Program Profile: Promoting First Relationships for Native Families

This is a home-visiting program to foster positive caregiver–child relationships in Native families. The program is rated Promising. The treatment group had higher quality caregiver–child interactions, and caregivers had increased knowledge of their children’s social–emotional needs and reported fewer depressive symptoms, compared with the control group. However, there was no statistically significant difference between the treatment and control groups on child externalizing behaviors.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

Research suggests that Native children are at risk of displaying more behavior problems and less social competence when their families are living in poverty and their parents are stressed or experience their own mental health challenges (Frankel et al. 2014; Sarche et al. 2009). One approach to addressing the potential issues of this population is by using culturally appropriate early preventive intervention programs that focus on enhancing parenting sensitivity and early childhood attachment security. Promoting First Relationships is a theory-driven, relationship-based strategy for primary caregivers and their young children, ages 0 to 5 years, which has been adapted for Native families (Oxford et al. 2020) and uses a strengths-based approach to support and build on the resilience of Tribal communities. The goal of the program is to increase caregivers’ awareness of their children’s social and emotional needs, including their need for a sense of safety and security, and to understand their own needs as caregivers.

Program Components/Key Personnel

Overall, the program aims to promote trusting and secure caregiver–child relationships and healthy child development. The Promoting First Relationships intervention is delivered through a brief home-visiting program that includes 10, 1-hour sessions. The program providers—who are also members of the Tribal community—interact with caregivers in ways that do not contribute to their shame, guilt, or defensiveness, but rather build on their parenting strengths and improve their reflective capacity (Booth-LaForce et al. 2023a). The Promoting First Relationships providers work to create trusting relationships with the caregivers to enhance their feelings of safety and security, which is the foundation for supporting positive changes in parenting and the caregiver–child relationship (Crittenden 2016; Graybeal 2007).

The 10 in-home sessions are conducted by trained providers who follow a manualized curriculum and use five specific consultation strategies: Joining, Positive Feedback, Instructive Feedback, Reflective Questions and Comments, and Discussion with Handouts. These are designed to create trust and rapport between the providers and the caregivers and to engage with the caregivers in addressing the social and emotional needs of their children. Each session has a different theme, specific goals, and deliverables, and includes a check-in, a reflection on the previous week’s content, a discussion topic for the current week, a video recording or observation, and handouts (14 total illustrations and charts). Providers also offer caregivers support and engage in open dialogue about specific situations around the child’s needs, even if they do not fit into the theme of the weekly session (Booth-LaForce et al. 2023b).

One essential component of the program is that a portion of each home visit is set aside for either recording an interaction between the caregiver and the child (weeks 1, 3, 5, 7, 9), or observing and reflecting on a video of the interaction (weeks 2, 4, 6, 8, 10), for a total of five opportunities for video reflection. The providers and caregivers view the videos together, and the caregivers are invited to reflect on both their own and their child’s behaviors, feelings, and needs. Promoting First Relationships providers do not tell caregivers how to parent; instead, they encourage caregivers to reflect on their own and their child’s underlying needs and behaviors. Therefore, Promoting First Relationships is personalized to support the existing strengths of the caregiver–child relationship.

The Promoting First Relationships program was adapted for Native families. Modifications included 1) changing the logo to align with the Tribe’s culture and language; 2) lengthening the home visit to include more time for conversation and checking in, which is consistent with cultural norms; 3) providing a small gift to the child at each data-collection visit, in accordance with cultural practices; 4) adding a handout on caregiver–child transitions and separations; and 5) asking caregivers to recall “a time when they felt cared for by an adult,” rather than about “any memory of a first emotion,” an adaptation that was made because of the amount of childhood trauma the original exercise elicited and the desire to focus on a less traumatizing experience. None of these adaptations changed the basic format, structure, or principles of the Promoting First Relationship program.

Program Theory

Promoting First Relationships is grounded in attachment theory (Bowlby 1969, 1982; Booth-LaForce et al. 2023b) which posits that caregiver sensitivity and responsiveness are critical for a child’s development of a secure (versus insecure) attachment, leading to adaptive (rather than maladaptive) child outcomes (Cassidy, Jones, and Shaver 2013). Therefore, the program was designed to target the foundation of children’s attachment security by supporting caregivers to respond sensitively to their children’s age-appropriate behaviors and needs.

Study

Booth?LaForce and colleagues (2023a) conducted a randomized controlled trial to examine the effect of Promoting First Relationships for Native families on the quality of caregiver?child interactions, caregivers? knowledge of their children?s needs, caregiver depression, and child externalizing behaviors after three months.

The study took place on a rural reservation in the Northern Plains area of the United States. Potential participants were recruited at community events; from the Special Supplemental Nutrition Program for Women, Infants and Children; and through flyers/brochures, word of mouth, and Facebook. Further, community programs and providers (including the Birth-to-Three program, health care providers, Head Start, Department of Social Services, and childcare providers) also recommended the study to their patients or clients. Interested individuals were contacted by a Native Research Visitor, who provided detailed information on the study, determined eligibility, and then scheduled a home visit to obtain informed consent and collect baseline data. To be eligible for the study, families were required to have at least one parent or guardian who 1) was at least 18 years old and lived on or near the reservation; 2) spoke English; 3) was the primary caregiver for a child ages 10?31 months and reported to be Native by their caregiver; 4) had telephone access; 5) was not living in a treatment facility or shelter, hospitalized, or imprisoned; and 6) was willing to have study staff come to their home. After baseline data collection, an algorithm was used to randomize the 162 total participants, blocking on caregiver sex, in equal numbers to the treatment group (Promoting First Relationships, n = 81) and control group (Resource and Referral, n = 81).

Individuals in the Promoting First Relationships treatment group received the intervention as described in the program description above. Those in the Resource and Referral control group received three phone calls from a local Native staff member and answered questions about health care, financial needs, and personal or family struggles. These participants were sent information on more than 75 local services and recommendations tailored to their needs and received two follow-up calls two weeks and then three months after the initial call.

At baseline, children in the treatment group were on average 19.9 months old and 49.4 percent female. Of the caregivers in the treatment group, 93.8 percent were female, 96.3 percent were American Indian or Alaska Native, 80.2 percent were birth parents to the child, and 16 percent were relatives. Of these caregivers, 59.3 percent were married or partnered, 37 percent had some college education or more, and 24.7 percent had less than a high school education. Children in the control group were on average 20.3 months old and 50.6 percent female. Of caregivers in the control group, 91.4 percent were female, 95.1 were American Indian or Alaska Native, 84 percent were the birth parents to the child, and 14.8 percent were relatives. Of these caregivers, 64.2 percent were married or partnered, 38.3 percent had some college education or more, and 28.4 percent had less than a high school education. At baseline, there were no statistically significant differences between the treatment and control groups on any demographic variables.

To measure the quality of caregiver?child interactions, video recordings of these interactions were assessed using the Nursing Child Assessment Teaching Scale, which contains 73 ?yes or no? items that evaluated the caregiver?s sensitivity, stimulation of the child, and emotional responsiveness; and the child?s clarity of cues and responsiveness to the caregiver. The ?Raising a Baby? questionnaire was used to assess caregiver knowledge of the social?emotional needs of infants and toddlers. Caregivers rated 16 items on a 4-point scale (from ?strongly agree? to ?strongly disagree?), with higher scores indicating a higher level of caregiver knowledge. The 20-item Center for Epidemiological Studies-Depression Scale was used to assess caregivers? depressive symptoms. Caregivers rated how often over the past week they experienced symptoms associated with depression, such as restless sleep, poor appetite, and feeling lonely. Response options were 0 (?rarely or none of the time?), 1 (?some or little of the time?), 2 (?moderately or much of the time?) or 3 (?most or almost all the time?). The 125-item Infant?Toddler Social Emotional Assessment, a comprehensive caregiver-report measure, was used to assess the children?s social?emotional competencies and behavior problems. The mean summary score for the externalizing domain was used. Caregivers rated each item on a 3-point scale (0 = ?not true/rarely,? 1 = ?somewhat true/sometimes,? 2 = ?very true/often?).

The treatment and control groups were compared on immediate post-intervention outcomes (Time 2) and outcomes three months later (Time 3), controlling for baseline (Time 1) values. The CrimeSolutions review of this study focused on the outcomes at Time 3. A series of repeated-measures multivariate analyses of covariance were used to assess the effect of the intervention on the outcomes. No subgroup analysis was conducted.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Booth-LaForce, Cathryn, Monica L. Oxford, Celestina Barbosa-Leiker, Ekaterina Burduli, and Dedra S. Buchwald. 2020. “Randomized Controlled Trial of the Promoting First Relationships® Preventive Intervention for Primary Caregivers and Toddlers in an American Indian Community.” Prevention Science 21:98–108. (This study was reviewed but did not meet CrimeSolutions' criteria for inclusion in the overall program rating.)

Booth-LaForce, Cathryn, Monica L. Oxford, Rae O’Leary, Jennifer Rees, Anthippy Petras, and Dedra S. Buchwald. 2023b. “Implementation Fidelity of the Promoting First Relationships Intervention Program in a Native Community.” Translational Behavioral Medicine 13:34–41.

Bowlby, John. 1969, 1982. Attachment and Loss: Vol. 1. Attachment (2nd ed.). New York, New York: Basic Books.

Cassidy, Jude, Jason D. Jones, and Phillip R. Shaver. 2013. “Contributions of Attachment Theory and Research: A Framework for Future Research, Translation, and Policy.” Development and Psychopathology 25:1415–34.

Crittenden, Patricia M. 2016. Raising Parents: Attachment, Representation, and Treatment (2nd ed.). Oxfordshire, United Kingdom: Routledge.

Frankel, Karen A., Calvin D. Croy, Lorraine F. Kubicek, Robert N. Emde, Christina M. Mitchell, and Paul Spicer. 2014. “Toddler Socioemotional Behavior in a Northern Plains Indian Tribe: Associations with Maternal Psychosocial Well-Being.” Infant Mental Health Journal 35:10–20.

Graybeal, Clay T. 2007. “Evidence for the Art of Social Work.” Families in Society: Journal of Contemporary Social Services 88:513–23.

Oxford, Monica, Cathryn Booth-LaForce, Abigail Echo-Hawk, Odile Madesclaire, Lorilynn Parrish, Mylene Widner, Anthippy Petras, Tess Abrahamson-Richards, Katie Nelson, Dedra Buchwald, and the CATCH Project Team. 2020. “Promoting First Relationships: Implementing a Home Visiting Research Program in Two American Indian Communities.” Canadian Journal of Nursing Research 52(2):149–56.

Sarche, Michelle C., Calvin Croy, Cecelia Big Crow, Christina M. Mitchell, and Paul Spicer. 2009. “Maternal Correlates of 2-Year-Old American Indian Children’s Social–emotional Development in a Northern Plains Tribe.” Infant Mental Health Journal 30:321–40.

Following are CrimeSolutions-rated programs that are related to this practice:

Early Developmental Prevention Programs for At-Risk Youths

This practice consists of early developmental programs that focus on enhancing child, parent–child, or family well-being to prevent social deviance and criminal justice involvement among at-risk children under age 5. The practice is rated Effective for reducing deviance and criminal justice involvement in youths who participated in early developmental prevention programs, compared with youths in the control group who did not participate.

Evidence Ratings for Outcomes

	Crime & Delinquency - Multiple crime/offense types
	Crime & Delinquency - Criminal justice involvement

Early Family/Parent Training Programs

This practice includes programs that seek to provide families and parents with training and skills to help promote their children’s physical, mental, and social skills. The practice is rated Effective for reducing child problem behaviors for children whose families participated in early family/parent training programs, compared with control group children whose families did not participate in programming.

Evidence Ratings for Outcomes

Juvenile Problem & At-Risk Behaviors - Multiple juvenile problem/at-risk behaviors

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?