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.
| Screening decision | Screening conclusion | HomVEE procedures and standards version |
|---|---|---|
| Passes screens | Eligible for review | Version 2 |
| Rating | Design | Attrition | Baseline equivalence | Compromised randomization | Confounding factors | Valid, reliable measure(s) |
|---|---|---|---|---|---|---|
| High | Randomized controlled trial | Low | Not assessed for randomized controlled trials with low attrition |
No | No |
Yes, details reported below for findings on valid, reliable outcomes |
The findings for the immediate post-intervention follow-up received a high evidence rating. The findings measured at six months post-intervention received a low evidence rating because attrition was high, and the findings did not satisfy the baseline equivalence requirement. The authors’ analyses controlled for whether the child experienced multiple removals from the birth home, for the caregiver type (biologically-related or foster), and for the age of the child. The authors’ analyses also controlled for the baseline measures of the following findings: caregiver sensitivity, support, commitment, understanding of toddlers, parenting stress, child's attachment security, engagement, competence, and problem behavior. Some findings in the manuscript were not eligible for review because they measured growth from the immediate post-test to the six-month follow-up and did not measure the impact of the intervention. Information that demonstrated the reliability of the outcome measures and baseline equivalence of the intervention and comparison groups was based on correspondence with the authors.
| Study participants | Study participants were caregiver and child dyads residing in and recruited from one county in Washington State. The study authors recruited eligible dyads through referrals from the Department of Child and Family Services. To be eligible, the child in the dyad had to be between the ages of 10 and 24 months with a court-ordered placement that resulted in a change in primary caregiver within the prior 7 weeks. The caregivers all spoke English, and caregivers were foster parents or biological parents (or adult kin). More than one-quarter (27 percent) of the caregivers were biological parents, 31 percent were other kin, and 42 percent were foster parents. Of 427 dyads contacted to participate in the study, 210 were eligible and randomly assigned to either the Promoting First Relationships – Home Visiting Intervention Model (105 dyads) or to the comparison group (105 dyads). Some children (29 in total) had a placement change within 4 months of study enrollment. However, these children and their caregivers remained in the intervention condition to which they were first assigned. The study sample at the immediate post-intervention follow-up included 175 dyads: 86 in the PFR group and 89 in the comparison group. Children were an average of 18 months old at the time of enrollment. Most caregivers and children were White (77 percent of caregivers and 57 percent of children); 10 percent of caregivers and 14 percent of children were Black and 9 percent of caregivers and 10 percent of children were Hispanic or Latino. About one-quarter of dyads reported household incomes less than $20,000 per year. Caregivers reported an average of 13 years of education. |
|---|---|
| Setting | The study took place in one county in Washington State. |
| Intervention services | Promoting First Relationships – Home Visiting Intervention Model consisted of 10 weekly sessions, each lasting 60 to 75 minutes. The home visit content was informed by attachment theory and aimed to increase parenting sensitivity. All sessions took place in the families' homes. During weekly home visits, home visitors covered the activities and instructional content in the Promoting First Relationships manual, tailoring the pace of delivery for each caregiver. Home visitors videotaped five caregiver-child interactions; they reviewed these videos with the caregivers and guided a discussion about the strengths demonstrated by the caregiver and the caregiver’s interpretation of the child's cues. Additional activities during the home visits included the review of handouts on topics related to attachment theory. |
| Comparison conditions | The comparison group members were not offered intervention services through Promoting First Relationships. Dyads assigned to the comparison group received Early Education Support, which consisted of three monthly 90-minute home visits conducted by home visitors with bachelor’s degrees. The home visitor helped connect families to resources such as Early Head Start, early intervention, housing, mental health services, and child care; and suggested activities to promote the child's growth and development. |
| Subgroups examined |
This field lists subgroups examined in the manuscript (even if they were not replicated in other samples and not reported on the summary page for this model’s report). There were no subgroups reported in the manuscript. |
| Funding sources | This research was supported by Award Number R01 MH077329 from the National Institute of Mental Health and Award Number P30 HD02274 from the National Institute of Child Health and Human Development. |
| Author affiliation | The authors are affiliated with the Barnard Center at the University of Washington, which sponsors Promoting First Relationships. Monica Oxford, one of the authors of the manuscript, is the executive director of Promoting First Relationships. Jean F. Kelly, another author, is a developer of the Promoting First Relationships model. |
| Peer reviewed | Yes |
Clinicaltrials.gov Identifier: NCT00339365. SocialScienceRegistry.org Identifier: None found. Registry of Efficacy and Effectiveness Studies Identifier: None found. Study registration was assessed by HomVEE for Clinicaltrials.gov beginning with the 2014 review, and for other registries beginning with the 2021 review.
Findings that rate moderate or high
| Rating | Outcome measure | Effect | Sample | Timing of follow-up | Sample size | Intervention group | Comparison group | Group difference | Effect size | Statistical significance | Notes |
|---|---|---|---|---|---|---|---|---|---|---|---|
| High | Attachment security: Toddler Attachment Sort-45 (TAS45, modified version of Attachment Q-Sort, using trilemmas) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
175 children | Not reported | Not reported | Not reported | Not available | Not statistically significant, p= >0.10 |
Finding estimated with hierarchical linear model (HLM). |
| High | Attachment security: Toddler Attachment Sort-45 (TAS45, modified version of Attachment Q-Sort, using trilemmas) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
175 children | Adjusted mean = 0.58 | Adjusted mean = 0.54 | Mean difference = 0.04 | Study reported = 0.16 | Not statistically significant, p= 0.41 |
|
| High | Competence: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 11 item subscale) | FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
175 children | Not reported | Not reported | Not reported | Not available | Not statistically significant, p= >0.10 |
Finding estimated with hierarchical linear model (HLM). |
| High | Competence: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 11 item subscale) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
163 children | Adjusted mean = 17.35 | Adjusted mean = 16.38 | Mean difference = 0.97 | Study reported = 0.42 | Statistically significant, p= 0.03 |
|
| High | Problem behavior: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 31 item subscale) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample | Post-intervention |
175 children | Not reported | Not reported | Not reported | Not available | Not statistically significant, p= >0.10 |
Negative effect is favorable to the intervention. Finding estimated with hierarchical linear model (HLM). |
| High | Problem behavior: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 31 item subscale) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
163 children | Adjusted mean = 10.81 | Adjusted mean = 10.72 | Mean difference = 0.09 | Study reported = -0.02 | Not statistically significant, p= 0.92 |
Negative effect is favorable to the intervention. |
| Rating | Outcome measure | Effect | Sample | Timing of follow-up | Sample size | Intervention group | Comparison group | Group difference | Effect size | Statistical significance | Notes |
|---|---|---|---|---|---|---|---|---|---|---|---|
| High | Stress-Difficult Child: Parenting Stress Index-Short Form (PSI-SF, Difficult Child subscale, 12 items) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
175 caregivers | Not reported | Not reported | Not reported | Not available | Not statistically significant, p= >0.10 |
Negative effect is favorable to the intervention. Finding estimated with hierarchical linear model (HLM). |
| High | Stress-Difficult Child: Parenting Stress Index-Short Form (PSI-SF, Difficult Child subscale, 12 items) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
175 caregivers | Adjusted mean = 10.45 | Adjusted mean = 9.50 | Mean difference = 0.95 | Study reported = -0.22 | Not statistically significant, p= 0.22 |
Negative effect is favorable to the intervention. |
| High | Stress-Dysfunctional Interaction: Parenting Stress Index-Short Form (PSI-SF, Parent-Child Dysfunction subscale, 11 items) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
175 caregivers | Adjusted mean = 6.13 | Adjusted mean = 5.65 | Mean difference = 0.48 | Study reported = -0.13 | Not statistically significant, p= 0.48 |
Negative effect is favorable to the intervention. |
| High | Stress-Dysfunctional Interaction: Parenting Stress Index-Short Form (PSI-SF, Parent-Child Dysfunction subscale, 11 items) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention | 175 caregivers | Not reported | Not reported | Not reported | Not available | Not statistically significant, p= >0.10 |
Negative effect is favorable to the intervention. Finding estimated with hierarchical linear model (HLM). |
| Rating | Outcome measure | Effect | Sample | Timing of follow-up | Sample size | Intervention group | Comparison group | Group difference | Effect size | Statistical significance | Notes |
|---|---|---|---|---|---|---|---|---|---|---|---|
| High | Commitment: This Is My Baby (TIMB) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
169 caregivers | Not reported | Not reported | Not reported | Not available | Not statistically significant, p= >0.10 |
Finding estimated with hierarchical linear model (HLM). |
| High | Commitment: This Is My Baby (TIMB) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
169 caregivers | Adjusted mean = 4.10 | Adjusted mean = 4.21 | Mean difference = -0.11 | Study reported = -0.17 | Not statistically significant, p= 0.35 |
|
| High | Engagement: Indicator of Parent-Child Interaction (IPCI, 9 item subscale) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
173 children | Not reported | Not reported | Not reported | Not available | Not statistically significant, p= >0.10 |
Finding estimated with hierarchical linear model (HLM). |
| High | Engagement: Indicator of Parent-Child Interaction (IPCI, 9 item subscale) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
173 children | Adjusted mean = 2.08 | Adjusted mean = 2.15 | Mean difference = -0.07 | Study reported = -0.15 | Not statistically significant, p= 0.39 |
|
| High | Sensitivity: Nursing Child Assessment Teaching Scale (NCATS, without 6 items on child distress) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
167 caregivers | Adjusted mean = 13.26 | Adjusted mean = 11.76 | Mean difference = 1.50 | Study reported = 0.41 | Statistically significant, p= 0.02 |
|
| High | Support: Indicator of Parent-Child Interaction (IPCI, 15 items) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
173 caregivers | Not reported | Not reported | Not reported | Not available | Not statistically significant, p= >0.10 |
Finding estimated with hierarchical linear model (HLM). |
| High | Support: Indicator of Parent-Child Interaction (IPCI, 15 items) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
173 caregivers | Adjusted mean = 2.18 | Adjusted mean = 2.14 | Mean difference = 0.04 | Study reported = 0.11 | Not statistically significant, p= 0.49 |
|
| High | Understanding of toddlers: Raising a Baby (RAB, 16 items) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention | 175 caregivers | Not reported | Not reported | Not reported | Not available | Statistically significant, p= <0.01 |
Finding estimated with hierarchical linear model (HLM). |
| High | Understanding of toddlers: Raising a Baby (RAB, 16 items) |
FavorableUnfavorable or ambiguousNo Effect |
PFR vs. EES, one county in Washington state, 2007-2010, full sample |
Post-intervention |
175 caregivers | Adjusted mean = 52.16 | Adjusted mean = 50.92 | Mean difference = 1.24 | Study reported = 0.36 | Statistically significant, p= 0.04 |