Program Profile: Expanded Early Pathways for Young Traumatized Children

This is an at-home parent and child therapy program for young children with behavioral and emotional problems who have experienced trauma and live in poverty. The program is rated Effective. Treatment group children had statistically significant reductions in challenging behaviors and anxious/withdrawn and fearful symptoms of trauma, compared with children on a waitlist. The quality of caregiver–child relationships also had statistically significant improved.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

An Effective rating implies that implementing the program is likely to result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

Expanded Early Pathways for Young Traumatized Children provides weekly, in-home, parent–child therapy for children from 1 to 5 years old living in poverty. It is an expansion of the Early Pathways program that includes trauma-informed and culturally-adapted strategies to meet the needs of diverse families, while also addressing the shortage of mental health providers trained to work with this younger population. The goal of the program is to treat and prevent disruptive behaviors in very young, traumatized children.

Program Components

Expanded Early Pathways for Young Traumatized Children involves an integration of the Early Pathways program with a new trauma-informed component. The five core elements of the original Early Pathways program are 1) strengthening the parent–child relationship through child-led play, attunement practices (engaging with someone else’s feelings), and other nurturing activities; 2) helping parents maintain developmentally appropriate expectations for their child; 3) helping parents learn cognitive strategies to respond calmly and thoughtfully to their child’s challenging behaviors; 4) using positive reinforcement to strengthen the child’s prosocial behaviors and listening sessions to improve the child’s compliance with parent requests; and 5) using limit-setting strategies to reduce the child’s challenging behaviors, such as redirection, ignoring, or timeout (Fox 2017).

For the Expanded Early Pathways program, limit-setting strategies are modified to reflect practices in trauma-informed care. In addition, the trauma-informed treatment components include basic safety, caregiver–child relationship, a predictable and nurturing environment, calming strategies, naming and practicing feelings, healthy thoughts and feelings, identifying sources of support, building prosocial skills, trauma narrative development and implementation, and seeking closure.

This is a hands-on, instructional treatment approach that involves three steps: 1) having clinicians describe for parents the rationale for the treatment strategies and modeling these techniques for parents within their unique home setting, 2) having parents practice strategies with their child during treatment sessions in their natural home setting, and 3) having clinicians provide direct feedback to parents to ensure appropriate implementation of the strategies.

Expanded Early Pathways with the added trauma component was originally designed to take an average of 16 weeks to complete, depending on the individual needs of the child and family. Treatment sessions are scheduled to last 1 hour, but can be extended if needed. Additional booster sessions are sometimes provided after the 4- to 6-week follow-up session, depending on the needs of the family and clinical judgment of the therapist.

Key Personnel

Clinicians include licensed mental health professionals and graduate students enrolled in mental health programs. Spanish-speaking clients receive the treatment program from either a bilingual therapist or an English-speaking therapist with a translator. All therapists who deliver this program have received extensive training and experience with the original Early Pathways program. The didactic training for trauma-informed components includes formal workshops, weekly staff meetings, additional training sessions, and an ongoing review of the integrated treatment manual.

Program Theory

Early Pathways is rooted in several different theories, including developmental theory, interpersonal and humanistic approaches for developing therapeutic alliances with parents, cognitive–behavioral strategies, and social learning theory (Fox 2018). For Expanded Early Pathways with the added trauma component, the trauma literature and available trauma-informed programs were reviewed (e.g., Briere and Scott 2012; Cohen, Mannarino, and Deblinger 2006; Ford et al. 2005; National Child Traumatic Stress Network 2012; Herman–Smith 2013; Thompson 2014). Practical treatment strategies based on attachment theories to address parent–child relationships and cognitive–behavioral therapy to focus on symptom reduction and emphasize positive parenting strategies for caregivers were integrated with the original Early Pathways program. Recent research in the treatment of toxic stress in early childhood, following an ecobiodevelopmental framework (Shonkoff et al. 2012) also was included.

Study

Love and Fox (2019) used a randomized controlled trial to assess the effectiveness of the Expanded Early Pathways program with an added trauma component on children’s challenging behaviors, trauma symptoms, the quality of parent–child relationships, and caregiver adherence to program strategies.

Study participants were 64 children ages 1 to 5 referred to a clinic that specialized in serving very young children in poverty with emotional and behavioral problems. Children were eligible if 1) they were 5 years old or younger at the start of treatment; 2) they had experienced some form of potentially traumatizing event, as indicated on the Traumatic Events Screening Inventory–Parent Report Revised, with at least one positive response on the inventory; 3) they exhibited at least four symptoms of posttraumatic stress disorder (PTSD) as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (at least one symptom was an intrusion symptom, and one was an avoidance and negative alterations in cognition symptom); 4) their family received public assistance, indicating that the household income was below the federal poverty level; 5) their legal guardian provided consent; and 6) the child and primary caregiver completed the comprehensive intake evaluation and at least five treatment sessions.

Eligibility was determined after the completion of the intake evaluation. Referred participants meeting full criteria for inclusion were then randomly assigned to the immediate treatment group (n = 32) or the waitlist control group (n = 32), using a computer-derived random numbers table. Participants in the immediate treatment group were scheduled to start treatment within 1 week of their initial intake, and those randomly assigned to the waitlist control group waited 4 to 6 weeks for treatment services after their initial intake.

Immediate treatment children were an average of 3.4 years old, and waitlist control children were on average 3.1 years old. The study sample was mostly male (78.1 percent of the immediate treatment group, 59.4 percent of the waitlist group). Approximately 19.0 percent of immediate treatment children had a developmental delay, compared with 21.9 percent of the children in the waitlist group. With regard to race/ethnicity, children were Black (31.3 percent of immediate treatment, 53.1 percent of the waitlist); multiracial (34.4 percent of the immediate treatment group, 21.9 percent of the waitlist group), and Latino/Latina (21.9 percent of the immediate treatment group, 15.6 percent of the waitlist group). Caregivers were primarily biological mothers (57.8 percent across the entire sample). No statistically significant differences between groups were found on demographic variables, but participants in the immediate treatment group endorsed more potentially traumatic events in the child’s lifetime based on the Traumatic Events Screening Inventory–Parent Report Revised, compared with children in the waitlist control group.

Numerous measures were used at intake, during treatment sessions, and at follow-up. The Traumatic Events Screening Inventory–Parent Report Revised was administered only at intake (Time 1) to screen for the presence of potentially traumatizing events. It included 24 items such as “Has your child experienced the death of someone close to him or her?” and was answered by a caregiver with either “Yes,” “No,” or “Unsure.” The Early Childhood Behavior Screen is a 20-item caregiver-report measure that assesses the frequency of a young child’s prosocial behaviors and challenging behaviors (for example, “hitting others”). Only the Challenging Behavior Scale was used. Total scores on this scale ranged from 10 to 30, with higher scores indicating a greater frequency of challenging behaviors. Items were rated by the primary caregiver on a three-point frequency scale (3 = often, 2 = sometimes, 1 = almost never). Two subscales from the Pediatric Emotional Distress Scale were used to assess for possible trauma symptoms: Anxious/Withdrawn and Fearful. The Anxious/Withdrawn subscale included six items (e.g., “seems worried”), with subscale scores ranging from 6 to 24. The Fearful subscale included five items (e.g., “has bad dreams”) with scores ranging from 5 to 20. Items are rated on a four-point Likert-type scale (1 = Almost Never, 2 = Sometimes, 3 = Often, 4 = Very Often). The Parent–Child Relationship Scale was used to measure the clinician’s subjective assessment of quality of the caregiver–child relationship and the caregiver’s adherence to the treatment program. It used a scale of 0–100 with 20-point intervals: poor (ranging from 0 to 20), below average (ranging from 20 to 40), average (ranging from 40 to 60), good (ranging from 60 to 80), and exceptional (ranging from 80 to 100). Multiple descriptive markers were provided for each interval (e.g., “Parent is often thoughtful when interacting with child” or “Parent can be responsive to child’s needs and set appropriate limits on child’s behavior, but not consistently”). The Therapist Treatment Report was completed during or immediately following each weekly treatment session, and included clinical notes, observations, and progress toward parent and child goals. The reports also included a four-item scale based on the primary objectives of Early Pathways, designed to assess caregiver adherence to program strategies. These items are a) “Does the parent maintain appropriate expectations?”; b) “Does the parent stop and think before responding?”; c) “Does the parent utilize rewards appropriately?”; and d) “Does the parent utilize appropriate discipline?” Items were rated by the clinician using a three-point, Likert-type scale (1 = rarely/not at all, 2 = sometimes, 3 = most times). The four scores were combined for a composite score that ranged from 4 to 12, with higher scores representing greater caregiver adherence to treatment. Therapists were trained to rate these items in the context of the child’s trauma. The primary assessments (Early Childhood Behavior Screen–Challenging Behavior Scale, Pediatric Emotional Distress Scale–Anxious/Withdrawn, Pediatric Emotional Distress Scale–Fearful, Therapist Treatment Report, and the Parent–Child Relationship Scale) were completed at each treatment session and at treatment completion. The waitlist control group completed the measures again when beginning the treatment program (second intake, or Time 2), and again at the completion of the program (Time 3).

Intention-to-treat analyses and analyses of covariance were used to examine the outcomes of challenging behavior, anxious/withdrawn and fearful behavior, parent–child relationship, and therapist report of caregiver adherence to the treatment program. For both groups, a follow-up occurred 6 weeks after the final posttest to assess for maintenance of treatment gains using the study’s primary measures (Early Childhood Behavior Screen–Challenging Behavior Scale, Pediatric Emotional Distress Scale–Anxious/Withdrawn, Pediatric Emotional Distress Scale–Fearful, Therapist Treatment Report, and the Parent–Child Relationship Scale). Subgroup analysis was conducted with the combined sample of both the immediate treatment group and waitlist control group participants who completed at least five treatment sessions and follow-up assessments.

Implementation information and an explanation of all treatment strategies can be found in Early Pathways: A Home-Based Mental Health Program for Very Young Children in Poverty Program Manual (Fox 2018). Further, a treatment fidelity checklist was used with each case to ensure that the Early Pathways program with the trauma component was implemented with fidelity (Love and Fox 2019).

Subgroup Analysis

Love and Fox (2019) conducted a subgroup analysis with the combined sample of both immediate treatment group and waitlist control group participants who completed at least five treatment sessions and posttreatment follow-up assessments (n = 21). Across the combined sample from pretest assessment to follow-up, there were statistically significant reductions in challenging behaviors, and in anxious/withdrawn and fearful symptoms of trauma, and statistically significant improvement in the quality of the caregiver–child relationships and in caregivers’ abilities to use therapy strategies.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Briere, John N., and Catherine Scott. 2012. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment (2nd ed.). Thousand Oaks, Calif.: Sage.

Cohen, Judith A., Anthony P. Mannarino, and Esther Deblinger. 2006. Treating Trauma and Traumatic Grief in Children and Adolescents. New York, N.Y.: Guilford.

Ford, Julian D., Christine A. Courtois, Kathy Steele, Onno van der Hart, and Ellert R.S. Nijenhuis. 2005. “Treatment of Complex Posttraumatic Self-Dysregulation.” Journal of Traumatic Stress 18:437–47.

Fox, Robert A. 2017. “Early Pathways: Home-Based Mental Health Services for Very Young Children in Poverty.” Unpublished manuscript, Marquette University.

Fox, Robert A. 2018. Early Pathways: A Home-Based Mental Health Program for Very Young Children in Poverty Program Manual.

Fung, Michael P., and Robert A. Fox. 2014. “The Culturally-Adapted Early Pathways Program for Young Latino Children In Poverty: A Randomized Controlled Trial.” Journal of Latina/o Psychology 2:131—45.

Harris, Sara E., Robert A. Fox, and Joanna R. Love. 2015. “Early Pathways Therapy for Young Children in Poverty: A Randomized Controlled Trial.” Counseling Outcome Research and Evaluation 6(1):3—17.

Herman–Smith, Robert. 2013. “Intimate Partner Violence Exposure in Early Childhood: An Ecobiodevelopmental Perspective.” Health and Social Work 38:232–39.

National Child Traumatic Stress Network. 2012. “ABC: Attachment and Biobehavioral Catch-Up. Trauma-Informed Interventions.”

Shonkoff, Jack P.; Andrew S. Garner; Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; and Section on Developmental and Behavioral Pediatrics. 2012. “The Lifelong Effects of Early Childhood Adversity and Toxic Stress.” Pediatrics 129:232–46.

Thompson, Ross A. 2014. “Stress and Child Development.” The Future of Children 24:41–59.

Following are CrimeSolutions-rated programs that are related to this practice:

Early Self-Control Improvement Programs for Children

This practice consists of programs designed to increase self-control and reduce child behavior problems (e.g., conduct problems, antisocial behavior, and delinquency) with children up to age 10. Program types include social skills development, cognitive coping strategies, training/role playing, and relaxation training. This practice is rated Effective for improving self-control and reducing delinquency.

Evidence Ratings for Outcomes

	Crime & Delinquency - Multiple crime/offense types
	Juvenile Problem & At-Risk Behaviors - Self-Control

Early Family/Parent Training Programs

This practice includes programs that seek to provide families and parents with training and skills to help promote their children’s physical, mental, and social skills. The practice is rated Effective for reducing child problem behaviors for children whose families participated in early family/parent training programs, compared with control group children whose families did not participate in programming.

Evidence Ratings for Outcomes

Juvenile Problem & At-Risk Behaviors - Multiple juvenile problem/at-risk behaviors

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?