Quasi-Experimental and Implementation Projects

In 1998, Dr. Kelly received a grant to provide Promoting First Relationships (PFR) to families experiencing homelessness. She and her colleague Kim Buehlman trained parent-child advocates in King County, WA. This project continued in 1999 through a collaboration between Health Care for the Homeless Network and the Department of Family and Child Nursing at the University of Washington, showing significant improvements in provider behavior and parent-child interactions, as reported in the Topics in Early Childhood Special Education, Vol 20, Issue 3, Fall of 2000: Training Personnel to Promote Quality Parent-Child Interaction in Families Who Are Homeless.  Providers became more positive, contingent and instructive to parents about their interactions with their young children. Mothers became more contingent, socially and emotionally growth fostering, and stimulating in their interactions with their children.

As a result of these successful efforts, in 2000, PFR partnered with the Washington State Department of Health and Healthy Child Care Washington to enhance relationships between childcare providers and young children. Nurse consultants were trained across Washington to promote social-emotional health and early development in childcare settings. Results from qualitative evaluations revealed that the unique on-site videotaping method and positive feedback approach were important elements of the training model. Providers reported improved understanding and empathy for children’s emotional needs and improved strategies for dealing with behavioral issues.

From 2001-2002, with funding from the Administration for Children and Families, PFR trained Early Head Start home visitors and center-based providers in western Washington. Trainees reported that videotaping is a powerful learning tool for both providers and families, and that caregivers value the attachment-based approach. Providers further reported that the training helped them understand the family’s and child’s world, and to help parents feel and become more successful in their parenting roles. This training project showed that PFR is successful and valued in both home and center-based settings.

In 2003, we again worked with Early Head Start as part of our Healthy Child Care Washington contract with the Department of Health. We partnered with a combination home- and center-based program to train the agency’s 25-member staff in Promoting First Relationships, and to evaluate the results of training on provider behavior in both home and center-based settings. Results showed significant changes from pre-training to post-training. On the “Ways of Being” measure (Kelly, Buehlman, & Korfmacher, 2003), center-based providers showed significant change, increasing their behavior that promoted mutuality and stimulated learning. Results were presented at the Zero to Three National Training Institute in Orlando, Florida (Oxford, M. & Kelly, J.F., 2007). See poster.

In 2002-2003, Promoting First Relationships was funded by the Washington State Department of Social and Health Services Infant-Toddler Early Education Program to train service providers in Washington State who work with young children (birth to three) with disabilities and their families, and to evaluate the results of training. Data analyses showed that as a result of training, service providers concentrated a significantly greater amount of their intervention on enhancing the parent-child relationship. Providers used more positive, instructive, and reflective strategies with the mothers. As a result, parents scored significantly higher on the NCAST Teaching Scale from before to after the 8 weekly intervention visits. Mothers became more growth fostering in their interactions with their young children, more contingent, and showed more overall responsiveness and sensitivity with their children. Additionally, children became more responsive and contingent with their mothers. Full results are reported in Infants and Young Children, Vol 21, No. 4, pp. 285-295.

With funding from the Annie E. Casey Foundation, beginning in 2004, the Promoting First Relationships program partnered with the Evans School of Public Affairs to improve the quality of care provided by “family, friends, and neighbors” for very young children. The program was implemented with low-income grandmothers who provided care to their grandchildren in different racial and ethnic communities, through both home visits and small-group classes. This project showed feasibility in offering PFR to grandmothers in both group and home-visiting models. As a result of the intervention, quantitative results showed improved caregiving skills and decreased grandmother depression. Qualitative analyses of post-intervention interviews showed perceived change in grandmother’s caregiving behaviors, children’s behaviors, and the grandmother-daughter relationship. These results are reported in Maher, E., Kelly, J.F., Scarpa, J. (2008). A Qualitative Evaluation of a Program to Support Family, Friend, and Neighbor Caregivers. The NHSA Dialog: A Research-to-Practice Journal for the Early Intervention Field, Volume 11, Issue 2, April. As part of this grant, we conducted a focus group on the cultural appropriateness of the PFR curriculum, involving participants from different cultural and ethnic groups, which led to improvements in the Promoting First Relationships curriculum.

From 2005-2007, the Promoting First Relationships program received funding from the Bill and Melinda Gates Foundation to reach the goal of family stabilization for families with young children transitioning from homelessness. The plan for the program, as informed by needs assessments gathered from families and transitional housing staff, was to increase family stabilization by providing training to program staff working with families with young children (birth through 6 years), and to evaluate the effects of training on staff skills and knowledge as well as parent and child functioning.

Participating in PFR training improved staff attitudes toward children and parents, expanded staff knowledge of relationship-focused content, and changed observed staff behavior with families such that it became less directive, more positive, and more supportive of the parent-child relationship from before to after training. Observed interactions showed that staff became more focused on the parent-child relationship instead of focused solely on the parent. In our model of change, as staff began to engage in more supportive relationships with parents, the parents were better able to support their children.

Parent and child outcomes demonstrated that the 10-session PFR individual and group training for parents is an effective intervention for families in the transition from homelessness. Specifically, participating in the PFR training had positive effects on parent attitudes, parent perceived stress, and their observed social and emotional growth fostering of their children. As a result of changes in parenting attitudes and interactional behavior, the children (observed interacting with their parents) began to interact more with their parents, became more securely attached, and became more socially competent then before the training, with fewer behavior problems. Presented by Kelly and Spieker (2008). Promoting First Relationships: Results of a Training Program with Providers Serving Homeless Families. Zero to Three National Training Institute, Los Angeles, November 2008. See Poster.

From 2007-2011, Promoting First Relationships contracted with the Washington State’s Children’s Administration to conduct training with family support home visitors and staff at therapeutic childcares, serving families with a Child Protective Services (CPS) referral and Foster Care parents. As part of this contract, Promoting First Relationships developed a Train-the-Trainer model in which providers received intensive on-site training with a Promoting First Relationships Master Trainer to learn how to deliver the PFR program to fidelity with families and to train colleagues at their agency to deliver PFR. The Train-the-Trainer model helped substantially increase the number of providers delivering PFR which increased the ability to reach more families and children.

From 2007 to Present (on-going), with funding from King County, Promoting First Relationships began training providers at local nonprofit agencies to utilize infant mental health practices in their work. The participating agencies include mental health agencies, family support centers, housing support, birth-to-three developmental centers, therapeutic childcares and public health. Both the Train-the-Trainer model (now called Level 3 Agency Trainer model) as well as the Train-the-Learner model (now called Level 2 Certified Provider model) are available for agencies to choose the training model that best fits the size of their organization and number of providers to be trained. This is an on-going contract that has trained approximately 270 providers over the years, with additional agencies applying for training each year.

Beginning in Fall 2011, the Promoting First Relationships program introduced their newly developed distance learning training in order to train providers across the United States and internationally.  PFR Master Trainers use a video series and online training platform that covers the core program principles as well as weekly online mentoring sessions to train providers in how to implement the PFR program with families at their site. Across the US, providers have been trained in Florida, Delaware, North Carolina, South Dakota, Kansas, Texas, New Mexico, Montana, Idaho, California and throughout Washington state using this distance learning format.  Additionally, we have been able to train providers around the world including in Australia, Canada, Turkey, and Switzerland.Top of Form

From 2013 to 2016, Promoting First Relationships was part of an implementation study conducted at the University of Delaware with Early Head Start staff. The study documented the experiences of seven home visitors’ experiences with the training, implementation, and use of the PFR program with families. Overall, home visitors had positive experiences with the program and found that they grew in their home visiting practice with families, and that families benefitted from the 10-week program.  Through this study, home visitors identified the need for additional ongoing support at their site, which prompted the decision to train an Agency Trainer who completed additional training to be able to support the home visitors locally. Results are reported in Han, M., Hallam, R., Hustedt, J. Vu, J., and Gaviria-Loaiza, J. (2016). Lessons from Training Early Head Start Staff to Implement an Evidence-Based Parenting Intervention. Dialog, 19 (3), 42-59.

From 2014 to Present (ongoing), the Washington State Children’s Administration, now Department for Children, Youth, and Families Child Welfare division, selected Promoting First Relationships as one of the approved evidence-based models to support parents and foster care parents who have children birth to five in their care, with an open case with Children’s Administration. Approximately 200 providers across the state have been trained in Promoting First Relationships.  As part of this contract, strict fidelity to the model is required. Active PFR providers receive monthly reflective consultation to support them in their work and complete an annual recertification process.

From 2016 to Present (ongoing), the Washington State Department of Early Learning, now Department for Children, Youth, and Families Early Support for Infants and Toddlers (ESIT) division, as Part C of the Individuals with Disabilities Education Act (IDEA), selected Promoting First Relationships as the statewide model dedicated to the outcome of promoting children’s social-emotional development through responsive, nurturing caregiver-child relationships. Over 1,200 providers across the state have been trained at the Level 1 workshop or above. More than 150 providers have received the more extensive Level 2 Certified Provider or Level 3 Agency Trainer training.  All DCYF ESIT providers have access to monthly reflective consultation either through their PFR Agency Trainer, a PFR Master Trainer, or an approved Infant and Early Childhood Mental Health consultant with the state.

After presenting research results at the 2018 Blueprints for Healthy Development conference, Promoting First Relationships caught the interest of a program director from Australia who was seeking an effective, relationship-focused program for families and young children. From 2018 to Present (ongoing), PFR began implementation with Kids First Australia located near Melbourne, Australia. The PFR program trains providers serving families impacted by family violence, and also staff in their early years department. To date, 38 providers have been trained at either PFR level 2 or level 3. Utilizing an Agency Trainer model at this site has been an important method to grow and sustain the program.

From 2018 to Present (ongoing), Promoting First Relationships began implementation in Cornwall, Ontario in their community mental health division. Public Health Nurses in Ontario identified the Promoting First Relationships model after receiving training in Parent-Child Relationship Programs’ PCI assessment scales and recommended the program to their community mental health department.

From 2019 to Present, Parent-Child Assistance Programs, a case management program that provides up to 3 years comprehensive support for parents impacted by substance use and their young children, began training providers in Promoting First Relationships. All case managers across the state receive at least Level 1 training, while over 25 providers have received the evidence-based level 2 model. Trained providers deliver the 10-week model and also infuse the PFR concepts into their case management work with families.

As a result of the pandemic, in late Spring of 2020, Promoting First Relationships redesigned its Level 1 training, which had always been delivered as an in-person workshop, to be delivered virtually. The training was converted from a 2-day workshop to a training conducted over 4 half-days in order to reduce screen time and online fatigue. PFR Master Trainer Carol Good was instrumental in transforming the workshop from a live to a virtual experience, creating an engaging and interactive experience. The creation of a virtual Level 1 training has led to record levels of trainings and participants, as people from around the country and around world are able to participate without the cost and time of travel.

From 2022 to 2025, the Northwest Center for Family Support at the University of Washington, with funding from the Foundation for Opioid Response Efforts, engaged in an implementation study to build capacity to support families impacted by opioid use disorder.  Promoting First Relationships was selected as the evidence-based birth to five model to support parents and young children throughout Washington state. Over the three-year project, nearly 40 providers were trained in the model. As part of this project, Promoting First Relationships was delivered on an individual basis utilizing the 10-week model, and also as a group model to parents in residential treatment homes who had their young children with them.

Starting in 2022, as Promoting First Relationships began to receive more national attention after being included in the top evidence-based lists such as the HomVee (Home Visiting Evidence of Effectiveness), California Evidence-Based Clearinghouse, and the clearinghouse for the Family First Prevention Services Act, agencies from states around the country have begun implementing the PFR model. PFR is currently implemented by San Mateo County in California, and Metrocare Dallas, Parkland Health, My Health My Resources of Tarrant County, Harris County, and Endeavors in Texas.

Email Jennifer Rees, rees@uw.edu for information on training in Promoting First Relationships.