Promoting First Relationships: Randomized Trial of a Relationship-Based Intervention for Toddlers in Child Welfare
Open accessAbstract
We conducted a community-based, randomized control trial with intent-to-treat analyses of Promoting First Relationships (PFR) to improve parenting and toddler outcomes for toddlers in state dependency. Toddlers (10–24 months; N = 210) with a recent placement disruption were randomized to 10-week PFR or a comparison condition. Community agency providers were trained to use PFR in the intervention for caregivers. From baseline to postintervention, observational ratings of caregiver sensitivity improved more in the PFR condition than in the comparison condition, with an effect size for the difference in adjusted means postintervention of d = .41. Caregiver understanding of toddlers’ social emotional needs and caregiver reports of child competence also differed by intervention condition postintervention ( d = .36 and d = .42) with caregivers in the PFR condition reporting more understanding of toddlers and child competence. Models of PFR effects on within-individual change were significant for caregiver sensitivity and understanding of toddlers. At the 6-month follow-up, only 61% of original sample dyads were still intact and there were no significant differences on caregiver or child outcomes.
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PFR did not change attachment security either immediately after intervention or at six months.
“Although successful in improving sensitivity, postintervention and 6-month follow up revealed no changes in attachment security.”
From Relational Interventions for Maltreated Children (2017) · cites this paper as Spieker et al., 2012
A randomized PFR trial found caregivers improved more than an educational comparison group in sensitivity (d=.41) and in understanding children's emotional needs (d=.36).
“demonstrated that caregivers in the PFR condition had greater improvements in sensitivity (d = .41) and understanding of children’s emotional needs (d = .36) postintervention than did those in the educational comparison condition (Spieker et al., 2012).”
From Relational Interventions for Maltreated Children (2017) · cites this paper as Spieker et al., 2012
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“…ABC intervention, PFR addresses the concern that children who have had multiple caregivers due to their involvement in the child welfare system may give confusing signals, preventing the child from eliciting the nurturing response that they are seeking from their caregiver (Spieker et al., 2012).”
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Promoting First Relationships ®
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“This study was a secondary data analysis of an RCT of the PFR intervention (see Spieker et al., 2012) involving 210 toddlers (M age¼ 18.01 months, SD¼ 4.73, 56% boys) and their caregivers who were recruited into the Fostering Families Project between April 2007 and March 2010.”
BackgroundMethodResultInfluentialSelf-citationKohlhoff, J. R., Lieneman, C. C., Cibralic, S., Traynor, N. M., & McNeil, C. B. (2022) · Clinical Child and Family Psychology Review · doi:10.1007/s10567-022-00405-4 · Cited by 45 · see citing works
Ahun, M. N., Ali, N. B., Hentschel, E., Jeong, J., Franchett, E. E., & Yousafzai, A. K. (2024) · Annals of the New York Academy of Sciences · doi:10.1111/nyas.15110 · Cited by 35 · see citing works
Spieker, S. J., Oxford, M. L., & Fleming, C. B. (2014) · Children and Youth Services Review · doi:10.1016/j.childyouth.2014.06.017 · Cited by 35 · see citing works
“Zeanah et al. (2001) compared the permanency outcomes of 145 children under four years who entered care four years before the implementation of a multimodal, individualized assessment and intervention program directed to both birth families and foster families (comparison group), and 95 children who entered care four…”
BackgroundSelf-citationIntervention Effects on Morning and Stimulated Cortisol Responses among Toddlers in Foster Care
Nelson, E. M. M., & Spieker, S. J. (2013) · Infant Mental Health Journal · doi:10.1002/imhj.21382 · Cited by 35 · see citing works
“42), relative to caregivers in the comparison condition (Spieker et al., 2012), but this association was not apparent in the substudy.”
InfluentialSelf-citationOxford, M. L., Marcenko, M. O., Fleming, C. B., Lohr, M. J., & Spieker, S. J. (2015) · Children and Youth Services Review · doi:10.1016/j.childyouth.2015.12.004 · Cited by 34 · see citing works
“Consequently, we examined outcomes in the reunified subsample using the same approach as the main effects study (Spieker et al., 2012a).”
BackgroundMethodResultInfluentialSelf-citationMarcellus, L., & Badry, D. (2021) · International Journal of Developmental Disabilities · doi:10.1080/20473869.2021.1945890 · Cited by 31 · see citing works
“…including the Attachment and Biobehavioral Catch-up (ABC) intervention (Dozier et al. 2013), the Foster Family Intervention (FFI) (Van Andel et al. 2016), the New Orleans Intervention Model (Zeanah et al. 2011), and the Promoting First Relationships (PFR) intervention (Spieker et al. 2012).”
BackgroundParenting Intervention Outcomes for Kinship Caregivers and Child: A Systematic Review
Wu, Q., Zhu, Y.-Q., Ogbonnaya, I., Zhang, S.-J., & Wu, S. (2020) · International Journal of Child Abuse & Neglect · doi:10.1016/j.chiabu.2020.104524 · Cited by 28 · see citing works
“Some interventions (Pasalich et al., 2016; Spieker et al., 2012; Spieker et al., 2014), such as the Promoting First Relationship program, focused on improving the relationship between caregivers and the cared for children.”
BackgroundOxford, M. L., Fleming, C. B., Nelson, E. M. M., Kelly, J. F., & Spieker, S. J. (2013) · Children and Youth Services Review · doi:10.1016/j.childyouth.2013.09.021 · Cited by 29 · see citing works
Self-citationImpact of a home visiting program on sleep problems among young children experiencing adversity
Hash, J. B., Oxford, M. L., Fleming, C. B., Ward, T. M., Spieker, S. J., & Lohr, M. J. (2019) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2018.12.016 · Cited by 28 · see citing works
“This finding is contrary to our hypotheses and conflicts with findings from the priormentioned study showing fewer sleep problems among infants and toddlers who received PFR (Oxford et al., 2013; Spieker et al., 2012).”
BackgroundMethodResultInfluentialSelf-citationPasalich, D. S., Fleming, C. B., Spieker, S. J., Lohr, M. J., & Oxford, M. L. (2018) · Child Maltreatment · doi:10.1177/1077559518809217 · Cited by 25 · see citing works
“Findings from a prior RCT of PFR in toddlers who had recently entered a new foster/kinship placement or were reunified (Spieker et al., 2012) indicate potential benefits of PFR for reducing risk of poor behavioral outcomes in children who have experienced unstable placements.”
Self-citationBooth‐LaForce, C., Oxford, M. L., Barbosa‐Leiker, C., Burduli, E., & Buchwald, D. (2019) · Prevention Science · doi:10.1007/s11121-019-01053-x · Cited by 25 · see citing works
“Both Spieker et al. (2012) and Oxford et al. (2016) found that PFR, compared with a control treatment, significantly improved the quality of parent-child interaction, as well as caregivers’ knowledge of toddlers’ social-emotional needs and level of developmentally appropriate expectations.”
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“That a relatively short-term, structured, and intensive intervention procedure like the AVI and others (Bernard et al., 2015; Spieker et al., 2012) serves to positively influence maternal sensitivity provides a degree of hope for both caseworkers and the families they work with.”
Schoemaker, N. K., Juffer, F., Rippe, R. C. A., Vermeer, H. J., Stoltenborgh, M., Jagersma, G., Maras, A., & Alink, L. R. A. (2020) · Children and Youth Services Review · doi:10.1016/j.childyouth.2020.104779 · Cited by 24 · see citing works
“Effectiveness studies of PFR showed positive effects on parental sensitivity, parenting knowledge, and attachment security (Pasalich, Fleming, Oxford, Zheng, & Spieker, 2016; Spieker et al., 2012).”
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Adapting an evidence-based parenting program for child welfare involved teens and their caregivers
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Kuklinski, M. R., Oxford, M. L., Spieker, S. J., Lohr, M. J., & Fleming, C. B. (2020) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2020.104515 · Cited by 15 · see citing works
“Significant intervention-related gains in parent understanding of toddlers, child atypical affective communication, and especially parent sensitivity (Booth-LaForce et al., 2020; Oxford, Marcenko, et al., 2016; Oxford, Spieker, et al., 2016; Spieker et al., 2012), along with improved child stress physiology (Hastings…”
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“In two prior RCTs conducted in child welfare populations, caregivers who participated in PFR demonstrated an increase both in observed caregiver sensitivity and in their knowledge of child development (Oxford et al., 2016; Spieker et al., 2012).”
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“…the parents notice, reflect on and interpret the meaning of their child’s behavior and thereby help the parents acquire deeper understanding of their child’s needs and expectations, reorganize the meaning of challenging behavior and regulate potential interaction problems (Spieker et al. 2012).”
BackgroundTouati, C. D., Miljkovitch, R., Sirparanta, A., & Deborde, A.-S. (2021) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2020.104886 · Cited by 13 · see citing works
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“Another RCT examined a parent training intervention that included 60-min in-home weekly sessions over 10 wk; the only signi fi cant caregiver outcome was improved sensitivity, with a medium effect size (Spieker et al., 2012).”
Jessee, A., McElwain, N. L., & Booth‐LaForce, C. (2016) · Parenting · doi:10.1080/15295192.2016.1134988 · Cited by 11 · see citing works
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Hash, J. B., Oxford, M. L., Fleming, C. B., Ward, T. M., & Spieker, S. J. (2019) · Behavioral Sleep Medicine · doi:10.1080/15402002.2019.1611579 · Cited by 11 · see citing works
“…the Promoting First Relationships home visiting program suggests that a home visiting model could be a feasible and effective way of reducing parent-perceived sleep problems among young children involved with CPS (Hash et al., 2019) and child welfare (Oxford et al., 2013; Spieker et al., 2012).”
BackgroundSelf-citationIntimate Partner Violence Across the Lifespan: Dyadic Theory and Risk and Protective Factors
Capaldi, D. M., Low, S. K., Tiberio, S. S., & Shortt, J. W. (2019) · Springer eBooks · doi:10.1007/978-3-319-62122-7_151-1 · Cited by 10 · see citing works
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“HHYP includes several delivery methods that have robust empirical support in trials with families at risk of, or with a history of, maltreatment, including video-feedback [e.g., 41–43] and in-vivo coaching [e.g., 44–46].”
Oxford, M. L., Hash, J. B., Lohr, M. J., Fleming, C. B., Dow‐Smith, C., & Spieker, S. J. (2023) · Infant Mental Health Journal · doi:10.1002/imhj.22050 · Cited by 8 · see citing works
Self-citationAttachment and Early Language Development: Implications for Early Intervention
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Parents' Perspectives on Early Relational Health: A Qualitative Study
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“37 Past work has indicated that a parent-child relational framework could be a promising strategy to train residents in developmental assessment.”
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Intimate Partner Violence Across the Lifespan: Dyadic Theory and Risk and Protective Factors
Capaldi, D. M., Low, S. K., Tiberio, S. S., & Shortt, J. W. (2021) · Springer eBooks · doi:10.1007/978-3-319-89999-2_151 · Cited by 5 · see citing works
Oxford, M. L., Abrahamson-Richards, T., O’Leary, R., Booth‐LaForce, C., Spieker, S. J., Lohr, M. J., Rees, J. R., & Kelly, J. F. (2024) · Infant Mental Health Journal · doi:10.1002/imhj.22153 · Cited by 5 · see citing works
“Two trials were conducted with child welfare populations (Oxford et al., 2016; Spieker et al., 2012), two with rural Native communities (Booth-LaForce et al., 2020, 2022), and one with Spanish and English-speaking new mothers who had received prenatal mental health referrals from community health…”
Self-citationProgress in Developing Responsive Parenting Programs for Child Welfare–Involved Infants
Barth, R. P. (2012) · Child Maltreatment · doi:10.1177/1077559512466586 · Cited by 5 · see citing works
“Despite these concerns, the Spieker et al. (2012) research does provide promising evidence for changing parenting behavior.”
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“Though prior randomized trials (Oxford et al., 2016; Spieker et al., 2012) show that PFR produces positive impacts in parenting, including increased sensitivity, we did not find direct effects of PFR on the outcomes examined in the current study.”
InfluentialChazan‐Cohen, R., Ende, A. V., & Lombardi, C. M. (2023) · Frontiers in Psychology · doi:10.3389/fpsyg.2023.1302687 · Cited by 5 · see citing works
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“…0.15 0.68 -0.37 .567 (Messer et al., 2018) -0.45 7.82 -8.50 .921 (Reddy et al, 2013) 0.31 0.77 -0.15 .193 (Smith et al, 2012) 0.58 1.29 -0.13 .112 (Spieker et al, 2012) 0 analyses using mixed-effects regression (methods of moment) revealed no statistically significant association between the…”
BackgroundInfluentialO’Leary, R., Oxford, M. L., Booth‐LaForce, C., London, S., & Buchwald, D. (2022) · Maternal and Child Health Journal · doi:10.1007/s10995-022-03533-z · Cited by 4 · see citing works
“, 2019), social attention and competence (Jones et al., 2017; Spieker et al., 2012), and normalizes stimulated cortisol (Nelson & Spieker, 2013), while decreasing the child’s affective communication errors (Oxford et al.”
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Psychosocial Consequences and Treatments for Maltreated Children
Fitzgerald, M., & Berliner, L. (2014) · Child maltreatment · doi:10.1007/978-94-007-7208-3_20 · Cited by 5 · see citing works
Response to the Barth Commentary (2012)
Spieker, S. J., Oxford, M. L., Kelly, J. F., Nelson, E. M. M., & Fleming, C. B. (2012) · Child Maltreatment · doi:10.1177/1077559512467396 · Cited by 3 · see citing works
“By the time we completed the trial examined in Spieker et al. (2012), PFR developers had piloted and revised a distance learning training model, with mentorship via video conferencing, making wider dissemination to child welfare agencies more feasible and affordable.”
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Self-citationThe Parent University Program: Factors Predicting Change in Responsive Parenting Behaviors
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Childhood maltreatment and sleep
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Women and Infants Affected by Incarceration: The Potential Value of Home Visiting Program Engagement
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Care practices and approaches with children experiencing attachment difficulties: A scoping review
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Home attachment-based interventions in child protection services: A systematic review
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Promoting Early Childhood Development in the Pediatric Medical Home
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Maltraitance et négligence de l’enfant : apport de la théorie de l’attachement
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“Nevertheless, there were no enduring post-intervention effects on attachment outcomes (Spieker, et al., 2012).”
BackgroundLessons from Training Early Head Start Staff to Implement an Evidence-Based Parenting Intervention
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Maltraitance et négligence de l’enfant : apport de la théorie de l’attachement
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I like you, do you like me? How gender, context, and aggression predict liking.
Marian, M., da Cunha, J. M., & Santo, J. B. (2019) · Psicologia Argumento · doi:10.7213/psicolargum.36.93.ao07
“Peer rejection is tied to peer victimization and can lead to maladjustment, poor grades, and other developmental issues (Crick et al., 2006; Lansford et al., 2010; Preddy & Fite, 2012; Spieker et al., 2012).”
BackgroundPsychosocial Treatments: Psychotherapy, Behavioral, and Cultural Interventions
Trujillo, M. (2023) · Springer eBooks · doi:10.1007/978-3-031-15401-0_11
Crittenden, P. M., Farnfield, S., Spieker, S. J., Landini, A., Oxford, M. L., Robson, K., Karlsen, S., Johnson, H., Ellis, V., & Ash, Z. (2024) · IntechOpen eBooks · doi:10.5772/intechopen.1005127
Self-citationHash, J. B., Oxford, M. L., Nelson, D. C., Lohr, M. J., Fleming, C. B., de Castro, A. B., & Spieker, S. J. (2025) · Journal of Child and Family Studies · doi:10.1007/s10826-024-03003-w
“…PFR improved at least one child regulatory outcome including sleep (Hash et al., 2019; Oxford et al., 2013; Spieker et al., 2012), social-emotional competence (Spieker et al., 2012), stress physiology (Hastings et al., 2018; Nelson & Spieker, 2013), and externalizing behavior (Oxford et al., 2021).”
InfluentialSelf-citationGilbert, D. J., Price, A. D., Cook, P. A., & Mukherjee, R. (2025) · Children · doi:10.3390/children12091133
“Interventions are available to address insecure attachment in typically developing individuals, such as, for example, the Attachment and Biobehavioural Catch-Up intervention, Child–Parent Psychotherapy, and Promoting First Relationships (PFR) [47–50].”
Child life specialists in foster care: A case for child life in a nontraditional setting
Meyer, L. (n.d.) · ProQuest Demo Repository
- Authors
- Spieker, S. J., Oxford, M. L., Kelly, J. F., Nelson, E. M., & Fleming, C. B.
- Affiliations
- University of Washington (US)
- Venue
- Child Maltreatment
- Publisher
- SAGE Publications
- Published
- 2012-09-04
- Volume
- 17
- Issue
- 4
- Pages
- 271-286
- ISSN
- 1077-5595 (ISSN-L)
- 1552-6119
- PMC
- PMC3552521
- OpenAlex
- W2038885525
- Cited by
- 104
- References
- 66
- Citations by year
- 2026: 3 · 2025: 4 · 2024: 4 · 2023: 9 · 2022: 10 · 2021: 12 · 2020: 8 · 2019: 9 · 2018: 7 · 2017: 10 · 2016: 14 · 2015: 4 · 2014: 3 · 2013: 4 · 2012: 2
- FWCI
- 10.82
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Child Maltreatment (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (R01MH077329)
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (P30HD02274, P30HD002274)
- Topics
- Social Sciences › Safety Research › Child Welfare and Adoption
- Social Sciences › Education › Early Childhood Education and Development
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Keywords
- parenting support, caregiver sensitivity, placement disruption, child welfare, child competence, social-emotional needs, family reunification
- MeSH terms
- Child Behavior, Child Health Services, Child Welfare, Child, Preschool, Female, Health Promotion, Humans, Interpersonal Relations, Male, Object Attachment, Parent-Child Relations, Parenting, Caregivers
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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