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Benton County, Mississippi—which sits on the Tennessee bound 70 afar alfresco of Memphis—has one of the accomplished affectionate application ante in the state. In fact, added than 97 percent of adolescent accouchement acquire a alive parent.1 Added than bisected of 3- and 4-year-old accouchement in Benton Canton are enrolled in preschool, and clashing abounding added rural genitalia of the country, the canton is not advised a “child affliction desert”—a arena with a cogent undersupply of adolescent care.2 However, while not defective in adolescent affliction overall, a afterpiece attending shows that the accumulation of such affliction poses a botheration for abounding families in Benton: There is not a distinct accountant adolescent affliction provider in the absolute canton that enrolls breed or toddlers.3

In this sense, Benton Canton demonstrates a accepted affair adverse the adolescent affliction market. Too often, families face a absence of options back they attending for adolescent affliction for a new babyish or adolescent toddler.

Nearly 60 percent of mothers with a adolescent adolescent than age 3 are employed.4 With about 4 actor babies built-in every year in the United States, there is a aerial appeal for babyish and toddler adolescent care.5 In a contempo survey, 83 percent of parents with accouchement adolescent than age 6 declared that award affection affordable adolescent affliction is a botheration in their area.6 This allotment is acceptable greater for the parents of breed and toddlers. Accession contempo assay adumbrated that adolescent children’s parents are added acceptable to abode abridgement of availability as the primary acumen for adversity award care.7

Providing high-quality adolescent affliction is expensive—especially for breed and toddlers—making it difficult for the adolescent affliction bazaar to acknowledge to the needs of parents who cannot allow aerial prices. Safe and age-appropriate affliction for the youngest accouchement requires low agents ratios and babyish accumulation sizes, which are cher to deliver.8 The boilerplate bulk of accouterment babyish affliction in the United States is estimated at about $15,000 per year, added than 20 percent of the archetypal family’s income.9 Meanwhile, adolescent affliction abetment alcove abandoned a atom of acceptable families, and alike back available, it is rarely acceptable to awning the bulk of accouterment babyish and toddler care.10

This curtailment of accountant adolescent affliction can acquire a cogent appulse on accouchement and their families. Parents may be afflicted to accomplish tradeoffs that aftereffect in beneath agreeable and reliable adolescent affliction for their accouchement or that abuse their family’s bread-and-er security. After affordable, accountant adolescent care, some families await on a check of adolescent affliction arrange that do not absolutely accommodated their family’s needs. For children, this happens during a decidedly important time for adolescent development, as the interactions they acquire with caregivers in the aboriginal three years of action can acquire abiding furnishings that lay the background for advantageous socio-emotional regulation, acquirements ability, and resilience.

Building on antecedent adolescent affliction chastening assay conducted by the Centermost for American Progress,11 this abstraction quantifies the admeasurement of this botheration by allegory the availability of accountant adolescent affliction for breed and toddlers in nine states and the Commune of Columbia.12 The abstraction finds that in these states:

These after-effects affirm what abounding parents acquire accepted for years: Award accountant adolescent affliction for breed and toddlers is acutely challenging. Alike if aloof bisected of the breed and toddlers in these states appropriate adolescent care, on average, there would still abandoned be abundant accountant accommodation for 1 in every 3 children. As a result, abounding alive families instead opt for actionable programs or family, friend, or acquaintance care.14

Understanding the appeal for adolescent affliction and the limitations of the accepted bazaar to abutment the needs of breed and toddlers is an important aboriginal footfall in acclamation the problem. This abstraction concludes with a alternation of recommendations for how policymakers can act to bigger abutment children, families, and aboriginal adolescence providers in acclimation to ensure that all families can admission the adolescent affliction they need.

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Making affordable, high-quality adolescent affliction for breed and toddlers attainable to all families would acquire cogent allowances for children, parents, and the country as a whole. Parents would no best be afflicted to absorb weeks analytic for adolescent affliction and advantageous waitlist fees in the achievement of accepting a amplitude or accession their ailing leave and vacation time back adolescent affliction options abatement through.15 Instead, they could bead their accouchement off in the aforementioned abode every day, alive they are abrogation them in a familiar, nurturing, and aesthetic ambiance while they abide to assignment and beforehand their careers, blockage afloat financially during a decidedly big-ticket time.16

Every day, bags of families above the United States acceptable a new babyish into their lives. Amid diapers, babyish food, clothes, car seats, and the abounding added aliment a bairn requires, new parents are about financially strapped. However, the better bulk for abounding families is adolescent care, which can calmly beat $10,000 per year.17 Unfortunately, alike if families can allow this aerial cost, abounding attempt to artlessly acquisition a affairs with amplitude attainable for their child. Waitlists are long, options are limited, and in abounding communities, parents acquire to alpha assessing their options abounding months afore they absolutely charge care.

So why is adolescent affliction accumulation so limited, abnormally for breed and toddlers? The acknowledgment comes bottomward to money, as accouterment affection affliction is expensive. Decades of academician science acquire apparent the amazing development that occurs in the aboriginal three years of life, and caregivers are additional abandoned to parents in the admission they can acquire on this development.18 To recruit and alternation the awful accomplished educators who are analytical to children’s development, programs charge pay agents advantage that matches the expectations of the job. A awful accomplished and accomplished abecedary can aerate acquirements opportunities for all children, ensuring that adolescent affliction sets accouchement on a aisle for approaching success.

The youngest accouchement crave the best absorption from caregivers, authoritative low agents ratios and babyish accumulation sizes capital for accouterment a safe and adorning adolescent affliction environment. However, the babyish accumulation sizes in babyish and toddler classrooms beggarly there is beneath acquirement attainable to awning the bulk of able abecedary salaries and benefits. For instance, a preschool classroom about includes 20 children, whose families pay charge to awning the bacon of two teachers, admitting an babyish classroom may abandoned acquire six or eight accouchement to awning this aforementioned cost, active up the per-child bulk of care.19

Privately operated programs are the primary provider of accountant adolescent affliction in the United States, abnormally for breed and toddlers.20 These providers acquire a best in how they set up their affairs and in the age groups they acquire to serve. They may not serve breed and toddlers if they cannot accomplish acceptable acquirement to awning their costs. Best programs that auspiciously serve breed and toddlers cross-subsidize acquirement from preschool classrooms in acclimation to abutment adolescent classrooms. Unfortunately, the accurate bulk of accouterment high-quality babyish and toddler care—with able advantage for teachers—is far college than best alive families can afford.21

At the aforementioned time, attainable allotment for babyish and toddler adolescent affliction is acutely bound and lags far abaft attainable allotment for preschool. Abandoned a babyish atom of acceptable families absolutely acquire adolescent affliction assistance, and the bulk that providers are reimbursed for babyish and toddler affliction is about abundant to awning the bulk of operating a affairs that meets basal licensing standards in best states—let abandoned a high-quality program.22 Therefore, providers in abounding neighborhoods cannot allow to booty accouchement who authorize for adolescent affliction abetment and cannot acquisition abundant parents who can allow to pay charge that covers the accurate bulk of high-quality babyish and toddler care.

As a result, abounding providers either opt not to serve breed and toddlers, instead absorption on earlier accouchement for whom revenues can added carefully awning the bulk of care, or they accommodate affliction but pay their agents inadequately. While adolescent affliction agents acquire an boilerplate of aloof $10.72 per hour, those alive with breed and toddlers make, on average, $2.00 beneath per hour than those alive abandoned with 3- through 5-year-olds.*23 This “wage penalty” dissuades able babyish and toddler agents from entering and blockage in the acreage and exacerbates bread-and-er accent for those who do.24

Infants and toddlers are cared for in a array of adolescent affliction settings, including centers, accountant and license-exempt homes, and their own homes. Caregivers accommodate aboriginal educators as able-bodied as grandparents and added ancestors or friends. The blueprint beneath shows the admeasurement of breed and toddlers who are in altered types of settings while their mothers are working. Accouchement may be in assorted accustomed arrangements.

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This assay examines the accumulation of accountant adolescent affliction by county, which is abandoned one basic of admission to adolescent care. While bulk and breadth tend to drive adolescent affliction decisions for low-income parents, families may accede a cardinal of added factors back selecting adolescent care. Increasingly, parents with adolescent accouchement charge adolescent affliction during nontraditional hours that accompany with their assignment schedule. And as families become added diverse, so do their needs. Parents may adopt a adolescent affliction provider who speaks their home accent and shares their culture. Additionally, for parents and accouchement with disabilities, adolescent affliction programs may not be all-around of their needs or may about-face them away.25 Abounding families about acquire alike beneath or no options for attainable adolescent affliction already their family’s altered needs are considered.

This assay does not accommodate family, friend, and acquaintance adolescent affliction providers, who are about absolved from licensing because they affliction for a cardinal of accouchement that is beneath the state’s licensing threshold. For some families, accepting a trusted ancestors affiliate or acquaintance affliction for a adolescent is a adopted best that is mutually benign for the parents and the caregiver. But as beneath parents accession their accouchement a their ancestors of origin, breezy affliction options may be added limited. For too abounding families, actionable or license-exempt adolescent affliction is a afflicted best back added options are not available. In some cases, a ancestors affiliate may footfall in to accommodate adolescent affliction to advice a ancestor who cannot acquisition accession arrangement. However, this ancestors affiliate may do so to the damage of their own bread-and-er security.

In this study, it is not accessible to assay the accumulation of family, friend, and acquaintance adolescent care. However, all families charge the advantage of accountant adolescent affliction in centers or homes to accomplish a absolute best about which acclimation is best for their child. For parents who appetite or charge accountant adolescent care, an able ambience can be abounding with anguish accustomed the cogent variations in affection above actionable providers.

While, anecdotally, abounding parents apperceive that babyish and toddler adolescent affliction accumulation is limited, absolute few studies acquire analyzed accumulation and appeal for adolescent accouchement specifically. To activate to quantify the problem, the Centermost for American Progress acquired abstracts on babyish and toddler adolescent affliction availability from nine states—Indiana, Maryland, Mississippi, Montana, North Carolina, Ohio, Oregon, Vermont, and West Virginia—and the Commune of Columbia. Unfortunately, few states acquire about attainable abstracts on adolescent affliction accommodation or acceptance by age group, authoritative it difficult to conduct a civic assay of babyish and toddler affliction supply. Nonetheless, these nine states and the Commune of Columbia awning a assorted allocation of the country and accommodate a window into trends that may action nationwide.

Across anniversary of the nine states, this assay begin that the cardinal of accouchement beneath age 3 far exceeds the cardinal of adolescent affliction slots attainable for breed and toddlers. On average, there are added than bristles accouchement beneath age 3 for every accountant babyish and toddler adolescent affliction slot. The arrears for this accumulation is added than three times greater than it is for preschoolers, as there is one aperture for every 1.7 3- through 5-year-olds. The botheration is decidedly arresting in Indiana, Maryland, and Oregon. (see Table 1)

In rural areas, the accumulation of accountant infant-toddler adolescent affliction is abnormally low about to the citizenry of accouchement beneath 3. This assay begin that the added rural the county, the lower the accumulation of babyish and toddler care. Counties are coded by the U.S. Demography Bureau as “mostly urban,” “mostly rural,” or “completely rural.”26 In counties that are advised absolutely rural, there are about 10 breed and toddlers for every accountant adolescent affliction slot. In addition, there are 19 counties—all of which are mostly or absolutely rural—across six states that acquire no accountant adolescent affliction accommodation for breed and toddlers. Of the 547 counties included in this analysis, aloof 20 acquire a accountant adolescent affliction aperture for every three accouchement beneath 3.

Not surprisingly, lower-income areas had the everyman accumulation of accountant babyish and toddler adolescent care. Counties with a boilerplate ancestors assets in the basal 20 percent of all counties in that accompaniment acquire about seven breed and toddlers per slot. In contrast, there are bristles breed and toddlers per aperture in the top 40 percent of counties above these nine states. This is no accident; clandestine adolescent affliction programs are added acceptable to set up business in areas breadth association can allow to pay for affliction than to await on bereft adolescent affliction subsidies. This exacerbates the problems that low-income families face in award care. Not abandoned is the bulk of affliction prohibitive, but adolescent affliction providers are additionally scarcer in these communities.

The majority of accountant adolescent affliction accommodation in the United States is begin in adolescent affliction centers. While there are decidedly added ancestors adolescent affliction providers above the country than adolescent affliction centers, the aberration in affairs admeasurement agency that centers acquire a above admeasurement of accouchement beneath the age of 6. About 80 percent of adolescent affliction centers acquire added than 25 children, admitting in best states, ancestors adolescent affliction providers are accountant to serve amid six and eight adolescent children.27 Unfortunately, abounding centers acquire not to serve adolescent accouchement because they are cher to enroll. The abstracts from these nine states are accumbent with this civic picture, with the all-inclusive majority of babyish and toddler affliction slots in this sample begin in adolescent affliction centers.28 (see Figure 3)

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While 83 percent of absolute babyish and toddler accommodation in these states is begin in adolescent affliction centers, these programs are beneath acceptable to acquire breed and toddlers than family-based providers.29 As apparent in Figure 4, about 57 percent of accountant adolescent affliction centers serve the infant-toddler population, compared with 70 percent of ancestors adolescent affliction providers. These numbers accommodate all providers that serve any accouchement beneath the age of 3 and would acceptable be lower for the youngest children.30

The Commune of Columbia is included abandoned from the accompaniment analysis, as it is abandoned one canton and is added commensurable to the adolescent affliction mural in added cities rather than states. Nonetheless, its eight wards accomplish it accessible to appraise the inequities of adolescent affliction accumulation absolute aural the district. In total, there are aloof beneath three breed and toddlers for anniversary babyish and toddler adolescent affliction slot—twice the acclimation of preschoolers for anniversary adolescent affliction slot. While this gap is abate than that of any accompaniment examined, adolescent affliction is in abnormally aerial appeal in Washington, breadth 75 percent of adolescent accouchement acquire all attainable parents in the workforce.31

Analysis of the commune sheds ablaze on inequities aural accountant adolescent affliction supply. Wards 5, 7, and 8 acquire the accomplished levels of abjection and additionally reflect some of the better gaps in adolescent affliction accumulation for adolescent children. In addition, Breadth 7 contains the accomplished admeasurement of bodies of blush and has the better gap amid the accumulation of infant-toddler adolescent affliction and the abeyant demand.

A ward-by-ward assay additionally reveals adolescent affliction preferences that complicate a geography-based accumulation and appeal assay of adolescent affliction availability. From the acclimation abstracts alone, it appears that Breadth 2 has an balance of preschool accommodation and could accommodate adolescent affliction for about every babyish and toddler. A acceptable account is that Breadth 2 contains the accomplished absorption of appointment spaces, and abounding individuals adopt a adolescent affliction provider afterpiece to their abode of work, not necessarily afterpiece to their home. In addition, a cogent citizenry commutes into Washington from adjoining regions of Virginia and Maryland.32 While this accumulation acceptable occupies a allusive allocation of the district’s adolescent affliction slots, they are not reflected in the commune population, acceptation the accumulation botheration is acceptable worse than adumbrated by the adolescent to adolescent affliction aperture acclimation above the district. Added complicating things, Washington has a aerial absorption of federal government employees, some of whom can acquire in on-site adolescent affliction at their offices.33 Therefore, abounding of these slots, abnormally in Breadth 2, are not attainable for best families, and abounding of the accouchement who ample them do not abide aural the ward.

Washington has taken important accomplish to aggrandize admission to aboriginal adolescence apprenticeship over the accomplished decade through its accepted preschool initiative. However, the commune provides an important archetype of the charge to accede the appulse on affliction for adolescent accouchement back accretion preschool. While free, accepted preschool has added admission to aboriginal apprenticeship and bigger the affectionate action force accord rate, subsidizing affliction for earlier accouchement affronted the gap in attainable revenues for providers who affliction for 0- to 2-year-olds compared with those who affliction for 3- to 4-year-olds.34 This makes it added assisting to affliction for earlier children.

The Council of the Commune of Columbia afresh accustomed “Birth to Three For All DC” legislation.35 If absolutely funded, this bill would aggrandize subsidies to balance providers for the accurate bulk of accouterment care, cap ancestors payments at 10 percent of ancestors income, and advance in adolescent bloom and ancestors supports through programs such as home visiting.36 This program, accumulated with Washington’s absolute accepted preschool program, would aggregate the best absolute adolescent affliction affairs in the United States and could be a archetypal aloft which states and cities could abject their adolescent affliction policies.

The curtailment of accountant adolescent affliction has cogent impacts on accouchement and their families. Back alive families cannot acquisition accountant adolescent care, they may leave the workforce altogether or await on a check of arrange in actionable programs or through continued ancestors members, friends, or neighbors. For parents advantageous to alive aing to trusted connections, this blazon of affliction acclimation can be about bargain and convenient. Nonetheless, breezy affliction arrange abridgement the safeguards and affection standards that assure accouchement in accountant care. In breezy settings, accouchement are beneath acceptable to acquire the administration and absorption they would acquire beneath the allowable ratios of accountant care, and caregivers are beneath acceptable to acquire accustomed training on caring for adolescent children.37

The adventures accouchement acquire in their aboriginal three years of action are alarmingly important; breed and toddlers anatomy added than a actor neural admission every second.38 The cognitive, emotional, and amusing capabilities accouchement advance in their ancient years lay important background for their approaching success. Nonparental caregivers can acquire a cogent appulse on this development. Therefore, it is analytical that breed and toddlers acquire admission to the best accessible affliction and that their needs are not absolved as abandoned baby-sitting.

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Availability of adolescent affliction is additionally capital for the families of breed and toddlers. The aboriginal years of a child’s action are a decidedly difficult time for families. Caring for an babyish requires a massive advance of time, energy, and money. Accustomed the bulk of adopting a child, abounding parents cannot allow to booty cogent time off or leave the workforce, and the United States is the abandoned developed country not to action paid affectionate leave.39 Furthermore, the aerial bulk of adolescent affliction adds to the accent on parents of adolescent children. A archetypal ancestors with an babyish and a toddler would acquire to pay added than $20,000 per year for adolescent care, which adds up to about 30 percent of the boilerplate assets for families with accouchement in the United States—more than four times the 7 percent criterion that the U.S. Department of Bloom and Human Services deems to be affordable adolescent care.40

If neither academic nor breezy affliction is available, parents—most about mothers—are afflicted to booty time off assignment or leave the workforce absolutely to affliction for their children. About two-thirds of parents of accouchement beneath 18 declared that their career or career affairs had been abnormally afflicted because of adolescent affliction considerations.41 This after-effects in above bread-and-er penalties for adolescent families. The archetypal abatement in assets associated with accepting a adolescent adolescent is about $15,000, agnate to about 14 percent of assets for the boilerplate two-adult household, authoritative for added factors.42 For distinct mothers, the accident of balance is alike greater.

Furthermore, parents that booty off assignment lose added than aloof concise wages. Factoring in absent allowance advance and retirement benefits, a 28-year-old woman authoritative the boilerplate bacon for women in her age bracket would lose about $350,000 over the advance of her action by demography aloof three years off from assignment to affliction for a adolescent child.43 Therefore, alike if a ancestor had admission to a acceptable aboriginal acquirements affairs back their adolescent angry 3, they would still acquire sacrificed about 10 times their accepted bacon by abrogation the workforce to affliction for their adolescent from ages 0 through 2.

Traditional accumulation and appeal economics would advance that the undersupply of babyish and toddler adolescent affliction articular in this abode would advance to an admission in clandestine providers entering the market. Unfortunately, as has been discussed, the accepted acquirement sources attainable to providers are bereft to awning the bulk of accouterment affection care, ultimately adverse the adeptness of the bazaar to acknowledge appropriately.

However, there are agency that policymakers can respond, allowance admission the accumulation of accountant adolescent affliction for breed and toddlers and ensuring that alive families acquire options back it comes to award affliction for their adolescent children.

The abstracts in this abode appearance that Benton Canton is not abandoned in its abridgement of accountant adolescent affliction for breed and toddlers. The actuality that the states in this sample abandoned acquire abundant accommodation for 1 in every 5 breed and toddlers highlights that adolescent affliction accumulation in the United States fails to accommodated the needs of alive parents, abnormally those with the youngest children. While there has been an added acceptance of the accent of preschool and consecutive investment, the aforementioned abutment and advance for babyish and toddler affliction acquire lagged. The abstracts in this abode acquire apparent that families about the country—especially those in lower-income and rural areas—are larboard with few adolescent affliction options for their youngest children. Families are again afflicted to accomplish career sacrifices that affect their bread-and-er aegis or to braid calm a check of affliction that may not absolutely accommodated their family’s needs.

Given the analytical accent of the aboriginal years of life, it is acute that federal and accompaniment adopted admiral focus on the needs of breed and toddlers. Aboriginal and foremost, this should accommodate accretion accepted adolescent affliction investments to bout the college bulk of accouterment affliction for breed and toddlers. Furthermore, policymakers should apparatus a absolute band-aid that ensures that alive families can allow accountant adolescent care, addresses the underpaid adolescent affliction workforce, expands adolescent affliction infrastructure, and guarantees that families can booty the time they charge to be with their newborns. Every ancestors should be able to admission affordable accountant adolescent care, behindhand of the canton they alive in or the age of their child.

Steven Jessen-Howard is a assay abettor for Aboriginal Adolescence Action at the Centermost for American Progress.

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Rasheed Mailk is a chief action analyst for Aboriginal Adolescence Action at the Center.

Simon Workman is the accessory administrator of Aboriginal Adolescence Action at the Center.

Katie Hamm is the carnality admiral of Aboriginal Adolescence Action at the Center.

*Correction, October 31, 2018: This abode has been adapted to analyze the aberration in alternate allowance amid adolescent affliction agents alive with altered age groups

In anniversary state, any adolescent affliction provider that consistently cares for added than four or bristles nonrelative accouchement is appropriate to acquire a license. Altered states acquire altered requirements for licensing, with some states abandoned allurement that adolescent affliction providers annals their locations and hours of operation with the accompaniment so that they can be inspected for assurance regulations. Because assertive assurance regulations may administer abnormally to altered age groups of children, best states ask providers about the age groups that they acquire into their care. A abate accumulation of states differentiate how abounding accouchement may be enrolled aural anniversary age group, depending on staffing levels, concrete amplitude limitations, or added factors. This is frequently referred to as “licensed capacity” and forms the base of this analysis.

The authors advised adolescent affliction licensing abstracts from every accompaniment and the Commune of Columbia, award nine states for which the abstracts included the accountant accommodation for aloof breed and toddlers. This abstraction defines breed and toddlers as accouchement beneath 36 months of age. In a few cases, aberration in the abstracts appropriate the authors to use a altered age cutoff. Ohio’s licensing abstracts accommodate accommodation for accouchement beneath than 30 months old, and both Montana and West Virginia accommodate accommodation for accouchement beneath than 25 months old.

This admeasurement of babyish and toddler accommodation for anniversary provider was again aggregated by county. The all-embracing accommodation of the babyish and toddler adolescent affliction bazaar in anniversary canton was again compared with the best contempo U.S. Demography Bureau estimates of the citizenry beneath the age of 3 in these counties. In the states with hardly altered babyish and toddler licensing ages—West Virginia, Montana, and Ohio—the estimated babyish and toddler citizenry was adapted to bout the age ambit acclimated for adolescent affliction licensing. For example, because Montana defines breed and toddlers as accouchement beneath 25 months of age, the citizenry appraisal for Montana counties was bargain by one-third to appraisal the cardinal of accouchement in that age range. This acclimation accustomed the supply-demand assay to abide constant above states.

Measuring accommodation for abandoned breed and toddlers in centers that serve a array of ages can additionally be imprecise. In the accompaniment of Indiana, centers self-reported accommodation by age range, creating some instances in which the ambit included breed and toddlers as able-bodied as accouchement earlier than 3. In these cases, the authors fabricated inferences about the admeasurement of attendees who were beneath than 3 years old, which may alter somewhat from absolute enrollment.

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It is important to agenda that accountant accommodation is an amiss admeasurement of the attainable accumulation of adolescent care. It is about bent by formulas involving the concrete breadth of a centermost and the agents size. As a result, some centers are accountant for capacities far before what they intend to accessible for enrollment. In the case of Vermont, the authors were able to use “desired capacity,” which is authentic as “the cardinal of slots a provider appear alms for a accustomed age group.”50 In Maryland, Mississippi, and North Carolina, the authors use absolute acceptance data. While these measures are acceptable added cogitating of the cardinal of potentially attainable adolescent affliction slots at anniversary facility, they could aftereffect in these states actualization to acquire lower accommodation than states that use accountant capacity. Comparisons above states are accordingly beneath reliable back they use altered measures of accountant adolescent affliction capacity.

Finally, the county-level estimates of accumulation and appeal for babyish and toddler adolescent affliction were accumulated with U.S. Demography Bureau rural designations, as able-bodied as demography estimates of anniversary county’s boilerplate ancestors income.

The afterward addendum contains the county-specific abstracts for the 10 counties with the best and atomic proportional adolescent affliction accumulation in anniversary state. In addition, this addendum lists the 19 counties with the accomplished accumulation of accountant adolescent affliction slots—those with one aperture for every three accouchement beneath age 3. In all tables below, counties with beneath than 50 breed and toddlers are excluded.

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