This paper is in the following e-collection/theme issue:

Research Letter (3) Parenting (283) Family Skills and Family-based Interventions to Support Communication and Social Ties Within Families (33) Anxiety and Stress Disorders (1138) Pediatrics (220)

Published on in Vol 8 (2025)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/67638, first published .
A Primary Care Group Resilience Intervention Promotes Child and Caregiver Behavioral Health

A Primary Care Group Resilience Intervention Promotes Child and Caregiver Behavioral Health

A Primary Care Group Resilience Intervention Promotes Child and Caregiver Behavioral Health

Authors of this article:

Joan Jeung1 Author Orcid Image ;   Andrew Nguyen2 Author Orcid Image ;   Jennifer Martinez3 Author Orcid Image ;   Li Zhang2 Author Orcid Image
Article Authors Cited by Tweetations Metrics

    1Department of Pediatrics, Division of Developmental Medicine, University of California San Francisco (UCSF) School of Medicine, 675 - 18th St, 2nd Floor, UCSF Box 3132, San Francisco, CA, United States

    2Department of Medicine, University of California San Francisco (UCSF) School of Medicine, San Francisco, CA, United States

    3Graduate Medical Sciences, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States

    Corresponding Author:

    Joan Jeung, MD, MPH


    This pilot study of the redesigned Resilience Clinic, a group-based psychoeducational intervention designed to promote relational health and child and family resilience provides preliminary evidence that participation in this intervention is associated with decreased caregiver stress, anxiety, and child behavioral concerns.

    JMIR Pediatr Parent 2025;8:e67638

    doi:10.2196/67638

    Keywords

    parenting education; parent-child relationship; adverse childhood experiences; child behavior; children; caregiver; caretaker; parenting; family; stress; anxiety; behavior; relational health; psychoeducation; psychological education; resilience intervention; group-based; pilot study 


    Since adverse childhood experiences (ACEs) including child maltreatment, family violence, parental substance abuse, and parental mental illness may increase health and behavioral risks [1,2], further research into preventive early childhood interventions, before the onset of ACE-associated sequelae is required [3]. The Resilience Clinic (RC) [4] is a primary care-based group psychoeducational intervention promoting resilience among children exposed to significant adversity. Initially serving children of all ages, this program was redesigned based on significant parent feedback to focus on early childhood (ages 0‐5); the curriculum incorporates Circle of Security-Parenting (building secure attachment) [5] and Dovetail Learning (mindful stress management) [6] in 6 weekly, hour-long group sessions. This study explored whether participation in RC decreased measures of (1) caregiver stress, anxiety, and depression, and (2) child behavioral challenges.


    This pilot study analyzed pre-post differences in caregiver-reported measures of behavioral health after RC participation. Eligibility criteria included children aged 0‐5, referred by primary care providers following positive ACE screening; siblings were excluded. Eligible participants were allowed to join the intervention without joining the study.

    Study measures included the Child Behavior Checklist (CBCL) for ages 1.5 to 5 years [7] to assess child behavioral challenges, Generalized Anxiety Disorder (GAD-7) [8] for caregiver anxiety, Patient Health Questionnaire (PHQ-8) [9] for caregiver depression, and Perceived Stress Scale (PSS-4) [10] for caregiver stress. Caregivers completed measurements at baseline and 3 months after intervention completion.

    To estimate intervention effect sizes, we used Cohen d or (standardized mean difference), for paired samples. Cohen d value cutoffs of 0.2, 0.5, and 0.8 are considered as small, medium, and large effect sizes, respectively. P values were constructed from the Wilcoxon signed-rank test since the variables were not normally distributed, with significance set at P<.05.

    This study was approved by the host institution’s Institutional Review Board (22‐37781) as minimal risk research. Signed informed consent was obtained from all participating caregivers. Data was stored on secure institutional servers and deidentified prior to analysis. Participants could receive up to $190 for completing all study activities.


    A total of 28 caregiver/child dyads were recruited; of these, 79% (n=22) preferred Spanish and 14% (n=4) preferred English. Median child age was 4.5 years (IQR 1.66) and 50% (n=14) were male. Participants who completed both pre and post data collection were included in this analysis.

    Three months post-intervention, caregivers reported large reductions in anxiety and perceived stress compared to baseline (Table 1).

    Table 1. Pre-post changes in caregiver behavioral health measures.
    ConstructMeasuresParticipants, na (N=28)Baseline scores median, (IQR)Post intervention scores, median (IQR)Cohen d (SMD)bP value
    Caregiver anxietyGAD-7c165.5
    (1.75-9.25)    		1.0
    (0-4.25)    		0.86.01
    Caregiver depressionPHQ-8d48.0
    (6.5-9.25)    		5.5
    (3.75-7.25)    		0.63.42
    Caregiver-perceived stressPSS)- 4e187.0
    (6-8)    		4.0
    (3-6)    		0.92.02

    aNumber of participants who completed both pre and postdata collection for that measure.

    bSMD: Standardized mean difference.

    cGAD-7: Generalized Anxiety Disorder-7-item.

    dPHQ-8: Patient Health Questionnaire-8-item.

    ePSS-4: Perceived Stress Scale-4-item.

    Notably, the decrease in caregiver anxiety (GAD-7: d=0.86, P=.01) and caregiver-perceived stress (PSS-4: d=0.92, P=.02) suggested large and statistically significant intervention effect sizes for parental anxiety and perceived stress among RC participants. The PHQ-8 responses were limited as the full instrument was administered only if the PHQ-2 score exceeded 4, making it difficult to draw conclusions.

    Similarly, moderate reductions were seen in postintervention measures of multiple child behavior challenges, including attention problems, aggression, externalizing problems, stress, and overall problems. The decrease in attention problems (d=0.72, P=.05) approached significance. Selected child behavior domains showing moderate postintervention score reduction are listed in Table 2.

    All other CBCL domains showed small effect sizes (d<0.5), including emotionally reactive (0.27), anxious depressed (0.12), somatic complaints (0.46), withdrawn (0.36), sleep problems (0.16), internalizing problems (0.32), anxiety problems (0.02), autism spectrum problems (0.48), and oppositional defiant problems (0.40).

    Table 2. Pre-post changes in the Child Behavior Checklist (CBCL).
    Child behavior domainNumber of participants, na (N=28)Baseline scores, median (IQR)Post-intervention scores, median (IQR)Cohen d (SMD)bP value
    Attention problems1162 (57.5-67)53 (51.5-62)0.72.05
    Aggressive behaviors1164 (51.5-70)56 (51-61)0.53.20
    Externalizing problems1164 (53-70)56 (48.5-60)0.70.11
    Overall problems1168 (53.5-72)58 (49.5-66.5)0.50.07
    Stress1170 (53-72)53 (52-62.5)0.74.09
    Depression1163 (53-69.5)56 (50-61.5)0.52.09
    ADHDc1164 (59-71)57 (52-65.5)0.72.08

    aNumber of participants who completed both pre and postdata collection for that measure.

    bSMD: Standardized mean difference.

    cADHD: Attention deficit hyperactivity disorder


    Three months post-intervention, caregivers reported significant reductions in anxiety and perceived stress and moderate reductions in their children’s attention problems, aggressive behaviors, externalizing problems, total problems, and stress and depressive problems. The decrease in caregivers’ anxiety and perceived stress was significant (P<.05), and the reduction in child attention problems approached significance (P=.05). These findings suggest that participation in this group resilience intervention may help improve caregiver stress and anxiety and child behavior.

    Study limitations include the small sample size and lack of a control group, which make the findings preliminary. Given these promising results, a randomized controlled trial is needed to confirm these intervention effects.

    Given the age of these children, when mental health diagnoses are rare, most children would not otherwise be receiving mental health services. This pilot study indicates that similar primary care-based, preventative group interventions may offer meaningful improvements in caregiver and child behavioral health in the context of childhood adversity.

    Acknowledgments

    This intervention pilot study and evaluation were funded by a University of California ACES Aware Network (UCAAN) PRACTICE grant sponsored by the State of California-Department of Health Care Services (CA-DHCS) and the California Office of the Surgeon General (CA-OSG). The Stupski Foundation also funded program re-designing and implementation at the study’s host institution, which preceded the community pilot reported in this manuscript. This publication was supported by the National Center for Advancing Translational Sciences, National Institutes of Health, through UCSF-CTSI Grant Number UL1 TR001872. The study authors would also like to thank the following colleagues from the University of California San Francisco (UCSF) School of Medicine, whose work on a companion study informed the design of this one: Neeta Thakur, MD, Associate Professor, Medicine; Dayna Long, MD, Professor, Pediatrics; Nicki Bush, PhD, Professor, Psychiatry; and Danielle Hessler Jones, PhD, Professor, Family and Community Medicine.

    Conflicts of Interest

    None declared.

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    ‎
    ACE: adverse childhood experiences
    CBCL : Child Behavior Checklist
    GAD-7: Generalized Anxiety Disorder -7 item (screening tool for anxiety)
    PHQ-8: Patient Health Questionnaire (PHQ)-8 item (screening tool for depression)
    PSS: Perceived Stress Scale
    RC: Resilience Clinic

    Edited by Sherif Badawy; submitted 16.10.24; peer-reviewed by Fernanda Loureiro, Orthelo Léonel Gbètoho Atigossou; final revised version received 30.12.24; accepted 02.01.25; published 10.02.25.

    Copyright

    © Joan Jeung, Andrew Nguyen, Jennifer Martinez, Li Zhang. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org), 10.2.2025.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Pediatrics and Parenting, is properly cited. The complete bibliographic information, a link to the original publication on https://pediatrics.jmir.org, as well as this copyright and license information must be included.