Promoting First Relationships (PFR)

Scientific Rating:
3
Promising Research Evidence
See scale of 1-5
Child Welfare System Relevance Level:
High
See descriptions of 3 levels

About This Program

The information in this program outline is provided by the program representative and edited by the CEBC staff. Promoting First Relationships (PFR) has been rated by the CEBC in the areas of: Infant and Toddler Mental Health Programs (Birth to 3) and Parent Training Programs that Address Behavior Problems in Children and Adolescents.

Target Population: Caregivers of children birth to three years

For children/adolescents ages: 0 – 3

For parents/caregivers of children ages: 0 – 3

Brief Description

Promoting First Relationships (PFR) is a manualized home visiting intervention/prevention program which includes parent training components based on strengths-based practice, practical, and in-depth strategies for promoting secure and healthy relationships between caregivers and young children (birth to 3 years). Features of PFR include:

  • Videotaping caregiver-child interactions to provide insight into real-life situations and help the caregiver reflect on the underlying needs of the child and how those needs impact behavior
  • Giving positive and instructive feedback that builds caregivers' competence with and commitment to their children
  • Focusing on the deeper emotional feelings and needs underlying children's distress and behaviors
  • Using handouts and homework to enhance parent insight and learning about child social and emotional development, needs, and concerns

Program Goals:

The goals of Promoting First Relationships (PFR) are:

  • Improve parent-child interactions and to build a positive, contingent, and mutually reinforcing relationship between parents and their children
  • Educate parents about children’s social emotional needs and increase their capacity to understand child’s cues
  • Promote trust and security between child and parent
  • Build competence and confidence in both parent and child
  • Promote emotion regulation and self-reflection in both parent and child
  • Help parents understand and learn how to address challenging behaviors with their infants and toddlers

Essential Components

The essential components of Promoting First Relationships (PFR) include:

  • Provider helps parents understand the social emotional needs behind a child’s challenging behavior and to meet those needs. Provider does not teach parents techniques to extinguish child’s challenging behavior.
  • Provider enhances parent’s ability to be reflective and to reframe the meaning of a child’s behavior in terms of social emotional needs.
  • Provider works dyadically so parent and child have a mutually enjoyable relationship.
  • Provider uses video feedback methods which include:
    • Giving positive and positive and instructive feedback
    • Being contingent
    • Using reflective comments and questions
    • Staying focused on the parent-child relationship
  • Provider consciously is positive and strengths-based and:
    • Avoids advice-giving
    • Avoids judging or correcting
    • Avoids ignoring or dismissing
    • Avoids taking an ‘expert’ stance
    • Avoids making other, unrelated comments
  • Provider videotapes the dyad interacting and reflects on this interaction with the parent. Uses video feedback to also focus on, not only the child’s social and emotional needs, but on the parent’s social and emotional needs as well.
  • Provider consciously uses a parallel process to acknowledge and understand the parent’s feelings and needs so that the parent in turn can acknowledge and understand the child’s feelings and needs.
  • PFR can be conducted with an individual dyad or in groups of 6 to 8 dyads.

Child/Adolescent Services

Promoting First Relationships (PFR) directly provides services to children/adolescents and addresses the following:

  • Challenging behavior, unmet social and emotional needs, emotional regulation

Parent/Caregiver Services

Promoting First Relationships (PFR) directly provides services to parents/caregivers and addresses the following:

  • Parent/Caregiver of small child (Birth to 3 years) who may lack the skills necessary to sensitively and appropriately respond to their child’s needs, feelings, and cues, and may have difficulty handling the young child’s challenging behaviors and emotions
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: PFR has a dyadic focus, but other parental caregivers may join sessions.

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Community Agency
  • Foster/Kinship Care
  • Outpatient Clinic
  • Residential Care Facility

Homework

Promoting First Relationships (PFR) includes a homework component:

Parent is given a handout ‘thought for the week’ that helps them focus and reflect on the topic of the week.

Languages

Promoting First Relationships (PFR) has materials available in a language other than English:

Spanish

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • Video camera and DVD player, IPAD, or laptop to view video with parent
  • PFR curriculum materials: book, handout, ‘Baby Cues’ cards, ‘Baby Cues’ video

Minimum Provider Qualifications

A 2-day workshop provides foundational knowledge about the PFR program and Bachelor’s degree or higher level of education preferred. Community distance learning provides in depth training and certification on how to implement PFR. See www.pfrprogram.org or NCAST.org

Education and Training Resources

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contacts:
Training is obtained:
  • Two-day training is offered twice a year in Seattle; special arrangements for group on-site training are frequently made.
  • Community Distance Learning occurs via online virtual meetings with PFR trainers.
Number of days/hours:
  • Two-day training is 15 hours total
  • Community Distance learning requires 15 sessions in a virtual classroom plus delivering PFR to one family

Implementation Information

Since Promoting First Relationships (PFR) is rated on the Scientific Rating Scale, information was requested from the program representative on available pre-implementation assessments, implementation tools, and/or fidelity measures.

Show implementation information...

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Promoting First Relationships (PFR) as listed below:

PFR partnered with the Washington State Children's Administration to develop a Readiness Assessment that helps evaluate an agency's, as well as a provider's, readiness to begin training in the program. Please contact Jennifer Rees at rees@uw.edu for a copy of this document.

Formal Support for Implementation

There is formal support available for implementation of Promoting First Relationships (PFR) as listed below:

Once providers have been trained in the PFR model, PFR trainers are available for further consultation to the agency to help support them as they implement the program. There are also established fidelity measures that the agency has access to, in order to help ensure fidelity to the model. Finally, PFR providers can receive group reflective practice to support them as they implement the program.

Fidelity Measures

There are fidelity measures for Promoting First Relationships (PFR) as listed below:

  • Video Feedback Fidelity form - This form is used to measure the provider's use of the PFR consultation strategies while viewing the parent-child play video with the parent/caregiver.
  • Whole Session Fidelity form - A provider's whole session is rated using 20 different categories. The session is also rated on 5 additional items that are to be avoided during the session.

PFR Master Trainers conduct initial fidelity checks with providers. Upon passing initial fidelity checks, Master Trainers can train identified individuals at an agency in how to use the fidelity measures. Jennifer Rees can be contacted at rees@uw.edu for more information about these fidelity measures.

Implementation Guides or Manuals

There are implementation guides or manuals for Promoting First Relationships (PFR) as listed below:

The PFR manual and reproducible handouts are included in the initial PFR 2-day workshop. The manual includes detailed instruction on delivering PFR to families. For those going on to get certified as a PFR provider and take the community distance learning course they will receive a detailed 10-week outline, checklist, and Thoughts for the Week to use with the parent-child dyad to providers who are receiving training to implement PFR.

Research on How to Implement the Program

Research has not been conducted on how to implement Promoting First Relationships (PFR).

Relevant Published, Peer-Reviewed Research

This program is rated a "3 - Promising Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least one study utilizing some form of control (e.g., untreated group, placebo group, matched wait list study) establishing the practice's benefit over the placebo, or found it to be comparable to or better than an appropriate comparison practice. Please see the Scientific Rating Scale for more information.

Child Welfare Outcomes: Permanency and Child/Family Well-Being

Show relevant research...

Kelly, J. F., Buehlman, K., & Caldwell, K. (2000). Training personnel to promote quality parent-child interaction in families who are homeless. Topics in Early Childhood Special Education, 20(3), 174-185. doi:10.1177/027112140002000306

Type of Study: One group pretest-posttest
Number of Participants: 4 advocates and 6 mother-child pairs

Population:

  • Age — Mothers: Mean=33.8 years, Advocates: Not specified, Children: Mean=16.3 months
  • Race/Ethnicity — Mothers and Advocates: 67% White, Children: Not specified
  • Gender — Mothers and Advocates: 100% Female, Children: Not specified
  • Status — Participants were homeless parents and their children.

Location/Institution: Not given

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study evaluated the effectiveness of parent-child advocates serving homeless parents and their children after the advocates have received training in Promoting First Relationships (PFR), a one-on-one early intervention to facilitate healthy parent-child interactions. Measures utilized include the Nursing Child Assessment Teaching Scale and the Bayley Mental Development Index. Trainers reported increased use of positive, contingent, and instructive feedback to parents about their interactions with their young children. Mothers who were trained in the techniques by the trainers also reported improved and more favorable interactions with their children. Limitations include lack of randomization, lack of control group and small sample size.

Length of postintervention follow-up: None.

Kelly, J. F., Zuckerman, T., & Rosenblatt, S. (2008). Promoting First Relationships: A relationship-focused early intervention approach. Infants and Young Children, 21(4), 285-295. doi:10.1097/01.IYC.0000336541.37379.0e

Type of Study: One group pretest-posttest
Number of Participants: 14 mother-child dyads

Population:

  • Age — Not specified
  • Race/Ethnicity — Not specified
  • Gender — Not specified
  • Status — Participants had a child diagnosed with a special need.

Location/Institution: Washington State

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study describes a relationship-focused approach to early intervention, Promoting First Relationships (PFR) and presents initial results from a research and training project using the PFR approach to improve the relationship-focused skills of personnel serving young children, birth to 3, with disabilities and their families. Measures include The Parent-Provider Coding System, NCAST Teaching Scale, and the Bayley Mental Development Index. Results show an increase in relationship-focused staff practices as a result of training and an increase in parent sensitivity and responsiveness and a corresponding increase in child contingency and responsiveness during parent-child interactions. Limitations include lack of control group and small sample size.

Length of postintervention follow-up: None.

Spieker, S. J., Oxford, M. L., Kelly, J. F., Nelson, E. M., & Fleming, C. B. (2012). Promoting First Relationships: Randomized trial of a relationship-based intervention for toddlers in child welfare. Child Maltreatment, 17(4), 271-286. doi:10.1177/1077559512458176

Type of Study: Randomized controlled trial
Number of Participants: 210 children

Population:

  • Age — 10-24 months
  • Race/Ethnicity — 55.2% White, 14.8% African American, 10% Hispanic, 6.7% Native American, 19.5% Mixed, and 4.3% Other
  • Gender — 56% Male
  • Status — Participants were children in foster care.

Location/Institution: Seattle, Washington

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study presents analyses on the Promoting First Relationships (PFR) program in regards to improving parenting and toddler outcomes for toddlers in state dependency. Toddlers with a recent placement disruption were randomized to 10-week PFR or the Early Education Support (EES) comparison condition. Measures include Nursing Child Assessment Teaching Scale (NCATS), the Indicator of Parent Child Interaction, This is My Baby, Raising a Baby, the Parenting Stress Index (PSI), the Toddler Attachment Sort – 45 (TAS45) , the Attachment Q Sort, the Brief Toddler Social and Emotional Assessment (BITSEA), Child Behavior Checklist for Ages 1 ½–5 (CBCL), Bayley-III Screening Test, and the Bayley Behavior Rating Scales. Results showed caregivers’ sensitivity improved more in the PFR participants than in the comparison subjects, although the differences were no longer significant at the 6-month follow-up. Subjects in the PFR condition also reported more understanding of toddlers and child competence than the comparison subjects, although, again, these differences were no longer significant at the 6-month follow-up. There were no significant differences between intervention and comparison children on security at either postintervention or 6-month follow-up. Limitations include an internal validity threat due to changes in child placement, which eliminated subjects from the sample at follow-up and reduced the study’s power.

Length of postintervention follow-up: 6 months.

Nelson, E., & Spieker, S. J. (2013). Intervention effects on morning and stimulated cortisol responses among toddlers in foster care. Infant Mental Health Journal, 34(3), 211-221. doi:10.1002/imhj.21382

Type of Study: Subset of randomized controlled trial
Number of Participants: 48 children

Population:

  • Age — 10-25 months
  • Race/Ethnicity — 68.8% White, 16.7% Black, 12.5% American Indian, and 2.1% Hawaiian Native
  • Gender — Not specified
  • Status — Participants were children in foster care.

Location/Institution: Seattle, Washington

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study involved a non-random sub-sample of participants from Spieker et al. (2012). This study tested whether toddlers with caregivers in the Promoting First Relationships (PFR) program would show post-intervention change in stimulated salivary cortisol patterns during a research home visit involving a separation-reunion procedure when compared to a condition including child development and resource advice, but no attachment strategies. Toddlers with a caregiver change within 7 weeks of enrollment provided 4 saliva samples during a 1.5-hour research visit and samples the next morning. Results indicated that 92% of children demonstrated atypically low morning cortisol. Results also indicated that at post-intervention, flat, decreasing and increasing patterns were also exhibited. Significantly more children in the PFR condition showed an increasing pattern. Limitations include lack of a non-maltreated or child welfare services involved comparison group, possible sample collection time variation, and small sample size.

Length of postintervention follow-up: None.

Oxford, M. L., Marcenko, M., Fleming, C. B., Lohr, M. J., & Spieker, S. J. (2016). Promoting birth parents' relationships with their toddlers upon reunification: Results from Promoting First Relationships® home visiting program. Children and Youth Services Review, 61, 109-116. doi:10.1016/j.childyouth.2015.12.004

Type of Study: Subset of randomized controlled trial
Number of Participants: 43

Population:

  • Age — Children: 10-25 months, Parents: Not specified
  • Race/Ethnicity — Children: 68.8% White, 16.7% Black, 12.5% American Indian, and 2.1% Hawaiian Native, Parents: Not specified
  • Gender — Children: 20 Males, Parents: 6 Males
  • Status — Participants were parents of children in foster care.

Location/Institution: Seattle, Washington

Summary: (To include comparison groups, outcomes, measures, notable limitations)
This study involved a nonrandom subsample of participants from Spieker et al. (2012). This study reports on the findings from a randomized control trial of Promoting First Relationships for a subsample of reunified birth parents that were part of the larger trial. Measures include Nursing Child Assessment Teaching Scale (NCATS), the Indicator of Parent Child Interaction, This is My Baby, Raising a Baby, the Parenting Stress Index (PSI), the Toddler Attachment Sort – 45 (TAS45), the Attachment Q Sort, the Brief Toddler Social and Emotional Assessment (BITSEA), Child Behavior Checklist for Ages 1 ½–5 (CBCL), Bayley-III Screening Test, and the Bayley Behavior Rating Scales. Results indicate that PFR produced positive results in this small sample of reunified birth families at the six-month follow-up, although not evident at the immediate posttest. These results, compared to results reported for the full sample including foster, kin, and birth parents indicate that the effect sizes at the immediate posttest were more negative for the birth parent sample. In contrast, the positive effect sizes at the six-month follow-up reported here for birth parents are larger than they were for the full sample. Limitations include small sample size, and participants in this study may differ from the general population of reunified birth families

Length of postintervention follow-up: 6 months.

The following studies were not included in rating PFR on the Scientific Rating Scale...

Oxford, M. L., Fleming, C. B., Nelson, E. M., Kelly, J. F., & Spieker, S. J. (2013). Randomized trial of Promoting First Relationships: Effects on maltreated toddlers' separation distress and sleep regulation after reunification. Children and Youth Services Review, 35(12), 1988-1992.

Note: This study was not used for rating Promoting First Relationships (PFR) in Infant and Toddler Mental Health (Birth-3) and Parenting Training Programs that Address Problem Behaviors in Children and Adolescents since subgroup analyses cannot be used for rating of a program designed for a broader target population. This study utilized only the birth parent participants from Spieker et al. (2012). This study investigates the impact of PFR on sleep problems among toddlers in child welfare recently reunified with their birth parent. Measures included parental report of sleep problems and research visitor observation of separation distress using the Toddler Attachment Sort-45, the Child Behavior Checklist (CBCL), and the Brief Infant Toddler Social and Emotional Assessment (BITSEA). Toddlers in the PFR condition showed a significant decrease in their separation distress scores, and toddlers exhibiting less separation distress had fewer sleep problems. This study is limited due to small sample size, participant attrition, and lack of generalizability beyond birth parents to other caregivers, due to their exclusion from these analyses.

Spieker, S. J., Oxford, M. L., & Fleming, C. B. (2014). Permanency outcomes for toddlers in child welfare two years after a randomized trial of a parenting intervention. Children and Youth Services Review, 44, 201–206.

Note: This study was not used for rating Promoting First Relationships (PFR) in Infant and Toddler Mental Health (Birth-3) and Parenting Training Programs that Address Problem Behaviors in Children and Adolescents since subgroup analyses cannot be used for rating of a program designed for a broader target population. This study uses the same sample as Spieker et al. (2012). This study reports on child welfare outcomes of a community-based randomized control trial of PFR, specifically on the stability of children’s placements and their permanency status two years after enrollment into the study. Children and their caregivers were randomized to PFR or a control treatment group. Measures include state child welfare administrative database provided dates of a child’s birth, entry into care, any placement changes while in care, when a discharge to a permanent placement occurred, and when a child re-entered care, if ever. Results indicate that there were no significant differences between the PFR and control groups on child stability or permanency outcomes. However, a subgroup analyses by caregiver type showed that more foster/kin caregivers who received the PFR intervention provided stable, uninterrupted care and eventually adopted or became the legal guardians of the toddlers in their care, compared to foster/kin caregivers randomized to the comparison condition. No differences were seen for other caregiver types. Limitations include small sample size, permanency had not been achieved for many of the children by the end of the follow-up period, and that significant results were only seen in a subset of the population.

References

The following is a response to a commentary written about the 2012 research study displayed in the above Relevant Published, Peer-Reviewed Research section: Spieker, S. J., Oxford, M. L., Kelly, J. F., Nelson, E. M., & Fleming, C. B. (2012). Response to the Barth commentary. Child Maltreatment, 17(4), 291-294. doi:10.1177/1077559512467396

Contact Information

Name: Jennifer Rees, MSW
Agency/Affiliation: Barnard Center for Infant Mental Health and Development
Website: www.pfrprogram.org
Email:
Phone: (206) 616-5389
Fax: (206) 543-9266

Date Research Evidence Last Reviewed by CEBC: July 2016

Date Program Content Last Reviewed by Program Staff: March 2016

Date Program Originally Loaded onto CEBC: March 2013