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Screen for Relational Health, Not Just Physical and Emotional Health


Attention frontline providers across all sectors! Attention public/population health professionals, too! We need to be asking our clients/patients/study cohorts – across all age groups – about their relational health.

In the latest meta-analysis of Adverse Childhood Experiences (ACEs) studies, which looked at 206 studies across 22 nations involving over 500,000 participants, ACEs were once again found to be common, with 60% of participants having at least one. People who have mental health issues or substance abuse/addiction issues, or who were unhoused were extremely likely to have ACEs scores of four or more, and ACEs’ potential impact to brain development, genetic expression, and risk for chronic health issues, due to the toxic stress, is mentioned and well-documented elsewhere (Merrick et al., 2019). But these risks aren’t a given. “(T)he occurrence of ACEs does not necessarily predict problematic outcomes for all victims, especially if they experience safe, stable and nurturing relationships at the family or community levels” (Madigan et al., 2023, p. 467).

Connection, in the form of attuned relationships, matters. Research on positive childhood experiences (PCEs) is burgeoning, showing that PCEs occur right alongside ACEs – and may in fact be more impactful than ACEs on health and well-being across the lifespan (Han et al., 2023). Back in 2013 (Schofield et al.), before anyone was calling them PCEs, another meta-analysis was published on the impact of safe, stable and nurturing relationships (SSNRs), showing that they interrupted the intergenerational cycle of child maltreatment – aka, stopping the cycle of parenting harshly if you we parented harshly. Further, this study showed that if the adults were in SSNRs – if they had a caring partner, co-parent, or friends – then that decreased the likelihood of child maltreatment as well.

Relational health is just as important for adults’ favorable health. While most people would say they understand the impact of social disconnection and loneliness on emotional health, few are aware of their impacts on physical health – social isolation increases the risk of heart disease by 29%, stroke by 32%, and, if experienced in older age, increases the risk of dementia by 50%! And people who feel socially isolated have a 29% increased risk of premature death by any cause (Holt-Lundstad, 2021). For me, as a former primary care nurse practitioner, reading these numbers is reminding me of when I first read the risks associated with ACEs. It’s mind-blowing.

And yet, it makes perfect sense. We are literally wired for connection – our nervous systems evolved to exist in proximity to others, from our mirror neurons to our amydalas to our vagus nerves, we need touch. We need eye contact. We communicate nonverbally so much more than verbally. I love the saying, “trauma happens in community…healing happens in community too.” When in the presence of someone who is attuned (think “gets me”) to us, we co-regulate one another, we can be a calming presence to one another.

We find ourselves now living through an “Epidemic of Loneliness and Isolation” according to the U.S. Surgeon General’s recent advisory with this title (Murthy, 2023). While certainly exacerbated by the COVID-19 pandemic, this loneliness epidemic began in the early 2000’s with the advancement of technology; some of the loneliest people in our country are young adults. How do we respond? We can use the Center for Disease Control and Prevention’s Social-Ecological Model (see title graphic) to help with screening:

We need to start with ourselves: assess your own relational health. How in touch are you with yourself, your own feelings? What relationships do you have with family and/or friends that make you feel seen and affirmed, that give you energy? Do you feel connected with your community? Do you volunteer, or belong to any organizations (faith-based or secular)? And how much to you feel you belong in our society?

For children: three assessments I recommend are 1. Dr. Christina Bethell’s positive childhood experiences, which include seven categories of embodied experiences, 2. Dr. Angela Narayan’s benevolent childhood experiences, 10 categories that reflect a combination of protective factors and social determinants of health – for adolescents, 3. The Child Youth Resilience Measure-Revised by Drs Jefferies, McGarrigle, and Unger – for early childhood.

For adults: no screening tool has risen to dominance, to date, though the Watts Connectedness Scale caught my eye. That said, nothing replaces a thoughtful conversation with a caring provider – it may well be enough to just bring it up and talk about it.

What gives me hope is that we have agency in this. We can make eye contact or provide physical touch, if those are appropriate and feel comfortable; we can be kind, we can bring intention to building connection – it all has ripple effects. And we can put.down.our.phones.! It’s important at home, and it’s important at work, where we spend so many hours of our days. Just keep reminding yourself…connections matter!


Han, D., Dieujuste, N., Doom, J.R., & Narayan, A.J. (2023). A systematic review of positive childhood experiences and adult outcomes: Promotive and protective processes for resilience in the context of childhood adversity. Child Abuse & Neglect 144, 106346.

Holt-Lunstad, J. (2021). The major implications of social connection. Current Directions in Psychological Science 30(3), 251-259.

Madigan, S., Deneault, A.A., Racine, N., et al., (2023). Adverse childhood experiences: a meta-analysis of prevalence and moderators among half a million adults in 206 studies. World Psychiatry 22: 463-471.

Merrick, M.T., Ford, D.C., Ports, K.A., et al., (2019). Vital Signs: Estimated proportion of adult health problems attributable to adverse childhood experiences and implications for prevention – 25 states, 2015-2017. Centers for Disease Control and Prevention [MMWR] 68(44), 999-1005.

Murthy, V.H. (2023). Our Epidemic of Loneliness and Isolation: The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community.

Schofield, T.J., Lee, R.D., & Merrick, M.T. (2013). Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: A meta-analysis. J Adolesc Health 53(4 0), S32-S38.

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I really wanted to read the Han et al. article, alas the DOI link is not working. This links goes to a download, though:  Do you happen to have a different link?

I hope to help teachers to be the PCE providers in their classrooms by helping them to provide transformative SEL experiences.


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