The rise of relational health in early childhood care

A quiet revolution is reshaping pediatric and postpartum care in the United States, centered on a powerful but often overlooked concept: early relational health. Psychologists have long known that infant, toddler, and caregiver mental health are inextricably linked. But the health care system typically considers caregivers and children separately. That stance is changing, thanks to a growing network of evidence-based programs—many developed by psychologists—that promote safe, stable, and nurturing early relationships; a call to action from the American Academy of Pediatrics; and a surge in public and philanthropic support.

In mid-July, Oregon expanded its efforts to promote early relational health, requiring insurance plans to cover doula and lactation services before, during, and after the birth of a baby. Also in July, Washington state’s Medicaid program began paying for community health workers trained in behavioral health to embed in pediatric clinics. The two states join at least nine others currently funding a variety of strategies focused on the relationship between children ages 0 to 3 years and their mothers and other caregivers. “This is a sea change,” said David Willis, MD, a professor of pediatrics at Georgetown University and cochair of the National Academies of Sciences, Engineering, and Medicine’s Forum for Children’s Well-Being. States have become the incubators of sustainable programs to support early relational health, he said.

Also driving this momentum to strengthen early relational health are philanthropies focused on improving the lives of children and families. They include national organizations like the Perigee Fund and Blue Meridian Partners and state and local groups like the Burke Foundation in New Jersey.

These programs, typically offered at home or to all families at a pediatrician’s office, involve working on two-way communication to build attachment between very young children and their primary caregivers. “Serve and return” interactions—such as mirroring a baby’s coos or gestures—are foundational to early communication and relational health. These reciprocal exchanges not only support language development but also build the infant’s sense of connection, safety, and responsiveness in relationships.

Promoting early relational health in this way yields huge mental health benefits, said Jessica Conner, PsyD, the director of behavioral health at Northeast Pediatrics and Adolescent Medicine in Ithaca, New York. One recent scoping review showed it is associated with reduced maternal depressive symptoms, increased maternal sensitivity to infant competencies, increased maternal confidence in child-rearing, better infant development, and enhanced positive early relationships (Yago, S., et al., Early Human Development, Vol. 183, 2023opens in new window).

HealthySteps, a long-standing but newly expanding model that embeds child development and behavioral health specialists into pediatric care teams, is one of the programs at the forefront of this trend of focusing on early relational health. (Northeast Pediatrics is a certified HealthySteps practice.) HealthySteps supports child development in the first three years of life along with parental mental health as integral to that development, offering services like maternal depression screening, psychoeducation, relationship guidance, and a family support line. HealthySteps, a program at zero to three, a nonprofit focused on the healthy development of the nation’s babies and toddlers, currently reaches more than 500,000 children in 25 states, in Washington, D.C., and on U.S. military bases in Germany and aims to double that figure by 2032.

Developmental Understanding and Legal Collaboration for Everyone (DULCE) is another pediatric innovation model that is building a focus on relational health. It shares many characteristics of HealthySteps but focuses on birth to 6 months of age and uses an interdisciplinary team, including local legal consultants, to mitigate the risks to family well-being posed by unmet social determinants of health, such as food or housing instability.

Other programs send providers—typically nurses or community health workers—to the home, providing a complementary model of care. One example is Family Connects, a home-visiting program created by psychologists and piloted in Durham, North Carolina, that is now scaling across states like Oregon and New Jersey. Family Connects, which often coordinates with HealthySteps, offers postpartum families one to three nurse visits to assess both medical and behavioral needs.

“The goal of Family Connects is universal, to try to reach every family giving birth in a geographic or identified community,” said Kenneth Dodge, PhD, professor of psychology and neuroscience at Duke University and the founder of Family Connects International, the nonprofit responsible for growing the program beyond North Carolina.

Research shows that the early years of a child’s life set the stage for their future, said Lisa Powell, PhD, a psychologist and growth manager at HealthySteps. “We know that 80% of brain development occurs in the first 3 years of life, 90% in the first 5 years—this all happens in the context of relationships,” Powell said. It is a period of enormous risk and opportunity and the most critical time to facilitate consistent, nurturing caregiving to promote optimal child mental health and, if there is a concern, to intervene before problems are entrenched, she said (Lenroot, R. K., & Giedd, J. N., Neuroscience & Biobehavioral Reviews, Vol. 30, No. 6, 2006opens in new window).

The pediatric community has come on board. A 2021 policy statement from the American Academy of Pediatrics urged “a paradigm shift toward relational health” because safe, stable, and nurturing relationships “not only buffer childhood adversity when it occurs but also promote the capacities needed to be resilient in the future” (Garner, A., and Yogman, M., Pediatrics, Vol. 148, No. 2, 2021opens in new window).

A decades-long study of abandoned Romanian infants and toddlers who were randomly assigned to foster care or the then-standard care in orphanages has yielded data demonstrating the long-lasting impact of early relational health. Followed through childhood and into their teens, children assigned to foster care had better cognitive and physical outcomes and less severe psychopathology than those in orphanages (King, L. S., et al., The American Journal of Psychiatry, Vol. 180, No. 8, 2023opens in new window).

“When we look at what might be driving the differences, it’s often through improved caregiving relationships that included nurturing and enriching interactions,” said one of the study’s coauthors, Kathryn Humphreys, PhD, an associate professor of psychology and human development at Vanderbilt University. “These interactions can be as simple as providing comfort during moments of fear or sadness or talking with and singing to the child.”

Before coming to HealthySteps, National Director Rahil Briggs, PsyD, worked as a clinician in a Bronx early childhood mental health clinic. “You could paint [the walls] whatever color you wanted, you could give out books, but nobody wanted to bring their toddler to see a psychologist” in a mental health clinic, she said. “For those select families who were brave enough to walk through the doors, it always felt like it was too late.” The youngest children were often at least 4 years old, with years of exposure to toxic stress, domestic violence, or other risk factors, Briggs said.

In contrast, the vast majority of parents take their infants and toddlers to a pediatrician, according to Centers for Disease Control and Prevention statistics, and the American Academy of Pediatrics recommends taking them often—at least 12 well-child visits over the first 3 years of life. “We see babies within 3 days of their discharge from the hospital,” said Conner of Northeast Pediatrics. That creates an opportunity to foster early relational health in pediatricians’ offices, which are “nonstigmatized…almost universally accessed and really trusted,” said Briggs. This kind of broad care of the general population, focusing on promoting and fostering positive behaviors to bolster general wellness, is also known as a population health approach.

At HealthySteps, psychologists play three sometimes overlapping roles, said Briggs. They can be a HealthySteps specialist—last year, 18% were psychologists, the rest primarily social workers; a supervisor and sometime clinician, like Conner, who oversees one HealthySteps specialist and two behavioral health consultants, who are social workers; and/or a psychologist at an academic medical center with a HealthySteps clinic who conducts program evaluation and research.

HealthySteps offers three tiers of program services based on health and social needs. In the first tier, the practice’s medical staff screen all infants, toddlers, and their families for developmental milestones and caregiver mental health as well as food insecurity, transportation needs, and other social determinants of health, and give families age-appropriate books and handouts. If concerns are expressed by families or identified during screening, families are bumped to Tier 2, where they receive behavioral health consults, typically to address stressful issues like feeding, sleeping, and behavioral challenges, said Powell. Tier 3 is for families at the greatest risk—for example, children who are already experiencing developmental delay, babies just out of the neonatal intensive care unit, or mothers who have screened positive for anxiety and postpartum depression. In these cases, the HealthySteps specialist attends every well-child visit.

“Maternal depression is considered an adverse childhood experience [ACE] for children and can have a huge impact on their development and emotional health,” said Powell. A recent study of electronic health records of one large health system found that postpartum depression diagnosis rates increased from 9.4% in 2010 to 19% in 2021 (Khadka, N., et al., JAMA Network Open, Vol. 7, No. 11, 2024opens in new window).

HealthySteps and programs like it work to reduce the likelihood of a child experiencing any of the items on the ACE list or to mitigate such experiences by providing healthy relational connection. “It’s about coaching, modeling, and practicing observing and responding to baby’s cues and promoting caregiver-child attachment and interaction,” said Powell. It may also involve some cognitive restructuring, said Conner.

Families enrolled in HealthySteps were more likely to receive a developmental assessment, attend well-child visits, receive vaccinations, have higher maternal depression referrals, notice behavioral cues, and share picture books and play with their infants daily, and they were less likely to use harsh punishment than families who were not enrolled in HealthySteps, according to an early study (Minkovitz, C. S., et al., JAMA, Vol. 290, No. 23, 2003opens in new window).

DULCE is smaller than HealthySteps and operated last year in 19 pediatric clinics across six states—California, Florida, Massachusetts, New Mexico, Rhode Island, and Vermont—serving 1,408 families. The model focuses on the baby’s first 6 months of life and conducts similar screening as HealthySteps. The DULCE family specialist, a specialized community health worker, attends well-child visits with families and provides them with relational and emotional support and guidance. Local mental health consultants, including psychologists and clinical social workers, help families access needed resources (Noël, W. H., et al., Child Welfare, Vol. 100, No. 6, 2023opens in new window).

Psychologists, psychiatrists, pediatricians, and other health care professionals from Boston Children’s Hospital’s Brazelton Touchpoints Center and the Brazelton Institute train DULCE family specialists. They learn the Newborn Behavioral Observations, a relationship-building tool that helps families recognize their baby’s cues and build responsiveness, and the Brazelton Touchpoints approach that offers families anticipatory guidance ahead of expected periods of disorganization and stress that precede spurts in a baby’s development. “This strengths-based stance toward children’s behavior and their parents promotes healthy interactions so as to prevent derailment in the relationship,” said Jayne Singer, PhD, the director of developmental and relational health at Brazelton Touchpoints Center.

In a randomized controlled study of the original DULCE pilot program conducted between 2010 and 2012, infants from families who received the intervention were more likely to receive vaccinations and less likely to have visited an emergency department by 6 months of age, compared with controls. DULCE families had greater access to concrete supports including utilities, income, and food assistance (Sege, R., et al., Pediatrics, Vol. 136, No. 1, 2015opens in new window).

Family Connects targets all postpartum families in a geographic area, no matter their income or circumstances. “All families have needs,” said cofounder Dodge, adding that targeting recipients based on income or risk can be stigmatizing.

Family Connects is being implemented in 55 communities across 22 states, from small cities to entire states, said Dodge. But reaching all families in a geographic area is a challenge, he said. Family Connects nurses access new parents through relationships with maternity wards in local hospitals as well as obstetricians and primary-care physicians. Family Connects staff also comb through public birth records to find new parents, Dodge said.

Family Connects nurses visit the family when the baby is about 3 weeks old to understand the family’s needs and to either provide a brief intervention or connect them to a community resource—anything from a mental health provider to an organization that supplies cribs. They follow up by phone or sometimes in person.

Studies have shown that families assigned to this brief intervention had more connections to community organizations and services, fewer child abuse investigations, fewer cases of maternal anxiety and depression, and fewer child emergency care visits (Goodman, W. B., et al., Maternal and Child Health Journal, Vol. 26, No. 5, 2022opens in new window; Goodman, W. B., et al., JAMA Network Open, Vol. 4, No. 7, 2021opens in new window).

A combination of public and private funding is fueling the growth of programs fostering early relational health.

Family Connects is free of charge to families, and each location finds its own way to pay for the service. Oregon passed a law in 2019 that requires Family Connects be offered to every baby born in the state. Either Medicaid or private insurance pays for the service, depending on a family’s health insurance. If a family does not have insurance, the state pays. Family Connects is scaling up in New Jersey and is in contract negotiations with Ohio and Maryland, said Dodge.

Family Connects has also begun a pilot program in North Carolina called Community Navigation to expand the nurse intervention from the second trimester through the baby’s third birthday. The Duke Endowment, a private foundation, and Blue Meridian Partners are funding the pilot.

“The role of philanthropy is to serve as a catalyst, piloting innovative programs and bringing people together to demonstrate new kinds of solutions,” said Lisa Mennet, PhD, a psychologist and founder of Perigee Fund, established in 2018 to finance, among other things, programs that support infant and early childhood mental health in pediatric and OB-GYN practices, childcare settings, and other family-focused environments. “Philanthropy also plays a critical role in advocating for government and private sector investments to scale up successful programs,” Mennet said.

Several states have stepped up. In March, Medi-Cal, the Medicaid program in California, finalized a new payment policy that allows pediatric practices to bill for dyadic care—behavioral health services delivered to caregiver and child together—without requiring a mental health diagnosis, said Kathryn Margolis, PhD, who leads the integrated behavioral health division at Zuckerberg San Francisco General Hospital, which includes HealthySteps services at its Children’s Health Center pediatric clinic. “Now we have a billable pathway to be able to provide this type of care that we’ve known for a long time has worked,” said Margolis. “This momentum is building in different ways across the country in different states.”

Medicaid programs, for example in Colorado, Massachusetts, New York, South Carolina, and North Carolina, also no longer require a diagnosis for integrated behavioral health providers to bill for dyadic behavioral health care, said Powell. In another change, Medicaid programs in Maryland, Arkansas, and New Jersey make enhanced payments to HealthySteps practices, she said.

Briggs said commercial insurance has not followed suit, although New Jersey and Massachusetts are considering legislation requiring insurers to reimburse for preventive services in pediatric practices without a behavioral health diagnosis.

Partly as a result of these expanded Medicaid payments, HealthySteps has expanded rapidly, growing from 200 sites in 2021 to more than 350 sites currently. However, the federal cuts to Medicaid recently signed into law by President Donald Trump threaten critical services and are expected to lead to millions of people losing insurance, said Powell. “We’re deeply concerned about the impact of cuts to Medicaid. We know that caregivers and children will need dyadic services more than ever and, at the same time, states and health systems will be under unprecedented financial strain,” she said.