Promoting First Relationships® (PFR)

Promoting First Relationships® (PFR) is sponsored by U.S. Department of Health and Human Services (HHS). A home visiting prevention program designed for caregivers of children ages 0–5 years to promote secure and healthy relationships.

Promoting First Relationships®: Randomized Trial of a 10-week Home Visiting Program with Families Referred to Child Protective Services - PMC As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. .

Author manuscript; available in PMC: 2018 Mar 19. Published in final edited form as: Child Maltreat. 2016 Sep 21;21(4):267–277.

doi: 10.

1177/1077559516668274 Promoting First Relationships ® : Randomized Trial of a 10-week Home Visiting Program with Families Referred to Child Protective Services 1 University of Washington Find articles by Monica L Oxford 1 University of Washington Find articles by Susan J Spieker 1 University of Washington Find articles by Mary Jane Lohr 1 University of Washington Find articles by Charles B Fleming 1 University of Washington ✉ Correspondence for this article should be addressed to Monica L.

Oxford, Box 357920, University of Washington, Seattle, WA 98195-7920. mloxford@uw. edu Monica L.

Oxford, Family & Child Nursing, University of Washington; Susan J. Spieker, Family & Child Nursing, University of Washington; Mary Jane Lohr, Family & Child Nursing, University of Washington; Charles B.

Fleming, School of Social Work, University of Washington PMCID: PMC5357588 NIHMSID: NIHMS829998 PMID: 27646148 The publisher's version of this article is available at Child Maltreat We conducted a community-based randomized control trial with intent-to-treat analysis on Promoting First Relationships ® (PFR), a 10-week home visiting program.

The study included 247 families with 10–24-month-old children who had a recent, open Child Protective Services investigation of child maltreatment. Families were randomly assigned to receive either the 10-week, home visiting PFR service or a telephone-based, 3-call resource and referral (R&R) service.

Across post-intervention time points, parents in the PFR condition scored higher than families in the R&R condition in parent understanding of toddlers’ social emotional needs ( d = . 35) and observed parental sensitivity ( d = . 20).

Children in the PFR condition scored lower than children in the comparison condition on an observational measure of atypical affective communication ( d = . 19) and were less likely than children in the comparison group to be placed into foster care through one year post-intervention (6% vs. 13%, p = . 042).

No significant differences were found on measures of parenting stress or child social-emotional competence, behavior problems, or secure base behavior. Overall, the results show support for the promise of PFR as an intervention for enhancing parent sensitivity and preventing child removals for families in the child welfare system.

Keywords: Child protective services, home visiting, randomized clinical trial (RCT), parental sensitivity, child welfare, Promoting First Relationships Children aged birth to three make up one-third of cases that come to the attention of child welfare services (CWS) in the United States, a rate higher than any other age group ( U.S. Department of Health and Human Services, 2015 ).

Infants and toddlers are vulnerable to stressful experiences, especially maltreatment. Early-life adversities affect later-life morbidity and early mortality ( Shonkoff et al. , 2012 ).

Maltreated children who become clients in CWS experience pervasive adversity and chronic stress that produce not only short-term mental and physical health problems, but also long-term health disparities and inequalities ( Danese & McEwen, 2012 ; Jaffee & Christian, 2014 ; Shonkoff, Boyce, & McEwen, 2009 ). The primary mechanism for intervention with child maltreatment cases is through state-supported CWS.

Families reported for allegations of maltreatment to Child Protective Services (CPS) face a range of outcomes, including closed cases with no services, court-mandated family services, or removal of children from the home and placement in foster care. Removal, however, may compound the adverse consequences of prior maltreatment ( Newton, Litrownik, & Landsverk, 2000 ; Rubin, O’Reilly, Luan, & Localio, 2007 ).

Providing parental services to CWS families to prevent removal is, as Barth et al. (2005) note, “clearly a linchpin of governmental responsibility … to provide, preserve, maintain, or reunify families. …Effective CWS must rely on effective parent training and support–as this is the primary intervention that child welfare agencies provide in trying to preserve or reunify families.

” (p. 353). Promoting First Relationships ® Promoting First Relationships ® (PFR ; Kelly, Sandoval, Zuckerman, & Buehlman, 2003 ; 2008 ) is a 10-week, relationship- and strengths-based home visiting service that aims to help families facing adversity, including those involved in CWS.

PFR seeks to increase caregivers’ awareness of their children’s social and emotional needs, including their need for a sense of safety and security, as well as increasing caregivers’ understanding of their own needs as parents. Better recognition and response to the child’s needs supports the development of a more secure attachment ( Bowlby, 1969 ; 1982 ).

Infants rely on the parent as a source of comfort when fearful or distressed and as a base from which to explore their world. From this they develop a sense of “felt security” that attachment figures are trustworthy and responsive. PFR service providers are trained to focus on the relationship between the parent and child and become keen observers of this dyadic dance, or the lack thereof.

Providers employ these observational skills using video-based feedback with parents. The parent and child are recorded playing together five times during the 10-week PFR program. The PFR provider will then review a recorded play session with the parent, typically the week following the date on which the session was recorded.

The provider and parent reflect on the recorded interactions, noting what the child is doing in relation to the caregiver’s behavior and what the caregiver is doing in response to the child. PFR service providers are also trained to interact with families in a way that does not contribute to a caregiver’s shame, guilt, and/or defensiveness.

This model is based on the belief that in order to effectively facilitate change in parenting and to enhance the parent-child relationship, it is essential to first establish a relationship with the parent that enhances the parent’s own feelings of safety and security ( Crittenden, 2016 ; Graybeal, 2007 ; Larrieu & Zeanah, 2004 ).

Crittenden (2016) has argued that a “bridge” should be created between the maltreating parent and the service provider’s goals of protecting the child and improving parenting. Under conditions of perceived threat, a parent relies on defensive and self-protective strategies, and this can jeopardize a parent’s ability to integrate insights with behaviors and capacities.

Threats from social service providers range from the capacity to remove a child from the home to more subtle behaviors such as use of judgmental language, derogatory labels, and actions that humiliate a parent or increase his/her guilt or shame ( Crittenden, 2016 ).

Thus, addressing the interactive behavior of service providers, including their use of verbal and nonverbal communication, should be the cornerstone of any intervention serving CWS families. Promising results in quasi-experimental studies led to the first randomized control trial (RCT) of PFR.

This trial was conducted within the CWS system and enrolled foster parents, kin providers, and birth parents caring for toddlers recently placed with or returned to them.

Parents in the PFR condition showed post-intervention improvements compared to the control group in parent understanding of toddlers’ social emotional needs, parent report of child competence, and observed parental sensitivity ( Spieker, Oxford, Kelly, Nelson, & Fleming, 2012 ).

Permanency outcomes (adoption or guardianship) achieved without any care disruptions were significantly higher in the PFR condition ( Spieker, Oxford, & Fleming, 2014 ). Secondary analysis identified stronger positive effect sizes at 6-month follow-up on the subsample of dyads headed by birth parents, relative to the full sample results ( Oxford, Marcenko, Fleming, Lohr, & Spieker, 2016 ).

In this study we report on the second RCT of PFR, which involved families with 10–24-month-old infants and toddlers who had recently been reported to CPS with allegations of child maltreatment. Like its predecessor, this RCT was a “real-world” evaluation that relied on community-based service providers to deliver PFR.

Families were recruited through a partnership with Washington State Children’s Administration CPS and then randomized to the experimental or comparison conditions. We hypothesized that PFR, as delivered by community providers, would result in improved parenting and child social and emotional outcomes relative to the comparison condition in which families received phone-based resource and referral services.

Further, we hypothesized that those receiving PFR would experience better outcomes within the child welfare system, including a lower likelihood of the child being removed from parental care and placed into foster care. The current study looks at the Supporting Parents Program (SPP).

With approval from the Washington State Institutional Review Board, the SPP enrolled 247 birth parents with infants and toddlers between January 2011 and January 2014. The flow of participant recruitment, assignment, and completion of assessments is shown in Figure 1 .

Supporting Parents Program study flowchart Eligibility and recruitment Participants were eligible if they were conversant in English, had housing, and lived in Snohomish, southern Skagit, or northern King County in Washington State.

Participants also had to have a child between the ages of 10–24 months and an open case with an allegation of maltreatment of any type recorded in the database of the regional CPS office at least two weeks prior. In 31 instances the identified child in our target age range (10–24 months) was not the identified victim according to CPS reports.

A Department of Child and Family Services (DCFS) volunteer, trained for the purpose of the study, scanned the Washington State Dept. of Social and Health Services (DSHS) database on a monthly basis and created a list of potentially eligible families (N = 1,070). She then went down the list, contacting potential participants and describing the study in detail.

If the potential participant was eligible and interested in the study, permission was obtained to forward contact information to the research team. The DCFS volunteer continued contacting potentially eligible families on the list until 7–8 families were enrolled in the study per month. Once the study had reached the monthly enrollment quota, no more families were contacted until the following month.

Overall, 514 of the 1,070 potential families (48%) did not have an initial contact, primarily because they did not answer their phones or had disconnected phones, and only occasionally because the monthly quota had been reached. Among the 556 families contacted by phone, we found 172 (31%) were not eligible, reflecting the fact that database information was inaccurate or incomplete.

Of the 384 eligible families, 251 agreed to an initial in-home research visit. The study research visitor met with families to obtain written consent and conduct the research visit. An additional four families were determined to be ineligible during these visits.

For those eligible, the study consent form was read to and discussed with parents to ensure they were aware that participation was voluntary, that the study did not fulfill any family service requirements by DSHS, and that subject incentives were for the research visits only. Study family compensation increased from $50 to $100 across the research visits for a total of $300 for all four assessments.

One parent and one child from each family were the primary participants in the interventions and were assessed at four time points (see Measures and Procedures for details). Following the first research visit, families were randomized to receive PFR (n =124) or the Resource and Referral (R&R) program (n =123), using a computer randomization program that blocked families based on race and ethnicity.

According to DSHS records, the 247 study families were similar to the 823 potential families identified in the DSHS database and not enrolled in terms of race, χ 2 (5, N = 1070) = 8. 10, p =. 15, and Hispanic ethnicity, χ 2 (2, N = 1070) = 1.

81, p = . 40. For the 216 families in which the enrolled child was the alleged victim of maltreatment according to CWS records, the mean number of weeks between initial allegation and enrollment in the research project was 8.

17 ( SD = 32. 46) and did not differ by condition, R&R: M ( SD ) = 7. 38 (33.

76); PFR: M ( SD ) = 8. 92 (31. 28); t (211) = 0.

35, p = . 729. Information on demographic and other baseline characteristics is shown by condition in Table 1 .

Among all the variables listed in Table 1 , there were no statistically significant (p< . 05) differences by condition. Baseline characteristics by intervention condition American Indian or Alaska Native American Indian or Alaska Native Neither high school graduate nor GED Other (disability/retired) Parent lives with spouse/partner Other children in the household Child age in months at baseline Past year household income ($) Notes.

R&R = Resource and Referral, PFR = Promoting First Relationships, GED = General Education Diploma. Promoting First Relationships® (PFR) Intervention Components The manualized Promoting First Relationships ® intervention was delivered by two providers from a community agency. Both providers were female, Caucasian, and had Master’s degrees in social work or counseling.

The providers completed PFR training over a five-month period and, after becoming certified, began meeting with study families. Throughout the study, fidelity was monitored by a PFR master trainer ( Oxford, Spieker, Lohr, Fleming, Dillon, & Rees, 2016 ).

The providers submitted videotapes of themselves working with the families (one videotaped session for each family on their caseload), which the master trainer used to rate the quality of delivery on a 1–5 scale. If a provider did not maintain fidelity (i.e., received a rating < 4 for a videotaped session), she received additional one-on-one mentoring until her fidelity to PFR was re-established.

The PFR training model also included weekly reflective practice group sessions, facilitated by a PFR consultant, to support providers in their work with vulnerable families which was often stressful.

After completing the PFR program, the families were given a 10-item questionnaire to evaluate their experience with the intervention (satisfaction, effectiveness, overall experience, usefulness, relevance), the provider (attentive, warm, affirming, sensitive), and their recommendation of PFR. The response rate was 78. 5%, and the internal consistency of the scale was good (α = .

77). PFR participants rated PFR very highly ( M = 3. 9, SD =.

2; range = 1–4, higher scores = greater satisfaction), and all would recommend the program ( Oxford, Spieker, et al. , 2016 ). Resource and Referral (R&R) Intervention Components The R&R program was delivered over the phone in three sessions.

A social service provider conducted a 30-minute needs assessment, mailed a packet of personalized information, and followed up with two 10-minute check-in calls. The main needs identified by study families were financial support, education, household items, housing, and parenting support. A standard resource list, developed by the study, was sent to each R&R family containing information on over 150 local services.

In addition, the social service provider included an average of six specific resources for each individual family (range = 0–15). Completion rates for the two interventions were high. In the PFR condition, 86% received a full course of ten sessions.

In the R&R condition, 89% had all three telephone sessions. Most of the families were able to begin the interventions: only 7% of the PFR families and 3% of the R&R families had no intervention sessions. Of those who started the PFR intervention, 7% missed between 1–9 sessions, and in R&R 10% missed 1 or 2 sessions.

The mean number of weeks required for completion of PFR was monitored and the R&R intervention was timed such that the average time from first to last intervention visit was equivalent, R&R: M ( SD ) = 14. 1 (3. 2), range = 7–35; PFR: M ( SD ) = 14.

3 (5. 4) ), range = 5–36; t (213) = 0. 23, p = .

82. Infants and their caregivers were assessed in 2-hour, in-home research visits at baseline, immediately after completion of the intervention (i.e., post-intervention), and at the 3- and 6-month post-intervention follow-ups. Assessments were conducted by study research visitors who had MSW degrees, were kept blind to intervention assignment, and whose offices were not near the PFR or R&R intervention staff.

Visits included the following elements: interview questions, self-report questionnaires, videotaped caregiver-child interactions of free play, a teaching task, and a brief separation procedure.

Although the mean number of weeks spent completing the intervention did not differ between the conditions, the actual number of weeks between baseline assessment and the post-intervention assessment was greater for dyads in the PFR condition, R&R: M ( SD ) = 16. 64 (3. 51); PFR: M ( SD ) = 18.

47 (6. 82); t (177) = 2. 54, p < .

05, because it took longer to schedule and complete the first PFR in-home intervention session compared to the first R&R phone session. Time between baseline and post-intervention follow-up was thus included as a covariate in analyses. A child that experienced a caregiver change following the intervention completed later assessments with the new caregiver.

Over the course of the study, 14 new, non-birth parent caregivers were enrolled and completed study procedures with the study child in their custody. For the analyses of intervention effects, data for post-intervention and follow-up time points come from visits with child-parent dyads that remained intact since baseline (see Figure 1 ). Analyses examining removals include the full sample of children.

There were few differences between dyads that remained intact and completed follow-up interviews compared to families that were not intact and/or did not complete follow-up interviews. At none of the four follow-up time points were there statistically significant differences by completion status on any of the sociodemographic variables listed in Table 1 .

Understanding of toddlers was measured by the Raising a Baby scale (RAB; Kelly, Korfmacher, & Buehlman, 2008 ) at the post-intervention and 6-month follow-ups. The RAB is a measure of caregiver knowledge of infant and toddler social emotional needs and developmentally appropriate expectations. Caregivers rated RAB items on a 4-point scale ( strongly agree to strongly disagree ) (16 items; alphas ranged from .

73–. 77). Higher scores indicate greater parental knowledge.

Parent sensitivity was measured at all four time points by a modified total score of the Nursing Child Assessment Teaching Scale (NCATS; Barnard, 1994 ), a videotaped interaction to assess caregiver sensitivity, stimulation of the child, and emotional responsiveness and contingent interactions between the parent and child. The scale was modified from the original measure to exclude some items that demonstrated low variability.

A total score was based on 45 items that covered mutuality (e.g. contingency, gaze, and positive affect), caregiver verbal and nonverbal support of child, and sensitive instruction during the teaching task. Items were scored yes (1) or no (0), and yes scores were summed. Cronbach’s alpha ranged from .

68–. 72, reflecting that the total sensitivity score covers a multidimensional construct. A single, blinded coder was trained to reliability by a certified NCATS instructor and passed regular reliability checks.

Parenting stress was measured by scales selected from the Parenting Stress Index and the Parenting Stress Index-Short Form (PSI-3, PSI-SF; Abidin, 1995 ). The Parent-Child Dysfunctional Interaction Scale from the PSI-SF (11 items) and the Parenting Competence Scale from the PSI-3 (11 items) were used. Items were rated on 4-point scales ( strongly agree to strongly disagree ).

Two items measuring parental educational attainment from the original parenting competence scale were omitted due to excessive missing data. Higher scores indicate greater parental stress associated with feelings of incompetence or dysfunctional parent-child interactions (i.e., interactions are not reinforcing or satisfying). Alphas ranged from .

71–. 94 across the two measures and across time points. Child social-emotional competence (11 items; alphas = .

69–. 70) and behavior problems (31 items; alphas =. 77–.

79) were measured by the Brief Infant Toddler Social and Emotional Assessment (BITSEA; Briggs-Gowan & Carter, 2002 ). Descriptions of positive and problematic social-emotional behaviors in the last month were rated on a 3-point scale ( not true/rarely; somewhat true/sometimes; very true/often ).

At baseline and again at the 3-month follow-up, blinded research visitors rated the child's behavior during administration of a standardized developmental test using the Bayley Behavior Rating Scales (BRS; Bayley 1993 ). Seven items in the BRS comprise the emotion regulation scale and capture how well the child adapts to challenging stimuli and frustration (alphas = . 79–.

83). Engagement/exploration consists of six items rated for exploratory behavior in the testing situation (alphas = . 75–.

76). Secure base behavior and atypical, affective communication were measured with the Toddler Attachment Sort-45 (TAS-45; Kirkland, Bimler, Drawneek, McKim, & Schölmerich, 2004 ).

The TAS-45 is based on 39 items from the Attachment Q-Sort (AQS; Waters, 1987 ), an attachment measure that has been extensively validated ( van IJzendoorn, Vereijken, Bakermans-Kranenburg, & Riksen-Walraven, 2004 ), plus six additional items tapping atypical, affective communication. Because we were dissatisfied with the TAS-45 trilemma scoring system used in our previous study ( Spieker et al.

, 2012 ), in this study we applied the five-pile sorting procedure that produced good psychometrics for an overall TAS-45 security score in the Early Childhood Longitudinal Study –Birth Cohort (ECLS-B) ( Andreassen, Fletcher, & Park, 2006 ).

Immediately after research home visits, the research visitors sorted cards for 45 descriptive statements of child attachment behavior into five piles representing “most like” to “least like” the child. A maximum of 18 cards could be placed in one pile. Item rankings were then used to calculate an overall security score and the orthogonal ‘D hotspot’ scale representing atypical affective communication.

Four research study visitors were trained over the course of the study to score the TAS-45 by taking into consideration the child’s behavior during home visits. These visits included a brief separation procedure in which the caregiver was instructed to play with the child for a minute, say good-bye, leave the home for three minutes, and then return. The research study visitor did not interact with the child during the separation.

To assess reliability across the project, 88 videotaped sessions were coded by pairs of raters. Inter-rater reliability was r = . 75 for security and r = .

79 for the D hotspot scale. Reliability was monitored and maintained during monthly meetings of the research study visitors and coinvestigator, when videotapes of parent-child interactions were coded and discussed. Information on allegations of child maltreatment after enrollment in the project and removals from the birth parent home was based on official CWS records obtained in September, 2015.

For each child in the study, we obtained records of new maltreatment allegations and CWS-initiated removals that occurred between baseline and 12 months after the child’s parent completed the PFR or R&R interventions.

For cases where the parent did not start or did not fully complete the intervention, we obtained information on allegations and removals that occurred within 12 months of when the parent would have completed the intervention if the parent had done so on schedule.

To assess PFR effects on all parent-report and observational measures, we used models that examined differences based on measures from post-intervention time points, adjusting for baseline score on the given measure, age of child at baseline, and months between baseline and post-intervention assessment.

For measures assessed at only one post-intervention time point (i.e., the two Bayley BRS scales), we used regression models with the post-intervention measurement as the measured, manifest dependent variable. For measures assessed at multiple post-intervention time points, mixed models were estimated in which post-intervention scores were nested within dyads.

The intercept (representing the average score across post-intervention time points) was modeled as having a random effect at the dyad level. The intercept in the mixed model was regressed on intervention condition (R&R = 0, PFR = 1) and covariates.

We also ran models that included an effect of time (with loadings of −1, 0, and 1 for the post-intervention, 3-month, and 6-month follow-up time points, respectively) and the interaction between time and intervention condition.

In none of the models were intervention effects on post-intervention slope (i.e., change across the three post-intervention time points) statistically significant, nor did modeling the slope and slope-by-intervention condition change the estimated effects of intervention on intercepts in terms of direction or significance level.

In no models was the variance of the random effect of time statistically significant, suggesting that there was little variability across dyads in linear change across the three time points. Thus, we present below the estimates for simpler models without the time effect.

We present both unstandardized intervention effects from these models and standardized effect sizes ( d ) based on re-running the models using standardized scores for the outcomes ( Lipsey & Wilson, 2001 ). Models were estimated using Mplus 7. 31 ( Muthén & Muthén, 1998–2015 ).

Full Information Maximum Likelihood (FIML) estimation allowed for inclusion of all cases, even those with partially missing data, although estimates are primarily informed by data on dyads that stayed intact through follow-up and completed follow-up assessments.

A small number of cases (< 5) had missing data on some baseline measures and, of intact dyads that completed follow-up assessments, missing data on particular measures were minimal (< 2%). FIML estimation makes the assumption that data were missing at random after taking modeled variables into account ( Graham, 2009 ). To assess intervention effects on allegations and child removals, we used continuous time survival models.

These models assess the effect of PFR on the likelihood of an allegation or the child being removed from the home from baseline through one year post-intervention. For children who were not removed from the home, survival model data were right censored at one year post-intervention completion, which is approximately 15 months post-baseline (i.e., the date beyond which we did not have CWS records).

The survival models included child age at baseline as a covariate. Means by condition on all continuous measures at all time points are shown in Table 2 . Difference of means tests indicate one statistically significant difference at baseline , with R&R dyads receiving higher scores on NCATS parenting sensitivity, t (244) = 2.

01, p < . 05. Means and standard deviations by experimental condition at four assessment time points by intervention condition.

Parent understanding of toddlers Parenting stress: dysfunctional interaction Parenting stress: competence a Child social-emotional competence Child engagement/exploration Child secure base behavior Child atypical, affective communication Notes. R&R = Resource and Referral, PFR = Promoting First Relationships. a Higher scores indicate feeling a lack of competence.

Estimates of PFR effects on measures post-intervention are shown in Table 3 . PFR had a positive and statistically significant effect on parent understanding of toddlers (RAB). The effect was equivalent to .

35 standard deviations on the measure, with parents in the PFR condition scoring higher than parents in the R&R condition. Although parents in the PFR condition scored significantly lower than R&R parents in observed sensitivity at baseline, parents in the PFR condition scored higher at all three post-intervention time points.

The estimated effect of PFR in the mixed model was equivalent to a fifth of a standard deviation in the outcome. Differences on parent-child interactions and parent feeling of competence as reported on the PSI were not different across condition.

Child behavioral outcomes as measured both by the parent-reports and study research visitor observational ratings of emotion-regulation and engagement/exploration on the Bayley Behavior Rating Scale, and secure base behavior on the TAS-45, also showed no evidence of PFR effects.

Differences on the observation of atypical affective communication were statistically significant, with children in the PFR condition scoring a fifth of a standard deviation lower than children in the R&R condition.

Estimates of effects of PFR on post-intervention scores Unstandardized PFR effect Parent understanding of toddlers Parenting stress: dysfunctional interaction Parenting stress: competence a Child social-emotional competence Child exploration/engagement Child secure base behavior Child atypical affective communication Notes.

B = effect of PFR on post-intervention scores; SE = standard error; d = effect size (effect of PFR in outcome standard deviation units). A positive d indicates a beneficial effect of PFR. For outcomes measured at two or three post-intervention time points, the PFR effect is based on estimates from mixed models with post-intervention time points nested within individuals.

For outcomes measured at one post-intervention time point, PFR is based on estimates from a linear regression model. Effect size ( d ) based on effect estimate from models using standardized outcome scores. a Higher scores indicate feeling a lack of competence.

Between enrollment and one year post-intervention, there were new allegations for 36 (29. 0%) children in the PFR condition and 42 (31. 6%) in the R&R condition.

Survival models indicated that chances of a new allegation did not differ significantly by condition, Hazard ratio = 1. 14; p = . 577; 95% Confidence Interval (CI) = 0.

72–1. 79. Children in the PFR condition were, however, less likely to be removed from a birth parent’s home.

Within one year post-intervention, 7 (5. 6%) children in the PFR condition had been removed from the home compared to 16 (13. 0%) children in the R&R condition.

Survival models indicated that chances of removal from the birth parent home were 2. 5 times greater for children in the R&R condition than children in the PFR condition at any given time, Hazard ratio = 2. 50; p = .

043; 95% CI = 1. 03–6. 10.

The cumulative difference in removals is shown in Figure 2 . Cumulative proportion removed from birth parent home after baseline by condition This study is part of an ongoing program of research on the effectiveness of the Promoting First Relationships ® (PFR) intervention in improving parent sensitivity, parent knowledge of child development, child secure base behavior, child social and emotional outcomes, and child welfare outcomes.

As in our prior RCT of PFR with families in new child welfare placements, we found evidence that PFR increases a caregiver’s knowledge of toddler social emotional needs and, based on an observational instrument, improves caregiver sensitivity to child cues and ability to engage in responsive interactions with children, relative to parents in the comparison condition.

These findings increase our confidence that PFR has beneficial effects on proximal outcomes of parent knowledge and parent sensitivity. We also found an important difference in child welfare experiences. All families in the current study had drawn attention from the child welfare system due to allegations of maltreatment, primarily of the child in our study or of a sibling while the