Introduction

Smiling faces, big hugs, crawling races, giggling, grab­bing, using a spoon, making messes, taking first steps, and using first sentences are some examples of how infants and toddlers navigate, explore, and discover themselves and the world. These experiences support the rapid growth of infants and toddlers^[1] and build on linguistic, intellectual, physical, social, and emotional milestones. During these early stages of development, parents and guardians and members of the early care and education (ECE) workforce^[2] are primary caregivers who play a critical role in the lives of infants and toddlers. Through these foundational relation­ships, connections, and attachments parents and guardians and ECE professionals form, foster, and nurture social-emo­tional bonds with children. However, during the COVID-19 pandemic, mask mandates, social distancing requirements, child care program closures, high staff turnover, fear, and income insecurities placed restrictions on these types of interactions and experiences.

Importance of Supportive Early Adult-Child Interactions

Adult-child interactions and experiences can be strength­ened through teachable moments, such as waving bye-bye for the first time to a familiar adult or intentional planning of developmentally appropriate activities to help an infant or toddler develop self-awareness. These early fundamental experiences and interactions “during the first thousand days of that child’s life impacts the lifelong health, wellbeing, and opportunity for the child”.¹

“What we’re really doing is building a foundation of security and confidence in themselves and that comes from that deep interac­tion and also that very close emotional bond, and that takes time and attention.”
— North Carolina infant toddler child care professional^[3]

However, during the pandemic, ECE professionals caring for infants and toddlers faced many barriers that inhibited their ability to engage in optimal and supportive interactions. For example, they wore masks, which restricted infants and toddlers from seeing their ECE teachers’ facial expressions. The routine nose wipes, diaper changes, and cuddles cre­ated fear of contagion and physical touch was limited.

“Social emotional development is a big thing right now, just because children are coming out of the COVID pandemic, and a lot of children are having to learn to communicate their feelings differently because they’ve been with adults for a while. These COVID babies only prefer adults because that’s all they know how to get along with.”
— North Carolina parent

Further, infants and toddlers—and their families—had protracted pandemic experiences, as young children were the last group to receive access to a COVID-19 vaccine. Families with very young children tend to be among the most vulnerable within already-marginalized groups. Adult well-being and mental health are critical in supporting the mental health needs of infants and toddlers. Unfortunately, in addi­tion to the negative economic impacts faced by most peo­ple during the pandemic, child care providers themselves are often members of historically marginalized groups and often receive lower wages than professionals with similar qualifications in other fields. According to “Equity Starts Early: Addressing Racial Inequities in Child Care and Early Education Policy,” a report from the Center for Law and Social Policy (CLASP), “forty percent of today’s early child­hood workforce is made up of people of color, who tend to be concentrated in low-level positions with lower credential requirements and relatively low pay”.² The COVID-19 pandemic exposed disproportionate access to: care options for parents and guardians while they are at work, adequate housing and health care options for low-income families, and other vulnerabilities for historically marginalized racial and socioeconomic communities that affect care and develop­ment. This article outlines these concerns and recommends future directions to support infants and toddlers and the ECE workforce.

Mental Health Impacts on Infants and Toddlers and their Early Care and Education Providers

There are many reasons North Carolina medical and mental health providers should be concerned about the social-emotional health of infants and toddlers, and that of the adults who care for them. Today’s children aged three and younger have never known a pre-pandemic existence. Children born between 2020 and 2022 likely were isolated from extended families and peers for a significant amount of time, and so were their families and caregivers. The Early Head Start program, the nation’s model for providing care and education services for children from low-income fami­lies, completely closed down for in-person care and learn­ing during the pandemic, and these programs struggled to maintain communication and relationships to identify and meet the support needs of families.³ Children enrolled in private programs (e.g., family child care homes, private child care centers) may have been able to attend in-person, but their care was likely disrupted by closures due to outbreaks; their families may not have been able to enter the building or classroom because of health concerns; and their teachers were required to wear masks at a critical time for language development. These challenges to providing consistent care with strong family engagement and clearly visible language modeling were unique experiences for children during this time period, with impacts on children’s optimal develop­ment and learning that are likely mixed.

The full impact of these experiences of social isolation for infants, toddlers, their parents/guardians, and their ECE providers is yet to be fully understood. Birthing parents had access to varying degrees of support during the birthing pro­cess, with some not allowed to have a support person attend the birth during the early days of the pandemic.⁴ They were also discharged from the hospital more quickly and received less feeding support prior to discharge, resulting in elevated levels of stress in the postpartum period.⁴ There were also reports of high levels of social isolation in this period of early infancy. When early care and education pro­grams reopened or when birthing parents needed to return to work, many parents either left the workforce or chose among fewer available infant-toddler spaces for enrolling their child. Where in-person options were offered as remote or web-based supports, these were offered less frequently for infants and toddlers.⁵

While immediate impacts on infant and toddler mental health are not yet apparent based on developmental screen­ings in pediatric settings, the adults who care for them do show signs of distress, which will likely impact these very young children’s longer-term trajectories.⁶ It may be dif­ficult to gather data on these impacts, however, since much of the research on infants and toddlers at this time reflects higher-income and whiter populations due to convenience sampling methods. Children and families with the most dif­ficult mental-health outcomes might not be represented in data collected in general pediatric settings. There is emerg­ing evidence that Black and Hispanic families and those with low incomes were disproportionately at risk for more severe mental health consequences due to frontline work and stress associated with exposure to transmission of the COVID-19 virus, and/or disruptions to employment and income.⁷

North Carolina Early Care and Education Workforce

The pandemic brought into focus that the early care and education system provides a critical support for fami­lies to enable them to work, yet the professionals providing this critical support are themselves underpaid and under-supported. In 2019, staff turnover in early care and educa­tion programs was reported to be high (more than 20%) for about one-third of programs nationally and was more likely to occur in programs serving infants and toddlers.⁸ Turnover causes stress for directors (hiring and training new staff), teachers (reduced continuity in routines and relation­ships), and families (reduced continuity of care for children). A stressed workforce and stressed families are less prepared to address the learning and development needs of children.

The COVID-19 pandemic and related stressors, including the workforce shortage, have also had a significant impact on the mental health of the child care workforce. According to a national survey conducted in 2022, nearly half of child care providers screened positive for potentially diagnosable levels of major depression two to three months into the pan­demic, with 67% reporting moderate to high levels of stress.⁹ According to 2022 data collected on the North Carolina workforce, child care employment was trending upward before the pandemic, but one year into the pandemic the North Carolina child care workforce experienced a sharp decline of nearly 5% and thisf has not yet returned to pre-pandemic levels.¹⁰

Thus, at a systems level, the early care and education of infants and toddlers is in need of attention. North Carolina medical and mental health providers can play a role in sup­porting this population through partnerships and co-loca­tion of services. Some examples of co-location of services in North Carolina include: Family Connects (home-visiting nurses who care for newborns and their entire families, including well-being, physical, and mental health needs), and Healthy Steps (whole-family, relational approach to pediatric primary care, with a focus on infants and toddlers).

Addressing the Staffing Crisis

Child care professionals who remained in the work­force during the COVID-19 pandemic had to make dramatic changes to their work environments and procedures to reduce likelihood of exposure and often had to work lon­ger hours or take on additional responsibilities, leading to increased stress and burnout. In addition, temporary clo­sures and reduced enrollment impacted the financial stabil­ity of child care businesses, creating a significant financial strain on child care providers. In March 2023, the North Carolina Child Care Resource and Referral Council con­ducted a survey to understand the impact of federal stabi­lization funds for compensation and bonuses on child care providers.¹¹ In total, about 60% of all licensed child care providers responded to the survey (N = 2518). In addition to salary increases and bonuses, nearly all responding pro­viders reported increasing benefits for staff or offering new benefits for the first time. Increases were greatest for men­tal health supports (14%) followed by paid sick leave (13%), paid vacation leave (12%), and provision of health insurance (10%). However, when asked if they would be able to sus­tain these benefits after the funds end in December 2023, more than 4 in 10 of the programs noted that they would be unlikely to do so.

“We all went through some type of trauma over the past two years, it was traumatic for us, and how that affected us, it changed our lives. At work we’re surviving, but we’re not thriv­ing… Mental health is so important not just for the children but for my teachers too because until they deal with their stuff they can’t help the children in their rooms.”
— NC Early Childhood Center Director

“Our teachers need mental health services, I am seeing our teachers fall down, like literally break down, like they are on the verge of quitting every single day because of staffing issues, because of illnesses in their own families, because of [unreliable] child care arrangements for their own children; their pay is not great compared to where they are getting poached from, our pay just doesn’t stack up to the public schools and we can’t compete with what they are offering, so they’re leaving.”
— NC Early Childhood Center Director

Recommendations and Future Implications

There are already great things in place to support medi­cal providers in meeting the needs of infants and toddlers by taking a more collaborative approach. Bright Futures is a national health promotion and prevention initiative led by the American Academy of Pediatrics. The Bright Futures Guidelines provide theory-based and evidence-driven guid­ance for all preventive care screenings and health supervi­sion visits. Bright Futures content can be incorporated into many public health programs, such as home-visiting, child care, and school-based health clinics. Materials developed especially for families are also available. The Healthy Steps program is an evidence-based, interdisciplinary pediatric primary care program designed to promote nurturing par­enting and healthy development for babies and toddlers, particularly in areas where there are persistent inequities for families of color or with low incomes.¹² In this approach, the entire practice works as a team to implement eight core components that strengthen the relationship between fami­lies and the practice and support strong parent/child attach­ment. A child development professional also connects with and guides families during and between well-child visits as part of the primary care team. North Carolina ECE programs have limited access to regional child care health consultants (CCHCs), trained health professionals who work with ECE programs to assess, plan, implement, and evaluate strate­gies for achieving high-quality, safe, and healthy child care environments.¹³ At the state level, through the Healthy Opportunities Pilots, the North Carolina Department of Health and Human Services is creating a statewide frame­work and infrastructure to address many social drivers of health, including affordable child care.¹⁴

Mental Health Supports for the Early Care and Education Workforce Working with Infants and Toddlers

To address this crisis, we need to focus on all the rela­tionships that surround young children. Families need to experience their communities rallying around them to offer opportunities for strengthening connection, reducing stress, and promoting resilience. All of the professionals serving infants and toddlers and their families need reinforcements to increase their capacity to identify and meet the needs of this vulnerable population. The child care community bears the burden of seeing the needs of infants, toddlers, and their families but not having the resources they deserve to under­stand or meet those needs. One proven strategy for sup­porting both the child care community and the children and families they serve is Infant/Early Childhood Mental Health Consultation (IECMHC). IECMH consultants offer a con­tinuum of services from prevention to intervention and can support the ECE workforce through on-site, relationship-based specialized consultation. In this approach, an infant/ early childhood mental health consultant is paired with adults in the settings where children aged five and under learn and grow, such as child care or their own homes. The aim is to build adults’ capacity to strengthen and support the healthy social and emotional development of children. Mental health consultation equips caregivers to facilitate children’s healthy growth and development.¹⁵ This type of support is available to caretakers of infants and toddlers enrolled in Early Head Start as a mandated service, but it is in short supply for the North Carolina child care commu­nity. North Carolina’s Healthy Social Behaviors project offers coaching support based on the Pyramid Model, supporting the use of evidence-based practices to promote social-emotional competence in ECE programs, but the demand for these services far exceeds the supply with only 32 special­ists in the state and their focus primarily on children over age three who are at greater risk of suspension/expulsion due to challenging behaviors.^16,17 Examples of state­wide community resources that medical professionals can help families access include Care Management for At-Risk Children (service coordination for children under age five with Medicaid), the North Carolina Infant-Toddler Program (NC-ITP), and the North Carolina Behavioral Consultation Line NC-PAL (child mental health consultation for physi­cians). Having easy access to infant/early childhood mental health consultation could potentially reduce stress, promote resilience, and create a system of support for infants and toddlers in group care.

Most child care professionals serving infants and tod­dlers in North Carolina do not have a full benefit pack­age that includes sick leave, paid health insurance, and an Employee Assistance Program (EAP). Having an EAP would give child care professionals access to counseling services to address their own mental health, reduce compassion fatigue and burnout, and help them manage stress at no cost. It is crucial that our early childhood system of care recognizes the unmet needs of the child care professionals caring for infants and toddlers, as these are foundational relationships that shape the health and well-being of the child, both in the moment and in the long term. Recognizing the power of healthy relationships to heal and protect, we can begin building resilience from birth and reduce the stress that young children experience.

Conclusion

The adults who care for, raise, and educate children under age three cannot thrive in isolation and deserve a strong network of support. Building bridges between the child care community, the medical community, and evidence-based resources like home-visiting, parenting education, and early intervention, create a network of support that reduces bar­riers and increases accessibility. Increased coordination between these providers has the potential to create a true system of care to more optimally support infants and tod­dlers, their care providers, and their families.

Disclosure of interests

No interests were disclosed.