“Exploring the Gaps in Early Relational Health Research”: An Investigation into the Science of Early Relationships from the Center for Early Relational Health at Columbia University

As a field catalyst promoting Early Relational Health (ERH), Nurture Connection focuses on six core concepts that form the foundation of ERH science, including dyadic (two-way) neuroscience; social-emotional development; flourishing; disruption and continuity in ERH and flourishing; ERH in practice; and longitudinal studies of ERH (those that follow a person or group of people over time). 

This article is the first in our “ERH Research in Action” series, which dives deeper into emerging research and work within the early childhood field that explores how ERH science can deepen our understanding of relational health — and help us transform systems and policies to better support the flourishing of children, families, and communities.

Dani Dumitriu, MD, PhD, and Andréane Lavallée, PhD, have worked with thousands of young families, Dumitriu as a pediatrician in the newborn medicine unit and Lavallée as a nurse in the neonatal intensive care unit. This clinical expertise played a crucial role in their current work leading research on the science of early relationships between caregivers and children: how they form, how they grow, and how they support positive future outcomes. 

The two scientists helped lead a gold-standard systematic review of existing research on Early Relational Health (ERH), which points to positive effects on ERH from dyadic interventions, while underlining the timeliness of dyadic and longitudinal studies going forward.

Recently, Dumitriu and Lavallée sat down with Harvard researcher and parenting expert Junlei Li, PhD, to answer questions about this essential science and what it might mean for families. 

Two Clinician-Scientists Take a Strengths-Based Approach

“You both come from a long history of clinical work,” Li began. “What is it about that work that inspired and motivated your Early Relational Health research?” 

Lavallée, a research scientist at Columbia University Irving Medical Center where she leads the Interpersonal Synchrony and Connection (InSynC) Lab, was initially drawn to ERH research through early career work in a Montreal neonatal intensive care unit (NICU). “There have been so many advances in the past couple years on how we can protect the preterm infants who are born early from adverse experiences, yet in the NICU it can also be very stressful,” she notes.

She began looking for NICU-based interventions to see what had been done and how parents could be better integrated into infant care — and learn how their preterm infant communicates with them. “Even if they’re very little, they’re still able to be partners in their relationship with their parents,” she says.  

Dumitriu, who is director of the Center for Early Relational Health (CERH) and principal investigator for the DOOR Lab at Columbia University, came to ERH research through a different experience, though still rooted in stress and resiliency. “Since the pandemic, as a frontline pediatrician with patients who were asking questions science didn’t yet have answers to, I’ve been very motivated to integrate my research and my clinical practice.” she says.

Both Dumitriu and Lavallée recall their excitement at the shift to a more strengths-based and health-promoting approach. 

Rather than focusing on adverse childhood experiences, or ACEs, Dumitriu says, the American Academy of Pediatrics released a statement in 2021 that encouraged providers to incorporate Early Relational Health into clinical practice and promote it within pediatric primary care visits to improve outcomes for children and families. Both she and Lavallée welcomed this move away from what Dumitriu calls “a deficit-based approach” to a strengths-based approach. 

Exploring “the Space Between” in Parent-Child Interactions

“It feels like we’ve been talking about dyadic relationships between parents and children since the very beginning of this science,” Li said. “But there seems to be something big that we’re not yet able to understand. What is that gap?”

“There’s really clear evidence out there showing that when there are good-quality, positive relationships, that tends to be associated with better outcomes for children,” says Lavallée. “We’ve studied that for a very long time. The piece we don’t quite yet understand is why there is this association and how it happens. In other words, what’s underneath the dyadic relationship that makes kids better prepared for going to school or forming relationships with other kids and other adults?”

Dumitriu, who served on the committee for the landmark NASEM report establishing the landscape of Early Relational Health science (alongside Nurture Connection founder David W. Willis), says there is “definitely” evidence that brainwaves and heart rates sync up between parent and child during face-to-face interactions, but the science behind it remains unclear: “We don’t actually know the mechanisms by which that happens — what I call the information transfer in ‘the space between.’  

“I often use the analogy of the infancy of neuroscience,” Dumitriu adds. She mentions that when the electron microscope was first developed, researchers could see down to the very synaptic level — the space between two neurons — for the first time. They already knew electricity could jump from one neuron — a brain cell that transmits information — to another. But what was unexpected, she says, “was that electricity can actually pass through an empty space.” But how?

“For those of you who are curious, it’s quite cool and a very elegant solution that nature came up with: Basically, it transforms the electrical signal in one neuron into a chemical signal,” she says. The chemical could travel the space between two neurons, then transform back into an electrical signal. “We couldn’t have guessed it — it took many decades of science to actually understand that process — and I think that’s where we are in relational health,” she concludes: unraveling the mechanisms behind parent-child interactions that can lead to positive flourishing outcomes.

Bridging ERH Research with Clinical Practice

“So what connections might we draw between trying to understand these mechanisms of relationships — and things that could actually change healthcare practice or even parenting practice?” asked Li.

Dumitriu concedes that this was often difficult. To examine the effectiveness of different ERH interventions, the two researchers helped lead a gold-standard systematic review, complete with a meta-analysis. 

The role of a systematic review, she notes, is partly to bridge the gap between rigorous basic science and the kind of human research that can lead to practice and policy transformation. “One of the big challenges with human research is that you can’t do mechanistic work very easily with humans — ‘mechanistic,’ by definition, means that you need to manipulate something and then see what the result is. 

“The closest you can get to that kind of mechanistic work,” she continues, “is a pooled systematic review where you take all the information from many, many studies out there, and you pull it together in order to see if there’s some sort of emergent trend across existing interventions out there — which is important, because there’s lots of evidence that there’s an association between good-quality relationships and improved child outcomes.”

But, she also reflects, that evidence is what we call correlative; whereas the kind of evidence you need for practice transformation is causative. So are those outcomes better because of early relationships? Or is there something above Early Relational Health and neurodevelopment that causes both of them to improve — for example, better socioeconomic status? In that case, she elaborates, interventions would need to focus on that aspect rather than the early relationship. “And so what we really wanted to go after in the systematic review is that cause — a link between quality of early relationships and child outcomes.”

Lavallée agrees, explaining how study design can help tease these apart. “Randomized controlled trials that look at improving early relationships assign families randomly: either to a group where they will receive an intervention aimed at improving Early Relational Health, or to a group where they’re receiving what we call ‘standard care’. All of these studies measured ERH to see if the intervention worked at improving the relationship, and some, though very few, also measured child developmental outcomes.” 

As part of the systematic review, the researchers looked at all the papers published since 2000 that evaluated a dyadic ERH intervention (one that involves both parent and child). They found 116 studies in which one group received standard care and others received an intervention such as promoting bonding, secure attachments, and supportive caregiving interactions.

“So if we put all of these studies together, are we seeing that globally interventions are working at improving Early Relational Health and child developmental outcomes?” Lavallée asks. “And we’re seeing that, statistically speaking, families that received these interventions are doing better on different Early Relational Health measures.”

Interestingly, different kinds of interventions promoted different outcomes. “The ones that were focused on physical proximity,” such as skin to skin (or “kangaroo care”), baby massage, or giving the caregivers a sling to wear the baby most of the day, “were the ones that were really working much better at promoting bonding, for example,” says Lavallée. “So, if we understand mechanisms better, we can better target interventions that are more precisely geared toward what we want to promote.”

“93% of the families represented in the [systematic review data] included just biological mothers and their child . . . which means we [as a field] have not really focused on other types of families and caregivers, like fathers and foster parents.

“We are able to improve Early Relational Health with supports, programs, and interventions . . . but there’s still a lot of room for more work.”

—Andréane Lavallée, PhD, Principal Investigator, Interpersonal Synchrony and Connection (InSynC) Lab; Associate Research Scientist, Center for Early Relational Health (CERH) at Columbia University

Tracking ERH Interventions and Developmental Outcomes 

Lavallée says the other piece they looked at in the meta-analysis was early child developmental outcomes. “We knew these interventions were working to promote Early Relational Health — so the question was, are they also doing the same thing for developmental outcomes? And here, what we actually found is only a very, very small effect on cognitive and language development, but it was still positive.

“Surprisingly, we didn’t find any positive effect on other aspects of development, like motor development, socioemotional functioning, and behavior in the existing research,” she continues. “But there’s only a very small portion of those 116 studies that actually measured child developmental outcomes, so there might not be a spillover effect on developmental outcomes. But it could also be that we just don’t have enough randomized control trials yet to support that causal effect or to see it statistically.”

Li points out that it’s possible the studies simply didn’t follow the child or the family long enough, noting that in all the early childhood education economists have done, most of the gains in academic achievement faded out within a year or two. “However, in cases in which they were able to follow the children longitudinally into their twenties, thirties, forties, that’s when you see a pronounced effect.”

Dumitriu agrees: “As we’ve seen, there are very few studies that have long-term follow-up. So, you know, the most important lesson learned here is that we need additional research that focuses on the outcomes we want to promote. And that’s exciting, to see where the high-impact research opportunities are.”

Partnering with Parents in ERH Research and Looking Ahead

Li had one last question: “Would you say that involving participants, more parent leaders, in the co-design of the research and studies is a promising way going forward?” 

For the researchers, this was a resounding yes. “We’re also identifying gaps in trying to listen to families, how they speak about their relationships to see if there are other constructs that we haven’t yet thought about,” says Dumitriu. “Our work at the center is also focused on developing novel ways of looking at these Early Relational Health constructs — including deep listening to parents about their relationships with their children.”

For both Dumitriu and Lavallée, the most important finding about Early Relational Health was that it was malleable. What Dumitriu also found exciting was even a small amount of closeness or another intervention could make a difference. “We wanted to also look at if the length of the intervention or the dose actually mattered,” she says, “and the answer was no — the dose, whether it was just a few minutes versus days or weeks of intervention, generally did not seem to play a role in the effectiveness. And that’s really good news for the world as we’re trying to adapt to a public health level, such that every child receives some sort of Early Relational Health support.”

“A lot of the work that we’re doing at the Center for Early Relational Health is to tease apart what we’re calling ‘the taxonomy of early relational constructs’ . . . things like bonding, maternal sensitivity, and attachment.

“We’re really in the infancy of this work . . . ”

—Dani Dumitriu, MD, PhD, Principal Investigator, the DOOR Lab; Director, Center for Early Relational Health (CERH) at Columbia University