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Promoting First Relationships®

Blueprints Program Rating: Promising

Trains 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.

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

    • Selective Prevention (Elevated Risk)
    • Indicated Prevention (Early Symptoms of Problem)

    Trains 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.

      Age

      • Infant (0-2)

      Gender

      • Male and Female

      Race/Ethnicity

      • All Race/Ethnicity

      Race/Ethnicity/Gender Details

      The study did not provide differential analysis by race/ethnicity or gender.

      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.

      • Family
      Risk Factors
      • Family: Parent stress

      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.

      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.

      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.

      • Attachment - Bonding

      Spieker et al. (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. (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.

      Spieker et al. (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. (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.

      A randomized control trial conducted by the developer (Spieker et al., 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. (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.

      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.

      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.

      All studies 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).

      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

      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).

      • Blueprints: Promising

      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

      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.

      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.