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COMMITTEE ON THE EARLY RELATIONAL HEALTH DETERMINANTS OF FUTURE HEALTH AND WELL-BEING

DAVID W. WILLIS (Chair), Nurture Connection, Georgetown University

MICHAEL ARENSON, Hennepin Healthcare and University of Minnesota

ELISABETH BURAK, Georgetown University

DOMINIQUE CHARLOT-SWILLEY, Georgetown University

DANI DUMITRIU, Columbia University

ANDREW GARNER, Case Western Reserve University and University Hospitals of Cleveland

ANDREA GONZALEZ, McMaster University

CHARLYN HARPER BROWNE, Independent Consultant

JUSTIN A. LAVNER, University of Georgia

BARBARA ROGOFF, University of California, Santa Cruz

MICHELLE SARCHE, University of Nebraska

Consultants

SHAYLA COLLINS, University of Washington

ANDRÉANE LAVALLÉE, Columbia University

Study Staff

EMILY P. BACKES, Study Director

MAYA REDDI, Research Associate

STACEY SMIT, Program Coordinator

BOARD ON CHILDREN, YOUTH, AND FAMILIES

JONATHAN TODRES (Chair), Georgia State University College of Law

TAMMY CHANG, University of Michigan

DEBRA FURR-HOLDEN, New York University

ANDREA GONZALEZ, McMaster University

NIA HEARD-GARRIS, Northwestern University Feinberg School of Medicine

NANCY E. HILL, Harvard University

CHARLES HOMER, Economic Mobility Pathways

MARGARET KUKLINSKI, University of Washington

MICHAEL C. LU, University of California, Berkeley School of Public Health

STEPHEN W. PATRICK, Vanderbilt University Medical Center

JENNY S. RADESKY, University of Michigan Medical School

STEPHEN RUSSELL, The University of Texas at Austin

JANE WALDFOGEL, Columbia University School of Social Work

JOANNA L. WILLIAMS, Search Institute

Staff

NATACHA BLAIN, Senior Board Director

EMILY P. BACKES, Deputy Board Director

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

MARGARITA ALEGRIA, Departments of Medicine and Psychiatry, Harvard Medical School; Chief, Disparities Research Unit, Massachusetts General Hospital

APRIL JOY DAMIAN, Vice President, Moses/Weitzman Health System; Director, Weitzman Institute, Washington, DC

WALTER S. GILLIAM, Executive Director, Buffett Early Childhood Institute, University of Nebraska

JONATHAN D. KLEIN, Marron and Mary Elizabeth Kendrick Professor of Pediatrics and Chief, Division of Adolescent Medicine, Stanford University

JOAN L. LUBY, Director, Early Emotional Development Program, Washington University School of Medicine

ALAN L. MENDELSOHN, Director, Division of Developmental-Behavioral Pediatrics, New York University Grossman School of Medicine and NYC Health+Hospitals/Bellevue

JOSHUA SPARROW, Executive Director, Brazelton Touchpoints Center at Boston Children’s Hospital; Associate Professor of Psychiatry, Harvard Medical School

ED TRONICK, Professor of Psychology, Psychiatry, and Pediatrics, Emeritus, University of Massachusetts, Boston and University of Massachusetts Chan Medical School

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by ELENA FUENTES-AF-FLICK, Association of American Medical Colleges, and SUSAN J. CURRY, The University of Iowa. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Acknowledgments

This report would not have been possible without the contributions of many people. First, the committee thanks the Centers for Disease Control and Prevention and the Trust for Learning, which sponsored this study. We also thank the many organizations and individuals that support the mission of the Board on Children, Youth, and Families: The Burke Foundation, the New Venture Fund, the Renaissance Charitable Foundation/RCF Giving Fund, the Robert Wood Johnson Foundation, David V. B. Britt, Tammy Chang, Greg J. Duncan, Sherry Glied, Andrea Gonzalez, Nia Heard-Garris, Nancy Hill, Charles J. Homer, Kay Johnson, Margaret Kuklinski, Michael Lu, Daniel Menelly, Linda A. Nelson, Stephen Patrick, Jenny Radesky, Stephen Russell, Nisha Sachdev, Jonathan Todres, Jane Waldfogel, Joanna Williams, and Barbara L. Wolfe.

Many individuals volunteered significant time and effort to share their perspectives, research, and personal experiences with the committee. We thank Alan L. Mendelsohn, Anne Seery, and Meredith Ansell, New York University Grossman School of Medicine; the American Academy of Pediatrics; Annie Davis Schoch, Katy Falletta, Rebecca Vivrette, and Sarah Crowne, Child Trends; Christina Bethell, Johns Hopkins Bloomberg School of Public Health; Claudia M. Gold, Hello Its Me Project; Craig Olsson, Jacqui Macdonald, Tracy Evans-Whipp, Juli Coffin, and Stephen Zubrick, Australian Early Relational Health Living Evidence Institute, SEED Centre for Lifespan Research; Division of Home Visiting and Early Childhood Systems, Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services; Dorothy T. Richardson, University of Massachusetts Chan Medical School; Jeffrey

Contents

Summary

1 Introduction

STUDY SCOPE AND METHODS

Study Scope

Study Methods

Information-Gathering Themes

GENERATIONAL AND CULTURAL ROOTS OF THE EARLY RELATIONAL HEALTH FRAMEWORK

EARLY RELATIONAL HEALTH: BENEFITS TO SOCIETY

ORGANIZATION OF THE REPORT

2 Understanding Early Relational Health

RELATIONSHIPS AS BIOLOGICALLY NECESSARY

Cycles of Relating, Rupture, and Repair

EARLY SENSITIVE PERIOD OF DEVELOPMENT

MOMENTS OF CONNECTION

Goodness of Fit

Caregiver Sensitivity

Bonding and Attachment

Intersubjectivity and Shared Intentionality

Empathy

MANIFESTATIONS OF EARLY RELATIONAL HEALTH

THE IMPACT OF EARLY RELATIONAL HEALTH

Early Relational Health and Children’s Health and Well-Being

Early Relational Health and Children’s Brain Development

EARLY RELATIONAL HEALTH AS A BUFFER AGAINST THE ADVERSE EFFECTS OF STRESS

Understanding Stress

Early Relational Health as a Buffer

EARLY RELATIONAL HEALTH AND POSITIVE CHILDHOOD EXPERIENCES

Expanding Understanding of Positive Childhood Experiences

CONCLUSION

3 Influences on Early Relational Health

INDIVIDUAL FACTORS

RELATIONAL FACTORS

RESOURCE FACTORS

Economic Security

Food Security

Housing Security

COMMUNITY FACTORS

Neighborhood Factors

Transportation Services and the Built Environment

MACRO-LEVEL FACTORS

Climate and Extreme Weather Events

Technology and Digital Environments

Cultural Connectedness

CONCLUSION

4 Supporting Early Relational Health in Early Childhood Systems

PUBLIC HEALTH APPROACH

KEY PRACTICES THAT ADVANCE EARLY RELATIONAL HEALTH IN EARLY CHILDHOOD SYSTEMS

1. Co-Design Local Solutions and Services with Family Participation in a Way That Is Community Driven and Culturally Specific

2. Prioritize Relationship-Building and Relational Practices Within Program Design for Family Support Programs and Systems and Implementation and Improvement Science

3. Provide Sustainable Reflective Supervision and Practices, Including Reflective Video Feedback, to Practitioners at All Levels in All Sectors of the Early Childhood System

4. Adopt Relational Abundance and Positive Family Assets Mindsets Using Relationally Focused, Healing-Centered Practices for Communities

5. Strengthen and Sustain Family Leadership Infrastructures in Communities

PROGRAMS AND INITIATIVES FOR ADVANCING EARLY RELATIONAL HEALTH

Individual- and Family-Level Efforts

Community-Level Efforts

System-Level Efforts

CONCLUSION

5 Opportunities for Policies and Investments to Advance Early Relational Health

POLICY FRAMEWORK FOR DECISION-MAKING

FINANCING OPPORTUNITIES TO ADVANCE EARLY RELATIONAL HEALTH

Opportunities in Medicaid to Advance Early Relational Health

Opportunities to Refocus Medicaid Policies on Young Children and Their Families

Other Financing Opportunities to Support the Health and Well-Being of Caregivers

POLICIES THAT SUPPORT FAMILIES IN MEETING BASIC NEEDS

Paid Family Leave

Economic Security

Food Security

COLLABORATION ACROSS SECTORS

Advancing the High-Performing Medical Home

POLICIES TO SUPPORT WORKFORCE DEVELOPMENT AND WELL-BEING

IMPLEMENTATION CONSIDERATIONS

CONCLUSION

6 Future Directions for Research

DEFINING EARLY RELATIONAL HEALTH CONSTRUCTS, PROCESSES, AND INDICATORS

EXPLORING RELATIONAL PROCESSES, CULTURAL VALUES, AND PRACTICES OF FAMILIES IN DISTINCT COMMUNITIES

IDENTIFYING OUTCOMES AND METRICS THAT ARE RELIABLE, VALID, AND STRENGTHS BASED AND REFLECT WHAT FAMILIES AND COMMUNITIES VALUE

IMPLEMENTING AND TESTING INTERVENTIONS THAT CAN BE SCALED AND SPREAD WITH IMPACT AND FLEXIBILITY FOR LOCAL COMMUNITIES

EVALUATING SYSTEM-LEVEL ACCOUNTABILITY

CONCLUSION

References

Appendix Committee Member and Staff Biographies

Boxes, Figures, and Tables

BOXES

S-1 Key Findings

1-1 Statement of Task

1-2 Early Relational Health as an Encompassing Concept

1-3 Indigenous Worldviews on Early Relational Health

2-1 Vignette of Moments of Connection

2-2 Examples of Questions Used to Assess Positive Childhood Experiences

4-1 Parent/Caregiver Perspectives

4-2 Principles for Advancing Early Relational Health Through Family Leadership

4-3 Smart Beginnings

4-4 The Pittsburgh Study’s Early Childhood Collaborative

4-5 Nurse Home Visiting Programs

5-1 Principles to Guide Policymaking Using the Early Relational Health Framework

5-2 Better-Financed Health Care Systems That Emphasize Prevention and Health Promotion

5-3 A Vision for Advancing Early Relational Health via Medicaid Policies

FIGURES

3-1 Parental well-being and relational capacity are shaped by concentric layers of influence

3-2 Rogoff’s lens metaphor for looking at children’s lives in ecological context, focusing on specific aspects while keeping others in the background

4-1 Comparing lead poisoning prevention and relational health promotion using the classic public health pyramid

4-2-1 The Pittsburgh Study’s Early Childhood Collaborative: A tiered approach to providing supportive parenting programs

TABLES

4-1 Positive Childhood Experience Domains Aligned with HOPE Framework Principles

4-2 Models Meeting HHS and MIECHV Criteria for Funding