Promoting First Relationships®
Promoting First Relationships® (PFR) is a home visiting prevention program designed for caregivers of children ages 0–5 years. PFR aims to promote secure and healthy relationships between caregivers and children through strengths-based parenting strategies. PFR uses reflective processes to help caregivers understand their own feelings and needs and those of their children. PFR promotes children’s social-emotional development, builds trust and security between children and caregivers, encourages children and caregivers’ emotion regulation and self-reflection, and helps caregivers address challenging behaviors.
Providers deliver weekly sessions to caregivers and their children. Providers use five strategies during sessions to enhance caregivers’ confidence and support children’s social-emotional development: (1) joining, in which the provider makes observational statements and asks open-ended non-judgmental questions to form emotional connections with caregivers; (2) reflective observation, in which the provider observes the relationships between caregivers and children and teaches caregivers how to observe children and respond to their needs, sometimes using videotaping to help caregivers reflect; (3) verbal feedback, in which the provider offers positive comments about observed interactions to enhance caregivers’ confidence and competence; (4) supporting reflective capacity, in which the provider discusses the importance of feelings and needs, helps caregivers understand how children’s behavior is linked to social and emotional needs, and teaches caregivers to read children’s nonverbal cues and to empathize with and provide comfort to children in distress; and (5) sharing information, in which providers offer caregivers resources about children’s social and emotional development.
PFR is rated as a supported practice because at least one study carried out in a usual care or practice setting achieved a rating of moderate or high on design and execution and demonstrated a sustained favorable effect of at least 6 months beyond the end of treatment on at least one target outcome.
Date Research Evidence Last Reviewed: Apr 2023
Sources
The program or service description, target population, and program or service delivery and implementation information were informed by the following sources: the program or service manual, the program or service developer’s website, the Blueprints for Healthy Youth Development registry, and the studies reviewed.
This information does not necessarily represent the views of the program or service developers. For more information on how this program or service was reviewed, visit the download the Handbook of Standards and Procedures, Version 1.0
Target Population
PFR is designed for caregivers of children ages 0–5 years. Providers can implement PFR with multiple populations, including parents, grandparents, childcare teachers, families experiencing homelessness, caregivers with a mental health diagnosis, adolescent mothers, first-time parents, foster parents, families with children in the child welfare system, or families of children with special needs.
Dosage
Providers deliver PFR to caregivers and their children in 10 weekly sessions lasting 60–75 minutes. In five of the 10 sessions, the provider videotapes a caregiver-child interaction for 10–20 minutes and discusses the video with the caregiver the following week.
Location/Delivery Setting
Recommended Locations/Delivery Settings
Providers can deliver PFR in-person in participants’ homes, in clinics and medical settings, or with caregivers in group care situations such as family home daycare, center-based childcare, and preschool classrooms. Providers can also deliver PFR online.
Location/Delivery Settings Observed in the Research
- Home
Education, Certifications and Training
PFR providers can be infant mental health specialists, child welfare providers, social workers, home visitors, early interventionists, family service workers, childcare providers, early childhood education teachers, and public health nurses.
The PFR Level 1 Training educates providers about how to use the program within their practice. The 14-hour training is delivered either in-person over 2 days or virtually over 4 half days. Participants learn about attachment theory, promoting secure caregiver-child relationships, development of self, understanding challenging behaviors, building caregiver reflective capacity, and use of consultation strategies.
Level 2 Certified Provider Training is a 15-week virtual mentoring professional development program for providers who have already completed the PFR Level 1 Training. For the first 5 weeks, providers watch intervention session videos to hone infant mental health observation and reflection skills. Providers discuss the videos with a master trainer and their peers. For the next 10 weeks, providers deliver the intervention with a caregiver/child dyad and receive individual mentoring. To become certified, providers must record and submit a full PFR session video that demonstrates fidelity to the model.
Level 3 Agency Training is for certified providers who exhibit high fidelity to the model and is offered by invitation only. Level 3 Training includes 15 weeks of additional mentoring from a master trainer. During the first 3 weeks, providers complete readings and view videos of parent-child interactions to hone observational skills. Providers meet weekly with the master trainer to discuss the content of the readings and videos. Providers then implement the intervention with a caregiver/child dyad for 10 weeks to grow their expertise and reflective skills. To become a certified PFR Agency Trainer, providers must record and submit a second full PFR session video that demonstrates fidelity to the model. Providers receive two additional training sessions to prepare them to train others within their agency. Certified PFR agency trainers participate in monthly group reflective consultation with a master trainer as they train and mentor others within their organization.
Program or Service Documentation
Book/Manual/Available documentation used for review
Kelly, J. F., Zuckerman, T. G., Sandoval, D., & Buehlman, K. (2016). Promoting First Relationships: A program for service providers to help parents and other caregivers nurture young children’s social and emotional development (3rd ed.). Parent-Child Relationship Programs at the Barnard Center, University of Washington.
Available languages
The PFR manual is available in English. Other PFR materials, such as caregiver handouts, are available in English, Somali, and Spanish.
Other supporting materials
For More Information
Website: https://pfrprogram.org/
Phone: (206) 616-5380
Contact form: https://pfrprogram.org/contact/
Note: The details on Dosage; Location; Education, Certifications, and Training; Other Supporting Materials; and For More Information sections above are provided to website users for informational purposes only. This information is not exhaustive and may be subject to change.
| Results of Search and Review | Number of Studies Identified and Reviewed for Promoting First Relationships® |
|---|---|
| Identified in Search | 9 |
| Eligible for Review | 5 |
| Rated High | 1 |
| Rated Moderate | 0 |
| Rated Low | 4 |
| Reviewed Only for Risk of Harm | 0 |
| Outcome | Effect Size
 and Implied Percentile Effect
|
N of Studies (Findings) | N of Participants | Summary of Findings |
|---|---|---|---|---|
| Child well-being: Behavioral and emotional functioning |
0.14
5 |
1 (3) | 252 |
Favorable:
1 No Effect: 2 Unfavorable: 0 |
| Adult well-being: Positive parenting practices |
0.27
10 |
1 (2) | 252 |
Favorable:
1 No Effect: 1 Unfavorable: 0 |
| Adult well-being: Parent/caregiver mental or emotional health |
0.10
4 |
1 (2) | 252 |
Favorable:
0 No Effect: 2 Unfavorable: 0 |
| Adult well-being: Family functioning |
0.10
3 |
1 (2) | 252 |
Favorable:
0 No Effect: 2 Unfavorable: 0 |
Note: For the effect sizes and implied percentile effects reported in the table, a positive number favors the intervention group and a negative number favors the comparison group.
| Outcome | Effect Size
and Implied Percentile Effect
|
N of Studies (Findings) | N of Participants | Summary of Findings |
Months after treatment when outcome measured
|
|---|---|---|---|---|---|
| Child well-being: Behavioral and emotional functioning |
0.14
5 |
1 (3) | 252 |
Favorable:
1 No Effect: 2 Unfavorable: 0 |
- |
| Study 14671 - Promoting First Relationships vs. Resource Packet Control (Oxford, 2021) | |||||
| Infant Toddler Social Emotional Assessment: Externalizing |
0.28
*
10 |
- | 252 | - | 6 |
| Infant Toddler Social Emotional Assessment: Internalizing |
0.11
4 |
- | 252 | - | 6 |
| Infant Toddler Social Emotional Assessment: Dysregulation |
0.04
1 |
- | 252 | - | 6 |
| Adult well-being: Positive parenting practices |
0.27
10 |
1 (2) | 252 |
Favorable:
1 No Effect: 1 Unfavorable: 0 |
- |
| Study 14671 - Promoting First Relationships vs. Resource Packet Control (Oxford, 2021) | |||||
| Nursing Child Assessment Teaching Scale |
0.25
9 |
- | 252 | - | 0 |
| Nursing Child Assessment Teaching Scale |
0.29
*
11 |
- | 252 | - | 6 |
| Adult well-being: Parent/caregiver mental or emotional health |
0.10
4 |
1 (2) | 252 |
Favorable:
0 No Effect: 2 Unfavorable: 0 |
- |
| Study 14671 - Promoting First Relationships vs. Resource Packet Control (Oxford, 2021) | |||||
| Maternal Confidence Questionnaire |
0.15
5 |
- | 252 | - | 0 |
| Maternal Confidence Questionnaire |
0.06
2 |
- | 252 | - | 6 |
| Adult well-being: Family functioning |
0.10
3 |
1 (2) | 252 |
Favorable:
0 No Effect: 2 Unfavorable: 0 |
- |
| Study 14671 - Promoting First Relationships vs. Resource Packet Control (Oxford, 2021) | |||||
| Infant CARE-Index: Dyadic Synchrony |
0.00
0 |
- | 252 | - | 0 |
| Infant CARE-Index: Dyadic Synchrony |
0.19
7 |
- | 252 | - | 6 |
*p <.05
Note: For the effect sizes and implied percentile effects reported in the table, a positive number favors the intervention group and a negative number favors the comparison group. Effect sizes and implied percentile effects were calculated by the Prevention Services Clearinghouse as described in the Handbook of Standards and Procedures, Section 5.10.4 and may not align with effect sizes reported in individual publications.
Only publications with eligible contrasts that met design and execution standards are included in the individual study findings table.
Full citations for the studies shown in the table are available in the "Studies Reviewed" section.
The participant characteristics display is an initial version. We encourage those interested in providing feedback to send suggestions to preventionservices@abtglobal.com.
The table below displays locations, the year, and participant demographics for studies that received moderate or high ratings on design and execution and that reported the information. Participant characteristics for studies with more than one intervention versus comparison group pair that received moderate or high ratings are shown separately in the table. Please note, the information presented here uses terminology directly from the study documents, when available. Studies that received moderate or high ratings on design and execution that did not include relevant participant demographic information would not be represented in this table.
For more information on how Clearinghouse reviewers record the information in the table, please see our Resource Guide on Study Participant Characteristics and Settings.
| Characteristics of the Participants in the Studies with Moderate or High Ratings | ||||||
|---|---|---|---|---|---|---|
|
Study Location
|
Study Year
|
Age or Grade-level
|
Race, Ethnicity, Nationality
|
Gender
|
Populations of Interest*
|
Household Socioeconomic Status
|
| Study 14671 - Promoting First Relationships vs. Resource Packet Control | ||||||
| Characteristics of the Children and Youth | ||||||
| King County, WA, USA | 2015 | Average age: 1.8 months old; Age range: 0-3 months |
58% Caucasian 53% Hispanic 23% Multiracial 15% African American 4% Other |
52% Male 48% Female |
-- | -- |
| Characteristics of the Adults, Parents, or Caregivers | ||||||
| King County, WA, USA | 2015 | Average age: 28 years; Age range: 18-42 years |
66% Caucasian 47% Hispanic 18% African American 10% Multiracial 7% Other |
100% Women |
100% Pregnant or had an infant under three months of age at intake; 35% PTSD |
11% Household income of $40,001 or more 11% Household income of $30,001 to $40,000 19% Household income of $20,001 to $30,000 21% Household income of $10,001 to $20,000 29% Household income of $10,000 or less 7% Household income - no response |
“--” indicates information not reported in the study.
* The information about disabilities is based on initial coding. For more information on how the Clearinghouse recorded disability information for the initial release, please see our Resource Guide on Study Participant Characteristics and Settings. The Clearinghouse is currently seeking consultation from experts, including those with lived experience, and input from the public to enhance and improve the display.
Note: Citations for the documents associated with each 5-digit study number shown in the table can be found in the “Studies Reviewed” section below. Study settings and participant demographics are recorded for all studies that received moderate or high ratings on design and execution and that reported the information. Studies that did not report any information about setting or participant demographics are not displayed. For more information on how participant characteristics are recorded, please see our Resource Guide on Study Participant Characteristics and Settings.
Studies Rated High
Study 14671Oxford, M. L., Hash, J. B., Lohr, M. J., Bleil, M. E., Fleming, C. B., Unutzer, J., & Spieker, S. J. (2021). Randomized trial of Promoting First Relationships for new mothers who received community mental health services in pregnancy. Developmental Psychology, 57(8), 1228-1241. https://doi.org/10.1037/dev0001219
This study was conducted in a usual care or practice setting (Handbook Section 6.2.2)Studies Rated Low
Study 14666Jones, E. J. H., Dawson, G., Kelly, J., Estes, A., & Webb, S. J. (2017). Parent-delivered early intervention in infants at risk for ASD: Effects on electrophysiological and habituation measures of social attention. Autism Research, 10(5), 961-972. https://doi.org/10.1002/aur.1754
This study received a low rating because baseline equivalence of the intervention and comparison groups was necessary and not demonstrated.Study 14775
Booth-LaForce, C., Oxford, M. L., O'Leary, R., & Buchwald, D.S. (2022). Promoting First Relationships for primary caregivers and toddlers in a native community: A randomized controlled trial. Prevention Science, 24, 39-49. https://doi.org/10.1007/s11121-022-01415-y
This study received a low rating because it did not meet design confound standards.Study 14662
Booth-LaForce, C., Oxford, M. L., Barbosa-Leiker, C., Burduli, E., & Buchwald, D. S. (2020). Randomized controlled trial of the Promoting First Relationships preventive intervention for primary caregivers and toddlers in an American Indian community. Prevention Science, 21(1), 98-108. https://doi.org/10.1007/s11121-019-01053-x
Oxford, M., Booth-LaForce, C., Echo-Hawk, A., Madesclaire, O., Parrish, L., Widner, M., Petras, A., Abrahasmson-Richards, T., Nelson, K., Buchwald, D. (2020). Promoting First Relationships: Implementing a home visiting research program in two American Indian communities. Canadian Journal of Nursing Research, 52(2), 149-156. https://doi.org/10.1177/0844562120914424
This study received a low rating because it did not meet design confound standards.Study 14669
Oxford, M. L., Spieker, S. J., Lohr, M. J., & Fleming, C. B. (2016). Promoting First Relationships: Randomized trial of a 10-week home visiting program with families referred to child protective services. Child Maltreatment, 21(4), 267-277. https://doi.org/10.1177/1077559516668274
Hash, J. B., Oxford, M. L., Fleming, C. B., Ward, T. M., Spieker, S. J., & Lohr, M. J. (2019). Impact of a home visiting program on sleep problems among young children experiencing adversity. Child Abuse & Neglect, 89, 143-154. https://doi.org/10.1016/j.chiabu.2018.12.016
Kuklinski, M. R., Oxford, M. L., Spieker, S. J., Lohr, M. J., & Fleming, C. B. (2020). Benefit-cost analysis of Promoting First Relationships: Implications of victim benefits assumptions for return on investment. Child Abuse & Neglect, 106, Article 104515. https://doi.org/10.1016/j.chiabu.2020.104515
Pasalich, D. S., Fleming, C. B., Spieker, S. J., Lohr, M. J., & Oxford, M. L. (2019). Does parents' own history of child abuse moderate the effectiveness of the Promoting First Relationships intervention in child welfare? Child Maltreatment, 24(1), 56-65. https://doi.org/10.1177/1077559518809217
Hash, J. B., Oxford, M. L., Fleming, C. B., Ward, T. M., & Spieker, S. J. (2019). Sleep problems, daily napping behavior, and social-emotional functioning among young children from families referred to child protective services. Behavioral Sleep Medicine, 18(4), 447-459. https://doi.org/10.1080/15402002.2019.1611579
Hash, J. B., Oxford, M. L., Ward, T. M., Fleming, C. B., & Spieker, S. J. (2020). Sleep patterns, problems and ecology among toddlers in families with a child protective services maltreatment referral. Journal of Pediatric Nursing, 51, 85-91. https://doi.org/10.1016/j.pedn.2019.12.015
Hastings, P. D., Kahle, S., Fleming, C., Lohr, M. J., Katz, L. F., & Oxford, M. L. (2019). An intervention that increases parental sensitivity in families referred to child protective services also changes toddlers' parasympathetic regulation. Developmental Science, 22(1), Article e12725. https://doi.org/10.1111/desc.12725
Spieker, S. J., Oxford, M. L., Fleming, C. B., & Lohr, M. J. (2018). Parental childhood adversity, depressive symptoms, and parenting quality: Effects on toddler self-regulation in child welfare services involved families. Infant Mental Health Journal, 39(1), 5-16. https://doi.org/10.1002/imhj.21685
This study received a low rating because it did not meet design confound standards.Studies Not Eligible for Review
Study 14665
Hustedt, J. T., Hooper, A., Hallam, R. A., Vu, J. A., Han, M., & Ziegler, M. (2022). Child temperament as a moderator of Promoting First Relationships intervention effects among families in Early Head Start. Prevention Science. https://doi.org/10.1007/s11121-022-01340-0
This study is ineligible for review because it is not a study of the program or service under review (Study Eligibility Criterion 4.1.6).
Study 14667
Kelly, J. F., Zuckerman, T., & Rosenblatt, S. (2008). Promoting First Relationships: A relationship-focused early intervention approach. Infants & Young Children, 21(4), 285-295. https://doi.org/10.1097/01.IYC.0000336541.37379.0e
This study is ineligible for review because it does not use an eligible study design (Study Eligibility Criterion 4.1.4).
Study 14672
Spieker, S. J., Oxford, M. L., Kelly, J. F., Nelson, E. M., & Fleming, C. B. (2012). Promoting First Relationships: Randomized trial of a relationship-based intervention for toddlers in child welfare. Child Maltreatment, 17(4), 271-286. https://doi.org/10.1177/1077559512458176
Barth, R. P. (2012). Progress in developing responsive parenting programs for child welfare-involved infants: Commentary on Spieker, Oxford, Kelly, Nelson, and Fleming (2012). Child Maltreatment, 17(4), 287-290. https://doi.org/10.1177/1077559512466586
Spieker, S. J., Oxford, M. L., Kelly, J. F., Nelson, E. M., & Fleming, C. B. (2012). Response to the Barth commentary (2012). Child Maltreatment, 17(4), 291-294. https://doi.org/10.1177/1077559512467396
Oxford, M. L., Fleming, C. B., Nelson, E. M., Kelly, J. F., & Spieker, S. J. (2013). Randomized trial of Promoting First Relationships: Effects on maltreated toddlers' separation distress and sleep regulation after reunification. Children and Youth Services Review, 35(12), 1988-1992. https://doi.org/10.1016/j.childyouth.2013.09.021
Oxford, M. L., Marcenko, M., Fleming, C. B., Lohr, M. J., & Spieker, S. J. (2016). Promoting birth parents' relationships with their toddlers upon reunification: Results from Promoting First Relationships home visiting program. Children and Youth Services Review, 61, 109-116. https://doi.org/10.1016/j.childyouth.2015.12.004
Pasalich, D. S., Fleming, C. B., Oxford, M. L., Zheng, Y., & Spieker, S. J. (2016). Can parenting intervention prevent cascading effects from placement instability to insecure attachment to externalizing problems in maltreated toddlers? Child Maltreatment, 21(3), 175-185. https://doi.org/10.1177/1077559516656398
Spieker, S. J., Oxford, M. L., & Fleming, C. B. (2014). Permanency outcomes for toddlers in child welfare two years after a randomized trial of a parenting intervention. Children and Youth Services Review, 44, 201-206. https://doi.org/10.1016/j.childyouth.2014.06.017
Nelson, E. M., & Spieker, S. J. (2013). Intervention effects on morning and stimulated cortisol responses among toddlers in foster care. Infant Mental Health Journal, 34(3), 211-221. https://doi.org/10.1002/imhj.21382
This study is ineligible for review because it does not use an eligible study design (Study Eligibility Criterion 4.1.4).
Study 14674
Peters, A., Laprade, V., & Olsen, L. (2016). Final report: Families Growing Together. Children's Friend and Service. https://cwlibrary.childwelfare.gov/permalink/01CWIG_INST/10a03se/alma991000721219707651
This study is ineligible for review because it is not a study of the program or service under review (Study Eligibility Criterion 4.1.6).