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| ID | Type | Description | Link |
|---|---|---|---|
| R01HD090176 | U.S. NIH Grant/Contract | View source |
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| Name | Class |
|---|---|
| Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) | NIH |
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Birth parents of young children who have been placed into foster care are a highly vulnerable population of caregivers. Little is known about the ability of existing prevention programs to intervene with birth parents who have recently been reunified with their children under the age of six. This project aims to evaluate a brief, home-visiting intervention model with a sample of reunified birth parents, examining its effectiveness to improve parenting and child wellbeing, and reduce reoccurrence of maltreatment and reunification failure.
There is no brief, home visiting, evidence-based intervention designed for and evaluated with Child Welfare System (CWS) birth parents and their children under six, once they are reunified. Why is this important? Because reunified birth parents represent one of the highest risk subpopulations of parents whose challenges contribute both to their child's exposure to stress and trauma and to the intergenerational transmission of impaired parenting, maltreatment, and foster care placement.
Reunified birth parents are more likely than other parents to have been foster children and survivors of childhood maltreatment. They have higher rates of co-morbid mental health disorders, substance abuse, poverty, low education, and homelessness. When their children are placed in out-of-home care as infants or toddlers, they are more likely to have longer stays in foster care than any other age group. Foster children are at risk for serious emotional, behavioral, neurological, and physiological health problems, and for continued relationship disruptions, maltreatment, and foster care placements throughout their life course. Birth parents need intervention services when they reunite with their child to support the already fragile parent-child relationship. Even when birth parents work hard to fulfill court requirements to regain custody of their child, they are often left without the skills necessary to establish a strong and lasting connection with their child. This failure of service, we believe, leads reunified families to experience a high rate of maltreatment reoccurrence and reentry into foster care.
In this application we will evaluate the effectiveness of a community based, home visiting intervention program with a population of birth parents recently reunified with their child under the age of six after a foster care placement. In order to do this, we first adapt the program by adding material relevant to reunified birth families and adapt the material for older children. We will evaluate the effectiveness of Promoting First Relationships ® (PFR; Kelly et al., 2008) to meet the parenting needs of this vulnerable population. Promoting First Relationships was originally designed for children birth to three, and we will expand the curriculum to meet the needs of children through age six. Through a strong, established community partnership between the state, a community mental health agency, and the University of Washington, we will 1) adapt Promoting First Relationships ® (PFR) for reunified birth families and older children; 2) test the effectiveness of PFR to improve parental quality and parent-child interaction as compared to a Resource and Referral service; 3) test the effectiveness of PFR on reducing social, emotional, and behavioral problems in a population of children at risk for elevated emotional and behavioral disorders; 4) test the effectiveness of PFR in reducing referrals to Child Protective Services (CPS) and re-entry into foster care.
Participants complete baseline assessments during an observation-only period. The parent-child dyad is randomized following the baseline assessment. They then receive the study intervention for 7-43 weeks, after which no further intervention is delivered. Outcome assessments are conducted during the post-intervention follow-up period immediately after completion of the intervention and again 6 months later. Outcome assessments are obtained (if possible) even when the intervention is not completed, for intent-to-treat analyses.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Promoting First Relationships | Experimental | The PFR program designed for birth families being reunited after foster care placement consists of a manualized 12-session intervention delivered in the home by trained providers. |
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| Resource & Referral | Other | The service consists of a needs assessment conducted by phone, followed by a personalized resource packet and referrals, and 3 monthly check-in phone calls. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Promoting First Relationships ® | Behavioral | Promoting First Relationships ® is based on attachment theory and is strengths-based. The 12 week intervention is delivered in the home of the family. Each week has a theme for discussion, handouts, an activity, and time for "joining" - checking in with the parent, listening to their concerns, and establishing a positive, supportive relationship. The provider videotapes playtime between parent and child, and alternates weeks watching the video with the parent, reflecting about the needs of both parent and child (reflective observation). PFR consultation strategies include Joining, Positive Feedback, Instructive Feedback, Reflective Questions and Comments, and Instruction with Handouts. These core strategies enhance parents' sense of security and competency. The provider helps the parent develop greater empathy and understanding of the child's needs and feelings, and helps the parent to identify their own feelings and needs around parenting. |
| Measure | Description | Time Frame |
|---|---|---|
| Child Welfare Services Removal From Birth Parent Home | Official child welfare administrative records indicating whether the child in they dyad was removed from the birth parent home. 18 months post enrollment is approximately 1 year post intervention for those who completed interventions on schedule | 18 months post enrollment in the study |
| Change in Parental Sensitivity (Video Recorded Observations Coded by Coders Blind to Intervention) | Parent sensitivity is measured by the Nursing Child Assessment Teaching Scale (NCATS; Barnard 1994), a videotaped interaction to assess caregiver sensitivity, stimulation of the child, and emotional responsiveness during interaction. The score is the sum of 37 items, ranging from 0 to 37; higher scores indicate greater parental sensitivity. | Post intervention (Time 2) -- approximately 6 months after Baseline (Time 1) |
| Change in Parental Sensitivity (Video Recorded Observations Coded by Coders Blind to Intervention) | Parent sensitivity is measured by the Nursing Child Assessment Teaching Scale (NCATS; Barnard 1994), a videotaped interaction to assess caregiver sensitivity, stimulation of the child, and emotional responsiveness during interaction. The score is the sum of 37 items, ranging from 0 to 37; higher scores indicate greater parental sensitivity. | 6 months post intervention (Time 3) -- approximately 12 months after Baseline (Time 1) |
| Change in Parenting Knowledge of Child Development | 14-item Likert-scale questionnaire developed by the study, "Raising a Child," is a measure of caregivers' knowledge of children's social-emotional needs and developmentally appropriate expectations. Items are scored on a scale ranging from 1 to 4 points. The Raising a Child scale score is the sum of the 14 items; the range is 14 to 56 with higher scores indicating greater parenting knowledge (better outcome). | Post intervention (Time 2) -- approximately 6 months after Baseline (Time 1) |
| Measure | Description | Time Frame |
|---|---|---|
| Change in Child Externalizing Problem Behavior | Child externalizing behavioral problems will be measured based on parent report using the Child Behavior Check List (CBCL: Achenbach & Rescorla, 2000). The externalizing scale has 24 items; raw scores can range from 0 to 48 with higher scores indicating more externalizing behaviors. | Post intervention (Time 2) -- approximately 6 months after Baseline (Time 1) |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Monica L Oxford, MSW, PhD | University of Washington | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University of Washington, Child, Family, and Population Health Nursing | Seattle | Washington | 98105 | United States |
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Of the eligible parent-child dyads (N=427), 264 dyads enrolled:1 parent and 1 child each equating to 528 total parent and child participants.
Recruitment took place between 12/2017 and 5/2023 in collaboration with the Washington State Department of Children, Youth, & Families (DCYF). A DCYF study liaison mailed opt-out letters to birth parents recently reunified with a child aged 1-5 years after a foster care placement (open case in Trial Return Home status), living in the greater Seattle, WA area. Parents who did not opt out were contacted by a study recruiter, screened for eligibility, and enrolled in the study.
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| ID | Title | Description |
|---|---|---|
| FG000 | Promoting First Relationships | The PFR program designed for birth parents being reunited after foster care placement consists of a manualized 12-session intervention delivered in the home by trained providers. |
| FG001 | Resource & Referral | The service consists of a needs assessment conducted by phone, followed by a personalized resource packet and referrals, and 3 monthly check-in phone calls. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Baseline Observation |
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| Intervention |
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| Post-intervention Follow-up |
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Data represent individual parents and children enrolled as dyads
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| ID | Title | Description |
|---|---|---|
| BG000 | Promoting First Relationships | The PFR program designed for birth parents being reunited after foster care placement consists of a manualized 12-session intervention delivered in the home by trained providers. |
| BG001 | Resource & Referral |
| Units | Counts |
|---|---|
| Participants |
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| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Data reported for parents and children separately |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | ||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Child Welfare Services Removal From Birth Parent Home | Official child welfare administrative records indicating whether the child in they dyad was removed from the birth parent home. 18 months post enrollment is approximately 1 year post intervention for those who completed interventions on schedule | Outcome measure assessed only in children who were not dropped due to COVID-19 pandemic. N for this outcome is 240 children. | Posted | Count of Participants | Participants | 18 months post enrollment in the study |
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From enrollment until end of 6-month post-intervention follow-up
All serious adverse events are reported regardless of relatedness to the study intervention. Both groups received positive services and no physical/medical intervention. No one was at risk for a serious adverse event or mortality from this behavioral positive parenting program. In attempting to locate a parent for the final data collection, we found their name listed as deceased in vital records. Data represent individual parents and children enrolled as dyads.
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Promoting First Relationships - Parents | The PFR program designed for birth families being reunited after foster care placement consists of a manualized 12-session intervention delivered in the home by trained providers. |
| Term | Organ System | Source Vocabulary | Assessment Type | Notes | Statistical Information |
|---|---|---|---|---|---|
| Death | General disorders | Non-systematic Assessment | In attempting to locate a parent for the final data collection, we found their name listed as deceased in vital records. We do not have any additional information on the cause. |
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Factors that may have contributed to the results of this study: Families were highly stressed, had few resources, and had many unmet basic needs, were affected by the COVID pandemic. Missing observational data due to the pandemic is a limitation as were unexpected low alpha reliabilities of the observational measure. The study took place during the synthetic opioid crisis and during changes in WA State child removal criteria in child welfare.
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Monica L. Oxford, Executive Director, Barnard Center for Infant and Early Childhood Mental Health | University of Washington | 206-685-6107 | mloxford@uw.edu |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot | Yes | No | No | Study Protocol | Apr 1, 2026 | Apr 1, 2026 | Prot_000.pdf |
| SAP | No | Yes | No | Statistical Analysis Plan | Jan 14, 2026 | Jan 24, 2026 | SAP_001.pdf |
| ICF | No | No | Yes | Informed Consent Form | Jun 16, 2021 | Jan 8, 2026 | ICF_002.pdf |
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| ID | Term |
|---|---|
| D006295 | Health Resources |
| D012017 | Referral and Consultation |
| ID | Term |
|---|---|
| D006285 | Health Planning |
| D004472 | Health Care Economics and Organizations |
| D003695 | Delivery of Health Care |
| D017530 | Health Care Quality, Access, and Evaluation |
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| Resource & Referral | Other | This condition consists of 1) Resource & Referral assistance provided over the phone, and 2) Local Services Resource Packet. Throughout the intervention period, the provider makes monthly phone calls to offer further support to families, answer questions, and provide additional resources. The provider has at least four interactions with each family served. In addition, families in this condition have the Resource and Referral Specialist's phone number and they can call if an additional need arises. The resource packet includes local information organized by type of need or resource. These packets are updated regularly as services change over time. |
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| Change in Parenting Knowledge of Child Development | 14-item Likert-scale questionnaire developed by the study, "Raising a Child," is a measure of caregivers' knowledge of children's social-emotional needs and developmentally appropriate expectations. Items are scored on a scale ranging from 1 to 4 points. The Raising a Child scale score is the sum of the 14 items; the range is 14 to 56 with higher scores indicating greater parenting knowledge (better outcome). | 6 months post intervention (Time 3) -- approximately 12 months after Baseline (Time 1) |
| Change in Child Externalizing Problem Behavior | Child externalizing behavioral problems will be measured based on parent report using the Child Behavior Check List (CBCL: Achenbach & Rescorla, 2000). The externalizing scale has 24 items; raw scores can range from 0 to 48 with higher scores indicating more externalizing behaviors. | 6 months post intervention (Time 3) -- approximately 12 months after Baseline (Time 1) |
| Change in Child Internalizing Problem Behavior | Child internalizing behavioral problems will be measured based on parent report using the Child Behavior Check List (CBCL: Achenbach & Rescorla, 2000). The internalizing scale has 36 items; raw scores can range from 0 to 72 with higher scores indicating more internalizing behaviors. | Post intervention (Time 2) -- approximately 6 months after Baseline (Time 1) |
| Change in Child Internalizing Problem Behavior | Child internalizing behavioral problems will be measured based on parent report using the Child Behavior Check List (CBCL: Achenbach & Rescorla, 2000). The internalizing scale has 36 items; raw scores can range from 0 to 72 with higher scores indicating more internalizing behaviors. | 6 months post intervention (Time 3) -- approximately 12 months after Baseline (Time 1) |
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The service consists of a needs assessment conducted by phone, followed by a personalized resource packet and referrals, and 3 monthly check-in phone calls. |
| BG002 | Total | Total of all reporting groups |
| Mean |
| Standard Deviation |
| Years |
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| Sex: Female, Male | Data reported for parents and children separately | Count of Participants | Participants |
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| Race (NIH/OMB) | Data reported for parents and children separately | Count of Participants | Participants |
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| Ethnicity (NIH/OMB) | Data reported for parents and children separately | Count of Participants | Participants |
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| Dyad enrolled relative to COVID-19 pandemic | Study enrollment was paused during the stay-at-home orders of the COVID-19 pandemic (2020 thru July 2021). This measure indicates whether the family was enrolled before or after the pause. | Data reported for the dyad as the analysis population | Number | dyads |
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| Resource & Referral |
The service consists of a needs assessment conducted by phone, followed by a personalized resource packet and referrals, and 3 monthly check-in phone calls. |
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| Primary | Change in Parental Sensitivity (Video Recorded Observations Coded by Coders Blind to Intervention) | Parent sensitivity is measured by the Nursing Child Assessment Teaching Scale (NCATS; Barnard 1994), a videotaped interaction to assess caregiver sensitivity, stimulation of the child, and emotional responsiveness during interaction. The score is the sum of 37 items, ranging from 0 to 37; higher scores indicate greater parental sensitivity. | Outcome measure assessed only in parents, number of participants analyzed reflect total parent participants assessed for this outcome. Technically, the models used full information maximum likelihood estimation and included cases with partial data (i.e., baseline scores but no follow-up scores) and help reduce bias due to attrition that is associated with nonmissing data on model covariates. The effective sample size, however, is the number of cases who with nonmissing data for follow-up scores. | Posted | Mean | Standard Deviation | scores on a scale | Post intervention (Time 2) -- approximately 6 months after Baseline (Time 1) |
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| Primary | Change in Parental Sensitivity (Video Recorded Observations Coded by Coders Blind to Intervention) | Parent sensitivity is measured by the Nursing Child Assessment Teaching Scale (NCATS; Barnard 1994), a videotaped interaction to assess caregiver sensitivity, stimulation of the child, and emotional responsiveness during interaction. The score is the sum of 37 items, ranging from 0 to 37; higher scores indicate greater parental sensitivity. | Outcome measure assessed only in parents, number of participants analyzed reflect total parent participants assessed for this outcome. The models used full information maximum likelihood estimation and included cases with partial data (i.e., baseline scores but no follow-up scores) and help reduce bias due to attrition that is associated with nonmissing data on model covariates. The effective sample size, however, is the number of cases with nonmissing data for follow-up scores. | Posted | Mean | Standard Deviation | scores on a scale | 6 months post intervention (Time 3) -- approximately 12 months after Baseline (Time 1) |
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| Primary | Change in Parenting Knowledge of Child Development | 14-item Likert-scale questionnaire developed by the study, "Raising a Child," is a measure of caregivers' knowledge of children's social-emotional needs and developmentally appropriate expectations. Items are scored on a scale ranging from 1 to 4 points. The Raising a Child scale score is the sum of the 14 items; the range is 14 to 56 with higher scores indicating greater parenting knowledge (better outcome). | Outcome measure assessed only in parents, number of participants analyzed reflect total parent participants assessed for this outcome. The models used full information maximum likelihood estimation and included cases with partial data (i.e., baseline scores but no follow-up scores) and help reduce bias due to attrition that is associated with nonmissing data on model covariates. The effective sample size, however, is the number of cases with nonmissing data for follow-up scores. | Posted | Mean | Standard Deviation | scores on a scale | Post intervention (Time 2) -- approximately 6 months after Baseline (Time 1) |
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| Primary | Change in Parenting Knowledge of Child Development | 14-item Likert-scale questionnaire developed by the study, "Raising a Child," is a measure of caregivers' knowledge of children's social-emotional needs and developmentally appropriate expectations. Items are scored on a scale ranging from 1 to 4 points. The Raising a Child scale score is the sum of the 14 items; the range is 14 to 56 with higher scores indicating greater parenting knowledge (better outcome). | Outcome measure assessed only in parents, number of participants analyzed reflect total parent participants assessed for this outcome. The models used full information maximum likelihood estimation and included cases with partial data (i.e., baseline scores but no follow-up scores) and help reduce bias due to attrition that is associated with nonmissing data on model covariates. The effective sample size, however, is the number of cases with nonmissing data for follow-up scores. | Posted | Mean | Standard Deviation | scores on a scale | 6 months post intervention (Time 3) -- approximately 12 months after Baseline (Time 1) |
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| Secondary | Change in Child Externalizing Problem Behavior | Child externalizing behavioral problems will be measured based on parent report using the Child Behavior Check List (CBCL: Achenbach & Rescorla, 2000). The externalizing scale has 24 items; raw scores can range from 0 to 48 with higher scores indicating more externalizing behaviors. | Outcome measure assessed only in parent's report of child, number of participants analyzed reflect total parent participants assessed for this outcome. The models used full information maximum likelihood estimation and included cases with partial data (i.e., baseline scores but no follow-up scores) and help reduce bias due to attrition that is associated with nonmissing data on model covariates. The effective sample size, however, is the number of cases with nonmissing data for follow-up scores. | Posted | Mean | Standard Deviation | scores on a scale | Post intervention (Time 2) -- approximately 6 months after Baseline (Time 1) |
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| Secondary | Change in Child Externalizing Problem Behavior | Child externalizing behavioral problems will be measured based on parent report using the Child Behavior Check List (CBCL: Achenbach & Rescorla, 2000). The externalizing scale has 24 items; raw scores can range from 0 to 48 with higher scores indicating more externalizing behaviors. | Outcome measure assessed only in parent's report of child, number of participants analyzed reflect total parent participants assessed for this outcome. The models used full information maximum likelihood estimation and included cases with partial data (i.e., baseline scores but no follow-up scores) and help reduce bias due to attrition that is associated with nonmissing data on model covariates. The effective sample size, however, is the number of cases with nonmissing data for follow-up scores. | Posted | Mean | Standard Deviation | scores on a scale | 6 months post intervention (Time 3) -- approximately 12 months after Baseline (Time 1) |
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| Secondary | Change in Child Internalizing Problem Behavior | Child internalizing behavioral problems will be measured based on parent report using the Child Behavior Check List (CBCL: Achenbach & Rescorla, 2000). The internalizing scale has 36 items; raw scores can range from 0 to 72 with higher scores indicating more internalizing behaviors. | Outcome measure assessed only in parent's report of child, number of participants analyzed reflect total parent participants assessed for this outcome. The models used full information maximum likelihood estimation and included cases with partial data (i.e., baseline scores but no follow-up scores) and help reduce bias due to attrition that is associated with nonmissing data on model covariates. The effective sample size, however, is the number of cases with nonmissing data for follow-up scores. | Posted | Mean | Standard Deviation | scores on a scale | Post intervention (Time 2) -- approximately 6 months after Baseline (Time 1) |
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| Secondary | Change in Child Internalizing Problem Behavior | Child internalizing behavioral problems will be measured based on parent report using the Child Behavior Check List (CBCL: Achenbach & Rescorla, 2000). The internalizing scale has 36 items; raw scores can range from 0 to 72 with higher scores indicating more internalizing behaviors. | Outcome measure assessed only in parent's report of child, number of participants analyzed reflect total parent participants assessed for this outcome. The models used full information maximum likelihood estimation and included cases with partial data (i.e., baseline scores but no follow-up scores) and help reduce bias due to attrition that is associated with nonmissing data on model covariates. The effective sample size, however, is the number of cases with nonmissing data for follow-up scores. | Posted | Mean | Standard Deviation | scores on a scale | 6 months post intervention (Time 3) -- approximately 12 months after Baseline (Time 1) |
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| 0 |
| 132 |
| 0 |
| 132 |
| 0 |
| 132 |
| EG001 | Promoting First Relationships - Children | The PFR program designed for birth families being reunited after foster care placement consists of a manualized 12-session intervention delivered in the home by trained providers. | 0 | 132 | 0 | 132 | 0 | 132 |
| EG002 | Resource & Referral - Parents | The service consists of a needs assessment conducted by phone, followed by a personalized resource packet and referrals, and 3 monthly check-in phone calls. | 1 | 132 | 1 | 132 | 0 | 132 |
| EG003 | Resource & Referral - Children | The service consists of a needs assessment conducted by phone, followed by a personalized resource packet and referrals, and 3 monthly check-in phone calls. | 0 | 132 | 0 | 132 | 0 | 132 |
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| D011364 | Professional Practice |
| D009934 | Organization and Administration |
| D006298 | Health Services Administration |
| Male |
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| Native Hawaiian or Other Pacific Islander |
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| Black or African American |
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| White |
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| More than one race |
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| Unknown or Not Reported |
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| Asian |
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| Native Hawaiian or Other Pacific Islander |
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| Black or African American |
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| White |
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| More than one race |
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| Unknown or Not Reported |
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| Unknown or Not Reported |
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| Not Hispanic or Latino |
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| Unknown or Not Reported |
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| Post-intervention follow-up |
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| Superiority |
| 6-month follow-up |
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| Superiority |
| Post-intervention follow-up |
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| 6-month follow-up |
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| Post intervention |
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| 6-month follow-up |
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| Post-intervention follow-up |
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| 6-month follow-up |
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