Early relational health care: What is known and what is new for family physicians

Amanda Bell; Richa Agnihotri

doi:10.46747/cfp.7005298

Article Figures & Data

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Table 1.

Strategies for promoting early relational health in all clinical encounters with children and families in any practice setting

STRATEGY	PRACTICAL STEPS
Focus on self-reflection, cultural humility	Consider implicit biases and attitudes toward families seen in practice Model respectful processes and open communication
Build a culturally safe practice	Train all staff in family-centred, antiracist, trauma-informed care Ensure flexible scheduling, personalized follow-up, closed-loop referrals, warm hand-offs Counsel on confidentiality and its limits, when needed
Assess and build on family strengths	Observe and praise attached, attuned parenting moments (eg, “Look, Desirée can’t take her eyes off you as we talk!”) Evaluate safe, stable, and nurturing relationships with parents, alternative caregivers, and extended family Explore and promote relational building blocks (eg, breastfeeding, shared reading and storytelling, serve-and-return interactions, play, healthy sleep routines) Emphasize parental self-care Help build community connections (eg, home visits, early childhood development programs, libraries, cultural networks, play groups)
Evaluate signs of resilience (and risk) at every visit	Watch for effect, mutual responsiveness, and secure attachment, and praise positive interactions Listen for questions about child’s behaviour Ask about parental response to child’s behaviour and about other family stressors Ask about parental upbringing and how the past might be influencing current parenting style and practice
Build an integrated practice	Nest mental health counselling, community support services, and social work, whenever possible Acknowledge and address biases or other barriers to health care through advocacy and through connections with supportive resources Maintain updated lists of community programs and resources for peer-to-peer or parenting support groups

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Table 2.

Comparison of trauma-informed care, ACEs, and ERH concepts

CHARACTERISTIC	CONCEPT
CHARACTERISTIC	TRAUMA-INFORMED CARE¹⁵	CONSIDERATION OF ACEs¹⁶	ERH¹⁷
Definition	Acknowledges that health care organizations and teams need to have a complete picture of a patient’s life to provide effective health care services with a healing orientation	Potentially traumatic events occurring in childhood	Emotional connections between children and trusted adults; often defined as an SSNR
Impact	Patients with trauma have difficulty maintaining open relationships with health care providers Improved long-term health outcomes for patients Providers working with populations experiencing trauma experience burnout and higher turnover	Associated with health or developmental challenges and negative long-term physical and mental effects	SSNRs serve as the foundation for building resilience Promotes health and development Leads to positive experiences Can buffer negative effects of trauma and adversity
Considerations	Core principles: Safety Trustworthiness and transparency Peer support Collaboration Empowerment Humility and responsiveness	Abuse (eg, physical, emotional, sexual) Neglect (eg, physical, emotional) Household challenges (eg, mental illness, parental history of violence, substance abuse, incarceration, divorce)	Use each clinical encounter to promote parenting behaviour that will help children develop
Methods	Create safe, caring, inclusive environments (physical, social, and emotional) for all patients Change organizational culture and atmosphere Address trauma with trained individuals at the clinical level	Seek to address modifiable risk factors to transmit resilience Teach parenting skills and family relationship approaches to strengthen parent-child relationships Understand and address factors that put people at risk for or protect them from violence Reduce stigma related to seeking help Advocate for stronger economic support of families Promote early childhood education Connect youth to caring adults and activities	Discuss specific aspects of parenting behaviour that support the concept (eg, noticing and responding to baby’s cues to promote secure attachment) Model behaviour during the visit (eg, warm back-and-forth interactions) Praise what you observe (eg, baby calms down when parent holds them) Recommend community support services
Rationale	Improves patient engagement Improves treatment adherence Improves health outcomes Improves provider wellness Reduces care visits and decreases costs to health care and social services	Reduces the incidence of chronic health conditions Addresses health inequity Decreases health care costs associated with ACE-related consequences	Preemptive parental assessment and guidance build confidence and skills in parents Positive parenting behaviour allows children to develop secure attachment, autonomy, self-regulation, perspective taking, and problem solving ERH is predictive of later well-being

ACE—adverse childhood experience; ERH—early relational health; SSNR—safe, stable, and nurturing relationship.
Data from the Center for Health Care Strategies,¹⁵ the Centers for Disease Control and Prevention,¹⁶ and Agnihotri and Williams.