Skip to main content

Development, Feasibility, and Refinement of a Toxic Stress Prevention Research Program

Abstract

Innovative interventions accessible to at-risk populations to prevent the intergenerational cycle of toxic stress are needed. This paper describes the iterative development of a community-based intervention, 2Gen Thrive, which was designed to prevent toxic stress and promote resilience by improving caregiver capacity to respond to children’s emotional, behavioral, and developmental needs. 2Gen Thrive leverages the collaboration between a Children’s Hospital and an Early Head Start/Head Start education center to help low-income, minority families thrive in the context of risk factors for toxic stress. In this paper, we focus on the process of developing, piloting, and refining our 2Gen Thrive preventive intervention research program, which has been developed following a community-based participatory research (CBPR) approach. The primary objective was to pilot test two prevention interventions we adapted for use in this target population: Classroom Theraplay, a classroom-wide intervention designed to prevent toxic stress among children exposed to adversity by fostering nurturing relationships with their teachers; and Dialectical Behavior Therapy Skills Training for Parents (DBT4P), a group intervention developed to bolster parental responsiveness by teaching Dialectical Behavioral Therapy (DBT) mindfulness and emotion regulation skills. We evaluated qualitative and process data as well as quantitative data from standardized instruments, including The Classroom Assessment Scoring System (CLASS), Patient Health Questionnaire (PHQ-9), Difficulties in Emotion Regulation Scale (DERS), and Parenting Stress Index (PSI/SF). Results demonstrate the feasibility, acceptability, and appropriateness of these preventive interventions delivered in the early education setting, and of conducting intervention research using a CBPR approach.

This is a preview of subscription content, access via your institution.

References

  1. Abiden, R. R. (1995). The Parenting Stress Index professional manual. Odessa, FL: Psychological Assessment Resources.

    Google Scholar 

  2. Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., & Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood: a convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256, 174–186. https://doi.org/10.1007/s00406-005-0624-4.

    Article  PubMed  Google Scholar 

  3. Badanes, L. S., Dmitrieva, J., & Watamura, S. E. (2012). Understanding cortisol reactivity across the day at child care: the potential buffering role of secure attachments to caregivers. Early Child Research Quarterly, 27(1), 156–165. https://doi.org/10.1016/j.ecresq.2011.05.005.

    Article  Google Scholar 

  4. Bernet, A. C., Willens, D. E., & Bauer, M. S. (2013). Effectiveness-implementation hybrid designs: implications for quality improvement science. Implementation Science, 8(Suppl 1), S2 https://doi.org/10.1186/1748-5908-8-s1-s2.

    Article  Google Scholar 

  5. Bethell, C. D., Newacheck, P., Hawes, E., & Halfon, N. (2014). Adverse childhood experiences: assessing the impact on health and school engagement and the mitigating role of resilience. Health Affairs, 33, 2106–2115.

    Article  Google Scholar 

  6. Booth, P., & Jernberg, A. M. (2010). Theraplay®. 3rd ed New York, NY: Jossey-Bass.

    Google Scholar 

  7. Brodsky, B. S., & Stanley, B. (2008). Adverse childhood experiences and suicidal behavior. The Psychiatric Clinics of North America, 31(2), 223–235. https://doi.org/10.1016/j.psc.2008.02.002.

    Article  PubMed  Google Scholar 

  8. Crandall, A., Deater-Deckard, K., & Riley, A. W. (2015). Maternal emotion and cognitive control capacities and parenting: a conceptual framework. Developmental Review, 36, 105–126. https://doi.org/10.1016/j.dr.2015.01.004.

    Article  PubMed  Google Scholar 

  9. Cronholm, P. F., Forke, C. M., Wade, R., Bair-Merritt, M. H., Davis, M., Harkins-Schwarz, M., & Fein, J. A. (2015). Adverse childhood experiences: expanding the concept of adversity. American Journal of Preventive Medicine, 49, 354–361. https://doi.org/10.1016/j.amepre.2015.02.001.

    Article  PubMed  Google Scholar 

  10. Curran, G. M., Bauer, M., Mittman, B., Pyne Jeffrey, M., & Stetler, C. (2012). Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Medical Care, 50, 217–226. https://doi.org/10.1097/MLR.0b013e3182408812.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Dum, M., Pickren, J., Sobell, L. C., & Sobell, M. B. (2008). Comparing the BDI-II and the PHQ-9 with outpatient substance abusers. Addictive Behaviors, 33, 381–387. https://doi.org/10.1016/j.addbeh.2007.09.017.

    Article  PubMed  Google Scholar 

  12. Evans, S., Davies, S., Williams, M., & Hutchings, J. (2015). Short-term benefits from the incredible years parents and babies programme in Powys. Journal of Community Practice, 88(9), 46–48.

    Google Scholar 

  13. Eyberg, S., (1993). Consumer satisfaction measures for assessing parent training programs. In L. VandeCreek, S. Knapp, T. L. Jackson, (eds.) Innovations in clinical practice: a source book. (Volume 12. 377–382). Srasota, FL: Professional Resource Press/ Professional Resource Exchange.

    Google Scholar 

  14. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8.

    Article  PubMed  Google Scholar 

  15. Frieden, T. R. (2014). Six components necessary for effective public health program implementation. American Journal of Public Health, 104(1), 17–22. https://doi.org/10.2105/AJPH.2013.301608.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Fruzzetti, A. E., & Iverson, K. (2004). Mindfulness, acceptance, validation and “individual” psychopathology in Couples. In S. C. Hayes, V. M. Follette & M. M. Linehan (Eds.), Mindfulness and acceptance: expanding the cognitive-behavioral tradition (pp. 168–191). New York, NY: Guilford Press.

    Google Scholar 

  17. Furlong, M., McGilloway, S., Bywater, T., Hutchings, J., Smith, S. M., & Donnelly, M. (2012). Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3–12 years. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD008225.pub2.

  18. Gopalan, G., Goldstein, L., Klingenstein, K., Sicher, C., Blake, C., & McKay, M. M. (2010). Engaging families into child mental health treatment: updates and special considerations. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 19(3), 182–196.

    PubMed  PubMed Central  Google Scholar 

  19. Gratz, K. L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment. https://doi.org/10.1023/B:JOBA.0000007455.08539.94.

    Article  Google Scholar 

  20. Hamre, B.K., Goffin, S. G., & Kraft-Sayre, M. (2009). Classroom assessment scoring system (CLASS) implementation guide. https://www.vbgrowsmart.com/providers/Documents/CLASSImplementationGuide.pdf. Accessed 7 July 2017.

  21. Hamre, B. K., La Paro, K. M., Pianta, R. C., & LoCasale-Crouch, J. (2014). Classroom Assessment Scoring System® (CLASS™) manual, infant. Baltimore, MD: Paul H. Brooks Publishing Co.

  22. Happ, M. B., Dabbs, A. D., Tate, J., Hricik, A., & Erlen, J. (2006). Exemplars of mixed methods data combination and analysis. Nursing Research, 55(Suppl 2), S43–49.

    Article  Google Scholar 

  23. Ingoldsby, E. M. (2010). Review of interventions to improve family engagement and retention in Parent and Child Mental Health Programs. Journal of Child and Family Studies, 19(5), 629–645. https://doi.org/10.1007/s10826-009-9350-2.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Jernberg, A. M. (1979). Theraplay: a new treatment for using structured play for problem children and their families. Washington, DC: Jossey-Bass.

    Google Scholar 

  25. Jernberg, A. M., & Booth, P. B. (1999). Theraplay: helping parents and child build better relationships through attachment-based play. San Francisco: Jossey-Bass.

    Google Scholar 

  26. Jones, C. H., Erjavec, M., Viktor, S., & Hutchings, J. (2016). Outcomes of a comparison study into a group-based infant parenting programme. Journal of Child and Family Studies, 25, 3309–3321. https://doi.org/10.1007/s10826-016-0489-3.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Juster, R. P., McEwen, B. S., & Lupien, S. J. (2010). Allostatic load biomarkers of chronic stress and impact on health and cognition. Neuroscience and Biobehavioral Review, 35(1), 2–16. https://doi.org/10.1016/j.neubiorev.2009.10.002.

    Article  Google Scholar 

  28. Kistin, C., & Silverstein, M. (2015). Pilot studies: a critical but potentially misused component of interventional research. Journal of the American Medical Association, 314, 1561–1562. https://doi.org/10.1001/jama.2015.10962.

    Article  PubMed  Google Scholar 

  29. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x.

    Article  PubMed  PubMed Central  Google Scholar 

  30. La Paro, K. M., Hamre, B. K., & Pianta, R. C. (2012). Classroom Assessment Scoring System® (CLASS™) manual, toddler. Baltimore, MD: Paul H Brookes Pub Co..

  31. Lenze, S. N., Pautsch, J., & Luby, J. (2011). Parent-child interaction therapy emotion development: a novel treatment for depression in preschool children. Depression and Anxiety, 28(2), 153–159. https://doi.org/10.1002/da.20770.

    Article  PubMed  Google Scholar 

  32. Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press.

    Google Scholar 

  33. Luthar, S. S., & Eisenberg, N. (2017). Resilient adaptation among at-risk children: harnessing science toward maximizing salutary environments. Child Development, 88, 337–349. https://doi.org/10.1111/cdev.12737.

    Article  PubMed  Google Scholar 

  34. McMillan, D., Gilbody, S., & Richards, D. (2010). Defining successful treatment outcome in depression using the PHQ-9: a comparison of methods. Journal of Affective Disorders, 127(1-3), 122–129. https://doi.org/10.1016/j.jad.2010.04.030.

    Article  PubMed  Google Scholar 

  35. Morris, A. S., Robinson, L. R., Hays-Grudo, J., Claussen, A. H., Hartwig, S. A., & Treat, A. E. (2017). Targeting parenting in early childhood: a public health approach to improve outcomes for children living in poverty. Child Development, 88(2), 388–397. https://doi.org/10.1111/cdev.12743.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Mortensen, J. A., & Barnett, M. A. (2016). The role of child care in supporting the emotion regulatory needs of maltreated infants and toddlers. Children and Youth Services Review, 64, 73–81. https://doi.org/10.1016/j.childyouth.2016.03.004.

    Article  Google Scholar 

  37. Munns, E. (2001). Group Theraplay®. In B. B. Bidwell (Ed.), Hand in hand II: an art/play therapist’s treasure chest (pp. 57–73). Canada: General Store.

    Google Scholar 

  38. National Scientific Council on the Developing Child (2007). Key concepts: toxic stress. http://developingchild.harvard.edu/science/key-concepts/toxic-stress/ Accessed July 7, 2017.

  39. Neacsiu, A., Bohus, M., & Linehan, M. M. (2014). Dialectical behavior therapy: an intervention for emotion dysregulation. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 491–507). New York, NY: The Guilford Press.

    Google Scholar 

  40. Palinkas, L. A., Aarons, G. A., Horwitz, S., Chamberlain, P., Hurlburt, M., & Landsverk, J. (2011). Mixed method designs in implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 38(1), 44–53. https://doi.org/10.1007/s10488-010-0314-z.

    Article  PubMed  Google Scholar 

  41. Randell, K. A., O’Malley, D., & Dowd, M. D. (2015). Association of parental adverse childhood experiences and current child adversity. JAMA Pediatrics, 169, 786–787. https://doi.org/10.1001/jamapediatrics.2015.0269.

    Article  PubMed  Google Scholar 

  42. Sandler, I., Ingram, A., Wolchik, S., Tein, J.-Y., & Winslow, E. (2015). Long-term effects of parenting-focused preventive interventions to promote resilience of children and adolescents. Child Development Perspectives, 9, 164–171. https://doi.org/10.1111/cdep.12126.

    Article  Google Scholar 

  43. Shonkoff, J. P. (2012) Leveraging the biology of adversity to address the roots of disparities in health and development. Proceedings of the National Academy of Sciences of the United States of America, 109 (Suppl 2), 17302–17307. https://doi.org/10.1073/pnas.1121259109

    Article  Google Scholar 

  44. Shonkoff, J. P., & Garner, A. S., The Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood Adoption and Dependent Care, and Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–246. https://doi.org/10.1542/peds.2011-2663.

    Article  PubMed  Google Scholar 

  45. Siu, A. F. Y. (2009). Theraplay in the Chinese world: an intervention program for Hong Kong children with internalizing problems. International Journal of Play Therapy, 18(1), 1–12. https://doi.org/10.1037/a0013979.

    Article  Google Scholar 

  46. Snell-Johns, J., Mendez, J. L., & Smith, B. H. (2004). Evidence-based solutions for overcoming access barriers, decreasing attrition, and promoting change with underserved families. Journal of Family Psychology, 18(1), 19–35. https://doi.org/10.1037/0893-3200.18.1.19.

    Article  PubMed  Google Scholar 

  47. Sweet, M. A., & Appelbaum, M. I. (2004). Is Home Visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75, 1435–1456. https://doi.org/10.1111/j.1467-8624.2004.00750.x.

    Article  PubMed  Google Scholar 

  48. Titov, N., Dear, B. F., McMillan, D., Anderson, T., Zou, J., & Sunderland, M. (2011). Psychometric comparison of the PHQ-9 and BDI-II for measuring response during treatment of depression. Cognitive Behaviour Therapy, 40(2), 126–136. https://doi.org/10.1080/16506073.2010.550059.

    Article  PubMed  Google Scholar 

  49. Valentine, S. E., Bankoff, S. M., Poulin, R. M., Reidler, E. B., & Pantalone, D. W. (2015). The use of dialectical behavior therapy skills training as stand‐alone treatment: a systematic review of the treatment outcome literature. Journal of Clinical Psychology, 71(1), 1–20.

    Article  Google Scholar 

  50. Webster-Stratton, C. H. (2011). Incredible babies: a guide and journal of your baby’s first year. Seattle, WA: Incredible Years Press..

  51. Webster-Stratton, C. H., & Reid, M. J. (2010). The incredible years program for children from infancy to pre-adolescence: prevention and treatment of behavior problems. In R. C. Murrihy, A. D. Kidman, & T. H. Ollendick (Eds.), Clinical handbook of assessing and treating conduct problems in youth (pp. 117–138). New York, NY, US: Springer..

    Google Scholar 

  52. Weisz, J. R., Krumholz, L. S., Santucci, L., Thomassin, K., & Ng, M. Y. (2015). Shrinking the gap between research and practice: tailoring and testing youth psychotherapies in clinical care contexts. Annual Review of Clinical Psychology, 11, 139–163. https://doi.org/10.1146/annurev-clinpsy-032814-112820.

    Article  PubMed  Google Scholar 

  53. Wettig, H. H. G., Coleman, A. R., & Geider, F. J. (2011). Evaluating the Effectiveness of Theraplay in Treating Shy, Socially Withdrawn Children. International Journal of Play Therapy, 20(1), 26–37. https://doi.org/10.1037/a0022666.

    Article  Google Scholar 

  54. Yancey, A. K., Ortega, A. N., & Kumanyika, S. K. (2006). Effective Recruitment and Retention of Minority Research Participants. Annual Review of Public Health, 27, 1–28. https://doi.org/10.1146/annurev.publhealth.27.021405.102113.

    Article  PubMed  Google Scholar 

  55. Yoshikawa, H., Whipps, M. D. M., & Rojas, N. M. (2017). Commentary: New directions in Developmentally Informed Intervention Research for Vulnerable Populations. Child Development, 88, 459–465. https://doi.org/10.1111/cdev.12736.

    Article  PubMed  Google Scholar 

Download references

Authors Contributions

B.W.J.: designed and executed the study, assisted with data analyses, and wrote the paper. C.C.S.: collaborated with the design and execution of the study, data analyses and writing of the paper. B.G.: collaborated with the design of the study and wrote part of the method. E.S.: analyzed the data and wrote part of the results. L.S. and V.T. assisted with writing of the results and editing the final manuscript. D.O.: collaborated in the editing of the final manuscript.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Briana A. Woods-Jaeger.

Ethics declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in this study were in accordance with the ethical standards of the Children’s Mercy Hospital Institutional Review Board and with the 1964 Helsinki declarations and its later amendments or comparable ethical standards

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Woods-Jaeger, B.A., Sexton, C.C., Gardner, B. et al. Development, Feasibility, and Refinement of a Toxic Stress Prevention Research Program. J Child Fam Stud 27, 3531–3543 (2018). https://doi.org/10.1007/s10826-018-1178-1

Download citation

Keywords

  • Adverse childhood experiences
  • Toxic stress
  • Prevention
  • Caregiver capacity
  • Poverty