Social Isolation and Loneliness: An Early Relational Health Perspective

By Claudia M. Gold, MD

In May 2023, U.S. Department of Health and Human Services Surgeon General Dr. Vivek Murthy, released a public advisory statement declaring social isolation and loneliness “a public health epidemic.” The advisory notes that “disconnection fundamentally affects our mental, physical, and societal health.” At its core, Early Relational Health (ERH) is about the fundamental need for positive relationships, especially in the early stages of life for a child and the way the foundational relationships between children and caregivers equip us for navigating life’s many challenges. The more we invest in ERH’s valuable lessons of connection and the policies, practices, and infrastructure supporting ERH, the more we can change the tide of this devastating epidemic. 

Social isolation and loneliness are two distinct and different phenomena. The first is an objective measure of social connections that can be mitigated by increasing social contacts. But loneliness is a subjective experience more difficult to understand, more devastating to our health and well-being, and more challenging to change. According to the advisory, both experiences of social disconnection have serious impacts on health, including a 29% increased risk of heart disease, a 32% increased risk of stroke, and an increased risk of premature death by more than 60%. 

Consider the story of Alicia, who came to see me in my pediatrics practice for help in managing her three-year-old son, Jorge’s frequent meltdowns at the slightest frustration. (Identifying information has been changed to protect privacy.) By examining her personal experience with belonging and early parent relationships, Alicia was able to reframe how she interacted with her child and develop a healthier and stronger relationship with Jorge. 

In her family of origin there was no room for conflict. Her father, Paul, an Iraq War veteran, was distant and emotionally closed off. Her mother, Delia, went to great lengths to protect her father from any emotional distress. Having immigrated to the United States from El Salvador to escape rampant community violence, Delia clung tightly to family rituals for her own sense of safety. Any expression of anger or sadness from her daughter was met with certainty that “you will be fine.” 

Alicia shared that loneliness in a crowd of people had plagued her much of her life. Our conversations brought up painful memories of her eight-year-old self in the lunchroom at school observing the easy back and forth of the other children with a profound sense of disconnection. 

We uncovered this deeper story not with traditional advice or behavior management but rather with time and space for what I call “playing in the uncertainty,” or approaching another’s behavior or stories without an agenda and with a tolerance for the discomfort that goes with not knowing exactly where we are headed. Jorge’s behavior represented an effort to communicate, “I need you to deal with what is troubling you, so you are free to be with me.” 

Groundbreaking research by psychologist Ed Tronick offers insight into the developmental origins of a sense of belonging, which is a core benefit of ERH-backed practices. Detailed video observation of infant-caregiver relationships demonstrates that a typical caregiver mismatches with their child’s needs in 70% of interactions! Mismatch and repair are essential to healthy development. Muddling through hundreds of thousands of missed cues and misconnections builds a feeling of belonging, a sense that “this is how we do things.” In contrast, in an environment without space for mismatch and repair, meanings of fear, anger, and disconnection take root. 

Alicia’s loneliness in the company of people can be understood as a response not only of her thinking mind but also of her autonomic nervous system, which functions as a frontline meaning-making system. These systems are largely developed in early childhood and reiterate the importance of having strong and positive early relationships. 

Neuroscientist Stephen Porges coined the term “neuroception” to describe how our bodies assess the safety of a situation in a way that is out of conscious awareness. When we sense threat, we may lose access to our social engagement system, which regulates our immune system, blood pressure, and internal organs. Loneliness exerts its harm by throwing these well-regulated physiologic processes into chaos.

A history of repeated lack of repair in important relationships may underlie this reaction. For people with relational histories rich in mismatch and repair, casual social interactions may seem effortless and harmless. But people who carry problematic meanings about social interaction, whether due to emotionally unavailable caregivers, intrusive caregivers who did not allow for any mismatch, or, at worst, abusive caregivers, may have an altogether different response. This reaction—which occurs outside of conscious awareness—can create a kind of vicious cycle, as a history of unrepaired mismatch prevents a person from accessing the healing power of social connection. 

This research points us both in the direction of prevention, as well as healing when meanings have gone awry. Meanings of loneliness and disconnection become embedded in the body, often before language and complex thought have come online. Creating new meanings at any age calls for bringing in the body in multiple relationships with room for safe mismatch and repair. Alicia first reclaimed joy in her relationship with her son when she joined him in taekwondo for preschoolers and parents. Not only the class itself, but also the rhythmic walk together to an activity they both enjoyed helped to heal their relationship. His improved behavior naturally followed.

Prevention lies in social policysuch as more robust maternity and paternity leave, quality affordable childcare, and embedding Early Relational Health services in pediatric practices—that supports parents in being present to engage in the inevitably messy process of getting to know their babies. In doing so we help to break these generational cycles and facilitate meaningful connection and belonging right from the start, and build a nation full of relational health, rather than loneliness and isolation.

Claudia M. Gold is a pediatrician and writer with over 30 years of clinical experience. She is on the faculty of UMass Chan Medical School Fellowship in Early Relational Health. She is the author of four books, most recently The Power of Discord: Why the Ups and Downs of Relationships Are the Secret to Building Intimacy, Resilience, and Trust (Little, Brown Spark 2020) with co-author Ed Tronick.