Promoting First Relationships rated well-supported for US foster-care prevention
- On 9 June 2026 the Administration for Children and Families (ACF) added three programmes to the Title IV-E Prevention Services Clearinghouse: Acceptance and Commitment Therapy (Well-Supported), the Ohio Kinship and Adoption Navigator (Supported) and Promoting First Relationships, or PFR (Well-Supported).
- PFR is a home-visiting programme for caregivers of children aged 0–5: 10 weekly sessions of 60–75 minutes. In five of them the provider videotapes a 10–20-minute caregiver–child interaction and discusses the recording with the caregiver the following week.
- The rating followed a re-review in June 2026. The Clearinghouse identified 10 studies of PFR, found 6 eligible and rated 2 high and 4 low on design and execution.
- Under 42 U.S.C. 674(a)(6), the federal government reimburses 50 percent of state prevention spending for quarters before 1 October 2026 and the Federal medical assistance percentage after that. Not less than 50 percent of that spending must go to well-supported practices.
A US federal agency has placed Promoting First Relationships, a ten-week home-visiting programme for caregivers of young children, in the top tier of its prevention register. For American states this is a budget question. For a clinician anywhere it is a rare chance to see what such a label is built from, because the register publishes its working.
How a tier becomes money
Title IV-E of the Social Security Act funds foster care. States can also claim federal money for prevention, but only for programmes the Clearinghouse rates promising, supported or well-supported, and at least half of that spending must go to the top tier. ACF's model plan language lets a state request a waiver of the evaluation requirement for a well-supported practice. Since December 2025 the ACF Assistant Secretary has had final approval authority over each rating. In this system "evidence-based" is an administrative category: a programme either sits in a tier that releases money or it does not.
Reading past the label
The well-supported criterion is procedural: favourable effects in a target outcome domain in at least two usual-care studies with non-overlapping samples, one sustained for 12 months or more. For PFR the two high-rated trials ran in Washington State, with 247 families referred to child protective services and 252 new mothers who had received community mental health services in pregnancy. The Clearinghouse records fewer removals from the birth parents' home 12 months after treatment, higher parent sensitivity 2 and 8 months after it (effect sizes 0.25 and 0.29) and fewer externalising problems at 8 months (0.28). Secure base behaviour on the Toddler Attachment Sort-45 ranged from 0.00 to 0.25, none of it marked significant. The register states that effect sizes play no part in the rating.
So when choosing a parent–infant method, open the outcome table rather than the tier. Check which outcome moved, against what comparison, and in which families. Outside the US the tier carries no weight; the table does.
A federal tier answers whether a programme can be paid for; the outcome table answers what it changed, for whom and against what.
This note draws on ACF documents and the Clearinghouse programme page, not on the trial publications. The effect sizes are the Clearinghouse's own calculations and, by its note, may differ from those reported in the papers. Four of the six eligible studies were rated low and did not contribute to the rating.