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Promoting First Relationships

A training program for service providers in the use of effective strategies for promoting secure and healthy relationships between caregivers and young children birth to three years of age.

Program Outcomes

  • Reciprocal Parent-Child Warmth

Program Type

  • Foster Care and Family Prevention
  • Home Visitation
  • Parent Training

Program Setting

  • Home
  • Mental Health/Treatment Center

Continuum of Intervention

  • Indicated Prevention
  • Selective Prevention

Age

  • Infant (0-2)

Gender

  • Both

Race/Ethnicity

  • All

Endorsements

Blueprints: Promising

Program Information Contact

Jennifer Rees, Program and Training Manager
University of Washington
CHDD South Building Room 212
Box 357920
Seattle, WA 98195
rees@uw.edu
206-616-5380

Program Developer/Owner

Monica Oxford, MSW, Ph.D.
University of Washington


Brief Description of the Program

Promoting First Relationship® trains workers in early intervention, community mental health, home visiting and early care and education settings to deliver a home visiting program based on infant mental health principles. Promoting First Relationships® is strengths based. It uses joint observation and reflection on videotaped caregiver-child interactions to increase caregivers' confidence and competence. Providers support caregivers' ability to read their child's nonverbal cues, empathize with and provide comfort when their child is distressed, and understand that their child's difficult behavior may reflect underlying social and emotional needs. The program is delivered in the home to caregivers and children (birth to 3 years of age) in 10 weekly sessions of 60-75 minutes. The program model requires that providers receive regular reflective consultation.

Outcomes

Spieker et al. (Study 1, 2012) showed significant improvement among children in the treatment group as compared to the control group at posttest in:

  • Caregiver perception of competence, though this effect was no longer present at a 6-month follow-up assessment.
  • Parent sensitivity, a measure of reciprocal parent-child warmth (though this effect was not sustained 6 months later)
  • Parent understanding of toddler social emotional needs and developmental expectations (which also was not sustained 6 months later)

Oxford, Spieker et al. (Study 2, 2016) found significant improvement in the treatment group, as compared to the control group for:

  • Child atypical affective communication (a risk factor)
  • Parent understanding of toddlers (only at posttest and 6-month follow-up)
  • Parent sensitivity, also a measure of reciprocal parent-child warmth (only at 6-month follow up)
  • Chances of removal from the birth parent home within one-year post intervention
Booth-LaForce et al. (Study 3 in press) found that, at the immediate posttest, compared to the control group, participants in the treatment group showed improved: 
  • Quality and contingent responsiveness of caregiver-child interactions
  • Knowledge of toddlers' social and emotional needs and level of developmentally appropriate expectations.

Brief Evaluation Methodology

Spieker et al. (Study 1, 2012) randomly assigned infant-caregiver dyads to either the Promoting First Relationships treatment program or a control group receiving another home visitation program. All participating infants had experienced a court-ordered change in caregiver and were referred by a state agency. The study assessed child behaviors and security and caregiver sensitivity and support at baseline, posttest, and 6 months after completion of the program. Using the same sample, Spieker et al. (2014) analyzed caregiver stability and permanency outcomes of children 2 years after they had enrolled in the study, and Pasalich et al. (2016) conducted additional moderation analyses. Meanwhile, two studies (Nelson & Spieker, 2013; Oxford et al., 2013) used a subsample of the dyads randomized in the Spieker et al. (2012) study to examine additional outcomes, including infant/toddler stress and sleep problems.

Oxford, Spieker et al. (Study 2, 2016) randomly assigned infant-caregiver dyads to either the Promoting First Relationships treatment program or to a control group receiving phone consultations and information on resources. All participating parents had been reported to child protective services for child maltreatment. The study assessed child and caregiver behaviors at baseline, posttest, 3-month follow-up, and 6-month follow-up.

Booth-LaForce et al. (Study 3, in press) randomly assigned 34 primary caregivers living on or near an American Indian reservation with their toddlers aged 10-30 months to either a treatment or waitlist control group. Measures of child and caregiver behaviors were collected at baseline and immediately after the intervention.

Study 2

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, 267-277.


Risk Factors

Family: Parent stress


* Risk/Protective Factor was significantly impacted by the program

Race/Ethnicity/Gender Details

The studies (Spieker et al., 2012; Oxford, Spieker et al., 2016; Booth-LaForce et al., in press) did not provide differential analysis by race/ethnicity or gender.

Promoting First Relationships® (PFR) includes 2 levels of training. Level 1 is a prerequisite for Level 2. The studies certified by Blueprints included service providers with Level 2 training.

Level 1-- Knowledge Building:

This two-day workshop is designed to give service providers knowledge about using Promoting First Relationships® within one's own practice. The workshop is taught by PFR Master Trainers and includes the curriculum, parent handouts, and training in the following:

  • Elements of a Healthy Relationship
  • Attachment Theory and Secure Relationships
  • Reflective Capacity Building
  • Development of Self for Infants and Toddlers
  • PFR Consultation Strategies
  • Challenging Behaviors
  • Intervention Planning Development

Level 2 -- Skill Building (Provider Level):

In the mentored distance learning, participants work individually or in pairs with a PFR Master Trainer.

  • First 5 weeks: Trainees view professionally filmed PFR intervention sessions with caregivers (parents and child care providers) and young children (infant, toddler, special needs). The videos were developed and narrated by Dr. Jean Kelly, PFR founder. After viewing two videos at a time, trainees and their PFR Master Trainer will meet every week online to reflect on the filmed sessions and the PFR infant mental health essentials.
  • Next 10 weeks: Trainees are mentored weekly online as they intervene with caregiver/child dyads at their own sites. Sessions include reflection on videos of the dyadic interactions that trainees upload to a secure website, and discussion about how to implement PFR concepts and consultation strategies.

Training Certification Process

Level 3 -- Agency Trainer Level Training (by invitation only):

Individuals who have successfully completed the Level 2 training, may participate in an Agency Trainer Level Training (Level 3), by invitation only. This training certifies individuals to provide Level 2 trainings to service providers within their own agencies per the Agency Trainer Guidelines.

  • First 3 weeks: Participants view parent-child observation videos to hone observation skills and practice applying PFR concepts. Additional readings cover topics in attachment, understanding children's behavior through a social-emotional lens, and providing reflective consultation. Trainees meet weekly with their PFR Master Trainer to discuss this content.
  • Next 10 weeks: Trainees are mentored weekly as they intervene with a second caregiver/child dyad at their own site. Trainees will increase skills in providing the PFR intervention as they gain experience with an additional dyad.
  • Agency Trainers receive 2 sessions after completing their second family to prepare them to train others within their agency.

Program Benefits (per individual): $763
Program Costs (per individual): $1,330
Net Present Value (Benefits minus Costs, per individual): ($566)
Measured Risk (odds of a positive Net Present Value): 47%

Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.

Start-Up Costs

Initial Training and Technical Assistance

Level 1 (Learner's Workshop): $425 per person for 2-day workshop in Seattle, WA.

Level 2 (Distance Learning): $2,150 per person when training as part of a pair group. $3,000 per person if trainee is a stand-alone individual (not part of a pair group). Conducted over 15 weeks and includes 16 contact hours (online) with a master trainer and the initial certification fee. Prerequisite is Level 1.

Note: The Blueprints certified studies included service providers with Level 2 training.

Curriculum and Materials

  • Curriculum is included in initial training costs.
  • $115 for supplemental materials including BabyCues video and cards, social emotional cards, and parent/caregiver video.
  • Additional fee for Spanish handouts ($25.00).

Licensing

None.

Other Start-Up Costs

  • Staff time and travel for trainings: Level 1 Workshop -- FTE 16 hours of release time, plus travel if needed. Level 2 Distance Learning -- FTE 24 hours of release time over the course of 5 months, plus transportation and mileage reimbursement for traveling to home of training practice family.
  • Internet access with high speed internet, webcam, access to ZOOM, office with a door for confidentiality.
  • Tablet or camera/laptop to take to families' homes for recording the parent-child interaction during play and playing the video back with the parent.
  • Toys (optional). Age-appropriate toys for parent and child to use during visit.

Intervention Implementation Costs

Ongoing Curriculum and Materials

None (though it may be necessary to replace toys periodically).

Staffing

Delivered as a home visit. Average home visit is one hour plus travel time and prep time. Estimated 2 hours per family per week over 10 weeks-20 hours FTE per family. Varies depending on time for travel.

Other Implementation Costs

  • Ongoing internet access; photo copy machine to copy handouts.
  • Program is designed to be delivered in the homes of families, though it can be used in a clinic. When delivered as a home visit, transportation costs are estimated at 10 visits per family multiplied by the mileage and the mileage reimbursement rate.
  • Confidential office space is recommended for viewing videos and receiving reflective practice supervision.

Implementation Support and Fidelity Monitoring Costs

Ongoing Training and Technical Assistance

None.

Fidelity Monitoring and Evaluation

$125 per year to reassess fidelity. Videos are sent to the program for coding and review. If the provider does not reach fidelity, he/she can get additional support.

Ongoing License Fees

None.

Other Implementation Support and Fidelity Monitoring Costs

No information is available

Other Cost Considerations

No information is available

Year One Cost Example

In this example, an agency uses four providers to deliver Promoting First Relationships® to client families. Each provider serves 20 families in the first year. At two hours per family, on average, and 20 families per year per provider, the average FTE for each provider required to serve 20 families is 0.20. The agency uses its own office space for training and video review. Equipment and travel expenses (for in-home visits) are not included here as they may vary substantially by location.

Level 1 Training: 4 x $425 $1,700.00
Travel to Level 1 Training: 4 x $1,000 $4,000.00
Level 2 Training: 4 x $2,150 $8,600.00
BabyCues video and cards, PFR parent/caregiver video and social/emotional cards: 4 x $115 $460.00
Annual Fidelity Monitoring: 4 x $125 $500.00
Total One Year Cost $15,260.00

The four providers collectively deliver the program to 80 families in the first year. Thus, the Year 1 per family expense is $190.75 (does not incude costs for travel or toys--toys are optional). The costs for subsequent years would be substantially reduced as most of the expense involves training.

Funding Overview

Promoting First Relationships® (PFR) is a home visiting program that offers early intervention services to promote healthy attachment and development for infants who have had a change in their primary caregiver. Federal funding streams aimed at promoting healthy development of young children and preventing child abuse, including Medicaid, Title V, IDEA Part C, and Title IV-B Child Welfare Services, can support Promoting First Relationships®. State funds allocated for child welfare services can also support Promoting First Relationships. Finally, the Affordable Care Act made an historic investment in home visiting, allocating $1.5 billion to support states in implementing evidence-based home visiting programs through the Maternal, infant and Early Childhood Home Visiting Program.

Allocating State or Local General Funds

In addition to commitments of state general fund dollars for Medicaid match, many states allocate state and county funds to support preventive child welfare services. These dollars are an important source of support for Promoting First Relationships®.

Maximizing Federal Funds

Entitlements:

Medicaid: If the intervention is delivered by Medicaid-eligible providers, the program can potentially be billed as a Medicaid therapeutic service, or through targeted case management services under Medicaid. Whether Medicaid billing is an option depends on the state Medicaid plan.

Formula Funds:

  • Maternal, Infant, and Early Childhood Home Visiting Grants - The Affordable Care Act created a dedicated funding stream to support evidence-based home visiting programs. Funds flow to a state agency designated by the governor to administer the program, which then assesses needs and administers funds to local communities.
  • Title V Maternal and Child Health Block Grant, which funds public health activities aimed at supporting healthy pregnancy and early childhood.
  • Title IV-B Child Welfare Services grant which can be used to fund child abuse prevention activities and family preservation services.
  • IDEA Part C: Early Intervention Services for Infants and Toddlers with Disabilities that supports early intervention services for children 0 - 3 with developmental delays or disabilities. Staff implementing EI services can be trained to deliver the PFR model.
  • Temporary Assistance for Needy Families which is the core funding stream dedicated to providing income support for low income families and can also be used fairly flexibly by states to support four key goals, including assisting needy families so children can be cared for in their own homes.

Discretionary Grants: There are many federal discretionary grants supporting child welfare and early care and education that can potentially support PFR, including programs within SAMHSA, the Department of Education and the Children's Bureau within DHHS.

Foundation Grants and Public-Private Partnerships

Foundations that prioritize investments in child welfare services and healthy early childhood development are good targets for investing in PFR. Local United Ways that invest in home visiting programs and child welfare have also supported PFR.

Generating New Revenue

Many states have Children's Trust Funds that are supported with dedicated revenue streams from license plates, commemorative documents and tax form check-offs. Children's Trust Funds support child abuse prevention services and are a potential source of support for PFR.

Program Developer/Owner

Monica Oxford, MSW, Ph.D.Research Professor, Family and Child NursingUniversity of WashingtonBOX 357920Seattle, Washington 206-685-6107mloxford@uw.edu

Program Outcomes

  • Reciprocal Parent-Child Warmth

Program Specifics

Program Type

  • Foster Care and Family Prevention
  • Home Visitation
  • Parent Training

Program Setting

  • Home
  • Mental Health/Treatment Center

Continuum of Intervention

  • Indicated Prevention
  • Selective Prevention

Program Goals

A training program for service providers in the use of effective strategies for promoting secure and healthy relationships between caregivers and young children birth to three years of age.

Population Demographics

The program targets infants and toddlers (birth to three) who are at elevated risk for child maltreatment or who have experienced a court-ordered change in caregiver.

Target Population

Age

  • Infant (0-2)

Gender

  • Both

Race/Ethnicity

  • All

Race/Ethnicity/Gender Details

The studies (Spieker et al., 2012; Oxford, Spieker et al., 2016; Booth-LaForce et al., in press) did not provide differential analysis by race/ethnicity or gender.

Other Risk and Protective Factors

Caregivers who exhibit sensitivity to children, offer support, express commitment, understand children, and experience less stress are more likely to have positive relationships with children.

Risk/Protective Factor Domain

  • Family

Risk/Protective Factors

Risk Factors

Family: Parent stress

Protective Factors


*Risk/Protective Factor was significantly impacted by the program

Brief Description of the Program

Promoting First Relationship® trains workers in early intervention, community mental health, home visiting and early care and education settings to deliver a home visiting program based on infant mental health principles. Promoting First Relationships® is strengths based. It uses joint observation and reflection on videotaped caregiver-child interactions to increase caregivers' confidence and competence. Providers support caregivers' ability to read their child's nonverbal cues, empathize with and provide comfort when their child is distressed, and understand that their child's difficult behavior may reflect underlying social and emotional needs. The program is delivered in the home to caregivers and children (birth to 3 years of age) in 10 weekly sessions of 60-75 minutes. The program model requires that providers receive regular reflective consultation.

Description of the Program

Promoting First Relationships® is an attachment-based, strengths based mental health training program for workers in early intervention, community mental health, home visiting and early care and education settings. It is designed to increase caregiver sensitivity and responsivity by helping caregivers identify possible "miscues," empathize with the child's underlying distress, and understand the child's behavior as reflecting an unmet need. A better understanding of cues is expected to then lead to more responsive, nurturing care. In addition, the program addresses the fact that infants and toddlers in child welfare may give behavioral signals that lead even nurturing caregivers to provide non-nurturing care. The program is delivered in the home to caregivers and children (birth to 3 years of age) in 10 weekly sessions of 60-75 minutes. Videotaping the dyad and reflective observations of the videotaped sessions occur on alternate weeks, for a total of five video reflective sessions. Promoting First Relationships® uses reflective practice principals with video feedback to focus on the deeper emotional feelings and needs underlying difficulties in the parent and child relationship and to help caregivers think about their child's developing mind. Learning materials include handouts, worksheets, and 'Thoughts for the Week' that are used in a flexible, adaptive manner to fit the needs of the dyad. These cover topics such as strategies for calming ourselves and our children, how to meet the socioemotional needs of young children, understanding and responding to challenging behavior, and recognizing the need for young children to feel safe and secure in their relationships with their caregivers.

Spieker et al. (2012) focused on children in foster care and Oxford, Spieker et al. (2016) enrolled families referred to child protective services. Booth-LaForce et al. (in press), however, tested the program in American Indian families living on a rural reservation. Authors adapted the program based on focus groups with community members and staff input to align with the tribe's cultural practices and preferences and hired and trained Native members of the tribal community who lived on the reservation to assist with implementation. Only those aspects of the program were adapted that could increase cultural relevance while maintaining core principles and components. This included: (1) creating a unique name for the study, (2) commissioning an appropriate study logy by a Native artist, (3) lengthening each home visit to include more time for conversation, (4) providing a small gift for the child at each research visit, and (5) adding one handout about caregiver-child transitions and separations.

Theoretical Rationale

Attachment formation is vital to child development and may be difficult for children who have experienced a change in primary caregiver; a lack of caregiver attachment can lead to problem behaviors and mental health issues.

Theoretical Orientation

  • Attachment - Bonding

Brief Evaluation Methodology

Spieker et al. (Study 1, 2012) randomly assigned infant-caregiver dyads to either the Promoting First Relationships treatment program or a control group receiving another home visitation program. All participating infants had experienced a court-ordered change in caregiver and were referred by a state agency. The study assessed child behaviors and security and caregiver sensitivity and support at baseline, posttest, and 6 months after completion of the program. Using the same sample, Spieker et al. (2014) analyzed caregiver stability and permanency outcomes of children 2 years after they had enrolled in the study, and Pasalich et al. (2016) conducted additional moderation analyses. Meanwhile, two studies (Nelson & Spieker, 2013; Oxford et al., 2013) used a subsample of the dyads randomized in the Spieker et al. (2012) study to examine additional outcomes, including infant/toddler stress and sleep problems.

Oxford, Spieker et al. (Study 2, 2016) randomly assigned infant-caregiver dyads to either the Promoting First Relationships treatment program or to a control group receiving phone consultations and information on resources. All participating parents had been reported to child protective services for child maltreatment. The study assessed child and caregiver behaviors at baseline, posttest, 3-month follow-up, and 6-month follow-up.

Booth-LaForce et al. (Study 3, in press) randomly assigned 34 primary caregivers living on or near an American Indian reservation with their toddlers aged 10-30 months to either a treatment or waitlist control group. Measures of child and caregiver behaviors were collected at baseline and immediately after the intervention.

Outcomes (Brief, over all studies)

Spieker et al. (Study 1, 2012) found caregivers in the treatment group reported greater child competence at posttest, but this result was no longer significant at a 6-month follow up assessment. The study found an effect for parent sensitivity (a measure of reciprocal parent-child warmth) at baseline and 3-month follow up but no effect after 6 months. Additionally, a significant effect was found at baseline for parent understanding of toddler social emotional needs and developmental expectations; this effect did not hold by the 6-month follow-up. Two years after enrollment in the study, Spieker et al. (2014) found no overall effect of the intervention on stability (i.e., placement with no interruptions or disruptions) or permanency (i.e., a stable placement ending with a legal discharge to the study caregiver).

Oxford, Spieker et al. (Study 2, 2016) found no effect for child behavioral outcomes but a small effect for child atypical affective communication (a risk factor). In addition, there were significant effects on 2 of 4 caregiver outcomes, both of which measured reciprocal parent-child warmth: 1) parent understanding of toddlers (assessed only at posttest and 6-month follow-up); and 2) parent sensitivity (only at 6-month follow up). In addition, within one-year post intervention, chances of removal from the birth parent home were greater for children in the control condition than children in the treatment condition at any given time.

Booth-LaForce et al. (Study 3, in press) found significant effects on 3 of 7 outcomes. Compared to controls, participants in the treatment group showed improved 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 across conditions.

 

Outcomes

Spieker et al. (Study 1, 2012) showed significant improvement among children in the treatment group as compared to the control group at posttest in:

  • Caregiver perception of competence, though this effect was no longer present at a 6-month follow-up assessment.
  • Parent sensitivity, a measure of reciprocal parent-child warmth (though this effect was not sustained 6 months later)
  • Parent understanding of toddler social emotional needs and developmental expectations (which also was not sustained 6 months later)

Oxford, Spieker et al. (Study 2, 2016) found significant improvement in the treatment group, as compared to the control group for:

  • Child atypical affective communication (a risk factor)
  • Parent understanding of toddlers (only at posttest and 6-month follow-up)
  • Parent sensitivity, also a measure of reciprocal parent-child warmth (only at 6-month follow up)
  • Chances of removal from the birth parent home within one-year post intervention
Booth-LaForce et al. (Study 3 in press) found that, at the immediate posttest, compared to the control group, participants in the treatment group showed improved: 
  • Quality and contingent responsiveness of caregiver-child interactions
  • Knowledge of toddlers' social and emotional needs and level of developmentally appropriate expectations.

Mediating Effects

Using a sub-sample of the dyads randomized in the Spieker et al. (2012) study, Oxford et al. (2013) found that toddlers in the treatment group showed a greater decrease, on average, in separation distress scores and toddlers with less separation distress had fewer sleep problems.

Effect Size

Spieker et al. (2012) reported a small-medium (d = .29-.41) - whereas Oxford, Spieker et al. (2016) reported a small (d = .20) - effect size for the parent sensitivity outcome. Meanwhile, Oxford et al. (2016) reported a medium effect size (hazard ratio = 2.5) for placement into foster care one-year post intervention. Booth-LaForce et al. (in press) reported medium (d = .58) to large (d = 1.02-1.21) effect sizes. 

Generalizability

Spieker et al. (2012) and Oxford, Spieker et al. (2016) were conducted in the same U.S. county and included infants and toddlers who were under investigation for child maltreatment or who had experienced a court-ordered change in caregiver, and these children's caregivers (which included birth parents, foster parents or adult kin). Booth-LaForce et al. (in press), however, tested the program in American Indian and Alaska Native toddlers and their caregivers living on a rural reservation.

Potential Limitations

Spieker et al. (2012)

  • Control condition received another home visitation program
  • The analysis of reciprocal parent-child interaction, a dyadic outcome, excluded children who experienced a caregiver change after enrollment in the study. This resulted in a substantial proportion of the sample lost to follow up due to foster care placement changes at the six-month time point and may lead to possible problems with intent-to treat analysis.
  • Tests of differential attrition were not reported
  • Medium-sized sample from one county
  • Caregivers both received the program and rated child outcomes and some caregiver outcomes (for example, parent understanding of toddlers)

Long-term study (Spieker et al., 2014) - same sample as Spieker et al. (2012) so the same limitations with the exception of intent-to-treat, as all children were included in the analysis of administrative child welfare data using an intent-to treat model. In addition:

  • No main effect

Oxford, Spieker et al. (2016)

  • Time between treatment and posttest varied by condition (included as a covariate)
  • Some but not all measures were independent
  • The analysis of reciprocal parent-child interactions, a dyadic outcome, excluded children who had experienced caregiver turnover during the study, which may lead to possible problems with intent-to-treat analysis.
  • One difference in a protective outcome measure between conditions at baseline favoring the control group
  • No differences by completion status on demographic variables but tests of differential attrition by outcomes were unclear
  • Did not test baseline-by-condition differential attrition
Booth-LaForce et al. (in press)
  • Randomized design compromised by a confound (a single person delivering the program)
  • Some measures from parents who helped deliver the program
  • Differences between conditions at baseline (included as a covariate)
  • Attrition (>5%) and no tests for differential attrition
  • Very small or specialized sample

Notes

Spieker et al. (2012) conducted the original experimental study in which infants and toddlers in foster care and their caregivers were randomly assigned to condition. Using the same sample, Spieker et al. (2014) analyzed caregiver stability and permanency outcomes of children 2 years after enrollment in the study and Pasalich et al. (2016) conducted additional moderation analyses. Meanwhile, Nelson & Spieker (2013) used a subsample of the dyads randomized in the Spieker et al. (2012) study to examine patterns of cortisol activity by condition in assessing responses to stress from pre- to post-intervention. Similarly, Oxford et al. (2013) used a subsample of the sample reported in Spieker et al. (2012) to assess differences between treatment and control in toddler sleep as well as the effect of the treatment on those children who were being reunified with their birth parents after a foster care placement (see Oxford, Marcenko et al., 2016).

Endorsements

Blueprints: Promising

Program Information Contact

Jennifer Rees, Program and Training Manager
University of Washington
CHDD South Building Room 212
Box 357920
Seattle, WA 98195
rees@uw.edu
206-616-5380

References

Study 1

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, 211-221.

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, 1988-1992.

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, 61, 109-116.

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, 175-185.

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.

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, 271-286.

Study 2

Certified 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, 267-277.

Study 3

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 Science21(1), 98-108.

Study 1

Evaluation Methodology

Design:

Recruitment: Researchers in the Spieker et al. (2012) study contacted caregivers of infants in one county between the ages of 10 and 24 months who had experienced a court-ordered placement that resulted in a change in primary caregiver within the prior 7 weeks, based on Department of Social and Health Services records. Initially, 427 caregivers were contacted and 280 cases were deemed eligible for the study (i.e., caregivers had to speak English and could be foster parents, biological parents or adult kin), of which 219 enrolled and 61 declined. After enrollment, an additional 9 dyads were declared ineligible, so the sample size at randomization was 210 caregiver/children dyads.

Assignment: Spieker et al. (2012) randomly assigned participating parent-child dyads, blocked by caregiver type (foster parents, biological parents or adult kin), to either the treatment or a control group. Control group participants received The Early Education Support program, which consisted of three monthly 90-minute home visits to promote growth and development and information on available resources. Of the 210 dyads, 105 were each randomly assigned to the treatment or control conditions.

Attrition: Of the 210 dyads randomized in Spieker et al. (2012), 175 (or 83%) completed the posttest with their original caregiver and thus were included in the analysis. At 6 months after the intervention, the sample included 129 dyads who completed the assessment with their original caregiver (70% of those randomized).

Spieker et al. (2014) also examined permanency and stability at 2-year follow-up. Presumably, although the authors did not discuss it, there was no attrition as the measures employed were obtained through state records. Pasalich et al. (2016) used the same sample and the same measures as Spieker et al. (2012).

Sample: Over half of infants in the Spieker et al. (2012) sample were male (55%) and approximately 55% of infants were white, 20% were mixed race, 15% were black, 10% were Hispanic, 7% were Native American or Alaskan native, and 4% were other races or were not identified. The average age of infants at the beginning of the study was 36 months and on average infants had experienced over 2 caregiver changes since birth. Approximately 27% of households in the study earned an income of less than $20,000 per year. On average, caregivers were around 36 years of age and had 13 years of education.

Measures: Spieker at al. (2012) and Pasalich et al. (2016) included 2 pre- and posttest measures of child behavioral outcomes and 3 child behavioral outcome measures administered at baseline and 6 months after the intervention (without posttest assessment). In addition, the authors used 5 measures of risk and protective factors and 6 assessing caregiver outcomes.

Child behavioral outcomes included:

  • Competence (sample α = .69-.70) and problem behavior (sample α = .77-.79), completed by caregivers at all three time points, were both assessed using the Brief Infant Toddler Social and Emotional Assessment.
  • The caregiver-reported Child Behavior Checklist scales of internalizing (α=.80) and externalizing (α=.90) behaviors, conducted at baseline and 6-month follow up.
  • Emotional regulation from the Bayley Behavior Rating Scale (sample α ranged from .79 to .87) completed by researchers blind to condition at baseline and 6-month follow up.

Risk & protective factor child outcome measures included:

  • Infant attachment security, scored by an observer at each time point (baseline, posttest and 6-month follow-up), was measured using the Toddler Attachment Sort-45 (interrater reliability conducted on 16% of the sample, r = .92).
  • Engagement was assessed by researchers at each time point using the Indicator of Parent-Child Interaction by coders (sample α = .79-.82).
  • Sleep problems (sample α=.70) and "other problems" (sample α=.70) assessed at baseline and 6-month follow-up using the Child Behavior Checklist completed by caregivers.
  • Orientation/engagement from the Bayley Behavior Rating Scale (sample α ranged from .79 to .87) completed by researchers blind to condition at baseline and 6-month follow up.

For caregiver outcomes assessing reciprocal parent-child warmth, Spieker et al. (2012) and Pasalich et al. (2016) included the Nursing Child Assessment Teaching Scale to report parent sensitivity, which was independently coded by researchers using a videotaped session (sample α ranged from .71 to .79). Parent sensitivity items represented aspects of positive interaction and indicators of mutuality (e.g., contingency, gaze, and positive affect), caregiver verbal and nonverbal support of child, and sensitive instruction during the teaching task. The Indicator of Parent-Child Interaction, also scored by observers, reported support (sample α ranged from .76 to .84), which included items such as "acceptance/warmth," "descriptive language," and "follows child's lead." Commitment to child, which assessed the caregiver's desire to parent the child as long as the child remains in care or is benefitting from care and the caregiver's ability to fully attach to the child without withholding feeling or putting up barriers to limit the extent of the attachment, was rated based on interviews with caregivers using the This Is My Baby questionnaire (interrater agreement was r = .89). Caregivers reported understanding of toddlers (which measured caregivers' knowledge of infant and toddler social-emotional needs and developmentally appropriate expectations) with the Raising a Baby survey (sample α ranged from .73 to .77). Finally, the caregivers rated their perception of having a difficult child (Stress - Difficult Child) and having a dysfunctional parent-child relationship (Stress - Dysfunctional Interaction) with the Parenting Stress Index (sample α ranged from .87 to .89). All six of these measures were administered at baseline, posttest and 6-month follow-up.

Two years after initial enrollment in the Spieker et al. (2012) study, Spieker et al. (2014) used state child welfare administrative data to measure whether a child had remained with the study caregiver since randomization (stability) and whether the child remained with the same caregiver with a legal discharge to that caregiver (permanency).

Analysis: Spieker et al. (2012) used analysis of covariance models to assess differences by experimental condition in caregiver and child outcomes at pretest, posttest, and follow-up. For posttest and 6-month follow-up, the baseline score on the given measure (when available) was included as a covariate, in addition to other demographic variables including whether the child experienced multiple removals from the birth home, caregiver type, and age of child. Pasalich et al. (2016) conducted an additional moderation analysis to analyze whether there was a differential effect of the treatment on a cascade from placement instability to insecure attachment to externalizing problems in toddlers.

At the two-year follow-up, Spieker et al. (2014) used logistic regression to predict stability and permanency, with intervention group and various demographic variables (i.e., age of child at randomization, time in child welfare at time of randomization, number of placement changes prior to randomization, multiple removals - whether the child experienced one or more failed reunifications with the birth parent prior to randomization, and commitment to child) included as covariates. Baseline outcomes for the Spieker et al. (2012) study were not used in the Spieker et al. (2014) analysis.

Intent-to-Treat: Spieker et al. (2012) reported using an intent-to-treat protocol and treated infant-caregiver dyads that did not remain intact at follow-up time points as missing or attrition. To analyze intervention effects on outcomes they used both ANCOVA models with a listwise deletion approach to missing data and growth models that used maximum likelihood estimates and included data on all participants, including those with missing data at follow-up time points. Pasalich et al. (2016) reported they used FIML to handle missing data. Using the same sample as Spieker et al. (2012), Spieker et al. (2014) included all 210 children, consistent with an intent-to-treat model.

Outcomes

Implementation Fidelity: Spieker et al. (2012) reported that three video feedback sessions per family were conducted during the study. Independent observers assigned a global rating on a scale of 1-5 assessing level of fidelity to each treatment segment observed, and reported an average score of 4.04 (SD = .76). In addition, 97% of activities were completed.

Baseline Equivalence: Spieker et al. (2012) reported no differences between conditions in outcome measures at baseline. Infants in the treatment condition were significantly more likely to have experienced multiple removals from their birth families, but it appears there were no other demographic differences at baseline.

Differential Attrition: Spieker et al. (2012) reported no differences between completers and attritors for condition, gender, caregiver type, multiple removals, or number of caregiver changes before enrollment. At posttest, treatment group participants who did not have a change in caregiver included younger children and were more likely to have completed all sessions of the intervention. However, differential attrition for dyads in the comparison was unclear, and the study did not analyze condition by outcome for attrition.

Posttest: At posttest, Spieker et al. (2012) found a significant improvement in caretakers' perception of child competence among treatment group infants and toddlers as compared to control group infants and toddlers. However, this significant difference did not remain at the 6-month follow-up. Spieker et al. (2012) also found a significant improvement in parent sensitivity and understanding of infants and toddlers among treatment caregivers as compared to infants and toddlers among control caregivers at posttest, but these differences also did not remain at 6-month follow-up.

Pasalich et al. (2016) found several moderator effects (no main effects were tested in this study). That is, among children with more than 4 placement changes (27% of the sample), those in the control group exhibited lower levels of attachment security as compared to children in the treatment group at posttest. In addition, the study found that placement changes were significantly and inversely associated with attachment security and lower levels of attachment security were associated with higher scores on externalizing problems at a later assessment.

Long-Term: Two years after initial enrollment in the study, Spieker et al. (2014) found no overall effect of intervention condition on stability (i.e., placement with no interruptions or disruptions) or permanency (i.e., a stable placement ending with a legal discharge to the study caregiver); a significant interaction effect between type of caregiver and condition on permanency was detected. Compared to controls, receiving treatment increased the likelihood of permanency among children with foster/kin caregivers than among children with birth parents, and the size of this effect was large (OR = 9.67).

Study 1 Cont'd

Evaluation Methodology

Design:

Recruitment: The Nelson & Spieker (2013) study invited 57 of the 210 caregiver-child dyads randomized in the Spieker et al. (2012) study to participate in additional analyses of child cortisol levels. It is not clear how participants were selected from the full sample and if the randomization achieved in the full sample was maintained. Drawing from the same overall sample, researchers identified 56 biological parents and their recently reunified toddlers to conduct additional analyses comparing differences by condition in sleep problems (Oxford et al. 2013) and emotion regulation (Oxford, Marcenko et al., 2016).

Assignment: Of the 57 dyads invited to participate in the Nelson & Spieker (2013) study, 54 agreed and provided baseline saliva samples. The study states that 21 dyads were assigned to the treatment group and 25 were assigned to the control group. However, this only accounts for 46 participants, not the 48 who provided data at both time points or the 54 originally selected. For the Oxford et al. (2013) and Oxford, Marcenko et al. (2016) studies, 43 (treatment = 18 and control = 25) of the 56 dyads remained intact from enrollment to 6-month follow up and were therefore included in the analysis.

Attrition: Of the 54 participants who participated in the Nelson & Spieker (2013) study and provided baseline measurements, 2 caregivers dropped out and 4 children experienced a placement change by the postintervention measure. In addition, baseline morning cortisol samples were collected on 43 children and this data point was used as a covariate in the overall analysis. Of the 56 dyads identified for the Oxford et al. (2013) and Oxford, Marcenko et al. (2016) studies, 43 dyads remained intact and were included in the analysis.

Sample: Ages in the subsample reported in Nelson & Spieker (2013) ranged from 10 to 25 months, at baseline. In addition, 38% of children were living with a foster parent, 38% had been returned to a birth parent, and 25% were living with a family member. A majority of participants were white (68.8%), 17% were black, 13% were American Indian, and 2% were Hawaiian Native. The majority of the infants in the subsample in Oxford et al. (2013) and Oxford, Marcenko et al. (2016) were white (67%), female (53%), had a female caregiver (88%) and came from a household that earned less than $20,000 a year (60%).

Measures: In the Nelson & Spieker (2013) study, at both time points, authors collected five saliva samples: on arrival, just before the brief separation from caregiver, 30 minutes after the return of the caregiver, 45 minutes after the return of the caregiver, and the following morning. Cortisol levels were analyzed in each sample. Researchers established a conservative cut point of .05 ig/dL based on average variability within the sample to allow for capture of meaningful changes in cortisol level across collection points. The average ¼ SD for collection points ranged from .051 to .018. In this study, increasing cortisol levels in theoretically stressful conditions were considered a more adaptive behavior, while flat cortisol levels were considered potentially deleterious.

Oxford et al. (2013) pulled items from the Child Behavior Checklist and the Brief Infant Toddler Social and Emotional Assessment to create a 6-item measure of sleep problems that was completed by caregivers in treatment and control at baseline and 6-month follow up (sample α = .87). Separation distress was measured using the Toddler Attachment Sort-45 (inter-rater reliability, r = .92).

Measures used in the Oxford, Marcenko et al. (2016) study were the same as those used in the Spieker et al. (2012) study.

Analysis: Nelson & Spieker (2013) conducted multinomial logistic regression to analyze the association between posttest cortisol pattern and intervention group. The categorical outcome variable was increasing, decreasing, or flat cortisol levels during the course of the research visit. Analyses controlled for condition, time of day, child's age, baseline morning cortisol level, and flat or not flat cortisol pattern observed at baseline. OLS regression was used in the Oxford et al. (2013) study, which included sleep problems at baseline, age in months at enrollment, whether the child had experienced multiple removals from the biological parent's home, and time between baseline and 6-month follow up as covariates.

Oxford, Marcenko at al. (2016) conducted the same analysis and used the same covariates as Spieker et al. (2012).

Intent-to-Treat: Nelson & Spieker (2013) excluded baseline data from the 2 participants who dropped out of the study and had missing data for morning cortisol for an additional 5 participants. Meanwhile, Oxford et al. (2013) and Oxford, Marcenko et al. (2016) both dropped 13 dyads that did not remain intact during the study period. As no information was provided on handling of missing data, it is not clear if these studies followed intent-to-treat protocol.

Outcomes

Baseline Equivalence: Nelson & Spieker (2013) found no significant differences between the treatment and control groups for morning cortisol levels, however there were no statistical tests conducted on the demographic variables of this subsample. Oxford et al. (2013) found no demographic differences between groups at baseline, but did not test for baseline outcome differences. Oxford, Marcenko et al. (2016) reported no significant group differences in scores on measures at baseline, but did not clarify whether demographic and outcome measures were both tested.

Differential Attrition: None of the studies discussed differential attrition among the subsample.

Posttest: At posttest, Nelson & Spieker (2013) found that children in the treatment group were significantly more likely to have increasing postintervention cortisol levels. In addition, moderator analyses found that older children were more likely to have increasing postintervention cortisol levels. The study was not found to affect morning cortisol levels. Oxford et al. (2013) found that treatment predicted fewer sleep problems. Meanwhile, Oxford, Marcenko et al. (2016) found no program effects at posttest but a significant effect on observed parent support at the 6-month follow-up in favor of the treatment group.

Study 2

Evaluation Methodology

Design:

Recruitment: Participants were eligible if they were conversant in English, had housing, lived in a certain region within Washington state, and had a child between the ages of 10-24 months and an open child welfare case with an allegation of maltreatment. To recruit participants, a Department of Child and Family Services volunteer contacted families who had recently been reported to Child Protective Services (N=1,070). Of the total 1,070 families contacted, 504 could not be reached, 172 were not eligible, and 133 declined to participate. A total of 251 families agreed to a home visitation, during which an additional 4 were deemed ineligible.

Assignment: A total of 247 families were randomly assigned to the treatment (n=124) or the control (n=123) group in racial/ethnic blocks. The control condition received 3 phone consultations providing a needs assessment, mailed packet of personalized information, and two 10-minute follow-up check-in calls.

Attrition: Participants were assessed at four time points: 1) pretest (n = 247); 2) posttest (n = 225, 91% of the randomized sample); 3) 3-month follow-up (n = 215, 87%); and, 4) 6-month follow-up (n = 211, 86%).

Sample: A majority of parents in the study were mothers (91%). In terms of race, most parents were white (77%), while 3% of the sample parents were American Indian or Alaska Native, 4% were Asian, 5% were African American, and 11% were of a mixed race or "other." Around 20% of parents were Hispanic. Parent education included high school graduation (45%), GED (31%), and neither high school graduation nor GED (24%). Less than one third (31%) were employed full or part time, 28% were unemployed and looking, and 41% were not employed (i.e., were homemakers, students, retired, on disability, other). Over half of parents were never married (56%), 24% were married at the time of the study, and 22% were separated or divorced. Most of the sample received food stamps (79%) and average household income in the past year was $21,883, indicating lower socioeconomic status. Just over half of children in the study were male (54%) and were, on average, 16.37 months at baseline.

Measures: The study included 2 pre- and posttest measures of child behavioral outcomes and 1 child behavioral outcome measure administered at baseline and 3 months after the intervention (without posttest assessment). In addition, the authors used 3 measures of risk and protective factors for children, and 4 assessing caregiver outcomes.

Child behavioral outcomes included:

  • Competence (sample α = .69-.70) and problem behavior (sample α = .77-.79), completed by caregivers at all four time points, were both assessed using the Brief Infant Toddler Social and Emotional Assessment.

Measures of risk & protective child outcomes included:

  • The observer-rated Toddler Attachment Sort-45 scales of secure base behavior and atypical, affective communication conducted at all 3 time points (interrater reliability based on videotaped sessions for this measure was .75-.79)
  • Emotional regulation and engagement/exploration from the Bayley Behavior Rating Scale (sample α ranged from .75 to .83) completed by researchers blind to condition at baseline and 3-month follow up.

Measures of caregiver outcomes assessing reciprocal parent-child warmth included:

  • Understanding of toddlers (which measured caregivers' knowledge of infant and toddler social-emotional needs and developmentally appropriate expectations), assessed at posttest and 6-month follow-up using the Raising a Baby scale, a self-rated measure. Sample α = .73-.77.
  • Parent sensitivity (α = .68-.72), assessed using the Nursing Child Assessment Teaching Scale, an observer-rated measure that was administered at posttest, 3-month follow-up, and 6-month follow-up. Parent sensitivity items represented aspects of positive interaction and indicators of mutuality (e.g., contingency, gaze, and positive affect), caregiver verbal and nonverbal support of child, and sensitive instruction during the teaching task.
  • Dysfunctional interaction and parenting competence (α = .71-.94), assessed using the Parenting Stress Index and the Parenting Stress Index-Short Form, a self-reported measure, that was administered at 3-month and 6-month follow-up.

In addition, the study gathered official records on additional allegations of child maltreatment and removals from the birth parent home. For each child in the study, records were obtained of new allegations and removals that occurred between baseline and 12 months after the child's parent completed the intervention. For cases where the parent did not start or did not fully complete the intervention, information was obtained 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.

Analysis: The study used mixed model regressions to predict outcome variables, with intervention condition, age of child at baseline, and months between baseline and post-intervention assessment (which varied between conditions) as covariates. For measures assessed at only one posttest time point, the study used regression models predicting the posttest outcome measure. For measures with multiple posttest scores, 2-level random effects models were conducted in which posttest scores were nested within dyads. Survival analysis was conducted for models involving child maltreatment outcomes (i.e., new allegations and removal from birth home, as measured by child welfare administrative data).

Intent-to-Treat: For the child welfare outcomes, all study children were included in the analysis, consistent with an intent-to-treat model. For the data collected in the home, the study used an intent-to-treat protocol and employed Full Information Maximum Likelihood (FIML) protocols to account for missing data; however, infants who experienced a change in caregiver during the course of the study were excluded (which could be a violation of intent-to-treat protocol).

Outcomes

Implementation Fidelity: To ensure fidelity, the study used video-taped sessions to review providers' interactions with families. However, the study did not provide quantitative measures of these reviews. In the treatment condition, 86% of participants received all 10 sessions and 89% of control participants received all 3 telephone consultations.

Baseline Equivalence: The study reported there were no differences between conditions on any demographic variables at baseline. There was one difference in caregiver outcome at baseline in which the control group had significantly higher scores on parenting sensitivity.

Differential Attrition: There were no differences by completion status on demographic variables, but tests of differential attrition by outcomes were unclear.

Posttest: The study found no significant effects on the three behavioral outcomes (social-emotional competence, behavior problems and emotion regulation). Findings, however, showed a significant effect in favor of the treatment group on 1 of 3 child risk and protective outcomes at posttest: child atypical affective communication. In addition, within one-year post intervention, chances of removal from the birth parent home were greater for children in the control condition than children in the treatment condition at any given time.

For caregiver outcomes, the study found a significant effect on parent understanding of toddlers, which was only measured at posttest and 6-month follow-up, and parent sensitivity, measured at all four time points.

Long-Term: The study did not report long-term findings.

Study 3

Evaluation Methodology

Design:

Recruitment: Researchers recruited American Indian and Alaska Native families from the tribal health clinic, but also posted flyers in the community, publicized the study on Facebook, and provided information to Head Start teachers. To be eligible, participants had to have at least one parent or guardian who 1) was at least 18 years old; 2) spoke English; 3) was the primary caregiver for an Native American child aged 10-30 months; 4) had telephone access; 5) was not in a treatment facility or shelter; 6) was not hospitalized or imprisoned; 7) was willing to have researchers come to their home; and 8) lived on or near the reservation. If the household included multiple children in the target age range, the child with whom the caregiver wished to work for was selected to participant in the study.

Assignment: Participants were 34 toddlers (10-30 months old) and their primary caregivers. Families were randomized to a treatment (n = 17) or waitlist control (n = 17) group Researchers used an algorithm to randomize participants, blocking on male or female caregiver, in equal numbers to the treatment and control group. Waitlisted families in the control group had the opportunity to receive the intervention after the study assessments.

A problem with the design stems from the reliance on a single provider to deliver the program to all intervention participants. Page 11 states, "We trained the PFR Provider, who was a tribal member living on the reservation." The characteristics of the single PFR Provider were thus confounded with the program.

Assessments/Attrition: Families in both groups completed the follow-up assessment after the intervention period concluded. In the treatment group, the median time between baseline and follow-up assessments was 15 weeks (M = 18.00, SD = 5.29). In the control group, the median time between assessments was 17 weeks (M = 19.14, SD = 9.45). Of the 34 parent-child dyads who completed baseline assessments, 23 dyads completed a posttest (see consort diagram in Figure 1), for an overall attrition rate of 32%.

Sample: Of the total sample, 73% of the primary caregivers identified as American Indian or Alaska Native, 15% as white, and 12% as mixed. All were living on the reservation, all of the non-Native caregivers had AI/AN partners or spouses, and all had an AI/AN child between 10 and 30 months old.

Measures:

The primary outcome measure assessed caregiver-child interaction and included the total score for Caregiver/Child Interaction on the Nursing Child Assessment Teaching Scale (NCATS), coded based on video recordings of the teaching task. A certified NCATS coder viewed the video recordings and scored them for caregiver sensitivity, stimulation of the child, and emotional responsiveness. The coder was blind to treatment group and time of assessment (baseline versus follow-up) and reviewed the videos in a randomized order provided by the investigators. The coder evaluated the caregiver's verbal and non-verbal support and the child's clarity of cues and response to the caregiver by responding to 73 yes/no items. "Yes" scores were summed to calculate the Caregiver/Child Interaction total score. Additionally, 32 of the 73 items on the NCATS refer to the contingent responsiveness of the caregiver to the child, or vice versa. Researchers summed the "yes" scores on the contingency items to yield a score for Caregiver/Child Contingency. Researchers state that the NCATS has excellent psychometric properties, though no information on reliability or validity was reported.

The following measures were completed by caregivers (and thus are considered non-independent outcome measures):

  • Caregivers' understanding of their children was assessed using Raising a Baby, a 16-item scale that measures caregivers' knowledge of the social-emotional needs of infants and toddlers as well as caregivers' level of developmentally appropriate expectations of their children. Internal consistency of the scale (Cronbach's α) was .64 at baseline and .70 at follow-up.
  • Parental stress associated with the perception of having a difficult child or a dysfunctional parent-child relationship was measured using the 36-item short-form Parenting Stress Index. Internal consistency of the scale was .91 at baseline and .93 at follow-up.
  • The 125-item Infant-Toddler Social Emotional Assessment (ITSEA) assessed children's social-emotional competences. Caregivers rated the domains of Internalizing (α = .70 at baseline and .88 at follow-up), Externalizing (α = .73 and .76), and Competence (α = .87 and .93).

Analysis: Researchers used multiple regression models, adjusting for caregiver race, time elapsed between assessments, and the baseline score on the given measure.

Intent-to-Treat: Based on the CONSORT diagram, only those participants completing the program also completed the follow-up assessment. However, researchers employed multiple imputation to include all cases in the analysis.

Outcomes

Implementation Fidelity: After initial certification, the intervention group leader submitted one video recording of an intervention session per family to enable a master trainer to monitor ongoing fidelity by rating the quality and completeness of intervention delivery on a 5-point scale (M = 4.21, SD = 0.70 in the present study). Nine of the 17 caregivers in the treatment group completed all 10 visits.

Baseline Equivalence: T-tests found no significant baseline differences on any variables except the ITSEA Competence score. For this measure, the treatment had higher baseline scores compared to the control group. In addition, Table 1 shows some large non-significant differences between conditions (e.g., 65% female child in the intervention group versus 41% in the control group).

Differential Attrition: No tests of differential attrition were conducted.

Posttest: At the posttest, compared to the control group, participants in the treatment group earned a higher Caregiver/Child total score (d = 1.02) - which measures caregiver's verbal and non-verbal support and the child's clarity of cues and response to the caregiver - and Caregiver/Child Contingency total score (d = 1.21), which assesses the contingent responsiveness of the caregiver to the child, or vice versa.

Parent reports of their children's internalizing, externalizing and competence were not statistically significant, though all outcomes favored the treatment group with small to large effect sizes).

Caregivers in the treatment group also reported higher scores for Raising a Baby (d = 0.58). Completed by caregivers, this instrument measured caregivers' knowledge of the social-emotional needs of infants and toddlers as well as caregivers' level of developmentally appropriate expectations of their children. No differences were detected in parental stress (a risk and protective factor).

Long-Term: Not reported.

Contact

Blueprints for Healthy Youth Development
University of Colorado Boulder
Institute of Behavioral Science
UCB 483, Boulder, CO 80309

Email: blueprints@colorado.edu

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Blueprints for Healthy Youth Development is
currently funded by Arnold Ventures (formerly the Laura and John Arnold Foundation) and historically has received funding from the Annie E. Casey Foundation and the Office of Juvenile Justice and Delinquency Prevention.