American Journal of Pediatrics

2020; 6(3): 223-227

http://www.sciencepublishinggroup.com/j/ajp
doi: 10.11648/j.ajp.20200603.18
ISSN: 2472-0887 (Print); ISSN: 2472-0909 (Online)

Factors Associated with Children’s Cognitives in Daycare

Ni Putu Andina Kluniari*, I Gusti Ayu Trisna Windiani, Putu Siadi Purniti,
I Wayan Dharma Artana, I Gusti Ngurah Made Suwarba, Putu Junara Putra
Department of Child Health, Faculty of Medicine, Udayana University, Denpasar, Indonesia

Email address:

*
Corresponding author

To cite this article:

Ni Putu Andina Kluniari, I Gusti Ayu Trisna Windiani, Putu Siadi Purniti, I Wayan Dharma Artana, I Gusti Ngurah Made Suwarba, Putu Junara
Putra. Factors Associated with Children’s Cognitives in Daycare. American Journal of Pediatrics. Vol. 6, No. 3, 2020, pp. 223-227.
doi: 10.11648/j.ajp.20200603.18

Received: April 12, 2020; Accepted: May 3, 2020; Published: June 4, 2020

Abstract: Cognitive development is the result of the relationship between nervous system and individual experiences to adapt
to its environment. A thorough social and demographic changes lead to increased number of children receiving non-parental care.
Some mothers entrust their child care in daycare. The impact of daycare service to the child's development depends on several
interrelated factors, including the personality of the child, stimulation, care setting, and family condition. In daycare facilites, the
children were cared non-parental or non-familial settings. Factors that may affect the child's development in a daycare are
duration of care, caregiver-to-child ratio, the level of caregiver education, and child stimulation during the daycare. The aim of
this study is to confirm association between the care duration, caregiver-to-child ratio, caregiver education, and daycare
stimulation on child’s cognitive in daycare. This was an observational analytical study with a cross-sectional design. This study
was conducted at the daycare in Denpasar since July 2018 to July 2019. The child’s cognitive was measured with Mullen score. A
total of 80 children in 6 daycares were included. The mean Mullen score was 91.71 (SD 10.4). The bivariate analysis of caregiver
education, caregiver-to-child ratio, and stimulation using independent T test showed significant differences. The level of
caregiver education showed a mean difference of 6.3 with a p-value of 0.045 (95% CI 0.129-12.411). The caregiver-to-child ratio
showed a mean difference difference of 10.1 with a p-value of <0.001 (95% CI 6.064-14.170). The multivariate analysis
demonstrated that caregiver education level have a koef B of 5.9 (95% CI 0.534-11.192) with a p-value of 0.031 and
caregiver-to-child ratio have a koef B of 9.5 (95% CI 5.675-13.357) with a p-value of <0.001 which showed significant
differences. Conclusion there are significant association between caregiver education and caregiver-to-child ratio with children’s
cognitive in day care.
Keywords: Daycare, Cognitive, Mullen Score, Children

disorders and cognitive disorders are part of developmental

1. Introduction disorders that occur in about 8% of children aged 2.5-5 years
A thorough social and demographic changes increased the [4]. A study conducted at one daycare in Denpasar showed a
number of children receiving non-parental care. Most mother 13.9% incidence of suspected developmental delay [5]. The
leave their children to a nanny or a relative during worktime. speech and language development of children aged 0-3 years
Another proportion of mother entrusted their children’s care in in eight daycare facilities di Banjarmasin showed normal
daycare. The impact of daycare service to the child's result which was appropriate for their age adjusted
development depends on several interrelated factors, developmental stage [6].
including the personality of the child, stimulation, care setting, Cognitive development is the result of the relationship
and family condition [1, 2]. between nervous system and individual experiences to
Developmental disorders for children aged 9-24 months in adapt to its environment. The main factors that affect the
the United States are estimated at 13% [3]. Communication child's Cognitive development is genetic and environmental
 American Journal of Pediatrics 2020; 6(3): 223-227 224

factors. Genetic factors are the mainstay on which to independent T-test and logistic regression.
achieve the outcome of child development. Environmental
factors determine whether or not the innate potential is 3. Results
achieved. A favorable environment will enable the most
innate potential, while the unfavorable environment will A total of 85 children participated in the study. During the
hamper it. The mother is the first and the closest interview, 85 parents agreed to participate. Five children were
environment from the fetal to adolescence stage. Hence, it excluded due to a history of low birth weight and suffering
is called microenvironment. In daycare facilites, the from chronic disease. A total of 80 children met the inclusion
children were cared non-parental or non-familial settings and exclusion criteria.
[7]. Factors that may affect the child's development in a The characteristics of the child's age were tested for
daycare are duration of care, caregiver-to-child ratio, the normality with the Kolmogorov-Smirnov test which showed
level of caregiver education, and child stimulation during abnormal distribution. The statistical test showed a median of
the daycare [8]. 27 months with an interquartile range (IQR) (6-36). The girl
One of the standarized tool to assess the development of was more common than the boy, with a ratio of 48 girls (60%)
children is Mullen scale. The Mullen scale was used to to 32 boys (40%).
measure cognitive function of children aged 0-68 months [9]. Mean Mullen score of children in the daycare was tested for
Based on epidemiologic rate, the critical period of normality with the Kolmogorov-Smirnov test which showed a
development and the necessity of children care in daycare normal distribution with a mean value of 91.71, standard
facilities are needed for detection as well as for confirmation deviation (SD) 10.4. The Mullen score category showed that
of the daycare’s quality in regard to the duration of care, most children were in the average category at 77 children
caregiver-to-child ratio, the level of caregiver education, as (96.2%), and below-average at 3 children (3.8%). The
well as children stimulation in day care to affect the cognitive characteristics of the research subjects are shown in table 1.
development of children
Table 1. Subject characteristics.

2. Materials and Methods Variables n=80

Age (months), median (min-max) 27 (6-36)
This cross-sectional study was done in day care facilities at Gender, n (%)
Male 32 (40)
Denpasar, Indonesia on 2018. Our study's Ethics Committee
Nutritional status, n (%)
and Institutional approval were obtained from Udayana Malnutrition 5 (6.3)
University. This study was designed to confirm the association Good nutrition 61 (76.2)
of duration of care, caregiver-to-child ratio, caregiver Overweight 14 (17.5)
education level, and children stimulation in day care on Exclusive breastfeeding, n (%)
Yes 30 (37.5)
children’s cognitive. The data of this study were obtained from
No 50 (62.5)
parents’ interview and measured using the Mullen scale. Father education level, n (%)
The cognitive development of children was measured using High school 14 (17.5)
the Mullen scale [8]. The day care’s duration was the length of College 66 (82.5)
time the child is in the facility measured in hours for 1 week in Mother education level, n (%)
High school 15 (18.7)
the last 3 months. The caregiver-to-child ratio was a
College 65 (81.3)
comparison between the number of children and caregivers in Father's occupation, n (%)
the facility based on the recommendations of the American Government employees 19 (23.8)
Academy of Pediatrics [9]. The level of caregiver education Private employee/self-employed 61 (76.2)
was the highest level of formal education completed by the Mother’s occupation, n (%)
Government employees 16 (20)
caregiver. Stimulation of the basic abilities of children in day
Private employee/self-employed 61 (76.3)
care carried out by the caregiver. All activities were scheduled Did not work 3 (3.7)
and implemented for 1 hour per session, 2 times a day for Number of children, n (%)
children in day care [3]. ≤2 64 (80)
Minimum sample size was based on the highest samples >2 16 (20)
Caregiver education level, n (%)
from the four variables with a result of 76 sample. The day
Did not finished high school 13 (16.3)
care facilities in Denpasar were selected using purposive High school 67 (83.7)
sampling. The inclusion criteria are children aged 6 months to Duration of care in daycare, n (%)
3 years who live in Denpasar in 6 predetermined day care >40 hours 49 (61.3)
facilities and the parent signed the informed consent. The ≤40 hours 31 (38.7)
Caregiver-to-child ratio, n (%)
exclusion criteria are is preterm birth, low birth weight,
Enough 39 (48.8)
children with physical limitations, suffering from chronic Not enough 41 (51.2)
diseases, mayor congenital abnormalities, history of asphyxia, Stimulation in daycare, n (%)
post intensive care and cerebral palsy. Collected data was Yes 35 (43.7)
analyzed using computer software. Analysis was done by No 45 (56.3)
225 Ni Putu Andina Kluniari et al.: Factors Associated with Children’s Cognitives in Daycare

Variables n=80 showed that children with a caregiver in a daycare facilities

Mullen score, mean, (SD) 91.7 (10.4) with at least 14-years of education have better cognitive
Mullen score category, n (%) outcomes and language ability [13].
Below average 3 (3.8)
Average 77 (96.2)
Children aged 6 months and over who have longer duration
of care indicated better cognitive and language development
Bivariate analysis was conducted using independent T-test. than children home-cared children. It is estimated that
Table 2 showed the comparison of Mullen score based on children in day care received more diverse language pattern,
factors affecting children's cognitive in day care. more language stimulation, and more opportunities to meet
with their friends to enable them to be more talkative about its
Table 2. The comparison of Mullen score based on factors affecting children's desire. These children gain experience and development
cognitive in day care.
stimulation from a daycare setting due to intensive and strong
Mullen score interaction every day [14, 15]. The duration of care in daycare
Variables Day care 95% CI p-value
Mean±SD within 1 week showed a mean difference of 0.3±2.7 which
Caregiver education level was not significant with a p- value of 0.079 (95% CI
High school 92.7±9.3
0.129-12 411 0.045 -4513-5030). Similar result were obtained in a study by the
Did not finished high school 86.5±14.1
Duration of care NICHD which showed the duration of care in a daycare
<=40 hours 91.87±12.0 facility is not associated with the child's cognitive. A study
-4513 to 5030 0.079
>40 hours 91.61±9.3 was conducted in US children aged 0-4.5 years who received
Caregiver-to-child ratio care at daycare facility with a prospective cohort design. This
Enough 96.90±9.0
6064-14170 <0.001 study did not find any association between duration of care in
Less 86.78±9.2
Stimulation day care per week with children's cognitive outcomes [16].
No 90.91±12.1 Another study by Cote et al (2013) showed a different result
-6500 to 2836 0.044
Yes 92.74±7.6 that duration of care in daycare was associated with children's
Abbreviation: SD=standard deviation; CI=confidence interval. cognitive outcomes. This study was a cohort design in which
children received day care facilities with cognitive evalution
The multivariate analysis was conducted using multiple at the age of 9 months, 3 years and 5 years [17].
linear regression. The analysis was carried out on the Early childhood is a critical period of children's
dependent variables including the level of caregiver education development. Studies have showed that high-quality
and the caregiver-to-child ratio as well as controlled variables education and early childhood care program may increase
including age, sex and parental education included in the child's development. It is important to identify the
analysis as covariates. Multivariate analysis is presented in environmental aspects which are the key aspect in supporting
table 3. the development of children. Organizations such as the
America Academy of Pediatrics (AAP) has identified
Table 3. The results of multiple linear regression analysis. indicators of a high-quality care program. The ratio of
Variables Koef B 95% CI p-value caregiver to children is a measureable structural aspect as an
Caregiver education level 5.9 0.534-11.192 0.031 indicator of the quality of early childhood care. Care group is
Caregiver-to-child ratio 9.5 5.675-13.357 <0.001 based on the needs of children in terms of fulfilling the task of
Gender 3.7 -0.154-7.591 0.060 child development; dividing the caregiver supervision with
Age 0.3 -0.510-0.081 0.008
the caregiver-to-child ratios based on The American Academy
of Pediatrics guideline [8].
4. Discussion Caregiver-to-child ratio showed a mean difference of
10.1±0.2 which was significant with a p-value of <0.001 (95%
Kolmogorov-Smirnov test for normality showed that the CI 6064-14170). Similar result was shown in a study by
distribution of Mullen score was normal. The bivariate Colwell et al (2013) which showed a significant association
analysis using independent T test on caregiver level of (p=0.003) between the caregiver-to-child ratio and cognitive
education showed a mean difference of 6.3±48 (significant outcomes using Bayley Short Form-Research Edition (BSF-R)
with a p-value of 0.045 (95% CI 0.129-12.41). The level of Mental Scale of children in day care facilities. A study of
education is among the factors which affect the quality of African descent in the United States in 2010 found that child
children care. The study by the NICHD concluded that in a day care facility a caregiver-to-child ratio appropriate to
children who receive high-quality care consistently American Academy of Pediatrics guideline have more
demonstrated better cognitive and language development over communication and cognitive abilities at the age of 36 months
the course of the first three year of life [11]. Similar, a study by [13].
Colwell et al (2013) showed a significant association (p=0.004) A different result found in a study in the Netherland, which
on caregiver education level with children’s cognitive showed a negative correlation between the caregiver-to-child
outcomes based on Bayley Short Form-Research Edition ratio with language and cognitive development of children in
(BSF-R) Mental Scale score in children in day care [12]. In a day care facilities. The explanation of this could be the lack of
study of African descendants in America, final analysis correlation due to the limited range of groups which raised
 American Journal of Pediatrics 2020; 6(3): 223-227 226

questions about whether there are other specific

characteristics of the Dutch situation such as a high parental
education. This study was conducted on 3000 children aged
References
0-4 years in Netherlands with a cross-sectional design [18]. [1] R. Bernal. The Effect of Maternal Employment and Child Care
Development stimulation refers to the extent to which on Children Cognitive Development. Int. Econ. Rev 2012; 49
caregivers engage in activities that are considered to improve (suppl. 4): 1173-209.
the children development, achievement, and learning. [2] P. H. Dworkin. Perawatan anak. In: R. Behrm, R. Kliegman,
Development stimulation by the mother at home has proven to editor. Nelson ilmu kesehatan anak. 20th ed., Jakarta: EGC,
contribute to the cognitive development of infants at the age of 2000 pp. 138.
15 months. Growth stimulation by caregivers are expected to [3] S. A. Rosenberg, Z. Duan, and C. C. Robinson. Prevalence of
positively contibute to the cognitive development of children, developmental delays and participation in early intervention
provided that these stimulations are in accordance with service for young children. Pediatrics. 2008; 121: pp. 1503-9.
children needs [13]. In this study, stimulation of children in
[4] Scheffler F, Vogel D, Astern R, Burgess J, Conneally T, Salerno
daycare facilities showed a mean difference of 1.8±4.6 which K. Screening for communication and cognitive disorders in
was non-significant with a p-value of 0.044 (95% CI infants and toddlers. Pediatr Nurs. 2007; 33 (6): 473-80.
-6500-2836). A different result was obtained in a study by
Estheret al (2010) where the results of stimulation by [5] B. Hartawan, I. G. A Windiani, Soetjiningsih. Karakteristik
Tumbuh Kembang Anak di Tempat Penitipan Anak Werdhi
caregivers in daycare facilites showed a significant Kumara 1, Kodya Denpasar. Sari Pediatri 2008. Jakarta, 10 (2):
association (B=0.38, p <0.05) to the children’s development. 134-8.
This study was conducted on 64 children with a mean age of 3
months with a cohort design. The stimulation was assessed [6] G. Gunawan, Destiana, Rusmil, K. Gambaran perkembangan
bicara dan bahasa anak usia 0-3 tahun. Sari Pediatri 2011, 13
using Observational Record of the Caregiving Environment (1): 21-5.
score [19].
Different results in these stimulatings factor may be due to [7] Soetjiningsih. Faktor-faktor yang Mempengaruhi Tumbuh
Mullen (cognitive) score of the children in daycare facilities Kembang. Soetjiningsih, I. G. Ranuh, H Suyitno, editor.
Tumbuh kembang anak. 2nd ed. Jakarta: EGC, 2012 pp. 61-72.
almost have same results (96.2%); it is estimated that there are
other factors that influence it. Family factors, such as greater [8] American Academy of Pediatrics, American Public Health
stimulation at home, may also contribute to this study. This Association, National Resource Center for Health and Safety in
study did not sought information about the stimulation in the Child Care and Early Education. Caring for our children:
National health and safety performance standards; Guidelines
family. Factors of stimulation that affect children's cognitive for early care and education programs. 3rd ed. Elk Grove
in addition to its quantity is its quality, such as the type of Village: American Academy of Pediatrics. 2011. pp. 3-7.
stimulation provided and the quality of stimulation facilities in
the form of educational game appropriate for the age and [9] E. M. Mullen. General Administration and Scoring Procedures,
dalam Mullen, E. M.: Mullen Scales of Early Learning AGS
adequate room for stimulation. In this study, stimulation is edition Manual, American Guidance Service Inc. 1995. pp.
only measured based on its quantity, which was the schedule 19-31.
and the presence of stimulation devices. This is likely to cause
the results in this study; in which daycare stimulation is not [10] Depdiknas. Pedoman Rintisan Program Taman Penitipan Anak.
Jakarta: Ditjen PLSP Depdiknas RI; 2016.
related to children's cognitive.
[11] NICHD Early Child Care Research Network. Early child care
and children’s development prior to school entry. Am Educ Res
5. Conclusions J 2002.39 (1): 133-64.
There were association of caregiver-to-child ratio and [12] N. Colwell, R. Gordon, K. Fujimoto, R. Kaestner, S. Korenman.
caregiver education level with children cognitive development New evidence on the validity of the Arnett Caregiver
in daycare facilites. Further studies examining the other Interaction Scale: results from the Early Childhood
conditions or quality of daycare influences children’s Longitudinal Study-Birth Cohort. Early Child Res Q 2013; 28
(2): 21-33.
cognitive are needed. This is especially important in the
context of governmental investments in daycare services. [13] M. R. Burchina, J. E. Roberts, R. Riggins, S. A. Zeisel, E.
Neebe, D. Bryant. Relating quality of center-based child care to
early cognitive and language development longitudinally.
Disclosure Child Dev 2000; 71 (2). NICHD Early Child Care Research
Network ans G. J. Duncan. Modeling the impacts of child care
All the authors do not have any possible conflicts of quality on children’s preschool cognitive development. Child
interest. Dev. 2003; 74: 1454-75.
[14] J. Belsky. 2011. Child Care and Its Impact on Young Childrel
Acknowledgements Downloaded on December 20th 2016 Available from: URL:
http://www.child-encyclopedia.com/sites/default/files/textes-e
None declared. xperts/en/857/child-care-and-its-impact-on-young-children.pd
f.
227 Ni Putu Andina Kluniari et al.: Factors Associated with Children’s Cognitives in Daycare

[15] A. E. Guttmacher. Findings for Children up to Age 41⁄2 Years, [17] K. O. W. Helmerhorst, J. Riksen-Walraven, M. J. J
national institute of child Health and Human Development, pp Deynoot-Schaub, L. C. W. Tavecchio, R. Fukkink. Child Care
16-7. Quality in The Netherlands Over the Years: A Closer Look.
Early Education and Development 2014; 26 (1): 89-105.
[16] S. M. Cote, A. Petitclerc, O. Doyle, L. Timmins. Child Care in
Infancy and Cognitive Performance Until Middle Childhood in [18] J. Albers, M. Esther, M. Developmental stimulation in child
the Millennium Cohort Study. Child Development 2013, (84): care centers contributes to young infants’ cognitive
1191–20. development. Infant Behavior & Development 2010; 33: 401–
8.