• Ira Hillman

Making the Relationship the Patient

Few things in life are certain, except death and taxes. And for the parents of young children, going to the doctor’s office.

Anyone raising young children, or whose children are now older, will easily conjure this scene. You are taking your six-month-old baby to the scheduled well-visit, but also have your two-year-old in tow. Earlier this week, you were excited about this appointment, eager to show off your adorable baby, hear how much your infant is growing, and feel good about yourself as a parent. Then, after the nurse takes your child’s vitals and leaves you in the exam room, your toddler snatches a toy from your baby, leading to a screaming fit. At this moment, the doctor opens the door to start the visit to find all three of you in tears.

Remember those films in school when the teacher stopped the action and asked you what you should do next? In a situation like the one described above, what would ideally happen next? What if instead of just focusing on the physical health of babies, pediatric care could also make the parent-child relationship a core focus of the visit?

Leveraging a Universal Access Point

The Early Periodic Screening, Diagnosis, and Treatment schedule for well-child care recommends 12 well-child pediatric visits in the first three years of life, and 15 by age five. Roughly 90 percent of children and their parents attend some or all of these pediatric well-child appointments in the child’s first three years. This is true, even for populations deemed high-risk. For example, 88 percent of children on Medicaid receive pediatric well-care in the first six months of life. As a result, pediatric primary care is a nearly-universal de-stigmatized point of connection for all families with young children.

With a dozen distinct chances for interaction (and most of those in the first year of life), well-visits create an opportunity for pediatricians to build trust with families. In addition, pediatric practices sit at a unique intersection between families and other parent-facing services in the community, often serving as the hub to other spokes of child and parental support including early intervention, social services, and child care.

Yet, this potential has not been fully leveraged to support child development. Research clearly shows that social-emotional development and nurturing relationships are critical components of a child’s growth, and they play an important role in children’s early school success and positive life outcomes. However, most pediatric practices are still stuck in old structures that focus on physical health with little attention, if any, paid to the critical element of early relational health and autonomic emotional connection between babies and their parents.

Identifying the Barriers to Change

Providers who are educated in the field of children’s health often lack the time, tools, and training – as well as the financial incentives – to observe and support parent-child relationships. One pediatrician told me, “When I was a resident, I learned how to make sure a baby didn’t have meningitis. No one taught me how to talk with parents and support their relationships with their children.” Yet, we know that parents do ask their pediatricians and other health care providers about parent-child bonding. Many providers would likely offer an anecdotal answer like, “My sister does this with my niece; maybe you could try that.”

Even for those doctors and nurses who have received additional training on early relational health, they still face the barriers of time and workflow. Clinics, hospitals, and busy pediatric practices are built around a well-visit that in 10 to 15 minutes requires a doctor to handle lots of data and verify the child’s physical growth. Dealing with numbers and charts isn’t conducive to observing the interactions between parents and their children.

Lastly, there’s the universal factor: money. Medicaid and other public insurance programs, as well as most private insurers, offer few financial incentives for doctors to spend their time and energy on social and emotional development or nurturing parent-child relationships.

A Collaborative Approach to Transformation

Nearly five years ago, Einhorn Collaborative published a report with Ariadne Labs and NICHQ titled, Promoting Young Children’s Socioemotional Development in Primary Care. Based on the recommendations in that report, and other conversations with field leaders, we sought out other national early childhood funders with an interest in elevating the well-child visit moment in the first three years of life. We had a shared goal of transforming the well-child visit to include resources and supports that encourage healthy social and emotional development for all families, ensuring each family is supported no matter where they go for care.

In March 2017, Einhorn Collaborative and four other funders launched Pediatrics Supporting Parents (PSP) with an ambitious goal to move beyond incremental approaches to supporting young children’s development, and instead collectively invest in big ideas with significant impacts. Many of the PSP funders had individually invested in scaling evidence-based programs that advance our shared goals of social and emotional development and parent-child relationships. Yet, it was clear to all of us that the barriers of time, tools, training, and financial incentives were bigger than any one program – and required resources and leadership beyond what a single funder could provide. Together with field leaders, pediatricians, and parents, PSP identified key research and tools that would form the foundation for broader community and practice change to better support families. PSP’s first project was an analysis of evidence-supported programs that were in, or proximate to, pediatric primary care and had positive outcomes related to social and emotional development, parent-child relationships, or parent mental health. In its analysis, the Center for the Study of Social Policy (CSSP) defined 14 common practices that help promote healthy social and emotional development and parent-child relationships within pediatrics. These practices fall into three major categories:

  1. Nurturing parents’ competence and confidence can be done through strengths-based observations or anticipatory guidance about the parent’s relationship with the child.

  2. Connecting families to supports to promote social and emotional development and address stressors happens more effectively when the pediatric practice has clear protocols around developmental screening and has cultivated community partnerships.

  3. Finally, new roles, ongoing learning opportunities, and initiatives that reduce provider stress and burnout help develop the care team and clinic infrastructure and culture.

Importantly, a common thread that ran through all of the 14 practices was that strong, strengths-based, trusting, and humble relationships among and between parents, the care team, and the community are essential for promoting the social and emotional development of young children.

With the identification of the three overarching actions and the 14 associated core practices, PSP next turned our attention to how we could spark systems-level changes that would make it easier for providers to embed these practices into their workflows. In conversations with field leaders, we heard that financing, technology, and measurement were key hurdles to enabling broader adoption of the core practices. PSP is supporting the development of tools and plans to address each of these three enabling conditions.

CSSP, in partnership with Manatt Health, have created two roadmaps for leveraging public financing to support the incorporation and implementation of the 14 common practices into pediatric primary care – a Blueprint for Leveraging Medicaid and CHIP as well as a Guide to Leveraging Opportunities Between Title V and Medicaid.

In terms of measurement, a team of field leaders from CSSP, HealthySteps, and Early Childhood Precision, Innovation, and Shared Measurement (EC PRISM) are exploring the potential of a community of practice to adapt observational research measures of parent-child relationships to meet the real-life needs of doctors to be able to observe those relationships in short well-child visits.

Similarly, Help Me Grow has been working closely with a variety of developers who have created developmental screens or tools to scope out a plan for an integrated, modular technology platform to support positive developmental health promotion, early detection, referral, and linkage to services across all early childhood sectors (not just health care, but also early childhood education, early intervention, and other sectors).

Moving from Best Practices to Real-World Implementation

For the past four years, Pediatrics Supporting Parents has coupled its investments with deep and ongoing field engagement, including partnering with parent leaders through our collaboration with Family Voices. Following a dedicated process of listening to the field, the initiative is now pivoting to a five-year commitment toward spreading the 14 common practices in three to five “proof point” communities, while still supporting national and state-level enabling conditions projects that are needed to integrate the practices.

We expect that insights from the community-level work will inform future investments in the enabling conditions at the state and national level. At the same time, the policy and systems change investments at both the national and state levels will facilitate change within communities. To support these goals, PSP will be implementing a collaborative model in which field leaders, funders, families, pediatricians, and community representatives co-create the initiative's strategic priorities across the various investment levels.

In a few years, PSP’s proof-point communities will be able to offer direct evidence of how families are building trust with their health care providers in the well-child visits. With that trust, and the time, tools, training, and financial incentives in place, that scene with the parent and two children in tears at the well-visit will have a very different ending. Doctors and nurses in PSP communities will utilize evidence-based research and newly-developed expertise to partner with parents in order to help them use their own strengths to nurture closer relationships with their young children. As a result, children in those communities will be better prepared for school and for life.


Ira Hillman leads Einhorn Collaborative’s Bonding strategy. You can learn more about our work in Bonding here and more about Ira here. Sign up here to receive our monthly newsletter and be the first to read Ira's blog posts.