Early Relational Health: Building Foundations for Child, Family, and Community Well-Being (2025)
Chapter: Summary
Summary
Early relational health, or the dynamic process of mutual, meaningful, and affirming moments of connection in the youngest relationships, is foundational in shaping lifelong physical, behavioral, and mental health. These early relational experiences, expressed through varied cultural pathways, serve as a key ingredient of early learning and well-being. They shape brain architecture; regulate stress physiology; and scaffold emotional, behavioral, cognitive, and physical development. Importantly, the development of early relational health cannot be separated from the broader health of families and communities. Though poor early relational health does not exclude the possibility for health, well-being, and flourishing across the lifespan, early relational health plays a powerful role in promoting lifelong well-being.
Communities, families, and caregivers across cultures and backgrounds have long understood the importance of connection and relationships for human development. Researchers, clinicians, and practitioners in disciplines across the developmental, educational, health, and social sciences have focused on these early relationships as a seminal source of wellness and flourishing. Rooted in these long-standing family and community perspectives and scientific understandings, the concept of early relational health has been introduced more recently as a framework and orientation anchored to families and communities as they care for their children and to the societal and policy choices that support them. When life’s challenges emerge, as they certainly will, a focus on early relational health can also identify opportunities for community- and society-wide relational supports, healing, and recovery.
In response to a request from the Centers for Disease Control and Prevention, the National Academies of Sciences, Engineering, and Medicine convened a committee of experts in child development, pediatrics, infant and early childhood mental health, child and family policy, neuroscience, psychology, parenting, and cultural research. This committee was asked to review the early relational health drivers of future health and well-being for infants, children, and families, focusing on future directions for research, policy, and practice to advance early relational health across health care, early care and education, and other community settings. In this report, the committee spotlights the current state of knowledge on early relational health as it pertains to early childhood and human development, infant and early childhood mental health, early childhood physical health, education, and learning. The report highlights the contexts and conditions that advance the health, well-being, and flourishing of children, families, and communities.
EARLY RELATIONAL HEALTH: BASIC TENETS
Relationships are biologically necessary for healthy development, wellbeing, and flourishing. Relational health evolves throughout the lifespan. However, the biological systems that support life course relational health develop during sensitive periods early in life. Early relational health begins with mutual, meaningful, and affirming moments of connection. These moments can occur in any context where children spend time, such as in families, in care settings, and in communities. They may include activities such as reading aloud, play, or interactive activities with nature.
Early relational health develops through a complex, dynamic, and cumulative process that includes a child’s genetic predisposition and social, physical, community, and societal experiences. It is experienced differently by each individual and manifests in person-, family-, and community-specific ways.
The committee identified research to date that encompasses a multitude of constructs related to early relational health. These constructs include secure attachments; emotional connection; caregiver sensitivity; emotional availability; caregiver behavioral predictability/unpredictability; coregulation and bonding; shared attunement; biobehavioral synchrony; family resilience and connection; positive or benevolent childhood experiences; and safe, stable, and nurturing interactions. Across these relational constructs, the report emphasizes that all relationships central to building relational health are shaped by the family and community environments in which they occur.
Early relationships provide the context in which young children experience trust and coregulation, build and sustain secure attachment, and
learn the concepts of societal reciprocity. Early relational health also affects children’s development by serving as a protective factor that can buffer against the adverse impacts of stressors, challenges, and adversities (i.e., moderating effects):
- A large and robust literature provides clear evidence for linkages between early relational health and children’s short- and long-term health and well-being. Overall, better early relational health is associated with positive outcomes in multiple domains, including (a) social-emotional well-being and mental health, (b) relational outcomes, and (c) physical health.
- Neuroscientific evidence has shown that sensitive caregiving in early life supports neurodevelopment. A small body of literature, including some randomized controlled trials, suggests that early relational experiences may be associated with the development of brain structure and connectivity throughout childhood, adolescence, and young adulthood.
- There is growing evidence that early relational health—and positive relationships during childhood more generally—can serve as protective factors that buffer against the adverse impacts of stressors on children’s stress biology, physical health, and psychosocial functioning.
Early relational health is not a fixed trait. Cycles of relating, rupture, and repair are inevitable in relationships, and children and caregivers can heal their relationship and reconnect. The inherent plasticity of the young brain means that early childhood experiences, both beneficial and adverse, have a profound ability to influence the long-term structure and function of the brain.
Individual, relational, community, and societal factors influence early relational health. Characteristics of individuals (e.g., caregivers’ history, current functioning, and caregiving behaviors; child’s characteristics and temperament) within the relationship influence early relational health. At the relational level, there is evidence of associations between early relational health and both the parents’ couple relationship and the coparenting relationship, as well as involvement of other family members such as siblings and grandparents. Early relational health is also shaped by the environmental system in which the family participates (e.g., social drivers of health, early care and education, health systems, and neighborhoods and communities). Understanding these factors can inform policy and program interventions to enhance early relational health and advance children’s flourishing and long-term outcomes. The committee’s key findings are outlined in Box S-1.
BOX S-1
Key Findings
- Relationships are biologically necessary for healthy development, wellbeing, and flourishing.
- Relational health evolves throughout the lifespan. However, the biological systems that support life course relational health develop during a sensitive period early in life.
- Early relational health develops over time through moments of connection. These moments can occur anywhere children spend time and socialize, such as in family, care, and community settings.
- Early relational health is experienced differently by each individual and manifests in person-, family-, and community-specific ways.
- Early relational health benefits every child, family, and community, shaping pathways for health and well-being across the life course. It is associated with positive psychological, social, and physical health outcomes, and it can buffer against the adverse effects of stressors, challenges, and adversities.
- Early relational health develops through a complex, dynamic, and cumulative process that includes a child’s genetic predisposition and social, physical, community, and societal experiences.
- Early relational health is shaped by many levels of influence, ranging from individuals, familial and extrafamilial relationships, community organization and systems, public policy, and social and environmental characteristics.
- The absence of adversity is not sufficient to promote early relational health. Neither does the presence of adversity foreclose early relational health. Supportive relationships, even in adverse contexts, can support healthy development and contribute to resilience.
- Systems, programs, and initiatives intended to promote early relational health need to facilitate and maintain connections at multiple levels (interpersonal, familial, community, and societal).
- Research and practice are strengthened by building family and caregiving voices, experiences, and cultural perspectives into the understanding of early relational health.
- A tiered, multifaceted, and cohesive approach is needed to promote early relational health and to prevent and mitigate barriers to early relational health. Building on a public health approach, supports for early relational health include societal, universal supports for promoting healthy relationships; preventive and targeted interventions across sectors; and indicated treatments in case of difficulties.
- Investments are needed to ensure that resources and solutions to challenges are family driven, community based, culturally responsive, and available to all families.
- Shared power and decision-making of families and communities, together with practitioners, are critical for creating supportive relational systems and environments.
SUPPORTING EARLY RELATIONAL HEALTH IN EARLY CHILDHOOD SYSTEMS
Promoting early relational health begins with both acknowledging individual children’s strengths and needs and understanding and supporting the caregiving of the adults, families, and communities in relationship with them; reducing adversity is important but insufficient to promote early relational health. Early relational health is enhanced when families are part of communities with a wide range of trusted resources. Public policy can both create the conditions for connectedness and provide the investments needed to seed and scale family-driven and community-based solutions when problems occur.
Systems, programs, and initiatives intended to promote early relational health need to facilitate and maintain connections at multiple levels. Interpersonal connection includes, for example, developmentally and culturally appropriate play and interactive activities, such as those offered by Reach out and Read and PlayReadVIP. Support for familial connections includes home visiting, peer and family caregiving supports, and mental health supports. Community connection is supported through, for example, family resource centers; proximity to green spaces and nature; and safe, connected neighborhoods. Societal supports for connection include adequate income, housing, food, employment, childcare, and paid family leave.
Developing and expanding a tiered, multifaceted, and cohesive approach to promote, prevent and mitigate barriers to, and repair ruptures in early relational health is also essential. A tiered public health approach includes societal, universal supports for promoting healthy relationships (e.g., public awareness campaigns); preventive and targeted interventions across sectors (e.g., a relational health workforce, home visiting services); and indicated treatments that repair strained relationships (e.g., access to programs such as Attachment and Biobehavioral Catch-up, Child-Parent Psychotherapy, and Parent-Child Interaction Therapy).
Because early relational health manifests in person-, family-, and community-specific ways, investments are needed to ensure that resources and solutions are family driven, community based, culturally responsive, and available to all families. Systems need to be incentivized, organized, and held accountable through policies that serve family and community relationships and connectedness.
An early relational health approach that attends to the needs of every child and family requires shifting from a deficit-based to an asset-based approach, recognizing and nurturing the unique and varied strengths of each family and community and their cultural values. The committee—drawing from the research literature, perspectives from scholars and practitioners, and its expert knowledge—identified five key principles for embedding
early relational health in early childhood programs and initiatives and child health system transformation:
- Co-design local resources and solutions to challenges with family participation in a way that is community driven and culturally specific.
- Prioritize relationship-building and relational practices within program and practice design and evaluation, implementation studies, and improvement science.
- Provide sustainable reflective supervision and practices, including reflective video feedback, to practitioners at all levels of the early childhood system.
- Adopt a relational abundance and positive family and community assets-based mindset using relationally focused, healing-centered practices for communities.
- Strengthen and sustain family leadership infrastructures in communities.
These principles can inform programs, practices, and initiatives that aim to promote early relational health within a tiered and integrated public health approach. The public health framework emphasizes that population-level approaches to early relational health need to go beyond identifying individual risks and instead focus on designing communities and systems that make strong relationships easier to form and maintain.
Efforts at the individual and family levels include models for supporting early relational health in pediatric primary care (e.g., HealthySteps, Smart Beginnings), evidence-based home visiting, early care and education (Head Start and Early Head Start, Native language immersion), and child welfare settings (Strengthening Families Approach, Safe Babies Initiative). Efforts at the community level include community and perinatal peer supports, community design and planning (e.g., proximity to green spaces, safe streets, and traffic-calming measures), and public awareness and education efforts (Little Moments Count, Small Moments Big Impact). Finally, several federal efforts support early relational health at the system level (e.g., Essentials for Childhood, Transforming Pediatrics for Early Childhood Program). Federal investments offer broad reach and scalability and provide funding to states, tribes, and jurisdictions that can be used to enable the implementation of evidence-based strategies that are responsive to each state’s needs and populations.
POLICY OPPORTUNITIES FOR SUPPORTING EARLY RELATIONAL HEALTH
Public policy and investments—federal, state, local, and philanthropic—can strengthen early relational health and promote child, family,
and community well-being. Policies can create conditions that facilitate family connections, meet basic needs, and support nurturing relationships. Evidence shows strong returns on investment from early learning programs, home visiting, and Medicaid coverage during pregnancy and early childhood. The report emphasizes a range of policy opportunities at the federal and state levels. Such opportunities will need to be coupled with investments and resources.
Financing Opportunities Through Medicaid
The health care system, with near-universal reach to infants and young children, can both provide a direct means for enhanced support to families and better coordinate linkages to other services and systems. As a major payer of child and adult health care, Medicaid is a policy linchpin and a programmatic strategy. Opportunities to advance early relational health within Medicaid include refocusing from the individual to the relationship through relational reimbursement; supporting team-based care models of primary care; modernizing Early and Periodic Screening, Diagnostic, and Treatment benefits and rules; financing community-based perinatal supports, including doulas and group pre- and postnatal supports; supporting perinatal substance use disorder treatment and peer supports; and braiding funding streams for family support and home visiting (e.g., Medicaid; the Maternal, Infant, and Early Childhood Home Visiting Program; the Temporary Assistance for Needy Families program; Title IV and V funding).
Opportunities to support early relational health by refocusing Medicaid policies on young children and their families include (a) rebalancing payment policies to prioritize prevention, elevate children’s earliest developmental needs, and center families; (b) reimbursing developmentally appropriate health interventions, including those that support parents and caregivers as key partners in children’s earliest development; and (c) ensuring continuous, consistent health coverage for children and their families. Public–private partnerships to advance early relational health also offer promising financing models, such as pay-for-success models applied locally.
Opportunities to Help Families Meet Basic Needs
Supporting early relational health necessitates ensuring families’ stable access to basic needs—such as housing, food, health care, and safety—since insecurity in these domains can elevate stress, disrupt caregiving capacity, and challenge relational stability. Paid family leave, currently enacted in 13 states and Washington, DC, can enhance parents’ opportunities to form connections and bond with their young children. Evidence from California shows significant increases in leave-taking by mothers and
fathers following implementation of a paid family leave policy. Policy opportunities to enhance families’ economic security include poverty-reducing tax credits such as the Earned Income Tax Credit and the Child Tax Credit, policies to increase minimum wage, and expanded support for early care and education. Programs such as the Supplemental Nutrition Assistance Program and the Special Supplemental Nutrition Program for Women, Infants, and Children can also reduce food insecurity and support early relational health.
Opportunities for Collaboration Across Sectors
Early relational health requires coordinated systems spanning health, education, family support, housing, and child welfare. Family leadership and partnerships are key. High-performing medical homes can be gateways that provide comprehensive, relational, and team-based care, meeting families where they are.
Opportunities to Support Workforce Development and Well-Being
Growing the pool of trained, community-based workers is another key leverage point for advancing early relational health, as investments in a relational workforce are investments in communities and families. It is crucial that this workforce is offered livable wages and a clear trajectory of career advancement. Similarly, supporting the well-being of the early care and education workforce through compensation, benefits, and other wellbeing supports can advance early relational health.
FUTURE RESEARCH DIRECTIONS
Research investments are urgently needed to advance foundational understanding of early relational health and to implement, scale, and disseminate promising policies, programs, and practices. The committee outlined an agenda for future research on proactive relational health promotion and intergenerational processes of healing that support health and well-being, to complement current research efforts on adversity and trauma. This agenda elevates family and community voice and calls for interdisciplinary collaboration to understand, measure, and support early relational health. It includes five priority research areas: (a) defining early relational constructs, processes, and indicators; (b) exploring relational processes through the lens of the cultural values and practices of families and communities across the nation; (c) identifying outcomes and metrics that are strengths based and that reflect what families and communities value; (d) implementing and
testing public messaging and early relational health interventions that can be scaled and spread with impact and flexibility for local communities; and (e) evaluating system-level accountability. Together, these priorities seek to build an actionable evidence base that can shape policy and drive change.
Several overarching principles can guide this research:
- Interdisciplinary studies: Embed methods and findings across disciplines and expand interdisciplinary studies across neuroscience, psychology, infant and early childhood mental health, social sciences, public health, pediatrics, nursing, social work, education, cultural anthropology, implementation/improvement science, and cultural knowledge systems, among others.
- Participatory research: Support longitudinal and participatory research designs that center families and communities.
- Population health measurement infrastructure: Advance an infrastructure—among researchers, in public health, and in communities—for measuring early relational health; this infrastructure could include common metrics, indicators, and public messaging that retain real-world relevancy across communities.
FINAL THOUGHTS
Ensuring early relational health for every child demands an expansion from focusing on preventing harm to investing in strengthening relationships and the contexts within which children and families thrive. It demands a reorientation from assessing a wide array of risks toward recognizing, uplifting, and supporting the strengths of families and communities. It requires supporting families and communities across the United States—in all their varied and vibrant forms—to engage in the moment-to-moment interactions that forge strong and enduring connections, nurture brains that are healthy and ready to learn, and ultimately build the nation’s prosperity. These moments happen amid a kaleidoscope of people, places, and policies: from the dinner table to the diaper changing table, from the laundromat to the grocery store to the doctor’s office, and from the bus and sidewalks in between. Early relational health must be supported within families and across communities and systems; every system and sector has a responsibility to invest in its promotion. This collective commitment will require system-level change, targeted investment, mindset shifts, and new ways of measuring and supporting human flourishing.
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