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What Children Need Most

The value of safe, stable, and nurturing relationships

Key points

  • To grow in healthy ways, babies need to synchronize heart, brain, and hormones with caregivers.
  • The toxic-tress framework is a deficits-based approach whereas emphasizing relational health is a solution-focused approach.
  • Trauma-informed practice must be accompanied by wellness-informed practice that promotes safe, stable, nurturing relationships in childhood.

A set of early childhood health experts have a new paper in the journal Pediatrics, put out by the American Academy of Pediatrics. Garner and colleagues warn about the detrimental, life-long effects of early life toxic stress. However, they support not only the prevention of toxic stress in early life but also the provision of safe, stable, and nurturing relationships (SSNRs).

They offer this addition to prior AAP statements due to the deepening understanding of how adverse and nurturing early life experiences become biologically embedded, influencing long-term outcomes in well-being as well as education and economic stability. Not mentioned but also relevant are long-term effects on social, emotional, and moral outcomes (Narvaez, 2014).

The authors support an “ecobiodevelopmental framework” where an individual’s ecology becomes not only biologically embedded through the interaction of biology and experience but drives development over the life span. Urie Bronfenbrenner (1979) developed an ecological systems framework of a similar nature, pointing out the interacting layers of social and community systems that influence a child’s development.

According to the authors, the goal for any ecobiodevelopmental-sensitive community is to avoid causing toxic stress, defined as “a wide array of biological changes that occur at the molecular, cellular, and behavioral levels when there is prolonged or significant adversity in the absence of mitigating social-emotional buffers” (Garner et al., 2021, p. 2).

The toxic-stress literature has burgeoned over the last decades, showing what happens biologically when there are no contemporaneous mitigating buffers. Biological changes from toxic stress include hyper-reactivity to perceived threat and an increase in the size or activity of the amygdala. Although such changes may be adaptive for the individual in the short term, over the long term they are linked to worse health outcomes. It is important to distinguish between this kind of functional adaptation within an individual’s life and evolutionary adaptation by natural selection, which occurs over generations in comparison to rivals (Narvaez, Gettler, Braungart-Rieker, Miller-Graff & Hastings, 2016).

The authors note that the toxic-stress framework is a deficits-based approach, focused on the problems causes by significant adversity when mitigating factors are not present. They suggest that a toxic-stress framework should be accompanied by a solution-focused approach, a promotion of relational health through “safe, stable, and nurturing relationships (SSNRs)” (Garner et al., 2021, p. 2). SSNRs are social-emotional buffers that help settle the stress response and promote capacities to deal with future stressors.

SSNRs are particularly needed by infants, who have a need to connect dyadically with caregivers. Critical in the life of a baby is the ongoing biobehavioral synchrony with parents, which includes the coupling of heart rhythms and autonomic function, coordination of brain oscillations, and coordination of hormone release like oxytocin. These are critical in a baby's life (recall that babies resemble fetuses of most other animals until at least 18 months of age) because of rapid brain growth occurring in the first years.

Biobehavioral synchrony lays the foundations for the child’s healthful development, future self-regulation, and social-emotional intelligence. The authors quote Ruth Feldman (2015): “This synchronous biobehavioral matrix builds the child’s lifelong capacity for intimacy, socio-affective skills, adaptation to the social group, and the ability to use social relationships to manage stress.” Without question, “early relational experiences with engaged and attuned adults have a profound influence on early brain and child development” (Garner et al., 2021, p. 7).

The authors say that pediatric care is on the verge of a paradigm shift toward adopting a public health approach that reprioritizes clinical, research, and advocacy practices toward relational health. The shift from focusing on the results of toxic stress to supporting SSNRs is based on neurobiological and child-to-adult long-term health studies. SSNRs buffer adversity and also support capacities for resilience in the future.

To emphasize relational health means to focus on a strengths-based approach capacities among individuals, families, and communities that promote SSNRs while buffering adversity and building resilience. The goals should include partnering with families and communities by integrating primary, secondary, and tertiary preventions and by including sectors beyond health care (e.g., schools).

What could be added to their list of recommendations

Although the authors mention the importance of responsive care, affectionate touch, positive community relationships, and play—all aspects of our species evolved nest—they miss a few components: extensive breastfeeding and nature connection. But they are mostly focused on healthcare providers. Unfortunately, they miss one of the most important aspects for child well-being, for which the medical profession is responsible.

The medical profession could make significant changes in order to prevent the toxic stress of perinatal trauma (Buckley, 2015). Many procedures in medicalized birth are unscientific, such as:

  • slowing down or speeding up labor
  • painful procedures like circumcision
  • separation of baby from mother.

Moreover, fewer than 80% of US hospitals are “baby-friendly” meaning they do not meet a 10-item list of health-supporting procedures (e.g., extensive breastfeeding support; no formula or sugar water given without medical reason).

All in all, the position paper represents a vital needed shift in public healthcare goals, including not only trauma-informed but also wellness-informed practice.


Bronfenbrenner, U. (1979). The ecology of human development. Cambridge, MA: Harvard University Press.

Buckley, S.J. (2015). Hormonal physiology of childbearing: Evidence and implications for women, babies, and maternity care. Washington, D.C.: Childbirth Connection Programs, National Partnership for Women & Families.

Feldman R. (2015). The adaptive human parental brain: implications for children’s social development. Trends in Neuroscience, 38(6), 387–399.

Feldman R. (2017). The neurobiology of human attachments. Trends in Cognitive Science, 21(2), 80–99.

Garner, A., Yogman, M., Committee on Psychosocial Aspects of Child and Family Health, Section on Developmental and Behavioral Pediatrics, Council on Early Childhood. (2021). Preventing childhood toxic stress: Partnering with families and communities to promote relational health. Pediatrics,148(2), e2021052582.

Narvaez, D. (2014). Neurobiology and the development of human morality: Evolution, culture and wisdom. New York: Norton.

Narvaez, D., Gettler, L., Braungart-Rieker, J., Miller Graff, L., & Hastings, P. (2016). The flourishing of young children: Evolutionary baselines. In D. Narvaez, J. Braungart-Rieker, L. Miller, L. Gettler, & P. Hastings (Eds.), Contexts for young child flourishing: Evolution, family and society (3-27). New York, NY: Oxford University Press.