- CDC —
- Centers for Disease Control and Prevention
- SSNRs —
- safe, stable, nurturing relationships
The field of child maltreatment prevention is undergoing a transformation. Clinical practice is moving toward the promotion of factors that support optimal child development and broadening its focus to include the healthy outcomes that arise from positive childhood experiences. In January 2014, the Centers for Disease Control held a kickoff meeting in Atlanta to begin state-level implementation of Essentials for Childhood: Steps to Creating Safe, Stable, Nurturing Relationships,1 a strategy designed to promote the development of family environments in which children thrive. We were members of a working group that advised the CDC on Essentials. This Perspective will highlight the new strength-based approach that guided its development.
By focusing on the key role of safe, stable, nurturing relationships (SSNRs), Essentials highlights the health effects of positive experiences in childhood. This emphasis reflects the evolution in the field from prevention of maltreatment to promotion of family health.
Essentials relies on 2 types of evidence that support this change. First, citing recent surveys,2 Essentials notes that “many, if not most, [cases of abuse] are never reported to social service agencies or the police.” This realization calls for broad-based campaigns to reduce maltreatment, because narrowly focused risk-based efforts may leave out many children and families. We also know that abuse affects the growing brain3 and has lifelong health consequences.4,5
Second, the presence of SSNRs helps reduce the incidence of child maltreatment and also improves child health and development. All families benefit from efforts to support these relationships, laying the foundation for a broad-based, universally applicable public health approach.
Essentials begins with a vision of ensuring that all children experience SSNRs. In departing from approaches that sought to identify and serve at-risk people, Essentials endorses the use of frameworks that emphasize the development of family strengths6 as the key to both preventing maltreatment and promoting child health. Helping parents understand their child’s development, learn effective parenting strategies, and experience the joys of child-raising now form the foundation of both Bright Futures7 and efforts that, like Essentials, seek to reduce child maltreatment.
Essentials identifies 4 main goals:
Raise awareness and commitment to promote SSNRs and prevent child maltreatment.
Use data to inform actions.
Create the context for healthy children and families through norm change and programs.
Create the context for healthy children and families through policies.
Clinicians have important roles to play in reaching these goals. Primary care for children directly aligns with the first Essentials goal of promoting SSNRs. Essentials next calls for development of data systems to monitor progress; these same systems may help broaden the evidence base for primary care.
Physicians can influence the development of community norms, commonly defined as values, beliefs, attitudes, and behaviors shared by most people in a group. Physicians’ connections with families with young children allow us to support the development of social norms related to SSNRs. Public health departments can develop and implement large-scale public education campaigns that promote health at the community level. As physicians, we can relate these campaigns to each family we serve. Anticipatory guidance encompasses a broad range of advice intended to address injuries, illness, and the new morbidities8 that share psychosocial etiologies. Beyond screening for and treating problems, clinicians have a role to play in cultivating an environment for positive childhood experiences that are the centerpiece of Essentials. When physicians promote back-to-sleep messages, encourage breastfeeding, and explain the need for car seats, we reinforce emerging social norms that have reduced the incidence of sudden unexpected infant death, increased the rate of breastfeeding, and decreased child passenger deaths.
Essentials calls for alignment of programmatic efforts to support SSNRs. Specific programs (including not only health care but also maternal–infant child home visiting and early intervention) offer crucial assistance to families with young children. However effective, each program on its own may be insufficient to create an overall context in which children thrive. Essentials calls for developing a shared vision of child and family support that will better align programs that differ in whom they serve and the services they offer. This approach also suggests that we can expand from programs that react to specific needs to include those that create conditions that will prevent some of those needs from arising. Essentials offers strategies that promote child health and create a positive context in which SSNRs can be cultivated.
Child health care is central to the CDC’s vision for Essentials. Nearly universal access to health care for infants and children allows the patient-centered medical home to play a key role in the promotion of SSNRs. Although their plans differ, each state is responsible for organizing a small group of local leaders who will form a backbone agency to align state efforts. This leadership team, in turn, will establish a large collective action team to develop messages, coordinate efforts, and work collaboratively to shift social norms and adopt policies that favor the development of strong families. Each state’s chapter of the American Academy of Pediatrics is a key component of the leadership and action teams. American Academy of Pediatrics chapters bring a commitment to the health of children and families, an understanding of the science of early brain development, and practical knowledge of how to work within complex, data-driven systems. Physicians reach families of infants and young children long before they enroll in school and are often the only professionals they interact with during infancy and early childhood.
The take-home lesson for physicians is simple yet profound: Health outcomes from positive experiences may be just as important as toxic outcomes from adverse experiences. SSNRs may promote one and prevent the other. Transforming clinical practice toward the promotion of factors that support optimal child development allows us to work collaboratively with families and communities and increases opportunities to align health care with other early childhood programs and policies. Essentials harnesses the public health approach to bridge the gap between harm prevention and health promotion. More research is needed on how we can continue to improve child health and well-being by focusing on the healthy outcomes of positive experiences. This is a transformation that physicians and the families we serve can work toward collaboratively.
- Accepted December 17, 2013.
- Address correspondence to Robert Sege, MD, PhD, Department of Pediatrics, Boston Medical Center, Dowling 4417, 850 Harrison Avenue, Boston, MA 02118. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
Dr Sege conceptualized and designed this article consultation with Dr Linkenbach, wrote the first draft, submitted it for review and revision by Dr Linkenbach, and prepared the final draft for submission; Dr Linkenbach participated in the conceptualization and design of this commentary and reviewed and revised the manuscript; and both authors approved the final manuscript as submitted.
- 1.↵National Center for Injury Prevention and Control at the US Centers for Disease Control and Prevention. Essentials for childhood: steps to creating safe, stable and nurturing relationships. 2013. Available at: www.cdc.gov/violenceprevention/pdf/efc-01-03-2013-a.pdf. Accessed October 17, 2013
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- Copyright © 2014 by the American Academy of Pediatrics