(Re)Thinking Relationally: A Response to the Recent AAP Statement on Early Relational Health
Idea in Brief
Preventing Childhood Toxic Stress: Partnering with Families and Communities to Promote Relational Health, is right to focus on the importance of relationships in both buffering adversity and promoting resilience. However, the statement could go further and deeper in key areas.
Building relational health in the earliest years of human development requires rethinking relationships more broadly.
In focusing on the need for new approaches, Preventing Childhood Toxic Stress downplays the need to strengthen eroding social infrastructures that already exist.
by Joe Waters
A recent policy statement from the American Academy of Pediatrics is a welcome summary of an emerging transformation in child health: promoting wellness and flourishing instead of narrowly focusing on diagnosing and treating disease. The statement, Preventing Childhood Toxic Stress: Partnering with Families and Communities to Promote Relational Health, is right to focus on the importance of relationships in both buffering adversity and promoting resilience. It is a significant, forward-leaning statement on safe, stable, and nurturing relationships (SSNRs) between children and their primary caregivers that also connects to the growing problem of social isolation.
However, the statement doesn’t go far enough or deep enough in several key areas. It also exhibits important blind spots.
“Are we autonomous, utility-maximizing individuals bound to one another by mutual contract? Or are we relational beings connected by our membership in the human family?”
Relational health requires rethinking relationships in general. The AAP’s statement does not name the root of relational breakdown in American society: its focus on individualism. While a philosophical treatment of this breakdown should not be expected of a policy statement from a medical organization, we cannot ignore the basic question Who are we? Safe, stable, and nurturing relationships cannot be built in a society that has consistently failed to correctly answer this question.
Are we autonomous, utility-maximizing individuals bound to one another by mutual contract? Or are we relational beings connected by our membership in the human family? Since the Enlightenment, the predominant culture of the West has answered this question wrong, stressing independence and self-interest. Instead, we must choose the second way. That means reorganizing our lives around the truth of our relationality, our belonging in the human family, our rootedness in particular places and families, and the fact that we are not reducible to homo economicus. Our failure to make this choice underlies our society’s fragmented relations.
Pediatrics should become a core ally in this reorientation because it has implications for the earliest years of human development and for promoting relational health.
We must confront structural changes in health care that undermine patients’ trust. The statement fails to meaningfully address the crisis in trust that undermines the health care system’s ability to promote relationships in clinical settings and in advocacy. Power in the medical industry continues to migrate from physicians and other providers to what Paul Starr has described as "complexes of medical schools and hospitals, financing and regulatory agencies, health insurance companies, prepaid health plans, and health care chains, conglomerates, holding companies, and other corporations." As Ian Marcus Corbin and I wrote recently in Newsweek, the transition to more specialized know-how in the medical industry has “shifted the center of gravity from practitioner-patient encounters to system-patient encounters. That shift has been very bad for the building and preservation of trust.” In 2018, only 34 percent of Americans reported having high confidence in medical leaders. Promoting relationships in both clinical settings and in advocacy is impossible without the deep trust that Americans used to have in medical leaders.
Paradoxically, this change has occurred just as pediatric providers have begun embracing the importance of relationships in the earliest years. This shift undermines efforts to build trusted relationships with patients through which to promote safe, stable, and nurturing relationships between children and their caregivers. The AAP’s policy statement missed an opportunity to address these systemic barriers to promoting SSNRs and possible policy solutions to overcome them.
Personal physicians are crucial to supporting relational health, but their numbers and impact are shrinking. The statement also does not reference the critical importance of personal physicians, who care for families across the course of their lives, in promoting SSNRs. Evidence suggests that a larger number of primary care physicians is associated with lower mortality-–yet the primary care physician workforce is shrinking. Furthermore, recent evidence suggests that not only the availability of primary care physicians matters, but continuity of care matters too. Researchers at the University of Bergen demonstrated that patients who have the same primary care physician for many years are “25 percent less likely to die than people registered with their GP for under a year.”
“The AAP’s policy statement missed an opportunity to address these systemic barriers to promoting SSNRs and possible policy solutions to overcome them. ”
Yet working as a personal physician is increasingly difficult today, given the previously referenced state of the medical-industrial complex, along with increasing specialization, the rise of the nonclinical “physician executive,” the growth of urgent care, and business pressures on primary care physicians. As a result, fewer parents have a trusted relationship with a physician who can counsel them on the safe, stable, and nurturing relationships that are foundational to health and flourishing from the earliest years of children’s lives.
Social change is necessary, but we must not ignore the existing, traditional social infrastructure. The statement correctly acknowledges the “role and toll of social isolation” but again fails to go far or deep enough. It promotes community-level changes to “repair strained or compromised relationships,” “identify and address potential barriers to SSNRs,” and “promote SSNRs by building 2-generational relational skills.” Among the examples given are “embrace restorative justice and social inclusion (over punitive measures and exclusion),” “identify and address sources of inequity, isolation, and social discord (poverty and racism),” and “implement home visiting; support extended family medical leave.”
These are just examples; undoubtedly, the authors expect them to be adapted according to local needs and for other changes to be developed. But the examples reveal a bias towards change rather than shoring up existing social infrastructure at risk of collapse. These traditional mechanisms are essential to fostering human development in the earliest stages of life and ameliorating distress for families with children. They include religious congregations (belonging to a religious congregation fell 20% points between 1999 and 2018), unions (in 1983, one in five American workers belonged to a union and in 2013, one in ten did), and, of course, the family itself (in recent decades the marriage rate has fallen about 20 percent and a growing share of adults don’t ever expect to have kids).
The authors do write that “an individual's degree of social isolation is a powerful predictor of mortality, much like traditional clinical risk factors (eg obesity or hypertension) or ACE scores.” They also note that “overall relational health is dependent not only on dyadic serve and return interactions with family members, but also on trusted, SSNRs with others in the community through interactions in the medical clinic, school, recreation leagues, faith-based and civic organizations, community improvement efforts, and employment opportunities.” In other words, the statement recognizes the importance of these traditional support mechanisms. But in focusing on the need for new approaches, it downplays the need to strengthen eroding social infrastructures that already exist. Advocacy and leadership in more deeply understanding and reimagining the role of these traditional mechanisms in supporting SSNRs are essential.
Joe Waters is the Co-Founder + CEO of Capita.