Identifying What Builds Family Trust in Early Childhood Developmental Health Systems
While there is a growing understanding that a child’s first few years strongly impact their future health and success, evidence suggests that access to necessary care and services remains limited.1 For example, of the children referred to IDEA Part C (a federal early intervention program for young children with disabilities) between July 2021 and June 2022, only 53% were ultimately enrolled.2 At the ECDHS: Evidence to Impact Center, we aim to help states and communities improve these outcomes by building strong, lasting early childhood developmental health systems – networks of organizations and services (e.g., pediatric care, family support) that work together to help babies, toddlers, and their families grow and thrive.
To guide our technical assistance with state and community teams, we held focus groups and interviews with pediatricians to learn about factors that affect a young child’s ability to get services across the full range – or continuum – of early childhood developmental care that supports the health and well-being of families. This continuum includes promotion and prevention, monitoring and screening, care coordination and linkage, and intervention.
We shared our research in a poster presentation at the 2025 Pediatric Academic Societies Conference, focusing on three key themes: facilitators (i.e., helpful strategies, resources, or concepts) to strong early childhood systems, challenges, and opportunities to strengthen systems. Highlights include:
- Facilitators: Trust-building between pediatricians and families emerged as a cornerstone for effective care, with programs like HealthySteps and Reach Out and Read supporting strong relational practices that foster engagement and developmental promotion. Four key components related to trust are reliable referral partners, attuning to families, early relational health, and warm hand-offs.
- Challenges: Structural issues within the healthcare system undermine prevention-focused care and limit access to early childhood developmental services.
- Opportunities: Systems can be strengthened through value-based payment reforms, adherence to EPSDT guidelines, and investment in team-based care models that improve coordination and support holistic, relationship-centered pediatric care.
Read on for further details about these facilitators, challenges, and opportunities.
Gaining Insights From Healthcare Professionals
Our partners at the American Academy of Pediatrics recruited seven general pediatricians, three developmental-behavioral pediatricians, and one clinical psychiatrist to participate in the focus groups. We also interviewed four general pediatricians and one developmental-behavioral pediatrician who hold national roles to advance early childhood developmental health. Our focus groups and interviews, conducted in January and February 2024, followed a list of open-ended questions to allow for flexible, yet guided, discussions.
Our questions explored both pediatric practice- and systems-level considerations:
- Practice-level questions focused on the challenges and helpful strategies, resources, or concepts (called “facilitators”) related to addressing early childhood developmental concerns, billing, and referrals.
- Systems-level questions asked about the policies, partnerships, and communication needed to strengthen early childhood developmental health systems.
Facilitators and Challenges to Implementing Strong Systems
A key theme across our focus groups and interviews was the role of trust. Trust-building practices can strengthen early childhood developmental health systems. On the other hand, a lack of trust – either between services or with families – can have detrimental impacts.
Facilitators (Helpful Strategies, Resources, or Concepts)
Participants frequently highlighted the importance of time with families to build trust and earn their buy-in. Negative perceptions, long wait times, and competing demands can affect how a family engages with the interventions and services recommended to them. When pediatricians have time to build relationships with families, they can better understand how to support them, and families are more likely to trust the system.
Pediatricians often highlighted early relational health as a key way to build trust with families. Early relational health refers to the emotional well-being that develops when babies and toddlers experience strong, nurturing relationships with their parents and caregivers. These positive connections help foster strong relationships between families and providers, too.
This [well-child visit] isn’t a one-time conversation, right? It’s like longitudinally building that trust, building that collaborative discussion little bits by little bits to steer that boat together.
-Research Participant
We identified four key components that can help providers establish and strengthen family trust, including:
- Reliable Referral Partners: When providers have strong relationships with the services and specialists they refer patients to, they can effectively manage families’ expectations.
- Attuning to Families: Mindful interactions help providers react to family cues, which creates trust in the patient-provider relationship.
- Early Relational Health: As highlighted above, a focus on early relational health helps providers promote the positive impact that early relationships and experiences have on a child’s healthy development throughout life.
- Warm Hand-Offs: When members of a healthcare team transfer care in front of the patient, the experience is more personalized and helps ensure the patient understands the next steps in care.
Many pediatricians also mentioned similar programs that foster relationships and promote early childhood development, including:
Challenges
Many pediatricians said the challenges they face come from the broader healthcare system, especially how payment structures and policies affect their work. In particular, the dominant model of healthcare emphasizes diagnosis over prevention, which shapes how pediatricians are trained, how they practice, and how they are compensated. This model does not align well with early childhood care, which largely focuses on prevention and early intervention, making it incompatible with the traditional fee-for-service delivery system. This tension is felt throughout the visit, as payers (the organization that pays for care services administered by a healthcare provider) and administrators may not value the time pediatricians spend with families and engage in developmental promotion.
Some pediatricians also said that the dominant healthcare model can impact young children’s access to services, as some programs have rigid eligibility requirements that require a diagnosis, which may not yet be feasible when working with young children.
Most of them [early childhood conditions] are not medically complex, but they are socially complex. They are developmentally complex, and that complexity is often lost in the way our systems currently operate.
-Research Participant
Opportunities for Stronger Systems
Through this research – and in our technical assistance work – the ECDHS: Evidence to Impact Center has identified ways to strengthen systems and reduce challenges.
- Value-Based Payment Structures: At the policy level, states should invest in pediatric-specific quality measures and apply more value-based payment structures, programs that reward health care providers with incentive payments for the quality of care. Additionally, state payers should keep behavioral health services as part of their health plans, because separating them makes it harder for families to receive coverage for these services within primary care.
- EPSDT Guidelines: States should follow the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) guidelines, as documented in the August 2022 CMS Bulletin. These guidelines emphasize the prevention services all children are entitled to under federal law. The bulletin urges payers to cover services when a behavior concern is identified, even without a formal diagnosis. Pediatricians should feel empowered to use non-specific diagnosis billing codes and can refer to our Billing and Coding Resource for support using these codes and age-appropriate diagnostic criteria.
- Team-Based Care: By considering strategies to enhance team-based care within their offices, practices can improve workflows, efficiencies, and relationship-building with families. Pediatricians can also enhance care coordination and linkage when they strengthen relationships with early childhood systems and services in their state. State-level organizations like Help Me Grow can assist by plugging community and pediatric providers into existing networks of resources.
The ECDHS: Evidence to Impact Center works with states and communities to put these recommendations into action. Through our technical assistance, we have helped states identify policy levers to support strong, high-quality early childhood systems. This work has also reinforced the need for coordination at all levels. For example, although EPSDT is a required Medicaid benefit, many states need support communicating the policy to payers and ensuring providers understand how to apply the guidance. Similarly, when states successfully establish enhanced reimbursement, they often require support to ensure payers and providers are aware and know how to use them effectively.
We also support pediatric practices with embedding early relational health, team-based care, and other family-centered strategies. As the Center continues its work, we are creating new resources and guidance to help more families get the support they need.
References
- Karoly, Lynn A., M. Rebecca Kilburn, and Jill S. Cannon, Early Childhood Interventions: Proven Results, Future Promise. Santa Monica, CA: RAND Corporation, 2005.
- Nowicki, Jacqueline. (2023). Report to Congressional Requesters: Additional Data Could Help Early Intervention Programs Reach More Eligible Infants and Toddlers. GAO-24-106019. United States Government Accountability Office.
