A pilot Roll-Out Implementation Optimization trial of an adjunctive intervention to improve teacher and caregiver uptake and adherence to a behavioral intervention for externalizing problems in preschool: a study protocol of Parent-Educator Action Response (PEAR).

A pilot Roll-Out Implementation Optimization trial of an adjunctive intervention to improve teacher and caregiver uptake and adherence to a behavioral intervention for externalizing problems in preschool: a study protocol of Parent-Educator Action Response (PEAR) - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Implement Sci Commun . 2026 Apr 22;7:110. doi: 10.1186/s43058-026-00938-7 A pilot Roll-Out Implementation Optimization trial of an adjunctive intervention to improve teacher and caregiver uptake and adherence to a behavioral intervention for externalizing problems in preschool: a study protocol of Parent-Educator Action Response (PEAR) Sarah R Eisenman 1 , Jocelin Vanegas 1 , Colleen Cicchetti 1, 2 , Scott N Compton 1, 2 , Walter S Gilliam 3 , Iheoma U Iruka 4 , Aaron R Lyon 5 , Lauren S Wakschlag 6 , Justin D Smith 7 , Andrea E Spencer 1, 2 , Courtney A Zulauf-McCurdy 1, 2, ✉ Author information Article notes Copyright and License information 1 Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL USA 2 Northwestern University Feinberg School of Medicine, Chicago, IL USA 3 Buffet Early Childhood Institute at the University of Nebraska, Omaha, NE USA 4 The University of North Carolina at Chapel Hill, Chapel Hill, NC USA 5 University of Washington School of Medicine, Seattle, WA USA 6 Northwestern University Clinical and Translational Sciences Institute, Chicago, IL USA 7 Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT USA ✉ Corresponding author. Received 2026 Jan 8; Accepted 2026 Apr 8; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13235087  PMID: 42021370 Abstract Background Behavioral interventions are well-established treatments for emerging externalizing problems in preschool. However, caregivers and teachers face barriers to implementing behavioral interventions across home and school. The current study aims to improve joint teacher and caregiver uptake and adherence to a behavioral intervention by testing a new adjunctive intervention co-developed with early childhood constituents, Parent-Educator Action Response (PEAR). PEAR consists of group-based motivational interviewing, psychoeducation, and action planning sessions for preschool teachers and caregivers of a preschooler with elevated externalizing problems, followed by a meeting with each caregiver-teacher dyad to agree upon a plan for supporting improvements in the child’s externalizing problems. Methods We will use a pilot Roll-Out Implementation Optimization (ROIO) design, with three clusters over 18 months to implement and evaluate PEAR. Participants will be approximately 24 preschool teachers and 24 caregivers of a preschool child. All participants will receive PEAR, delivered by a licensed clinical psychologist and supported by a bilingual community health worker. Throughout the study period, participants will be asked to implement the Daily Report Card (DRC), an evidence-based behavioral intervention for externalizing problems. Implementation of the DRC at home and preschool, the primary outcome, will be measured weekly for eight weeks. Additional outcomes will be measured at baseline, post-PEAR, and follow-up (4 weeks post-PEAR). Discussion This is one of the first pilot ROIO trials and trials in the preschool setting to study a new adjunctive intervention to improve both teacher and caregiver uptake and adherence to behavioral interventions for preschool externalizing problems. Findings are likely to generalize to other public health adjunctive interventions in community settings. Trial registration clinicaltrials.gov NCT 07203014 on 10–02-2025. Keywords: Externalizing problems, Preschool, Pilot ROIO, Adjunctive intervention Contributions to the literature. Parent Educator Action Response (PEAR) is a new adjunctive intervention, co-developed with early childhood constituents to increase teacher and caregiver uptake and adherence to an evidence-based intervention for preschool externalizing problems. This trial will use a novel Roll-Out Implementation Optimization design to pilot test PEAR in real-world settings and identify the most effective implementation strategies. This study’s findings have strong potential to generalize to improving uptake and adherence to interventions to promote positive child outcomes beyond preschool settings. Background The early childhood years are a time of rapid development, when common externalizing problems including attentional, oppositional, and conduct problems begin to emerge [ 1 ]. Prior research has found that between 16%–18% of 1–5-year-old children have a diagnosable mental health disorder [ 2 ], with recent research indicating that mental health concerns, particularly externalizing problems, are on the rise in young children [ 3 ]. When children enter preschool or any education setting that serves children prior to formal school entry [ 4 ], externalizing problems may become more visible and consequential, as children are navigating structured group settings with larger peer groups and higher behavioral expectations [ 5 ]. When these externalizing problems are not detected or prevented early, they are especially persistent, less responsive to medication management, and associated with poorer neurocognitive and behavioral functioning (e.g., social-emotional functioning; cognition, language, and motor skills; executive functioning including attention, inhibition, cognitive/behavioral flexibility; [ 6 , 7 ]). Providing early, evidence-based intervention for children at risk for externalizing disorders (e.g., ADHD, conduct disorder) can significantly reduce symptoms [ 7 ], increasing the potential to mitigate adverse outcomes and reduce the need for formal diagnosis and later treatment [ 8 ]. Despite the importance of early intervention, the majority of preschool-aged children with emerging symptoms do not receive evidence-based interventions, particularly children of minoritized backgrounds [ 9 , 10 ]. Evidence-based interventions for externalizing problems in preschool focus on training caregivers of young children (e.g., parents, teachers) on how to reduce specific, undesirable behaviors and promote positive behaviors in service of developing adaptive social, emotional, and behavioral skills [ 11 , 12 ]. For young children who are enrolled in a preschool setting, interventions that include both the teacher and caregiver are more powerful than targeting a singular context or adult [ 13 ]. In response to the growing awareness of the benefits of preventative interventions in community settings, there has been an increase in the development of behavioral interventions for preschool settings [ 14 , 15 ]. Despite the plethora of existing evidence-based interventions for externalizing problems, most do not make it to caregivers from historically minoritized backgrounds and teachers in under resourced contexts [ 16 ]. Even when caregivers or teachers access these evidence-based interventions, uptake and adherence are often complicated or even obstructed [ 17 ]. Further, as many evidence-based interventions were tested in rigorously controlled environments, they often fail to incorporate key perspectives and insights that address the unique considerations of intervention delivery in real-world contexts [ 18 , 19 ]. This “research-to-practice gap” [ 19 ], or the difference between ideal, controlled research settings and what happens in the real-world is problematic because many children do not receive the support they need to place them on a positive developmental trajectory. Teacher and caregiver engagement in behavioral interventions for preschool externalizing problems Despite being ideal candidates for learning the skills from evidence-based behavioral interventions, teachers and caregivers of young children face numerous barriers to uptake and adherence [ 20 ]. Preschool teachers are often overworked, stressed, and burned out, potentially limiting capacity and motivation [ 21 ]. Additionally, teachers often lack knowledge of effective interventions and the training and resources needed to implement them [ 22 ]. Feelings of efficacy is also a barrier, with teachers reporting less confidence in implementing behavioral interventions for children with persistent behavioral challenges [ 23 ], the children who would benefit the most from these interventions. Research also indicates that a teacher’s confidence in the potential effects of behavioral interventions and motivation to implement these interventions [ 24 ] are impacted by their perceptions of their relationship with a child’s caregiver [ 25 ] and their pereception of whether or not the caregiver will support the implementation of the intervention at home [ 26 ]. Caregivers also face barriers to initiating and adhering to behavioral interventions. Caregivers often lack knowledge or understanding of effective interventions [ 27 ] and when they do access interventions, caregivers may not know how to engage with them effectively [ 28 ]. Additional barriers related to joining with teachers to implement interventions across home and school may exist including difficulty attending school meetings due to conflicting work demands [ 29 , 30 ], and differences in knowledge of how to intervene [ 31 ]. Barriers may be particularly limiting for caregivers of minoritized backgrounds as they face systemic racism and classism present in the American education system [ 32 , 33 ]. For example, caregivers from historically minoritized backgrounds may have greater difficulty forming a relationship with teachers [ 34 ] and/or participating in school events or engaging with suggestions from the school [ 35 , 36 ] due to conflicting demands on their time in part due to structural racism (e.g., work, other children; [ 37 ]). Caregivers of minoritized backgrounds must contend with these barriers, in addition to carrying their own history of experiences with oppression in school [ 38 ]. Importantly, despite the many barriers that teachers and caregivers face, research demonstrates that some of the recipient-level factors that influence engagement, such as knowledge and motivation, are modifiable [ 39 ]. For example, group-based motivational interviewing has successfully improved general education teacher self-efficacy, adoption, and implementation of an evidence-based classroom management intervention [ 40 ]. However, existing strategies for improving implementation of behavioral interventions in preschools lack specific recommendations for how to target these recipient-level factors among teachers and caregivers [ 41 ]. A new adjunctive intervention to improve teacher and caregiver uptake and adherence to behavioral interventions for preschool externalizing problems To support teachers and families in joining together to initiate and adhere to a behavioral intervention for externalizing problems in preschool, our team has been working with early childhood constituents to develop a new adjunctive intervention, Parent-Educator Action Response (PEAR). PEAR aims to increase motivation, self-efficacy, and capacity to engage with behavioral interventions for externalizing problems for preschoolers among teachers and caregivers (see Fig. 1 ). By including teachers and caregivers in every step of the process, PEAR was specifically created to respond to the following needs: a) address unique recipient-level barriers that impact uptake and adherence among preschool teachers in under resourced settings and caregivers of historically minoritized backgrounds; b) target both teachers and caregivers to promote collaboration, joining, and activation of a behavioral intervention; and c) address barriers to uptake and adherence through motivational interviewing [ 42 ]. PEAR consists of three group sessions separately for caregivers and teachers, followed by a joint caregiver-teacher meeting to agree upon a plan for implementing an evidenced-based intervention for the child’s externalizing problems. Fig. 1. Open in a new tab Theoretical framework of PEAR In alignment with Smith and colleagues [ 43 ], we use the term adjunctive intervention to describe PEAR as it was developed to specifically support caregivers from historically minoritized backgrounds and preschool teachers in under resourced school settings to increase their motivation, self-efficacy, and capacity for initiating and adhering to behavioral interventions (See Table 1 ). Implementation science typically categorizes change methods as either interventions designed to improve health outcomes or implementation strategies designed to improve utilization of an intervention at the provider or system level [ 44 , 45 ]. However, as there is growing research indicating discrepancies in the classification of some change methods [ 46 , 47 ], some implementation scientists [ 43 ] encourage the use of adjunctive intervention conceptualization when a change method enhances the use of evidence-based interventions, but does not function like an implementation strategy (i.e., does not support delivery of the intervention itself). Table 1. Comparing the daily report card health intervention and the PEAR adjunctive intervention Health intervention Problem addressed by health intervention Adjunctive intervention Problem addressed by adjunctive intervention Implementation strategies for the health intervention Implementation strategies for the adjunctive intervention Daily Report Card Child behavioral challenges Parent-Educator Action Response (PEAR) Low caregiver and teacher motivation, lack of knowledge, self-efficacy, stigma, and poor adherence Training with examples, agreement between families and teachers on a plan, educational materials, revise standard operational procedures to expedite access to treatment Educational materials, provide incentives, no fee, change sites of care, administrator buy-in/workflow change Open in a new tab Discover, design/build, test framework To ensure that PEAR fits the needs of teachers and caregivers and the context of preschool settings, we incorporated early childhood constituents in every phase from development to testing. Specifically, our team followed the Discover, Design/Build, Test framework (DDBT; [ 48 , 49 ] which draws upon tenets of user-centered design [ 50 ] to ensure that users are included in every step of the process. User-centered design emphasizes the importance of understanding the range of users to effectively elicit the true spectrum of needs for a product [ 51 ] and to test the new product extensively to identify what may need additional changes [ 52 ]. During the Discover stage, we first asked teachers and caregivers to identify barriers they face when asked to use a behavioral intervention in preschool (Zulauf-McCurdy CA, Magro SW, Ilyumzhinova R, Clifton R, Basu H, Spencer AE, et al. Discovering strategies to support families and educators in joining together to implement interventions for disruptive behavior in preschool: innovation tournaments. (Under review)). During the Design/Build stage, we incorporated strategies addressing these barriers into the PEAR content and elicited feedback from an additional teachers, caregivers, and early childhood practitioners (Zulauf-McCurdy CA, Eisenman SR, Vanegas J, Magro SW, Spencer AE, Lyon AR. Iterative co-design of a new adjunctive intervention (PEAR) to improve teacher and caregiver uptake and adherence to evidence-based interventions for preschool externalizing problems. (Under review)). This paper describes the protocol for the Test stage. Study aims The primary aim of this study is to use a novel Roll-Out Implementation Optimization (ROIO; [ 53 ]) trial to pilot test the new adjunctive intervention, PEAR. During the pilot, we will refine the procedures for the trial and implementation (Aim 1), evaluate the preliminary acceptability and feasibility of PEAR (Aim 2), and test the effect on improving uptake and adherence of a behavioral intervention for preschool externalizing problems across home and preschool (the Daily Report Card; [ 54 ]; Aim 3). We will also gather preliminary estimates of adult and child outcomes. Methods/design Study setting, timeline, and status PEAR plus the Daily Report Card (DRC) intervention package will be operationalized and refined using a pilot ROIO [ 53 , 55 – 57 ] trial. The ROIO design involves optimizing intervention delivery in a sequential roll-out [ 55 , 57 ], such that the first participating group receives the intervention and implementation strategies are iteratively refined to inform delivery to the next group receiving the intervention and so on, typically over 3–4 groups to ensure optimization [ 58 ]. As the trial progresses, we will identify and incorporate the most important implementation strategies for PEAR delivery and meeting teacher and caregiver needs. ROIO designs can answer questions about practical and ethical considerations for intervention delivery in real-world settings [ 55 ]. During the 2025–2026 and 2026–2027 school years, we will pilot PEAR plus the DRC intervention package across five early childhood centers across the Chicago metropolitan area, with particular emphasis on centers which enroll children from low-income areas. See Fig. 2 for a detailed timeline of the ROIO trial. PEAR will be offered in English and Spanish, to reach as many caregivers as possible. Fig. 2. Open in a new tab ROIO design and timeline Recruitment and enrollment occur on a rolling basis within each cluster until participant caps are reached, or the group sessions begin. Within each cluster, each center is eligible to enroll each teacher from classrooms serving children 2–5 years of age. Once a teacher is enrolled, up to 4 families within that classroom can enroll. Enrollment began for cluster 1 in September 2025. The trial is ongoing; therefore, we use the present tense to describe study activities. Enrollment for cluster 2 will begin in January 2026 and cluster 3 will begin in August 2026. This study was reviewed and approved by the Ann & Robert H. Lurie Children’s Hospital of Chicago Institutional Review Board (ID 2024–7196; STUDY00000176). Study arm There is one study arm for all participants: PEAR + the Daily Report Card. The DRC is an evidence-based behavioral intervention for externalizing problems [ 59 ]. Following consent, all enrolled teachers receive instructional handouts on the DRC and are asked to create and implement a DRC for each child with each enrolled caregiver in their classroom. PEAR consists of three one-hour group sessions (one group for teachers and one for caregivers) followed by a 30-min meeting with each teacher-caregiver dyad with the licensed clinical psychologist who delivered PEAR. PEAR includes strategic education, social influencing techniques, and action planning to target caregiver and family self-efficacy, motivations, and attitudes. See Table 2 for a description of PEAR session content. Table 2. PEAR group session description and duration Session Duration Caregiver content Teacher content Caregiver-teacher content 1 60 min • Introduction to PEAR • Social-emotional development in early childhood • Qualities of a team • Discussion of many responsibilities of caregivers: what’s on your plate? • Introduction to PEAR • Social-emotional development in early childhood • Qualities of a team • Discussion of many responsibilities of teachers: what’s on your plate? 2 60 min • Why partner with teachers • What are teachers experiencing: what’s on their plates? • Discussion of racism and oppression • Psychoeducation on self-care practices • Why partner with caregivers • What are caregivers experiencing: what’s on their plates? • Discussion of racism and oppression • Psychoeducation on self-care practices 3 60 min • Elevating your strengths • Introduction to the Daily Report Card • Power of positive attention • Preparing for shared action plan • Recognizing strengths of child’s teachers • Vulnerable decision points/challenging our assumptions • Introduction to the Daily Report Card • Power of positive attention • Preparing for shared action plan • Recognizing strengths of child’s caregivers 4 (joint) 30 min • Sharing statements of care • Creating a Daily Report Card for the child • Creating a shared action plan • Anticipating barriers Open in a new tab Eligibility criteria Potentially eligible participants (teachers and caregivers) are identified based on the following inclusion and exclusion criteria. Inclusion criteria for teachers are: a) working in an identified center partner for one of the three clusters, b) lead, assistant, or co-teacher of a 2–5-year-old classroom; and c) English fluency (ability to read and understand English). Inclusion criteria for caregivers are: a) over the age of 18; b) legal guardian of a 2–5-year-old child in the same classroom as an enrolled teacher; c) English or Spanish fluency; and d) caregiver has asked teacher for more support with the child’s behavior or the teacher perceives that the child is having externalizing problems. Exclusion criteria for teachers: a) Float teacher, aide or substitute of a 2–5-year-old classroom; b) classroom age range is not between 2–5-year-old; and c) not fluent in English. Exclusion criteria for caregivers: a) not the legal guardian of a 2–5-year-old child in a participating classroom; b) not fluent in English or Spanish; and c) neither teacher nor caregiver perceives the child to need support with externalizing problems. Recruitment and study flow Five early childhood centers in the Chicagoland area will be identified and slotted (non-random assignment) into clusters of 1–3 schools based on when they expressed interest and when they indicated they would be ready to pilot. At the start of each cluster, the study team shares information with teachers and conducts consent visits. Teachers are then given a caregiver information sheet and the PEAR flyer to share with caregivers in their classroom. Teachers may either obtain verbal consent to share family contact information with the study team, or caregivers may reach out to the study team directly for more information. The study team screens caregivers for eligibility (i.e. whether the child is in the classroom of a participating teacher) and conducts consent visits with one caregiver from each eligible, interested family. After each cluster, feedback is evaluated from the previous cluster participants, and recruitment procedures are updated accordingly. Once a caregiver-teacher pair is enrolled and the schedule of group sessions is determined, assessment delivery begins. Participants complete four main assessment procedures, plus one optional assessment (exit interview). All participants complete a set of measures at baseline, post-PEAR (approximately week 4), and follow-up (approximately week 8). After completing the baseline assessment, teachers receive an email from the study team with routine information and handouts about the research behind the DRC and how to establish it. This material is set to mimic what teachers would receive in routine practice. Teachers are asked to establish the DRC with each child’s caregiver when they feel ready. To assess uptake and fidelity of the DRC throughout the study period, following the email with the DRC material, the lead teacher and caregiver are asked to complete a brief, weekly Daily Report Card survey for approximately 8 weeks. All quantitative assessments are delivered via the Research Electronic Data Capture (REDCap; [ 60 , 61 ] platform, which is a secure, browser-based application for survey data collection. For baseline, post-PEAR, and follow-up assessments, caregivers rate all participating teachers (e.g., lead and co-teacher) in their child’s classroom and all participating teachers rate caregivers and children. Caregivers receive $50 per completed set of measures for baseline, week 4, and week 8, and teachers receive $35 per set of measures per family (up to 4 families). The survey battery is expected to take between 30–60 min. The optional assessment is an exit interview conducted in person or via Zoom videoconferencing software. Interviews are conducted by a study staff member and occur individually with each participant. Participants are asked a range of open-ended questions to reflect on their experiences with PEAR, identify areas they felt were especially important or that could be removed, and to guide iterative revision of materials for the next cluster. Interviews last approximately 45 min, and participants receive a $25 gift card for participating. Notably, preschool administrators are also invited to participate in an exit interview to share their feedback on PEAR implementation, as prior literature shows that leadership support is important for successful intervention implementation in schools [ 62 , 63 ]. Implementation strategies Our team has created an Implementation Research Logic Model (IRLM; [ 64 ]) to inform the implementation strategies we prioritize in the ROIO. The use of IRLM to design and prepare for a ROIO has been described in prior studies [ 65 , 66 ]. We will use the IRLM to work with our community advisory board and study team members to identify changes to tailor or optimize strategies for both delivering PEAR and for improving uptake and adherence to the DRC intervention after each cluster of the ROIO. Tailoring/optimizing strategies may include adding new strategies, removing ineffective or infeasible strategies, and changing intensity of dose or frequency of strategies [ 58 ]. We use the Longitudinal Implementation Strategy Tracking System (LISTS; [ 67 ] to carefully document and track implementation strategy changes across each cluster. Interventionist qualifications and training The primary interventionist (CZM) is a licensed clinical psychologist with expertise in working with teachers and caregivers to support preschool-aged children with externalizing problems. She is present at each group session as the main facilitator. Other facilitators include a masters-level bilingual community health worker (JV) and a masters-level research coordinator (SRE), who have been trained on the PEAR manual by the primary interventionist as well as provided feedback on prior iterations of manual content. PEAR sessions are recorded and reviewed by the study team to enhance treatment fidelity and to capture suggestions for iteration and optimization suggested by participants. Measures Primary outcome measure The primary outcome measure is teacher and caregiver uptake of and adherence to the DRC at school and home, measured via a weekly survey. Within the survey, both the lead teacher and caregivers are asked to report on the use of the DRC in the classroom and home. Caregiver-teacher communication (frequency and mode) will also be measured in the survey. Secondary outcome measures and covariates Secondary outcomes include measures of child externalizing problems, teacher and caregiver stress, teacher-caregiver relationship quality, and teacher awareness of racial attitudes and beliefs. See Table 3 for a complete list of secondary outcome measures and covariates. Table 3. Secondary measures and covariates Measure Description Source Time point Caregiver Teacher Baseline Post-PEAR (4 weeks) Follow-up (8 weeks) Preschool Pediatric Symptom Checklist (Sheldrick et al., 2012) Social-emotional screening instrument for children 18–60 months old X X X X X Preschool ADHD Rating Scale Version IV (ADHD-RS-IV; McGoey et al., 2007) ADHD behavioral rating scale for preschool-aged children 3–5 years old X X X X X Working Alliance Inventory -Short Revised (WAI-SR; Hatcher & Gillaspy, 2006) Rating scale developed to measure therapist-client alliance. Note: authors adapted this scale for relevance to the alliance of caregivers and teachers in preschool context X X X X X Parent-Teacher Relationship Scale II (Vickers & Minke, 1995) Rating scale developed to assess parent-teacher relationship quality in the elementary school context. Note: authors adapted this scale for preschool context X X X X X Tool to Measure Parenting Self-Efficacy (TOPSE) – discipline/setting boundaries and control subscales (Kendall & Bloomfield, 2005) Scale measuring the challenges faced by parents of children under 6 years old and perceived parental self-efficacy in managing their children’s behavior X X X X Parental Stress Scale (Berry & Jones, 1995) Rating scale to assess level of parental stress and relationship with their child/ren X X X X Racial Awareness, Beliefs, and Attitudes (Fergus, 2016; Neville et al., 2000; Seattle Office of Civil Rights) A three-part measure assessing individuals’ racial awareness, beliefs, and attitudes in the U.S. context X X X X Teacher Self-Efficacy Scale (Tschannen-Moran & Woolfolk Hoy, 2001) Instrument measuring teachers’ beliefs about their ability to influence classroom management and student engagement. Note: authors adapted some items on this scale for relevance to the preschool context X X X X West Virginia Teacher Burnout Scale (Richmond, Wrench, & Gorham, 2001) A tool to measure teacher feelings about their job and categorize into levels of burnout X X X X Preschool Expulsion Risk Measure (PERM; Gilliam and Reyes, 2018) A rating scale assessing teacher perceptions of classroom disruption, hopelessness, fear of accountability, and stress regarding preschool children in their classroom X X X X Top problems A rating scale developed by the authors to assess child behavior on the top three behaviors selected to monitor on the Daily Report Card plus overall behavior X X X X Implementation outcomes (Weiner et al., 2017) Instrument adapted to measure feasibility, acceptability of PEAR adjunctive intervention X X X Child demographics Child age, sex, gender, race, history of early intervention and ongoing therapies (speech, occupational, etc.), school disciplinary history, and diagnostic status X X Caregiver demographics Caregiver age, sex, gender, sexual orientation, race, household composition, household income X X Teacher demographics Teacher age, sex, gender, sexual orientation, race, household composition, household income, years in early childhood education, years at current school X X Open in a new tab Implementation outcomes Participants will also complete a questionnaire in the post-PEAR survey battery assessing feasibility, acceptability, and appropriateness (Implementation Outcomes Survey; see Table 3 ). Additionally, we will ask questions around successful implementation strategies and suggestions for new strategies in the exit interviews. Sample size and power Because of the emerging consensus that estimates of population effect sizes based on small samples are often positively biased (i.e., too large), formal power considerations for pilot trials are typically deemed unnecessary [ 68 , 69 ]. Nevertheless, providing a sample size justification remains critical. In determining the sample size for this project, we adhere to the recommendations of Whitehead and colleagues [ 70 ], who emphasize that one of the main aims of pilot trials, in addition to evaluating feasibility and acceptability, is to obtain a stable estimate of the standard deviation of the primary outcome (fidelity of the DRC), which is essential for planning future larger studies. Following their guidance, for a future larger ROIO with a target effect size of 0.60 (medium), power set at 0.90, and a two-sided alpha of 0.05, a pilot study with a total sample size of N = 48 was deemed optimal for obtaining a reliable and stable estimate of the treatment effect standard deviation (or variance). This pilot sample size minimizes the total sample needed for both the pilot and a future larger study combined and will allow us to adequately evaluate the feasibility and acceptability of the treatment protocols, generate a stable estimate of the treatment effect standard deviation, and prepare our research team for a future “full-scale” randomized trial. Statistical analysis Basic data screening and descriptive analyses will be conducted for all variables, and we will screen for errors, distributional form, and missing data. For all models, we will check assumptions to ensure that results are not an artifact of violations. Below are analytic details for each sub aim. Aim 1. Are PEAR and the implementation strategies acceptable and feasible? Overall, PEAR acceptability and feasibility for all participants will be evaluated by examining the mean parent and teacher ratings of satisfaction, acceptability, appropriateness, and feasibility. Consumer fit will be considered acceptable if scores are above the neutral point of the scale for all measures except fidelity, which we will consider 80% as the target point. We will also examine whether acceptability and feasibility indices vary by classroom and participant demographics by treating these predictors as fixed effects in regression analyses. These latter tests will allow us to explore whether there are refinements needed prior to a large-scale trial to better support families of certain backgrounds. Aim 2. Are the ROIO trial procedures acceptable and feasible? This aim is focused on (a) refining recruitment procedures and study protocol to obtain an adequate sample of parents, (b) optimizing screening and assessment procedures in preschool, (c) optimizing procedures for sustaining participants in PEAR (i.e., minimizing drop-out), and (d) assess delivery costs and pilot data collection methods for future cost analyses. In addition, we hope to address some of the methodological challenges for ROIOs prior to a subsequent trial including: (a) number of clusters needed, (b) roll-out schedule to ensure sufficient time between clusters for optimization process, (c) selecting metrics that are sensitive to change and actionable, (d) optimizing analysis methods that are rapid and informative, and (e) creating a process for modification decisions. Aim 3. Does PEAR improve teacher and family fidelity to the Daily Report Card Fidelity will be defined as the proportion of weekdays the DRC is implemented at home, school, and both. We are interested in examining change in fidelity across time. Hierarchical multi-level models will be used to ensure inclusion of random effects, variations between clusters, variation between times within cluster, and fixed effects of time which will be estimated independently of treatment effect so that systematic change over time will not be mistaken for effect of treatment. Discussion This study is innovative in that it capitalizes on the unique and complementary methods from user-centered design, implementation science, and clinical research to refine, implement, and sustain a new adjunctive intervention to increase teachers and caregivers’ motivation, self-efficacy, and capacity to engage with behavioral interventions for externalizing problems in preschool. This is the first ROIO implemented in the preschool setting, affording an opportunity to evaluate the feasibility of this methodology in the early childhood context. Further, although this study focuses on teacher and caregiver recipient-level factors influencing uptake and adherence to behavioral interventions for externalizing problems among preschool children, the core components of PEAR may be transferable to other interventions that involve adults (e.g., caregivers, clinicians, teachers) working together across multiple contexts to support a child. The current study is not without challenges and limitations. One limitation is that randomization of early childhood centers was not possible because not all partner sites had agreed or were ready to participate before the first cluster began. Further, randomization was also not acceptable to our community partners due to concerns about some caregivers and teachers not receiving the intervention. Therefore, all participants will receive PEAR + DRC which is a strength of the ROIO design. Additionally, the number of possible participating centers is limited by the funding and time constraints of the grant mechanism. This study has the potential to make a substantial contribution to the field of implementation science by demonstrating the application of the newly described ROIO design in preschool settings, where implementation science is rarely studied [ 41 ]. Additionally, this study will provide knowledge of the potential benefits of a new adjunctive intervention, that is specifically designed to target recipient-level factors of both teachers and caregivers as well as their relationship. It is expected that this study will exert a significant public health impact by increasing teacher and caregiver uptake and adherence of evidence-based interventions for preschool externalizing problems. Acknowledgements We wish to thank the preschools, teachers, and families participating in PEAR for their time, energy, and thoughtful suggestions for improvement. Abbreviations DDBT Discover, Design/Build, Test DRC Daily Report Card IRLM Implementation Research Logic Model LISTS Longitudinal Implementation Strategy Tracking System PEAR Parent-Educator Action Response ROIO Roll-Out Implementation Optimization Authors’ contributions SRE drafted the manuscript. JV edited the manuscript. CC contributed to the conceptualization of the project. SC wrote and provided feedback on the analytical plan. WSG contributed to the conceptualization of the project and edited the manuscript. IUI contributed to the conceptualization of the project and edited the manuscript. ARL contributed to the conceptualization of the project and edited the manuscript. LSW contributed to the conceptualization of the project and edited the manuscript. JDS contributed to the conceptualization of the project and edited the manuscript. AES contributed to the conceptualization of the project and edited the manuscript. CZM received the grant funding, conceptualized the study, and wrote and edited the manuscript. All authors read and approved the final manuscript. Funding Sarah R Eisenman was supported by the National Institute of Mental Health Grant number K23MH129575 awarded to Courtney A Zulauf-McCurdy. Courtney A Zulauf-McCurdy is supported by the National Institute of Mental Health Grant numbers K23MH129575 and L30MH141709 as well as a philanthropic donation from the foundry10. Lauren S Wakschlag, JD Smith, and Andrea E Spencer were supported by National Institute of Mental Health Grant number P50MH132502. Aaron Lyon was supported by National Institute of Mental Health Grant number P50MH115837. Data availability No datasets were generated or analysed during the current study. Declarations Ethics approval and consent to participate This study was approved by the Ann & Robert H. Lurie Children’s Hospital of Chicago Institutional Review Board on 3–27-2025 (Protocol ID: 2024–7196; STUDY00000176). Participant consent is conducted via REDCap e-consent. Written consent from preschools was not required for participation in the study. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Footnotes Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Danielson ML, Bitsko RH, Ghandour RM, Holbrook JR, Kogan MD, Blumberg SJ. Prevalence of parent-reported ADHD diagnosis and associated treatment among US children and adolescents, 2016. J Clin Child Adolesc Psychol. 2018;47(2):199–212. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. von Klitzing K, Dohnert M, Kroll M, Grube M. Mental disorders in early childhood. Dtsch Arztebl Int. 2015;112(21–22):375–86. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. Ng CSM, Ng SSL. Impact of the COVID-19 pandemic on children's mental health: a systematic review. 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