The Fifth Vital Sign in the First 1000 Days: Early Relational Health

Abstract

Early childhood development forms the cornerstone for a healthy, fulfilling, and productive life. Research in health psychology and longevity highlights that social relationships are the most significant determinant of lifelong health and development. Among these, early attachment between children and caregivers, bolstered by positive experiences and nurturing environments, is pivotal for optimal growth, development, and well-being. This highlights the need for holistic approaches in healthcare, particularly during the critical first 1000 days of life. To address these needs, comprehensive evaluations must include assessments of child-caregiver interactions alongside biological, psychological, social, and environmental factors. Recognizing this, the American Academy of Pediatrics has embraced the Early Relational Health (ERH) framework, focusing on fostering healthy relationships during this crucial period. The framework encompasses all caregivers, including parents, extended family, and peers. The ERH framework emphasizes a broad assessment of factors affecting health—biological, psychological, interactional, economic, and environmental—within the child and caregivers’ living contexts. The primary objective is not to teach parenting skills but to cultivate safe, stable, nurturing relationships supporting lifelong well-being. The ERH underscores the critical importance of assessing relational health as a “fifth vital sign,” alongside traditional measures such as respiratory rate, heart rate, temperature, and blood pressure, in the first 1000 days. Integrating this framework into health systems can enhance the well-being of children and caregivers, ensuring a robust foundation for lifelong development.

Introduction

Early Relational Health (ERH) focuses on the interaction of the child, parent, and environment in the first 1000 days. It aims to create early intervention opportunities for the child to reach the child’s potential in the first 1000 days. American Academy of Pediatrics (AAP) introduced the ERH Framework as the “foundation of lifelong health, growth, and development” through safe, stable, and nurturing relationships and experiences.¹ The ERH concept emerged from extensive research on early childhood development (ECD), relational health, and health psychology.^2-6 In 2021, the AAP introduced a paradigm shift by adopting the ERH Framework in place of the toxic stress approach. Since then, the AAP has proposed several strategies to integrate this framework into residency programs and healthcare systems across the United States. This shift reorients the focus from identifying populations at risk for toxic stress and related morbidities to fostering resilience through Safe, Stable, and Nurturing Relationships (SSNRs). It emphasizes universal coverage and evidence-based interventions, including attachment therapy, psychotherapy, and interaction-based treatments. To provide ERH, it is necessary to evaluate all the systems in which the child and caregivers live and the biological, psychological, cultural, social, economic, and environmental factors.^7-9

The basic framework for this review was based on the AAP’s website, which defines ERH and includes research, guidelines, and policy documents on the philosophy of ERH.¹⁰ In Türkiye, no research using ERH terminology was found, but 2 articles reviewing studies on ECD were found. The first article evaluated studies on ECD, including research papers, review articles, theses, projects, and reports published between 2000 and 2007. It was determined that the studies addressed the issues of child health and education in early childhood. Nearly one-third of the studies were related to child health, with 16.8% of them focused on children aged 0-2 years and mostly relating to breastfeeding. Universities conducted most studies with academic purposes rather than service delivery, while most studies on child health evaluated indirect factors related to child development.¹¹

The second review analyzed master’s and doctoral dissertations on the development, education, health, care, and nutrition of children aged 0-3 years, published between 1994 and 2016. The documentary analysis technique was used and determined that most studies were about child health, especially related to care and nutrition. This review includes some tools, like the mother-infant interaction observation form (2-30 months of age) and the child-parent relationship scale (4.5-5.5 years of age), that were used from an educational perspective.¹²

Additionally, various tools have been developed to observe parent-child interactions, including the Ainsworth Maternal Sensitivity Scale and Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO). However, these tools were not part of a holistic, relational health perspective that includes biological, psychological, cultural, social, economic, and environmental factors and systems¹² (Table 1).

Table 1.

Tools for Evaluating Early Relational Health^12,45,47

Tool	Purpose	Limitations
Spesific Tools	Measures parent interaction skills	Focuses on separate parent/child behaviors rather than dyadic interactions Limited clinical applicability due to long observation times and non-natural protocols (e.g., still face) Examples include: Ainsworth Maternal Sensitivity Scale, Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO), Keys to Interactive Parenting Scale
Early Relational Health Screen (ERHS)	Assesses dyadic interactions through video/interview for children aged 6-24 months	Validity and reliability established Suitable for clinical and research use Further research needed for cultural adaptability and equity
Nonspesific Tools used for Early Relational Health Assesment	Assess specific domains like perinatal depression, Social Determinants of Health (SDH), social-emotional development, adverse childhood experiences, resilience, and household context	Examples include: Edinburgh Postnatal Depression Scale, Patient Health Questionnaire-2/9, Ages and Stages Questionnaire (ASQ), Brief Infant-Toddler Social and Emotional Assessment (BITSEA), Safe Environment for Every Kid (SEEK), Early Childhood Screening Assesment (ECSA)

The health system in Türkiye provides access to legally mandatory premarital screening tests for couples about to get married, and widely accessible primary health care services provided by family physicians make it possible to reach families, pregnant mothers, and newborns for health surveillance.¹³ The health system has a unique role in providing ERH as the earliest and most frequent way to reach families, and ERH should be considered a routine vital sign of healthcare as well as respiratory rate, heart rate, body temperature, and blood pressure.^14,15

This review aims to evaluate and discuss the ERH Framework and has 3 main objectives:

• 1. To evaluate the concept of ERH and related terminology, making the concept visible and debatable.

• 2. To address the strategies recommended by AAP related to the ERH Framework.

• 3. To bring the ERH Framework and suggested strategies to the agenda in Türkiye.

Terminology

Early Relational Health–related terminology (Table 2) includes Attachment and Bonding, Biobehavioral Synchrony, SSNRs, Positive Childhood Experiences (PCEs), Allostatic Load, and Social Determinants of Health (SDH).^16-25

Table 2.

Basic Terms in Early Relational Health

Term	Definition	Key Points	References
Attachment	Emotional connection between infants and caregivers in the first year of life.	Facilitated by caregiver sensitivity and responsiveness; leads to feelings of security and emotional well-being.	16
Bonding	Physical proximity and emotional ties parents build with their infants from pregnancy onward.	Enhances parental acceptance and nurturing care.	16
Biobehavioral Synchrony	Co-regulation of psychobiological responses and behaviors through parent-child interactions.	Synchronization of cardiovascular, neuroendocrine, and central nervous systems (CNSs); supports socialization with mothers and exploration with fathers.	17-19
Safe, Stable, and Nurturing Relationships (SSNRs)	Trusting, supportive, and secure relationships that foster growth and development.	Provide love, security, and skill development for children.	20,21
Positive Childhood Experiences (PCEs)	Positive interactions and environments that support a child’s development.	Includes family communication, safety, peer support, school belonging, and caring adults.	22
Allostatic Load	The body’s adaptation mechanism to stress and adverse experiences.	Involves multiple physiological systems; linked to chronic disease and aging.	5,23
Social Determinants of Health (SDH)	Conditions shaping a person’s life and health outcomes.	Includes economic, educational, social, healthcare, and environmental factors.	24,25

Definitions and ages of acquisition regarding ERH development in the first 1000 days, such as mutual attention, engagement, responsiveness, enjoyment, pacing, initiation, imitation, cooperation, response to challenge, shared goal and pretend play, and recognition of affect state, are shown in Figure 1.^15,26

Figure 1.

Early relational health development in the first 1000 days.

Clinical and Research Consequences

Relationships, Interaction, and Health

Research on health psychology and longevity highlights ECD and social relationships as critical predictors of lifelong health. Early childhood development establishes the foundation for well-being, while positive social relationships enhance health by influencing cognitive, emotional, behavioral, and biological pathways.^5,6 A prospective study identified satisfying social relationships at age 50 as the strongest predictor of extreme longevity (≥85 years), even after accounting for healthy lifestyle factors and depression. Social integration fosters increased support, quality of life, productivity, purpose, optimism, resilience, self-esteem, effective communication, and cognitive function.⁶ Lifelong health and longevity are driven by positive factors and experiences rather than merely the absence of disease or risk reduction. Genetic predispositions play a role, but environmental and epigenetic interactions are equally significant, reinforcing the adage, “Good genes are nice, but joy is better.” This evidence underscores the importance of promoting nurturing relationships and supportive environments to optimize health and longevity.^5,6

The World Health Organization (WHO) defines health as “physical, mental, and social well-being.”²⁷ Health systems must holistically evaluate population health and health needs, including clinical and social services. What about the factors contributing to health outcomes? In the United States of America, the University of Wisconsin Population Health Institute has been studying these health factors affecting health outcomes since 2004. They evaluated 4 health factors: “health behaviors, clinical care, social-economic factors, and physical environment.” The health outcomes were “length and quality of life.” When health factors were weighted according to their impact on health outcomes, it was found that the most important health factor was social-economic factors (40%), while clinical care accounted for only 20% of health outcomes.²⁸

Relationships, Interaction, and Early Childhood Development

Early brain development in the first 1000 days is critical, as the cerebral cortex reaches 97% of adult thickness and 69% of surface area, the hippocampus completes myelination, and over 1 million neuronal connections form per second during the synaptogenesis process.²⁹ This period, unparalleled in its developmental significance, offers key opportunities for lifelong health and developmental interventions.³⁰

Biobehavioral synchrony begins as a dyadic process between the mother and fetus, supporting fetal allostasis during pregnancy. After birth, it evolves into a triadic interaction with the father’s involvement, facilitated by sensory experiences such as skin-to-skin contact, breastfeeding, and warm vocal communication. These interactions help synchronize biological rhythms, including heart rate, oxytocin responses, and alpha and gamma brain wave activity. Biobehavioral synchrony provides neurodevelopmental maturation for both the parents and the baby. This is a mutual and simultaneous evolutionary adaptation process involving genetic and epigenetic effects covering behaviors, emotional states, and biological rhythms and is an important milestone for attachment and bonding. This synchronization provides lifelong social-emotional development and well-being and the development of adequate parenting skills in the next generation.^{3,17,18,19,31}

The responsive breastfeeding process establishes the first interaction between mother and baby after birth, enabling the mother to recognize and respond to the baby’s feeding cues with compassion and love, and maintaining a sense of comfort and security as well as nourishment.³² Breast milk affects the growth and development of the baby’s organ systems, especially brain development, due to its biochemical content specific to the baby’s physiological needs. While the responsive breastfeeding process affects motherhood constellation and behaviors on the one hand, it also affects the child’s first ecological experiences and long-term neurocognitive development. It has been shown that breastfeeding mothers interact more with their babies than non-breastfeeding mothers.³³ Responsive feeding (RF) engages parents and other caregivers in a reciprocal relationship with the feeding process and can improve both physical health and developmental outcomes. Responsive feeding is a key principle in the “Guidelines for Complementary Feeding of Breastfed Children” published by the WHO.³⁴

Positive and Adverse Childhood Experiences

It is well known that early childhood experiences can lead to DNA changes through epigenetic mechanisms. If adverse experiences occur, these changes can lead to an increase in various deadly diseases like cancer and mental health illnesses.^20,23

The health system is the earliest and most widespread service that children benefit from, and early interventions should serve to promote PCEs. Research shows that children with more than 3 ACEs are 3 times more likely to experience academic failure, 5 times more likely to have difficulty attending school, and 6 times more likely to have behavioral problems. Adults with 4 or more ACEs have a 7-fold increased risk of alcoholism, a 2-fold increased risk of cancer, and a 4-fold increased risk of emphysema, and adults with 6 or more ACEs have a 30-fold increased risk of suicide.^35-37 Therefore, ACEs are an urgent public health problem. All services, beginning with health services, should develop strategies to empower and support families and caregivers to prevent ACEs and promote PCEs.^20,22,38 Early Childhood Development is a dynamic process, and a child who experiences ACEs may develop resilience in a supportive environment and become a healthy, successful adult, or a child who experiences PCEs may experience disasters later in life and have a difficult adulthood due to a lack of supportive environments. It is also known that some adverse experiences and stress can be subjective, and the event itself cannot define or measure the intensity of adversity.^35,39,40 Consequently, the critical intervention for children experiencing ACEs or toxic stress is to make a significant impact on the well-being and child-rearing skills of future caregivers.⁴¹

Scope of the Early Relational Health Framework

The ERH framework focuses on the first 1000 days, patterns of attachment and relationships between the child, parents, other caregivers (relatives, peers), and holistic physical, cognitive, social, emotional, mental, and cultural well-being with unique features and experiences that include diversity and experiences^9,14

The ERH framework provides a broad perspective on the child and the environment; it not only addresses parents, attachment, clinical care, or parenting education but also focuses on a holistic consideration of all factors affecting health and building SSNRs between caregivers and the child in all areas of life. This perspective requires an integrated public health approach, including health, education, justice, and social services. Family dynamics, cultural social norms, behavioral patterns, and their effects on relationships must be evaluated.^20,26

Monitoring and supporting ERH strengthens families and increases society’s social capital. It also supports the social-emotional capacities of the child and society by ensuring positive family-child interactions, thus paving the way for lifelong health and development. The ERH approach supports early learning, resilience, and recovery processes, even after traumatic experiences. The ERH Framework has 3 outcomes: health, early learning, and developing social-emotional capacities. Therefore, considering the studies about ERH, AAP emphasizes that ERH is an important vital symptom in 1000 days and should be included in routine child health care.^10,14

Basic Approaches To Support Early Relational Health

Basic approaches to support ERH include evidence-based, culturally sensitive, family-centered, and strengths-based (emphasizing protective factors for development) modalities. These modalities are based on a 2-generation approach that includes the assessment and promotion of social and economic capital, employment, ECD, and the health and well-being of the whole family. Strengthening parenting and family literacy to support ECD and monitor child health are examples of child-focused, parent-inclusive strategies. Supporting access to basic life needs such as food and shelter, planning for childcare and employment, and supporting families of school-aged children are examples of parent-focused, child-inclusive strategies. The 2-generation approach includes supporting short, quality shared moments for a positive effect on the child and family. These basic approaches prioritize human rights models to support individuals’ access to needed services and basic human rights.^9,20,42

Policies to support ERH can be categorized as universal preventive interventions, targeted interventions, and indication-based interventions. These strategies can be summarized respectively as “be well,” “stay well,” and “get well.” Universal preventive interventions include supporting ERH, positive parenting, home visits, and quality early childhood care and education services within the scope of both primary health services and community-based social and education services. This also includes preventive mental health services within the scope of comprehensive primary health services. Targeted interventions include monitoring and supporting ECD, assessing SDH, and promoting family strengths and protective factors for child development. Indication-based interventions include providing a family-centered holistic service model: a “medical home model” to children with special needs and their families and both individualized and community-based early intervention services.^2,20

Supporting Early Relational Health: 3 Purposes 3 Methods

Strategies to support ERH should aim to reduce the impact of ACEs and risk factors, build resilience, and support and enrich the environments in which children grow up. To achieve these goals, 3 methods—such as assessing developmental risks, addressing families’ strengths and protective factors approach, and effective communication techniques—should be used.⁴³

Developmental risks include both health-related risks (e.g., genetic predisposition to chronic diseases and developmental difficulties, health status of caregivers) and SDH (e.g., poverty, low socio-economic level, all kinds of inequality, discrimination). Some of these risks arise in the prenatal period, while others (such as lack of stimulation, inadequate nutrition, living in nursing homes, and ACEs) may develop in the postnatal period.⁴⁴

Addressing families’ strengths and protective factors approach includes supporting and advocating for parents’ resilience, socialization, interaction capacities, and knowledge about child development. It also includes providing concrete support and referral to services when needed, supporting children’s social-emotional capacities, and ensuring that basic living conditions are sustainable. This approach facilitates and enhances families’ ability to adapt to adverse experiences in a healthy way, establish meaningful relationships, cope with problems, have the chance to ask questions and find solutions with the support of health providers, and encourage participation in community activities. With this approach, parents are enabled to establish a certain number of quality interactions, develop nurturing and competent parenting, increase their self-esteem and sense of responsibility toward their children, and reduce their anxiety and depression. The nurturing, sustainable, and secure relationship between the child and the family constitutes the ERH and is the basis for the development of the child’s protective factors throughout life as a future adult.⁴³

The importance of using effective communication techniques for public health policies, such as supporting ERH and approaching families with vaccine hesitancy, is well known. American Academy of Pediatrics recommends a variety of techniques for healthcare providers to support ERH on its website.^43,45,46 Some of these techniques are:

• 1. Motivational interviewing techniques develop partnership, validation, and compassionate communication with the family and aim to understand the family’s priorities, values, and strengths. For example, the OARS technique (using Open-ended questions, Affirmations, Reflective listening, and Summary reflections) and the BATHE technique (asking about Background, Affect, Troubles, and Handling ways of the family and showing Empathy).⁴⁵

• 2. Ask about SDH (well-being of parents, basic life needs like shelter, food availability, and social needs), ERH, and identify and refer families to community resources and services.⁴⁵

• 3. Common factors approach (HELP), encouraging realistic Hope, listening with Empathy, using clear non-stigmatizing Language, demonstrating Loyalty to the family, building Partnership, asking for Permission for a detailed assessment, and Planning the next steps with the family.⁴⁶

• 4. Strategies based on families’ preferences, priorities, and partnerships. For example, deciding whether to start a treatment or request a referral for further evaluation, learning about alternative treatments and available resources, changing lifestyle habits, keeping a diary of symptoms, parenting strategies, etc.⁴⁶

• 5. A model derived from “Bright Futures” includes “Exploring the quality of the home environment, building nurturing, reciprocal, responsive relationships, cultivating child development, and developing parenting confidence, competence and satisfaction by strengthening parents’ well-being and needs” (EBCD).⁴⁷

• 6. Developing a storytelling perspective for families involves providing respectful, culturally sensitive approaches and creating opportunities for families to share their thoughts and feelings, and feel understood. This perspective also includes being aware of their interactions, stories, and capacities for resilience, and building SSNRs with the support of service providers.⁸

From Biomedical to Biopsychosocial Model: Toxic Stress or Early Relational Health Approach?

The traditional biomedical model of health describes only the “absence of disease” (absence of the problem), while the biopsychosocial model describes a holistic approach including physical and psychosocial evaluation for health assessment. Similarly, the toxic stress approach only assesses the presence and prolongation of the problem (overactivation of stress systems and the lifelong negative effects of ACES).⁴⁸ The ERH approach emphasizes the capacity of the individual, family, and community to develop SSNRs, which reduce adversity and build resilience across the lifespan.^20,26

In the toxic stress approach, the primary goal is to prevent ACEs; the secondary goal is to screen at-risk populations with an ACE score or DNA methylation pattern, and the tertiary goal is to treat toxic stress-related morbidities (anxiety, attention deficit disorder, posttraumatic disorders, depression, etc.). The primary goal of the ERH approach is to support SSNRs and resilience skills. The secondary goal is to remove barriers that prevent individuals, families, and communities from developing their SSNRs, and the tertiary goal is to focus on evidence-based, attachment, psychotherapy, and interaction treatments. In summary, the ERH approach focuses on building relationships for solutions that bring out individual, family, and community resilience and strengths, while the toxic stress approach focuses only on screening risks, problems, and medical treatments.⁴⁹

Tools For Evaluating Early Relational Health

American Academy of Pediatrics defines nonspecific tools for ERH assessment developed for evaluating specific domains like perinatal depression, SDH, and social-emotional development of children (Table 1). There are also specific tools to measure parenting skills which were developed for special research needs. These tools were neither designed to develop relational patterns nor include the comprehensive ERH framework⁵⁰ (Table 1). Using the IMPACT Measure Tool Scoring system, it was determined that there was no tool suitable for widespread use when criteria such as cultural appropriateness, equity, usability, and family acceptance were taken into consideration.⁵⁰

The Early Relational Health Screen (ERHS) tool was developed in 2002, and the latest version was developed in 2017. The ERHS has been used in pediatric care and home visiting programs, utilizing video recordings and moment ratings to assess parent-child dyadic interactions. The ERHS was validated using a reliable tool, the National Institute of Child Health and Human Development Early Childhood Scales. It effectively evaluates dyadic reciprocity and predicts social-emotional development, as demonstrated through the Ages and Stages Questionnaire (ASQ: social emotional [SE]). The tool emphasizes the importance of nurturing care in promoting child development, mitigating the negative effects of Adverse Childhood Experiences (ACEs), and highlighting the link between parental depression and dyadic interactions^15,50 (Table 1).

American Academy of Pediatrics Recommendations for Supporting Early Relational Health

Nationally representative data on which the AAP’s recommendations on ERH are based indicate that the lifetime prevalence of mental disorders in individuals >18 years of age in the United States is estimated to be 51%, with most of it originating in childhood. These mental disorders are depression, attention-deficit/hyperactivity disorder, phobias, panic disorders, post-traumatic stress disorder, oppositional defiant disorder, and behavioral difficulties. Other research showed that most of the adolescents (75%) with mental health disorders are untreated, and suicide is the second most frequent cause of death in the young population. Finally, it has been shown that the prevalence of mental health disorders is increasing and that this increase is seen in children of families with high socioeconomic status.^46,51

In light of these studies, AAP called for “the training and competence of future pediatricians including pediatric subspecialists for child mental health care” to be a national priority, starting in primary care. The AAP has stated that a pediatrician’s approach to a child with a fever of unknown origin is similar to that of a child with a developmental difficulty. Pediatricians should receive training in assessing the severity of mental health symptoms in children, indications for referral to mental health specialists, intervention steps until referral, and follow-up of the children without indication for referral. The AAP defines mental health specialists as child psychiatrists, developmental-behavioral pediatricians, adolescent specialists, and pediatric neurologists.^46,52

The AAP also emphasizes that pediatricians are team members in the process of monitoring and caring for children’s mental health. The team includes the child, family, preventive health care clinician, mental health specialist, nurse, psychologist, social worker, early intervention specialist, and education specialist^46,52

Pediatricians’ interventions involve children with mild to moderate mental health symptoms, and pediatricians need an additional 10-15 minutes for these interventions. These brief therapeutic interventions aim to build PCE by focusing on the strengths of the child and the family, improving the child’s functioning, and preventing the development of disorders that may occur later. In addition, the intervention aims to reduce the anxiety of the child and the family, facilitate the family’s access to mental health services, and continue the intervention and follow-up until the referral.^46,52

Examples of these brief therapeutic interventions include shared book reading, planning specific daily times for parent-child interactions, family meals, play, organizing interactive and outdoor activities according to the child’s preferences, supporting positive peer activities, creating daily routines for healthy behaviors such as sleep and self-care, limiting children’s screen time, and positive feedback given to children by adults.^46,52

Pediatricians must have certain competencies to be effective team members in the process of monitoring and caring for children’s mental health. These competencies include primary and secondary preventive care for children’s mental health, management of common developmental difficulties, indications for referral, triage for social and psychiatric emergencies, information on the availability and referral status of community resources and services for children’s mental health, the ability to work as a team member, and basic communication skills. For this purpose, goals such as basic approaches to children’s mental health, the use of mental assessment tools, and the acquisition of evidence-based psychopharmacological treatment skills should be added to the pediatric curriculum. The AAP recommends this approach for the “best interest of children,” but also emphasizes that this is not just about changing the pediatric curriculum. These changes require national child health policy commitments, including healthcare payment systems, a philosophy of accepting mental health practices as an integral part of childcare, training and collaboration of practitioners (pediatricians), time, culture, and a well-defined process.^46,52

Conclusion

The ERH framework describes the implementation of ecological systems theory to the critical first 1000 days of life, which is the foundation for lifelong health and well-being. The ERH framework first addresses the attachment patterns and relationships between the child and caregivers, that is, the emerging “microsystem.” From a broad perspective, the ERH framework considers the mesosystem, exosystem, macrosystem, and chronosystem to provide, support, advocate, and ensure the well-being of microsystems. With this perspective, the ERH framework defines a holistic approach that includes health, education, social services, SDHs, social norms, cultural characteristics, living conditions, political decisions and practices, global threats and opportunities, as well as historical context. The ERH aims to increase the social capital of societies, and to this end, it aims to increase SSNR and PCEs to protect children from ACEs. The ideal intervention is to prevent ACEs and build resilience and recovery after ACEs. Evidence-based, culturally sensitive, family-centered (microsystem-centered), and strength-based strategies should be implemented starting in primary care.^9,20,26,42 Another important intervention to support ERH is to consider the concept of ERH as a 5th vital sign after respiratory rate, heart rate, body temperature, and blood pressure at 1000 days of life.^14,15

It is necessary to develop practical and widely available tools to assess ERH. And finally, to develop global health policy commitments to shift the philosophy to recognize mental health practices as a fundamental part of child health and care from an ecological perspective. In the provision of health and social services, child mental health services should be provided by a team consisting of family physicians, pediatricians, psychiatrists, psychologists, nurses, social workers, and early intervention and education specialists. For this purpose, the training and competence of family physicians, pediatricians, and nurses who are members of the team should be developed related to child mental health. Community-based policies, education, cultural, social, and bureaucratic arrangements should be made to prepare the macrosystem and chronosystem for these processes.^46,52

Funding Statement

The authors declared that this study has received no financial support.

Data Availability Statement:

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.