Study of the Effectiveness of Primary Project

The early years of formal education are a major adjustment period for young children (Duda & Minick, 2006). While a variety of interventions focus on children who exhibit early problems in the classroom and with peers, it is also essential for prevention programs to engage with children at risk for, but not yet clearly exhibiting, these adjustment issues. The proposed study is a randomly controlled trial (RCT) test of the impacts of such a prevention program, the Primary Project (formerly Primary Mental Health Project; Cowen et al., 1979; Lotyczewski et al., 2024). Following is a description of the prevention program and aims of the proposed RCT study. Status of the play therapy literature Child-centered play therapy (CCPT; Cochran et al., 2010) has been adapted for use in many different school-based interventions and is considered the most popular approach to play therapy in the United States (Lambert et al., 2007). The impact of CCPT has been examined across many domains of children’s adjustment, including anxiety and depressive symptoms (Post, 1999), rule-breaking and aggressive behavior (Ritzi et al., 2017; Schumann, 2010), and social skills and self-regulatory abilities (Taylor & Ray, 2021). CCPTs provide a safe, non-directive environment within which children express emotions and process their experiences through play (Ray & Landreth, 2016). Child-center play interventions (CCPIs; based on the tenets of CCPT) have been found to be effective across multiple domains of development, particularly for younger children who may not be able to verbally express themselves well (Lin & Bratton, 2015). While there is a plethora of research on the effectiveness and types of CCPIs, there is much less current research available on the long-term effectiveness of such programs that directly compares the impact of the intervention against the development of students who would be eligible for such programs. RCTs are needed to establish causal links between CCPIs and socioemotional outcomes(Cochran et al., 2010). Through randomization, researchers are better able to pinpoint the causal mechanisms through which CCPIs improve behavior and outcomes. The proposed study is such an RCT, examining the causal impact of Primary Project on socioemotional behaviors of at-risk elementary students assigned to a treatment group or a waitlist-control group. We were specifically interested in testing the effectiveness of Primary Project (i.e., causal impact of the intervention in real-world versus controlled conditions; Onken et al., 2014). Introducing Primary Project Primary Project (formerly Primary Mental Health Project) is a play-based, tier 2 (i.e., preventive intervention for students at risk but who do not require intensive individualized services) school-based intervention that was developed in the late 1950s. It is intended for children in grades kindergarten through third grade exhibiting difficulty with school adjustment (see Peabody et al., 2019). Primary Project is unique as a CCPI due to six aspects of the intervention: 1) a focus on young (i.e., kindergarten through third grade) children; 2) early, universal screenings prior to the onset of behavior problems; 3) the use of para-professionals who are trained on non-directive roles; 4) the role of school mental health professionals as consultants; 5) ongoing program evaluation; 6) intervention occurs in the school setting rather than a clinical setting. As of 2015, Primary Project had been implemented in over 1,000 schools nationwide across 15 states and in Toronto, Canada (Children’s Institute, 2016). With this far reach of the intervention, however, it is important for an updated RCT to explore the ways in which children are impacted by this intervention. Each school that implements Primary Project is given the same guidance for its implementation. First, all students in a participating school and within the appropriate grade levels (K through 3rd grade) are screened by teachers in the beginning of the school year, approximately four to six weeks after school began to allow for teachers to get to know their students. Primary Project guidance indicates that children considered “at-risk,” and therefore eligible for the intervention, are those students whose subscale scores fall within the 15th to 30th percentile rank in one or more of the four domains in the screening. Typically, mental health professionals and teachers then meet to discuss and select students based on their assessment results. Students participating in Primary Project receive 12-15 thirty minute sessions with a para-professional (“child associate”) trained in child-led, non-directive play therapy with a focus on reflective interactions. At the end of the sessions, teachers complete another screening measure in order to assess change, and child associates complete a log to indicate the duration and length of sessions. Previous trials with Primary Project Several recent studies have assessed outcomes of Primary Project. Absenteeism was shown to drop in the Primary Project treatment group as compared to the control group (Lotyczewski et al., 2024), though this study did not utilize a waitlist control group and thus changes may partly reflect normal developmental change over time. The authors also noted the need for comparisons by urbanicity as well as the inclusion of potential confounding variables. Students enrolled in Primary Project partially closed the gap in math and reading between students who qualified for services and those that did not (Massengale & Perryman, 2021), and show greater academic gains that students not enrolled (Perryman et al., 2020). While these recent papers give information about the current effectiveness of Primary Project, none of them used a randomized clinical trial design that included a waitlist control group. As such, the evidence of the effectiveness of Primary Project is now stale and the time is ripe for a new RCT. Additionally, the present study is the first to test the effectiveness of Primary Project using the updated, shortened screening tool now used in the program. The Teacher-Child Rating scale-short form was developed recently to reduce teacher workload, with a total of 16 items rather than the original 32 (Weber et al., 2017). The T-CRS-sf has recently been examined in terms of factor structure (Duprey et al., under review), but its use as the pre- and post-Primary Project screening tool has yet to be examined. While annual pre- post- designs produce some evidence substantiating program effectiveness, it has been several decades since a randomized study examined outcomes for Primary Project participants compared with an appropriate control group. Furthermore, the mechanisms underlying pre/post changes are unknown. The current study was designed to reestablish program effectiveness under real-world (in vivo) conditions using sound scientific methods.

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