Home Program Early Pathways Program

Early Pathways Program (EPP)

Topic Areas
Scientific Rating
Child Welfare Relevance
Parent Training Programs that Address Behavior Problems in Children and Adolescents
3  — Promising Research Evidence
High

About This Program

Target Population: Children 6 years of age and younger with significant behavior and/or emotional problems including trauma and their primary caretaker(s)

For children/adolescents ages: 0 – 6

For parents/caregivers of children ages: 0 – 6

Program Overview

EPP is a home-based, parent-child therapy program for children 6 years of age and younger with significant behavior and/or emotional problems including trauma. It was designed specifically for a diverse population of very young children who come from families living in poverty, most of whom meet criteria for a psychiatric diagnosis. EPP emphasizes psychoeducation, direct clinician modeling to parents and other primary caretakers of effective strategies to strengthen the child's positive behaviors and reduce challenging ones, parent practice of new strategies with clinician feedback, and parent coaching. Treatment occurs weekly for an average of 8-12 weeks with booster sessions added as needed

Program Goals

The goals of the Early Pathways Program (EPP) are:

  • Strengthen the parent-child relationship
  • Improve parent-child interactions during play
  • Reduce the child's behavior problems
  • Reduce child's trauma symptoms
  • Increase the child's positive behaviors
  • Improve the parent's nurturing skills
  • Improve the parent's appropriate limit-setting skills for the child's challenging behaviors while discouraging the use of verbal and corporal punishment
  • Increase the parent's knowledge of appropriate developmental expectations for their child and to apply them
  • Improve the parent's thoughtfulness and calmness when managing their child's behavior problems
  • Improve the parent's confidence in managing new problems that emerge after EPP ends

Logic Model

The program representative did not provide information about a Logic Model for Early Pathways Program (EPP).

Essential Components

The essential components of the Early Pathways Program (EPP) include:

  • Establishing rapport and trust between the clinician, parent (or primary caregiver), and child
  • Communicating clear rules for in-home, EPP sessions [e.g., parent and child present for all sessions; other immediate and extended family members and nonfamily members (mother's partner) are encouraged to participate; cancellation and no-show policy]
  • Completing of required paperwork (e.g., informed consent, HIPPA, release of information)
  • Conducting a clinical interview, self-report instruments on child's behavior and parenting practices, and direct observation of parent-child play interactions
  • Developing an initial treatment plan and goals with copy given to parent at the first session and updated at subsequent sessions
  • Ensuring child safety by having clinicians observe the home and provide necessary safety supplies to fix problems such as a window lock for an open second floor window, outlet covers for uncovered electric outlets, cupboard locks for easy to open cupboards with potentially poisonous cleaning materials, safety gates for stair, etc.
  • Providing advocacy by having clinicians routinely ask parents about family and child needs and assist in meeting these needs (scheduling an appointment with a pediatrician, enrolling the child in a school or arranging an evaluation for special services - speech, special education) or make appropriate referrals to community agencies and providers (counseling for a parent who is depressed, contacting agencies that provide the family with basic needs - food, housing, electricity, heat)
  • Teaching Child-Led Play strategies to parents with toys available in the home or brought by the clinician which requires the parents to observe and positively comment on child's play without directions or questions; encouraging parents to continue this activity daily in-between therapy sessions to strengthen the parent-child relationship]
  • Using a Cognitive Parenting Strategy, such as the familiar Stop and Go Traffic Light with a STAR acronym, when confronted with challenging behaviors, parents are taught to Stop (red light), Think (yellow light), Ask (yellow light), and Respond (green light) to encourage the parents to slow down their impulsive and often negative reactions and instead interact with their child in a calm, thoughtful manner; teaching brief anger and stress management strategies to parents is included
  • Instructing parents in normal early childhood developmental expectations and encouraging them to monitor their expectations for their children to ensure they are being reasonable
  • Strengthening positive child behaviors (e.g., compliance, picking up toys, going to bed, toileting, etc.) by teaching parents how recognize and consistently reinforce positive behaviors in their child using a variety of positive child-specific rewards including edibles and tangibles
  • Reducing problem child behaviors (e.g., serious tantrums, property destruction, self-injury, aggression, hyperactivity, noncompliance, etc.) by teaching parents effective, behavior-specific treatment strategies including redirection (for children under 2 years old), ignoring (extinction), natural consequences, and time-out
  • Addressing emotional problems (e.g., separation anxiety, nightmares, fears, trauma) by working with the child and parent to address the child's emotional difficulties
  • Creating a more predictable home environment by assisting parents in establishing regular routines for their young child in terms of mealtimes, play time, bath and bedtimes and often creating a family-specific visual chart to help parents maintain a regular routine
  • Assessing the child's progress during each session using a Treatment Report and sharing it with the parent at the end of the session and asking the parent about how the week went and any new concerns that arose with their child or new advocacy needs
  • Concluding the final session with a posttest that essentially repeats the intake evaluation, encouraging parents to contact the clinician if new issues/questions emerge, and providing booster sessions in the home when needed
  • Note: Normally, if progress in the young child's behavior is not observed by the third treatment session, the clinician and parent have a frank discussion about the parent's level of engagement and follow through with EPP. As families in poverty have many barriers that interfere with treatment adherence and ongoing family crises (child illness, intimate partner violence), it may not be reasonable for them to fully implement EPP. Clinicians and parents may agree to suspend treatment until the family is in a better position to become fully engaged and implement the program with their young child.

Program Delivery

Child/Adolescent Services

Early Pathways Program (EPP) directly provides services to children/adolescents and addresses the following:

  • Serious tantrums, property destruction, aggression, self-injury, hyperactivity, noncompliance and other behavior problems; separation anxiety, fears and nightmares, other emotional difficulties including trauma

Parent/Caregiver Services

Early Pathways Program (EPP) directly provides services to parents/caregivers and addresses the following:

  • Parent or caregiver of a young child (6 years and under) with serious behavior problems; parents with significant problems/symptoms of their own are referred to other community resources, agencies and providers
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: All individuals living in the home (older siblings, extended family members, parent partners) are encouraged to participate in EPP so that the child is receiving consistent feedback from everyone to strengthen their positive behaviors and reduce their problem ones. At times, a special family meeting may be called to encourage everyone to "get on the same page" for the child's benefit.

Recommended Intensity:

One session/week from 1 to 1½ hours

Recommended Duration:

8-12 weekly visits including an intake and termination session; provide additional sessions if needed and booster sessions following discharge.

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Foster / Kinship Care
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider

Homework

Early Pathways Program (EPP) includes a homework component:

Parents are provided a Behavior Plan at the conclusion of each session describing what they are to do for the week before the next session. A place on the Behavior Plan is included for the parent to check whether or not they followed the plan. These plans are reviewed at the beginning of each home session

Languages

Early Pathways Program (EPP) has materials available in a language other than English:

Spanish

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • Clinicians must be trained in EPP and have safety training for going into homes in unsafe neighborhoods.
  • An area of the home needs to be identified that will provide as few distractions as possible (no TV, cell phones, etc.).
  • Clinicians bring appropriate toys, safety devices, rewards (stickers), program materials (home routine chart).
  • Clinicians carry a guide that has available community services and providers for the child, parent, and family.
  • Clinicians need reliable transportation.
  • Clinicians have a file for each child including all of the required paperwork.

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Clinicians normally have a minimum of a master's degree in the human services field and normally are licensed or license-eligible in their respective states as a mental health service provider. However, due to the severe shortage of such individuals with training and experience in working with children during the early childhood period as well as home visiting experience, EPP training program is also open to individuals with a bachelor's degree in the human services field or those with extensive experience as a home visitor with the understanding that they will have regular access to a qualified supervisor. Supervisors normally have a master's degree in psychology, social work or counseling, are licensed in the state, and have three years of experience implementing EPP.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual details:

  • Fox, R. A. (2019). Early Pathways: Home-based mental health services for very young children in poverty. Unpublished Program Manual, Penfield Children's Center.

It is available from the training contact listed below.

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

A two-day live training workshop is provided at a training site convenient for the participants and includes a full PowerPoint presentation that is provided as well as the EPP Program Manual. Following the two-day workshop, 6-12 consultation sessions are provided normally using an on-line audio/visual technology. Successful participants must complete two cases and submit paperwork for review and certification. Overviews of EPP are presented at state, regional, and national conventions.

Number of days/hours:

The live professional training workshop is 12 hours long. Follow-up consultation sessions are 1 to 1½ hours each.

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Early Pathways Program (EPP) as listed below:

Often, a one-hour overview of EPP is provided to agencies including issues of participant qualifications, EPP outcome measures and treatment strategies, and an organization's ability to offer EPP once there staff are trained.

Formal Support for Implementation

There is formal support available for implementation of Early Pathways Program (EPP) as listed below:

The EPP Certification Program includes a separate syllabus with program content and participant requirements to be certified as an EPP provider. Participants must attend 9 of 12, biweekly, 1½ hour live or videoconference sessions that start a month following the two-day training program. These consultation sessions are led by a licensed professional who has used the EPP for a minimum of three years and has been trained by the program developer in consultation using EPP. In addition to attending the consultation sessions, participants must successfully implement EPP with a minimum of two children and their primary caregiver. Form reports are required following a standard format that includes pretest and posttest measures. These reports are reviewed by the consultant and written feedback is provided to participants. Successful participants receive a Certificate that documents they have completed all of the necessary requirements to be certified as an EPP provider. Group fees are charged for the consultation sessions and review of required reports.

Fidelity Measures

There are fidelity measures for Early Pathways Program (EPP) as listed below:

There is a fidelity measure where basic treatment concepts and strategies are broken down in measurable units and supervisors directly observe providers with parents to determine if they are implementing the program as intended. This fidelity measure does not have psychometrics. While use of the fidelity measure is strongly encouraged during training, but not required.

Implementation Guides or Manuals

There are no implementation guides or manuals for Early Pathways Program (EPP).

Implementation Cost

There are no studies of the costs of Early Pathways Program (EPP).

Research on How to Implement the Program

Research has not been conducted on how to implement Early Pathways Program (EPP).

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Carassco, J. M., & Fox, R. A. (2012). Varying treatment intensity in a home-based parent and child therapy program for families living in poverty: A randomized clinic trial. Journal of Community Psychology, 40(5), 621–630. https://doi.org/10.1002/jcop.21492

Type of Study: Randomized controlled trial
Number of Participants: 60

Population:

  • Age — Children: Mean=2.49–2.72 years; Parents: Mean=28.5–31.9 years
  • Race/Ethnicity — Children: 36 African American, 10 Latino, 8 Mixed, and 6 Caucasian; Parents: Not specified
  • Gender — Children: 42 Male and 18 Female; Parents: Not specified
  • Status — Participants were children with developmental disabilities with externalizing behavioral problems and their parents.

Location/Institution: Large, urban Midwestern city

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to address the question of whether increasing the intensity of the Parenting Young Children Program (PYC) [now called the Early Pathways Program (EPP)] would improve results for young children with significant behavior problems from families living in poverty. Participants were randomly assigned to either a standard condition or an intensity condition that provided 50% more treatment over a standard 8-week treatment period. Measures utilized include the Eyberg Child Behavior Inventory, the Parent Behavior Checklist (PBC), the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS-PL), the Parent-Child Relationship Scale, and the Family Satisfaction Survey. Results indicate that based on multiple parent-report, direct observation, and clinician-report measures of the children and their caregivers, both groups improved on all measures from pretest to posttest and from pretest to follow-up. No differences in outcomes were found between the standard and intensity groups at posttest or follow-up. Limitations include reliance on self-reported measures, small sample size, and length of follow-up.

Length of controlled postintervention follow-up: 4–6 weeks.

Fung, M. P., & Fox, R. A. (2014). The culturally-adapted Early Pathways program for young Latino children in poverty: A randomized controlled trial. Journal of Latina/o Psychology, 2(3), 131–145. https://doi.org/10.1037/lat0000019

Type of Study: Randomized controlled trial
Number of Participants: 137

Population:

  • Age — Children: Mean=3.89 years; Parents: Mean=28.87 years
  • Race/Ethnicity — Children: 49% Mexican, 27% Puerto Rican, 15% Other (Dominican, Central American, Spanish), 10% Mixed Ethnicities (Mexican/Puerto Rican, Mexican Dominican); Parents: Not specified
  • Gender — Children: 73% Male and 27% Female; Parents: 95% Female
  • Status — Participants were Latino children referred for severe behavior and emotional problems and their parents.

Location/Institution: Large urban community in the upper Midwest

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the efficacy of a culturally adapted version of Early Pathways (EP) [now called Early Pathways Program (EPP)] for children with severe behavior and emotional problems, such as aggression, oppositional behavior, self-injury, and property destruction. Participants were randomly assigned to either immediate or delayed treatment groups. Measures utilized include the Short Acculturation Scale for Hispanics (SASH), the Early Childhood Behavior Screen (ECBS), the Parent Behavior Checklist (PBC), Diagnostic and Statistical Manual of Mental Disorders (DSM), Parent-Child Relationship Scale (PCRS), Family Satisfaction Survey (FSS), and the Parent-Child Play Assessment (PCPA). Results indicate significant differences between the immediate and delayed treatment group on all post-test measures with the pre-test scores as covariates. After the delayed group completed treatment, repeated measures, multivariate analyses of variance (MANOVA) showed significant improvement for both groups on all measures with maintenance at four-to-six-week follow-up. Outcomes include reduced child behavior problems, increased child pro-social behaviors, improved caregiver limit setting, enhanced caregiver nurturing, improved parent-child relationships, and a decrease in clinical diagnoses following treatment. Limitations include high attrition rate, all participants in the wait-list group did not always complete treatment, reliance on self-reported measures, and the length of follow-up.

Length of controlled postintervention follow-up: 4–6 weeks.

Harris, S. E., Fox, R. A., & Love, J. R. (2015). Early pathways therapy for young children in poverty: A randomized controlled trial. Counseling Outcome Research and Evaluation, 6(1), 3–17. https://doi.org/10.1177/2150137815573628

Type of Study: Randomized controlled trial
Number of Participants: 199

Population:

  • Age — Children: 1–5 years; Parents: Mean=28.16 years
  • Race/Ethnicity — Children: 41% Latino and 39% African American; Parents: Not specified
  • Gender — Children: 70% Male; Parents: Not specified
  • Status — Participants were children with disruptive behaviors and their parents.

Location/Institution: A large, urban Midwestern city

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to examine the effectiveness of the Early Pathways Program (EPP) in decreasing challenging behaviors in children. Participants were randomly assigned to one of two EPP groups: An immediate treatment (IT) or wait-list control (WL) group. Measures utilized include the Early Childhood Behavior Screen (ECBS), the Parent Behavior Checklist (PBC), and the Family Satisfaction Survey. Results indicate that parents in the IT group reported significant improvements in their child’s disruptive and prosocial behaviors. In addition, they reported increased nurturing and decreased use of corporal and verbal punishment by themselves compared to the WL families. Limitations include reliance on self-reported measures, lack of generalizability due to gender, and lack of controlled postintervention follow-up.

Length of controlled postintervention follow-up: None.

Love, J. R., & Fox, R. A. (2019). Home-based parent child therapy for young traumatized children living in poverty: A randomized controlled trial. Journal of Child & Adolescent Trauma, 12(1), 73–83. https://doi.org/10.1007/s40653-017-0170-z

Type of Study: Randomized controlled trial
Number of Participants: 64

Population:

  • Age — Children: Mean=39.11 months; Parents: IT: Mean=32.16 years, WL: Mean=30.91 years
  • Race/Ethnicity — Children: 42% African American, 28% Multiracial, 19% Latino or Hispanic, and 11% European American; Parents: Not specified
  • Gender — Children: 69% Male and 31% Female; Parents: IT: 53% Female; WL: 63% Female
  • Status — Participants were children with trauma symptoms and their parents.

Location/Institution: A large, urban Midwestern city

Summary: (To include basic study design, measures, results, and notable limitations)
The purpose of the study was to evaluate the effectiveness of the Early Pathways Program (EPP) for toddlers and preschoolers living in poverty with trauma symptoms. Participants were randomly assigned to one of two EPP groups: An immediate treatment (IT) or wait-list control (WL) group. Measures utilized include the Trauma Events Screening Inventory Parent Report Revised (TESI-PRR), the Early Childhood Behavior Screen (ECBS), the Pediatric Emotional Distress Scale (PEDS), the Parent-Child Relationship Scale (PCRS), the Therapist Treatment Report (TTR), and the Family Satisfaction Survey. Results indicate that significant between group differences were found on all posttreatment measures, and that after the WL group completed treatment, significant improvements were reported on all measures at six-week follow-up. Outcomes include reduction in challenging behaviors and emotional symptoms of trauma, improved caregiver-child relationships, and increased caregiver adherence to treatment strategies. Limitations include that the study utilized a convenience sample of clients, the therapist both provided the therapy and administered the outcomes measures, high attrition rate, and lack of controlled postintervention follow-up.

Length of controlled postintervention follow-up: None.

Additional References

Gresl, B., L., Fox, R. A., & Besasie, L. A. (2016) Development of a barriers scale to predict early treatment success for young children in poverty with behavior problems. Clinical Practice in Pediatric Psychology, 4, 249-262. doi:10.1037/cpp0000124

Harris, S. H., & Fox, R. A. (2019). Assessment of trauma symptoms in toddlers and preschoolers living in poverty. Child Maltreatment, 24(3). doi:10.1177/1077559519830790

Contact Information

Robert A. Fox, PhD
Agency/Affiliation: Marquette University, College of Education
Department: Department of Counselor Education and Counseling Psychology
Website: www.earlypathways.com
Email:
Phone: (262) 894-7888

Date Research Evidence Last Reviewed by CEBC: September 2024

Date Program Content Last Reviewed by Program Staff: August 2019

Date Program Originally Loaded onto CEBC: May 2016