“Toxic stress” as a concept has gained a firm foothold in our health discourse and even crossed over into the mainstream. That’s because we can so clearly see the physiological and behavioral effects it is having on our children.
But what do we do about it? And how do we shift our attention from merely identifying toxic stress as a problem to buffering it? How do we build healthy, resilient children and families?
The American Academy of Pediatrics released a policy statement last year that says the answer lies in fostering relational health between children and adults in pediatric primary care practice.
But how we foster relational health remains up for interpretation. As the policy statement reports, many pediatric and early childhood professionals have long recognized the vital importance of the parent-child relationship, and yet “the elemental nature of relational health is not reflected in much of our current training, research, practice, and advocacy.”
From our perspective here at the Nurture Science Program, there are three central reasons relational health has not become an integral component of pediatric care.
1. Relational Health is still largely considered psychological.
2. Most existing relational health screens look separately at parent or child, take time, and are difficult to code.
3. Within existing frameworks, such as attachment theory, each individual develops a fixed attachment style, which means it does not change. Early intervention then becomes the only hope for the developing child.
Through our lens and work on autonomic emotional connection, we hope to provide a practical, scalable solution.
1. Relational health is biological, physiological, and interpersonal.
Over decades of research we have uncovered that there is something happening between mother and infant when they get emotionally connected—not just in the brain, but on a deep body-to-body level, which is where we can observe and measure it. That is why we call it autonomic emotional connection.
The autonomic nervous system is the nervous system that modulates our stress response; it makes our hearts beat and lungs breathe without our having to think about it; these processes regulate our emotional behavior. When mom and baby are emotionally connected on the autonomic level, they are actually regulating each other’s heart rates and hormones and positively affecting each other’s stress responses. In other words, when a mom and baby are cuddling, talking and cooing warmly with each other, making eye contact, listening and responding to each other, they are influencing the very physiological functions that underlie their health.
It sounds strange, I know. We don’t think of things like cuddling and cooing as science—but they are behavioral manifestations of essential physiological and biological processes happening between two bodies.
And the impacts these behaviors have on our physiology are profound. Through our randomized control trial of Family Nurture Intervention (FNI) in NICU, we found that engaging mothers and children in autonomic emotional connection dramatically improves babies’ development, sleep, stress resilience, attention, cognitive, learning, and language scores. Mothers also saw improved mental health and lower cardiac risk. Five years later, both mother and child still had better physiological regulation and stress resilience (which is important when we’re worried about the effects of toxic stress).
Once parent-facing professionals can understand that relational health produces physiological outcomes and observable behaviors—rather than being an ephemeral concept—they can seamlessly integrate relational health observation into an office visit where they are already checking vital signs and motor skills.
All they need is a brief observational tool that evaluates parent and child in relationship with each other.
2. To measure relational health, we need to observe parent and child interacting with each other face-to-face.
Unlike existing relational health screens that only look at the child or the parent, the Welch Emotional Connection Screen (WECS) focuses on the behaviors between parent and child. It is a quick (20-30 second), easy to use, non-invasive, validated screen that a parent-facing professional can employ while observing a mother and infant interacting face-to-face with the child on the parent’s lap.
The WECS organizes the visible behaviors of their relationship into the following four domains:
- Mutual Attraction (Do mom and baby want to be close to each other?)
- Vocal Communication (Is their vocal tone warm and engaging?)
- Facial Expressiveness (Are they trying to communicate using their faces?)
- Reciprocity (Are they sensitive to each other’s expressed emotions? Do they follow-up with each other?)
In clinical research, pairs who exhibit all of the above receive a high WECS score. And in mother-baby pairs with high WECS scores, we see improved neurobehavioral outcomes, both short and long-term.
In widespread practice, a parent-facing professional can use the WECS, even without formally scoring it, to help identify the families that can most benefit from support.
3. Emotional connection is a state not a trait.
The fact that emotional connection is a state between two people and not a trait of just one person is the most hopeful takeaway from our work. It means we are not fully “baked” with a maladaptive attachment style based on whether our needs were met in childhood. It means your toddler with behavioral problems is not destined to always have behavioral problems. No matter our age or life experience, we can enter into a state of emotional connection and share its health benefits.
Fortunately, the very same behaviors that the WECS observes can also be used to get two people connected—by conditioning the underlying physiological mechanisms of relational health. The context is still sensory—physical touch, eye contact, vocal communication—but the activity is emotional expression.
In a pediatric primary care setting, the intervention is brief: emotional exchange between parent and child, with the child sitting on the parent’s lap. Parents respond to a prompt on an emotional topic (such as “tell your child the story of how you picked their name,” or “tell your child the story of their birth”), in their primary language. The prompt works when it elicits deep emotional expression from the parent.
During FNI (an intervention used in extreme cases, such as preterm birth), mothers are guided through what we call calming cycles. A nurture specialist prompts mothers to express their feelings to their babies while engaging their senses (e.g. skin-to-skin, making eye contact, etc). This emotional expression engages the child’s orienting reflex, and often prompts some kind of response (their oxygen saturation may go up or they may look at their mom for the first time). This cycle continues as parent and child move from mutual states of distress to mutual states of calm. Once calm and connected, we can see evidence that their physiological co-calming mechanism (what we call co-regulation) is in effect. Any further nurturing interactions between them will continue to strengthen and condition that mechanism.
We hypothesize that the mechanism of co-regulation underlies and facilitates all of the physiological improvements, developmental gains, and emotional and mental well-being we see in our results. And because emotional connection and co-regulation feel good, moms and babies will continue to do these sensory and emotional activities, not because they have been told to, but because they want to. That may be part of why mothers and children show physiological benefits related to stress resilience (HRV) even 5 years after the intervention.
It’s Time for a Paradigm Shift
The quality of our relationships can alter the landscape of our physical and mental health, lifelong. Relational health, it turns out, is an absolutely essential part of our wellbeing, and we can foster it by looking through the lens of autonomic emotional connection.
When we do so, we will see that relational health is behavioral and can be observed; its impacts are physiological and can be measured; and it is a state that we move in and out of with our loved ones throughout our lifetimes. The reason to start early, and to target the mother-infant relationship as a mediator of positive effects on relational health, is not merely to prevent later problems, it is to experience maximum benefit at every stage of our lives.
This paradigm shift would necessarily impact the way that health conditions are viewed and treated: by creating environments and relationships capable of fostering the growth and health we all deserve.
Disseminating these tools and practices to researchers, clinicians, and parent-educators has the potential to help children and their families experience deep autonomic emotional connection with each other—opening the door to intergenerational health and thriving.