Children Need Safe, Stable, and Nurturing Relationships: New AAP Statement

Prevention of toxic stress must be partnered with relational health, says AAP. 


  • To grow in healthy ways, babies need to synchronize heart, brain and hormones with caregivers.
  • The toxic stress 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 trade group, 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 wellbeing, as well as education, and economic stability. Not mentioned, but also relevant, there are long term effects on social, emotional and moral outcomes (Narvaez, 2014).

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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 hyperreactivity to perceived threat and an increase in the size or activity of the amygdala. They note, that although these 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 from 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 are 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, then, lays the foundations for the child’s healthful development, future self-regulation and social-emotional intelligence. They 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).

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 health care providers. Unfortunately, they miss one of the most important aspects for child wellbeing 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:

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

Moreover, less than 80% of US hospitals are “Baby-Friendly” meaning they do not meet the 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 health care 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.

There is a lot of misinformation about babies and their needs, and parents are often encouraged to ignore baby’s signals. Bad idea. Babies are “half-baked” at birth and have much to learn with the help of physical and emotional support from caregivers. Taking care of baby’s needs is an investment that pays off with a happier, healthier child and adult. Here are 28 days of reminders about babies and their needs.

The full 28 day card campaign can be found on the Evolved Nest’s website here under Self-Nesting Tools here. Find the card series below and on our social media pages.
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