Early Relational Health: Building Foundations for Child, Family, and Community Well-Being (2025)
Chapter: 6 Future Directions for Research
6
Future Directions for Research
Chapter Highlights
- Future research on early relational health will need to expand to include relational health promotion and intergenerational mechanisms of healing and ensuring health and well-being across the life course.
- Additional research is needed to further understand the multiple constructs of early relational health and how they independently and/or synergistically relate to overall early relational health and how they differentially relate to health and well-being outcomes, such as school readiness.
- Support is needed for a broad portfolio of interdisciplinary research on the varied individual and interpersonal processes of early relational health.
- Research is needed on a broader scope of interventions to include the wider relational ecology around the child, including family networks, workplaces, and community settings.
- Research needs to intentionally use a strengths-based lens, including focus on positive childhood experiences that promote early relational health.
This report is grounded in a body of evidence demonstrating that early relational health benefits children, shaping lifelong health and well-being. Yet, additional investments are needed to enable foundational discoveries to advance understanding of early relational health; to develop greater understanding of family, community, and cultural aspects of relationality and development; and to bolster the implementation, scaling, and spread of promising programs, practices, resources, and solutions.
This chapter outlines an agenda for future research on promoting relational health and intergenerational mechanisms for healing and ensuring health and well-being, in addition to understanding the impact of adversity and its intergenerational effects on health. The committee identified five research priority areas: (a) defining early relational health constructs, processes, and indicators; (b) identifying relational processes, cultural values, and practices of families in distinct communities; (c) identifying outcomes and metrics that are reliable, valid, and strengths based, and that reflect what families and communities value; (d) implementing and testing public messaging and early relational health efforts 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: Integrate methods and findings across disciplines and expand interdisciplinary studies across neuroscience, pediatrics, nursing, social work, psychology, infant and early childhood mental health, social sciences, public health, education, cultural anthropology, implementation/improvement science, and family knowledge systems, among others.
- Participatory research: Support longitudinal and participatory research designs that center families and communities (see, for example, Wallerstein et al., 2018; Wilson, 2020).
- Population health measurement infrastructure: Advance an infrastructure—among researchers, in public health, and in communities—for measuring early relational health at the population level, with efforts to support healthy relationships and to mitigate potential risks and harms; this infrastructure could include common metrics, indicators, and public messaging tailored to communities.
DEFINING EARLY RELATIONAL HEALTH CONSTRUCTS, PROCESSES, AND INDICATORS
Although decades of research confirm the importance of early relational health and its contribution to the health and well-being of parents/
caregivers and children, to date, constructs have largely been studied independently (Dumitriu et al., 2023). Additional research is needed to generate a more comprehensive picture of early relational health: how constructs independently and/or synergistically relate to health and well-being outcomes (Dumitriu, 2024; Dumitriu et al., 2023; Nevarez et al., 2018; Petrova et al., 2024).
Moreover, efforts are needed to examine the multiple intersecting influences of early relational health across relationship types and ecological levels. A clear taxonomy of early relational health will need interdisciplinary development; it could leverage methods such as systematic reviews and meta-analyses to aggregate data already available. These efforts would be bolstered by longitudinal cohorts to understand how early relational health leads to long-term outcomes, such as later interpersonal relationship functioning, social connectedness, mental and physical health, and future flourishing, and to better assess sensitive periods and developmental changes. Such longitudinal research could also explore the impact of social drivers of health and policies for supporting healthy relationships, the promotion of healthy relationships or adverse impact, individual and contextual differences in both the formation and consequences of early relational health, and which early relational health constructs are most predictive of specific outcomes.
It will also be important to explore how families define relational health in their own words and contexts, document cultural caregiving practices that promote early relational health across a range of communities, explore how early relational health constructs operate across different family and community and relational contexts, and identify practices and family strengths that promote relational health and flourishing. Researchers also need to develop reliable measures that reflect the specific constructs of early relational health in families and within cultural and community contexts. This includes research that builds on the Flourishing Index from the National Survey of Children’s Health.1
Furthermore, much of the existing research on early relational health has focused on the family microsystem, often on the mother–child relationship. There is a need for research on the contributions of a broader array of family members and caregivers—including fathers, grandparents, siblings, and early educators—as well as research that captures the wider social ecology of child development, including extended kin and non-kin caregiving networks, community and early education settings, and the governmental and nongovernmental supports available to caregivers. Further, there is limited research about the biology of family systems in a range of community contexts (Gettler & Oka, 2016). A small but
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1 See https://nschdata.org/browse/survey/results?q=10092&r=1.
growing body of empirical research has demonstrated that there are neural, hormonal, and other biological changes that accompany the transition to fatherhood and caregiving (Feldman et al., 2019; Gettler, 2014). Fathers affect children’s outcomes both directly and indirectly, but fathers remain understudied, particularly in terms of children’s physiology (Gettler & Barr, 2022). This work could benefit from new methods of social network analysis to better describe the complex systems of relationships around the developing child.
Specific questions of importance include the following:
- What are the processes through which early relational health develops, and how does an individual’s biological sensitivity to context influence that development? Given the heterogeneity in an individual’s sensitivity to context, what contextual features are most relevant for whom?
- What are the influences of other caregivers—fathers, grandparents, extended kin, day care providers, etc.—(and their interrelations) on caregiver and child well-being and development, and what is the impact of other important relationships, such as siblings and peers?
- What are the developmentally sensitive periods for promoting different early relational health constructs such as trust, coregulation, and mutuality?
- What processes are involved in creating synchrony, mutuality, and early relational health development across various contexts? How do cultural models of synchrony and mutuality vary in prioritizing dyadic versus larger group arrangements?
- What are the linkages between early relational and physical health, not only in childhood but across the life course?
- Which of the salient features of or inputs to early relational health are modifiable? What scalable interventions can be developed and deployed in various settings (e.g., pediatrics, doulas, home visiting, educational settings) to influence these modifiable features and inputs?
- What family strengths and practices promote early relational health?
- What is the impact of poverty, housing instability, and food insecurity on early relational health, and what protective factors may mitigate these risks?
- How do influences at the individual, relational, community, systemic, and broader sociopolitical levels, including global forces such as climate change, interact to shape early relational health, and how might these interconnected factors either strengthen or undermine it?
- How do neighborhood safety, childcare availability, and social cohesion support or hinder healthy early relationships?
- How does screen use by either the child or parent in the early years shape early relational health between parents and children? How does this vary by child age, type of device and tech (e.g., AI), and other contextual factors (e.g., parental stress, household chaos, access to extracurricular activities and community support programs)?
EXPLORING RELATIONAL PROCESSES, CULTURAL VALUES, AND PRACTICES OF FAMILIES IN DISTINCT COMMUNITIES
Much of the existing literature uses measures and procedures developed among middle-class European-heritage children and families, reflecting their cultural values and practices. Broader research could examine variations in family and community practices and values that contribute to child development and could observe the strengths and challenges of distinct communities. This will require an expansive portfolio of research methods, especially focusing on in-depth methods that involve observing the practices and listening to the values of families in the communities studied. To develop measures that can be used across communities requires research examining the applicability of measures in ways that maintain fidelity to the distinct communities’ practices and values. Developing supports for the well-being of children and families in different communities requires foundational research on local cultural values and practices, as well as procedures for tailoring interventions to local circumstances.
A pressing need, therefore, is to expand the supports for a research portfolio on the multiplicity of processes of early relational health. Research training needs (a) to be expanded into a range of research methods necessary to develop conclusions that apply to children and families broadly and (b) to include greater emphasis on increasing expertise in carrying out and interpreting this broader cultural research scope (including in middle-class European-heritage communities).
Specific questions of importance include the following:
- How do multigenerational caregiving relationships influence early relational health in children under 5 years of age?
- What caregiving practices are used and enhance early relational health in culturally distinct communities?
- What are valid and culturally responsive methods to develop tools for measuring early relational health in various populations?
- How do families in different communities describe early relational health? What are they trying to promote for their children?
IDENTIFYING OUTCOMES AND METRICS THAT ARE RELIABLE, VALID, AND STRENGTHS BASED AND REFLECT WHAT FAMILIES AND COMMUNITIES VALUE
Looking toward the future of measurement, a shift in principles is needed from a deficit-focused approach to one that centers family strengths and community-defined priorities. A strengths-based approach centers relationships rather than deficits and captures connection, mutuality, and coregulation; such an approach broadens the lens from understanding adversity and intergenerational transmission of trauma to one that captures relational health and intergenerational transmission of health and well-being. Measures will need to be applicable and feasible across child-serving systems (including pediatric, home visiting, and early care and education systems); monitor relational strengths, risks, resilience, and protective experiences; be grounded in developmental science; and span the prenatal through early childhood period.
Future measurement strategies need to reflect what matters most to families and communities and include caregiver and community voices in both data interpretation and tool design. Consideration of costs and benefits of different measurement strategies is also needed. The development of early relational health measures, interventions, and research agendas will need to meaningfully engage families and communities as co-creators with commensurate resources to compensate for their time and expertise. Established participatory and community-led research approaches can help ensure that the questions asked, tool development, and interpretation of data all reflect lived experience and contextual relevance (see, e.g., Wallerstein et al., 2018; Wilson, 2020). Moreover, researchers will need opportunities for professional development and reflective practice and supervision to engage in such partnerships.
Understanding the drivers of early relational health would be enhanced by a broader understanding of relational health itself. The development of multilevel, integrated indicators of relational health (e.g., indicators of connections and mutuality) could measure changes in relational health at the individual, population, and systems levels and could combine indicators of relational strengths and risks at each ecological level in a way that recognizes how dyadic, familial, neighborhood, and community relational experiences co-evolve and influence one another. Examples could include dyadic strengths measures, such as engaged and attuned caregivers, and dyadic adversity measures, such as abuse and neglect; family strengths measures, such as social connectedness and social capital, and familial adversity measures, such as intimate partner violence and parental stress; neighborhood strengths measures, such as belonging and cohesion and access to social groups, and neighborhood adversity measures, such as home abandonment, community violence and danger, and social isolation; and finally, cultural strengths measures, such as social networks, micro acts of kindness, and
media celebrating interpersonal support, and cultural adversity measures, such as racism, hate crimes, microaggressions, and media covering violence and extremism. Such an effort may take time, and potential risks and harms will need to be carefully weighed and mitigated by child-serving agencies together with communities (see, e.g., Call et al., 2023; Heifetz et al., 2009). While the committee recognizes current limitations of the available data, it nonetheless offers a vision for the future.
IMPLEMENTING AND TESTING INTERVENTIONS THAT CAN BE SCALED AND SPREAD WITH IMPACT AND FLEXIBILITY FOR LOCAL COMMUNITIES
Although the knowledge base supporting early relational health is expanding rapidly, gaps remain in the data needed to guide policy and practice. Additionally, many existing systems are not equipped to measure the full scope, quality, or ecological complexity of early relational health. As the field works to move from understanding to building systems that promote early relational health, implementing and evaluating scalable and spreadable interventions will play an important role in bridging science and practice. This includes understanding what works, for whom, and in what contexts.
Next-generation research questions will seek to better understand the following:
- How systems and policymakers in partnership with communities can build and tailor programs to respond to local strengths, values, and practices
- How to integrate and/or sequence programs to produce more meaningful, lasting outcomes
- How to use a strengths-based perspective to scaffold families’ experiences of navigating systems, empowering them to make decisions that fit their needs best
- How to expand access for families facing barriers to early relational health, ensuring they have access to and can benefit from programs
- How to better connect those on the ground (practitioners/implementers) with researchers to strengthen the evidence base and the field’s understanding of the breadth and depth of available early relational health interventions
- The extent to which early relational health–focused systems of care can yield public health benefits and returns on investment
- In what ways health care, social services, and education systems could better coordinate to support early relational health across the life course
- What policies can foster collaboration between local communities and formal systems
- How investment in community infrastructure (e.g., safe housing, green space, family-friendly workplaces) can strengthen the conditions for relational health
- How researchers, practitioners, and policymakers can co-produce knowledge that informs responsive and sustainable policy solutions
At the same time, while many existing interventions exclusively target populations facing barriers to early relational health (often termed “at risk”), future interventions need to include those that benefit families across all settings. This requires a reorientation away from treatment and toward health promotion. Addressing these issues will require broadening the scope of interventions to include the relational ecology around the child, including family networks, community settings, and workplaces that support caregiving. More intentional trial designs and implementation studies are needed to adapt, personalize, and scale programs based on the varying needs of families and communities, ensuring real-world impact and long-term relational health for children (Olsson et al., 2025).
In addition to designing effective interventions, future research will need to explore how to build and sustain systems of care for supporting early relational health. These must be ecologically grounded, relationally organized, and meet families where they are. Implementation and improvement science can guide the development of relational referral systems, integrated care models, and public health strategies that center relationships beyond a singular focus on diagnoses or service eligibility. These methods also offer tools for understanding how best to scale and spread promising practices, including examining fidelity, integrity (flexibility for local context), and sustainability in real-world settings (see, e.g., Berwick, 2008; Bryk, 2021; Pawson & Tilley, 1997). To ensure that early relational health science is translated into action, future research will need to do the following:
- Develop tools for easily and quickly quantifying early relational health “in the field”; such tools need to be based in research with distinct communities and have the flexibility to adapt to those distinct communities.
- Pilot and test which early relational health policies result in stronger flourishing, as measured by population-based tools, and credible return on investment strategies.
- Pilot and test the best strategies for integrating early relational health into clinical practice, leveraging insights from implementation and improvement science.
- Measure the community impacts of deploying a universal early relational health workforce that has skills in adapting to local cultural values and circumstances.
- Identify what and where are the most impactful early relational health promotion messages in communities.2
- Develop tools for strengthening referral pathways to services and increasing exposure to services, and for supporting efforts to meet families where they are.
- Evaluate the effectiveness of different training models and identify best practices for integrating early relational health principles into research training and professional practice.
EVALUATING SYSTEM-LEVEL ACCOUNTABILITY
Embedding early relational health into measurement systems—particularly those linked to payment, quality improvement, and public health monitoring—can elevate its visibility and empower communities to hold systems accountable for outcomes. When designed thoughtfully, early relational health metrics can help ensure that all families receive the support needed to build connectedness. Public health monitoring systems are well positioned to embed relational health indicators—such as caregiver–child connection, community trust, and family resilience—into ongoing monitoring systems (see, e.g., Bethell et al., 2023). State- and local-level innovation in early relational health monitoring (e.g., through Title V, Early Childhood Comprehensive Systems, and Pregnancy Risk Assessment Monitoring System [PRAMS] modules) offers examples of how public health systems can elevate relational drivers of health.
Future research and data-gathering efforts need to (a) strengthen place-based, community-led monitoring systems that monitor health and development from early childhood through to young adulthood, with a focus on the quality of relationships in their everyday social networks; (b) embed these monitoring activities within robust community-based participatory research frameworks that ensure collaboration between families, community leaders, government, early childhood practitioners,
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2 Importantly, the context of rapidly evolving technology and digital environments is an understudied area of influence on early relational health (see Mackay et al., 2022).
and researchers to co-design, interpret, and act on local data; and (c) use population-level relational data to target resources in real time (Olsson et al., 2025).
CONCLUSION
Investments in research on early relational health offer the potential to improve child well-being and to build a more connected, resilient, and thriving society. To advance that vision, researchers must understand and build on community strengths and knowledge; bridge disciplines; develop measurement tools and examine meaningful impacts; and shape systems that value, support, and are accountable for relational flourishing.
