Promoting First Relationships (PFR)

About This Program

Target Population: Caregivers of children birth to five years

For parents/caregivers of children ages: 0 – 5

Program Overview

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 5 years). Features of PFR include:

  • Video recording 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 interactions with your child and learn how to build a positive, contingent, and mutually reinforcing relationship with your child
  • Learn about children’s social emotional needs and increase your capacity to understand your child’s needs and cues
  • Increase trust and security in your relationship with your child
  • Increase competence and confidence in your parenting
  • Help your child increase their competence and confidence
  • Learn how to regulate emotion and to self-reflect
  • Help your child learn how to regulate emotion
  • Understand and learn how to address challenging behaviors with your young child

Logic Model

View the Logic Model for Promoting First Relationships (PFR).

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, 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 video records the dyad interacting and reflects on this interaction with the parent. Uses video feedback to focus not only on 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.
  • Provider discusses handouts with the caregiver that contain concepts about attachment, emotion regulation, and social and emotional development.
  • PFR can be conducted with an individual dyad or in groups of 6 to 8 dyads.

Program Delivery

Parent/Caregiver Services

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

  • Parent/Caregiver of young child (birth to 5 years) who lack the skills necessary to sensitively and appropriately respond to their child’s needs, feelings, and cues, and may have difficulty handling their 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.

Recommended Intensity:

1 hour per week

Recommended Duration:

10 weeks

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Foster / Kinship Care
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • Group or Residential Care
  • Public Child Welfare Agency (Dept. of Social Services, etc.)
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)
  • Virtual (Online, Telephone, Video, Zoom, etc.)

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 languages other than English:

Somali, Spanish

For information on which materials are available in these languages, 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, iPad/tablet, or laptop to view video with parent
  • PFR curriculum materials: manual, parent/caregiver handouts, BabyCues cards/video/handout and social-emotional needs cards

Manuals and Training

Prerequisite/Minimum Provider Qualifications

The Level 1 workshop, available in-person and virtually, provides foundational knowledge about the PFR program and a Bachelor’s degree or higher level of education is preferred. Level 2 distance learning provides in-depth, mentored online training and certification on how to implement PFR. See www.pfrprogram.org or www.pcrprograms.org.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

The manual information is:

  • Kelly, J. F., Zuckerman, T. G., Sandoval, D., & Buehlman, K. (2003, 2008, 2016). Promoting First Relationships®: A program for service providers to help parents and other caregivers nurture young children's social and emotional development. Parent-Child Relationship Programs at the Barnard Center for Infant Mental Health and Development, University of Washington.

The manual is available at www.pcrprograms.org

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:
  • The Level 1 Workshop training (delivered as 2 full days in-person or 4 half days virtually) is offered several times per year; special arrangements for group on-site training are frequently made.
  • Level 2 Certified training is delivered over 15 weeks via online virtual meetings with a PFR master trainer, and includes implementing the PFR program to one caregiver–child dyad.
Number of days/hours:
  • Level 1 workshop training is 14 hours total.
  • Level 2 Certified training requires 15 one-hour sessions in a virtual classroom with PFR master trainer, 10 hours viewing professional videos of PFR providers implementing the program with different caregiver/child dyads, and delivering 10 one-hour PFR sessions to a caregiver–child dyad.

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. PFR also has an inquiry packet with additional pre-implementation information. Please contact the program representative listed at the bottom of the page for copies of these documents.

Formal Support for Implementation

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

Following training, PFR offers optional technical assistance sessions to support organizations or individuals’ implementation of the program at their site. These sessions are conducted via video conference in order to support program fidelity and to provide site-specific guidance to providers and leadership. There are also established fidelity measures that the agency has access to, in order to help ensure fidelity to the model. Additionally, small group monthly reflective consultation is available to support providers as they implement PFR with the caregiver–child dyads with which they work.

Fidelity Measures

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

Providers video record a PFR session with a caregiver–child dyad that they are working with and submit this for fidelity. These recordings are scored by PFR master trainers using two fidelity measurements:

  • Video Feedback Fidelity form - measures provider's use of the PFR consultation strategies while viewing the caregiver–child interaction video with the caregiver/parent.
  • Whole Session Fidelity form – rates provider's whole session using 20 different categories. The session is also rated on 6 additional items that are to be avoided during the session.

Providers are required to pass these fidelity measures annually in order to keep their PFR certification. Master Trainers can train experienced individuals at an agency in how to use the fidelity measures. The program representative listed at the bottom of the page can be contacted 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:

PFR has a Best Practices document and Implementation Guidelines to support agencies in implementing the program within their organization. Please contact the program representative listed at the bottom of the page to obtain copies.

Implementation Cost

There have been studies of the costs of implementing Promoting First Relationships (PFR) which are listed below:

Kuklinski, M. R., Oxford, M. L., Spieker, S. J., Lohr, M. J., & Fleming, C. B. (2020). Benefit-cost analysis of Promoting First Relationships®: Implications of victim benefits assumptions for return on investment. Child Abuse & Neglect, 106, Article 104515. https://doi.org/10.1016/j.chiabu.2020.104515

Research on How to Implement the Program

Research has been conducted on how to implement Promoting First Relationships (PFR) as listed below:

Han, M., Hallam, R., Hustedt, J. T., Vu, J. A., & Gaviria-Loalza, J. (2016). Lessons from training early head start staff to implement an evidence-based parenting intervention. Dialog, 19(3), 42-59. https://journals.charlotte.edu/dialog/article/view/455

Oxford, M., Booth-LaForce, C., Echo-Hawk, A., Madesclaire, O., Parrish, L., Widner, M., Petras, A., Abrahamson-Richards, T., Nelson, K., Buchwald, D., & the CATCH Project Team. (2020). Promoting First Relationships®: Implementing a home visiting research program in two American Indian communities. Canadian Journal of Nursing Research, 52(2), 149–156. https://doi.org/10.1177/0844562120914424

Oxford M. L., Spieker, S. J., Lohr, M. J., Fleming, C. B., Dillon, C., & Rees, J. (2017). Ensuring implementation fidelity of a 10-week home visiting program in two randomized clinical trials. Maternal and Child Health Journal, 22(3), 376–383. https://doi.org/10.1007/s10995-017-2387-8

Relevant Published, Peer-Reviewed Research

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

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. https://doi.org/10.1177/1077559512458176

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

Population:

  • Age — 10-24 months
  • Race/Ethnicity — 55% White, 20% Mixed, 15% African American, 10% Hispanic, 7% Native American, and 4% Other
  • Gender — 56% Male
  • Status — Participants were children in foster care.

Location/Institution: Seattle, Washington

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to present analyses on the Promoting First Relationships (PFR) program in regards to improving parenting and toddler outcomes for toddlers in state dependency. Participants were randomly assigned to 10-week PFR or the Early Education Support (EES) comparison condition. Measures utilized include the 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 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 controlled postintervention follow-up: 6 months.

Nelson, E. M., & 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. https://doi.org/10.1002/imhj.21382

Type of Study: Randomized controlled trial
Number of Participants: 48

Population:

  • Age — 10-25 months
  • Race/Ethnicity — 69% White, 17% Black, 13% American Indian, and 2% Hawaiian Native
  • Gender — Not specified
  • Status — Participants were children in foster care.

Location/Institution: Seattle, Washington

Summary: (To include basic study design, measures, results, and notable limitations)
This study used a sub-sample from Spieker et al. (2012). The purpose of the study was to test whether toddlers with caregivers in the Promoting First Relationships (PFR) program would show postintervention 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. Participants were toddlers with a caregiver change within 7 weeks of enrollment in PFR. Measures utilized include 4 saliva samples during a 1.5-hour research visit and samples the next morning. Results indicate 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 nonmaltreated or child welfare services involved comparison group, possible sample collection time variation, lack of follow-up, and small sample size.

Length of controlled 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. https://doi.org/10.1016/j.childyouth.2015.12.004

Type of Study: Randomized controlled trial
Number of Participants: 43

Population:

  • Age — Children: 10-25 months; Parents: Not specified
  • Race/Ethnicity — Children: 69% White, 17% Black, 13% American Indian, and 2% Hawaiian Native; Parents: Not specified
  • Gender — Children: 20 Male; Parents: 6 Male
  • Status — Participants were parents of children in foster care.

Location/Institution: Seattle, Washington

Summary: (To include basic study design, measures, results, and notable limitations)
This study used a subsample from Spieker et al. (2012). The purpose of the study was to report on the findings from a randomized control trial of Promoting First Relationships (PFR) for a subsample of reunified birth parents that were part of the larger trial. Measures utilized include the 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 although the sample size was small and most of the estimates of intervention effects were not statistically significant, the effect sizes and the pattern of results suggest that the intervention may have improved both observed parenting sensitivity and observed child behaviors as well as decreased parent report of child behavior problems. Limitations include small sample size, and participants in this study may differ from the general population of reunified birth families.

Length of controlled postintervention follow-up: 6 months.

Oxford, M. L., Spieker, S. J., Lohr, M. J., & Fleming, C. B. (2016). Promoting First Relationships®: Randomized trial of a 10-week home visiting program with families referred to child protective services. Child Maltreatment, 21(4), 267-277. https://doi.org/10.1177/1077559516668274

Type of Study: Randomized controlled trial
Number of Participants: 247 families

Population:

  • Age — Children: R&R: Mean=16.77 months, PFR: Mean=15.97 months; Adults: R&R: Mean=27.04 years, PFR: Mean=26.41 years
  • Race/Ethnicity — Child: R&R/PFR: 59%/65% White, 35%/27% Other, 29%/34% Hispanic, 4%/4% African Am., 2%/0% Am. Indian/Alaska Native., 0.8%/3% Asian; Parent: R&R/PFR: 77%/77% Wh., 19%/20% Hisp., 11%/10% Oth., 6%/5% Afr. Am., 3%/5% As., 2%/3% AI/AN
  • Gender — Children: R&R: 58% Male, PFR: 50% Male; Parents: R&R: 91% Female, PFR: 90% Female
  • Status — Participants were toddlers and their caregivers involved with child welfare services (CWS).

Location/Institution: Washington State

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine Promoting First Relationships (PFR) effect on enhancing parent sensitivity and preventing child removals for families in the child welfare system. Participants were randomly assigned to PFR or a control treatment group (brief resource and referral [R&R]). Measures utilized include the Raising a Baby scale (RAB), the Nursing Child Assessment Teaching Scale (NCATS), the Brief Infant Toddler Social and Emotional Assessment (BITSEA), the Bayley Behavior Rating Scales (BRS), the Attachment Q-Sort (AQS), the Parenting Stress Index (PSI-3), and the Parenting Stress Index-Short Form (PSI-SF). Results indicate that across postintervention time points, parents in the PFR condition scored higher than families in the control group in parent understanding of toddlers’ social emotional needs and observed parental sensitivity. Children in the PFR condition scored lower than children in the comparison condition on an observational measure of atypical affective communication and were less likely than children in the comparison group to be placed into foster care through one-year postintervention. No significant differences were found on measures of parenting stress or child social-emotional competence, behavior problems, or secure base behavior. Limitations include lack of generalizability due to ethnicity of participants and reliance on self-reported measures.

Length of controlled postintervention follow-up: 1 year (for CWS records only)

Jones, E. J., Dawson, G., Kelly, J., Estes, A., & Webb, S. J. (2017). Parent‐delivered early intervention in infants at risk for ASD: Effects on electrophysiological and habituation measures of social attention. Autism Research, 10(5), 961-972. https://doi.org/10.1002/aur.1754

Type of Study: Randomized controlled trial
Number of Participants: 33

Population:

  • Age — 9-11 months
  • Race/Ethnicity — 87% White
  • Gender — 36% Female
  • Status — Participants were parent–toddler dyads.

Location/Institution: Not specified

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to determine the efficacy of Promoting First Relationships (PFR) for parents with infants at high familial risk for autism spectrum disorder (ASD) with treatment between 9 and 11 months. Participants were randomly assigned to either PFR or on-going assessment without intervention. Measures utilized include the Mullen Scales of Early Learning. Results indicate that compared to infants who only received assessment and monitoring, infants who received PFR showed improvements in neurocognitive metrics of social attention, as reflected in a greater reduction in habituation times to face versus object stimuli between 6 and 12 months, maintained at 18 months; a greater increase in frontal EEG theta power between 6 and 12 months; and a more comparable P400 response to faces and objects at 12 months. The high-risk infants who received the intervention showed a pattern of responses that appeared closer to the normative responses of two groups of age-matched low-risk control participants. Limitations include small sample size, participant attrition, and length of follow-up. 

Length of controlled postintervention follow-up: 6 months.

Pasalich, D. S., Fleming, C. B., Spieker, S. J., Lohr, M. J., & Oxford, M. L. (2019). Does parents’ own history of child abuse moderate the effectiveness of the Promoting First Relationships® intervention in child welfare? Child Maltreatment, 24(1), 56–65. https://doi.org/10.1177/1077559518809217

Type of Study: Randomized controlled trial
Number of Participants: 247 families

Population:

  • Age — Children: 10-24 months; Adults: Not specified
  • Race/Ethnicity — Children: 32% Hispanic and 31% Biracial; Adults: 77% White, 19% Hispanic, and 10% Mixed Race
  • Gender — Not specified
  • Status — Participants were toddlers and their caregivers involved with child welfare services.

Location/Institution: Washington State

Summary: (To include basic study design, measures, results, and notable limitations)
This study used the sample from Oxford et al. (2016). The purpose of the study was to examine whether parents’ own history of child abuse moderated the indirect effects of the Promoting First Relationships® (PFR) intervention on toddlers’ secure base behavior via parental sensitivity. Participants were randomly assigned to PFR or a control intervention. Measures utilized include the Childhood Trauma Questionnaire–Short Form, the Nursing Child Assessment Teaching Scale, and the Toddler Attachment Sort-45. Results indicate that the PFR group demonstrated greater parental sensitivity at postintervention than the control group, which in turn led to higher levels of toddler secure base behavior at 6-month follow-up. Findings also indicated that these intervention effects were only evident for parents who experienced physical abuse in their childhood. Parents’ history of sexual or emotional abuse did not significantly moderate outcomes. Limitations include the measure of toddler attachment used, reliance on parents’ retrospective reports of their abuse experiences in childhood, a lack of information on parents’ child neglect experiences, and concerns about generalizability beyond the majority White sample.

Length of controlled postintervention follow-up: 6 months.

Booth-LaForce, C., Oxford, M. L., Barbosa-Leiker, C., Burduli, E., & Buchwald, D. S. (2020). Randomized controlled trial of the Promoting First Relationships® preventive intervention for primary caregivers and toddlers in an American Indian community. Prevention Science, 21(1), 98–108. https://doi.org/10.1007/s11121-019-01053-x

Type of Study: Randomized controlled trial
Number of Participants: 34 child-caregiver dyads

Population:

  • Age — Children: Immediate: Mean=18.53 months, Waitlist: Mean=17.29 months; Caregivers: Not specified
  • Race/Ethnicity — Children: Immediate: 100% American Indian/Alaska Native, Waitlist: 100% American Indian/Alaska Native; Caregivers: Immediate: 59% American Indian/Alaska Native, 29% White, and 12% Mixed; Waitlist: 88% American Indian/Alaska Native and 12% Mixed
  • Gender — Children: Immediate: 65% Female, Waitlist: 41% Female; Caregivers: Not specified
  • Status — American Indian/Alaska Native children living on or near the reservation, and their primary caregivers.

Location/Institution: Rural reservation in the Northwest region (as defined by the Indian Health Service) of the USA.

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to test the efficacy of the Promoting First Relationships® (PFR) program in American Indian families living on a rural reservation. Participants were randomly assigned to PFR or waitlist group. Measures utilized include the Nursing Child Assessment Teaching Scale, the Raising a Baby scale, the short-form Parenting Stress Index and the Infant-Toddler Social Emotional Assessment (ITSEA). Results indicate that the PFR group, compared with waitlist, had significantly higher scores on the quality and contingent responsiveness of caregiver-child interactions, as well as on caregiver knowledge of toddlers’ social and emotional needs and level of developmentally appropriate expectations. Caregiver stress and caregivers’ reports of child behavior did not differ significantly. Limitations include small sample size, lack of post-intervention follow-up, high attrition rate, and whether the findings would generalize to American Indian families or others not living on a rural reservation.

Length of controlled postintervention follow-up: None.

Oxford, M. L., Hash, J. B., Lohr, M. J., Bleil, M. E., Fleming, C. B., Unützer, J., & Spieker, S. J. (2021). Randomized trial of promoting first relationships for new mothers who received community mental health services in pregnancy. Developmental Psychology, 57(8), 1228–1241. https://doi.org/10.1037/dev0001219

Type of Study: Randomized controlled trial
Number of Participants: 252 mothers and their infants

Population:

  • Age — Children: PFR: Mean=1.8 months, Control: Mean=1.9 months; Mothers: PFR: Mean=28.8 years, Control: 27.4 years
  • Race/Ethnicity — Children: PFR/Control: 62%/54% Caucasian, 54%/53% Hispanic, 20%/26% Multiracial, 16%/14% African American and 2%/6% Other; Mothers: PFR/Control: 66%/65% Caucasian, 49%/46% Hispanic, 17%/18% African American, 13% Multiracial, 5%/9% Other, and NR/8% Multira
  • Gender — Children: PFR: 56% Male and 44% Female, Control: 51% Female and 49% Male; Mothers: 100% Female
  • Status — Participants were mothers who had begun treatment for a mental health diagnosis (depression, anxiety, and/or posttraumatic stress disorder/PTSD) at a community or public health center in pregnancy.

Location/Institution: King County, Washington

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to test the effectiveness of Promoting First Relationships® (PFR) in underserved communities. Participants were randomly assigned to the PFR program or receipt of a resource packet. Measures utilized include the Nursing Child Assessment Teaching Scale (NCATS), the Infant CARE-Index (ICI), the Raising a Baby Scale (RAB), the Maternal Confidence Questionnaire (MCQ), and the Infant Toddler Social Emotional Assessment (ITSEA). Results indicate that compared to mothers in the control condition, mothers in the PFR condition had significantly higher observed sensitivity scores at both follow-up time points, improved understanding of infant-toddler social emotional needs at both time points, and reported less infant externalizing behavior at age 12 months. Limitations include poor inter-rater agreement of the ICI coders and a smaller Spanish speaking sample than intended.

Length of controlled postintervention follow-up: Varied.

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. https://doi.org/10.1016/j.childyouth.2013.09.021

This study used a subset of the sample from Spieker et al. (2012). The purpose of the study was to investigate the impact of Promoting First Relationships® (PFR) on sleep problems among toddlers in child welfare recently reunified with their birth parent. Measures utilized include 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). Results indicate that toddlers in the PFR condition showed a significant decrease in their separation distress scores, and toddlers exhibiting less separation distress had fewer sleep problems. Limitations include small sample size, participant attrition, and lack of generalizability beyond birth parents to other caregivers, due to their exclusion from these analyses. 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

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. https://doi.org/10.1016/j.childyouth.2014.06.017

This study used the sample from Spieker et al. (2012). The purpose of the study was to report on child welfare outcomes of a community-based trial of Promoting First Relationships (PFR), specifically on the stability of children’s placements and their permanency status two years after enrollment into the study. Participants were randomly assigned to PFR or a control treatment group. Measures utilized include a state child welfare administrative database. Results indicate that there was no difference by intervention group on stability or permanency, but there was a significant interaction between caregiver type (birth parent vs. foster/kin) and intervention group. 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. Limitations include small sample size, permanency had not been achieved for many of the children by the end of the follow-up period, and significant results were only seen in a subset of the population. 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.

Pasalich, D. S., Fleming, C. B., Oxford, M. L., Zheng, Y., & Spieker, S. J. (2016). Can parenting intervention prevent cascading effects from placement instability to insecure attachment to externalizing problems in maltreated toddlers?. Child Maltreatment, 21(3), 175–185. https://doi.org/10.1177/1077559516656398

This study used the sample from Spieker et al. (2012). The purpose of the study was to conduct secondary data analysis of a randomized controlled trial to examine whether Promoting First Relationships (PFR) reduced risk for a maladaptive cascade from placement instability to less secure attachment to elevated externalizing problems. Participants were randomized to PFR or a control treatment group. Measures utilized include the Brief Infant Toddler Social and Emotional Assessment (BITSEA), the Toddler Attachment Sort-45 (TAS45), and the Child Behavior Checklist (CBCL). Results indicate that PFR weakened the association between multiple placement changes (baseline) and less security (postintervention) and that the indirect effect of placement instability on greater externalizing problems (6-month follow-up) via less security was evident only in toddlers in the comparison condition. Limitations include small sample size at 6-month follow-up and utilization of subset of original population. 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.

Additional 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. https://doi.org/10.1177/1077559512467396

Contact Information

Jennifer Rees, MSW
Agency/Affiliation: Barnard Center for Infant Mental Health and Development
Website: www.pfrprogram.org
Email:
Phone: (206) 616-5389 or (206) 909-6992

Date Research Evidence Last Reviewed by CEBC: April 2021

Date Program Content Last Reviewed by Program Staff: June 2021

Date Program Originally Loaded onto CEBC: March 2013