Early Childhood Research Quarterly 42 (2018) 93–104

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Early Childhood Research Quarterly

journal homepage: www.elsevier.com/locate/ecresq

Video-feedback intervention in center-based child care: A randomized MARK

controlled trial
⁎
Claudia D. Werner , Harriet J. Vermeer, Mariëlle Linting, Marinus H. Van IJzendoorn
Leiden University, Centre for Child and Family Studies, The Netherlands

A R T I C L E I N F O A B S T R A C T

Keywords: In the current study we aimed to improve center-based child care quality with an attachment-based program:
Center-based child care The Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline for Child Care (VIPP-
Attachment-based intervention CC). Professional caregivers (N = 64) from child care centers in urban areas in the Netherlands participated in
Professional caregiver training our pretest-posttest randomized controlled trial. The VIPP-CC was effective for increased observed sensitive
Randomized controlled trial
responsiveness in the group setting of the professional caregiver and led to a more positive attitude towards
caregiving and limit setting. Post hoc analyses revealed that the intervention effect was apparent for caregiver
sensitive responsiveness in structured play situations. The VIPP approach can now be expanded from the family
setting to out-of–home group settings with larger groups of children and professional caregivers. This is a
promising conclusion for millions of children enrolled in center child care from a very young age.

1. Introduction full-time attendance in child care is very common (Organization for

Center-based child care is an important support system for parents
of young children. Quality of center child care has been subject of he-
ated debates, and most of the research efforts have concentrated on
trying to describe the consequences of center care on the development
of children (Love et al., 2003; Lowe Vandell, Belsky, Burchinal,
Steinberg, & Vandergrift, 2010; Sylva, Melhuish, Sammons, Siraj-
Blatchford, & Taggart, 2011; Votruba-Drzal, Levine Coley, Maldonado-
Carreno, Li-Grining, & Chase-Lansdale, 2010). Much less research has
been devoted to the improvement of quality of center care although the
need for careful experimental work showing how to enhance child care
quality has been emphasized by parents, professionals, and policy
makers (Besharov & Morrow, 2006; Janus & Brinkman, 2010).
On average, across 40 OECD countries, one third of all children
under the age of three attended professional child care in 2010. For
instance, in the Netherlands, 60% of the children under three years of
age were in formal child care, whereas this percentage was 43% in the
US (Organization for Economic Co-operation and Development, 2013).
Because the intensity of child care use varies considerably across
countries, these participation rates may decrease after adjusting for
intensity of use. In the Netherlands, the average number of child care
use is 17 h per week (Central Bureau for Statistics, 2016), which leads
to a fulltime equivalent enrollment rate of 37%. In the US full-time
equivalent rates are comparable to participation rates (43%), because
Economic Co-operation and Development, 2013). These estimates in-
clude all types of professional child care: center-based care, home-based
care or family-based care, and preschools. In the Netherlands regulation
of child care is provided by the government, requiring minimal edu-
cational levels for professional caregivers and minimum staff-child ra-
tios, dependent on the type of care and the age of the children.
Center-based care refers to care provided in a center with large
groups of children and more than one caregiver present. Home-based
care, or family-based care, is usually provided in the caregiver’s home
with fewer children present (a maximum of six) and one caregiver.
Preschools, or playgroups, in the Dutch context are intended for chil-
dren from 2 to 4 years of age; children often spend a few mornings a
week in these settings. Center-based care and home-based care can
provide fulltime day care for children under four years of age although
most children attend these types of care part time (Central Bureau for
Statistics, 2016). In the Netherlands, center-based care is the most
common type of care in this age group. Seventy-one percent of all
children in child care attended center-based child care in the Nether-
lands in 2015 (Central Bureau for Statistics, 2016). Professional care-
givers in both center-based care and home-based care are legally bound
to formal training. Also in other countries center-based care is the most
common type of non-parental care for children in the age range of 0–3
years (Organization for Economic Co-operation and Development,
2013), which points out the possible impact of improving the quality of

⁎
Corresponding author at: Leiden University, Centre for Child and Family Studies, P.O. Box 9555, 2300 RB Leiden, The Netherlands.
E-mail addresses: wernercd@fsw.leidenuniv.nl (C.D. Werner), vermeer@fsw.leidenuniv.nl (H.J. Vermeer), linting@fsw.leidenuniv.nl (M. Linting),
vanijzen@fsw.leidenuniv.nl (M.H. Van IJzendoorn).

http://dx.doi.org/10.1016/j.ecresq.2017.07.005
Received 1 November 2016; Received in revised form 16 March 2017; Accepted 28 July 2017
0885-2006/ © 2017 Published by Elsevier Inc.
C.D. Werner et al.
center-based child care.
In the present study we report one of the few randomized control
trials aimed at enhancing quality of center child care for children aged
0–4 years. A video-feedback intervention to promote positive car-
egiving with an emphasis on sensitive discipline is adapted to center
child care and we test the effects on professional caregiver sensitivity,
professional caregiver attitudes and general child care quality.
1.1. Quality of child care
Scientists, policy makers and parents agree that high quality child
care can be achieved through four fundamental goals: (1) providing
children with a sense of emotional security, (2) enhancing their per-
sonal competence, (3) enhancing their social competence, and (4) sti-
mulating their socialization process (Riksen-Walraven, 2004). The ex-
tent to which a child care center succeeds in reaching these goals
determines the quality of care. Quality of child care can be defined in
terms of distal factors and proximal factors, which contribute to
achieving these four main goals. Distal factors are the more ‘structural’
aspects of the child care setting, such as the use of space in the room
and furniture, play materials, professional caregiver education level,
and group size (Howes, Philips, & Whitebook, 1992). However, the
most important aspects of child care quality are formed by proximal
factors or process quality: caregiver-child interactions, peer interac-
tions, and the interaction of the child with the physical environment
(Howes et al., 1992; Riksen-Walraven, 2004). Process quality is as-
sessed primarily through observation and may be affected by structural
aspects: for instance more professional caregiver training and lower
staff turnover rates are related to higher quality caregiver-child inter-
actions (De Schipper, Tavecchio, Van IJzendoorn, & Linting, 2003;
Gerber, Whitebook, & Weinstein, 2007). However, structural aspects
are more ‘fixed’ because of government legislation and therefore less
easily changed. In the current study, general child care quality refers to
the experiences of children within the child care environment including
their interactions with others, materials, and activities. Features of the
physical environment (personal care, space, furniture, and physical
safety) are also part of general child care quality.
In the Netherlands, repeated quality assessments in nationally re-
presentative samples of child care centers using the Early Childhood
Environment Rating Scale-Revised (ECERS-R; Harms, Clifford & Crier,
1998) and the Infant/Toddler Environment Rating Scale-Revised
(ITERS-R; Harms et al., 1998) have shown a decrease in child care
quality during the last two decades (Helmerhorst, Riksen-Walraven,
Gevers Deynoot-Schaub, Tavecchio, & Fukkink, 2015; Vermeer et al.,
2008). Mean quality levels were reported around 3 on a 7-point scale,
representing minimum standards. This is even lower than the world-
wide mean: In a recent meta-analysis (Vermeer, Van IJzendoorn,
Cárcamo, & Harrison, 2016) that combined data from 23 countries an
average score of nearly 4 was reported.
In the intervention that is part of our investigation, we focus on
improving the core element of process quality in child care settings,
that is, caregiver sensitivity.
1.2. Importance of caregiver sensitivity
For optimal social-emotional and cognitive development children
need stable attachment figures that are available and responsive to
them when they are distressed or anxious (Bowlby, 1969). Given the
fact that many young children across western countries attend formal
child care, this need extends to child care settings. A sensitive profes-
sional caregiver in the child care setting, who responds promptly and
adequately to the child’s signals and provides comfort and security
(Ainsworth, Bell, & Stayton, 1974) may fulfill the crucial role of sec-
ondary attachment figure (Ahnert, Pinquart, & Lamb, 2006;
Barnas & Cummings, 1994; Badanes, Dmitrieva, & Watamura, 2012; De
Schipper, Tavecchio, & Van IJzendoorn, 2008; Goossens & Van
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Early Childhood Research Quarterly 42 (2018) 93–104
IJzendoorn, 1990; Howes & Spieker, 2008; Vermeer & Bakermans-
Kranenburg, 2008). The quality of attachment relationships between
children and their professional caregivers can be predicted by caregiver
sensitivity and frequency of interactions (De Schipper et al., 2008).
Ahnert et al. (2006) suggested in their meta-analysis that ‘group sen-
sitivity’, directed at the group of children, but not caregiver sensitivity
directed at the individual child, is predictive of the child’s attachment
security towards the professional caregiver.
Thus, an intervention program involving professional caregiver
training may be effective in improving caregiver sensitivity, and, to a
lesser extent, general child care quality. Only few of the many inter-
vention programs in child care targeting caregiver-child interactions
through caregiver training have been tested in randomized controlled
trials (Besharov & Morrow, 2006; Werner, Linting, Vermeer, & Van
IJzendoorn, 2016). The focus of interventions is often school readiness
or child behavior, but not the caregiver-child (attachment) relationship.
In the current study, we tested the effectiveness of an attachment-based
intervention that was originally developed for parents.
1.3. Aims and contents of the current intervention
There is a need for more experimental studies on the effectiveness of
intervention programs focused on the professional caregiver-child re-
lationship in center child care, internationally as well as in the
Netherlands (Werner et al., 2016). Therefore, we designed a rando-
mized controlled trial to test an attachment-based program that has
evidence to support effectiveness in various family settings and in
home-based child care (Juffer, Bakermans-Kranenburg, & Van
IJzendoorn, 2014). The Video-feedback Intervention to promote Posi-
tive Parenting and Sensitive Discipline (VIPP-SD, Juffer, Bakermans-
Kranenburg, & Van IJzendoorn, 2008a) was designed to be used in fa-
milies with children in the preschool age and can be used for children
zero to six years old. The program aims to improve the parent-child
relationship and by providing personal video-feedback on sensitive
responsiveness in daily situations as well as the use of sensitive dis-
cipline in challenging caregiver-child interactions. The program ela-
borates on four themes regarding sensitivity: (1) recognizing the child’s
exploration versus attachment behavior, (2) recognizing the child’s
signals, which is accomplished by taking the child’s perspective through
the technique ‘speaking for the child’, (3) explaining the relevance of
prompt and adequate response to the child’s signals, and (4) sharing
emotions. In addition, four themes of sensitive disciplining are ad-
dressed: (1) using inductive discipline and distraction methods, (2)
using positive reinforcement, (3) giving sensitive time-outs, and (4)
showing empathy towards the child in disciplining situations. Starting
point are the actual behaviors of the child and parent on the videotape.
By watching child behavior together with the parent the video-feedback
intervention provides opportunities to practice observational skills and
to reinforce sensitive behaviors (for more information, see Juffer et al.,
2008a). The program consists of six biweekly visits of approximately
1.5 h that are carried out according to an elaborate protocol. The last
two visits, so-called ‘booster sessions’ are used to repeat the themes of
all previous sessions.
1.4. VIPP-SD: evidence base
The VIPP-SD was tested in several randomized trials in different po-
pulations. Maternal sensitivity improved as a result of the intervention for
mothers with insecure attachment representations (Klein Velderman,
Bakermans-Kranenburg, Juffer, & Van IJzendoorn, 2006), insensitive mo-
thers (Kalinauskiene et al., 2009), mothers of adopted children (Juffer,
Bakermans-Kranenburg, & Van IJzendoorn, 2005; Juffer, Bakermans-
Kranenburg, & Van IJzendoorn, 2008b), mothers with children high in
externalizing behavior problems (Mesman et al., 2008; Van Zeijl et al.,
2006), mothers with eating disorders (Stein et al., 2006; Woolley,
Hertzmann, & Stein, 2008), and mothers of low SES at risk for maltreating
C.D. Werner et al. Early Childhood Research Quarterly 42 (2018) 93–104

their children (Negrão, Pereira, Mesman, & Soares, 2014). Moreover, a

recent randomized control trial showed that the VIPP-SD for Child Care
(VIPP-CC), a variant of the VIPP-SD for group child care, was also found to
be effective for professional caregivers in home-based child care
(Groeneveld, Vermeer, Van IJzendoorn, & Linting, 2011), where one pro-
fessional caregiver takes care of a small group of children, generally up to
seven, in her own home. As a result of the intervention, general caregiving
quality improved and caregivers had more positive attitudes toward sen-
sitive caregiving and limit setting (Groeneveld et al., 2011).
These findings support the hypothesis that this intervention method
could also be suitable for use in center child care. Given the need for
quality improvement (Burchinal, Cryer, Clifford, & Howes, 2002) and
the emphasis on the caregiver-child attachment relationship in center-
based care, we applied the VIPP-CC to center-based child care. How-
ever, as home-based care and center-based care are quite different from
one another in terms of group sizes, routines and physical environment,
we cannot generalize the findings by Groeneveld et al. (2011) to center
child care. Therefore a randomized controlled trial to evaluate the ef-
fectiveness of the VIPP-CC in center child care is needed. The current
randomized controlled trial aims to investigate whether the VIPP-CC is
effective in enhancing professional caregiver sensitive responsiveness,
improving general child care quality and increasing professional care-
giver’s attitudes towards sensitive caregiving and limit setting in center-
based care. Drawing on results in families and home-based child care,
we hypothesize that the VIPP-CC in center-based care will be effective
not only with respect to (attitudes towards) sensitive caregiving, but Fig. 1. Flow chart of recruitment (I = intervention group, C = control group).
also with respect to general child care quality.

criteria was randomly selected.

2. Method
Selection of children for participating in the intervention or dummy
intervention was based on parental consent and their attendance on the
2.1. Recruitment and randomization
day scheduled for the intervention. If more than four children with
consent were present at the day of the intervention in one classroom,
Participants in this study were professional caregivers in child care
selection was done randomly. There was a minimum of three and a
centers. For recruitment we targeted child care centers in the western
maximum of four children per classroom for each session of the inter-
part of the Netherlands. Because it has been reported that the im-
vention. An overview of recruitment and participants is shown in Fig. 1.
provement of child care quality may be especially beneficial for chil-
Randomization was performed hierarchically: Centers were first
dren from low-income or at-risk environments (e.g. Clarke-Stewart,
randomly assigned to either the intervention condition or the control
Vandell, Burchinal, O’Brien, & McCartney, 2002) we made special ef-
condition. Next, within each center, one classroom was randomly se-
forts to include child care centers in less privileged areas. These areas
lected to participate, and third, within each classroom, one professional
were selected as identified by the Dutch government in 2007 based on
caregiver was randomly selected. From the 91 centers that initially
demographic information considering SES, social cohesion, school
agreed to participate by letter or by phone, 66 actually started with the
dropouts, housing problems, and problems in the public domain such as
pretest assessment. The other 25 centers showed non-response (27%),
criminal activities and safety (Government of the Netherlands, 2007).
rather than dropping out after assessment. The non-response centers did
Letters of invitation were sent to 180 organizations that included a
not differ significantly from participating centers in terms of demo-
wide range of centers. Managers were informed that the aim of the
graphic region, neighborhood or center size. The most common reason
study was to compare the effectiveness of two types of training: Video-
for centers not to take part in our study was the lack of parental consent
feedback training and “coaching by telephone”. In our design, the latter
for at least three children in the group who attended the child care
was used as a placebo intervention for the professional caregivers in the
center on the same day (n = 13 centers). Other reasons for not parti-
control group. Toddler classrooms (for children 2–4 years) and mixed
cipating were a lack of interest from the managers (n = 3) or unwill-
age classrooms (for children 0–4 years) were eligible for participation.
ingness of professional caregivers to participate (n = 6). From the 69
Because the instrument to assess general quality of the centers is aimed
centers that agreed to take part, three centers withdrew from the study
at children 2.5–5 years old, the following inclusion criterion was set for
directly after the first assessment; the managers did not allow us to use
the mixed-aged groups: at least 50% of the children within the class-
the observational data in our study. From the 66 centers that completed
room were to be older than 2.5 years.
pretest, two centers did not complete the posttest. Finally, 64 profes-
All parents from children in eligible classrooms received consent
sional caregivers completed both pretest and posttest (34 in the inter-
forms and no exclusion criteria were established for the children.
vention group and 30 in the control group) and are included in this
Participation of at least three children per classroom was needed in
study. Given the variety of participating organizations and spread in
order to carry out the videotaped observation and the intervention.
demographic region our sample reflected the composition of Dutch
Therefore, classrooms were eligible for participation if parents of at
child care centers in the western part of the Netherlands, which is the
least three children attending the classroom on the same day of the
most densely populated.
week provided written consent for videotaping. One classroom per
center was randomly selected for participation. Professional caregivers
from eligible classrooms had to be working for a minimum of two days 2.2. Participants
(16 h) per week in a fixed classroom, and be available and willing to
participate during the study period of approximately six months. From The intervention group and control group were compared on
each classroom one professional caregiver who met these inclusion background characteristics regarding centers, classrooms, and

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C.D. Werner et al. Early Childhood Research Quarterly 42 (2018) 93–104

professional caregivers. child care quality. In addition, professional caregiver behavior was vi-
In total, 27% of the centers (n = 17) were located in less privileged deotaped for ten minutes with a digital video camera at three pre-
areas. Percentages did not differ significantly between the intervention determined time points during regular activities at 9.30 A.M.,
group (21%, n = 7) and control group (33%, n = 10) (Χ2 (1) = 1.33, 10.30 A.M. and 11.30 A.M. Regular activities included snack time,
p = .25). No significant differences were found between the interven- diaper change, free play, lunch, or group activity initiated by the
tion group and control group for years of existence (intervention group caregiver such as crafts or dancing. The professional caregivers re-
M = 15.77, SD = 8.43; control group M = 10.52, SD = 10.76, ported that the types of regular activities during pretest were re-
p = .05) number of classrooms per center (intervention group presentative for a typical day at the child care center. Using Pearson Chi
M = 3.80 SD = 1.60; control group M = 3.42, SD = 1.25, p = .34), Square tests, no significant differences were found between the inter-
and the number of children in the center (intervention group vention group and control group with regard to types of activities
M = 66.92, SD = 37.63; control group M = 61.38, SD = 29.56, during the three time points at pretest. With regard to the first time
p = .57). Regarding age range of the children, 43 toddler classrooms point most caregivers were observed during snack time, free play,
and 18 mixed age classrooms participated. For three classrooms the age group activities, or diaper change. With regard to the second time point
range was not reported. The distribution of the age groups was not most caregivers were observed during free play or group activities.
significantly different for the intervention group (24 toddler class- With regard to the third time point caregivers were mostly involved in
rooms, 8 mixed age classrooms) and the control group (19 toddler having lunch with the children at the table.
classrooms and 10 mixed age classrooms) (Χ2 (2) = 2.30, p = .32). The first session of the placebo or intervention was held within three
No significant group differences were found for number of children weeks after the pretest. After the pretest, questionnaires were sent to the
in the classroom at pretest or posttest. On average, ten children were caregivers and the center managers. Center managers were asked to pro-
present during the pretest (intervention group M = 10.12, SD = 2.95; vide background information with respect to the child care centers’ years
control group M = 10.28, SD = 2.37, p = .82) and the posttest (in- of existence, number of classrooms per center, and the number of children
tervention group M = 9.52, SD = 4.00; control group M = 9.90, in the center. In a background questionnaire for the caregivers, informa-
SD = 2.67, p = .66). tion was gathered on their age, level of education, birth country, years of
For professional caregiver characteristics, no significant differences working experience in child care, and working hours per week.
were found between the intervention group and control group on age,
years of experience in child care, years of working in the particular 2.3.2. Posttest
classroom, number of working hours, level of education and nationality Posttests took place 2–4 weeks after the last session of the placebo or
(see Table 1). The majority of professional caregivers were Dutch (93% intervention. Procedures for posttest assessments were similar to those of
in the intervention group and 84% in the control group; Χ2 (5) = 6.38, the pretests, including the administration of the shortened ECERS-R and
p = .27) and born in the Netherlands (in the intervention group 89% the videotaped observation of regular activities. The professional care-
and in the control group 79%; Χ2 (4) = 8.93, p = .06). givers reported that the types of regular activities during posttest were
Independent samples t tests showed that there were no significant representative for a typical day at the child care center. Using Pearson Chi
differences between the group that did not complete posttest assess- Square tests, no significant differences were found between the interven-
ments (N = 5) and the complete group (N = 64) on the pretest scores tion group and control group with regard to types of activities during the
for ECERS-R (incomplete group M = 3.92; complete group M = 3.94, three time points at posttest. With regard to the first time point most
p = .97) or the caregiver sensitivity pretest scores (incomplete group caregivers were observed during snack time, free play, group activities, or
M = 4.78; complete group M = 4.77, p = .99). diaper change. With regard to the second time point most caregivers were
observed during free play. With regard to the third time point caregivers
were mostly involved in having lunch with the children at the table or
2.3. Procedure play. In addition, three structured play tasks of the caregiver with four
children were videotaped, that is, storybook reading, putting together a
2.3.1. Pretest jigsaw puzzle and tidying up the jigsaw pieces.
All professional caregivers were visited for a pretest assessment After the posttest, caregivers filled out a questionnaire on their attitude
from 9:00 A.M. until 1:00 P.M. During the pretest, a shortened version towards caregiving and they completed evaluation forms. The duration of
of the Early Childhood Environment Rating Scale-Revised (ECERS-R; the project from pretest to posttest was approximately six months. All
Harms et al., 1998; Vermeer, 2012) was administered to assess general videotaped episodes (regular activities and structured play tasks) were
rated afterwards on caregiver sensitive responsiveness by coders who were
Table 1 blind to condition of the classroom (intervention or control group) for
Characteristics of the Professional Caregivers. pretest and posttest. See Fig. 2 for an overview of the procedure.
Intervention (N = 29) Control (N = 24) p-value
2.4. Intervention
M SD M SD
2.4.1. Adaptations to center-based care
Caregiver age (years) 32.45 8.87 31.42 8.68 .67
The VIPP-SD (Juffer et al., 2008) was adapted for use in home-based
Experience in child 8.71 6.17 6.66 7.67 .28
care (years) child care in a previous study, resulting in the VIPP-SD for Child Care or
Experience on group 3.76 3.37 3.66 6.31 .94 VIPP-CC (Groeneveld et al., 2011). A main issue in adapting the family
(years) intervention to the child care setting (for home-based and center-based
Working hours per 30.50 6.33 29.15 4.96 .40 care) was the focus on several children at the same time in a group
week
Highest level of .49a
setting; how to divide attention adequately among the children and
education respond to them in a developmentally appropriate way. Perspective
high school (%) 3% 12% taking was modified so that speaking for the child became speaking for
vocational training 83% 76% the children. Especially in mixed age classrooms this is an important
(%)
topic, given the varying developmental levels. Another important dif-
bachelor or master 14% 12%
degree (%) ference is the nature of the relationship of the professional caregiver
with the children, and accordingly, the relationship of the professional
Note: a
Pearson Chi square test: Χ2 (2) = 1.44, p = .49. caregiver with the intervener. In the Netherlands, caregivers in child

96
C.D. Werner et al.
Fig. 2. Overview of the procedure and measured variables.
care are professionals who have completed a 4-years intermediate vo-
cational degree in Early Childhood Education. Therefore, during the
intervention, comments and themes for discussion were also related to
general child developmental themes on a more professional level than
in the original VIPP-SD, which was developed for parents. For instance,
when discussing how to manage difficult behavior of children in a
positive way by using techniques such as distraction, showing empathy,
induction and rewarding positive behavior, we mentioned that these
themes may be familiar to the professional caregiver from what was
taught during her formal training and asked her about it. It was then
explained that it would be interesting for the professional caregiver to
watch herself using these techniques with this particular group of
children on the video. The professional caregiver is viewed and referred
to as the expert on this particular group of children. Moreover, no
‘secondary’ professional caregiver was invited during the booster ses-
sions, which is common for the use of VIPP-SD in families. In the cur-
rent study, we used the manual for the VIPP-CC in home-based care
(Groeneveld et al., 2011) as a basis.
Finally, some minor adaptations – based on a pilot study in two
centers – were made from the home-based day care version to a center-
based version of the VIPP-CC in play material and tasks. First, the ti-
dying-up task used in home-based care proved too easy as a discipline
task for children in center-based care, and was therefore replaced by an
adaptation of the ‘Do not touch’- task from the original VIPP-SD. A
transparent open box with attractive toys is placed in front of the
children. The professional caregiver is instructed to have the children
sit and wait for four minutes without touching the toys. In addition,
instead of a TV screen and DVD player, we used laptops for viewing the
video clips with the professional caregivers, because in the majority of
child care centers TV equipment is not available. The outline and
themes of the intervention were unchanged (for an overview see
Appendix A).
2.4.2. Procedure
The intervention program encompasses six intervention visits of
approximately 1.5 h that are scheduled two to four weeks apart. During
the very first visit (visit zero), the first three videotapes are made of the
professional caregiver with a group of four children in the classroom.
Each subsequent visit (visit 1–6) starts with making new videotapes of
the caregiver in the classroom in three or four semi-structured five-
minute play tasks with a group of four children. Afterwards, the 15–20-
min video-taped observations of the previous visit are reviewed and
discussed for approximately one hour according to the theme of that
visit (see Appendix A). Generally, the video-feedback hour is planned
directly after the videotaping or during lunch break of the professional
caregivers. The play tasks are protocol-led for each visit and the
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Early Childhood Research Quarterly 42 (2018) 93–104
materials are brought along by the intervener. Examples of the play
tasks are story book reading, playing with Lego, playing with hand
puppets, singing songs together and building a tower of blocks. Play
tasks especially designed for the discipline themes are, for example,
letting the children take turns during play and letting them wait before
they can play with new toys. During the third visit a mealtime is dis-
cussed.
In between two visits, the video-taped sessions are reviewed by the
intervener and prepared for the next intervention session, using micro-
analysis. That is, the intervener writes comments in the form of a
“script” on the observed behavior of the caregiver and the children for
every 10–30 s per video clip. These comments are directed by guide-
lines in the intervention manual and the general theme of the next visit.
Video clips are not edited or cut. Positive and successful interaction
moments are emphasized, to reinforce positive behavior of the profes-
sional caregiver. General themes of child development and daily rou-
tines in the classroom are discussed as well.
2.4.3. Program fidelity
Interveners were the first author and four MA students in child
development who were trained as VIPP-SD interveners by experts at
Leiden University. The training consisted of five days (40 h) of group
lectures, discussions and practice with micro-analyzing video clips. In
addition, the interveners practiced the original intervention in a family
setting with expert feedback. Next, they practiced the adapted VIPP-CC
for use in a child care center. Weekly three hours supervision meetings
were held with the first and third authors of this paper, who are both
certified VIPP-SD interveners with experience in applying the inter-
vention. Program fidelity during the research project was assured by
two hour supervision meetings every three weeks. In addition, prepared
“scripts” were reviewed and discussed by supervisors and co-inter-
veners through email. Finally, interveners videotaped themselves
during each third feedback session with the professional caregivers.
These videos were viewed and discussed during supervision meetings.
All participating caregivers in the intervention group completed the full
VIPP program of six intervention visits. As a reward for their taking part
in the project, the professional caregivers in the intervention group
received a storybook for use in their child care group, given by research
assistants directly after posttest assessment. No other incentives were
given.
2.4.4. Control group
The placebo intervention for the control group consisted of six bi-
weekly protocol-led telephone calls of approximately 15 min, and was
provided by three MA students and the first author. During the tele-
phone calls, professional caregivers were interviewed about general
developmental issues of four target children in their classroom, con-
cerning playing, eating and sleeping habits at the center. After the
fourth interview, professional caregivers were sent a brochure about
play material for children 0–4 years old. Although the placebo inter-
vention was labeled “coaching by telephone”, the researchers were
instructed never to give any actual advice to the professional caregivers
and to only engage in listening to the caregiver talking about the
children. The researchers carrying out the placebo intervention at-
tended a two hours instruction meeting to get familiar with the protocol
prior to the study. To assure program fidelity, they were instructed to
make notes during the interviews with the professional caregivers re-
garding the contents of the interviews, which were checked by the first
author on a regular basis. During the research project, bimonthly one-
hour supervision meetings were held to discuss issues concerning con-
tact with caregivers or with the use of the manual. All participating
caregivers in the control group completed the placebo of six phone
calls. As a reward for their taking part in the project, the professional
caregivers in the control group received a storybook for use in their
child care group, given by research assistants directly after posttest
assessment. Approximately three months after completion of the study
C.D. Werner et al.
professional caregivers in the control group were invited to attend a
free, full-day workshop on the research project and key elements of the
VIPP-CC.
2.5. Measures
2.5.1. Caregiver sensitive responsiveness
The scale to code caregiver sensitive responsiveness is part of the
Caregiver Interaction Profile scales (CIP; Helmerhorst, Riksen-
Walraven, Vermeer, Fukkink, & Tavecchio, 2014) that were developed
and validated by the Dutch Consortium for Child Care Research (De
Kruif et al., 2007; NCKO, 2006). This is a group rating scale based on
scales developed to measure sensitivity in the parent-child context
(Ainsworth, Bell, & Stayton, 1974; Erickson, Sroufe, & Egeland, 1985).
Caregiver sensitive responsiveness refers to the degree to which the
caregiver provides adequate and sufficient emotional support to all
children in her care who need it, during stressful and non-stressful si-
tuations. It also refers to the level to which a professional caregiver is
able to adequately divide attention among the children, showing in-
terest in the children’s activities and acknowledging their needs, emo-
tions and competences. Sensitive responsiveness ratings are presented
on a seven-point scale, ranging from 1 (very low) to 7 (very high). A
professional caregiver scoring high on the scale is very much involved
with the children, and responds promptly and adequately to the signals
of all children in her care, by taking the children’s perspective. A
caregiver scoring low on this scale may show either emotional distance
or indifference towards the children, or she may be uninvolved with the
children, because of administrative or cleaning tasks and therefore she
may miss signals of the children.
Caregiver sensitive responsiveness was coded for nine videotaped
episodes: Three ten-minute episodes in naturalistic situations (‘un-
structured’) during predetermined time points at pretest and posttest,
and three five-minute play tasks (‘structured’) during posttest.
Caregivers received one score for each 10-min episode. For the struc-
tured play tasks the professional caregiver was asked to sit with a small
group of four children from her classroom and (1) read a storybook, (2)
let the children put together a jigsaw puzzle, and (3) let the children
tidy up the jigsaw puzzle.
For pretest, an average score was computed across the three un-
structured episodes, Cronbach’s alpha = .67. Regarding posttest, in-
ternal consistency for the three unstructured episodes was Cronbach’s
alpha = .72 and for the structured episodes Cronbach’s alpha = .74. A
combined score for posttest sensitive responsiveness was computed,
averaging the scores for unstructured and structured situations. For the
computation of this combined score at least one structured episode and
one unstructured episode was required. Internal consistency of the
combined measure was Cronbach’s alpha = .69.
Three independent observers were trained to be reliable coders,
using the official NCKO dataset. Intra class correlation for the coders
was .75 (absolute agreement). To obtain independency in ratings, re-
searchers who administered the ECERS-R did not code video material
from that particular setting. In addition, caregiver sensitive respon-
siveness was coded by different researchers for pretest and posttest si-
tuations and coders were blind to the condition of the classroom (in-
tervention or control group).
2.5.2. General child care quality
To assess general child care quality a shortened version of the
ECERS-R (Harms, Clifford, & Cryer, 1998; Vermeer, 2012) was ad-
ministered in all participating classrooms at pretest and posttest. The
ECERS-R is one of the most widely used instruments to measure child
care quality. Although it was developed to evaluate process quality in
early child care settings, the instrument has often been criticized in
relation to a perceived omission of process items and/or indicators.
Several studies (e.g., Cassidy, Hestenes, Hegde, Hestenes, & Mims,
2005) have shown that the ECERS-R includes elements of both process
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Early Childhood Research Quarterly 42 (2018) 93–104
quality and structural quality, which are intertwined within the items
and indicators. Thus, the ECERS-R does not allow a disentanglement of
process quality and structural quality. In the current study, we refer to
the ECERS-R as a measure of general child care quality.
Training and administration of the full ECERS-R is time consuming;
therefore in the current study a shortened version with 18 items was
used, which showed good psychometric properties (Vermeer, 2012). To
constitute this shortened version of the ECERS-R, Vermeer (2012) se-
lected various sets of items on the basis of a merged dataset with
ECERS-R data from 103 centers from three previous studies. This pro-
cedure was comparable to the procedure described by Perlman,
Zellman, and Le (2004). These sets of items were compared on internal
consistency and correlation with the original ECERS-R. The set of 18
easy-to-administer observational items was used in the current study,
because of the high correlation with ECERS-R total score (r = 0.94) and
good internal consistency (Cronbach’s alpha = 0.78). The following
scales were included: Space and Furnishings (3 items), Personal Care
Routines (2 items), Language-Reasoning (2 items), Activities (5 items),
Interaction (4 items), Program Structure (2 items). Items from the
subscale Parents and Staff were not included in the shortened ECERS-R,
because the items from this subscale do not reflect the children’s ev-
eryday experiences, that is, process quality. The ECERS-R item scores
are presented on a seven-point scale, and the final score for general
child care quality is computed as the average of 18 items, ranging from
1 (inadequate quality) to 7 (excellent quality). More detailed information
about the items can be found in Appendix B.
Internal consistency of the shortened ECERS-R in the current study was
adequate, with Cronbach’s alpha of .85 at pretest and .81 at posttest. Seven
observers (six BA students and one MA student) were trained by the
second author to be reliable on the shortened ECERS-R. The training in-
cluded reviewing and discussing the items and field observations. Inter
rater reliability was established to a criterion of 80% agreement within
one rating point for three consecutive observations for all observers. The
mean percentage of agreement for these three observations was 90%
(range 87% to 92%). Mean intra-class correlation (two-way mixed, abso-
lute agreement) was .84 (range .81–.92). To guarantee the independence
of ratings, observers administered the ECERS-R in one classroom only once
(either pretest or posttest) and coders were blind to the condition of the
group (intervention or control).
2.5.3. Caregiver-child ratios and group size
During pretest and posttest, numbers of children and professional
caregivers present were registered by the observers. The caregiver-child
ratio was calculated as the number of children divided by the number of
qualified caregivers in the room. In some child care centers, caregivers-
in-training or group assistants are present. As a result, the number of
children in the group and the caregiver-child ratio do not always re-
present the crowded nature of the child care setting. We wanted to
address this concept of crowding. Therefore, in our study, group size
refers to the total number of people in the room, both children and
caregivers. In the Netherlands, group size and caregiver-child ratio for
child care classrooms are legislated. Child care classrooms may range
from 9 to 16 children with 2–4 professional caregivers, dependent on
the age of the children. Group size and number of children in the group
were highly correlated in our study (for the intervention group bi-
variate correlations were 0.98 and 0.84 for pretest and posttest re-
spectively; for the control group correlations were 0.88 and 0.95 for
posttest respectively), therefore we chose to include group size in our
analyses. The numbers did not significantly differ between the inter-
vention group and control group.
2.5.4. Attitude towards caregiving
Immediately after the posttest, professional caregivers were handed
a questionnaire regarding their attitude towards sensitive caregiving
and limit setting (Bakermans-Kranenburg & Van IJzendoorn, 2003).
Caregivers were asked to indicate their opinion on 15 items in a 5-point
C.D. Werner et al. Early Childhood Research Quarterly 42 (2018) 93–104

Table 2
Pearson Correlations Between the Main Variables.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

1. Group conditiona 1.00

2. Group size pretest −0.01 1.00
3. Group size posttest −.06 .66** 1.00
4. Child/caregiver-ratio pretest −.15 .30* .19 1.00
5. Child/caregiver-ratio posttest −.23 .43** .52** .29* 1.00
6. General quality pretest −.13 −.18 −.11 −.05 −.14 1.00
7. General quality posttest −.16 .02 −.02 .20 .04 .21 1.00
8. Cg. yrs. experience child care .01 −.20 .02 .02 .06 .20 .07 1.00
9. Cg. yrs. experience on group .15 −.24 −.10 −.19 .01 .28* .15 .69** 1.00
10. Cg. work hours per week .12 −.09 −.04 −.20 −.11 - .37* −.25 −.17 −.06 1.00
11. Cg. Sens. resp. (U) pretest −.26* .05 .20 .30* .05 .45** .20 .02 −.07 −.29* 1.00
12. Cg. Sens. resp. (U) posttest −.12 −.14 −.08 .15 .13 .18 .06 .03 −.05 −.06 .30* 1.00
13. Cg. Sens. resp. (S) posttest .07 .15 .05 .20 −.07 .14 .22 −.07 −.12 −.03 .20 .20 1.00
14. Cg. Sens. resp. (C) posttest .01 .03 −.04 .24 .05 .23 .18 −.01 −.08 −.07 .32* .76** .79** 1.00
15. Cg. Attitude .37* −.01 −.03 .18 −.09 .21 .18 .07 −.17 −.21 .18 .14 .10 .17 1.00

a
Note: *p < .05, **p < .01 Intervention group = 1, Control group = 0; Cg = caregiver; U = unstructured episodes; S = structured episodes; C = Combined episodes.

Likert format, ranging from 1 (strongly disagree) to 5 (strongly agree).
Examples of items are “Playing together with the children will prevent
difficult behavior” and “The children need to learn that I will get angry
when they do not listen to me” (reversed). Internal consistency was
adequate, with Cronbach’s alpha of .60.
2.5.5. Evaluation forms
To evaluate the research project and the intervention program, the
professional caregivers received an evaluation form. Caregivers were
asked to express on 5-point Likert scales how much they learned from
the training, and how informative and useful the training was to them
(ranging from 1 not at all to 5 very much). They were also asked whether
they would recommend the training to colleagues, to inexperienced and
experienced professional caregivers and to the standard vocational
curriculum for prospective professional caregivers (ranging from 1
certainly not to 5 certainly). Professional caregivers and center managers
were invited to provide comments on the research project and the
training.
2.6. Attrition and missing data
As presented in Fig. 1, attrition rates were low (7%, n = 5). From
the initial 69 professional caregivers who agreed to participate, three
professional caregivers did not continue to participate after the pretest
and two professional caregivers did not complete posttest measures.
Attrition rates were 6% for the intervention group (2 out of 36 pro-
fessional caregivers) and 9% for the control group (3 out of 33 pro-
fessional caregivers), resulting in differential attrition of 3%. In our
sample, 64 professional caregivers were included who completed
pretest, posttest and all sessions of the intervention or placebo sessions,
that is, the phone calls.
There were no missing data on the main outcome variables general
child care quality and sensitive responsiveness at pretest. Missing data
on sensitive responsiveness during posttest ranged from 6% in the in-
tervention group to 7% in the control group, resulting in 1% differential
attrition between groups. In two cases there was a clear reason for
missing data: One professional caregiver in the intervention group
could not be filmed during any of the unstructured episodes, because on
the day of observation she and the children went outside the whole
morning and it was not possible to videotape her with the children in
the public areas. One professional caregiver in the control group did not
find the time to carry out the structured play tasks. Background ques-
tionnaires on center information were missing for five centers in the
intervention group and for six centers in the control group (5% differ-
ential attrition between groups). Posttest caregiver questionnaires on
attitude and program evaluation were missing for 14 professional
caregivers in the intervention group and for 11 professional caregivers
in the control group (4% differential attrition between groups).
2.7. Statistical analysis
To investigate intervention effects on general child care quality and
caregiver sensitive responsiveness, repeated measures ANOVAs were
conducted to examine changes from pretest to posttest. Caregiver atti-
tude towards sensitive caregiving and limit setting, and program eva-
luations were measured during the posttest only. Therefore, in-
dependent samples t-tests were used to investigate differences between
the intervention and control group.
3. Results
3.1. Bivariate correlations and descriptive statistics
In Table 2 bivariate correlations between the main variables are
presented. General quality during pretest was significantly associated
with caregiver sensitive responsiveness during pretest, indicating that a
higher score on the ECERS-R was associated with a higher score on the
sensitivity scale. Furthermore, professional caregivers with more years
of experience on their group showed higher general quality during
pretest. Caregiver working hours were negatively associated to general
quality and sensitive responsiveness during pretest. Professional care-
givers who worked more hours per week had lower scores on general
quality and on sensitive responsiveness during pretest. Surprisingly, a
higher number of children per caregiver (caregiver-child ratio) was
associated with higher scores of sensitive responsiveness during pretest.
Descriptive statistics of the outcome variables are provided in Table 3.
3.2. Intervention effects
3.2.1. Caregiver sensitive responsiveness
At pretest there was a significant difference between the interven-
tion group and the control group for sensitive responsiveness (p = .04),
indicating that despite the randomization the control group scored
significantly higher. To investigate intervention effects, we conducted
three repeated measures ANOVAs for three different models.
In the first analysis we combined the unstructured and structured
episodes in the posttest, to test the overall effect of the VIPP-CC. The
repeated measures ANOVA of this model (Model 1) showed that there
was no significant main effect for time (Pillais F(1, 60) = 0.00, p = .96,
η2partial = .00) or group (Pillais F(1, 60) = 2.06, p = .16, η2partial = .03).
However, there was a significant interaction effect (Pillais F(1, 60)
= 4.72, p = .03, η2partial = .07), indicating that the change over time in

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C.D. Werner et al. Early Childhood Research Quarterly 42 (2018) 93–104

Table 3 Table 4
Descriptive Statistics for the Intervention Group and Control Group During Pretest and Caregiver Evaluations of the Training.
Posttest.
Intervention group Control group p d
Intervention group Control group N = 20 N = 18

N M SD N M SD M SD M SD

General quality pretest 34 3.85 .81 30 4.04 .76 The training was informative 3.89 .96 2.83 .79 .00a 1.21
General quality posttest 34 4.10 .71 30 4.33 .73 to me
Sensitive responsiveness U pretest 34 4.54 1.05 30 5.03 .76 The training was interesting to 3.95 .62 3.28 .90 .01 0.87
Sensitive responsiveness U posttest 32 4.58 .99 28 4.80 .82 me
Sensitive responsiveness S posttest 33 4.90 .90 29 4.79 .85 The training was useful to me 3.88 .70 3.27 .88 .04 0.77
Sensitive responsiveness C posttest 32 4.78 .73 30 4.76 .68 I would recommend training to 4.70 .73 3.64 1.32 .00b 0.99
starting caregivers
Note: U = unstructured episodes; S = structured episodes; C = combination of struc- I would recommend training to 3.21 1.69 3.00 1.37 .69 0.14
tured and unstructured episodes, at least one episode of each type. experienced caregivers
I would recommend training to 3.63 1.46 3.31 1.30 .50 0.23
colleagues
caregiver sensitive responsiveness was different for the two groups. We I would recommend training to 4.47 .77 3.50 1.41 .01 0.85
computed an effect size for this change using the formula advocated by the standard vocational
Morris (2008), which is based on the mean pre-post change in the curriculum for prospective
treatment group minus the mean pre-post change in the control group, caregivers
divided by the pooled pretest standard deviation. The resulting effect a b
Note: p = .001; p = .004.
size was d = 0.55, which indicates a medium effect. The sensitive re-
sponsiveness of the caregivers in the intervention group increased from
informative (t (34) = 3.60, p < .01, Cohen’s d = 1.21), interesting (t
pretest to posttest, whereas the control group showed a decline over
(35) = 2.66, p = .01, Cohen’s d = 0.87), and useful (t (30) = 2.20,
time.
p = .04, Cohen’s d = 0.77) (see Table 4). Finally, the intervention
To test the differential effects for sensitive responsiveness assessed
group scored significantly higher than the control group on their will-
in the structured and unstructured episodes, two additional analyses
ingness to recommend the training to starting caregivers (t (35) = 3.06,
were conducted. The repeated measures ANOVA of Model 2, including
p < .01, Cohen’s d = 0.99), and advocate it to be part of the standard
unstructured episodes only, showed that there was no main effect for
vocational curriculum for prospective caregivers (t (33) = 2.58,
time (Pillais F(1, 58) = 0.88, p = .35, η2partial = .02), nor group (Pillais F
p = .01, Cohen’s d = 0.85).
(1, 58) = 3.89, p = .05, η2partial = .06), nor an interaction effect (Pillais
F(1, 58) = 1.26, p = .27, η2partial = .02). It should be noted, however,
that although the group effect did not reach statistical significance 4. Discussion
(p = .053), there was a trend towards the control group scoring higher
during the unstructured episodes than the intervention group. The The effects of the VIPP-CC in center-based child care on caregiver
corresponding effect size according to Morris (2008) would be d = .29, sensitive responsiveness, general child care quality and attitude to-
indicating a small effect. wards sensitive caregiving and discipline were tested in a randomized
In the repeated measures ANOVA of the third model, including only controlled trial. With respect to caregiver sensitive responsiveness, we
the structured episodes of the posttest, no main effects for time (Pillais F showed that the VIPP-CC was indeed effective for professional care-
(1, 60) = 0.18, p = .67, η2partial = .00) or group (Pillais F(1, 60) = 1.06, givers in center-based care: after the intervention, observed sensitivity
p = .31, η2partial = .02) were found, but a significant interaction effect increased, but only in the intervention group. Analyses regarding the
emerged (Pillais F(1, 60) = 4.37, p = .04, η2partial = .07), with a medium intervention effect for caregiver sensitivity in unstructured and struc-
effect size (Morris, 2008) of d = 0.64. The intervention group showed tured situations showed that the structured play situations accounted
an increase over time, whereas the control group showed a decline from for the increase in sensitivity over time. The structured situations were
pretest to posttest. in smaller groups and were more focused at in the VIPP training than
unstructured settings. Therefore, an intervention effect may become
most apparent in these settings, because learning experiences are
3.2.2. General child care quality
probably activated more automatically in situations somewhat similar
The intervention group and the control group did not differ sig-
to the training. Additionally, for professional caregivers it may be easier
nificantly on ECERS-R scores at pretest (p = .33). The repeated mea-
to perceive and adequately interpret signals in a smaller group of
sures ANOVA showed that there was a significant main effect for time
children present during structured play than in a larger group in un-
(Pillai’s F (1, 62) = 5.18, p = .03, η2partial = .08), indicating that general
structured settings, because there are fewer children needing attention
quality in both groups increased over time. We did not find a significant
and signaling their needs, in line with findings from Ahnert et al.
main effect for group (Pillai’s F (1, 62) = 2.09, p = .15, η2partial = .03),
(2006). Even so, the intervention effect may transfer to unstructured
nor an interaction effect (Pillai’s F (1, 62) = 0.17, p = .90,
situations in a later stage, once the professional caregivers have con-
η2partial = .00) with a very small effect size (Morris, 2008) of d = .05.
solidated their newly learned behavior in structured settings (Tziner,
Haccoun, & Kadish, 1991). Our findings are promising, because even in
3.2.3. Caregiver attitude our sample of qualified staff with quite some years of experience and
After the intervention, caregivers who had participated in the in- relatively high scores for sensitivity at baseline, the intervention was
tervention reported a more positive attitude towards caregiving and effective.
limit setting (M = 4.11, SD = .42, n = 20) than caregivers in the Considering caregiver attitude towards sensitive caregiving and
control group (M = 3.80, SD = .38, n = 19) (t (37) = 2.39, p = .02, discipline, an intervention effect was found, which is in accordance
Cohen’s d = 0.77). with previous findings in home-based care (Groeneveld et al., 2011).
After the VIPP-CC training, professional caregivers showed a more
3.2.4. Evaluations positive attitude towards caregiving and limit setting than the control
Caregivers in the intervention group reported significantly higher group. We speculate that the intervention led to a change in caregiving
scores than caregivers in the control group on finding the training attitude first, which in turn led to observable changes in behavior.

100
C.D. Werner et al.
Because of the change in underlying attitude, improved sensitive re-
sponsiveness in other situations than structured play tasks might be-
come apparent at a later stage. These findings are in line with those
reported by Susman-Stillman, Pleuss, and Englund (2013) who showed
that for center-based care, more positive caregiver attitudes and beliefs
are related to higher quality caregiving practices.
Apart from the observed changes in caregiver behavior and the re-
ported change in attitude towards sensitive caregiving, professional
caregivers evaluated the video-feedback intervention very positively,
indicating that the training was informative, interesting and useful to
them and that they would recommend the training for newly starting
professional caregivers. They supported the idea of including the
training as a standard part of the educational curriculum for new pro-
fessional caregivers. Apparently, professional caregivers are open to
and in need of individual training methods to improve their skills and
they consider the VIPP-CC a promising method to provide training-on-
the-job.
Our study showed that the intervention can be adapted to fit the
busy time schedule of the professional caregivers, who often have
multiple tasks such as caring for the children, cleaning the room and
keeping up administration. In the Netherlands, as part of center care
rules and regulations, most of the time there are two or three caregivers
in a group, which makes it possible for one of the caregivers to be video-
taped with a small group of children, while the other caregivers look
after the rest of the group. Videotaping only takes about 20 min and can
be done in the same room, so that supervision of the children does not
have to be compromised. The feedback session of one hour can be
carried out during the professional caregivers’ lunch break, or at a time
when most of the children are asleep. Given the fact that there are only
six intervention sessions that are scheduled every two to three weeks,
having extra staff or supervision by assistants or center managers on the
group for one hour might be feasible to achieve without much extra
costs. As suggested, VIPP-CC could be incorporated into the curriculum
for caregivers-in-training or as annual training-on-the job. We would
suggest to train center managers or center assistants, who may have a
higher degree in Early Child Care Education, as VIPP-CC interveners,
that is, the ones who deliver the intervention to the professional care-
givers. In the Netherlands, most child care centers are part of larger
child care organizations, so that one VIPP-CC expert could be trained to
carry out the intervention with several caregivers in their organization.
Given the fact that there are few evidence-based intervention programs
that target professional caregiver interaction skills through the care-
giver (Werner et al., 2016), the VIPP-CC may be interesting for policy
makers in terms of cost-effectiveness for professional development.
With regard to our placebo intervention, some professional care-
givers in the control group may have been misled by the name
“coaching by telephone”. Indeed, some professional caregivers asked
for more information or even showed some frustration when issues of
child development that they addressed were not responded to during
the phone calls. Interestingly, however, professional caregivers in the
control group perceived their so-called telephone training generally as
somewhat informative and useful and some of them would recommend
this training to starting professional caregivers. Although program fi-
delity was monitored in the control group and despite the fact that
professional caregivers were only asked questions and not given advice,
the biweekly phone calls may have increased awareness of the children
in the group. Some professional caregivers pointed out that they started
to pay more attention to what the children were doing and what kind of
play materials they were using.
With regard to general quality, moderate general quality at both
time points in both groups was observed, representative for Dutch child
care centers (Fukkink, Gevers Deynoot-Schaub, Helmerhorst,
Bollen, & Riksen-Walraven, 2013). In contrast with results of the VIPP-
CC in home-based care (Groeneveld et al., 2011), no intervention effect
was found. One reason may be that structural aspects that contribute to
general quality (e.g. space and furniture, the presence of adequate play
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Early Childhood Research Quarterly 42 (2018) 93–104
material, safety and hygiene practices) were not the focus of our in-
tervention. More importantly, these aspects are not easily influenced by
professional caregivers, but rather by center managers and through
authority regulations. The situation is different for professional care-
givers in home-based care, where individual caregivers are directly
responsible for the physical environment in their own homes. This may
explain the different results on general quality in our study compared
with the Groeneveld et al. (2011) study. It was remarkable that for
general quality, both intervention and control group showed a small,
yet significant increase over time. A possible explanation is that during
posttest, mean group sizes were slightly smaller, so that adequate su-
pervision may have been easier to accomplish. Another explanation
could be that participating in research observations may have led to
caregiver’s increased awareness of their classrooms, an example of the
so-called Hawthorne effect. As a consequence, caregivers may have
changed certain classroom aspects such as child decorations, the of-
fering of specific play materials and hygiene activities from pretest to
posttest. We should stress the fact that the intervention effect that we
found for sensitive responsiveness was apparent only in structured play
situations, whereas general quality is reflected by both unstructured
and structured situations.
4.1. Limitations
A number of limitations to this study should be acknowledged. First,
the sample size was modest, so that subgroup analyses for more detailed
investigation of effects were not possible. Second, although randomi-
zation was carried out carefully, in relatively small samples group dif-
ferences may occur by chance. This may explain why at baseline, there
was a difference between the control group and the intervention group
regarding sensitive responsiveness. To control for these initial differ-
ences, repeated measures ANOVAs were conducted. Internal validity
was further ensured by careful procedures for recruitment, the pretest-
posttest design, the use of reliable instruments, and blinding of the
coders to avoid experimenter bias. Although intercoder reliability was
adequate for caregiver sensitivity and general child care quality, the
questionnaire to assess professional caregiver attitude towards car-
egiving showed only moderate reliability. We point out that the study
did not include long term follow-up assessments and that we showed
effects on the short term.
With respect to external validity, our sample was representative for
the population of child care centers in urban areas of the Netherlands,
comparable to other study samples in the field. In the current study,
professional caregivers and centers were independent: one professional
caregiver from each center was randomly selected to participate, pre-
venting potential spill-over effects from the treatment group to the
control group. When the VIPP-CC would be brought to scale and used
by all professional caregivers in a center its effects might be enhanced
or restricted by the different social contexts. Further translational re-
search is needed to settle this issue.
The highly standardized VIPP manual presents advantages for re-
search and practice, helping to maintain high levels of program fidelity,
because all videotaped episodes and interventions sessions are struc-
tured. However, a setback of this intervention method may be that the
unstructured and varying nature of activities and daily care routine in
the child care context is not sufficiently addressed. Another limitation is
that caregiver sensitivity in structured play situations and attitude to-
wards sensitive caregiving and discipline were measured during
posttest only. In spite of this we believe that the carefully conducted
randomization allowed us to compare scores on variables for which no
pretest scores were available.
Furthermore, a downside of our multi-method approach of assess-
ments (live observations, videotaping, questionnaires) may have been
that it caused some non-response in posttest questionnaires about car-
egiving attitudes and caregiver evaluations. In the current study, we did
not impute missing data as the number of missing values was small and
C.D. Werner et al.
concentrated in a few professional caregivers who did not complete a
whole questionnaire or did not have a score on the most important
outcome variable, namely sensitivity. In our study, we did not have
specific information on child characteristics such as SES, level of be-
havior problems or temperament, because the intervention focused on
caregiver behavior towards a group of children. This may be viewed as
a limitation, because we could not investigate whether certain inter-
vention effects were moderated by child characteristics (Klein
Velderman, Bakermans-Kranenburg et al., 2006).
4.2. Implications for future research and child care practice
We point out five areas for future research. First, long-term effects of
VIPP-CC should be investigated. In future studies the placebo treatment
should not be presented as providing advice, in order to not raise un-
realistic expectations. Second, child characteristics such as SES, tem-
perament behavior problems should be included to study the relation to
improvements of caregiver sensitivity and to analyze potential inter-
vention effects on the child level. Third, the VIPP-CC may be further
adapted so that the full scope of daily care routines, including un-
structured situations such as free play, are taken into account during
the intervention. Changes in sensitivity in both structured and un-
structured situations could then be investigated. Fourth, given the fact
that positive evaluations were given for the idea of having VIPP-CC
implemented in the formal caregiver training, research should focus on
how caregiver training in this early stage may contribute even more to
sensitive caregiving. Finally, future research may focus on how the
VIPP-CC can be useful in center-based child care in other countries and
different settings, such as center-based child care for children with
special needs. The feasibility of the program in other countries has been
demonstrated in one study, in which the VIPP-CC program was trans-
lated to Spanish and successfully implemented in a small scale RCT in
Montevideo area, Uruguay (Ortiz, 2016). Results showed good feasi-
bility, and positive evaluation of the program for Early Childhood
Educators in areas of low SES (Ortiz, 2016).
With regard to child care practice, our findings are highly relevant for
Appendix A
See Table A1.
Table A1
Overview of the VIPP-CC sessions.
Visit Video-taped episodes for feedback
0 –
1 • Building blocks together
• Clearing up the toys
• Turn taking
2 • Children playing by themselves
• Playing together
• Clearing up the toys
• Storybook reading
3 • Lunch or snack
4 • Caregiver only responds to
invitation from children
• Singing songs together
• Building a tower together
5 • Playing together with dolls
• Do-not-touch-task
• Reading a storybook
6 • Building together
• Clearing up the toys
• Playing together
102
Early Childhood Research Quarterly 42 (2018) 93–104
professional caregivers, children and parents, given the fact that a large
number of children under age five attend center-based child care in
Europe and the US (Organization for Economic Co-operation and
Development, 2013). General quality and the caregiver-child relationships
need constant monitoring by researchers and authorities, especially when
for-profit centers are tempted to compromise caregiver-child ratios in
economic low tides. Authorities in the US and in the European Union
recognize the importance of high quality care and education for children
in the preschool age and by subscribing to the Starting Strong II plan
(Organization for Economic Co-operation and Development, 2006) they
have obliged themselves to address child care quality and the formal
education for professional caregivers. Effective narrow-focus intervention
programs that target the professional caregiver could be a start for im-
proving quality. These programs can be implemented at an early stage in
the professional career or they can become part of the employee curri-
culum of centers as an annual training.
In light of the above, the VIPP-CC has the potential to be implemented
as a cost-effective way to increase caregiving quality because of the
standardized program that has a relatively short duration, that is, six 1.5 h
visits. The VIPP-CC could be implemented as additional training-on-the-
job, or as suggested by many participating professional caregivers, at an
earlier stage during internships for caregivers who are still in training.
4.3. Conclusion
We have shown that the attachment-based intervention VIPP-CC is
effective in improving professional caregivers’ behavior in center-based
child care. Caregiver sensitivity to the group, which is an important
predictor of a secure child-caregiver attachment, can thus be improved
in structured situations. With this study, the effectiveness of the VIPP
approach has expanded from family settings (including family child
care) to child care environments with larger groups of children. Future
studies might focus on adapting the intervention program even further
for group settings in which quality of care is highly disadvantageous for
young children, for instance in institutionalized care and orphanages.
Themes during intervention
Filming only, no intervention
Sensitivity: Exploration versus
contact seeking
Discipline: Inductive discipline
and distraction
Sensitivity: Speaking for the
children
Discipline: Positive reinforcement
And all previous themes
Sensitivity: Sensitivity chain
Discipline: Sensitive time-out
Sensitivity: Sharing emotions
Discipline: Empathy for the
children
And all previous themes
All of the above
All of the above
C.D. Werner et al. Early Childhood Research Quarterly 42 (2018) 93–104

Appendix B

See Table B1.

Table B1
Items within short ECERS-R.

Full version Shortened version

Space and Furnishings

1. Indoor space +
2. Furniture for routine care, play and learning +
3. Furnishings for relaxation and comfort
4. Room arrangement for play
5. Space for privacy
6. Child-related display +
7. Space for gross motor play
8. Gross motor equipment

Personal Care Routines

9. Greeting/departing
10. Meals/snacks
11. Nap/rest
12. Toileting/diapering +
13. Health practices
14. Safety practices +

Language-Reasoning
15. Books and pictures +
16. Encouraging children to communicate
17. Using language to develop reasoning skills
18. Informal use of language +

Activities
19. Fine motor +
20. Art +
21. Music/movement
22. Blocks +
23. Sand/water +
24. Dramatic play +
25. Nature/science
26. Math/number
27. Use of TV, video, and/or computers
28. Promoting acceptance of diversity

Interaction
29. Supervision of gross motor activities
30. General supervision of children (other than gross motor) +
31. Discipline +
32. Staff-child interactions +
33. Interactions among children +

Program Structure
34. Schedule +
35. Free play +
36. Group time
37. Provisions for children with disabilities

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compensation, workplace support, and links to quality of center-based child care and
teachers’ intention to stay in the early childhood profession. Early Childhood Research
Quarterly 22, 261–275. 10.1016/j.ecresq.2007.03.004.