The most prominent organizations in children's mental health have declared a national emergency due to the sharp rise in pediatric mental health disorders (3). The critical nature of the situation was first highlighted in 2020 (4) and reiterated in 2022 (5) by the AAP, the American Academy of Child and Adolescent Psychiatry (AACAP) and the Children's Hospital Association (CHA), who joined efforts to tackle the continued rising number of children struggling with mental health disorders across the nation. The February 2022 Center for Disease Control and Prevention Morbidity and Mortality Weekly Report estimated that mental health disorders affect as many as 40% of all children (6). Associated with the child mental health crisis, U.S. Surgeon General Dr. Vivek Murthy officially declared in 2023 an epidemic of loneliness, raising awareness about the long-lasting damaging impacts of social disconnection (7). Human social connection is a complex phenomenon shaped by the structure, functions and quality of relationships (8) stemming from the early-life experiences in the parenting/caregiving environment (9). These national emergencies call for urgent public health research and action to identify and implement effective strategies that strengthen family and community connectedness and promote life-course health and well-being, even in the presence of mental health disorders (10, 11).

There is strong evidence that exposure to childhood adversity conveys risk for poor mental and physical health outcomes across the life-course (12–22) and profoundly impacts overall child well-being. The original Adverse Childhood Experiences (ACE) Study assessed seven specific adverse experiences: psychological, physical, or sexual abuse; violence against mother; and living with household members with substance abuse, mental illness/suicidality, or ever imprisoned (23). Addressing a limitation of the original ACE study that was conducted with White, middle-class individuals, further research including more diverse populations expanded the list of ACEs to better represent common experiences (24).

Critically, during discussions following our in-person meeting, the ERH Learning Community recognized post-pandemic trends of spiking poverty and food insecurity (25), parent/caregiver psychopathology (26–35), child maltreatment (36) and neglect (33), breaks in provision of protective services (37), family and domestic violence (38–42), racism (43, 44), parental/caregiver loss (45), social isolation (46) and loneliness (47). Situated in this context, we refer to childhood adversity as an inclusive term that encompasses adverse community environments (e.g., poverty, racism, cyberbullying), and family-level and contextual stressors (48) (e.g., parent/caregiver psychopathology, domestic violence, neglect). This centering of both individual and community experiences to be “representative of America” is an important driver toward our emergent research agenda. We recognize that what works for whom, under what conditions, and toward what benefit, might not be universal. Thus, an inclusive and equitable investigation of the promotion of ERH must be designed to identify the specific needs and, even more importantly, the diverse strengths of different communities.

ERH encompasses diverse theoretical constructs including bonding, sensitivity, attachment, and emotional connection, that ultimately converge in their shared objective of describing distinct facets of the parent/caregiver-child relationship. Decades of accumulating evidence points to ERH playing a fundamental role in child physical health, cognitive and socioemotional development, and well-being (49, 50). ERH is also thought to protect against the negative effects of childhood adversity (14, 23, 51–53).

Given the far-reaching implications of strong ERH for child mental health and development (49, 52–54), the AAP published a policy statement in 2021 reorienting pediatric care toward an emphasis on ERH as a promoter of health and well-being across the lifespan (51, 52). Strength-based promotion of healthy early relationships is proposed as a support for families during the current mental health crisis by buffering against childhood adversity, leading to improved health, sense of competence, connection and well-being of both children and their parents/caregivers.

The AAP policy statement also emphasized the importance of developing strategies that focus on early childhood, and the opportunity offered by the pediatric primary care setting for promoting ERH. The first 1,000 days of an infant's life are a critical period for promoting positive and mutually nurturing parent/caregiver-child relationships (11) owing to developmental embedding that has the potential to affect long-term health and well-being. In the face of adversity, a study of 3,500 children showed that the quality of ERH in infancy mattered more than the severity of perinatal adversity in predicting later functioning (55). Pediatric primary care offers standardized, pre-established, consistent, accessible and affordable care in the first few years of a child's life (54–56). It occupies the privileged position of having widespread access to infants, with an estimated well-child visit attendance rate of 63%–93% in the first 3 years of life, even in low income families (57). In commercially insured children, preventative primary care visits increased by 9.9% from 2009 to 2016 (58). Pediatric primary care is delivered in different settings, including within family-centered medical homes where pediatricians are expertly prepared to handle child health needs by providing continuous, affordable, compassionate care with cultural humility (56). Other settings include group well-child care which is thought to increase equitable health care delivery (59) with many documented health benefits for families experiencing marginalization and underserved communities. Benefits include increased adherence to well-child visits, better child nutritional behaviors, increased rates of breastfeeding, optimal child health status and development, and increased parental social support, caregiving behaviors, self-efficacy and psychological well-being (60). Pediatric primary care is thus an ideal setting for widespread implementation of time-efficient and cost-effective strategies focused on promoting ERH (51, 61).

Prior to our in-person meeting, several of the ERH Learning Community members (AL, MF, DW, NS, DD) contributed to a systematic review and meta-analysis that assessed the global effectiveness of contemporary parent/caregiver-child interventions, initiated within the first six months of life, specifically aimed at improving ERH (62). Consistent with other reviews, we confirmed the effectiveness of the identified interventions in improving a heterogenous set of ERH outcomes including maternal bonding, child attachment, parent/caregiver-child emotional connection, and parent/caregiver emotional availability. However, effect sizes were mostly small-to-moderate and time-limited, with most of the significant effects observed immediately after the intervention ended, and very few studies investigating long-term effects past a few months to years out.

Importantly, our meta-analysis did not provide significant evidence from real-world contexts to support the abundant body of work establishing an association between ERH and later child emotional, mental, and physical health (63–68). These results do not necessarily reflect a lack of causal effect between improved ERH and later child outcomes, but rather underscore the need for additional investigation into the processes and mechanisms underlying the relationship between ERH and life-course health and well-being, as well as exploring the real-world conditions that influence the effectiveness of interventions.

Another identified gap in our systematic review was that only 3 (69–71) of the 93 interventions were implemented by pediatricians or in family-centered pediatric medical homes. Yet it is widely recognized, including in the AAP policy statement, that leveraging pediatric primary care for universal promotion of ERH holds significant potential to yield public health benefits (51).

Additionally, 95% of identified studies focused on biological mothers and only 8% targeted a population at-large rather than focusing on groups with specific risk-factors, pointing to potential lack of generalizability of results to a more inclusive view of families and communities. Finally, we note that no study to-date has included a comprehensive battery of all constructs within the ERH literature (i.e., bonding, attachment, emotional connection, repair, etc.), but rather focus on one or a few of these constructs, limiting the interpretability of which interventions improve which specific ERH constructs. We view these gaps as opportunities that pave the road to a comprehensive research agenda that expands our understanding of underlying mechanisms underpinning the emergence and maintenance of ERH, and uses this knowledge to simultaneously develop and refine effective, equitable, evidence-based ERH interventions. Favorably, our systematic review also found that relational interventions improve ERH outcomes non-dose-dependently, supporting the possibility for scalable light-touch interventions.

Transformation of Care (subtheme 1) was the most prominent subtheme mentioned in 59 written responses. This subtheme translates the Community's goal of transforming and rethinking pediatric primary healthcare. Centering well-child visits on health, wellness, and strengths of the parent/caregiver-child relationship is at the core of this subtheme. Centrality of Relationships (subtheme 2) was mentioned in 36 written responses and encompasses the ERH Learning Community's acknowledgement that “relationships matter” and that pediatric care should strive to become relationship-centered. The importance of centering relationships bled into subtheme 3, which focuses the research agenda on Positive Outcomes Across Multiple Levels (n = 37). Congruent with the ERH literature, a research agenda centered around universal promotion of ERH needs to be outcome-focused, demonstrating improved objective measures of health and well-being. However, the ERH Learning Community also identified the need to measure more subjective outcomes, such as love, joy, empathy, strength, forgiveness, repair, etc., and the importance of measuring outcomes not only in children but also in families and communities. Additionally, adoption of a Collaborative Learning approach (subtheme 4; n = 9) emerged as a subtheme for participation of pediatric clinicians, parents/caregivers, scientists, and policymakers.

Consistent with our collaborative learning approach, the importance of having Parents/Caregivers at the Core (subtheme 5) was present in 37 written responses. Parents/Caregivers partnering at every step with scientists and other collaborators as the research agenda is developed and carried out is critical. As this partnership unfolds, the ERH Learning Collaborative is adopting a Values-Based (subtheme 6; n = 23), as well as a Strengths-Based (subtheme 7; n = 5) approach. Principles of equity, diversity, representation, respect, and cultural humility (74) drive not only the relationships among members of the ERH Learning Community but also fundamentally influence how the research agenda will be strategized and implemented. Finally, another emerging subtheme underlying our processes is the focus on the Parent/Caregiver-Child-Clinician Partnership (subtheme 8; n = 18), building on trust, value, and collaboration to abolish the traditional hierarchical model.

The third theme defined how the ERH Learning Community conceptualized the “who/when/where/how” to be targeted via a comprehensive research agenda. To promote ERH effectively, our work will center on parent/caregiver-child relationships from Birth to 5 Years, with a Particular Focus on Birth to 3 Years (subtheme 9; n = 13). Efforts will Prioritize Clinician-Parent/Caregiver Encounters (subtheme 10; n = 21) as opportunities for widespread foundational promotion of ERH, with recognition that our work must ultimately be Integrated Within Many Systems of Care (subtheme 11; n = 9), eventually extending beyond pediatrics to be inclusive of educational settings, home visiting, and other parent/caregiver-child facing contexts. Using Simple but Impactful Strategies (subtheme 12; n = 8) is also critical for feasibility and effectiveness. The “how” also included Improved ERH Training (subtheme 13; n = 8) for pediatric clinicians, and most importantly an Iterative, Practice-Informed and Data-Driven Multi-Level Research Approach (subtheme 14; n = 27), including new and improved measures of ERH.

The emerging themes define the ERH Learning Community's unified goals, core processes, and strategies, and guide the development of a multi-layered, iterative approach with emphasis on lived experiences and experiential learning leading to innovations.

Establishing a large prospective ERH-focused cohort of children and their parent(s)/caregiver(s) is critical for deep investigation of the role played by different ERH constructs in health and well-being over the life-course. With increasing understanding for the critical need for “big data”, large multidisciplinary datasets are being established to delve into other key outcomes. Examples include the ABCD study (78) aimed at elucidating the building blocks of brain development from imaging the brains of thousands of children at multiple times during infancy through adolescence, and the RECOVER study (79) aimed at understanding the long-term effects of SARS-CoV-2 infections on a variety of health outcomes. To the best of our knowledge, no ongoing or currently planned similar dataset exists to generate foundational knowledge about ERH.

Goal 1 therefore seeks to expand and leverage existing successful infrastructures (80–83), to develop a large open science dataset by enrolling and following a national cohort of thousands of children and their parent(s)/caregiver(s). Importantly, all efforts will be made to ensure this cohort is “representative of America”, with US census-congruent representation of families of different socioeconomic status, race, and ethnicity.

This data-driven process will ascertain the eco-bio-developmental factors associated with strong ERH and explore the underlying mechanisms of ERH through rigorous data analysis. In collaboration with experts from interconnected and complementary research fields, we will incorporate state-of-the-art methodologies, including machine learning, neural and physiological synchrony, brain imaging, genetics, medicine, and developmental science to establish the foundations of ERH. Importantly, this exploration of ERH will not focus on singular constructs within the field, such as bonding, attachment, emotional connection, or emotional availability, but rather seek to collaboratively generate the most comprehensive picture of ERH through all available lenses and in the context of every family's unique experience, structure, and strengths. For rapid generation and dissemination of actionable knowledge, this dataset will be freely and openly shared with the entire ERH community, with anyone joining the overarching Nurture Connection hub.

A successful example of this type of data-driven process is currently employed by the Center on the Developing Child at Harvard University, which has spearheaded the dissemination of concepts such as toxic stress (84) and serve and return (85), as well as implementation of evidence-based practices building on these concepts (86). Strengths of utilizing this process include the ability to conduct rigorous analyses to isolate mechanisms of change that emphasize internal validity (87, 88), and a large prospective design to identify predictors of ERH (89). In alignment with the ERH Learning Community's research agenda discussion resulting from the co-design activity, this data-driven process will innovate by emphasizing a strengths-based focus on positive predictors, mediators, and outcomes of ERH, including positive childhood experiences (PCEs) as opposed to ACEs, and flourishing and thriving as opposed to mental health disorders.

The practice-informed process brings the research within the context of practice (90) to explore together with families, practitioners and communities what strategies work, for whom, and under which conditions. Consistent with the themes in our co-design activity, we propose to use the established Reach Out and Read large network of pediatric primary care clinics and clinicians as a platform for the practice-informed process. The Reach Out and Read model has been integrated successfully into more than 6,000 clinics across the U.S. and is an ideal platform for practice-based research on ERH. There is a strong evidence base documenting the effectiveness of integration of Reach Out and Read into pediatric primary care (91). Critically, this network offers broad representation from a range of pediatric primary care settings, including all major US geographic areas, rural and urban settings, and professional contexts (e.g., academic/private/community practices and pediatric/family medicine specialties). Drawing from broader literature, initiatives embedded in primary care, such as the Developmental Understanding and Legal Collaboration for Everyone (DULCE) approach, have demonstrated the advantages of leveraging well-child visits to improve pediatric health care and family outcomes at scale (92). As noted previously, limited experimental evidence is available to support timely implementation of evidence-based interventions in the realm of ERH (62). Given the uniqueness of this endeavor, though, we propose starting with pediatric primary care as a foundation, in partnership with Rearch Out and Read, which may lead to rethinking primary care (61) and to new avenues for further exploration.

We will employ Community Activated Research [i.e., engaging parents/caregivers/communities in the research process and giving their voices high priority (93)] to ensure integration of co-design with parents/caregivers, clinicians and communities. To generate knowledge within practice, community activated research will be supplemented by methodologies such as real-world pragmatic designs (94), qualitative research, continued quality improvement [CQI; e.g., quick learning cycles, such as Plan-Do-Study-Act (PDSA)], implementation science (95). Knowledge generated can be used for internal improvement within an organization (96), or disseminated through learning networks (97).

Our research will include determination of the factors that strengthen the clinician-parent/caregiver-infant relationship and ensure integration of effective real-world promotion of ERH into pediatric primary care; development and evaluation of tools to equip pediatric clinicians to both observe and promote ERH; and cultivation of adaptations of the well-child visit that provide opportunities for interventions that effectively advance ERH.

This practice-informed process, which emphasizes external validity, will support the identification of ERH innovations that can be successfully implemented within a variety of health care and related settings (e.g., team-based care, family practice), and with diverse communities. Current successful examples of this methodology include the Home Visiting Collaborative Improvement and Innovation Network (HV CoIIN), which employs CQI to improve the quality of home visiting programs (98), and the IDEAS Impact Framework, which employs rapid-cycle testing to generate evidence for early childhood programs (99). Strengths of this process include higher likelihood of successful implementation due to stronger understanding of practical considerations, shorter timeline to share and scale evidence-informed innovations, and greater considerations of cultural aspects that may influence ERH and its promotion within the pediatric primary care setting.

The most innovative aspect of our research approach is our intention to utilize both evidence-based practice and practice-informed evidence methodologies in a seamless and integrated manner. In other words, to operationalize this approach, we will leverage the large dataset established in our data-driven process to explore mechanisms that support ERH (and the individual variation in the influence of eco-bio-developmental factors on ERH) and feed this knowledge into our practice-informed research. At the same time, the practice-informed research will define feasible practice to cycle back and further test through the data-driven process. The evidence-based practice and practice-informed evidence research will be operated simultaneously, in continuous cycles, each with their specific research methodologies. Findings will be disseminated through our network to inform future cycles of evidence-based practice and practice-informed evidence research. For example, research questions can be generated by any member or affiliate of the ERH Learning Community, including academic researchers, parents/caregivers, and clinicians. Our extensive dataset will allow for a rapid examination of both predictors of ERH, as well as how ERH predicts later outcomes. Identified mechanisms will inform the development of promising new practices that improve ERH. Likewise, promising strategies arising from the practice-informed methodology will inform new hypotheses for mechanisms underlying strong ERH. This combined approach is uniquely promising in answering: what works for improving ERH, for whom do certain supports/interventions work, and under what contexts do these supports/interventions work best (100, 101). In conjunction with traditional hypothesis-driven research (102), we will leverage increasingly popular inductive analytic processes to explore patterns both within the large datasets, as well as through practice-based innovations (103). This inductive, dual-research approach will allow for a high level of collaboration and connection between both research methodologies, ensuring both internal and external validity are valued and maximized throughout the learning and innovation process (104).

The culmination of this integrative research approach will be to achieve population health impacts. We anticipate our preliminary work in the prior years will have demonstrated both testable and promising strategies that improve ERH and subsequent child development, as well as the conditions and context necessary to embed and scale a program or set of practices. Once these advances are achieved, it will be critical to test our assumptions and to demonstrate the impact of our intervention program to generate the level of evidence required for widespread policy changes. We anticipate this demonstration will result from large-scale rigorous mixed methodologies, including a randomized controlled trial (RCT) as a strong basis for supporting causal inference between our proposed innovations and population health impacts. Findings will be communicated through traditional scientific dissemination of results through publications and presentations as well as to a variety of audiences through Nurture Connection (e.g., policymakers, early educators, health care clinicians) to broadly support dissemination and implementation of identified evidence-based practices that support ERH.