Non-parental childcare attendance prior to school entry and children’s internalising and externalising symptoms: an individual participant data meta-analysis of six child cohort studies (EU Child Cohort Network)

doi:10.21203/rs.3.rs-3899625/v1

Purpose

To test associations between children’s attendance of non-parental childcare prior to school entry and internalising and externalising symptoms throughout childhood and young adolescence.

Methods

Data come from six parent-offspring prospective birth cohort studies across five European countries within the EU Child Cohort Network. A two-stage individual participant data meta-analysis was performed. Linear regression models where implemented to test associations between non-parental childcare attendance anytime between ages 0-4 years and children’s scores of internalising and externalising symptoms (measured in three age groups: 5-6 years, 7-9 years, 10-13 years), in each cohort separately, and then cohort-specific coefficients and standard errors were combined using random-effects meta-analysis to attain overall association estimates. To test possible subgroup effects, statistical analyses were stratified by family socioeconomic position (SEP) and child’s sex.

Results

Internalising symptoms were studied among 74 453 children and externalising symptoms among 74 446 children. Compared to children cared for by their parents, those who attended centre-based childcare had lower levels of internalising symptoms between 10-13 years [-1.06 (95%CI: -1.95, -0.17), p=0.02]; in younger age groups we observed similar results but the coefficients did not reach statistical significance. Children who attended non-institutionalised childcare appeared to have elevated levels of internalising symptoms between 7-9 years [0.91 (95%CI: 0.23, 1.58), p=0.009]. Attendance of non-institutionalised childcare was also associated with increased levels of children’s externalising symptoms between 5-6 years [2.45 (95%CI: 0.35, 4.55), p=0.02] and 7-9 years [2.78 (95%CI: 0.60, 4.95), p=0.01]. Stratifying on family SEP, we observed that children from more deprived families who attended centre-based childcare had lower internalising symptoms between 5 and 6 years. To the contrary, children growing up in intermediate/high SEP families attending centre-based childcare appeared to experience higher levels of externalising symptoms between 5 and 6 years . Stratifying on child’s sex, we observed that boys seemed to particularly benefit from centre-based childcare attendance in terms of internalising symptoms in all studied age groups, but displayed high levels of externalising symptoms if they attended centre-based childcare (between 5 and 6 years) or non-institutionalised childcare (all age groups studied).

Conclusions

Our study suggests that attendance of centre-based childcare is associated with lower levels of internalising symptoms among children after school entry, but non-institutionalised childcare shows opposite associations with internalising and externalising symptoms. The effect of childcare attendance may be moderated by family’s SEP and child’s sex. Overall, our results suggest that attendance of centre-based childcare may be associated with positive impacts on children’s emotional development and could contribute to reducing social inequalities in this area in childhood and young adolescents.

centre-based childcare

non-parental childcare

internalising symptoms

externalising symptoms

epidemiology

child cohorts

High quality, early non-parental childcare is associated with improved cognitive abilities, positive peer interactions, and lower levels of problem behaviours in early childhood in certain countries.
More research differentiating the effects of types of childcare on children’s behavioural development is needed.

What is New

Across 6 European countries, compared to exclusive parental care, centre-based childcare was associated with lower levels of internalising symptoms in children.
Other forms of childcare were associated with higher levels of internalising and externalising symptoms compared to exclusive parental care.

In the European Union (EU) in 2020, approximately 53.4% of all children under the age of 3 were exclusively taken care of by their parents, 32.3% were in formal childcare for at least one hour per week and 20.9% were cared for by their grandparents, other relatives or professional childminders [1]. Non-parental childcare, defined as any care a child receives outside of his/her parents, is often divided into institutionalized childcare (centre-based childcare) or non-institutionalized childcare (childcare professional, home day-care, nanny, relatives or acquaintances). Understanding how non-parental childcare impacts a child’s development may provide families and policymakers with valuable information on whether increasing availability of non-parental childcare can benefit not only work-life balance but also children’s socio-emotional and cognitive development.

Attendance of high quality of childcare - particularly centre-based care - has been associated with children’s improved cognitive and language acquisition skills and later achievement in school [2–5], as well as fewer peer problems and lower levels of emotional problems [6, 7]. Centre-based childcare can provide children with an array of learning opportunities that they may not have at home or with a nanny [5, 8] and especially benefit those who come from disadvantaged backgrounds and experience family adversity.

The long-term impact of early childcare arrangements on children’s emotional development is of interest due to the negative repercussions that early onset internalising and externalising symptoms can have. One study found a prevalence of 18.4% of internalising and 7.8% of externalising symptoms among children aged 6-12 years in 8 EU countries [9]. Children with internalising symptoms in early adolescence are at higher risk of alcohol dependency, lower intimate partnership, higher welfare benefits and psychopathology later in life [10, 11]. Children who displayed externalising symptoms early on and continued displaying these behaviours into adolescence were associated with decreased opportunities for social growth, lower school achievement, worse psychosocial outcomes and less financial stability in their 20s and early 30s [10].

Our aim was to study the relationship between childcare arrangements prior to school entry and children’s internalising and externalising symptoms in childhood and early adolescence, testing the hypothesis of a protective effect of centre-based childcare. We used data from five EU countries to test: (i) whether centre-based childcare attendance is associated with lower levels of internalising and externalising symptoms compared to non-institutionalised childcare and exclusive parental childcare, and (ii) whether associations between childcare attendance and children’s internalising and externalising symptoms are moderated by family socioeconomic position (SEP) and child’s sex.

Design and Oversight

This study includes 6 parent-offspring prospective birth cohort studies across five European countries participating in the EU Child Cohort Network (EUCCN) [12].The EUCCN is part of the EU Horizon 2020 LifeCycle project, funded in 2017 with the overarching aim of understanding relationships between early-life stressors and child development, health and disease throughout the life course. Cohorts were included in the study if they (i) collected information about non-parental childcare before school entry and recorded children’s internalising and externalising symptoms at least once during follow-up, (ii) were approved by their institutional review boards, and (iii) had harmonized data available for analysis via DataSHIELD [13] (Figure 1). Participating cohorts include: the Avon Longitudinal Study of Parents and Children [14] (ALSPAC; recruitment from 1 April 1991 to 31 December 1992) in the United Kingdom, The Generation R study [15](GenR; recruitment from 1 April 2002 to 31 January 2006) in The Netherlands, the Danish National Birth Cohort [16](DNBC; recruitment from 1995 to 2002) in Denmark, the INfancia y Medio Ambiente Project [17](INMA; recruitment from 1997 to 2008) in Spain, the Étude des Déterminants pré Et postnatals du Développement de la santé de l'enfant [18](EDEN; recruitment from 27 January 2003 to 6 March 2006) in France, and the Étude Longitudinale Française depuis l'Enfance[19](ELFE; recruitment on 25 selected days of 2011 spread over the year) in France. The cohorts were approved by their local institutional review boards, written informed consent from all participants or parents was obtained, and all cohorts provided written informed consent for use of their data in this project. The study design and characteristics of participants of each cohort have been described in detail elsewhere [14–19].

Participants

Complete data from 74 453 (76.12%) and 74 446 (75.84%) participants in the six participating parent-offspring cohorts were used to study internalising and externalising symptoms, respectively (Figure 1).

Measures

Exposures of interest

Non-parental childcare care attendance

Parents reported their children’s primary childcare at least one time between the ages of 0-4 years (Supplementary Table 1). If the parent reported that their child was in centre-based care at least once, they were considered to be in centre-based childcare [yes/no]. If the parent reported that their child was in non-institutionalised childcare, which includes day-care centres, child care professionals, relatives/friends/nanny/babysitter/au pair and/or someone other than the parents, they were consider to be in non-institutionalised childcare [yes/no].

Outcomes of Interest

Children’s internalising and externalising symptoms

Children’s internalising and externalising symptoms [20] were reported by parents using either the Strengths and Difficulties Questionnaire (SDQ) [21]or Child Behavioural Checklist (CBCL) [22]. Information regarding the use of different measures, ages of assessment and standardisation process for the scores is shown in Supplementary Table 1.

Covariates

Maternal age in years was measured at child’s birth. In the first 12 months of the child’s life, maternal educational level: high (short cycle tertiary, bachelor, masters, doctoral or equivalent), intermediate (upper secondary, post-secondary non-tertiary) or low (no education, early childhood, pre-primary, primary, lower secondary or second stage of basic education), based on the International Standard Classification of Education 97/2011 (ISCED-97/2011) [23, 24], maternal employment status: [employed, unemployed, other (student, apprentice, domestic tasks, inactive/receiving benefits, etc.)] and parental separation: did the parents split up during the first year of the child's life [yes/no]) was assessed.

Parents reported if the participating child was a first-born [yes/no]. The child’s birthweight was reported in grams and child’s sex was recorded at birth (male/female).

Statistical Analyses

To study the relationship between non-parental childcare attendance and children’s internalising and externalising symptoms, we implemented a two-stage individual participant data (IPD) meta-analysis.

First, linear regression models were implemented in each cohort separately. Second, cohort-specific coefficients and standard errors were combined using random-effects meta-analysis with a restricted estimate maximum likelihood (REML) approach to attain overall effect estimates. Based on the measurement timing of children’s internalising and externalising symptoms in each cohort, we distinguished three age-groups (5-6 years, 7-9 years, 10-13 years). In the ALSPAC, GenR, EDEN, DNBC and ELFE cohorts, regression models were adjusted for maternal age, educational level, employment status, parental separation, only child status, child’s weight and child’s sex at birth. In the INMA cohort, regression models were adjusted for the previous variables except parental separation status, which was not measured.

The combined estimates testing associations between non-parental childcare attendance and children’s internalising and externalising symptoms are presented with their accompanying 95% confidence intervals (95% CI), the estimated p-value and their heterogeneity statistics (Q, degrees of freedom (df), p-value, I², H²). An I² statistic > 75% or I2 ~ 75% with effect estimates in different directions represents moderate to substantial heterogeneity [25, 26].

In a sensitivity analysis, we additionally adjusted our regression models separately for maternal post-partum depression (PPD) [yes/no] following the year of the child’s birth and gestational age at birth when available to test if the results differed from the primary analysis.

Additionally, we tested for statistical interactions between childcare attendance and a) maternal educational level (low vs. intermediate/high)[27], and b) child’s sex [28].

All statistical analyses were performed using DataSHIELD (packages: dsBase version 6.1.0; dsHelper version 4.21.1), a tool for federated analyses of individual-level data [29, 30]. Due to unavailability of imputation methods in DataSHIELD, we were only able to study complete case samples (Supplementary Table 2). Compared to participants who were included in the statistical analyses, participants who were excluded due to missing data on covariates were significantly different in terms of all covariates except child’s sex (Supplementary Table 2). All statistical codes used to analyse data for this project have been made publicly available: https://github.com/katybarry/nonparental-care-attendance-and-childrens-behaviors.git

Participants’ characteristics

Table 1 shows the combined sample characteristics of participants by age group.

Children’s internalising symptoms

Compared to children who were cared for by their parents prior to age 4, those who attended centre-based childcare had lower levels of internalising symptoms between 10-13 years: β: -1.06 (95%CI: -1.95, -0.17), p=0.02 (Figure 2).

Attendance of non-institutionalised childcare was associated with higher levels of internalising symptoms between 7-9 years [β: 0.91 (95%CI: 0.23, 1.58), p=0.009](Figure 2).

Children’s externalising symptoms

Regarding non-institutionalised childcare, we found associations between 5-6 years and 7-9 years : 5-6 years [β: 2.45 (95%CI: 0.35, 4.55), p=0.02]; 7-9 years [β: 2.78 (95%CI: 0.60, 4.95), p=0.01] (Figure 3). We observed potential heterogeneity in the 10-13 years age group (I²= 84.4%).

All cohort-specific associations can be found in the Supplementary Information (Supplementary Figures 1 -12).

Additional statistical analyses

After additional adjustment of mother’s PPD, we found lower levels of internalising symptoms between 7-9 years [β: -1.67 (95%CI: -2.51, -0.83), p=0.001] among children who attended centre-based childcare, and higher levels of internalising symptoms between 7-9 years [β: 1.05 (95%CI: 0.36, 1.74), p=0.003] among children who attended non-institutionalised childcare (Supplementary Figure 13). Regarding externalising symptoms, non-institutionalised childcare was associated with increased levels of externalising symptoms between ages 5-6 years and 7-9 years, respectively: [β: 2.35 (95%CI: 0.18, 4.53), p=0.03]; [β: 2.77 (95%CI: 0.63, 4.91), p=0.01](Supplementary Figure 13).

After additional adjustment of gestational age, we found children who were in centre-based childcare had higher levels of externalising symptoms between 5-6 years [β:2.15 (95%CI: 0.06, 4.23), p=0.04] (Supplementary Figure 14).

Effect modification by family SEP and child sex

The likelihood ratio p values testing interactions between SEP*childcare and child’s sex*childcare can be found in Supplementary Table 3. After stratification, children who attended centre-based childcare and came from a low SEP family were more likely to have low levels of internalising symptoms compared to exclusive parental care between 5-6 years: [β: -2.49 (95%CI: -4.85, -0.13), p=0.04] (Figure 4). Children from intermediate/high SEP families who attended centre-based or non-institutionalised childcare from had higher levels of externalising symptoms between 5-6 years: [β: 3.17 (95%CI:1.07, 5.27), p=0.003; β: 2.87 (95%CI: 0.42, 5.33), p=0.02], respectively (Figure 4).

Among children who attended centre-based childcare, boys had lower levels of internalising symptoms across childhood and young adolescence than girls: 5-6 years [β: -2.46 (95%CI: -4.64, -0.29), p=0.03]; 7-9 years [β: -1.68 (95%CI: -2.82, -0.53), p=0.004];10-13 years [β: -1.40 (95%CI: -2.68, -0.13), p=0.03] (Figure 5).

Boys who attended centre-based or non-institutionalised childcare had increased levels of externalising symptoms between 5-6 years: [β: 2.78 (95%CI: 0.68, 4.89), p=0.009 ; β: 2.46 (95%CI: 0.83, 4.10), p=0.003], respectively. This association was also observed at later ages for non-institutionalised childcare: 7-9 years: [β: 1.97 (95%CI: 0.73, 3.22), p=0.002]; 10 -13 years: [β: 1.74 (95%CI: 0.09, 3.39), p=0.004] (Figure 5).

Main findings

Studying 6 European mother-child cohorts which included over 74 000 participants, we found indications that attendance of non-parental childcare may be associated with children’s psychological and behavioural outcomes before and after school entry. Attendance of centre-based childcare was associated with lower levels of internalising symptoms; however, attendance of non-institutionalised childcare was associated with higher levels. Moreover, attendance of non-institutionalised childcare was also associated with children’s elevated levels of externalising symptoms.

Children from low SEP families who attended centre-based childcare had lower levels of internalising symptoms after school entry than those with exclusive parental care. However, children from intermediate/high SEP families had higher levels of externalising symptoms if they attended centre-based or non-institutionalised childcare. Boys who attended centre-based childcare showed lower levels of internalising symptoms than those who were cared for by their parents, but they also displayed higher levels of externalising symptoms. Overall, our study suggests that non-parental childcare care may be associated with children’s psychological development over the mid and long-term, the greatest benefits being reached in the case of centre-based childcare.

Comparison with past research

Past scientific literature on relationships between non-parental childcare and children’s development has shown somewhat inconsistent findings depending on the type of childcare, the setting and children’s age.

Studying associations between centre-based childcare and children’s internalising symptoms, studies in Europe reported that children who attended centre-based childcare below the age of 3 years display fewer internalising symptoms and higher levels of prosocial skills [6, 31–33]. Children in centre-based care may learn cooperation and conflict resolution skills as well not experience as many withdrawal behaviours compared to being in other forms of non-parental childcare where the child may be one of many children of various ages [31]. In contrast, if children come from families with differing behavioural norms than those implemented in centre-based care, they may experience higher rates of anxiety and depression due to this dissonance, as one Swiss study reported [34].

When studying children’s externalising symptoms, a meta-analysis reported no association between the number of hours spent in centre-based care and externalising symptoms below 5 years of age [35]. In contrast, time spent in centre-based childcare was related to higher levels of self-reported aggression at ages 7- 8 years as well as self-reported Attention-Deficit/Hyperactivity Disorder (ADHD) symptoms at ages 15-17 years in Switzerland [34] and more teacher-reported externalising symptoms from 52 months to grade 5 in the United States [11, 36]. Some of the variation across studies may also reflect differences in the quality, governance, accessibility and affordability of centre-based childcare provided for children before they start school in each country. Only one-third of countries part of the Organization for Economic Co-operation and Development (OECD) have strict guidelines regarding the educational curriculum implemented in centre-based childcare centres [37]. Quality care as well as the number of children per centre-based childcare professional have been associated with fewer behavioural difficulties and better social skills in children, particularly among those who come from vulnerable backgrounds [6, 34, 38, 39]. The quality of centre-based childcare provided in each country may therefore play a role in children’s behavioural outcomes and may be an underlying factor at play.

We found a positive association between non-institutionalised childcare and elevated levels of internalising symptoms between 7-9 years. This aligns with a study conducted in Britain which found that high use of non-institutionalised care during early childhood was linked to increased levels of teacher-rated anti-social behaviour up at age of 7 years; however, this association did not persist at age 10 years [40, 41]. In Switzerland, the authors found that children who visited a playgroup were more aggressive at ages 7 and 8 and had more self-reported symptoms of delinquency and substances use at age 13 if they were cared for by acquaintances rather than their parents [34].This is consistent with our study, which showed that children who attended non-institutionalised childcare were more likely to experience externalising difficulties between the ages of 5-6 and 7-9 years.

When examining possible moderating effects of family SEP, we found that children from a low SEP family experienced lower levels of internalising symptoms between ages 5-6 years if they attended centre-based childcare. This is consistent with another study which found that children from low-income families had less internalising symptoms if they received quality centre-based childcare [42]. Children growing up in disadvantaged families may benefit from interactions with the caregivers which may encourage exploration and development, as well as provide cognitive stimulation and education, which may improve the child’s social development [42]. We also found that children growing up in intermediate/high SEP families who attended non-centre based childcare had higher levels of externalising symptoms between ages 5-6 years and 7-9 years than exclusive parental care. These results differ from some research showing that children from disadvantaged backgrounds can experience a reduction in physical aggression and externalising symptoms if they attend a centre-based childcare or other type of non-parental childcare service [43, 44] whereas other research has indicated that SEP is not a moderating factor [35].

Between genders, we found boys had decreases in levels of internalising symptoms among those who attended centre-based childcare but the opposite affect among boys who attended non-institutionalised childcare. The differences we see in boys compared to girls may be due to gender-based difference in the type of teaching, parenting, expectations and discipline styles implemented. For instance, some studies found that harsh discipline practices were more strongly associated with boys’ than girls’ externalising symptoms as rated by teachers [45–47]. It has been suggested that girls undergo faster biological, cognitive and social maturation than boys, which could lead them to develop more adaptive behaviour regulation skills at an earlier stage than boys [47]. Moreover, girls might be socialized to exhibit internalising symptoms instead of externalising symptoms [47].

Limitations and Strengths

Our study has some limitations which need to be acknowledged. First, child cohorts included in our study were characterized by missing data which we could not impute due to underdevelopment of DataSHIELD, the software used to meta-analyse the data. We observed some differences between participants excluded from the analyses and those who were included in our study, and it may be that we underestimated the proportion of children experiencing emotional or behavioural difficulties. Second, our study may be affected by residual confounding as covariates included had to be available in all child cohorts included. Nevertheless, the covariates included in our study, derived from a Directed Acyclic Graph (DAG), probably capture most variability related to confounding factors. Third, some children attended different types of childcare, which we recoded to identify children who experienced centre-based childcare. This may have introduced some misclassification bias, as studies have shown that children who attend multiple childcare arrangements may display more behavioural problems, possibly in part due to insecure attachment with adults that care for them[48]. Lastly, parent-reported children’s internalising and externalising symptoms may underestimate their offspring’s psychological difficulties [49]. However the use of standardized measures of mental health which have previously been validated is likely to reduce this type of bias [20].

Despite these limitations, our study also has strengths which should be highlighted. First, this is a federated analysis of individual level data from six different cohorts across five European countries. The geographic diversity of the study sample provides enhanced location coverage across Europe and improves the generalizability of the results and facilitates intra- and inter-population comparisons. Second, the consistent harmonization process for each variable across each cohort reduced between-study heterogeneity and strengthened the generalizability, external validity and reproducibility of findings. Third, we were able to account for key covariates and test whether the reported associations varied across family socioeconomic position and child sex.

Our study, based on data from six epidemiological cohorts of children recruited across multiple European settings highlight complex associations between different types of non-parental childcare and children’s emotional and behavioural outcomes in mid-childhood and early adolescence. Our results indicate that children attending centre-based childcare have fewer internalising symptoms whereas those who attend non-institutionalised care report higher levels of internalising and externalising symptoms compared to exclusive parental care. Access to quality centre-based childcare could be a propitious way of promoting child well-being and psychological development in the mid and long-term.

Attention-Deficit/Hyperactivity Disorder (ADHD)

Avon Longitudinal Study of Parents and Children (ALSPAC)

Child Behavioural Checklist (CBCL)

Danish National Birth Cohort (DNBC)

Étude des Déterminants pré Et postnatals du Développement de la santé de l'enfant (EDEN)

Étude Longitudinale Française depuis l'Enfance (ELFE)

EU Child Cohort Network (EUCCN)

European Union (EU)

The Generation R Study (GenR)

INfancia y Medio Ambiente Project (INMA)

Individual Participant Data (IPD)

International Standard Classification of Education (ISCED)

National Institute of Child Health and Human Development (NICHD)

Organization for Economic Co-operation and Development (OECD)

Post-Partum Depression (PPD)

Socioeconomic Position (SEP)

Strengths and Difficulties Questionnaire (SDQ)

95% Confidence Interval (95% CI)

Funding

ALSPAC

The Avon Longitudinal Study of Parents and Children (ALSPAC) receives core funding from the University of Bristol, UK Medical Research Council and Wellcome (217065/Z/19/Z). A comprehensive list of grants funding is available on the ALSPAC website (http://www.bristol.ac.uk/alspac/external/documents/grant-acknowledgements.pdf).

Generation R

The general design of the Generation R Study is made possible by financial support from the Erasmus MC, University Medical Centre, Rotterdam, Erasmus University Rotterdam, Netherlands Organization for Health Research and Development (ZonMw), Netherlands Organisation for Scientific Research (NWO), Ministry of Health, Welfare and Sport and Ministry of Youth and Families. This project received funding from the European Union's Horizon 2020 research and innovation programme (LIFECYCLE, grant agreement No 733206, 2016; EUCAN-Connect grant agreement No 824989; ATHLETE, grant agreement No 874583).

DNBC

The Danish National Birth Cohort (DNBC) was established with a significant grant from the Danish National Research Foundation. Additional support was obtained from the Danish Regional Committees, the Pharmacy Foundation, the Egmont Foundation, the March of Dimes Birth Defects Foundation, the Health Foundation and other minor grants. The DNBC Biobank has been supported by the Novo Nordisk Foundation and the Lundbeck Foundation. Follow-up of mothers and children have been supported by the Danish Medical Research Council (SSVF 0646, 271-08-0839/06-066023, O602-01042B, 0602-02738B), the Lundbeck Foundation (195/04, R100-A9193), The Innovation Fund Denmark 0603-00294B (09-067124), the Nordea Foundation (02-2013-2014), Aarhus Ideas (AU R9-A959-13-S804), University of Copenhagen Strategic Grant (IFSV 2012), and the Danish Council for Independent Research (DFF – 4183-00594 and DFF - 4183-00152).

INMA

the INfancia y Medio Ambiente Project (INMA) was funded by grants from the Instituto de Salud Carlos III (Red INMA G03/176) and the Generalitat de Catalunya-CIRIT (1999SGR 00241). INMA-Valencia was funded by Grants from UE (FP7-ENV-2011 cod 282957 and HEALTH.2010.2.4.5-1), Spain: ISCIII (G03/176; FIS-FEDER: PI09/02647, PI11/01007, PI11/02591, PI11/02038, PI13/1944, PI13/2032, PI14/00891, PI14/01687, and PI16/1288; Miguel Servet-FEDER CP11/00178, CP15/00025, and CPII16/00051), and Generalitat Valenciana: FISABIO (UGP 15-230, UGP-15-244,and UGP-15-249). INMA-Gipuzkoa was funded by grants from the Instituto de Salud Carlos III (FISFIS PI06/0867, FISPS09/0009) 0867,Red INMA G03/176) and the Departamento de Salud del Gobierno Vasco (2005111093 and 2009111069) and the Provincial Government of Guipúzcoa (DFG06/004 and FG08/001). INM-Menorca was funded by grants from the Instituto de Salud Carlos III (Red INMA G03/176). This study was supported by funding from the European Community’s Seventh Framework Programme (FP7/2007-206) under grant agreement no 308333—the HELIX project.

EDEN

The Étude des Déterminants pré Et postnatals du Développement de la santé de l'enfant (EDEN) study was supported by Foundation for medical research (FRM), National Agency for Research (ANR), National Institute for Research in Public health (IRESP: TGIR cohorte santé 2008 program), French Ministry of Health (DGS), French Ministry of Research, INSERM Bone and Joint Diseases National Research (PRO-A) and Human Nutrition National Research Programs, Paris-Sud University, Nestlé, French National Institute for Population Health Surveillance (InVS), French National Institute for Health Education (INPES), the European Union FP7 programmes (FP7/2007-2013, HELIX, ESCAPE, ENRIECO, Medall projects), Diabetes National Research Program (through a collaboration with the French Association of Diabetic Patients (AFD)), French Agency for Environmental Health Safety (now ANSES), Mutuelle Générale de l’Education Nationale a complementary health insurance (MGEN), French national agency for food security, French speaking association for the study of diabetes and metabolism (ALFEDIAM).

The study received approval from the ethics committee (CCPPRB) of Kremlin Bicêtre on 12 December 2002 and from CNIL (Commission Nationale Informatique et Liberté), the French data privacy institution. Women gave written informed consent for themselves and their child. Fathers gave written informed consent for themselves.

ELFE

The Étude Longitudinale Française depuis l'Enfance (ELFE) cohort received funding from the National Research Agency Investment for the Future program [ANR-11-EQPX-0038]; French National Institute for Research in Public Health (IRESP TGIR 2009-2001 program); Ministry of Higher Education and Research; Ministry of Environment; Ministry of Health; French Agency for Public Health; Ministry of Culture; and National Family Allowance Fund.

Competing interests

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Author contributions

KMB, DA and MM conceptualized and designed the present study. interpretation of the results. KMB, DA, and TC planned and performed the statistical and data analysis. KMB drafted the article. DA, TM, AE, HEM, PWJ, MW, AMNA, KSL, LGS, RSB, FBZ, JJ, MV, BH, MAC, ARG, and MM provided insights on the interpretation of the data and additional analyses to perform. All authors read and revised this manuscript critically for important intellectual content and finally approved this version of the manuscript for submission.

Ethics approval

ALSPAC

Ethical approval for the study was obtained from the ALSPAC Ethics and Law Committee and the Local Research Ethics Committees. Informed consent for the use of data collected via questionnaires and clinics was obtained from participants following the recommendations of the ALSPAC Ethics and Law Committee at the time Pregnant women resident in Avon, UK with expected dates of delivery 1st April 1991 to 31st December 1992 were invited to take part in the study.

Generation R

The general design, all research aims and the specific measurements in the Generation R Study have been approved by the Medical Ethical Committee of Erasmus MC, University Medical Center Rotterdam. Participants need to give written informed consent for each phase of the study (fetal, preschool, childhood and adolescence period).

DNBC

The Danish National Birth Cohort (DNBC) is a nationwide longitudinal cohort that enrolled pregnant women through their general practitioners during early gestation (weeks 6 to 12) (Olsen et al., 2001). Written informed consent was obtained from all participants at recruitment, and again during followed up.

INMA

The study has been approved by Ethical Committee of each participating centre and written consent was obtained from participating parents. Data for this study comes from INMA-Asturias, INMA-Gipuzkoa, INMA-Sabadell and INMA-Valencia subcohorts.

EDEN

The study received approval from the ethics committee (CCPPRB) of Kremlin Bicêtre on 12 December 2002 and from CNIL (Commission Nationale Informatique et Liberté), the French data privacy institution. All subjects gave their informed consent for inclusion before they participated in the study. Consent for the child was obtained from both parents after the child's birth

ELFE

Ethical approvals for data collection in maternity units and for each data collection wave during follow-up were obtained from the national advisory committee on information processing in health research (CCTIRS: Comité Consultatif sur le Traitement de l’Information en matière de Recherche dans le domaine de la Santé), the national data protection authority (CNIL: Comission Nationale Informatique et Liberté) and, in case of invasive data collection such as biological sampling, the committee for protection of persons engaged in research (CPP: Comité de Protection des Personnes). The ELFE study was also approved by the national committee for statistical information (CNIS: Conseil National de l’Information Statistique). Informed consent was signed by the parents or the mother alone, with the father being informed of his right to deny consent for participation.

Consent to participate

ALSPAC

Participants who returned completed questionnaires (either by post or by email) provided written consent to participate.

Generation R

Participants provided written informed consent for each phase of the study (fetal, preschool, childhood and adolescence period).

DNBC

Written informed consent was obtained from all participants at recruitment, and again during followed up.

INMA

Written consent was provided by all participating parents at the beginning of the study.

EDEN

Consent for the child was obtained from both parents after the child's birth

ELFE

Informed consent was signed by the parents or the mother alone, with the father being informed of his right to deny consent for participation.

Availability of Data and Materials

The datasets generated and analyzed during the current study are not publicly available due to data regulations and for ethical reasons, considering that this information might compromise research participants’ consent because our participants only gave their consent for the use of their data by the original team of investigators. However, all the code for the data management and analysis are open sourced and publicly available: https://github.com/katybarry/nonparental-care-attendance-and-childrens-behaviors.git

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Table 1: Covariate, exposure and outcome information in the combined samples from the 6 participating cohorts in the EU Child Cohort Network (ALSPAC, GenR, DNBC, INMA, EDEN, ELFE

	Combined internalising symptoms sample, N=74 453			Combined externalising symptoms sample, N= 74 446
Age group	5-6 years (n=20 797)	7-9 years (n=54 964)	10-13 years (n= 45 025)	5-6 years (n=20 806)	7-9 years (n=54 934)	10-13 years (n=45 027)
Included cohorts	4	5	3	4	5	3
Mother’s age, median, (IQR)	30.70 (27.75 – 33.73)	30.07 (27.09 – 33.02)	29.91 (26.92 – 32.90)	30.70 (27.76 – 33.74)	30.07 (27.09 – 33.02)	29.91 (26.92 – 32.90)
Mother’s educational level
High, n (%)	10 809 (52.00)	27 144 (49.40)	22 807 (50.70)	10 812 (52.00)	27 128 (49.40)	22 907 (50.70)
Medium, n (%)	8592 (41.30)	15 678 (28.50)	12 570 (27.90)	8595 (41.30)	15 670 (28.50)	12 571 (27.90)
Low, n (%)	1396 (6.71)	12 142 (22.10)	9648 (21.40)	1399 (6.72)	12 136 (22.10)	9649 (21.40)
Mother’s employment status
Employed, n (%)	16 127 (77.54)	43 311 (78.80)	35 346 (78.50)	15171 (72.92)	42263 (76.93)	35 348 (78.50)
Unemployed, n (%)	670 (3.22)	1833 (3.33)	1320 (2.93)	671 (3.22)	1829 (3.33)	1320 (2.93)
Other, n (%)	4000 (19.23)	9820 (17.87)	8359 (18.56)	4964 (23.85)	10842 (19.74)	8359 (18.56)
Parental separation (yes), n (%)	345 (1.67)	615 (1.14)	481 (1.09)	345 (1.66)	615 (1.14)	481 (1.09)
Child’s sex (female), n (%)	10 174 (48.90)	26 949 (49.00)	22 586 (50.20)	10 180 (48.90)	26 935 (49.00)	22 588 (50.20)
Only child (yes), n (%)	9960 (47.90)	26 988 (49.10)	22 016 (48.90)	9964 (47.90)	26 980 (49.10)	22 016 (48.90)
Child’s birthweight in grams, median (IQR)	3395.46 (3082.22 – 3704.57)	3566.64 (3250.93 – 3911.58)	3575.59 (3264.75 – 3921.59)	3395.81 (3082.38 – 3704.60)	3566.68 (3250.91 – 3911.47)	3575.59 (3264.75 – 3921.58)
Types of childcare
Centre-based childcare, n (%)	5862 (28.20)	14 524 (26.40)	11 367 (25.20)	5868 (28.20)	14 515 (26.40)	11 367 (25.20)
Other nonparental childcare, n (%)	11 070 (53.20)	28 051 (51.00)	23 493 (52.20)	11 072 (53.20)	28 041 (51.00)	23 493 (52.20)
None, n (%)	3865 (18.60)	12 389 (22.50)	10 165 (22.60)	3866 (18.60)	12 378 (22.50)	10 167 (22.60)
Internalising symptoms percentile score, median (IQR)	46.51 (17.92 – 73.06)	46.03 (5.19 – 65.20)	43.50 (23.85 – 71.43)	-	-	-
Externalising symptoms percentile score, median (IQR)	-	-	-	43.87 (20.52 – 71.47)	43.33 (15.41 – 70.69)	39.84 (20.39 – 68.85)

No competing interests reported.

SupplementaryInformation.docx

Non-parental childcare attendance prior to school entry and children’s internalising and externalising symptoms: an individual participant data meta-analysis of six child cohort studies (EU Child Cohort Network)

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Abstract

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Introduction

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Conclusion

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