Early Childhood Care in the Former East Germany and Mental Stress in Adulthood

Background: It is still debated in Germany whether early childhood care outside the family might cause mental stress in adulthood. In the German Democratic Republic (GDR—the former East Germany before unification), children were often cared for outside the family from a very early age.

Methods: To determine the relation between early childhood care outside the family and mental stress in adulthood, we carried out a survey among 1575 persons who were born and socialized in the GDR. They were classified into four care groups according to the age at which they were first cared for outside the family. Associations with depressiveness, somatization disorders, and anxiety disorders in adulthood were tested with logistic regression analysis. Care group–specific prevalences of experiences of abuse and neglect in childhood were estimated with analysis of variance.

Results: Comparisons of persons cared for outside the family before the age of three, or from the age of three onward, with persons cared for within the family in their preschool years did not reveal any difference with respect to depressiveness (odds ratio [OR] = 0.95; 95% confidence interval [0.58; 1.55]; OR = 1.05 [0.63; 1.74]), somatization disorders (OR = 1.11 [0.74; 1.67]; OR = 1.09 [0.71; 1.66]), or anxiety disorders (OR = 0.87 [0.46; 1.64]; OR = 1.12 [0.59; 2.10]). Nor were there any intergroup differences with respect to experiences of abuse and neglect. Certain features of the very small group of children who had long-term care outside the family are discussed in the article.

Conclusion: No relation was found between early-childhood care in day-care centers in the GDR and mental stress in adulthood. The data were too sparse for any conclusions about specific aspects of care outside the home (e.g., quality or child-rearing norms).

Since 1996 a legal entitlement has existed in Germany to a place in care outside the family for children aged 3–6 years. Since 2013 this entitlement has also included children younger than 3 years (1). This ignited once again the debate about appropriate childcare and the question of whether negative long-term consequences are to be expected as a result of care outside the family.

In the past this debate was conducted differently in the new German states (Länder) than in the old ones. By contrast to the Federal Republic, the practically free childcare provided in the German Democratic Republic (GDR) was part of the state education system, in order to support women’s gainful employment and bring up children in the sense of socialist ideals (1, 2). Care outside the family was therefore continually expanded; in the year 1989, more than 80% of the children aged 1–3 years and more than 90% of 3–6 year olds were cared for outside the family (2). Placement in institutions outside the family in the GDR was and is, however, by no means uncontroversial. Israel and Kerz-Rühling (3) concluded from life story interviews that affection in terms of time and emotion given by carers was unsatisfactory in the GDR. Repressive educational practices and the enforced subordination of children’s own interests to group interests allegedly hampered the “active acquisition of rules and compassion” (4). By contrast, results of empirical-quantitative analyses imply that as regards depression and anxiety, no differences exist between adults who had previously been placed in creches and adults who were cared for in their families as young children (2, 5). Growing criticism of the care culture even during the times of the GDR, however, resulted in places for weekly and seasonal care being gradually reduced and later to the introduction of a “baby year” (2).

Today, childcare provision in the new Länder is much better developed than in the old Länder (1). The reasons for these differences lie in West Germany’s decades of predominantly family based, especially maternal, care of preschool children (6). While 74% of West German parents in 2017 adhered to the model of the male main breadwinner and the female additional earner, the proportion in the east was 45% (7).

Independently of the form of care, children can be exposed to harmful influences both within their families and in external institutions. Experiences of abuse or neglect during childhood are risk factors for (poor) mental health (8, 9). For this reason we used these two variables for our analyses as indicators for an abusive upbringing, in order to estimate the prevalence rates of childhood experiences with abuse and neglect for the groups receiving different types of care.

This study aimed to clarify how different forms of care outside the family in early childhood are associated with later mental health. The focus is especially on the presence of somatization disorders, anxiety, and depression. Anxiety and depression are the most common mental disorders (10, 11) in Germany. They are often accompanied by comorbid somatization disorders (12, 13). During our analyses we also identified a need for research into associations between forms of care and childhood experiences of abuse and neglect.

Our study adds to research into the possible psychological effects of care outside the family in early childhood in various ways. On the one hand, the dataset we used provides a rare opportunity to evaluate a large survey designed to be representative for East Germany. On the other hand, the specific interrogation of the data by age of the first occasion of care outside the family enables closer insights into the early childhood care in the former GDR.

Methods

Sample

Our analyses are based on data from a survey designed to be representative and conducted in the new German Länder, carried out by the independent market research organization USUMA. The eBox contains the description of how participants were recruited. The way we used to draw our sample is associated with lower selection bias and therefore higher data quality (14). The data collection was a cooperative project of several universities with different survey topics. We included in our analysis men and women born in the GDR between 1949 and 1983 who reported having grown up primarily there. Persons with missing data for the variables used in our analysis were excluded, with the number of missing values per variable not exceeding 5% (15). The final case number was N=1575 persons. The mean age of the sample was 56.69 years (standard deviation [SD] =10.09); 871 persons (55.30% of survey participants were female).

eBox

Recruitment of participants

eFigure

Flowchart of recruitment of and interviews with survey participants

Variables

The constructs we used can be found in the e-questionnaire except for the Childhood Trauma Screener (CTS), which is protected by a license. The care groups were categorized on the basis of the question: “How were you cared for during your preschool years?”, with the two subcategories

• „“Before the age of three, mainly by […]”
• “From the age of three to starting school primarily by […]”.

Possible responses existed in the shape of multiple selection (“mother,” “father,” “other relatives,” “day care,” “foster family,” “creche,” [or, beginning at age 3, “nursery/play school”], “children’s home”, “other”). If care outside the family was reported, the timing/timescale was asked for (“half days,” “all day,” “seasonal,” “weekdays with overnight stay,” “permanently/long term”). From this, four care groups were formed:

• Persons who reported no care outside the family (not cared for outside the family during preschool age), who had not selected the options “day care” or “creche,” “nursery/play school” as care types at all
• First occasion of care outside the family at an age below 3 years (children cared for outside the family when younger than 3 years)
• First occasion of care outside the family from the age of 3 years (children cared for outside the family from the age of 3 years)
• Persons who reported long term care outside the family—cared for outside the family on a weekly, seasonal, or long term/permanent basis in children’s homes outside the family. Because of the small number of cases (n=27) of those cared for long term we considered this group only descriptively.

As hardly any differences were seen in mental stress between persons cared for on a full-day or half-day basis we did not distinguish between these two groups in our analyses.

Depression, anxiety, and somatization disorders were determined by applying the validated scales PHQ-9 (depression; 16, 17), GAD-7 (anxiety; 18, 19), and SSS-8 (somatization disorders; 20,21). We used these scales to interrogate for frequency of impairment due to certain symptoms over the preceding two weeks (PHQ-9, GAD-7) or the preceding seven days (SSS-8). From the responses (1=”not at all,” 2=”on several days,” 3=”on more than half the days,” 4=”nearly every day”) we formed sum scores that formed the basis for dichotomous variables. From a score of 10 (depressiveness, anxiety) or 12 (somatization disorders) we assumed a clinically relevant burden of symptoms (19, 21, 22).

The CTS is a short version of the Childhood Trauma Questionnaire (CTQ) and shows neglect and the experience of violence in childhood. The individual questions represent the dimensions emotional neglect, emotional violence, physical neglect, physical violence, and sexual violence. Survey participants were able to select between the response options 1=”never truel” to 5=”very often true,” in order to document how often while they were growing up they were beaten so violently by a family member that they had bruises or scratches.

In addition to the validated sum score from the individual dimensions of the CTS (23) we documented for each dimension prevalence rates I the care groups descriptively. To this end we used the following classification (23): emotional and physical abuse had to be mentioned at least 3=”sometimes true,” whereas emotional or physical neglect had to mentioned at least 4=”often true,”, and sexual abuse had to be mentioned at least 2=”rarely true.” Furthermore we included the following sociodemographic control variables:

• Sex (male/female)
• Age (continuously in years)
• Educational attainment (entitled to access university —yes/no)
• The household net equivalent income at the time of the survey, divided by 1000
• Information on whether the survey participant lived with a partner in one household.

Analyses

In addition to the descriptive between-group comparisons, we calculated variance analyses between the care groups as a first step, focusing on anxiety, depressiveness, somatization disorders, as well as neglect and experienced violence in childhood by using post hoc Tukey-HSD tests and chi square tests. Subsequently we used three logistic regressions for the dependent variables anxiety, depression, and somatization disorders.

Results

Descriptive results

Table 1 shows the descriptive results as well as the results from the analyses of variance. The different care groups differed regarding their sociodemographic characteristics. This can be read from the footnotes of the individual data in Table 1. Children being cared for outside the family in the age group younger than 3 years (mean value b=52.99) were younger than those receiving care inside the family and persons from the age of 3 being cared for (mean a=59.48 [−7.97; −5.01]; mean c=57.88 [−6.49; −3.27]). Children below the age of three who were being cared for outside the family had a higher household net equivalent income (mean b=€2181.84) (mean a=€1810.29 [225.92; 517.19]; mean c=€1888.98 [134.76; 450.96]; mean d=1676.69 [22.72; 987.58]). Those receiving care outside the family below the age of 3 years more commonly lived with a partner in a household as adults (74.34%).

Table 1

Descriptive distribution of used variables after first early childhood care outside the family

The only statistical differences regarding mental stress were found in the group of those who had been cared for outside the family for the long term. The group showed abnormalities in the rates of clinically relevant depression (29.63%) and somatization symptoms (22.22%). The same was the case for differences in prevalence rates of experiences of abuse and neglect in childhood. Only the group of those receiving long term care outside the family showed abnormalities for the prevalence rates for emotional violence (22.22%) and neglect (11.11%) in childhood. Children who had not been cared for outside the family reached a mean sum score of 2.43 (SD=2.70), the value for children cared for below the age of 3 years was 2.39 (SD-2.74) and in the age group from 3 years it was 2.21 (SD=2.42). Altogether 8.00% of all included survey participants had experienced emotional violence in childhood. 8.57% of survey participants had experienced physical violence. 5.33% were victims of sexual violence. 5.59% reported that they had been emotionally neglected. Physical neglect was documented for 12.95% of participants.

Results of the logistic regressions

Table 2 shows the three logistic regressions. Day care outside the family under or from the age of 3 years did not differ statistically from the reference groups of those who were not cared for outside the family at preschool age. Compared with the reference group the values of those who were cared for outside the family under the age of 3 years did not substantially deviate from 1 for depression (odds ratio [OR]=0.95; 95% confidence interval [0.58; 1.55]), somatization disorders (OR=1.11 [0.74; 1.67]), and anxiety (OR=087 [046; 164]); the probability of reporting clinically relevant symptoms is therefore to be assessed as identical in both groups. The same was the case for the comparison between the reference group and the group of those cared for outside the family from the age of 3 years (depression: OR=1.05 [0.63; 1.74]; somatization disorders: OR=1.09 [0.71; 1.66]; anxiety: OR=1.12 [0.59; 2.10]). Higher CTS scores were consistently associated with a greater probability of clinically relevant symptoms regarding depression (OR=1.18 [1.12; 1.25]); somatization disorders (OR=1.17 [1.11; 1.23]) and anxiety (OR=1.17 [1.09; 1.25]). A higher household equivalence income was associated with lesser symptoms of depression (OR=0.60 [0.45; 0.79]). Finally, in women the probability of reporting clinically relevant scores for somatization disorders was 1.68 [1.20; 2.38]) times that in men.

Table 2

Logistic regressions with early childhood care as a predictor for depression, somatization disorders, and anxiety

Discussion

This study aimed to analyze the associations between care in early childhood and mental stress in adulthood as well as the prevalence rates that were specific to the care groups, of childhood experiences with abuse and neglect.

No differences were seen regarding symptoms of depression, anxiety, and somatization disorders in adulthood between persons who were cared for in daycare institutions outside the family before or from the age of 3 years and those who had not been cared for outside the family at preschool age. Our finding is consistent with the results of Brückner et al. (2) and Berth et al. (5), who did not observe any difference regarding anxiety, depression, physical symptoms, and additional indicators between those who had previously been cared for in a creche and those who had been cared for within the family as young children. Altogether these findings suggest that care outside the family in early childhood in daycare institutions in the former GDR (even before their third birthday) is not categorically associated with later symptoms of mental stress.

Abnormalities were seen as regards depression and somatization disorders in those persons who at preschool age had been cared for outside the family by the week, seasonally, or permanently/long term. The data from this group should be interpreted with caution, however, since the group is small and the reasons for prolonged care outside the family—for example, illness in the family—may have influenced the results. Future research should test these types of care with larger case numbers to determine the effects that a longer-term separation from the family environment may have.

Our results confirm earlier findings (8, 9) as regards experiences of abuse and neglect in childhood. These experiences are more than averagely commonly associated with mental stress in adulthood. This result is consistent with the results of a meta-analysis, which found higher scores for depression and anxiety in the context of sexual and physical violence in childhood (24). However, we were also able to show that the prevalence of such experiences is not associated with the early childhood forms of care on the former GDR. With a view to research results to date, the question arises whether care outside the family can also confer protection from a pathological family environment. Findings to date suggest that experiences of child neglect and abuse were rarer in East Germans (who in general had been cared for outside the family to a greater extent) than in West Germans (25, 26). In 2020, for example, 39.7% of West German survey participants but only 25.2% of surveyed East Germans reported at least one harmful childhood experience (25). Data from 2010, 2013, and 2016 also found that the probability for the prevalence rates of the individual components of the CTS was 1.56 times to 2.61 times higher in West Germans than in East Germans (26).

Since the institutions with an educational function in the former GDR had the remit to educate children according to socialist values, such as those or the superordinate collective interest, it should be noted that future research should intensify the subject of [child]care in socialist regimes so as to determine other possible implications. In addition to health aspects, research regarding care outside the family has to date focused on personality aspects, behavior, and cognition. These items should also be investigated for the consequences of early childhood care in the former GDR.

Furthermore, longitudinal observations of mental health could continue to consider health related interventions. For example, in the case of inpatient institutions in the former GDR it was shown that underage persons experienced suffering rather than improvement as a result of psychotherapy (27).

Furthermore, future analyses should include West Germany so as to consider different care cultures. This comparison could be differentiated with a focus on potential effects of age effects, period, and cohort. It is possible that cultural values or norms/standards for parenthood influence the effects of early childhood care. The acceptance and use of early childhood care outside the family, which was increasingly accepted in the times of the GDR, might also explain why our results did not imply any association between care outside the family and mental stress in adulthood. Early care outside the family could therefore rather be associated with experiences of stigmatization in West Germany.

One of the strengths of the present survey may lie in the fact that the questionnaires varied by subject. Selection bias in favor of or against certain topics should therefore be less pronounced. It is still thinkable, however, that particularly stressed persons in inpatient care were not contactable at home after the randomized selection and were therefore less likely to be part of the survey. Furthermore, a retrospective cross sectional data collection does not allow for causal assumptions in the interpretation, and it should be considered that one’s own care was potentially not remembered at all or only incorrectly.

Also, the prevalence rates determined in this article deviate from estimates in the general population to date (we did not collect lifetime prevalence data). As regards mental stress indicators, Jacobi et al. reported affective disorders in 9.8% of cases, somatoform disorders in 3.5%, and anxiety disorders in 15.4% of cases (10). Childhood experiences with abuse and neglect were also reported with values that differed from those in our study (23).

Glaesmer et al. determined

• Emotional abuse in 5.2–6.7%
• Physical abuse in 4.7–5.3%
• Sexual abuse in 4.3–6.9%
• Emotional neglect in 6.7–10.1%
• Physical neglect in 10.6–14.7%.

These discrepancies can probably be explained with our focus on the birth years 1949–1983.

Further relevant factors were not considered in the present study. The quality of care outside the family is certainly a relevant variable of influence if collecting positive experiences of bonding, which may protect against mental stress. The lack of important predictors is a possible cause of the comparatively wide confidence intervals.

Conclusions

In spite of these limitations our results suggest that early care outside the family and provided in day care institutions of the former GDR is not categorically associated with stronger mental stress symptoms in adulthood even before the third year of life. Future research should further differentiate the type and quality of early childhood care provision and verify the results on the basis of greater case numbers—especially with a focus on those who were cared for over long time periods.

Ethics approval

The study received approval from the ethics committee at the medical faculty of Leipzig University (ref: 091/22-ek, 28.03.2022).

Funding

This study was funded by the German Federal Ministry of Education and Research (funding ref: 01UJ1911AY)

Conflict of interest statement

AH is a board member of the Society of Psychoanalytic Social Psychology (GfpS)

The remaining authors declare that no conflict of interest exist.

Manuscript received on 27 July 2023, revised version accepted on 14 December 2023.

Translated from the original Germany by Birte Twisselmann, PhD.

Corresponding author
Lisa Braunheim

Klinik und Poliklinik für Psychosomatische Medizin und Psychotherapie

Universitätsmedizin der Johannes Gutenberg-Universität Mainz

Untere Zahlbacher Straße 8

55131 Mainz

Cite this as:
Braunheim L, Heller A, Helmert C, Kasinger C, Beutel ME, Brähler E: Early childhood care in the former East Germany and mental stress in adulthood. Dtsch Arztebl Int 2024; 121: 182–7. DOI: 10.3238/arztebl.m2023.0276

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