to a health care consultant; enhance health and safety of children; meal times as social learning experiences; nutritious food MD Extended Elementary Education Program (EEEP) Standards for Implementing Quality Pre-K Programs (similar to NAEYC) — — ME Family Focused Standards for Early Intervention (in keeping with serving the child and family as outlined in the state created Individualized Family Service Plan (IFSP)) Indoor/outdoor environment provide basic health activities management should be Snack provided; required school nurse, needs. Behavior age appropriate, environment should be safe and minimize the risk of transmission of communicable disease
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Eager to Learn: Educating our Preschoolers Cognitive (General) Numeracy Language Social-Emotional Aesthetics Encourage children to think, reason, and question and opportunities to make comparisons, analyze, observe, plan, and discuss experiences, observations, and feelings; science activities in work areas Provide an area to accommodate and encourage math Encourage language development (in children’s native language and English) Foster a positive self-concept, respect cultural and economic diversity, develop social skills; ability to have child-initiated play and teacher-initiated play; smooth transitions between activities; encouraged good manners Encourage creative expression and appreciation for the arts by means of dramatic play, art, and music — — — — — Age-appropriate — — Encourage self-esteem, behavior management —
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Eager to Learn: Educating our Preschoolers Cognitive (General) Numeracy Language Social-Emotional Aesthetics Consistent with sound child development practices; minimum of 10 hrs/wk of child participation in center activities; foster intellectual growth; expose children to new ideas concepts and experiences — Language skills curriculum by local decision Meet unique local community needs; cultural and ethnic pride; appropriate environment for emotional and social growth — the 31 states’ standards varied across these domains: (1) motor development, (2) health, safety, and nutrition, (3) general cognitive development, (4) numeracy, (5) language, (6) social-emotional, and (7) aesthetics. Generally speaking, state preschool programs followed one of three overarching frameworks for their guidelines. One group of three states (Delaware, Ohio, and Oregon) reported that they adopted Head Start standards and require that all state-funded preschool programs adhere to those guidelines. A second group of states (Massachusetts2 and Nebraska) adopted National Association for the Education of Young Children guidelines. The third group, consisting of the remaining 26 state-funded preschool education programs, developed and implemented their own standards. Although many of these individualized standards are based on Head Start or NAEYC guidelines (in some cases these guidelines are recommended but not required), each 2 In Massachusetts, all programs must be NAEYC accredited. In addition, programs located in public schools must meet state standards.
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Eager to Learn: Educating our Preschoolers state developed its own unique approach to establishing program requirements. General observations based on data provided by these 26 states are provided below.3 Structural Components Preschool program standards typically guide both structural and program components or activities. Structural specifications include materials available in the classroom, the site and layout of work and play areas, safety demands that ensure appropriate classroom and playground equipment, health and nutrition, class size, teacher-child ratios, and teacher qualifications. With regard to classroom materials, standards require reading materials to promote language development (Arkansas) and “real-life materials” to provide hands-on experimentation (Louisiana). Classroom layout is addressed in required space for dramatic play, art, and block building (Kentucky) and areas to accommodate and encourage mathematics skills (Massachusetts). In general, state standards regarding structural aspects of programming addressed both materials and classroom environment. In terms of health, nutrition, and safety standards, guidelines ranged from basic (e.g., Oklahoma programs must provide bathroom facilities) to more detailed descriptions (e.g., Massachusetts and Vermont). Preschool education program regulations for class size and teacher-child ratios were comparable from state to state and are related to the ages of the children in the program. The majority of programs limited class size to 15 to 20 students and permitted a teacher-child ratio of no more than 1:10. Standards addressing teacher qualifications varied widely: many states required a bachelor’s degree in early childhood or elementary education, whereas other states recommended a designated number of documented hours or years of experience in the child care field 3 Incomplete information exists for the following states: Colorado, District of Columbia, Illinois, Iowa, Maryland, New York, Pennsylvania, Texas, Virginia, West Virginia, and Wisconsin. In 1998, legislation was passed in New York mandating the implementation of a universal state-funded preschool program (subsequently defunded).
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Eager to Learn: Educating our Preschoolers along with a teaching certificate. Overall, state standards in this domain were more stringent than those for Head Start, for which a child development associate (CDA) degree is currently sufficient. Certification issues are discussed in more detail below. Program Components Standards related to program components determine what goes on in the classroom. These may include guidelines for curriculum content, daily activities, and peer or teacher-child interactions. Standards may be very specific (e.g., in specifying the activities children should participate in, such as those activities that develop numeracy and shape recognition, aid in the development of gross and fine motor skills, and encourage vocabulary development), such as those developed in Arizona, Georgia, and Michigan. In contrast, some standards were less specific and established a general approach to teaching (e.g., recommending developmentally appropriate practices), as in California, New Jersey, and Maine. As shown in Table 8.2, standards for program process tended to consist of creating opportunities for learning. Language that builds on terms such as “encourage,” “facilitate,” and “promote” is typical, as is appropriate to preschool settings. Program standards also addressed the domain of socioemotional development. Most state program standards mentioned aspects of developmentally appropriate practices, such as positive self-esteem, social skills, emotional well-being, and behavioral self-regulation. Summary of State Standards State standards are generally very vague in their reflection of current understanding of children’s thinking and learning. They were generally strong on requiring adequate teacher training. However, one aspect of program implementation and administration is a potential cause for concern: in some states—notably Louisiana and New Jersey—legislation guiding the program gives full control of program details to local areas. Whereas this level of devolution from central to local control could be seen as a positive move, because it allows individual sites to tailor the program
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Eager to Learn: Educating our Preschoolers to local needs, it also makes it virtually impossible to determine the nature of the program as a whole. STANDARDS OF PRACTICE Over the past 20 years, there have been a number of attempts to improve the quality of programs for children by setting standards for practice. Some efforts have focused on centers and homes as the point of entry and created accreditation systems, while others have stressed certificates or credentials for individuals. Approaches also differ in whether systems are mandatory, as are state licensing, public school teacher certification, and Head Start performance standards, or voluntary, as are certification by the National Board for Professional Teacher Standards and center accreditation by the National Association for the Education of Young Children. Teacher Certification As a general rule, most early childhood educators have neither certification nor standard preservice preparation. Public schools and Head Start are the only two systems that require certification: public schools usually require a certificate before beginning to teach, and Head Start requires that a percentage of the teachers in a program have a credential. Both systems serve children at risk of school failure because of poverty, home language other than English, and developmental disabilities. Currently 17 states require preschool teaching certification for early childhood teachers in the public schools (Knitzer and Page, 1996). In special education, teachers often first have a B.A. and a regular early childhood education teaching credential and then specialized education in early childhood special education. Because of the legal and regulatory requirements that children be placed in the least restrictive environment which serves their educational needs, most young children with disabilities will be included in regular early childhood programs. According to National Council for the Accreditation of Teacher Education guidelines, all teacher credentialing programs must integrate the special education content throughout all teacher education courses; however,
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Eager to Learn: Educating our Preschoolers most regular early childhood education programs do not adequately prepare teacher candidates to work with children with special needs. Standardized tests sharply limit the number of students who complete the requirements for teacher certification. As a result, racial and cultural imbalance between the population of children in public schools and their teachers affects early childhood programs (Meek, 1998). Fields reported in the Chronicle of Higher Education that in 19 states in which test failures were reported by race, 38,000 blacks, Hispanics, Asians, American Indians, and other minorities did not pass the state exam (Fields, 1988). The high failure rate of these potential teachers is presumably explained by the poor quality of their general education, as well as by the teacher preparation program. Many critics of competency examinations claim that the minorities who fail them are the same ones who do poorly on other standardized tests because of their linguistic and cultural differences. The disproportionate failure rate of blacks, Hispanics, and American Indians is also reported by the National Board for Professional Teaching Standards. While test makers assert that the tests correct for cultural bias, the failure rate of minorities nevertheless reinforces the imbalance between students of color and their teachers (Fields, 1988). In 1972, Head Start established the child development associate program nationwide, in order to meet the needs for skilled early childhood teachers (Hinitz, 1998). The CDA identifies six competencies indicating basic skills that a teacher must master to teach young children: (1) establishes safe and healthy environment, (2) advances physical and intellectual competence, (3) builds positive self-concept and individual strength, (4) promotes positive functioning of children in groups, (5) brings about optimal coordination of home and center childrearing practices and expectations, and (6) carries out supplementary responsibilities related to programs. Kontos, et al. (1997) found that teachers with a CDA credential or its equivalent were warmer and more sensitive and had higher-quality classrooms than teachers with less education. Candidates for the CDA demonstrate their competence through the preparation of portfolios and are assessed by parents, a trainer/supervisor, and an independent observer. The
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Eager to Learn: Educating our Preschoolers CDA credential is awarded to teachers who are judged competent. In the early years, few teachers applied for or received the credential because early childhood programs seldom gave additional compensation to teachers with a certificate. However, the program has gradually expanded; since 1990, as a part of the efforts of the Council for Early Childhood Professional Recognition, it has experienced considerable growth. Its value to the quality of children’s programs has been increasingly recognized (Kontos et al., 1997), and it is now required by Head Start. Currently the council provides an assessment and credentialing process for teachers in three settings—center-based, family child care, and home visitor—with endorsements for working with infants or toddlers, preschool, and bilingual children. Education for the CDA is provided by qualified trainers; in 1996, all but four states had colleges and universities that provide CDA education (postsecondary education institutions offering CDA training), and many schools give 12 hours of college credit to students who complete a CDA in nonacademic systems. Professional Standards Professional communities have also influenced education through the development of standards of good practice. In response to the school reform movement of the 1980s, the National Board for Professional Teaching Standards was established in 1987. Probably the best known standards were published by the National Association for the Education of Young Children under the title, Developmentally Appropriate Practice (DAP). National Board for Professional Teaching Standards The primary mission of the National Board for Professional Teaching Standards is to establish high, rigorous standards and develop a voluntary accreditation system to recognize exemplary teachers. Committees of teachers and experts in a variety of grade levels and disciplinary fields were given the tasks of defining specific standards, and the national board developed an assessment and certification system. Standards committees were guided by five core propositions in defining what teachers should know and
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Eager to Learn: Educating our Preschoolers be able to do: (1) teachers are committed to students and their learning; (2) teachers should know the subjects they teach and how to teach students; (3) teachers are responsible for managing and monitoring student learning; (4) teachers think systematically about their practice and learn from experience; and (5) teachers are members of learning communities. Among the first set of standards developed were those for early childhood generalists, teachers working with children ages 3 to 8. Eight standards, equally important, define excellent early childhood teaching: (1) understand young children, (2) promote child development and learning, (3) knowledge of integrated curriculum, (4) multiple teaching strategies for meaningful learning, (5) assessment, (6) reflective practice, (7) family partnerships, and (8) professional partnerships. Each standard contains more specific required knowledge or skills, but they do not mandate a particular philosophical or theoretical bias. Unlike best practice documents, no research rationale is provided for the standards; rather, they represent the professional judgment of teachers and other experts about what excellent teachers know and can do. Teams of professional assessors, arriving at consensus judgments, decide if certification candidates’ work meets these standards. Developmentally Appropriate Practice The document Developmentally Appropriate Practice was first approved by the Board of National Association for the Education of Young Children in 1987 and was disseminated broadly. To convey the implications of developmental principles in determining practices, examples of good and bad practice were given, with the rationale for why they were so judged. This format led to considerable misunderstanding, with many practitioners viewing DAP as a set of good practices instead of principles of practice. In 1996, the NAEYC board charged a new committee to review the principles and make clearer the relationship of the practices to developmental principles. The current version of developmentally appropriate practices (Bredekamp and Copple, 1997) was approved by the board of NAEYC in 1997 and focuses on three developmental principles as
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Eager to Learn: Educating our Preschoolers relevant to early childhood professional practice: children’s ages, their individual differences, and their home language and culture. The revised version of DAP continues to reflect a constructivist orientation and directs teachers’ (and parents’) attention to children’s need to make meaning from their experiences. It wisely cautions against either/or approaches that pit child-initiated against teacher-directed curricula. As Chapter 5 of this report emphasizes, research suggests that many teaching strategies can work, and no teaching strategy is sufficient for all purposes. The key is for a teacher to be attuned to the child’s current level of development and developmental challenges, and to select from a toolkit of possible pedagogical approaches one that complements the learning opportunity in question. The principles of developmentally appropriate practice have been widely accepted and endorsed by other professional groups and incorporated into teacher education programs through the National Council for the Accreditation of Teacher Education (NCATE). Colleges and universities offering teacher certification in early childhood and seeking NCATE approval are expected to explain in their applications how their program meets these standards. A number of states have incorporated the NCATE standards into their state accreditation process, further expanding the acceptance of DAP as the underlying structure for early childhood teachers. The heavy emphasis in DAP on play and self-selected activities for children and the teacher as an observer has led to criticisms of it as a model for practice. Objections include that teachers misinterpret it to mean that children learn by themselves; that it lacks subject-matter substance; that it fails to provide the information children need, particularly low-income and minority children; and that it does not take advantage of new information regarding young children’s intellectual potential. As educators become conversant with the new research on learning, they will be better equipped to understand the implications of constructivist learning theory for teaching in a way that guides and supports learning. Two useful sources of guidance for early childhood educators who want to enrich their DAP-oriented classrooms are the joint NAEYC-IRA (International Reading Association) statement clarifying the expectations for literacy
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Eager to Learn: Educating our Preschoolers and language stimulation and a book by Neuman and Copple (2000), published by IRA. Regulation of Early Childhood Education and Care Often neglected, the regulation of child care and early education facilities is a critical part of quality programs. Facility regulations are important because there is a clearly documented and unequivocal relationship between regulation and quality. States with more demanding licensing requirements have fewer poor-quality centers that put children at risk of harm and do little to enhance their development (Kagan and Newton, 1989; Cost, Quality and Child Outcomes Study Team, 1995). When facility regulations are more stringent, children show more advanced cognitive, social, and language development and have more secure attachments to teachers and fewer behavioral problems (Galinsky et al., 1995; Howes et al., 1995; Kontos, 1992; Kontos et al., 1995). Although regulation is designed to safeguard children from harm and to provide parents with basic rights and consumer protections, the reality is that states vary significantly in their degree of regulation and in the stringency of enforcement (Azer et al., 1996). The situation is complex because, in a given state, regulatory authority is often delegated to one or more agencies, sometimes without the involved agencies realizing that regulatory responsibility is spread. Regulations may be contradictory and, in some cases, domains may be totally neglected (U.S. Advisory Commission on Intergovernmental Relations, 1994). The result is that often programs must figure out and bear the burden and cost of multiple regulatory entities, each of which is imperfect. Many states have attempted to raise standards for teachers through their licensing requirements. All states have mandatory licensing regulations based on minimum standards for the care and education of young children and include requirements for the facility as well as for staff-child ratios and teacher education. The licensing standards vary enormously from state to state (see Table 8–3 for a recent review of child care licensing). Variations in requirements usually involve the number of hours of operation and size of the center, and they differ for cen-
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Eager to Learn: Educating our Preschoolers TABLE 8–3 Child Care Licensing, State Requirement Requirement or Guidelinea Percentage of States with Requirement or Meeting Guideline Require Preservice for Teachersb CDA 23 BA 2 Require Preservice for Program Directorsb CDA 45 BA 4 Specified Group Sizes for 2- and 3-year-olds ≤12% 18 ≤18% 44c ≤24% 60c Staff/Child Ratios for 2- and 3-year-oldsd 15 Staff/Child Ratios for 3- and 5-year-oldsd 3.8 NOTE: CDA, Child Development Associate; BA, Bachelor of Arts. aData from The Children’s Foundation (1999). bAzer and Hanrahan (1998). cScores cumulative. dData from Standards set forth in American Public Health Association and American Academy of Pediatrics Collaborative Project (1992). ter-based staff and family child care providers. Some states exempt large numbers of family child care homes, church-sponsored programs, part-day programs, and school-sponsored programs from all licensing requirements. Indeed, it has been estimated that nationwide, more than 40 percent of all children in early childhood education and care attend programs that are legally exempt from state regulation (Adams, 1990). As an example, in 38 states, many family child care homes are not subject to facility licensing requirements. Efforts to advance a more stringent and effective regulatory system at the federal level have taken place over time, but with little success (Garwood et al., 1989). Resistance to the develop-
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Eager to Learn: Educating our Preschoolers ment of regulations reflects not only a difficulty in building a national consensus around the content of the recommendations, but also the fear that more stringent requirements could result in higher parent fees, the need for additional government investment, and the reduced availability of care (Gormley, 1992, 1995).
Representative terms from entire chapter: