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Washington State Strategies
IECMH in Pediatric Care: Promoting First Relationships in Pediatric Primary Care

Since 2016, a growing number of pediatricians in Washington State have been trained on Promoting First Relationships in Pediatric Primary Care (PFR-PPC), a manualized program for pediatricians to help them support stable and secure relationships between parents and their young children. The model is an adaptation of the Promoting First Relationships (PFR) 10-week evidence-based home-visiting program that uses video feedback and consultation strategies to promote positive parent-child relationships. The pediatric adaptation gives providers insights and tools that can be used during 20-minute well-child visits.

In 2012, pediatricians who had taken a PFR workshop reported that the PFR program offered new, helpful insights about helping families with common difficulties related to feeding, sleep, and challenging behaviors. The pediatricians asked to work together with the PFR developers to adapt the model for use in pediatric clinical settings. PFR-PPC uses the consultation strategies from the home-visiting model that include: connecting with parents, supporting parents with concerns by responding to their needs, observing and commenting on in-the-moment parent-child interactions and the importance of the parent-child relationship, noticing the child’s cues, offering strengths-based positive feedback, and sharing well-timed anticipatory guidance along with parent handouts during well-child visits in the first three years. Topics addressed in anticipatory guidance and handouts include responsive caregiving, relationship-focused approaches to promoting healthy sleep and feeding, and ways to understand and help with challenging behavior.  Content is delivered in a positive way that emphasizes parent strengths.

Training in PFR-PPC aims to help pediatricians better understand parent-child relationships and elements of responsive caregiving while providing tools for talking about stressors and challenging behavior. The PFR-PPC lens helps parents view a child’s challenging behavior as potentially arising from the child’s or parents’ unmet needs. This approach helps providers and families look beneath the behavior to better understand what the underlying feelings and needs might be so that parents can more effectively help the child feel less distressed. For example, understanding a worried young child’s need for reassurance from a parent can help the parent provide appropriate support so that the child’s distress, which can lead to challenging behavior, does not escalate. Pediatricians are also trained to become more attentive when observing parent-child interactions. For instance, there are many opportunities, starting at the earliest visits, to notice shared attention between the parent and child. Noticing and talking about aspects of the parent-child relationship (e.g., shared attention; parents’ role in helping their child cope with strong emotions) can help parents see the importance of their role in their child’s development and well-being.

PFR-PPC has been most widely implemented in Washington State at Seattle Children’s Hospital, where it has been incorporated into training for all pediatric residents. Since 2016, 40 to 45 residents per year have been trained, for a total of more than 170 residents. Two doctors lead the PFR-PPC training, and all of the hospital’s clinical supervisors are also trained. Initial training consists of a four-hour workshop for cohorts of 4-7 residents during the first year of their residency. The residents also have access to the PFR-PPC – trained supervisors if they have questions or concerns about challenging cases. More recently, a PFR-PPC online classroom became available with additional video case studies, booster sessions, and specific anticipatory guidance information sheets that pediatricians can use in visits.

The lead doctors have organized voluntary reflection groups for clinical supervisors, beginning in 2019. The sessions involve a case study discussion and members’ reflection on their own cases and response to families. These sessions serve as a form of reflective consultation and support for the lead doctors and pediatricians who supervise the residents; both the frequency of the sessions and attendance have increased during the COVID-19 pandemic.

Outside of Seattle Children’s Hospital, PFR-PPC training is offered by Parent-Child Relationship Programs at the Barnard Center for Infant Mental Health and Development in the form of workshops and follow-up consultation. These full-day workshops are typically delivered to pediatric clinics and include pediatricians, nurses, social workers, and family navigators. More than 100 pediatricians in Washington State have received PFR-PPC training through these workshops; they have also been delivered to clinics in Ohio, Montana, Tennessee, North Carolina, Texas, and California.

Feedback from those who have taken the training workshops revealed an interest in technical assistance to further support PFR-PPC implementation. The PFR-PPC online classroom and follow-up consultation with the instructor is now being offered to support this need.


Training in Seattle Children’s Hospital has recently been funded by King County Best Starts for Kids, a levy-funded public health initiative to promote resilience and reduce risk among young children.  In Washington State, the Health Care Authority has funded PFR-PPC workshops that have been adapted to focus on women with opioid use disorder and their newborns.

Data Monitoring

Traditional PFR, delivered as a home-visiting program, has shown positive outcomes for caregivers and children in a number of randomized controlled trials (also see the home visiting research summary for more information). PFR-PPC has not been formally evaluated, though the developers are seeking funding for an evaluation.

PFR-PPC at Seattle Children’s Hospital is evaluated internally for quality improvement purposes every year through provider feedback. Anecdotal evidence suggests that PFR-PPC-trained pediatricians have fewer no-show appointments, more satisfaction with clinic visits, and a greater understanding of child social and emotional needs. Additionally, providers who have taken the training rate it very highly.

A report from the Center for the Study of Social Policy on social-emotional supports in pediatric primary care included findings from case study site visits in pediatric settings implementing PFR-PPC. In these visits, staff reported better relationships with parents, and parents reported that PFR-PPC helped them support their children’s social-emotional development.

Special thanks to the following individuals for providing information for and reviewing this profile: Jennifer Rees, Director, Promoting First Relationships; Monica Oxford, Executive Director of the Barnard Center for Infant Mental Health and Development; and Jeannie Larsen, MD, Allegro Pediatrics – Bellevue, WA and Lead Trainer, Promoting First Relationships in Pediatric Primary Care.

Last updated February 2021