Program Profile: Early Pathways

This is a home-based, parent-and-child therapy program for the treatment of disruptive behaviors (such as physical aggression and oppositional behaviors) in toddlers and preschoolers who are living in poverty. The program is rated Promising. Compared to the control group, there were statistically significant positive effects found for improving children’s prosocial and challenging behaviors, parent and child play, and the discipline and nurturing behavior of caregivers.

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Goals/Target Population

Early Pathways is a home-based, parent-and-child therapy program for the treatment of disruptive behaviors in children between the ages of 1 and 5 who are living in poverty. Disruptive or externalizing behaviors include physical aggression, verbal aggression, oppositional behaviors, hyperactivity, impulsivity, and weak attentional control. The program is designed to strengthen the parent-child relationship through numerous cognitive-behavioral strategies such as positive reinforcement; predictable home routines; and the STAR technique, in which caregivers learn to manage parental thoughts and feelings and related responses to challenging behavior. The intervention also addresses barriers to treatment attributed to poverty such as loss of phone services, financial and family crises, and frequent relocation (Nicholson et al. 1999).

Key Personnel

Early Pathways is delivered by clinicians who are either licensed professional counselors or graduate students in community counseling, counseling psychology, or clinical social work.

Program Components

The Early Pathways program includes four core components designed to

1. Strengthen the parent–child relationship through child-led play (a non-directive interaction in which the children choose and lead play while the parents/caregivers follow and respond with positive comments).
2. Help parents maintain developmentally appropriate expectations for their children and learn cognitive strategies to respond calmly and thoughtfully to their children’s challenging behaviors.
3. Use positive reinforcement, teaching strategies, and establishment of family routines to strengthen the children’s prosocial behaviors.
4. Use limit-setting strategies to reduce the children’s challenging behaviors such as redirection, ignoring, or timeout.

The first four to six treatment sessions focus on providing parents with psychoeducation to help them differentiate between their children’s behavior and temperament/personality and to help build the parent-child relationship. Clinicians conduct an intake at the first session, and the family receives referrals to advocacy resources as needed. Clinicians deliver a treatment plan at the second session. Treatment is terminated when the clinicians and the parents agree that the goals outlined in the treatment plan have been met.

During the next sessions, parents are coached on how to engage with their children during playtime and how to praise their children using positive reinforcement (e.g., social, tangible, and edible). Clinicians first model appropriate play before parents practice and receive feedback. Parents conduct child-led play once daily for 15 minutes as a part of the treatment. Later sessions use problem-solving strategies to adapt the treatment techniques to the child’s unique home situation. These sessions also focus on helping caregivers develop disciplinary strategies that improve the children’s listening skills and create a safe and predictable home routine.

Parents learn a cognitive-behavioral technique known as STAR or Stop, Think, Ask, and Respond. STAR addresses children’s challenging behaviors and helps parents from engaging in a negative behavior cycle. Parents are taught to not respond immediately to their children’s negative behaviors (unless a safety concern is present); think about how their children’s behavior is affecting their own thoughts and feelings; ask themselves about the challenging behavior within the context of their children’s developmental level; and respond in a manner that is thoughtful, deliberate, and in line with their goals for their children.

Additional Information

The Early Pathways program was culturally adapted per guidelines established by the ecological validity model (Bernal, Bonilla, and Bellido 1995) and the process model (Domenech-Rodríguez and Wieling 2004). Based on these guidelines and feedback from Latino families, the program was modified in the following ways: 1) a community partnership with a large, nonprofit organization in the area was established; 2) program materials were translated into Spanish; 3) bilingual clinicians and a Spanish interpreter joined the clinical staff; 4) an acculturation measure was included to identify adherence to cultural values; and 5) clinicians underwent cultural competence training.

Study 1

Fung and Fox (2014) used a randomized design to evaluate the efficacy of a culturally adapted version of the Early Pathways program. Participants were 137 Latino children younger than 6 who came from low-income families from a large urban Midwestern community and were referred for severe behavior problems. Services were delivered in participants’ homes. Participants were eligible for treatment if 1) the child was younger than 72 months; 2) the child was referred for a significant mental health concern such as aggression, self-injury, hyperactivity, or separation anxiety; 3) the child did not have a serious physical disability or health concern or meet the criteria for moderate-to-profound intellectual disability or autistic spectrum disorder, but may have had a developmental delay (e.g., cognitive, speech, motor); 4) at least one of the child’s parents was Latino; 5) the family met federal criteria for living in poverty (e.g., were eligible for public assistance programs); and 6) the primary caregiver signed an IRB-approved informed consent form for the child and family to participate in this study.

Of the 137 participants, 73 percent were boys. Nearly half were of Mexican descent (48.5 percent), 27.2 percent were Puerto Rican, 14.7 percent were of other ethnicities (e.g., Dominican, Spanish), and 9.6 percent were of mixed ethnicities (e.g., Mexican-Puerto Rican). Mothers were most often the primary caregivers (94.9 percent), and 60.6 percent of the primary caregivers were unemployed. The average age of the primary caregivers was 28.9, and the average child age was 3.9. Of the study participants, 47.4 percent completed the treatment program in Spanish, 44.5 percent in English, and 8 percent in Spanish and English. Approximately 47 percent of the children were diagnosed with a developmental delay, of which 82 percent were language disorders. At intake, 88.7 percent of children received an initial psychiatric diagnosis. Disruptive behavior disorder NOS was the most common primary diagnosis at intake (45.1 percent). Other diagnoses included oppositional de?ant disorder (23.8 percent), adjustment disorder (9.8 percent), other disorder (8.1 percent), parent-child relationship problem (6.6 percent), posttraumatic stress disorder (4.1 percent), and attention deficit hyperactivity disorder (2.5 percent). There were no statistically significant differences between the treatment group and control group on demographic variables at baseline, except for employment of primary caregivers. There were a larger number of employed parents in the treatment group, compared with the control group.

Using a random-number generator, participants were randomly assigned to either an immediate treatment group (n = 80) or to the delayed treatment or control group (n = 57). However, children who were identified at intake as having a significant trauma history or a serious behavior problem that compromised the safety of the child or others received immediate treatment regardless of randomization protocol to ensure participant safety. Caregivers completed the Short Acculturation Scale for Hispanics (SASH) during intake evaluation. The SASH is designed to measure the acculturation status in Latino populations and evaluates preference for speaking Spanish or English, consuming Spanish or English media, and ethnic and social relations such as asking about the ethnicities of the respondent’s close friends (Marin et al. 1987). Following intake evaluation (pretest), the immediate treatment group completed the 8- to 10-week treatment program, a posttest, and 4- to 6-week follow-up sessions. The delayed treatment group, which served as the control group, also completed an intake (pretest measures), waited 4 to 6 weeks, and repeated the pretest measures during a second intake before following the same treatment and assessment protocol as the immediate treatment group. The delayed treatment group’s repeated pretest scores were then compared with the posttest scores of the immediate treatment group. Both groups completed posttest assessments upon at the end of the treatment program and participated in follow-up assessments 4 to 6 weeks later.

Outcomes were scored using several assessment tools. The Early Childhood Behavior Screen (ECBS) was used to score prosocial behavior using the Positive Behavior Scale, and to score challenging behavior, using the Challenging Behavior Scale (Holtz and Fox 2012). The Parent-Child Play Assessment (PCPA) was used to measure five dimensions of the child’s behavior and six dimensions of the parent’s behavior in regard to play activity (Crawley and Spiker 1983; Fung, Fox, and Harris 2014). The Parent Behavior Checklist’s (PBC’s) discipline and nurturing subscales were used to measure the behaviors and expectations of parents of young children. The Parent-Child Relationship Scale (PCRS) was used to globally assess the parent-child relationship on a scale of 0 to 100, with higher scores indicating a stronger relationship. The Global Assessment of Functioning (GAF) Scale was used to subjectively rate the social and psychological functioning of the children (American Psychiatric Association 2000). The child’s psychiatric diagnosis was evaluated as an outcome after the intervention.

Intent-to-treat analysis was used to examine the data (i.e., all families who had data available were included in the analyses, regardless of whether they dropped out of treatment). The researchers used multivariate analyses of covariance (MANCOVA) to determine if the immediate treatment group differed from the delayed treatment group (control group) on posttest measures when controlling for pretest scores. The authors did not conduct subgroup analyses.

Study 2

Harris and colleagues (2015) conducted a randomized design of the Early Pathways program to evaluate the effectiveness of the treatment of disruptive behaviors in young children living in poverty. The total sample included 199 clinically referred children, between the ages of 1 and 5, who were randomly assigned to the immediate treatment (IT) condition (n = 102) or waitlist control (WL) condition (n = 97). For the entire sample, the average age was 2.9 years and was predominantly composed of male (70.4 percent), Latino/a (41.2 percent), and African American (38.7 percent) children. The primary caregivers’ average age was 28.2 years. The primary caregiver was typically the mother (95.5 percent), and most caregivers were unmarried (73.1 percent). There were no statistically significant differences on any demographic variables between the WL and IT groups.

The IT group took the pretest, immediately began treatment, and completed a posttest at the end of the program. The WL repeated the intake assessments after 4 to 6 weeks before completing the treatment program and posttest assessments. The IT group’s posttest and the WL’s repeated intake (pretest) scores were compared for analysis. Both the IT and WL groups were assessed again at a follow up 3 months after completion of the program.

Children’s challenging behaviors and caregivers’ play, discipline, and nurturing behaviors were assessed using the same instruments as in Study 1 (Fung and Fox 2014), including the ECBS, PCPA, and PBC. Intent-to-treat analysis was used to examine the data (i.e., all families who had data available were included in the analyses, regardless of whether they dropped out of treatment). The researchers used analyses of covariance (ANCOVAs) to determine if the immediate treatment group differed from the delayed treatment group (control group) on posttest measures when controlling for pretest scores. The authors did not conduct subgroup analyses.

Implementation information and a thorough explanation of all treatment strategies can be found in the Early Pathways Treatment Program Manual (Fox and Gresl 2014).

Clinicians who deliver the program receive extensive training and supervision in four modules:

1. Working with diverse families of young children with developmental delays who live in poverty and maintaining personal safety in the home setting in unsafe neighborhoods
2. Clinical skills needed for interacting with children younger than 6 and their caregivers
3. Treatment theory, program content, and procedures for working with less educated parents from different cultural backgrounds
4. Assessment administration and data collection

Trainings are based on a comprehensive training manual, relevant empirical literature articles, treatment program videotapes, and shadowing treatment sessions with veteran clinicians. For the culturally adapted version of the program delivered to Latino populations, clinicians are either bilingual or assisted by a Spanish interpreter.

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

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