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Washington State Institute for Public Policy
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Promoting First Relationships

Child Welfare
Benefit-cost methods last updated December 2024.  Literature review updated June 2021.
Promoting First Relationships is a 10-week home visiting program for toddlers and their caregivers who are experiencing adversity. In the studies included here, children were either dependents of the state or alleged victims of child maltreatment. The program aims to strengthen the relationship between parent and child, thereby increasing the child’s sense of safety and security. Home visitor therapists focus on increasing sensitive parenting behaviors using consultation and video feedback to observe and support child-caregiver interactions. In the studies used in this analysis, participating families received an average of 9.5 visits.
 
ALL
BENEFIT-COST
META-ANALYSIS
CITATIONS
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2023).  The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $933 Benefits minus costs ($569)
Participants $439 Benefit to cost ratio $0.64
Others $36 Chance the program will produce
Indirect ($376) benefits greater than the costs 47%
Total benefits $1,033
Net program cost ($1,602)
Benefits minus cost ($569)

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the program impacts measured in the research literature (for example, impacts on crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information on how we estimate effect sizes.

The effect size may be adjusted from the unadjusted effect size estimated in the meta-analysis. Historically, WSIPP adjusted effect sizes to some programs based on the methodological characteristics of the study. For programs reviewed in 2024 or later, we do not make additional adjustments, and we use the unadjusted effect size whenever we run a benefit-cost analysis.

Research shows the magnitude of effects may change over time. For those effect sizes, we estimate outcome-based adjustments, which we apply between the first time ES is estimated and the second time ES is estimated. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age Primary or secondary participant No. of effect sizes Treatment N Effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Child abuse and neglect
Substantiated or founded reports to child protective services.
 1 Primary 1 124 -0.021 0.337 1 -0.021 0.337 17 -0.058 0.865
Out-of-home placement
The removal of a child from parental care, most often to foster care.
 1 Primary 1 124 -0.124 0.341 1 -0.124 0.341 17 -0.345 0.316
Permanent placement^
“Final” placement in a permanent home, which can include reunification with parents, formalized guardianships, or legal adoption.
1 Primary 1 105 0.057 0.260 2 n/a n/a n/a 0.158 0.583
Externalizing behavior symptoms
Symptoms of externalizing behavior (e.g., aggressive, hostile, or disruptive behavior) measured on a validated scale.
 1 Primary 1 127 -0.099 0.126 1 -0.054 0.079 4 -0.274 0.031
Internalizing symptoms
Symptoms of internalizing behavior (e.g., sadness, anxiety, or withdrawal) measured on a validated scale.
 1 Primary 1 127 -0.039 0.126 1 -0.039 0.126 3 -0.108 0.392
Secure attachment^
A measure of the how readily a child feels comforted and protected by the caregiver. This is typically determined using validated assessments based on observation of child and caregiver by trained observers.
 1 Primary 1 124 0.065 0.256 1 n/a n/a n/a 0.182 0.478
Parental stress^
Stress reported by a parent, typically measured on a validated scale such as the Parental Stress Index. 
 27 Secondary 1 124 0.008 0.256 27 n/a n/a n/a 0.023 0.929
Supportive parenting^
A measure of the caregiver’s supportive and encouraging relationship with the child, typically measured through validated assessments based on observation parent-child interaction.
 27 Secondary 1 127 0.053 0.126 27 n/a n/a n/a 0.147 0.246
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Child abuse and neglect Criminal justice system $15 $0 $28 $7 $50
Child abuse and neglect $30 $12 $0 $15 $57
K-12 grade repetition $2 $0 $0 $1 $3
K-12 special education $58 $0 $0 $29 $87
Property loss associated with alcohol abuse or dependence $0 $0 $0 $0 $0
Health care associated with PTSD $8 $2 $9 $4 $24
Labor market earnings associated with child abuse & neglect $178 $419 $0 $0 $597
Mortality associated with child abuse and neglect $3 $6 $0 $49 $58
Out-of-home placement Out-of-home placement $639 $0 $0 $320 $959
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($801) ($801)
Totals $933 $439 $36 ($376) $1,033
Click here to see populations selected
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $1,331 2017 Present value of net program costs (in 2023 dollars) ($1,602)
Comparison costs $0 2017 Cost range (+ or -) 15%
The per participant cost of the program is based on the average number of sessions per family in the included studies (9.5). We apply the reimbursement rate paid by the Department of Children, Youth, and Families ($138 per session, per fee schedule for Promoting First Relationships, https://www.dcyf.wa.gov/sites/default/files/pdf/PFR-fee.pdf) and add $20 per case for fidelity monitoring.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in discounted dollars. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Citations Used in the Meta-Analysis

Oxford, M., Hash J., Lohr, J.J., Bleil, M., Flemieng, C., Unutzer, J., & Spieker, S. (2021). Randomized trial of Promoting First Relationships for new mothers who received community mental health services in pregnancy.

Oxford, M.L., Spieker, S.J., Lohr, M.J., & Fleming, C.B. (J2016). Promoting First Relationships®: Randomized trial of a 10-week home visiting program with families referred to child protective services. Child Maltreatment, 21(4), 267-277.

Spieker, S.J., Oxford, M.L., & Fleming, C.B. (2014). Permanency outcomes for toddlers in child welfare two years after a randomized trial of a parenting intervention. Children and Youth Services Review, 44, 201-206.