Oct 18, 2016


Promoting First Relationships (PFR) is a home-based program designed to strengthen relationships between infants and toddlers and their caregivers, to support socio-emotional development in these children, and to improve caregiver sensitivity. An experimental study found that children in the group receiving PFR had significantly higher socio-emotional competence scores than children in the control group at the posttest evaluation. Similarly, a two-year follow-up study found positive impacts of PFR on stability and permanency among children whose primary caregivers were foster/kin caregivers. There were no significant impacts on other outcomes, such as attachment security, engagement, and emotional regulation, in either the immediate posttest evaluation or the six-month follow-up.


Target population: Infants, toddlers, and their caregivers

The relationships infants and toddlers form with their caregivers provide a foundation for social and emotional development. The Promoting First Relationships program was designed to foster these relationships, with a focus on improving caregivers’ understanding of children’s behavior and emotions. PFR providers use home visits to provide feedback to caregivers on videotaped interactions between caregivers and their children, giving insight into the underlying causes of behavior in infants and toddlers. These providers receive at least two days of training; higher levels of training include twenty mentored site visits, or the completion of an online course. Additional PFR resources used in the program include print and DVD learning materials for caregivers.

The main goal of PFR is to build a stronger, more secure, and more trusting relationship between caregiver and child. On the caregiver side, PFR encourages caregivers to reflect on past interactions to better understand children’s needs, emotions, and actions. The intended outcome of PFR is care that is more responsive to the child and better promotes their socio-emotional development. The program consists of 10 weeks of one-hour sessions with a provider. The PFR curriculum is standardized and taught through print materials and training sessions.


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 Maltreatment17, 271-286.

Evaluated population: At the beginning of the program, 210 toddler (10 to 24 months old) and caregiver pairs made up the study sample for this evaluation. Fifty-five percent of the toddlers were white, 20 percent had mixed-raced heritage, 15 percent were African American, and the remaining 10 percent were from other races. Hispanic infants made up 11 percent of the sample. The mean age was 18 months. Forty-two percent of caregivers were foster parents, 31 percent were adult kin, and the remaining 27 percent were biological parents. Just under a quarter of the toddlers were in households that earned less than $20,000 per year. The average number of caregiver changes the children had experienced since birth was 2.7, and the average age at the time of first removal from a caregiver was approximately 11 months.

Approach: Toddler-caregiver dyads were identified as eligible for the study if the toddler was 10 to 24 months old, had experienced a court-ordered change in primary caregiver in the previous seven weeks, and if their primary caregiver was an English-speaking foster parent, biological parent, or adult kin of the child. Dyads were contacted, identified as eligible, and recruited by a state Department of Social and Health Services worker. The 210 dyads eligible at the beginning of the study were randomly assigned to the PFR intervention group or the Early Education Support (EES) control group. At baseline, children in the intervention group were more likely to have experienced two or more removals from their birth home, but otherwise the control and treatment groups were demographically similar. The PFR group received ten weeks of 60-75-minute-long sessions with a provider in the caregiver’s home, consistent with the PFR curriculum. The EES group received one 90-minute home visit from a provider, each month for the three-month duration of the study, during which providers would connect caregivers with child care resources, and suggest activities the dyad could engage in to foster growth and development. PFR providers went through 90 hours of training over six months, including practice site visits with trained PFR mentors. Ultimately, 71 percent of PFR caregivers received all ten weekly sessions, and 81 percent of EES caregivers received all three monthly sessions.

The child outcomes measured were attachment security, engagement with caregivers, socio-emotional competence, problem behavior, emotional regulation, and orientation; each construct was scored using behavioral assessment tools. Data on all outcomes except emotional regulation and orientation were collected at enrollment, posttest, and in a six-month follow-up. Emotional regulation and orientation data were collected only at the start of the study and in the follow-up. If a dyad separated between the start of the study and a subsequent measurement period, data from that dyad unwire not used. Out of the original 210 dyads, 175 remained unseparated at the end of the study, and 129 were still intact for the follow-up.

Results: While researchers found significant improvements in caregiver sensitivity in the PFR group, child outcomes were not significantly improved. At posttest, toddlers who received the PFR treatment had a significant improvement in their socio-emotional competence compared with the control group (an effect-size of 0.42). However, this positive impact was not found at the six-month follow-up. In the six-month follow-up, researchers found a marginally significant decrease in reported sleeping problems (an effect-size of 0.34) among PFR-treated toddlers. Besides these two positive impacts, the treatment group did not demonstrate greater improvements in the measured outcomes compared with the EES group, in either the posttest or follow-up evaluations. However, researchers did not find the PFR treatment had any significant negative impacts on children.

Spieker J.S., 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.

Evaluated Population: Same as above.

Approach:  This study was a two-year follow-up after the initial randomization of the child and caregiver dyads into the PFR or EES interventions, and it examined the outcomes of stability and permanency. Stability was determined by whether or not the child had stayed with the same caregiver, such as a parent or foster/kin caregiver. Permanency was determined by placement with parent, adoption by a kin or non-kin caregiver, or legal guardianship by a kin.

Results:   The study condition (intervention or control) did not have a significant overall impact on the likelihood of the child achieving either permanency or stability. However, significant interactions were found between caregiver type and group assignment. Among children whose caregivers were foster parents or kin, a marginally significant positive impact of PFR was found on stability (OR=3.91), and a significant positive impact of PFR was found on permanency (OR=9.67), compared with children whose caregivers were their birth parents.


Curriculum materials available for purchase at:


Spieker, S.J., Oxford, M.L., Kelly, J.F., Nelson, E.M., & Fleming, C.B. (2012). Promoting first relationships: Randomized trial of a relationship-based intervention for toddlers in child welfare. Child Maltreatment, 17, 271-286.

Spieker J.S., 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.

Contact Information

Jennifer Rees, Program and Training Manager


KEYWORDS: Infants (0-12 months), toddlers (12-36 months), males and females (co-ed), home-based, community-based, manual, home visitation, parent or family component, family therapy, parent training/education, child care, child maltreatment, conduct/disruptive disorders, other social/emotional health, other behavioral.

Program information last updated on 10/18/2016.