Randomized Trial of Promoting First Relationships: Effects on Maltreated Toddlers' Separation Distress and Sleep Regulation after Reunification

Trying to Do What's Best: Maternal Perspectives About Toddler Sleep Health Among an Underresourced Sample of Mothers With Diverse Racial and Ethnic Identities

INTRODUCTION

This study describes mothers' knowledge, attitudes, beliefs, and practices about their toddler's sleep health among an underresourced sample of mothers with diverse racial and ethnic identities.

METHOD

This was a descriptive qualitative study with 16 mothers and their 12- to 36-month-old child. Mothers completed a semistructured, audio-recorded interview about their toddler's sleep health. Data were analyzed using inductive content analysis on the basis of established methods.

RESULTS

Mothers self-identified as 18.8% Black, 43.8% White, 12.5% multiracial, 25.0% other race, and 37.5% Hispanic. Of the mothers, 80.0% reported a past year household income of ≤ $40,000. A core construct, "Trying to do What's Best," emerged from the interview data, and this construct included three domains: Getting Good Sleep, Getting Thrown Off, and Rolling With It.

DISCUSSION

Findings support future strengths-based and multilevel sleep health-promoting interventions.

What works for whom? Mother's psychological distress as a moderator of the effectiveness of a home visiting intervention

Attachment-based home visiting programs that serve new mothers experiencing psychological distress may advance health equity by helping families systemically exposed to adversity. This study examined whether one such program (Promoting First Relationships/PFR) had particularly beneficial effects on maternal and child relationship outcomes for mothers reporting the greatest psychological distress. A randomized controlled trial of the PFR program included a low-income sample of 252 Spanish- and English-speaking mother-child dyads referred prenatally for mental health concerns. The sample of mothers was 65.5% White, 17.5% Black, and 17.1% multiracial or other racial groups; 47.2% reported Hispanic ethnicity. The moderating variable of psychological distress was measured using maternal-reported screening tools for symptoms of depression, anxiety, anger, post-traumatic stress, and interpersonal sensitivity. Outcomes included observed parenting sensitivity and self-reported understanding of infants/toddlers, caregiving confidence, and child externalizing behavior. Results showed a significant treatment condition by baseline psychological distress interaction for observed parenting sensitivity such that differences in outcomes favoring the PFR condition were greatest among those with high baseline psychological distress (baseline child age 6-12 weeks). In a low-income sample of new mothers, those with the greatest need, as indicated by high psychological distress, showed greater improvements in their sensitive and responsive caregiving if they were randomized to the PFR treatment condition.

Implementation fidelity of the Promoting First Relationships intervention program in a Native community

Promoting First Relationship (PFR) is an evidence-based intervention designed to promote positive, supportive relationships between primary caregivers and their young children. Implementing and testing the efficacy of PFR in a remote Native community is especially challenging and requires methods and tools for ensuring implementation fidelity. Tribal members of a Native community were successfully trained and certified to deliver PFR by university-based personnel. During PFR delivery, they achieved very high scores on adherence to intervention content (M = 0.99, SD = 0.02), and their quality of delivery uniformly exceeded established criteria. High attrition occurred before PFR was delivered. However, participants who remained in the study completed all 10 sessions of PFR content. Participants' satisfaction with the program was very high (M = 3.90 [of 4 points], SD = 0.19). High implementation fidelity was attained in the face of many inherent challenges. The suite of methods and tools used for training, monitoring, and evaluating implementation fidelity in this study provides an example that may be useful in the evaluation of evidence-based programs more generally.

Promoting First Relationships® for Primary Caregivers and Toddlers in a Native Community: a Randomized Controlled Trial

This study tested the effectiveness of Promoting First Relationships^® (PFR), a preventive intervention program aimed at fostering positive caregiver-child relationships in Native families living on a rural reservation. Participants were 162 primary caregivers (96% Native; 93% female) and their Native toddlers (10-31 months old; 50% female). Families were randomized to a PFR group (n = 81) or Resource and Referral (RR) control group (n = 81), after baseline data collection (Time 1) to assess the quality of caregiver-child interaction, caregiver knowledge about children's social-emotional needs, caregiver depressive symptoms, and child externalizing behavior. After delivery of the PFR intervention or the RR service, follow-up assessments were repeated immediately post-intervention (Time 2) and 3 months later (Time 3). After controlling for baseline assessments, multivariate analyses of covariance revealed that caregivers in the PFR group had significantly higher scores on knowledge about children's social-emotional needs at Time 2 (p < .01, η² = .06) and Time 3 (p < .05, η² = .04) and less severe depressive symptoms at Times 2 and 3 (both p < .05, η² = .04). At Time 3, the quality of caregiver-child interaction was better in the PFR group (p < .01, η² = .06), an effect that was moderated by severity of depressive symptoms (p = .05, η² = .06), with PFR having the greatest impact at low levels of initial symptoms (p = .02). Results support the positive impact of PFR in a Native community and suggest conditions under which the intervention may be most effective.

Sleep ecology, sleep characteristics and behavior problems in young maltreated children: A scoping review

BACKGROUND

Behavior problems are highly prevalent in young maltreated children. Their etiology is multifactorial and has been widely documented. Lately, researchers paid increased attention to the role of sleep in non-maltreated children's behavior problems. They showed that poor sleep (e.g., short sleep duration, nocturnal awakenings) increased behavior problems. In addition, an inadequate sleep ecology (e.g., lack of sleep hygiene or bedtime routine) may lead to sleep problems.

OBJECTIVE

As maltreated children often live in disorganized environments, this study aims to map knowledge about sleep ecology and sleep characteristics, as well as their associations with behavior problems in young maltreated children from one to five years old.

METHOD

A scoping review was performed according to the PRISMA-SR checklist. Bibliographic databases were searched from 1993 to May 2020.

RESULTS

From the 650 studies screened, nine reported results about sleep ecology or sleep characteristics or their associations with behavior problems in young maltreated children. Only one study described their sleep ecology. Eight studies documented or compared sleep characteristics, showing slight differences between maltreated and non-maltreated children (e.g., longer nighttime sleep duration or shorter naps in maltreated children). Four studies revealed associations between sleep characteristics and behavior problems in young maltreated children (e.g., shorter sleep duration was associated with more externalizing behaviors).

CONCLUSION

Literature about sleep ecology, sleep characteristics, as well as with their associations with behavior problems in young maltreated children is scarce. Their sleep ecology especially deserves to be investigated. Longitudinal studies, studies with comparison groups, combining objective and subjective validated sleep measures, and taking into account maltreatment characteristics and children's developmental stage should be pursued.

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).

Sleep Patterns, Problems and Ecology among Toddlers in Families with a Child Protective Services Maltreatment Referral

PURPOSE

To describe sleep patterns, problems, and ecology among toddlers (13 to 36 months) from families referred to Child Protective Services (CPS) for maltreatment and to compare sleep duration among a subgroup (24- to 36-month-olds) to previously published population-based data.

DESIGN AND METHODS

A secondary analysis of a larger longitudinal study was conducted. Participants included 113 parent-toddler dyads recruited out of CPS offices based on having a recent maltreatment referral. Parents reported about their toddler's sleep at two time points (approximately six months apart).

RESULTS

At the earlier and later time points, respectively, mean sleep duration was 11.03 and 10.90 h (nighttime), 1.36 and 1.36 h (daytime), and 12.47 and 12.28 h (total 24-h). Of the toddlers, 24% and 17% had two or more nighttime awakenings, 34% and 33% had at least a somewhat hard time falling asleep, and 25% and 26% had difficulty sleeping alone. Mean bedtimes were 8:50 pm and 8:58 pm. Nighttime sleeping arrangement/location, nap arrangement/location, and method of falling asleep at night varied. Compared to the population-based data, nighttime sleep duration was 43 min longer and nap duration was 46 min shorter in the CPS sample.

CONCLUSIONS

Symptoms of behavioral sleep problems were common in this sample of toddlers from families referred to CPS for maltreatment. Distribution of sleep, but not total 24-hour sleep, differed significantly between the CPS sample and the population-based data.

PRACTICE IMPLICATIONS

Nurses caring for toddlers from families involved with CPS can play an integral role promoting sleep health and addressing behavioral sleep problems.

Sleep Problems, Daily Napping Behavior, and Social-Emotional Functioning among Young Children from Families Referred to Child Protective Services

OBJECTIVE/BACKGROUND

Insufficient and/or poor-quality sleep may contribute to poor social-emotional well-being, and vice versa, among young children who have experienced maltreatment. This study examined longitudinal associations between sleep and social-emotional functioning among a sample of infants and toddlers from families involved with Child Protective Services (CPS) for maltreatment.

PARTICIPANTS

Participants were 123 parents and their infant or toddler (baseline age 10 to 24 months) from families referred to CPS for maltreatment.

METHODS

Data were collected at baseline and at 3, 6 and 9 months post-baseline. At all time points, parents completed a questionnaire about their child's social-emotional functioning including internalizing behavior, externalizing behavior, and competence in social-emotional skills and social relatedness. At 3 months post-baseline, parents reported about their child's sleep problems and daily napping behavior.

RESULTS

Higher baseline externalizing behavior was associated with a greater propensity for sleep problems at 3 months post-baseline. Sleep problems at 3 months post-baseline were associated with higher internalizing and higher externalizing behavior at 9 months post-baseline. Daily napping at 3 months post-baseline was associated with lower internalizing behavior, lower externalizing behavior, and higher competence at 9 months post-baseline.

CONCLUSIONS

Among this sample of young children from families involved with CPS for maltreatment, parents' concerns about their child having a sleep problem longitudinally associated with children's internalizing and externalizing behavior. Children's daily napping behavior longitudinally associated with later internalizing behavior, externalizing behavior, and competence.

Sleep duration associates with moderate-to-vigorous intensity physical activity and body fat in 1- to 3-year-old children

Sleep during early childhood is important for many developmental outcomes and shows promise as an important correlate of both obesity risk and physical activity behaviors. This was a cross-sectional study concerning the relationships between sleep and moderate- to - vigorous intensity physical activity and body fat percentage in a sample of 1- to 3-year-old children (N = 50; ages 27.512 ± 10.363 months). Sleep was measured with a caregiver questionnaire. Sedentary time, light, moderate, vigorous, and moderate- to - vigorous intensity physical activity were measured with Actigraph wT3x-BT accelerometers. Body fat was measured using Air Displacement Plethysmography with the BodPod Pediatric Option. Moderate- to - vigorous intensity physical activity and body fat percentage both associated with sleep duration, controlling for age and accelerometer wear time. These factors combined explained 54.3 % of the variance in sleep duration present in the sample. These results suggest the presence of relationships between sleep and physical activity and body composition constructs in this sample. Sleep may be an important variable in efforts to both promote early childhood physical activity and healthy body composition.

Impact of a home visiting program on sleep problems among young children experiencing adversity

BACKGROUND

Adversity may negatively impact young children's sleep but receiving home visitation services could buffer children from this potential consequence of adversity.

OBJECTIVE

This study examined whether young children's adverse experiences increased their risk for sleep problems and if Promoting First Relationships® (PFR), a home visitation program, reduced children's risk for sleep problems both directly and indirectly through increased parenting sensitivity.

PARTICIPANTS AND SETTING

Participants were 247 parents and their 10- to 24-month-old child recruited from Child Protective Services offices.

METHODS

A secondary analysis of a randomized controlled trial comparing PFR to a resource and referral control condition was conducted. Four time points of data were collected from baseline to 6 months post-intervention. Parenting sensitivity was measured at all time points using a parent-child interaction tool. Children's adversities were measured at various time points using caregiver report tools and official state records. Children's sleep problems were reported by parents at 6 months post-intervention.

RESULTS

The likelihood of having a sleep problem increased as children's adversities increased (β = .23, SE = .08, p = .005). There was no effect (direct or indirect) of treatment assignment on children's sleep problems (ps > .05). Post hoc analyses showed a treatment assignment by adversity interaction such that children's odds of having a sleep problem increased as their adversities increased, but only among children in the control condition (b = -0.37, SE = 0.17, p = .030).

CONCLUSIONS

Experiencing more adversities associated with a greater risk for sleep problems, but PFR buffered children from this risk.

A Proposed Nursing Theory: Infant Sleep and Development

Although well positioned to work with families of young children, nurses do not yet have a theory that guides practice and research by relating infant sleep to child and family development. The authors of this paper describe a proposed theory that combines Bronfenbrenner's bioecological theory of human development with the Barnard model of parent-child interaction to inform nursing practice and research related to infant sleep and optimizing child and family development. The theory focuses on sustainability of change in family processes and infant sleep, with a goal of optimizing family wellness as the proximal environment for child development.

Ensuring Implementation Fidelity of a 10-Week Home Visiting Program in Two Randomized Clinical Trials

Introduction Implementation fidelity is a challenge for the adoption of evidence-based programs within social service broadly and child welfare specifically. However, implementation fidelity is critical for maintaining the integrity of clinical trials and for ensuring successful delivery of services in public health settings. Methods Promoting First Relationships ® (PFR), a 10-week home visiting parenting intervention, was evaluated in two randomized clinical trials with populations of families in child welfare. Seven providers from community agencies participated in the trials and administered PFR. Fidelity data collected included observational measures of provider behavior, provider records, and input from clients to assess training uptake, adherence to content, quality of delivery, program dosage, and participant satisfaction. Results In mock cases to assess training uptake, providers demonstrated an increase in PFR verbalization strategies and a decrease non-PFR verbalizations from pre to post PFR training, and overall this was maintained a year later (Mann-Whitney U's = 0, p's < .01). Adherence to content in actual cases was high, with M = 97% of the program elements completed. Quality of delivery varied across providers, indicated by PFR consultation strategies (Wilks' Lambda F = 18.24, df = 15, p < .001) and global ratings (F = 13.35, df = 5, p < .001). Program dosage was high in both trials (71 and 86% receiving 10 sessions), and participant satisfaction was high (M = 3.9, SD = 0.2; 4 = greater satisfaction). Discussion This system of training and monitoring provides an example of procedures that can be used effectively to achieve implementation fidelity with evidence-based programs in social service practice.

The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis

BACKGROUND

Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems.

OBJECTIVES

To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment.

STUDY DESIGN

For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views.

PARTICIPANTS

Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months.

INTERVENTIONS

Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment.

MAIN OUTCOME MEASURES

Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability.

METHODS

Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible.

RESULTS

We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive-behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) -0.44 (95% CI -4.43 to -1.53)], depression [mean difference -2.83 (95% CI -4.53 to -1.13)] and anxiety [SMD -0.23 (95% CI -0.03 to -0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist-child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself.

CONCLUSIONS

It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions.

LIMITATIONS

Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses.

FUTURE WORK

Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003889.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Right from the start: protocol for a pilot study for a randomised trial of the New Baby Programme for improving outcomes for children born to socially vulnerable mothers

BACKGROUND

Children born to mothers who experience social complexity (e.g. substance misuse, intimate partner violence, mental ill health, a history of maltreatment) are at increased risk for a range of adverse outcomes at birth and during development. Home visiting programmes have been advocated as a strategy for improving outcomes for disadvantaged mothers and children, such as the Nurse-Family Partnership for young, socially disadvantaged first-time mothers. However, no evidence-based programme is available for multiparous women or older first-time mothers. The New Baby Programme was developed in Northern Ireland. It augments the universal health visiting service available in the UK with a content designed to promote maternal health and well-being in pregnancy, maximise secure attachments of children and parents and enhance sensitive parenting and infant cognitive development.

METHODS/DESIGN

This pilot study is designed to investigate whether it is possible to recruit and retain socially vulnerable mothers in a randomised trial that compares the effects of the New Baby Programme with standard antenatal and postnatal care. Feasibility issues include the referral/recruitment pathway (including inclusion and exclusion criteria), the consent and randomisation, the ability to maintain researcher blinding, the acceptability of the intervention to participants, and the feasibility and acceptability of the outcome measures. The results of the study will inform a definitive phase-3 RCT.

DISCUSSION

Trials of complex social interventions often encounter challenges that lead to the trial being abandoned (e.g. because of problems in recruitment) or present considerable analytic challenges relating to dropout, attrition and bias. This pilot study aims to maximise the chances of successful implementation.

TRIAL REGISTRATION

ISRCTN35456296 retrospectively registered.

A scoping review of evidence-based interventions available to parents of maltreated children ages 0-5 involved with child welfare services

Parents referred to child welfare services for child maltreatment often struggle against chronic risk factors including violence, substance abuse, mental health concerns, and poverty, which impinge upon their ability to be sensitive caregivers. The first line of intervention within the child welfare context is to modify parenting behavior. This scoping review comprehensively surveyed all available literature to map the extent and range of research activity around the types of interventions available within a child welfare context to parents of infants and toddlers (0-5 years of age), to identify the facilitators and/or barriers to the uptake of interventions, and to check that interventions match the risk factors faced by parents. This scoping review engaged in stringent screening of studies based upon inclusion/exclusion criteria. Sixty-five articles involving forty-two interventions met inclusion criteria. Interventions generally aimed to improve parenting practices, the relationship between parent and child, and/or attachment security, along with reducing child abuse and/or neglect. A notable finding of this scoping review is that at present, interventions for parents of children ages 0-5 involved with the child welfare system are most frequently measured via case study and quasi-experimental designs, with randomized control trials making up 26.2% of included study designs.

Testing the limits: Extending attachment-based intervention effects to infant cognitive outcome and parental stress

Using a sample of 41 infants and toddlers (21 interventions, 20 controls) who were neglected or at serious risk for neglect, this randomized clinical trial examined the efficacy of a parent-child attachment-based video-feedback intervention on parental sensitivity, parental stress, and child mental/psychomotor development. Results showed that following the 8-week intervention, scores for maternal sensitivity and child mental and psychomotor development were higher in the intervention group than in the control group. The intervention appears to have no effect on self-reports of stress. All parents report lower levels of stress postintervention; however, when defensive responding is not considered (i.e., extremely low score of parental stress), parents in the control group report somewhat lower scores, raising questions as to the significance of this finding. Considering the small nature of our sample, replication of the present results is needed. Nevertheless, the present findings contribute to the burgeoning literature suggesting that the early attachment relationship provides an important context that influences developmental outcome in different spheres and raises questions as to how such intervention strategies may or may not affect the subjective experience of parenting.

Fostering secure attachment in low- and middle-income countries: Suggestions for evidence-based interventions

Children struggling with the effects of trauma in low- and middle-income countries (LMIC) face a substantial mental health resource gap that limits their opportunities for positive psychosocial development. Multidisciplinary interventions working to close this gap may benefit from incorporating an empirically supported treatment (EST) into their approach that targets a universal mechanism implicated in resilience, like attachment. ESTs should be selected based on their level of empirical support and cultural adaptability, and then modified on the basis of qualitative evaluations conducted with the local population and stakeholders. This paper will provide an overview of attachment as a mechanism of resilience, a critical analysis of existing attachment-based ESTs, and recommendations for overcoming EST implementation barriers in LMIC.

Maltreatment in Infancy: A Developmental Perspective on Prevention and Intervention

Burgeoning research has documented high rates of maltreatment during the first 3 years of life. Early exposure to maltreatment is related to a host of negative physical, developmental, and mental health outcomes in childhood and adulthood. Scientists have documented the "biological embedding" of maltreatment, including alterations in the structures and processes of the young brain. Maltreatment is a complex phenomenon, which manifests in contexts of family poverty, inadequate parental knowledge and skill regarding child development and caregiving, social isolation of parents, disruptions in parent-child relationships, compromised parental psychological functioning, and concrete issues that affect parenting. Capitalizing on research on young child maltreatment, interventions have been designed to ameliorate infant/toddler maltreatment, buffer young children against the effects of maltreatment, and promote the well-being of maltreated young children. There is a growing empirical base on interventions to address early maltreatment within the context of a public health prevention framework. Primary prevention programs aim to reduce the incidence of maltreatment and related outcomes for infants, toddlers, and their families through the implementation of population-based programs, such as home visiting and early care and education programs. Secondary prevention models target families with specific risk factors associated with maltreatment, such as maternal depression. Tertiary programs generally entail involuntary services, designed to prevent maltreatment recurrence and to improve parenting skills through therapeutic approaches targeting the parent-child dyad. Empirical knowledge about maltreated young children and their families and interventions to support them can inform the design and delivery of child welfare services.

Permanency Outcomes for Toddlers in Child Welfare Two Years After a Randomized Trial of a Parenting Intervention

This study reports on child welfare outcomes of a community based, randomized control trial of Promoting First Relationships® (PFR; Kelly, Sandoval, Zuckerman, & Buehlman, 2008), a 10-week relationship-based home visiting program, on stability of children's placements and permanency status two years after enrollment into the study. Toddlers 10 - 24 months (N = 210) with a recent placement disruption were randomized, along with their birth or foster/kin parents, to PFR (n = 105) or a comparison condition (n = 105). A stable placement had no interruptions or disruptions. A permanent placement was a stable placement ending with a legal discharge to the study caregiver. Logistic regression models predicting the dichotomous stability and permanency variables, controlling for caregiver type, child welfare variables, and caregiver commitment, were conducted. There was no difference by intervention group on stability or permanency, but there was a significant interaction between caregiver type (birth parent vs. foster/kin) and intervention group. More foster/kin caregivers who received the PFR intervention provided stable, uninterrupted care and eventually adopted or became the legal guardians of the toddlers in their care, compared to foster/kin caregivers randomized to the comparison condition.