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Almost a decade after policy on toxic stress, ‘relational’ health seen as key approach

July 26, 2021

The concept of toxic stress may be more relevant than ever as we face structural racism; widening disparities in health, educational and economic outcomes; and a socially isolating pandemic. A revised AAP policy statement argues that to build healthy, resilient children and adolescents, family-centered pediatric medical homes need to be integral elements of community efforts to foster “relational” health.

Relational health refers to the ability to develop and sustain safe, stable and nurturing relationships with emotionally available, engaged and attuned adults. The adults provide children and adolescents with the positive experiences that buffer adversity and build the foundational social and emotional skills needed to be resilient in the face of adversity.

Relational health is both the treatment for and mitigation of childhood toxic stress. This concept builds on the 2012 AAP policy and technical report that described how early childhood experiences are biologically embedded and influence developmental outcomes across the life course.

The policy statement Preventing Childhood Toxic Stress: Partnering With Families and Communities to Promote Relational Health, from the AAP Committee on Psychosocial Aspects of Child and Family Health, the Section on Developmental and Behavioral Pediatrics and the Council on Early Childhood, is available at and will be published in the August issue of Pediatrics.

Power of positive experiences

Toxic stress refers to the molecular, cellular and behavioral changes brought on by significant adversity that occurs in the absence of safe, stable and nurturing relationships. Stress-induced changes then become risks factors for poor outcomes in health, education and economic productivity. Toxic stress from early childhood adversities can become biologically embedded and worsen life course trajectories. Toxic stress also explains why many of society’s most intractable disparities begin in childhood.
But new evidence suggests that positive childhood experiences due to nurturing relationships also are biologically embedded and improve life course trajectories. Fields like epigenetics and developmental neuroscience have shown that toxic stress-induced changes, such as DNA methylation and brain activity patterns, can be prevented and even reversed through interventions that promote relational health.

Strengths-based model

Promoting relational health and preventing toxic stress are two sides of the same coin. Toxic stress is a deficits-based model that describes what goes wrong in the absence of nurturing relationships. Conversely, relational health is a strengths-based model that describes what goes right when children are afforded safe, stable and nurturing relationships and positive early experiences.
Building relational health is at least a two-generational endeavor. For children to fulfill their biological potential, parents and caregivers — as well as grandparents, extended family, teachers, coaches and neighbors — need to be in “relational mode” and available, engaged and attuned to the child’s emotional needs. If the adults in a child’s world are in “survival mode” due to their own adversities or social determinants of health, they are less able to provide the pivotal positive childhood experiences that buffer adversity and encourage both resilience and relational health in the next generation.
Building our collective relational health is an enormous undertaking that family-centered pediatric medical homes cannot accomplish alone. Childhood toxic stress is a public health crisis and demands a public health response that promotes relational health in an integrated manner.

Public health approaches

A vertically integrated public health approach that promotes relational health is grounded in universal primary preventions that proactively support stable relationships in a two-generational manner (e.g., Reach Out and Read, developmentally appropriate play). It also layers secondary interventions that address potential barriers to the formation of stable relationships such as parental depression and poverty and tertiary treatments for relationships that have been strained or ruptured (e.g., the Attachment and Biobehavioral Catch-up program or child-parent psychotherapy).

A horizontally integrated public health approach advocates for policies and practices that support relational health in child- and family-serving sectors outside of medicine, including the educational, social service and justice systems. Pediatricians often think of relational health as being primarily dyadic (e.g., parent-child), but it also is intrafamilial (“Are the family dynamics nurturing or harsh?”) and societal (“Are our social norms and patterns of behavior inclusive or exclusive; restorative or punitive?”).

In short, toxic stress defines the problem. Toxic stress explains how many of society’s most intractable problems (disparities in health, education and economic stability) are rooted in our shared biology but divergent experiences and opportunities. Relational health defines the solution. Relational health explains how the individual, family and community capacities that support the development of safe, stable and nurturing relationships also buffer adversity and build resilience across the life course.

Dr. Garner is a lead author of the updated policy statement and the original policy and technical report from 2012.

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