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

Introduction

Since adverse childhood experiences (ACEs) including child maltreatment, family violence, parental substance abuse, and parental mental illness may increase health and behavioral risks [Shonkoff JP, Garner AS, Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, Section on Developmental and Behavioral Pediatrics. The lifelong effects of early childhood adversity and toxic stress. Pediatrics. Jan 2012;129(1):e232-e246. [CrossRef] [Medline]1,Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The adverse childhood experiences (ACE) Study. Am J Prev Med. May 1998;14(4):245-258. [CrossRef] [Medline]2], further research into preventive early childhood interventions, before the onset of ACE-associated sequelae is required [Garner A, Yogman M, Committee on Psychosocial Aspects of Child and Family Health, Section on Developmental and Behavioral Pediatrics, Council on Early Childhood. Preventing childhood toxic stress: partnering with families and communities to promote relational health. Pediatrics. Aug 2021;148(2):e2021052582. [CrossRef] [Medline]3]. The Resilience Clinic (RC) [Jeung J, Hessler Jones D, Frame L, et al. A caregiver-child intervention for mitigating toxic stress (“The Resiliency Clinic”): a pilot study. Matern Child Health J. Oct 2022;26(10):1959-1966. [CrossRef] [Medline]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) [Yaholkoski A, Hurl K, Theule J. Efficacy of the circle of security intervention: a meta-analysis. J Infant Child Adolesc Psychother. Apr 2, 2016;15(2):95-103. [CrossRef]5] and Dovetail Learning (mindful stress management) [Dovetail Learning - We Are ResilientTM practical skills for coping with stress. URL: https://dovetaillearning.org/ [Accessed 2024-09-25] 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.

Methods

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 [Achenbach TM, Rescorla LA. Manual for the ASEBA Preschool Forms and Profiles. University of Vermonth, Research Center for Children, Youth and Families; 2001. URL: https://store.aseba.org/MANUAL-FOR-ASEBA-PRESCHOOL-FORMS-PROFILES/productinfo/605/ [Accessed 2025-01-22] 7] to assess child behavioral challenges, Generalized Anxiety Disorder (GAD-7) [Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. May 22, 2006;166(10):1092-1097. [CrossRef] [Medline]8] for caregiver anxiety, Patient Health Questionnaire (PHQ-8) [Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. Sep 2001;16(9):606-613. [CrossRef] [Medline]9] for caregiver depression, and Perceived Stress Scale (PSS-4) [Cohen S, Kamarck T, Mermelstein R. A global measure of perceived stress. J Health Soc Behav. Dec 1983;24(4):385-396. [CrossRef] [Medline]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.

Results

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).

Construct	Measures	Participants, na (N=28)	Baseline scores median, (IQR)	Post intervention scores, median (IQR)	Cohen d (SMD)b	P value
Caregiver anxiety	GAD-7c	16	5.5 (1.75-9.25)	1.0 (0-4.25)	0.86	.01
Caregiver depression	PHQ-8d	4	8.0 (6.5-9.25)	5.5 (3.75-7.25)	0.63	.42
Caregiver-perceived stress	PSS)- 4e	18	7.0 (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).

Child behavior domain	Number of participants, na (N=28)	Baseline scores, median (IQR)	Post-intervention scores, median (IQR)	Cohen d (SMD)b	P value
Attention problems	11	62 (57.5-67)	53 (51.5-62)	0.72	.05
Aggressive behaviors	11	64 (51.5-70)	56 (51-61)	0.53	.20
Externalizing problems	11	64 (53-70)	56 (48.5-60)	0.70	.11
Overall problems	11	68 (53.5-72)	58 (49.5-66.5)	0.50	.07
Stress	11	70 (53-72)	53 (52-62.5)	0.74	.09
Depression	11	63 (53-69.5)	56 (50-61.5)	0.52	.09
ADHDc	11	64 (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

Discussion

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.