What is the Need for Promoting First Relationships Training

There is substantial evidence that the foundation of emotional organization, attention regulation, and communicative skill emerges from early, pleasurable interactions with caregivers (Emde and Sameroff, l989; Shonkoff and Phillips, 2000). All children are born into this world totally dependent on the relationships they develop with their parents and their caregivers, the people who are closest to them. These first relationships are the foundation for young children's growth and development in social, emotional, behavioral, language and cognitive domains. This is true for all children, including children with, or at risk for developmental disabilities.

A young child's social and emotional development, that is a positive sense of self and of others, can only be developed in the context of relationships. Social and emotional development, or mental health, begins from the first day of life and future growth and experiences are based on what a young child internalizes about himself and others. “Children grow and thrive in the context of close and dependable relationships that provide love and nurturance, security, responsive interaction, and encouragement for explorations. Without at least one such relationship, development is disrupted, and the consequences can be severe and long lasting” (Shonkoff and Phillips, 2000).

In a child's early years, what a child has internalized about his/her effect on others affects the child’s perception of social transactions, cognitions about social transactions, and behavioral responses. In addition, the child’s language and representational abilities permit the development of negotiation and joint plans with the caregiver regarding issues of self-control, emotion regulation, exploration, and safety. Robust findings in the field of psychology show a strong association between secure caregiver-child relationships and better functioning in a number of domains, including early language acquisition, peer competence, and resilience. In summary, young children need sensitive and secure relationships with the adults who are most important to them in order to grow in social-emotional, language and cognitive domains.

History
Dr. Jean Kelly first became interested in attachment theory in the late 1970’s while doing her dissertation research. She was greatly influenced by the work of Bowlby, Ainsworth, Chess, Thomas & Birch, Brazelton, Stern, etc.; as well as that of Kathryn Barnard, who was on her doctoral committee and one of her professors. In 1978, Dr. Kelly began her doctoral dissertation to promote parent-child relationships when the child has a diagnosed disability. The intervention she used at that time, a very early precursor to Promoting First Relationships, was the use of videotaped mother-child play and teaching to help mothers observe their interactions with their newborn to 3-year-old children. The intervention was a home-based, verbal feedback approach with an emphasis on reinforcing positive aspects already present in the interaction. Results of the treatment/matched control group study showed that parents in the treatment group became significantly more positive and less controlling in their initiations and responses to their children’s behavior. These results were published in the Journal of the Division for Early Childhood in 1982 (Vol. 5, June).

In the late 1980’s, Dr. Kelly had the privilege of coordinating the Attachment Working Group funded by the MacArthur Network on Transition from Infancy to Early Childhood. During this two-year period, Dr. Kelly learned much from Mary Ainsworth and her colleagues as they discussed and worked on attachment related issues and measures. It became clear that the effects of the attachment relationship on child development were substantial and long-lasting. Dr. Kelly’s subsequent role in the 1990’s as project director and investigator in the NICHD Study of Early Child Care further showed the importance of the early attachment relationship on developmental outcomes. In the late 1990’s she decided to turn from longitudinal research on social-emotional precursors, and revisited her initial work in the intervention field. In 1998, Dr. Kelly began one of many training and research grants using a videotape, verbal feedback approach to observe and support caregiver-child relationships. Thus began the intervention program, Promoting First Relationships, an attachment theory and reflective practice based approach to promoting secure and trusting caregiver-child relationships.

Results of Promoting First Relationships Training Efforts with Various Early Childhood Populations
In 1998, Dr. Kelly received a grant from the Royalty Research Fund to provide Promoting First Relationships to homeless families. Dr. Kelly and her colleague, Kim Buehlman, trained service providers (parent-child advocates) working with homeless families in King County, WA.  In 1999, this work continued in a collaboration between Health Care for the Homeless Network and the Department of Family and Child Nursing at the University of Washington. The results from this initial project were quite significant and are reported in 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. The article reports the significant change in provider behavior as a result of training. Providers became more positive, contingent and instructive to parents about their interactions with their young children. Mothers became more contingent, social and emotionally growth fostering, and stimulating in their interactions with their children.

As a result of these successful efforts, in the year 2000, PFR partnered with the Washington State Department of Health and Healthy Child Care Washington to enhance relationship quality between childcare providers and young children.  In this partnership, nurse consultants were trained to support childcare providers in their efforts to promote young children's social-emotional health and early development within the childcare setting. PFR staff trained nurse consultants and childcare providers in every health jurisdiction in the state of Washington. Trained nurses are expected to continue to train childcare providers within their jurisdiction.  Results from qualitative evaluations revealed that the unique on-site videotaping method and positive feedback approach are important elements of the training model. Providers expressed how they changed their perspective on children’s emotional needs, learned to be more empathetic, learned new strategies for dealing with behavioral issues, and came to better appreciate the important role they play in the child’s social and emotional development.

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 behavior to coach mothers during dyadic interaction. 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. Partial results were presented at the Zero To Three National Training Institute (December, 2003).  Dr. Kelly presented full results at the Society for Research in Child Development (SRCD) in Atlanta, GA (April, 2005), and full results are reported in Infants and Young Children, Vol 21, No. 4, pp. 285-295 .

From 2001-2002, PFR, funded by the Administration for Children and Families trained Early Head Start providers in western Washington (Region X). This project combined expertise in working with both child care providers and parent-child advocates, offering training to Early Head Start center-based providers as well as home visitors who work and intervene with the parent-child relationship. 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 training 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. Data collection ended in June, 2004. 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 from before to after PFR training. Specifically, they more often used interactive behaviors that promoted mutuality and stimulated learning. These results were presented at the Zero to Three National Training Institute in Orlando Florida (Oxford, M. & Kelly, J.F., 2007). Please click here to see poster.

With funding from the Annie E. Casey Foundation, beginning in 2004, the Promoting First Relationships program partnered with the Human Services Policy Center in the Evans School of Public Affairs.  This partnership was devised to address the limitation on improving the quality of care provided by "family, friends, and neighbors," as these populations comprise a significant percentage of all non-parental care, especially for very young children.  We implemented the Promoting First Relationships program 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. We also, as part of this grant, conducted a workshop on the cultural appropriateness of the PFR curriculum, involving participants from different cultural and ethnic groups, which led to several changes 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 to living in a home with a functional and satisfying family life.  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, and parent and child functioning. For evaluation purposes, we examined the skills and knowledge of both the PHN staff members and families from before to after training.

Participating in PFR training improved staff attitudes toward children and parents, expanded staff knowledge of relationship-focused content, and changed actual 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 staff/parent interactions showed that interactions became more focused on the parent-child relationship instead of focused solely on the parent. In our model of change, PHN staff members began to engage in supportive relationships with the parents so that, in turn, the parents could better support their children.

The training also resulted in very encouraging results for families. The pattern of results for parent and child outcomes strongly supports the conclusion 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 parents rated their children 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. Please click here to see poster.

In early 2006, Promoting First Relationships began a 5-year project funded by the National Institute of Mental Health to acquire crucially needed evidence to support interventions promoting infants’ mental health in foster care. This project is also designed to build community capacity to deliver infant mental health interventions and services to foster families.  This research project is a longitudinal, randomized controlled trial, and will involve over 200 foster families in Western Washington. The Promoting First Relationships staff will collaborate with community partners to conduct the research and assist in modifying the existing interventions for implementation with infants in foster care and their caregivers.  A process evaluation of the collaborative partnership will be conducted, as will a test of the effectiveness of the interventions on the following outcomes: foster caregiver sensitivity, infant attachment security and emotional, behavioral, and developmental functioning, and placement stability.

In 2007, Promoting First Relationships began another 5- year randomized trial funded by National Institute of Child Health and Development to study the effects of early detection and intervention for infants at risk for autism. In 2007, Promoting First Relationships also started a program of training (Promoting First Relationships in King County) funded by the King County Children and Family Commission to train local agencies in infant mental health practices. The participating agencies include mental health agencies, therapeutic child cares and the King County Health Department. After intensive on-site training with a Promoting First Relationships Master Trainer, the trained providers then have the ability to use their newly acquired skills with the families and children whom they serve and to mentor others in their agencies to infuse infant mental health practices into their work. This is currently an on-going contract, with additional agencies applying for training each year.

Additionally, Promoting First Relationships currently has an on-going contract (Promoting First Relationships Training for Children’s Administration Service Providers) with the Washington State’s Children’s Administration to conduct state-wide training with family support home visitors, as well as staff members from therapeutic childcares. These services are provided by Children’s Administration and contracted through community providers offering services to families that have received a Child Protective Services (CPS) referral. Services are also provided to foster care parents caring for children who are born drug-affected.  After intensive on-site training with a Promoting First Relationships Master Trainer, the home visitors and child care consultants then have the ability to use their newly acquired skills with the families and children whom they serve and to mentor others in their agencies.

Beginning in 2009, Promoting First Relationships began working on a one-year contract (Promoting First Relationships: Supporting the Social/Emotional Development of Young Children in Child Care) from the Boeing Foundation to provide training to Pierce and Snohomish County child care consultants in infant mental health. After intensive on-site training with a Promoting First Relationships Master Trainer, the child care consultants then have the ability to use their newly acquired skills with the families and children whom they serve and to mentor others in their agencies to infuse infant mental health practices into their work. In 2010, Promoting First Relationships began a third, 5-year NIH funded randomized trial to study the effects of PFR intervention with families involved in the Child Protective System.

There has been a very positive response to these training opportunities, and the participants have reported a “mental shift” in the way in which they communicate and empathize with the families in their care.  Additionally, the preliminary fidelity to the measures checks, which are done through coding videotaped interactions, have been positive, demonstrating that these skills can be learned and maintained. 
In summary, Promoting First Relationships training has proved effective for promoting secure and nurturing parent-child relationships and child care provider-child relationships and is currently being used in a variety of early childhood settings.

Emde, R. N., & Sameroff, A. J.  (1989).  Understanding early relationship disturbances.  In A. J. Sameroff & R. N. Emde (Eds.), Relationship disturbances in early childhood:  A developmental approach.  New York:  Basic Books.

Kelly, J. F., Buehlman, K., & Caldwell, K. (2000).  Training personnel to promote quality parent-child interaction in families who are homeless.  Topics in Early Childhood Special Education, 20, 174-185.

Kelly, J.F., Zuckerman, T., & Rosenblatt, S. (2008). Promoting First Relationships: A Relationship-Focused Early Intervention Approach. Infants and Young Children.

Shonkoff, J. & Phillips, D. (2000).  From Neurons to Neighborhoods: The Science of Early Childhood Development.  Washington, DC: National Academies Press.

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.