Years ago, a medical encounter with a young child and their family might have started with the question “What is wrong with you?” More recently, as part of patient-centred and trauma-informed care, a family doctor is more likely to ask “What has happened to you and your family?”1 A newer paradigm—early relational health (ERH) care—encourages primary care providers to ask parents, “What is going right with you and your family?”2-5 Family physicians have the necessary expertise to assess strengths of relationships (eg, closeness, support, protection, love) and positive function (eg, healthy routines, supportive networks) in the families they see.5
In 2023 the Canadian Paediatric Society’s Early Years Task Force published a position statement examining a shift in focus from adverse childhood experiences (ACEs) to ERH.6 The position paper was inspired in part by the work of Dr Andrew Garner, an author of American Academy of Pediatrics policy statements on this topic, and of Dr David Willis, a senior fellow with the Center for the Study of Social Policy.7-10 Rooted in the latest research on child development, ERH builds on the earliest emotional connections between infants or young children and their primary caregivers to promote healthy development, lead to positive experiences, and buffer negative effects of stress, adversity, and trauma.7,10-12 Early relational health care looks first for a family’s assets rather than its deficits and emphasizes that any clinical interaction is an opportunity to “check in” and reinforce these strengths.13 We propose adopting an ERH lens in all clinical encounters with a child and their family, rather than thinking about ERH as a separate assessment, as summarized in Table 1.
Strategies for promoting early relational health in all clinical encounters with children and families in any practice setting
Familiar and unfamiliar concepts
In line with trauma-informed care practices, ERH recognizes, acknowledges, and validates specific family struggles, even when they are difficult to modify or influence, such as racism, systemic oppression, and poverty.10,14 Family physicians are aware of these challenges in the lives of their patients. Screening routinely for parental mental health issues can have positive long-term effects on parent-child relationships and on family life. Their regular engagement in antenatal and infant care enables family practitioners to build on relational opportunities in exceptional ways. For example, by asking parents about their own upbringing—with the goal of eliciting past and present parenting styles—concerns can be addressed preemptively. Concepts in ERH may seem familiar to family physicians who have learned related concepts under other names such as trauma-informed care or ACEs, as described in Table 2.15-17 Early relational health is a new lens through which the provision of care aims to enhance healthy child and family development.
Comparison of trauma-informed care, ACEs, and ERH concepts
What may be less familiar is that ERH assessment begins with ongoing self-assessment. Health care providers bring their implicit biases (unconscious attitudes or stereotyping) to everyday practice as a normal—but malleable—component of social cognitive processing.18 Cultural humility involves recognizing this and reflecting on how personal biases may influence medical encounters, especially with families from populations that are marginalized. Continually mitigating bias is part of culturally safe practice and is an essential step in ERH care, which depends on respectful in-office processes and mutually trusting relationships.19,20 A culturally safe practice honours each family’s cultural identity and socioeconomic background and includes their perspectives and input as part of health care planning and delivery.21
Early relational health assessment involves strategies that family physicians use every day, such as developmental monitoring, directed history taking, observing relationships,21 active listening, and health teaching. Any visit is an opportunity to evaluate parent-child attachment based on signs practitioners look for routinely: exchanges of gaze, touch, and sensitivity and reciprocity of response.9,21 How the ERH approach differs is through its closer attention to the safe, stable, and nurturing relationships in each child’s life, which research in child development increasingly shows are foundational to healthy development and to building resilience.7,10 Early relational health assessment verifies whether a child has at least 1 caring, supportive, and emotionally available adult in their life and builds from there.22-24
Family-based interventions
The negative impact of toxic stress on individual and family function has been demonstrated in ACE- and ERH-based research.13,25 The parent-child relationship is a leading—and modifiable—mechanism of risk and resilience.2,23 When secure attachment is lacking, family-based interventions can help. Family-centred, ACE-based, and ERH care models all recommend taking a 2-generation approach to intervention7,25,26 with the experiences of children as the central focus.2,10 And while it is ideal to encourage and reinforce positive routines and effective parenting prenatally or during a child’s earliest years,27 evidence also suggests it is never too late to promote, teach, and model relational skills with families.23,28 Programs that promote parental sensitivity can help mitigate or interrupt intergenerational effects of ACEs.25,29
In an ERH model, parents and physicians are partners who share responsibility for care and for decision making. In practice, this means respecting parents as experts in their lived experiences; eliciting their observations and input on what works best for their child; and inviting them to guide discussion, establish boundaries, and choose next steps for care planning.2,4,20,23,24,27,30 Partnership may mean accepting that some parents wish to be less involved and some will be “team leaders” when required. It also means attending to parental self-care by providing information and resources.2,13,21,31-34
Another opportunity for connection is when we understand how families are part of communities and what support they receive from their communities. Many family physicians routinely inquire about the presence of other caring adults in children’s lives whose involvement is supportive of parents,5,23,35 is enriching for children, and can help buffer against toxic stress and adversity. Many also maintain lists of community resources and regularly connect families with libraries, child care centres, public health units, recreational facilities, and culturally specific programs to promote social connection and build resilience.23,25,29,31,34
Implementation
Implementation of ERH in the context of a family practice can occur during any visit for preventive care, acute illness, or chronic illness in children. For example, your patient Sapna (age 35) presents with her 4-month-old baby, Rohan, for his well-baby visit. Before you enter the room you check your own biases and knowledge gaps about this specific family, their circumstances, and their cultural background. While watching Sapna interact with Rohan, you notice she makes frequent eye contact, holds him in a comforting position, and chats with him. You highlight and encourage this interaction, informing Sapna that talking in a “singsongy” voice, singing, and playing with or reading to Rohan all encourage his speech and language development.
While examining Rohan you describe what you are doing for mom and baby and use his name while speaking. After his immunizations, Rohan is fussing and Sapna comforts him with a hug and gentle words. Throughout the visit you acknowledge positive behaviour with Sapna, letting her know that she is helping her baby feel loved and safe and that he can rely on her. You praise her attention to his needs and point out how quickly he calms down in her arms, letting her know she is helping Rohan learn to deal with discomfort, to regulate his emotions, and to trust his mother to provide comfort and safety. This sense of safety and security can help him build resilience, which may in turn help cushion against negative effects of stressful experiences in life, leading to better health in the short and longer term. You praise the secure attachment Rohan has clearly formed with Sapna thanks to her attentiveness. You ask about community services the family is currently accessing, and she shares they are new to the community and have not accessed any services yet. You give Sapna a brochure for the local EarlyON Child and Family Centre (a government-funded program in Ontario),36 which lists drop-in hours and infant-parent offerings. You wave goodbye to Rohan and Sapna and express eagerness to see them again when Rohan is 6 months old or sooner if they have any concerns.
The need for enhanced training and support in early child development and ERH-based approaches is pressing. The Keystones of Development program in the United States teaches the ERH approach to both medical learners and physicians in practice.37 It has been adopted by more than 300 US residency programs and advocates are calling for Canadian programs to do so, as well. Making ERH an intentional focus in clinic visits will improve outcomes at no additional cost while we continue to call on governments for increased funding for community support services that encourage development and strengthen parenting skills, such as EarlyON centres, allied child health providers, and interprofessional health care teams that include social workers and early childhood specialists. Other resources available to help family physicians learn more about ERH are provided in Box 1.
Early relational health resources
Nurture Connection. Why ERH matters: early relational health explained. Washington, DC: Center for the Study of Social Policy; 2024. Available from: https://nurtureconnection.org/early-relational-health/early-relational-health-explained. Accessed 2024 Apr 2.
Early relational health. Itasca, IL: American Academy of Pediatrics; 2022. Available from: https://www.aap.org/en/patient-care/early-childhood/early-relational-health. Accessed 2024 Apr 2.
Garner AS, Shonkoff JP; American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics 2012;129(1):e224-31. Epub 2011 Dec 26.
Li J, Ramirez T. Early relational health: a review of research, principles, and perspectives. Princeton, NJ: Burke Foundation; 2023. Available from: https://www.gse.harvard.edu/sites/default/files/2023-09/ERH-Report_final.pdf. Accessed 2024 Apr 2.
Conclusion
Early relational health is a proactive and holistic approach to health care that family physicians are well qualified to deliver, especially with community support services. Family doctors engage in care across generations of families and have unparalleled opportunities to model, teach, reinforce, and celebrate ERH approaches. With appropriate support, family physicians can be leaders in and strong advocates for ERH approaches, which have the potential to mitigate effects of childhood trauma and enhance the health and well-being of an entire generation of children.
Acknowledgment
We acknowledge the support of Dr Robin Foster, Elizabeth Moreau, and Jennie Strickland from the Canadian Paediatric Society in the preparation and editing of this manuscript.
Footnotes
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.
This article has been peer reviewed.
Cet article se trouve aussi en français à la page 305.
- Copyright © 2024 the College of Family Physicians of Canada
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