Child Flourishing: A Critical Indicator for Early Relational Health

Early Relational Health (ERH) is the foundation of child flourishing, which is measured nationally and across all states using data from the National Survey of Children’s Health (NSCH).^1,2 While child health is often measured based on the absence of health problems and risks, measures of flourishing assess the positive development and well-being of children.  

The Child Flourishing Index (CFI) for young children, developed for use in the NSCH, assesses children’s sense of safety and emotional connection to their caregivers, openness and curiosity in learning new things, resilience around daily stress, and positive emotions and enjoyment in daily life.^3,4

Each of these qualities is fostered when children experience strong, positive, and nurturing relationships in their daily lives and are less commonly demonstrated when children face threats to nurturing relationships, like with the presence of adverse childhood experiences (ACEs).^1,5

How the Child Flourishing Index Works

The Child Flourishing Index (CFI) for young children, developed for use in the National Survey of Children’s Health (NSCH), assesses how often children six months to five years of age demonstrate four distinct aspects of child flourishing:

(1) Having a sense of safety and emotional connection to their caregiver(s) 

(2) Openness and curiosity in learning new things 

(3) Resilience to bounce back quickly with daily challenges or stresses 

(4) Positive emotions and enjoyment in daily life^3,4  

The CFI for young children^† counts how many of the four CFI criteria children meet. There are four possible answer choices: Always, Usually, Sometimes, and Never. 

As summarized in Tables 1 and 2, analysis of the recently released 2022–23 NSCH data finds that about 30% (28.8%) of young children in the United States “always” demonstrated each of the four CFI criteria and 78.3% “usually” or “always” did so. The child resilience criterion (“bounces back when faced with a challenge”) is the least likely to be met, with 34.7% of young children consistently demonstrating this CFI characteristic of a child’s affect regulation.

^†The Child Flourishing Index for young children is for 6 months to 5 years. There is also a version for ages 6 to 17, which shows similar results.

Table 1: Prevalence of Children 6 Months to 5 Years of Age in the United States by their Child Flourishing Index Score: 2022–2023 National Survey of Children’s Health

Table 2: Prevalence of Children 6 Months to 5 Years of Age in the United States by each CFI Criterion: 2022–2023 National Survey of Children’s Health 

How the CFI Relates to Child Health and Development Outcomes

Further analysis of the NSCH reveals that children who meet more CFI criteria are much more likely to also meet criteria for being ready for school, which is also assessed in the NSCH based on whether a child meets criteria on at least four of five domains related to their (1) early learning skills; (2) social and emotional development; (3) self-regulation; (4) motor development; and (5) overall health status.⁶ Like many health indicators, the CFI measure shows a dose-response effect whereby the more criteria met, the more positive are other child health outcomes, like school readiness. As shown in Figure 1, children 3–5 years old who “usually” or “always” meet all four CFI criteria are about four and a half times more likely to meet criteria for being on track on the new NSCH School Readiness indicator compared to those who meet only 0 or 1 CFI criterion. Those meeting all four versus only three criteria are about one and a half times more likely to be healthy and ready for school (73.5% vs. 48.2%).

Figure 1: Prevalence of Children Aged 3-5 Years in the United States Who Meet Criteria for Being Healthy and Ready for School by Their Child Flourishing Index Score¹

*Flourishing Items for Young Children (how often): 1) is this child affectionate and tender with you?; 2) does this child bounce back quickly when things do not go their way?; 3) does this child show interest and curiosity in learning new things?; 4) does this child smile and laugh?

Early Childhood Flourishing as an Indicator of Early Relational Health 

It is important to consider a child’s overall CFI score as well as responses to specific CFI criteria, each of which represents distinct aspects of flourishing that research shows are associated with and reflect the quality of a child’s Early Relational Health.  Looking at each CFI criterion on its own we find important differences between children whose caregivers report their child “always” meets each criterion compared to those reporting that they “usually” do so. Figure 2 illustrates this point, showing that children whose caregivers report that their child “always” demonstrates each flourishing criterion are significantly more likely to also meet school readiness criteria.

Figure 2: Prevalence of Publicly Insured Children Aged 3-5 Years in the United States Who Are “On Track” on School Readiness Measure by Caregiver Responses to Each Child Flourishing Index Criterion. Data: 2022–23 National Survey of Children’s Health (NSCH)

Research conducted during the development and testing of the CFI confirmed that when caregivers report “always” this does not mean that their children never have times when they do not demonstrate the CFI criterion (e.g., always is not literally always). Rather, reports of “always” indicate that the CFI criterion is consistently and reliably demonstrated. On the other hand, research does suggest that caregivers who report “usually” instead of “always” may have specific concerns about the consistency with which their child demonstrates each criterion and that routine gaps may exist, indicating a need for additional support. Depending on the use of the CFI, it may be important to distinguish among children whose caregivers provide “always” or “usually” responses. On the other hand, reports of “sometimes” or “never” are strong predictors of gaps in school readiness as well as other indicators of well-being. If used as a measure to guide engagement with families to promote ERH, reports of “always” across all CFI criteria would support a “celebrate and reinforce” response whereas any criterion lacking an “always” response might support a “celebrate and support” response that recognizes what is going well while proactively fostering improvements for children.

Family Resilience and Parent-Child Connection Index

Finally, closing the loop to return to the critical importance of promoting Early Relational Health to foster child flourishing, research on the CFI demonstrated the critical impact of family resilience and parent-child connection^‡ (FRCI) to foster child flourishing. FRCI is ascertained through the NSCH by assessing how often caregivers:

• Feel hopeful and recognize strengths they can draw on when things are hard 
• Prioritize communication and connection as a family when challenges arise 

Studies have found that when the FRCI is lower so too is child flourishing. This relationship is found irrespective of whether adversities such as Adverse Childhood Experiences, economic hardship, and having a disability or chronic health problem have been experienced.⁷ 

Because the FRCI is an indicator of ERH, and due to the relationship between ERH and child flourishing, this data suggests that while lessening or removing the stressors experienced by families is important, it is also vital to promote family resilience and connection — and thus ERH — at a population-wide level in order for children to flourish.

^‡ Also referred to as the Family Resilience and Connection Index (FRCI).

CFI and FRCI as Population-level Indicators of ERH

Measures of child flourishing and family resilience and parent-child connection like those included in the NSCH are important to track as indicators of success in promoting Early Relational Health. As an important population health indicator, the Child Flourishing Index was included by the federal Maternal and Child Health Bureau as a National Outcome Measure for Title V Block Grant programs in states in 2024.  Child flourishing is also featured as a key outcome for advancing integrated early childhood health systems as outlined in the Engagement in Action Framework (EnAct!), which was created through phase one of the Early Childhood Developmental Health Systems’ (ECDHS) program.⁸  And now child flourishing is embraced as the guiding outcome — the North Star — for the second phase of the ECDHS program, being led by Zero to Three and the Evidence to Impact Center.⁸  The CFI and FRCI can also be used locally and in clinical and other settings with families. These indicators are included in the CAHMI’s Well Visit Planner (WVP) tools for engaging families to personalize and optimize the quality of well child care services.  See this recent Zero to Three Evidence to Impact Center webinar on the WVP.

References 

1. Black MM, Behrman JR, Daelmans B, et al. The principles of nurturing care promote human capital and mitigate adversities from preconception through adolescence. BMJ Glob Health. 2021;6(4):e004436. doi: 10.1136/bmjgh-2020-004436. 
2. Child and Adolescent Health Measurement Initiative. Fast facts about the 2022-2023 National Survey of Children’s Health. https://www.childhealthdata.org/docs/default-source/nsch-docs/2022-2023-nsch-fast-facts_cahmi.pdf. Published 2024. Accessed November 19, 2024.
3. Moore KA, Bethell CD, Murphey D, Martin MC, Beltz M. Flourishing from the start. Published March 2017. Accessed November 19, 2024. https://cms.childtrends.org/wp-content/uploads/2017/03/2017-16FlourishingFromTheStart-1.pdf. 
4. Bruner C, Bethell CD. Child health care transformation, nurturing, and resilience: developing transformed metrics for young children. https://www.inckmarks.org/docs/newresources/InCKWP6MetricsTransformation.pdf. Published 2021. Accessed November 19, 2024. 
5. Bethell CD, Gombojav N, Solloway M, Wissow L. Adverse childhood experiences, resilience and mindfulness-based approaches: common denominator issues for children with emotional, mental, or behavioral problems. Child Adolesc Psychiatr Clin N Am. 2015. doi:10.1016/j.chc.2015.12.001.
6. Health Resources and Services Administration, Maternal and Child Health Bureau. National Survey of Children’s Health School Readiness Measure. https://mchb.hrsa.gov/sites/default/files/mchb/data-research/2023-nsch-hrtl-brief-oct-2023.pdf. Published October 2023. Accessed November 19, 2025. 
7. Bethell CD, Gombojav N, Whitaker RC. Family resilience and connection promote flourishing among US children, even amid adversity. Health Affairs. 2019. doi:10.1377/hlthaff.2018.05425.
8. Engagement In Action Framework (EnAct!). The ECDHS: Evidence to Impact Center. https://earlychildhoodimpact.org/resource/engagement-in-action-enact-framework/. Accessed November 19, 2024.

Christina Bethell, PhD (she/her) is a professor at Johns Hopkins University in the Bloomberg School of Public Health and School of Medicine. Her research and advocacy work focuses on building and translating the science of healthy development to promote early and lifelong health of children, youth, families, and communities. She is the founding director of the Child and Adolescent Health Measurement Initiative and the National Data Resource Center for Child and Adolescent Health (childhealthdata.org), and she led the design of the new Engagement in Action Framework (EnAct!) and early childhood Well Visit Planner and Online Promoting Healthy Development Survey digital resources for families and pediatric providers.

David Willis, MD, FAAP, s a professor of pediatrics at Georgetown University’s Center for Child and Human Development (GUCCHD). He was previously a senior fellow at the Center for the Study of Social Policy, and the executive director of the Perigee Fund, promoting Early Relational Health. Prior to that, Dr. Willis served as director of the Division of Home Visiting and Early Childhood Services at the U.S. Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau.