Putting Families First

Positive interactions between children and their parents/caregivers are crucial to lifelong development and health outcomes. Yet a recent fieldwide meta-analysis showed a surprising lack of data to support implementation of dyadic ERH interventions in pediatric clinical care, to promote better outcomes. These findings helped crucially narrow the spotlight for the field of early relational health (ERH): to develop relational interventions, we need relational evidence. 

COMBO’s national expansion is a groundbreaking partnership to uncover the science of Early Relational Health, toward universal interventions for clinicians and families.

Uncovering Childhood Origins of Lifelong Wellness

After 10+ years of searching for effective ways to protect children from the harmful effects of toxic stress, the American Academy of Pediatrics (AAP) came to a powerful conclusion: not only do positive interactions between children and their parents/caregivers buffer the effects of toxic stress, they deeply impact children’s lifelong development. 

The AAP resolutely called for a fieldwide paradigm shift toward promoting parent/caregiver-child relational health in pediatrics. They named safe, stable, nurturing relationships “biological necessities for all children” to promote future resilience and prevent future disease. This newfound urgency to support early relationships through universal pediatric practice catalyzed the emerging field of Early Relational Health (ERH).

“Understanding and harnessing the early innate power of relationships will usher in an era of universal strengths-based pediatric practice, where pediatricians and families can find the best strategies for promoting each child’s well-being, together,” says Dr. Dani Dumitriu, a pediatrician and neuroscientist trained in environmental health, and inaugural director of Columbia’s Center for Early Relational Health.

So for clinicians who are ready to move into an era of ERH-focused prevention and promotion, what interventions are out there and ready for use in pediatric practice? 

At the Center for ERH, we’re clinicians and researchers ourselves, and we wanted to know the answer. 

The best way to survey the field is a meta-analysis: a systematic review that combines results from all studies done on a particular topic, within a given timeframe, to produce the highest-quality evidence for clinical practice guidelines. Thanks to the AAP’s rallying call, we had over a decade’s worth of relationships-focused pediatric research to look at. We did a deep dive into what the science says so far — and the results surprised us.

A Meta-Analysis To Understand the Landscape of Relational Interventions

Led by Andréane Lavallée, PhD, with key collaborators from Nurture Connection at Georgetown University’s Thrive Center, our 2022 meta-analysis focused specifically on the relational health between parents/caregivers and children. For that reason, we zeroed in on “dyadic” interventions that actively involve both a parent/caregiver and baby, rather than separate individuals. For example: joint music therapy or infant massage.  

Our team looked at 93 studies, published between 2000 and 2022, for a total of nearly 15,000 families. The results of this enormous fieldwide analysis were shocking: there is not sufficient data for any dyadic ERH intervention that would support its implementation into pediatric clinical care, to improve health or development.

This isn’t merely a reflection of the fact that no clear “winner” was identified. Looking at the data from all the interventions tested over the last two decades, we found that there were some improvements in the quality of parent/caregiver-child ERH, but they were relatively minor and didn’t last longer than a year or two. Strikingly, the data showed no improvements in child outcomes outside of ERH, such as development or health. 

That doesn’t necessarily mean dyadic interventions don’t improve these outcomes — the data simply doesn’t exist yet. Indeed, the meta-analysis revealed that only a quarter of studies actually measured the impacts of these interventions on child development or health, and they didn’t follow those children long-term. 

We also found that most current interventions are for families already at high risk for impaired ERH, meaning that these strategies may not apply to early relationships, broadly. That limited scope is perhaps one reason why only three randomized control trials (RCTs) of these ERH tools have actually been used in pediatric settings so far. 

“While the AAP’s stance remains critical,” says Dani, “the fact is: as pediatricians, we simply do not have the tools to do what the AAP wants us to do — yet.” 

Andréane adds, “Ultimately, what this comprehensive evaluation demonstrates is a critical need to develop, evaluate, and implement universal tools that any parent/caregiver and child could benefit from, to set every family up for future positive outcomes. But to do that, we have to dig deeper to uncover the scientific mechanisms of early relationships.”

So Why Have No Dyadic Interventions Emerged To Support Health & Development?

The meta-analysis revealed that ERH research so far shows correlation, not causation. 

(You may remember this classroom-favorite example of correlation vs. causation: when ice cream sales go up, so do shark attacks. But does one cause the other? Of course not — they’re each a function of what people do in hotter summer weather: eat ice cream and swim.)

The meta-analysis’ findings are not counter to the AAP’s call for relational interventions. Rather, they point a compass toward a critical gap in the research: the scientific mechanism of what actually happens between two people’s bodies and brains remains almost entirely unknown. That leaves doctors and scientists without concrete data on what specifically causes better outcomes as a function of relationships. 

The meta-analysis shows us that we can indeed promote ERH — we just don’t yet know how to make those effects last, or spill over into specific measures of health and development. These surprising findings helped crucially narrow the spotlight for the field of ERH: to develop relational interventions, we need relational evidence. 

A Key Partnership To Uncover the Science of Early Relationships

The Center for ERH’s core mission is to build the scientific evidence base for the growing field of early relational health. Dani is resolute that, while the meta-analysis’ findings are certainly surprising, they are not bad news. “The fact that we do see an effect of pooled interventions on early relationships is hugely positive: it means ERH is malleable, most specifically in this 0-6 month range, and that’s critical.”

That’s why we partnered with Reach Out and Read to design and conduct the kind of long-term, prevention-and-promotion-focused research the field needs to create validated dyadic interventions and build them into the fabric of universal pediatric care. 

Reach Out and Read sees every day how impactful positive interactions are in the early years. Their one-of-a-kind network of pediatric clinics, serving nearly 5 million families across America, implements a unique early literacy model into well-child visits (the only pediatric literacy model endorsed by the AAP). 

Their Chief of Research and Innovation, Nikki Shearman, PhD, has helped guide this model of care toward a strong ERH focus, from a family’s first visit. “Reach Out and Read has recognized that sharing books together is a special opportunity for families to connect with their young children right from the beginning,” Nikki says. “We train clinicians delivering our program to talk about this with parents, and model with them how to engage with their infants, toddlers, and preschoolers through books.”

Together, we’re launching “COMBO National”: a nationwide expansion of COMBO (the Center for ERH’s large-scale clinical study), to build an unprecedented understanding of the full space of early relationships. COMBO National will also expand its enrollment within families: involving not just mothers, but as many caregivers as possible for each baby, to generate the most comprehensive, concrete data on how early relational experiences shape individual and social resilience, and impact long-term health outcomes.

“We know that positive interactions between parents or caregivers and young children support healthy growth and development,” says Nikki, who leads the implementation research arm of this groundbreaking study. “Together, we’re trying to learn more about why these early interactions make such a difference, so that families can do what they most want to do — help their young children thrive.”

COMBO National’s pilot phase began in 6 states in April 2025, and soon, recruitment will take place nationwide through Reach Out and Read clinics. 

A Truly Groundbreaking Study of Early Relational Health

While other parent/caregiver-child studies look at a single, one-way construct of relational health (like attachment, which is child-to-parent; or bonding, which is parent-to-child), COMBO National is the first study to look at every known component of early relationships. 

Both COMBO and COMBO National include these unidirectional ERH constructs (and others, like maternal sensitivity) — and the dyadic construct of emotional connection: an understudied two-way component of ERH that focuses on the unique feeling of being in sync with each other during face-to-face interactions. 

And while very few relational health studies measure other health outcomes, COMBO National will evaluate how each component of ERH maps onto children’s developmental outcomes throughout their lives. 

Finally, by involving many kinds of foundational caregivers in families all across the country, COMBO National will gather essential ERH data at a scale not yet seen in dyadic research. This large, unprecedented dataset will live in perpetuity, providing ongoing opportunity to generate novel ways of measuring relationship quality.

Advancing the Field of Relational Health in a Uniquely Relational Way

In further partnership with the Nurture Connection’s ERH Learning Community, the Center for ERH and Reach Out and Read co-designed this phase of the study with the families and pediatricians themselves — listening to the lived experiences of those who will be most impacted by the research, and by any interventions that come out of it. 

This visionary approach to family-focused research is an essential step in producing real-world data that is both actionable and scalable. With this foundational data, COMBO National seeks to begin to answer the AAP’s call, building a world where pediatricians and families have access to truly evidence-based dyadic interventions for those critical early years. 

In a field that so profoundly affects lifelong outcomes, designing, conducting, and spreading this relational work in a relational way holds enormous potential to promote the well-being of the American family and invest in our future generations.

An Exciting New Era for Early Relational Health

Good science takes time. The first 10+ years of ERH research were hugely important in making it possible for our meta-analysis to identify the gap between knowing how crucial early relationships are — and understanding how to promote the interactions that help children thrive, from the very beginning. 

There is a critical need to re-examine how we look at relational health during early childhood, when it has the potential to influence a child’s (and thus, a family’s) lifelong development and health. “The pediatric community is ideally positioned to partner with families, offering tools to help them to love and care for their child in the best way for them,” says Nikki. To create those tools, we need more causative science. 

This is what the Center for Early Relational Health was established to do: provide a unified home for the foundational research we need to finally bridge the key gap in the field of ERH, and universally promote strong early relationships. COMBO National is a meaningful step toward developing, evaluating, and implementing universal tools that any parent/caregiver and child could benefit from. “We had the era of treatment,” says Dani. “It’s time for the era of strengths-based prevention and promotion.”