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.
