A Primary Prevention Trial to Strengthen Child Attachment in a Native Community

Children are considered gifts and play a central role in American Indian (AI) culture. However, AI children are at elevated risk for experiencing poverty, parental mental health disorders, household exposure to substance use, domestic violence, and maltreatment, all of which increase their risk of poor mental and physical health outcomes as adolescents and adults. Virtually no evidence-based programs exist that can be administered in a resource-poor tribal setting, can be culturally adapted, can be exported, and hold promise for sustainability. The needs of these vulnerable AI children, thus, remain almost entirely unmet. Decades of research have shown that secure attachment in infancy and early childhood is a key developmental building block that predicts adjustment and promotes resilience in children who grow up under stressful circumstances. Because secure attachment develops from caregiver sensitivity and responsiveness, it is critical to address caregiver sensitivity in early childhood. Several studies have shown diverse positive effects of PFR on the caregiver-child relationship for at-risk populations. Therefore, we are testing the Promoting First Relationships (PFR) program, a theoretically driven relationship- and strengths-based primary prevention program, in a Northwest tribal community that has stated that the health and well-being of children and young adults are their primary concerns. We are working collaboratively with the tribe, with whom we have developed a strong, long-term relationship, to adapt PFR to ensure cultural appropriateness. We will train tribal members to provide PFR for the study, thereby promoting sustainability after project completion. Then we will conduct a randomized, controlled trial to compare the PFR intervention with a control group receiving periodic information on resources and referrals. Our primary purpose is to test the effectiveness of PFR in improving the caregiver’s sensitivity to the child (primary outcome). We will also examine the child’s social and emotional functioning. Our specific aims are to 1) adapt the PFR intervention using focus groups; 2) assess the adequacy of training by examining the pre- and post-training attitudes and consultation strategies used by the PFR providers with caregivers and infants; and 3) compare the PFR and control group on caregivers’ sensitivity and responsiveness and children’s social and emotional functioning. By promoting sensitive caregiving and child attachment security, we aim to minimize the impact of contextual stressors on children living on the reservation, to foster their resilience, and improve their risk outlook.