A large primary care clinic completed two years implementing a four-tiered primary care treatment program for children with difficult behaviors. A frequent behavioral concern parents bring to their child’s doctor is externalized behavior (Meadows et al., 2011). Parents often ask their child’s medical provider to assess and intervene in their child’s externalized behavioral problems that have disrupted the child’s success at school, daycare and/or home(Schilling et al., 2017). The stepped-care program allows parents and children to receive the treatment they are requesting in their pediatric clinic. The tiers of treatment are based on symptom severity and stated need and clinician availability. The physician refers the patient to one of the following tiers: Targeted case management for evaluation and school support; Integrated Child Adult Relationship Enhancement (I-CARE) (brief 3-4 sessions), or the highest level of care PCIT or TF-CBT. Program evaluation data indicates that patients experience a reduction in symptoms according to the EBCI, parents like the therapy models, and is a feasible multi-tier model for primary care clinics to respond to pediatric patient need. Chart review indicates that this treatment approach reduces time-to-treat. Additionally, the program focuses on training family medicine residents, nurses and front desk staff in the Child Adult Relationship Enhancement (CARE) model to increase a trauma-informed care approach and maximize pediatric interaction with staff in the clinic (Scott et al., 2021).