Intervention to Improve Outcomes for Foster Children Reunited With Their Birth Families
Phase: NA
Conditions: Child Abuse, Child Neglect
Sponsor: University of Washington

Cover Page 
Study Protocol 
 
Official title of the study: Intervention to Improve Outcomes for Foster Children Reunited with Their 
Birth Families 
Brief title: Families Together: Intervention for Reunified Families 
NCT Number: NCT04382677 
 
Date of document: 4/1/2026 
 
 

Research Plan and Methodology 
All procedures were reviewed and approved by the Washington State Institutional Review Board 
(WSIRB; study number D-110816-Y17.18). A Data Safety and Monitoring Board (DSMB), an external, 
independent oversight board, monitored the study's conduct to assess ongoing feasibility, data integrity, 
and safety. The research team selected DSMB members who had expertise and no conflicts of interest. 
The three participants had individual expertise in clinical trials/methods/research in child welfare 
systems [ME], clinical content area/collaborative research with parent support programs [LR], and 
clinical trials/methods/biostatistical issues [JR]. During the enrollment and intervention phases, 
meetings occurred annually. [The group agreed not to meet during 2020 and 2021 when the study 
temporarily stopped research activities due to COVID-19.]  
Study Design 
This study was a randomized controlled trial. The effects of the intervention were tested in a 
two-arm trial comparing Promoting First Relationships (PFR; Arm 1) with the Resource and Referral 
(R&R) control condition (Arm 2). Assessments were completed at Time 1 (baseline, before 
randomization), immediately after the intervention (Time 2), and 6-month follow-up (Time 3).  
Recruitment and Study Procedures 
Eligibility and recruitment. Between December 2017 and May 2023, the Families Together 
project enrolled parent-child dyads into the study. Parents were eligible if they had an open case in 
“Trial Return Home” status through a participating Department of Children, Youth, and Families (DCYF) 
office in the greater Seattle, Washington area; were age 18 or older; were conversant in English; had 
access to a telephone; had a minimum of temporary housing; and had not previously received PFR. At 
enrollment, children were between 1 and 5 years of age and recently reunified with a birth parent after 
a foster care placement.  

Study recruitment was conducted in collaboration with the Washington State Department of 
Children, Youth, and Families (DCYF). A DCYF--study liaison received bi-monthly lists of potentially 
eligible families from a DCYF data manager. The liaison mailed opt-out recruitment letters to 1,082 
potentially eligible families, briefly describing the study. A study recruiter attempted to contact the 882 
families that did not opt out to explain the study and conduct additional screening. Of these families, 
168 could not be reached, and 287 were determined ineligible. Of the eligible families (N=427), 264 
were interested in the study. For each of these families, a DCYF social worker was contacted to obtain 
consent for the child to participate (100% of contacted social workers signed the consent form). A 
research visitor then scheduled to meet in the family’s home to obtain written consent from the parent 
and conduct the first research visit. The enrolled dyad included one identified parent and one identified 
child in the family who were followed throughout the study. Enrolled parents agreed to randomization 
(PFR or R&R) and three in-home research visits (T1: baseline, T2: post-intervention, and T3: 6 months 
post-intervention). For families who did not complete the intervention, post-intervention and 6-month 
post-intervention assessments were scheduled based on the dates they would have completed the 
interventions if they had kept their appointments. The project compensated participants $75 after each 
research visit. The research visitor was not informed of the randomization group of enrolled families, 
and reminded the parent at each follow-up research visit not to share with them what group they were 
in. 
Randomization. Randomization to condition occurred after the baseline interview. The project 
director initiated the computerized randomization program, based on the minimization method: parent-
child dyads were stratified based on parent’s race, parent’s Hispanic ethnicity, child’s age (1–2 years, 3–
5 years), and geographic region, then subsequently randomized within strata into the PFR intervention 
or control condition. The algorithm conditioned the probability of assignment on prior allocations to 

generate roughly balanced numbers in the intervention and control conditions, while avoiding 
predetermined assignments that could be anticipated by research staff. 
COVID-19 impact. By February 2020, we had enrolled 168 families into the project. Due to stay-
at-home orders related to the COVID-19 pandemic in the spring of 2020, the project received approval 
from the WSIRB and the funding agency to pause intervention and recruitment activities. Families who 
were in the intervention phase at the onset of the pandemic were dropped from the research study 
because stay-at-home orders prevented completion of the home-based intervention for those 
randomized to PFR (n=11; of those, 5 had not started PFR). To maintain balance, those randomized to 
the control group during that period were also dropped (n=13). Families who had completed the 
treatment phase and were due for follow-up assessments had research visits by telephone but were 
unable to complete the video-recorded activities. Thus, 7 participants at T2 and 37 participants at T3 are 
missing the observational assessments. In August 2021, the study resumed enrolling participants and 
conducting in-home visits, and by May 2023, another 96 families were enrolled, yielding a final retained 
longitudinal sample of 240 parent-child dyads (264 – 24 dropped due to COVID-19 = 240). 
Interventions  
Promoting First Relationships (PFR) (Kelly, et al., 2003, 2008, 2016, 2025) aims to train service 
providers to use an attachment theory-based intervention program that is strengths-based. The PFR 
program designed specifically for birth families being reunited with their child consists of a 12-week 
intervention that is delivered in the home (or in rare cases, an alternate location). Each week has a 
theme for discussion, an activity which includes videotaping or viewing and reflecting on a videotaped 
session, and time for “joining.” Joining is described as checking in with the parent, listening to their 
concerns, and establishing a positive, supportive relationship. Each session includes at least two 
handouts, one with the content area covered that day and one titled “Thoughts for the Week” which 

asks parents to think about a topic discussed during the session and apply it to their relationship with 
their child. The provider videotapes playtime between parent and child five times and alternates every 
other week with watching the video with the parent, called Reflective Observation. When the parent 
and provider watch the previous session of playtime on video, they reflect on what the needs are of 
both the parent and the child; the provider helps the parent “enter the mind” of the child to develop 
greater empathy and understanding of the child’s needs and feelings. The provider also helps the parent 
identify her own feelings and needs around parenting. In addition to training providers to deliver the 
intervention to parents, PFR also teaches providers five consultation strategies that are strengths-based 
methods for conveying information (such as child development expectations) and enhancing parents’ 
self-efficacy in parenting. The consultation strategies include: Joining, Positive Feedback, Instructive 
Feedback, and Reflective Questions and Comments, and Instruction with Handouts. It is argued that 
these core strategies, which enhance parents’ sense of security and competency, are the heart of the 
PFR program. 
For this study, we adapted the PFR model to be sensitive and relevant to the family’s 
reunification process. The standard 10-week program was expanded to 12 weeks to include two 
additional parent-only sessions: (1) session 1 to build rapport, discuss reunification challenges, and set 
boundaries for discussing sensitive topics when the child was present and (2) session 4 to support the 
parent in reflecting on the parent’s own childhood experiences and how those experiences relate to the 
parent’s caregiving. All other sessions followed the standard PFR model, involving both parent and child.  
Providers deliver the following weekly content to families:  
Week 
Theme-Discussion/Handouts 
Activity and Handout (HO) 
Thoughts for the Week 
1.  
Introduction to PFR and Social and 
Emotional Health 
Elements of a Healthy Relationship 
Video 
Healthy relationships 
2. 
Attachment Behaviors, Social & 
Emotional Needs of Children 
Videotape Play Session & Developing 
Trust HO 
Attachment behaviors 

3. 
How We Can Meet Social and 
Emotional Needs  
Reflective Observation and  
Calming Myself HO 
Social and emotional 
needs 
4. 
Repair In Relationships, When 
Things Go Wrong 
Repair & Staying Connected during 
Difficult Moments HO 
Staying connected 
5.  
Learning the Non-Verbal 
Language of Young Children 
Videotape Play Session, Baby Cues 
and Teach/Play HO 
Nonverbal 
communication 
6.  
Understanding Challenging 
Behaviors  
Reflective Observation and 
Challenging Behavior HO  
Social and emotional 
needs 
7. 
Separations and Transitions  
Videotape Play Session, & Separations 
and Transitions  
Separations & 
transitions  
8. 
Calming Myself, Calming my Child 
Reflective Observation & Calming HO 
Calming steps 
9. 
Encouraging Cooperation 
Videotaped play session & Balanced 
Parenting and Cooperation 
Setting limits & offering 
choices 
10. 
Behaviors, Feelings and Needs 
Reflective Observation & 
Understanding Behavior 
Behaviors, feelings, 
needs 
11. 
Focus on Consolidating Gains   
Videotape Play Session 
Choose two things to 
focus on 
12. 
Closing 
Reflective Observation 
Certificate of 
completion 
 
All providers of PFR were from the community and had been previously trained and certified to 
deliver PFR, unrelated to the study. Providers had various degrees of experience providing the program 
directly to families. The providers were required to either have an active certification or update their 
certification by demonstrating fidelity with a practice family prior to seeing a study family. 
Approximately five providers were employed by the study at any given time. Due to staff turnover 
during the COVID-19 pandemic, 16 different PFR providers served study families throughout the study. 
All providers were female. Of the 16 PFR providers, 4 had bachelor’s degrees and 12 had master’s 
degrees.  
Provider fidelity to the PFR model was continuously monitored. Providers videotaped 
themselves providing reflective video feedback with each family at the sixth PFR visit. These fidelity 

videos were then reviewed and coded by an expert PFR trainer, who rated the delivery quality on a 1- to 
5-point scale (with higher scores indicating greater fidelity). If a provider received a rating of less than 4, 
she received additional mentoring until fidelity to PFR was reestablished. The provider continued to 
serve study families on her caseload; however, she did not receive any new cases until fidelity was 
reestablished. Of the 121 cases randomized to PFR, 77 had 6 or more sessions and should have had a 
fidelity video. However, 7 were not completed, and 4 could not be coded due to technical problems. Of 
the 66 submitted videotapes, the average delivery quality score was 4.64 (SD=0.54), and 97% passed.  
The Resource and Referral (R&R) program was delivered by one of three providers via phone, 
text, postal mail, and email. All providers were female; one had a master’s degree, and two had 
bachelor’s degrees.  
A needs assessment was conducted during an initial phone call, after which the provider 
compiled a personalized resource and referral list, which was emailed or mailed to the parent. Three 
additional check-in calls, texts, or emails occurred over the subsequent months to offer additional 
resources if requested. 
Outcome Measures 
Child Welfare Services removals were identified from placement records obtained from DCYF 
that covered allegations, removals, and placements prior to enrollment and up to two years post-
intervention, with complete coverage of 18 months after study enrollment for all families. These records 
were used to assess CWS removals in the 1.5 years subsequent to enrollment.   
Parental sensitivity was measured observationally at each research visit using the Nursing Child 
Assessment Teaching Scale (NCATS; Barnard, 1994). The NCATS was designed for use with children aged 
3 years and under; here, we adapted the NCATS for use with older children up to age 6 years by allowing 
for more complex teaching tasks and minor word changes for 22 of 50 items to be more appropriate for 

preschool-aged children (e.g., the infant item, “Caregiver positions child so that it is possible for them to 
have eye- to-eye contact...” was modified to “Caregiver assumes a position that facilitates eye-to-eye 
contact with the child...”). Parents were presented with a list of activities and instructed to select the 
first task their child could not yet do (e.g., stack blocks, string beads, draw a shape, print his/her name) 
and to attempt to teach it to their child. The research visitor provided a standard set of manipulatives 
and video-recorded the teaching interactions. A single coder, masked to the intervention condition and 
trained in reliability with a certified NCATS instructor, coded all tapes. For reliability checking, 18.8% of 
the videos were also coded by one of two expert trainers. Overall inter-rater agreement was 86.7%. 
Videotapes were scored on 50 dichotomous (0 = no, 1 = yes) items measuring sensitivity to cues; 
response to distress; social, emotional, and cognitive growth fostering; and contingency between 
mother and child. The sum of items yields a total parenting sensitivity score. Thirty-seven items were 
used for this study; we did not use the Response to Distress subscale and two other items deemed not 
appropriate for older children. Thus, sensitivity scores could range from 0 to 37, with higher scores 
indicating greater sensitivity. Cronbach’s α in the study sample ranged from .57 to .62 across the three 
time points. 
Parenting knowledge of child development was measured by the Raising a Child (RAC) Scale, 
adapted from the Raising a Baby Scale (RAB; Kelly & Korfmacher, 2008), a measure of caregivers’ 
knowledge of children’s social-emotional needs and developmentally appropriate expectations. The 
adaptation included changing the language from “babies” and “toddlers” to “children” to be more 
relevant to the sample. Two items that only applied to babies were also removed (“Parents spoil babies 
by picking them up when they cry,” “Talking to babies only really becomes important when they are old 
enough to start using some of their own words”), for a total of 14 items that parents rate on a 4-point 
scale (strongly agree to strongly disagree). The RAB evidences construct validity in other studies of PFR 
and has shown treatment effects in CWS-involved populations (Oxford, Spieker, et al., 2016; Spieker et 

al., 2012).  Cronbach’s αs ranged from .61 to .63 across the three time points. The scale was summed, 
and scores could range from 14 to 56, with higher scores indicating greater parental knowledge.  
Child externalizing problem behavior and child internalizing problem behavior were assessed 
via parent report using the Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2000). The CBCL is a 
99-item clinical tool appropriate for children 1.5 to 5 years old that measures social, emotional, and 
behavioral problems in young children. Parents rate their child on a three-point response (0 = not true to 
2 = very true or often true). The externalizing domain has 24 items, and the internalizing domain has 36 
items; raw scores were used in analysis; higher scores indicate more problem behavior. Across the three 
time points, Cronbach’s αs ranged from .90 to .91 for externalizing and .86 to .88 for internalizing. 
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