TREE (Talk Read Engage Encourage) Program: Promoting Positive Parent Child Relationships in Low Income Families with Young Children by Pediatric Providers During Well Child Encounters

Background: Children living in poverty may endure Adverse Childhood Experiences (ACEs) that can affect their cognitive and social-emotional development. Safe and nurturing caregiver-child relationships mitigate many of the deleterious effects of ACEs. Child development research suggests that talking, reading, and playing with young children living in poverty improves their developmental outcomes.
Developmental coaching, unlike traditional anticipatory guidance, is an interactive format engaging caregivers through self-reflection, encouraging parents to attempt novel interaction approaches, and strengthening parent self- confidence through positive feedback.
This study examined the efficacy of the Grow Your Kids: TREE (Talk Read Engage Encourage) program, an interactive developmental coaching program promoting positive caregiver-child interactions during well-child encounters (ages 0-2) with low-income families. The TREE program was developed by the Emotional Health Committee of the Maryland Chapter American Academy of Pediatrics. (https://www.mdaap.org/tree/)

Methods: The study used a quasi-experimental design in two pediatric training programs in an eastern mid-sized city (residents: intervention n=24, control n=42). A convenience sample (n = 167 families) was recruited (79 intervention; 88 control). Data collection included parent STIMQ2 pre/post (4-6 and 9-15 months of age) and pediatric resident report of training impact. The StimQ2 is a structured validated parent measure designed to assess caregiver-child interactions at home.

Results: Recruited children were 3-10 months old (both sites), predominantly Black (76% intervention; 77% control), and on Medicaid (81% intervention; 78% control).
Due to COVID-19, follow-up data was obtained from 45% of families (38 intervention; 38 control). A significance level of p < .10 was used due to the small sample size. Analyses demonstrated differences in the STIMQ2 total (d = .43; 95% CI, -.04 to .89; p = .07) and Parent Verbal Responsivity scales (d = .68; 95% CI, .17 to 1.18; p = .009). There was also a significant change over time in the intervention group for reading quality subdimension (d= -.34, 95% CI, -.7 to .03, p=.07), whereas the control group’s reading quality decreased.
Intervention residents demonstrated significantly greater change in talking to, reading to, and being positive and encouraging with infants and toddlers as well as confidence in fostering interactions, conveying child development, and providing feedback (all p-values = .005 to .09).

Conclusion: The TREE program is a feasible, brief, inexpensive, easily replicated and learned, universal developmental coaching intervention delivered by pediatric primary care providers during well child encounters that enhances caregiver-child interactions among low-income families.
The study demonstrated increased overall parent-reported caregiver-child interactions, including verbal responsivity and reading behaviors and had a significant effect on pediatric residents’ perceptions of their competency in promoting positive caregiver-child interactions.