The Minneapolis child care provider who attempted to hang a toddler last month and then fled her home might have been an extreme case, but industry experts say she reflects a broader problem of stress and isolation that can increase the risk of harm to children in day care.

Changes in child care regulations and practices have reduced the number of infants dying in Minnesota day cares due to unsafe sleep practices since 2013.

But there has been less attention to the 9,000 licensed home day care providers themselves and the challenges of monitoring highly active children day in and day out, often alone and often under chaotic conditions.

A Star Tribune review of 89 suspensions or revocations of family child care licenses so far this year found 22 instances in which children were physically abused by their providers, assistants or other adults living in the homes.

Some involved patterns of corporal punishment, such as a Rosemount provider who regularly flicked her finger at children’s mouths and caused vomiting by forcing food into one child’s mouth.

But state records described impulsive incidents, too. An Anoka provider hit a child so hard that he smacked into a slow cooker and cut his head. A New Hope provider threw a bowl at a child and whipped the child’s legs with a cord.

Such cases are rare, but can leave parents stunned.

Parents described Nataliia Karia as a dedicated child care provider, but then on Nov. 18 she reportedly said she “couldn’t take it anymore” and fled her Uptown Daycare in Minneapolis, where a parent found a baby alive but hanging from tights that had been fashioned into a noose.

“A case like this always puts everybody on alert about the sensitivity … of having a single caregiver providing for multiple children,” said Chuck Johnson, deputy commissioner for the Minnesota Department of Human Services, which enforces child care regulations in partnership with county inspectors.

Licensed family homes care for an estimated 80,000 children in Minnesota during school years and can be indispensable for working families in rural areas that lack large child care centers.

Given those huge numbers, abuse cases reflect the exception, not the rule, of family child care, said Barb Wagner, executive director of the Minnesota Licensed Family Child Care Association. But she is seeking grant funding to restore the association’s peer mentoring program, which ran out of money about three years ago, to give providers the outlets and support they need if they are feeling overwhelmed.

“I think it’s clear that providers just need someone to talk to,” she said.

Oversight of licensed day care homes is limited. Federally regulated food providers visit homes and are instructed to look for problems. And county inspectors check day care homes once every other year in Minnesota. A new federal mandate will require annual inspections by the state, but legislation to make that switch wasn’t passed in the 2016 Legislature. Lawmakers will consider it next year.

Johnson said parents are the best eyes and ears to detect problems in day cares and encouraged them to come forward — though some might hesitate to report suspicions that haven’t yet resulted in harm if it disrupts their child care routine.

“We really want the … parents to know what to be looking for,” he said.

Thoughts of self-harm

In addition to license revocations related to physical abuse, the Star Tribune found seven incidents of homes being shuttered this year due to children in care being touched inappropriately or sexually assaulted.

Another 53 homes have been temporarily shut down, but the state won’t disclose whether problems were related to abuse or other forms of maltreatment until it issues final penalties.

Not included in the Star Tribune tally of abuse cases was the shutdown of a South St. Paul day care home, where a provider confided that she no longer cared about her children, that she yelled at one child and wanted to slap another, and that she had thoughts of self-harm and inquired about a gun.

Dakota County inspectors were notified about her feelings and intervened before an incident such as the Uptown Daycare hanging ever had a chance to occur.

The 16-month-old hanged in the Uptown home survived. The provider, Karia, has been charged with attempted murder. She also faces charges for hitting and seriously injuring two people with her minivan as she sped from her home.

Training requirements

A Star Tribune investigative series in 2012 revealed an increase in children dying in licensed homes, mostly infants placed in unsafe sleeping positions. Deaths declined from 11 in 2011 to one in 2014.

Three children have died in care this year, including a child confined by a Circle Pines day care provider to a crib covered by a lofted bed. The child died when he tried to get out and was pinned between the crib and loft.

Advocates worried that the public attention to cases of deaths and neglect — and the heightened regulations that followed — would drive some providers out of the business. The number of licensed providers has declined — from 11,104 in 2012 to 8,985 this June — raising concerns about the state’s day care supply.

Wagner said many extraordinary and loving providers remain — but that even the best need to take time for themselves:

“They don’t take time off because they don’t want to inconvenience their families. I always tell them, ‘you have to take that time off for you.’ ”

Providers must complete 16 hours of annual training to keep their licenses and can choose courses on stress and anger management.

Lois Nilson, who manages Hennepin County’s child care licensing, encourages providers to take the courses, give themselves respite, find colleagues for support, and alert anyone if they are struggling.

“This is a stressful job,” she said, “[Providers] need to make sure they are reaching out for support if they feel they need it.”