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."
在一个位于明尼苏达州德卢斯的家庭托儿所中，德博拉·斯坦森用一种不寻常的方式来安慰婴儿。每当婴儿吵闹或不喝奶时，她会解开衣服，让婴儿吮吸自己的乳房，但她并没有分泌乳汁或在给自己的孩子喂奶。
监督机构后来发现，更糟的是，一些父母对斯坦森这种做法毫不知情，另一些父母要求她不要这样带他们的孩子，她却公然违背了这些父母的要求。最后，有人向圣路易斯县有关监督部门投诉，监督部门1月取缔了斯坦森的托儿所，4月吊销了她的执照。颁发执照的官员说：“她越过了身体接触的界限，事态很严重。”
斯坦森的例子虽然很极端，但也反映出获得营业执照的家庭托儿所中存在的固有问题——这个问题也许与近日明尼苏达州托儿所死亡事件增加有关联。缺乏培训、定期检查过少及各个县法律执行力度不一，在这种情况下营业的家庭托儿所负责人独自照料多达12个儿童时，可能会采取各种方法，包括不恰当或危险的方法。
《星论坛报》检查执照的数据后发现，明尼苏达州对家庭托儿所的培训要求是全美最宽松的。家庭托儿所负责人无需有高中文凭或儿童发育的专门知识就可以获得执照；每两年才进行一次检查。一个监察组织估计在明尼苏达州，检查员与托儿所负责人的比率是全美最低的。
“风险就在于低标准造成低质量，”阿米·拉普·佩恩说，“如果不是法规要求，那些负责人不会去做。”阿米曾在2011年为“全美儿童保育安全监督管理协会”写过一篇影响颇深的报告。
在明尼苏达州，即使标准很松，成千上万的托儿所熟练地照顾孩子，没有儿童死亡或安全违规行为。但是查看备案材料后发现，宽松的法规纵容不合格的托儿所经营者留在托儿所行业，将儿童置于危险中。比方说，2010年，德拉诺曾有个家庭托儿所负责人发现孩子在地上小便后，把那个孩子的脸按到那滩尿液中。材料显示那个女人用力太大，擦伤了孩子的前额。
还有些负责人把孩子泡在水里，给孩子喂辣椒酱，或者抓他们、打他们时用力过大，造成孩子骨折。《星论坛报》发现尽管明尼苏达州法律禁止儿童体罚，从2007年起，共发生了70起这样的事件。
明尼苏达州获得执照家庭托儿所协会曾试图筹得资金，让家庭托儿所负责人接受有经验的同行的培训，甚至是此举都受到了阻力。这个协会代表着小型家庭托儿所。
“大家的想法是‘照顾小孩子的人为什么需要培训？’”此协会的执行理事凯蒂·蔡斯说，“大家都觉得我们生来就会正确地照顾儿童。”
结果就是双重托儿所系统：一重是约1500家大型托儿所中心，雇员更多，培训要求更高，由明尼苏达州的监管部门定期检查；另一重是约1.11万家小型家庭托儿所，负责人往往独立经营，没有人帮忙，很少有人来检查。
照看者筋疲力尽
通过查看执照文档和死亡记录，《星论坛报》发现，自2002年起，有85次儿童死亡事故，其中82起发生在家庭托儿所中，而不是托儿中心中。过去5年中，死亡数字将近增加了一倍。
有几位研究者检查了全美托儿所儿童死亡原因，其中一人表示缺乏监督增加了儿童死亡的风险。
纽约城市大学的社会学家茱莉亚·里格丽发现获得执照的家庭托儿所中儿童的死亡率比托儿中心要高。她的结论是大型托儿中心更安全，因为托儿中心随时有多位雇员照看小孩，并阻止同事犯错。
“成年人会筋疲力尽。他们会变得心烦、受挫。照顾小孩时，这些都可能是风险因素，”茱莉亚说，“但是如果有其他成人在那，他们可以保证安全。”
过去十年中，明尼苏达州的立法机关多次考虑增加家庭托儿所的培训和提高对他们的标准，但由于担心提高标准将增加成本，让人觉得政府在干预小型企业，立法者对此多次闪烁其词。
《星论坛报》查看了2007年以来针对明尼苏达州有执照的家庭托儿所发布的1100项惩戒性措施，结果发现隔离家庭托儿所负责人作用显著。超过300项处罚措施是因为负责人没有照看好孩子，这往往是因为她们无力同时照顾太多孩子。
2010年，罗切斯特有一名家庭托儿所负责人把两个学龄前儿童关在地下室7小时（有一个孩子被关在约1.2米的笼子里），以让他们远离修炉工。去年秋季，在罗斯克里克的一家日托所里，一个1岁的孩子无人照看，独自游荡了两个街区，到了一家五金店里。
增强执行力度？
为帮助那些尽力保证托儿所质量和安全的负责人，倡导者认为明尼苏达州需要设定更高的标准和增强执行力度。
《星论坛报》查看的众多幼儿死亡事件中，很多都是由于负责人无法执行基本的安全睡眠法则。2007年以来，至少有10起幼儿死亡事件涉及到婴儿背朝天睡觉——明显违反了标准——或在不安全的表面睡觉。数起死亡事件涉及到婴儿睡觉时，长时间无人查看——有一例中，三个小时内，无人查看婴儿。
明尼苏达州要求婴儿睡觉时，家庭托儿所负责人和托儿所中心员工必须能看到或听到孩子的动静。但是往往只有托儿所中心要求员工每15分钟检查一下熟睡中的婴儿。
2010年，堪萨斯州全面修订了照看儿童的规定，要求家庭托儿所负责人每15分钟查看一次熟睡中的幼儿。至少有六个州要求家庭托儿所在孩子小睡期间查看幼儿，堪萨斯州就是其中的一个。
5月3日，明尼苏达州人类服务部监察长杰里·科伯给家庭托儿所负责人寄了一封信，信中说道，人类服务部将查看托儿所中心和获得许可的家庭托儿所之间幼儿死亡率差别如此之大的原因，看看是否需要给家庭托儿所负责人提供额外的培训或监督。
另外，一些倡导者认为明尼苏达州需要更好的日托所视察。据研究与监督机构美国儿童看护意识估计，在明尼苏达州，每150个家庭托儿所配有一名县级视察员，这在全美倒数前十之列。
真实的比率根据不同的县而不同。在安诺卡县，超过200名负责人仅配有3名视察员，视察员无法给每个负责人那里安排尽可能多的时间。
“如果我们真的想知道家庭托儿所的真实情况，最好的办法是派个人在那里看着，”伊芙琳·内尔逊说，“我们没有那么多人力。”内尔逊是安诺卡县视察办公室的负责人。
据美国儿童看护意识的调查，全美有26个州每年至少视察一次家庭托儿所，其中有14个州是每年2次以上，包括怀俄明州在内的4个州每个季度至少视察一次。在怀俄明州每68家家庭托儿所配有1名视察员。
改善培训？
多项研究显示，为家庭托儿所负责人提供更好的培训也能改善看护儿童的质量。
美国儿童看护意识的调查显示，在明尼苏达州，家庭托儿所负责人获得执照前必须接受急救和心肺复苏术的培训，但是要等到家庭托儿所开业后才要求其负责人接受儿童发展的培训。明尼苏达州要求每年接受8小时的培训，这在给小型家庭托儿所颁发执照的42个州中排名第33位。
威斯康星州要求最少要接受40小时的前期培训，其中包括儿童发展方面的培训，并且每年必须接受18小时培训。
“我们觉得增加培训可以提高孩子看护的安全度，”美国儿童看护意识的公共政策主管格蕾丝·丽芙说，“同时还关乎到儿童的健康成长。”
明尼苏达州对《星论坛报》的调查做出了回应，管理机构最近建议增加在安全睡眠姿势和心肺复苏术方面的培训。
但是增加培训的提议可能会遇到政治上的阻力。2006年，明尼苏达州的立法者反对将培训时间增加到12小时，结果只从6小时增加到了8小时。
“保守派反对保姆式国家。”支持家庭托儿所培训法案的前参议员约翰·豪廷杰说。
一些立法者对更多管控持怀疑的态度。“管控无止境。我们在管控上加新的管控，在培训上加新的培训，”共和党员史蒂夫·哥特瓦特说，“除非你有铁证证明六个小时为孩子增加了多少安全度。为何不增加到12小时？为何不增加到36小时？为什么不要求家庭托儿所负责人获得硕士学位？”
里格勒说，培训不是万能锁。她的幼儿死亡研究结果是家庭托儿所的环境比其负责人缺乏教育问题更大。斯坦森因为用让孩子吮吸乳房的方法控制他们的行为而被吊销执照，但她本人接受过心理和社会工作的大学培训。
斯坦森说她办了自己的托儿所是因为她不满意看护孩子方法的限制性，她想要办个支持额外做法的托儿所，如布尿布、亲密育儿和延长母奶喂养等。她不赞同明尼苏达州的报告，反驳道大多数父母都知道她的安慰式抚养法。“大多数父母觉得，”她说，“我的做法很自然地吻合了”他们的育儿理念。
家庭托儿所协会的成员凯蒂·蔡斯认为提供更多的培训会提高育儿的质量。她还提到，公共资助每年只覆盖5名家庭托儿所负责人。
《全美育儿指导》的作者佩恩说最终还是要靠各个州来保证家庭托儿所的安全。
“这是家庭托儿所的家，”她写着“但是对孩子来说安全吗？这是我们的底线。”
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