In “Pediatric Primary Care and Partnerships Across Sectors to Promote Early Child Development”, we discussed the importance of early relational health (parenting practices, relationship quality) in supporting early child development and suggested that there is need to expand programs that promote it.1 We also identified barriers that limit population-level reach of such programs, and strategies that address these barriers moving forward. Here, we summarize progress made in these areas and additional work that is needed to encourage early relational health and ensure that all children thrive.
Positive Childhood Experiences
Overwhelming evidence shows that positive childhood experiences, including positive parenting behaviors, are critical for children’s optimal development and flourishing, and can help buffer the consequences of adversity due to poverty and racism.2,3 For instance, children with high adversity (high Adverse Childhood Experiences scores) and high family connection/resilience are more likely to be flourishing (i.e., interested in learning, persistent, able to regulate emotions) than children with low adversity and low family resilience/connection.2,3 This evidence has supported a paradigm shift in conceptualization of early relational health, with a growing recognition of the role of positive childhood experiences both as a central indicator of early relational health and as a strategy for building early relational health.4
Pediatric Primary Care: A Context for Promoting Positive Childhood Experiences and Early Relational Health
Given this new paradigm, there has been an increase in clinical and policy focus on the promotion of positive childhood experiences and early relational health with emphasis on delivering interventions in primary care. Pediatric primary care has been highlighted as an advantageous platform for supporting early relational health due to its capacity to reduce barriers in achieving universal reach. It also has potential for high dose (14 well-child visits between 0-5), and low cost (due to use of existing infrastructure). Given this, and the fact that health care is one of the most equitable contexts for supporting early relational health, there have been calls to support and scale pediatric-based early relational health programs from the American Academy of Pediatrics and others.2,4 Additionally, the need to deliver strengths-based positive parenting interventions has become increasingly accepted. Such approaches are important because they recognize and build on families’ goals and priorities, and are therefore respectful and engaging to families who face adversity.
Evidence for Pediatric Primary Care Based Strategies
There is growing evidence documenting impacts of pediatric primary-care-based parenting interventions and highlighting the strategies that represent best practices for supporting positive childhood experiences and early relational health. For instance, Jimenez demonstrated that use of multiple strategies (provision of books, guidance, modeling) in Reach Out and Read (ROR) was associated with increases in reading aloud beyond that seen for strategies provided individually.5 Furthermore, research from the Video Interaction Project (VIP) showed that even brief intervention (1-2 contacts) had significant effects on responsive parenting behaviors.6 In addition, research of the integrated Smart Beginnings (SB) model linking VIP with Family Check Up has shown that strengths-based primary care preventive intervention can increase engagement in targeted home-visiting services.7 Recent studies of SB have replicated and generalized findings of VIP impact on early relational health among families diverse in race/ethnicity.8 These findings show the promise of the pediatric platform for advancing early relational health.
Supporting Early Relational Health through Partnerships across Sectors
Documented impact of programs supporting early relational health has resulted in the development and implementation of population-level initiatives that reach families through access points across multiple sectors and address heterogeneity in family strengths and challenges through layered interventions and integrated models. 3-2-1 IMPACT layers programs across prenatal and pediatric primary care, including, ROR, Video Interaction Project, HealthySteps, and mental health services, to provide an integrated two-generational strategy for promoting early relational health; scaling is currently taking place across the NYC Health+Hospitals system. City’s First Readers, an initiative of the New York City Council, builds links between literacy resources for families across platforms (libraries, preschools, pediatrics). The Pittsburgh Study provides interventions tailored to family need across different contexts (texting, pediatrics, home visiting), and includes Smart Beginnings as a core component. Together Growing Strong is a placed-based initiative in Sunset Park, Brooklyn that integrates services in healthcare, early childhood education, and the community tailored around neighborhood resources and needs. Some programs have successfully addressed family heterogeneity by not only connecting services across sectors, but also providing services across multiple levels (e.g., Smart Beginnings, see above).8 Other multilevel, multisector initiatives include Get Ready Guilford in North Carolina, First 5 California, and the Pediatric Public Health Initiative in Flint, Michigan, which partner with early childhood interventions and programs broadly, while also providing direct resources to families. While there is variation in the scope of these initiatives, together they seek to support positive childhood experiences and early relational health for large numbers of children and families, and in turn support healthy child development.
Focus on Structural Factors
There is increasing recognition of the importance of addressing structural factors (e.g., racism, socioeconomic status, rurality) through systems change to facilitate early relational health.2,4,9 This includes understanding root causes for disparities in early relational health as well as identifying methods and addressing system-level issues that impact early relational health.10 While programs and initiatives that promote early relational health do not directly address the underlying causes of disparities, they are critically important in their support for resilience even in the face of adversity.2,3 A strong focus on broader structural issues (e.g., reducing poverty, environmental justice, racism) concurrent with support for early relational health in families affected by those structural issues will be critical for advancing equity.
Summary
There has been considerable progress in disseminating research that demonstrates the efficacy of interventions seeking to enhance positive childhood experiences and early relational health and the introduction of initiatives that build on those findings. Together, these findings and implementations suggest that strategies that use primary care as a platform and are strengths based, culturally aligned, and community informed show great potential in helping to achieve the goal of population-level reach and impact on positive childhood experiences and early relational health for families.
Acknowledgments
Funding statement: Funded by the National Institutes of Health (NIH), grant numbers R01HD076390; 3R01HD076390-08S1; R01HD109187; 1R01HD096909; K01MD017290
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Declaration of interests
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
References
- 1.Roby E, Shaw DS, Morris P, et al. Pediatric primary care and partnerships across sectors to promote early child development. Acad Pediatr. 2021; 21(2):228–35 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Garner A, Yogman M, Committee on Psychosocial Aspects of Child and Family Health. Preventing childhood toxic stress: partnering with families and communities to promote relational health. Pediatrics. 2021;148(2). [DOI] [PubMed] [Google Scholar]
- 3.Bethell CD, Garner AS, Gombojav N, Blackwell C, Heller L, Mendelson T. Social and relational health risks and common mental health problems among US children: The mitigating role of family resilience and connection to promote positive socioemotional and school-related outcomes. Child Adolesc Psychiatr Clin. 2022;31(1):45–70. [DOI] [PubMed] [Google Scholar]
- 4.Willis DW, Eddy JM. Early relational health: Innovations in child health for promotion, screening, and research. Infant Ment Health J. 2022;43(3):361–372. [DOI] [PubMed] [Google Scholar]
- 5.Jimenez ME, Uthirasamy N, Hemler JR, et al. Maximizing the impact of Reach Out and Read literacy promotion: Anticipatory guidance and modeling. Pediatr Res. In press. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Piccolo LR, Roby E, Canfield CF, et al. Supporting responsive parenting in real-world implementation: Minimal effective dose of the Video Interaction Project. In revision. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Canfield CF, Miller EB, Zhang Y, et al. Tiered universal and targeted early childhood interventions: Enhancing attendance across families with varying needs. Early Child Res Q. 2023;63:362–369. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Miller EB, Roby E, Zhang Y, et al. Promoting cognitive stimulation in parents across infancy and toddlerhood: A randomized clinical trial. J Pediatr. 2023;255:159–165. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Noble KG, Magnuson K, Gennetian LA, et al. Baby’s first years: design of a randomized controlled trial of poverty reduction in the United States. Pediatrics. 2021;148(4). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Roby E, Scott RM. Financial concern reduces child directed speech in a socioeconomically diverse sample. Sci Rep. 2022;12(1):9173. [DOI] [PMC free article] [PubMed] [Google Scholar]