Components associated with the effect of home visiting programs on child maltreatment: A meta-analytic review

Strategies to Prevent Violence Against Children in the Home: A Systematic Review of Reviews

Violence against children (VAC) in the home, or by household members, is a human rights and social problem with long-lasting consequences for individuals and society. Global policy instruments like the INSPIRE package have proposed strategies to prevent VAC, including Implementation and enforcement of laws, Norms and values, Safe environments, Parent and caregiver support, Income and economic strengthening, Response and support services, and Education and life skills. This systematic review of reviews aimed to synthesize the recent evidence base (i.e., published since 2000) for each INSPIRE strategy to reduce VAC in the home or by household members. We searched four databases using controlled vocabularies and keywords and searched for additional records in prior reviews of reviews. A total of 67 studies were included in this review, including literature reviews, meta-analyses, systematic reviews, and other types of reviews. We found extensive evidence supporting the effectiveness of parent and caregiver support interventions. However, reviews on other INSPIRE strategies were scarce. We also found a vast underrepresentation of samples from low- and- middle-income countries, children with disabilities, and families affected by forced displacement and conflict. In sum, this systematic review suggests that there are several promising strategies to prevent VAC (e.g., home visiting and parent education), but further research is necessary to strengthen the current body of evidence and effectively inform the implementation and scale-up of evidence-based interventions to protect children from violence globally.

Injury prevention in the US Maternal, Infant and Early Childhood Home Visiting programme

BACKGROUND

Many home-based interventions have been demonstrated to reduce unintentional and intentional injuries in young children aged 0-4 years, but an understanding of their inclusion in federally-funded home visiting programmes in the USA is needed.

METHODS

The study team administered a survey to key informants at each of the 21 home visiting models approved for United States Maternal, Infant, and Early Childhood Home Visiting program funding being implemented in 2023. Respondents were based across the United States and in other developed countries. The survey collected information about the content used by models to address unintentional injury, parental health/wellbeing, and child abuse/neglect in children aged 0-4 years.

RESULTS

Completed surveys were returned by all respondents (n=21). Most models reported the inclusion of some unintentional injury, parental health/well-being and child abuse/neglect content. While models on average covered four of the five child abuse/neglect topics listed, only five of the nine topics listed for unintentional injury and parental health/well-being were covered. Among the services used by models to address topics, covering content via standardised curriculum and referrals were the most frequent while less than one-quarter of models (n=5) provided families with safety equipment to address unintentional injury. Less than half of the models evaluated outcomes from their injury prevention services, and no models conducted cost-effectiveness evaluations.

CONCLUSIONS

Home visiting programmes are a promising way to reduce injuries in children at high risk, but further development and evaluation of their injury prevention content could increase their impact in the USA.

Family Partner: study protocol for a pilot randomised study of a home-visitation intervention in Norway

AIM

Every year, about 5% of children in Norway experience severe child maltreatment and need support from the child welfare services. However, research-supported interventions for this group are lacking. The current study piloted an intensive home-visitation intervention, Family Partner, which aims to reduce child maltreatment among at-risk parents by improving parental skills, agency and trust in the welfare services, and children's well-being. The randomised controlled trial piloted in this study examines the acceptability of the Family Partner intervention for staff and families and evaluates its feasibility for a full-scale randomised controlled trial.

METHODS

This protocol outlines a prospective, parallel, pilot randomised trial of the Family Partner intervention in three Norwegian municipal child welfare services. The participants are families with children under 12 years of age, where the parents are identified as having challenges. Families in the treatment group receive the Family Partner intervention, while families in the control group receive ordinary child welfare services. Data are collected at baseline, and at 3, 6, 12 and 18 months after recruitment. The pilot study monitor retention and adherence to inform the feasibility of a future full-scale randomised study. To assess the acceptability of the trial and intervention, a subsample of the participating families, as well as the family partners and representatives of the child welfare services in each municipality, are invited to complete qualitative interviews.

CONCLUSIONS

The results will guide the design of a fully powered randomised controlled trial of the Family Partner intervention compared with ordinary child welfare services.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04957394; Pilot Trial of Family Partner: a Child Maltreatment Prevention Intervention (FAMPART); registered on 12 July 2021.

A comparison of virtual versus in-person delivery of SafeCare on parent and implementation outcomes

BACKGROUND

Evidence-based prevention services for child abuse and neglect (CAN), typically delivered via home visiting (HV), pivoted to virtual delivery in 2020 to continue family services while adhering to the COVID-19 public health guidelines.

OBJECTIVE

The study aims are to compare parent and implementation outcomes for the HV program, SafeCare©, delivered virtually versus in-person, across a 2-year period.

METHODS

Three data sources were used to examine parent program engagement and skill mastery, as well as provider fidelity. Sources included: 1) quantitative service data collected as part of routine SafeCare implementation (in-person families, n = 923; virtual families, n = 1978), 2) qualitative survey data collected from SafeCare providers (n = 212) and 3) focus group data with SafeCare Providers (n = 9).

RESULTS

Service data were examined using mixed models due to the nesting of the data, with all analyses controlling for time. Qualitative data from the survey and focus groups were analyzed using thematic coding. Data were triangulated from the three sources to answer the primary research question. Findings suggest that virtual delivery of SafeCare holds promise, with parents who participated virtually completing more modules at a faster pace than in-person clients. SafeCare parents demonstrated positive programmatic outcomes regardless of whether they participated in the program virtually or in-person. Provider fidelity remained high in the transition to virtual delivery. However, technology-related logistical issues and provider self-efficacy related to virtual delivery presented challenges to program success.

CONCLUSIONS

The study has multiple implications for the HV field about the viability of virtual service delivery. Further research is warranted with data collected directly from parents, and a more critical analysis of what works best for whom and when to further advance the field.

The effectiveness of interventions to prevent and reduce child maltreatment in high-income countries: An umbrella review

BACKGROUND

In recent decades, many interventions targeting the occurrence (primary prevention) or the recurrence (secondary prevention) of child abuse and neglect have been tested. Findings have been synthesized in several meta-analyses and systematic reviews. However, the range of interventions addressed in these studies is very broad, and an integrative assessment of this large spectrum is lacking.

OBJECTIVE

Focusing on high-income countries, we ask (i) what is known about the effectiveness of interventions to prevent or reduce child abuse and neglect and (ii) how robust this evidence is.

METHODS

A systematic review of systematic reviews, called an umbrella review, was conducted. Ten databases on OvidSP and Web of Science were searched up until April 2023. Narrative synthesis was used to document the publications' findings.

RESULTS

44 publications were included in the umbrella review. We did not find that any type of intervention had a clear, consistent, and robust track record of preventing or reducing the occurrence of child abuse and neglect. Rather, publications examining the effectiveness of interventions in all areas frequently reported non-existent, small or inconsistent effects. However, positive effects for particular interventions in specific settings did emerge. Research methodologies showed several and often severe problems.

CONCLUSIONS

We suggest several measures to improve the quality of research and call on practitioners to be persistent in developing more effective interventions.

Home visitors' needs and perceptions of the benefits of a home visiting program for childcare support in Japan: A qualitative study of home visitors

BACKGROUND

The Home Visiting Program for Childcare Support (HV-CCS; "Yoiku Shien Homon Jigyo" in Japanese) has targeted families in need of parenting support and those at risk of child maltreatment in Japan.

OBJECTIVE

The aim of this study was to explore the needs and perceptions of benefits of home visitors in HV-CCS.

PARTICIPANTS AND SETTING

Sixteen home visitors agreed to participate in the interview.

METHODS

This study conducted 1-hour semi-structured interviews with 16 home visitors and analyzed approximately 18 h of interview data using thematic analysis.

RESULTS

The findings suggested that home visitors required training to enhance individual skills and knowledge about mental health of caregivers or children. Additionally, they required environmental support, particularly for transportation expenses and parking places. Multidisciplinary communicative support is also necessary, as well as system to improve the process of support. Home visitor perceived the HV-CCS as beneficial in preventing child maltreatment by improving parenting skills and home environment, providing psychological support for mothers, and entering families' intimate spaces.

CONCLUSIONS

To ensure the continuity and improvement of home visits for parents and children in Japan, it is essential to address the identified needs of home visitors.

Family Club Denmark: A Quasi-Randomized Study of a Volunteer-Based Intervention to Support Vulnerable Families

Volunteer interventions play a vital role in supporting families by offering accessible and community-based resources outside the formal professional sector. This study examines the impact of the volunteer intervention known as Family Club Denmark (FCD) on the well-being of parents and children. FCD aims to provide families with positive experiences and support relationship building. The intervention, open to families from diverse social backgrounds, comprises volunteer-led family clubs where parents and children aged 2-12 years engage in activities and meals. We allocated 510 families (363 vulnerable families) to FCD or placed them on a waiting list based on a first-come, first-served principle. We conducted baseline, post-intervention, and follow-up assessments through questionnaires, observations, and interviews. On average, families participated in 5.8 sessions, with both families and volunteers reporting high satisfaction. When compared to control families, we find that vulnerable FCD parents feel more confident playing with their children (p = 0.04, [0.01; 0.40], d = 0.25), require less assistance in playing with their children (p = 0.01, [-0.34; -0.05], d = 0.33), and report that their children have a more challenging time forming friendships (p = 0.01, [-0.51; -0.09], d = 0.29). However, we did not find significant effects on mental health, parenting stress, self-efficacy, self-worth, family routines, or child well-being. We observed similar results for the full sample. The discovery that parents feel more confident playing with their children after participating in FCD highlights the vital role of volunteer-based interventions in enhancing parental engagement and fostering positive parent-child interactions. Trial registration: ClinicalTrials.gov NCT03657888 (registered 29 August 2018).

Linking child adjustment difficulties with mother's maladaptive parental behavior: The mediating roles of parental cognitions and parenting stress

Child abuse is prevalent worldwide, with most of the burden in developing countries. To reduce and prevent child abuse occurrence, many efforts are directed toward reducing maladaptive parental behaviors (MPBs), a predictor of parents' risk of engaging in child abusive behaviors. MPBs have been associated with child (e.g., behavioral difficulties) and parent characteristics (e.g., parenting stress and parental cognitions), although little research tested for mediational pathways. This study aimed to test the pathways through which child and parent characteristics are linked to MPB. Consistent with the social information processing model of parenting, we hypothesized that child behavioral difficulties would exert an indirect influence on MPB through parenting stress and that parenting stress will exert a direct and indirect effect on MPB through parental cognitions (i.e., expectations, attitudes, and attributions). This study used data from 243 mothers of children aged between 2 and 9 years in Romania. Two-stage structural equation modeling was employed to test the hypothesized model. Results support the role of child behavior, parenting stress, and parental cognitions in predicting MPB (R2 = 0.69). Significant indirect effects were found from child behavior to MPB via parenting stress and parental cognitions. Direct effects from parenting stress and parental cognitions to MPB were significant. Findings show that parenting stress and parental cognitions are important mechanisms through which child behavioral difficulties influence maladaptive parental behavior, underscoring the need to focus on these mechanisms when assessing or intervening with families at risk for child abuse.

Examining Impacts of Healthy Families America on Infant Health Care

OBJECTIVE

Healthy Families America (HFA) is an evidence-based home visiting program that provides parenting education with the overall goal of preventing child maltreatment and optimizing child development. This study compares the health care utilization and vaccination of infants enrolled in HFA with similar infants not in the program.

METHODS

From January 2014 to December 2020, 604 children served statewide by HFA in Arkansas were identified in vital statistics and administrative medical claims records. Using propensity score matching, infants in HFA were matched with nonprogram control infants based on family demographics and birth characteristics. Double propensity-score adjustment method and generalized linear models were used to estimate program effects.

RESULTS

In the first year after birth hospital discharge and compared to a propensity score matched cohort of infants not enrolled, those enrolled in HFA had significantly greater use of the emergency department overall (incidence rate ratios (IRR) = 1.24 [95% confidence interval (CI) = 1.07-1.43], P = .004) and for less complex conditions (IRR = 1.22 [95% CI = 1.04-1.44], P = .01), more outpatient medical appointments for child wellness (IRR = 1.09 [95% CI = 1.03-1.15], P = .003), illness (IRR = 1.17 [95% CI = 1.07-1.29], P = .001), and speech and language therapies (IRR = 2.86 [95% CI = 1.18-6.93], P = .02), and more medical visits during which vaccinations were provided (IRR = 1.09 [95% CI = 1.04-1.15], P = .002).

CONCLUSIONS

Findings from the current study suggest that HFA supports increased health care utilization and visits in which vaccinations occurred during the first year of life.

Leveraging machine learning for effective child maltreatment prevention: A case study of home visiting service assessments

BACKGROUND

Early identification of children and families who may benefit from support is crucial for implementing strategies that can prevent the onset of child maltreatment. Predictive risk modeling (PRM) may offer valuable and efficient enhancements to existing risk assessment techniques.

OBJECTIVE

To evaluate the PRM's effectiveness against the existing assessment tool in identifying children and families needing home visiting services.

PARTICIPANTS AND SETTING

Children born in hospitals affiliated with the Bridges Maternal Child Health Network in Orange County, California, from 2011 to 2016 (N = 132,216).

METHODS

We developed a PRM tool by integrating a machine learning algorithm with a linked dataset of birth records and child protection system (CPS) records. To align with the existing assessment tool (baseline model), we limited the predicting features to the information used by the existing tool. The need for home visiting services was measured by substantiated maltreatment allegation reported during the first three years of the child's life.

RESULTS

Of the children born in Bridges Network hospitals between 2011 and 2016, 2.7 % experienced substantiated maltreatment allegations by the age of three. Within the top 30 % of children with high-risk scores, the PRM tool outperformed the baseline model, accurately identifying 75.3 %-84.1 % of all children who would experience maltreatment substantiation, surpassing the baseline model's performance of 46.2 %.

CONCLUSIONS

Our study underscores the potential of PRM in enhancing the risk assessment tool used by a prevention program in a child welfare center in California. The findings provide valuable insights to practitioners interested in utilizing data for PRM development, highlighting the potential of machine learning algorithms to generate accurate predictions and inform targeted preventive services.

Evidence-Based Home Visiting Provisions and Child Maltreatment Report Rates: County-Level Analysis of US National Data From 2016 to 2018

This observational ecological study examined county-level associations between evidence-based home visiting (EHV) provisions and child maltreatment report (CMR) rates, using national county-level data from 2016-2018. We found that longitudinal changes of EHV provisions were significantly negatively associated with county CMR rates while controlling for potential confounders. Our model estimated that after EHV provisions were launched in counties, their CMR rates decreased (or after they were ceased, rates increased) by 2.21 per 1000 children overall, 2.88 per 1000 children aged 0-5, 2.59 per 1000 children aged 6-11, 2.13 per 1000 male children, and 2.24 per 1000 female children. When limiting attention to EHV provisions funded by the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program, we found no significant association perhaps because MIECHV-funded EHV provisions were a small subset of all EHV provisions. These findings propose potential protective impacts of county EHV provisions on overall county CMR rates. Yet, the small effect sizes suggest that EHV provisions should be considered as a part of a complete response to child maltreatment rather than in isolation. Given that EHV is provided to a very small part of the population, nevertheless, our findings suggest that expanding coverage would increase effect sizes.

Intergenerational transmission of child protective services involvement: Exploring the role of ACEs and domestic violence among families who receive home visiting services

BACKGROUND

Adverse childhood experiences (ACEs) are associated with negative outcomes over the life course and across generations, including domestic violence (DV) and child maltreatment. However, no studies have examined the connection between parents' ACEs and their child's risk of child protective services (CPS) involvement or possible mechanisms of transmission.

OBJECTIVE

In addition to describing the prevalence and correlates of CPS involvement, our primary aims are to test whether parental adversity in childhood is associated with CPS involvement and whether DV victimization mediates the ACE-CPS association.

PARTICIPANTS AND SETTING

The sample included 3039 primary caregivers and 3343 children served by home visiting programs in Wisconsin between 2014 and 2019.

METHODS

Using matched home visiting and CPS records, we generated prevalence estimates of screened-in CPS reports and assessed bivariate associations between CPS involvement and ACEs, DV, and household demographics. We then conducted a two-stage path analysis to test the association between ACEs and CPS involvement and whether DV mediated the ACE-CPS association.

RESULTS

Overall, 22.8 % of caregivers had a screened-in report. Prevalence rates were higher among women who endured ACEs and DV, and they varied by demographic characteristics. ACEs were directly linked to DV and CPS involvement, and there was an indirect pathway linking ACEs to CPS involvement through DV exposure.

CONCLUSIONS

Home visiting programs serve families that frequently interact with the child welfare system. By enhancing the trauma-responsive potential of these interventions, it may be possible to interrupt intergenerational mechanisms that contribute to child abuse and neglect and CPS involvement.

Knowledge Gains from the Implementation of a Child Sexual Abuse Prevention Program and the Future of School-Based Prevention Education

School-based child sexual abuse (CSA) programs effectively increase students' CSA-related knowledge. This study focuses on an implementation trial of Safe Touches, an empirically supported, school-based CSA prevention program, that was disrupted by the COVID-19 pandemic. We sought to demonstrate gains in CSA-related knowledge following Safe Touches but were limited to a pre-post design. A total of 2,210 students across five counties in a Mid-Atlantic state received the Safe Touches workshop between September 2019 and March 2020. McNemar's chi-square test was used to assess changes in the proportion of correct responses pre-workshop (Time 1) and one-week post-workshop (Time 2). Students' CSA-related knowledge increased significantly based on changes in mean CSA knowledge scores and the number of correct item-level responses assessed at Time 1 and Time 2 (p < .000). Leveraging the experience of the facilitators' who delivered these workshops prior to the disruption of implementation, we gathered facilitators' perspectives to explore the viability of offering Safe Touches virtually. In July 2020, 16 facilitators completed an electronic survey designed to understand the viability of a virtual Safe Touches workshop. Three themes emerged from facilitator feedback on virtual programming: student engagement concerns, handling disclosures, and technology access to a virtual program. The findings of this study indicate that the Safe Touches workshop significantly increased CSA-related knowledge and, overall, facilitators supported further exploration and development of a virtual Safe Touches workshop. The transition of empirically supported school-based CSA prevention programs to a virtual delivery modality is necessary to maintain an effective means of primary prevention and opportunity for disclosure.

Effects of the Attachment Video-feedback Intervention (AVI) on parents and children at risk of maltreatment during the COVID-19 pandemic

BACKGROUND

The global health crisis caused by the COVID-19 pandemic has led to an increase in situations of risk of child abuse and neglect.

OBJECTIVE

The objective of this study was to examine whether the Attachment Video-feedback Intervention (AVI) program can improve protective factors (decrease parental stress and household chaos, increase parent-child emotional availability and parental reflective functioning) that may diminish child maltreatment in a group of families at risk for child abuse and neglect during the COVID-19 pandemic.

PARTICIPANTS AND SETTING

The sample consisted of 41 children aged between 0 and 5 years (Mage = 35.36 months, SD = 14.65; 85.4 % boys) and their parents (Mage = 35.44, SD = 6.04; 75.6 % mothers).

METHODS

The study design incorporated two randomized groups (Intervention group: AVI; Control group: treatment as usual) with pre- and post-test evaluations.

RESULTS

In comparison to the control group, parents and children exposed to the AVI showed increases in emotional availability. Parents in the AVI group also presented increases in certainty regarding their child's mental states and reported lower levels of household chaos compared to those of the control group.

CONCLUSIONS

The AVI program is a valuable intervention for increasing protective factors in families at risk of child abuse and neglect in times of crisis.

Community home visiting services and child maltreatment report rates, Illinois zip codes, 2011-2018

BACKGROUND

Research is sparse on the community-level impacts of home visiting programs on child maltreatment.

OBJECTIVE

To examine community-level associations between state-funded home visiting programs (i.e., IDHS-HV), federal-funded home visiting programs (i.e., MIECHV), and child maltreatment report (CMR) rates, overall and within subgroups of age, sex, and maltreatment type.

PARTICIPANTS AND SETTING

3824 zip code-years during 2011-2018 in Illinois for IDHS-HV/CMR associations and 1896 zip code-years during 2015-2018 for MIECHV/CMR associations.

METHODS

We measured county-level IDHS-HV rates (per 1000 children aged 0-5) since data were only available at that level. MIECHV rates (per 1000 children aged 0-5), CMR rates (per 1000 children), and all controls were measured at the zip code level. We used spatial linear models to handle spatial autocorrelation.

RESULTS

Adjusted for controls, longitudinal increases of IDHS-HV rates were significantly associated with decreased overall CMR rates (coefficient: -0.28; 95 % CI: -0.45, -0.11), age 0-5 CMR rates (-0.52; -0.82, -0.22), age 6-11 CMR rates (-0.31; -0.55, -0.06), male CMR rates (-0.25; -0.45, -0.05), female CMR rates (-0.29; -0.49, -0.08), and neglect report rates (-0.13; -0.24, -0.02). In contrast, longitudinal increases of MIECHV rates were significantly associated with increased CMR rates within several subgroups.

CONCLUSIONS

Our findings suggest that increasing state-funded home visiting services in communities may have benefits in lowering their CMR rates. Given the very low MIECHV service rates and the federal policy that requires MIECHV to target at-risk communities, the significant positive MIECHV/CMR associations we found might indicate MIECHV programs are typically in higher risk communities.

Quasinatural Experiment of Postnatal Home Visiting: An Independent Impact Study of Family Connects

INTRODUCTION

Family Connects (FC) is a postnatal nurse home visiting program that has scale-up potential because it is brief, inexpensive, and universal. Three investigations have linked Family Connects to improved maternal and family outcomes, but no independent impact studies have been conducted to date.

METHODS

This study investigates a FC program in Racine County, WI that was implemented by a multimunicipal health department in partnership with a local hospital. The sampling frame included all women who gave birth at the hospital from July 1, 2018 to August 31, 2019 (N=1,511). A quasinatural experiment resulted from systematically restricting FC recruitment to weekdays. All eligible women whose birth records and addresses were obtained from a vital records office were mailed a 6-month postpartum survey. Data collected from 489 respondents (32.4%) were analyzed in February 2022 to estimate the impact of FC on maternal health, infant health and development, and parenting behavior outcomes under intent-to-treat and per protocol assumptions.

RESULTS

No significant differences were observed between study groups at baseline. Despite evidence that the FC program in Racine met many model standards for implementation fidelity, null effects were observed at 6 months after delivery for most outcomes. Results suggested that parents from eligible households reported more frequent infant emergency medical episodes than parents who were not offered the program.

CONCLUSIONS

This study found few significant effects associated with FC participation. Further investigation is needed to identify the populations with and conditions under which the program produces its intended effects.

Toward tailored care for families with multiple problems: A quasi-experimental study on effective elements of care

Several effective interventions have been developed for families with multiple problems (FMP), but knowledge is lacking as to which specific practice and program elements of these interventions deliver positive outcomes. The aim of this study is to assess the degree to which practice and program elements (contents of and structure in which care is provided) contribute to the effectiveness of interventions for FMP in general and for subgroups with child and/or parental psychiatric problems, intellectual disabilities, or substance use. We performed a quasi-experimental study on the effectiveness of practice and program elements provided in attested FMP interventions. Using self-report questionnaires, we measured primary (child's internalizing and externalizing problems) and secondary (parental stress and social contacts) outcomes at the beginning, end, and three months thereafter. By means of Latent Profile Analysis, we identified groups of families receiving similar combinations of practice elements ("profiles"), and we calculated propensity scores. Next, we assessed how practice element profiles and program elements affected improvement in outcomes, and whether these effects were moderated by subgroup characteristics. We found three practice element profiles (explorative/supportive, action-oriented, and their combination), which were equally effective. Regarding program elements, effects were enhanced by more frequent telephone contact between visits and more frequent intervision. Effectiveness of practice and program elements varied for specific FMP subgroups. Variations in the content of care for FMP do not affect its effectiveness, but variations in the structure of the care do. This finding can help to further improve effective interventions.

Randomized trial of promoting first relationships for new mothers who received community mental health services in pregnancy

The effectiveness of Promoting First Relationships (PFR), a 10-week home visiting program with video feedback, was tested in a randomized controlled trial involving 252 mothers and their 8- to 12-week-old infants. Mothers were eligible if they initiated treatment after mental health screening (depression, anxiety, posttraumatic stress disorder [PTSD]) at a community or public health primary care center in pregnancy. At baseline, 51% had mild to severe depression symptoms, 54% had mild to severe anxiety, and 35% had PTSD. Their ages ranged from 18 to 42 years. Mothers were 66% White, 18% Black, and 16% other races. Forty-seven percent identified as Hispanic, and 33% preferred to read and speak in Spanish. The median family annual income was less than $20,000. The PFR program or receipt of a resource packet (control condition) followed the baseline assessment and randomization; we assessed outcomes when infants were age 6 and 12 months. Compared to mothers in the control condition, mothers in the PFR condition had significantly (ps < .05) higher observed sensitivity scores at both follow-up time points (d = .25, d = .26), had improved understanding of infant-toddler social-emotional needs at both time points (d = .21, d = .45), and reported less infant externalizing behavior at age 12 months (d = .28). This study is the fourth completed randomized controlled trial of the PFR program, all involving populations experiencing adversity. (PsycInfo Database Record (c) 2021 APA, all rights reserved).