Changing the Mindset: Foundational Relationships Counter Adversity with HOPE

Posted on by David Willis, MD and Robert Sege | Kay Johnson
Father smiling at newborn baby.

The three of us have been talking together for years, and have come to believe that it is important to articulate our common vision for the work we lead on behalf of children, families and communities. We are making a commitment to become allies in this important work, intentionally aligning the work on foundational relationships and early relational health led by David Willis; the work on Healthy Outcomes from Positive Experiences (HOPE) led by Bob Sege; and the leadership by Kay Johnson for maternal-child health, early childhood system building, and Medicaid policy. 

Early childhood experiences, especially foundational relationships, are important drivers of healthy child development and future adult health. The contexts of those experiences, such as the protective factors articulated in CSSP’s Strengthening Families Protective Factors Framework and other social determinants of health, also matter. While early relational health may be a new term, it builds upon decades of research from the fields of child development, infant mental health, and neurodevelopment, that has established the centrality of relationships between caregivers and very young children for future health, development, and social-emotional well-being.1 Our work aims to galvanize the interest in foundational relationships among many more providers, stakeholders, and leaders in child health and early childhood systems—those concerned with supporting families, healthy development, and the social-emotional needs of infants and young children. In addition to supporting the community context, we are engaging with network partners to advance activities that support strong foundational relationships for all families with infants and toddlers, an age group that is often forgotten.  

Positive Childhood Experiences (PCEs) have profound effects on development.2,3 While Adverse Childhood Experiences (ACEs) endanger mental and physical health in childhood and throughout the lifespan, emerging science helps us to understand how PCEs promote optimal health and well-being.4 Balancing knowledge of ACEs with Healthy Outcomes from Positive Experiences (HOPE) calls for the engagement with families in new way. Incorporating the HOPE framework into pediatric medical homes, early care and education, home visiting programs, child welfare services, and other child service systems, brings attention to the child, family, and community strengths and resilience. The building blocks of HOPE—relationships, environment, engagement, and opportunities for social-emotional development are accessible to all families and relevant in all communities and cultures. Recognizing, celebrating, and bolstering these strengths in all families and communities provides a bridge to issues of equity and the respect for human dignity within an anti-racist agenda.5

Based on current understandings of human development and factors that strengthen families, it is past time to shift child health and development services from its continued focus on risk and deficit to a holistic, strengths-based, family-centered and community context approach. Building momentum across systems of care for children and families can accelerate a changing mindset that offers better ways to serve children, their families, and their communities.

This 21st century perspective on fostering child development to promote lifelong health and well-being is grounded in research:

  • Early childhood experiences promote brain development, and children develop in an environment of foundational relationships.6
  • Safe, stable, and nurturing relationships and environments are essential to preventing child abuse and neglect.7
  • Healthy children live in families, environments, and communities that provide them with the opportunity to reach their fullest developmental potential.8,9
  • Society benefits socially and economically from providing current and future generations of parents with the support they need to raise healthy and thriving children.10

Current knowledge supports approaches that implement a social ecological model, moving from a traditional focus on babies, to one which includes the people who care for them, the places where they live and grow and the public policies that impact their lives.

Strengths-based, family-centered, and anti-racist efforts aspire to transform pediatric care, early childhood systems, and social norms. We are witnessing an urgency for change that has spread through pediatric primary care, home visiting, and child welfare, as well as early childhood systems and community partnerships across the country. In addition to countless papers, editorials, and reports, numerous programs and providers have successfully implemented approaches in this vein, including, among others:  Strengthening Families, Bright Futures Fourth Ed., Reach Out and Read, DULCE, HealthySteps, Incredible Years, Promoting First Relationships, and Essentials For Childhood. While every model program and newly funded initiative (including our own) strives to spread and protect its brand, transformation now requires the clarity of common terminology, alignment, partnering and networking.

We aim not to advance another model but to accelerate a change in framing and mindset and the alignment of efforts that are:

  • Authentic partnerships with families and communities to advance equity;
  • Based on the importance of early, foundational, and ongoing relationships;
  • About positive relationships, environments, and local communities that promote well-being;
  • Grounded in human dignity and therefore deeply opposed to systemic racism and xenophobia;
  • Science-based, strengths-based, family-centric, and community-based;
  • All-in approaches representing multiple partnerships among providers, parents, and communities with existing programs and practices all moving together; and
  • Committed to changing practice, programs, and public policies.

Parents universally want the best for their children, and their passion and devotion to them drives many important adult decisions. However, a narrow focus on parenting skills or the parent-child relationship alone is too simplistic and risks reinforcing the “family bubble” model or “blaming the victim.” Strong communities, socioeconomic safety networks, and the corresponding public policies are critical to support foundational relationships and other positive childhood experiences.

Protecting the well-being of children and families necessarily includes addressing social determinants of health and social context. Societal factors such as racism, inadequate income, food, and housing often impact parents’ capacities to provide safe, stable, and nurturing environments for their children. Too many parents in the United States face substantial headwinds when raising their children, despite their own best intents. Improving their families’ lives begins with our nation’s commitment to all our children and their families.

Even before the COVID-19 crisis, one-third of young children faced physical, developmental, social, or emotional risks that could affect their health and well-being for a lifetime. Millions more families are in stressful situations that could disrupt the hopes and dreams for a better future for their children. Even if no one in a family gets sick or dies from COVID-19, parents feel the pressures of going to work on the front lines in jobs they worry about losing; of coping without income to pay the bills; managing without sufficient food; and fulfilling multiple roles as teacher, nurse, coach, and parent for their children. Thus, the COVID-19 crisis has dramatically raised the level of need, the urgency for action, and the importance of our opportunity to change the way we provide services to families. Building effective, comprehensive early childhood systems that prioritize foundational relationships, equity, and HOPE is our visible goal post.

We need an all-in approach: partners and networks, families, communities, government agencies, funders and, in fact, all of us. In our work, we want to do more than identifying, evaluating, and expanding successful practices—we want to be part of a networked movement that celebrates optimism and respect for families, that commits to trusted and authentic relationships with families and each other. To quote Hunkpapa Lakota religious leader and tribal chief, Sitting Bull: “Let us put our minds together and see what kind of future we can create for our children.”

We have committed to working towards this transformation. Will you?

  1. Institute F. Building relationships: Framing early relational health. Washington, DC: FrameWorks Institute;2020.
  2. Narayan AJ, Ippen CG, Harris WW, Lieberman AF. Protective factors that buffer against the intergenerational transmission of trauma from mothers to young children: A replication study of angels in the nursery. Development and Psychopathology. 2019;31(1):173-187.
  3. Crandall A, Miller JR, Cheung A, et al. ACEs and counter-ACEs: How positive and negative childhood experiences influence adult health. Child abuse & neglect. 2019;96:104089.
  4. Bethell C, Jones J, Gombojav N, Linkenbach J, Sege R. Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample: Associations Across Adverse Childhood Experiences LevelsPositive and Adverse Childhood Experiences and Adult Mental and Relational HealthPositive and Adverse Childhood Experiences and Adult Mental and Relational Health. JAMA Pediatrics. 2019:e193007-e193007.
  5. Sege RD, Harper Browne C. Responding to ACEs With HOPE: Health Outcomes From Positive Experiences. Academic Pediatrics. 2017;17(7, Supplement):S79-S85.
  6. National Scientific Council on the Developing Child. Working Paper #1: Young Children Develop in an Environment of Relationships. Center on the Developing Child – Harvard University;2004.
  7. CDC. Essentials for Childhood: Creating Safe, Stable, Nurturing Relationships and Environments for All Children. Atlanta GA: National Center for Injury Prevention and Control; Division of Violence Prevention, CDC.;2018.
  8. Daelmans B, Darmstadt GL, Lombardi J, et al. Early childhood development: the foundation of sustainable development. The Lancet. 2017;389(10064):9-11.
  9. Hagan J, Shaw, JS, and Duncan, PM, eds Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents. 4th Edition. Elk Grove Village, IL: American Academy of Pediatrics; 2017.
  10. National Academies of Sciences E, and Medicine. Parenting Matters: Supporting Parents of Children Ages 0-8. Washington DC: Institute of Medicine;2016.