Parent-Child Interaction Therapy with At-Risk Families

ISSUE BRIEF

January 2013

Parent-Child Interaction Therapy With At-Risk Families

Parent-child interaction therapy (PCIT) is a family-centered What’s Inside: treatment approach proven effective for abused and at-risk children ages 2 to 8 and their caregivers—birth parents, • What makes PCIT unique? adoptive parents, or foster or kin caregivers. During PCIT, • Key components therapists coach parents while they interact with their • Effectiveness of PCIT children, teaching caregivers strategies that will promote • Implementation in a child positive behaviors in children who have disruptive or welfare setting externalizing behavior problems. Research has shown that, as a result of PCIT, parents learn more effective parenting • Resources for further information techniques, the behavior problems of children decrease, and the quality of the parent-child relationship improves.

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This issue brief is intended to build a better of the model, which have been experienced understanding of the characteristics and by families along the child welfare continuum, benefits of PCIT. It was written primarily to such as at-risk families and those with help child welfare caseworkers and other confirmed reports of maltreatment or neglect, professionals who work with at-risk families are described below. make more informed decisions about when to refer parents and caregivers, along with their children, to PCIT programs. This information may also help parents, foster parents, and “Parent-child interaction therapy is one other caregivers understand what they and of the most effective evidence-based their children can gain from PCIT and what practices in the field today. Using an in to expect during treatment. This brief also vivo training technique, parents acquire may be useful to others with an interest in more effective parenting skills, children’s implementing or participating in effective behavioral problems improve, and parent-training strategies. together they develop a more positive and affectionate relationship. The positive affiliative nature developed as a result of participation in PCIT strengthens What Makes PCIT Unique? attachment and builds resilience in at-risk families.” Introduced in the 1970s as a way to treat Anthony Urquiza, Ph.D., Director of Mental Health young children with serious behavioral Services and Clinical Research at the University of California at Davis CAARE Center problems, PCIT has since been adapted successfully for use with populations who have experienced trauma due to child Reduces Behavior Problems in abuse or neglect. The distinctiveness of this Young Children by Improving approach lies in the use of live coaching Parent-Child Interaction and the treatment of both parent and child together. PCIT is the only evidence-based PCIT was originally designed to treat children practice in which the parent and child are ages 2 to 8 with disruptive or externalizing treated together throughout the course of behavior problems, including conduct all treatment sessions. As a result, it is a and oppositional defiant disorders. These more intensive parenting intervention and children are often described as negative, most applicable for children with serious argumentative, disobedient, and aggressive. behavioral problems, parents with significant PCIT addresses the negative parent-child limitations (e.g., substance abuse, limited interaction patterns that contribute to the intellectual ability, mental health problems), disruptive behavior of young children (Bell & and/or parents at risk for child maltreatment. Eyberg, 2002). Through PCIT, parents learn In randomized testing, including families to bond with their children and develop more identified by the child welfare system, PCIT effective parenting styles that better meet has consistently demonstrated success in their children’s needs. For example, parents improving parent-child interactions. Benefits learn to model and reinforce constructive

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ways for dealing with emotions, such as child discipline, as most physical abuse does. frustration. Children, in turn, respond to these While child behavior problems and child healthier relationships and interactions. As a physical abuse often co-occur, PCIT may help result, children treated using PCIT typically change the parental response to challenging show significant reductions in behavior child behaviors, regardless of the type of problems at home and at school (Brinkmeyer behavior problem. & Eyberg, 2003; Gallagher, 2003; McNeil, Foundational research has shown that many Eyberg, Eisenstatdt, Newcomb, & Funderburk, complex factors contribute to abusive 1991; McNeil & Hembree-Kigin, 2010; behaviors, including a coercive relationship Nixon, Sweeney, Erickson, & Touyz, 2003; between the parent and child (Fisher & Kane, Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998; Urquiza & McNeil, 1996). Abusive 1998). and at-risk parents often interact in negative Treats the Parent and Child Together ways with their children, use ineffective and inconsistent discipline strategies, and rely too While many treatment approaches target much on punishment. These same parents either parents or children, PCIT focuses on rarely interact in positive ways with their changing the behaviors of both the parent and children (e.g., rewarding good behavior). At child together. Parents learn to model positive the same time, some physically abused and behaviors that children can learn from and are at-risk children learn to be aggressive, defiant, trained to act as “agents of change” for their noncompliant, and resistant to parental children’s behavioral or emotional difficulties direction (Kandel, 1992; Larzelere, 1986). The (Herschell & McNeil, 2005). Sitting behind reciprocal negative behaviors of the parent a one-way mirror and coaching the parent and child create a harmful cycle that often through an “ear bug” audio device, therapists escalates to the point of severe corporal guide parents through strategies that reinforce punishment and physical abuse. The negative their children’s positive behavior. In addition, behaviors of the parent—screaming and PCIT therapists are able to tailor treatment threatening—reinforce the negative behaviors based on observations of parent-child of the child—such as unresponsiveness and interactions. As such, PCIT can help address disobedience, which further aggravates the specific needs of each parent and child. parent’s behavior and may result in violence. PCIT helps break this cycle by encouraging Decreases the Risk for Child Physical positive interaction between parent and child Abuse and Breaks the Coercive Cycle and training parents in how to implement consistent and nonviolent discipline PCIT has been found effective for physically techniques when children act out. abusive parents with children ages 2 to 12 (Borrego, Urquiza, Rasmussen, & Zebell, Parents and caretakers completing PCIT 1999; Chaffin et al., 2004; Chaffin et al., 2009; typically: Hakman, Chaffin, Funderburk, & Silovsky, • Show more positive parenting attitudes and 2009; Chaffin, Funderburk, Bard, Valle, & demonstrate improvements in the ways that Gurwitch, 2011). PCIT is appropriate where they listen to, talk to, and interact with their physical abuse occurs within the context of children (McNeil & Hembree-Kigin, 2010)

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• Report less stress (Timmer, Urquiza, Zebell, • Parents are provided with opportunities to & McGrath, 2005) practice newly taught skills. • Use less corporal punishment and physically • Therapists can correct errors and coercive means to control their children misunderstandings on the spot. (Chaffin et al., 2011) • Parents receive immediate feedback. In addition, parent satisfaction with PCIT is • Parents are offered support, guidance, and typically high (Chaffin et al., 2004). encouragement as they learn. Offers Support for Caregivers • Treatment gains (e.g., increases in child Including Foster Parents compliance) are recognized by the parent “in the moment”–which supports continued PCIT is now recognized as a way to help use of effective parenting skills. support foster parents caring for children with behavioral problems by enhancing the Research is currently underway to determine relationship between foster parents and if PCIT training can be administered via the foster children and by teaching foster parents Internet with Remote Real-Time (RRT) training. behavior management skills. In addition The University of Oklahoma is piloting to reporting decreases in child behavior these studies (see http://www.oumedicine. problems, foster parents frequently report com/pediatrics/department-sections/ less parental stress following PCIT and high developmental-behavioral-pediatrics/child- levels of satisfaction with the program (McNeil, study-center/programs-and-clinical-services/ Herschell, Gurwitch, & Clemens-Mowrer, parent-child-interaction-therapy/information- 2005; Timmer, Urquiza, & Zebell, 2005). One for-professionals/pcit-research-at-ouhsc). benefit of providing foster parents with PCIT skills is that they can use these same effective Adaptations for Various Populations parenting skills with future generations of While PCIT was originally applied to Caucasian foster children. families, it has been adapted for use with various populations and cultures, including: Uses Live Coaching • Families in which child abuse has occurred PCIT is a behavioral parent-training model. (Chaffin et al., 2011; Timmer, Urquiza, What makes PCIT different from other parent Zebell, & McGrath 2005) training programs is the way skills are taught, using live coaching of parents and children • Trauma victims/survivors (The National together. Live coaching provides immediate Child Traumatic Stress Network, n.d.; prompts to parents while they interact with Urquiza, 2010) their children. During the course of this • Children with prenatal exposure to alcohol hands-on treatment, parents are guided to (e.g., Bertrand, 2009) demonstrate specific relationship-building and discipline skills. • Children aged 18–60 months with externalizing behaviors who were The benefits of live coaching are significant: premature births (Bagner, Sheinkopf, Vohr, & Lester, 2010)

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• Children with developmental delays and/or mental retardation (Bagner & Eyberg, 2007) Key Components • Older children (McNeil & Hembree-Kigin, 2010) PCIT is typically provided in 10 to 20 sessions, • Foster parents and maltreated children with an average of 12 to 14 sessions, each (Timmer, Urquiza, & Zebell, 2005) lasting about 1 to 1.5 hours. Occasionally, additional treatment sessions are added as • African-American families (Fernandez, needed. Butler, & Eyberg, 2011) The PCIT curriculum uses a two-phase • Latino and Spanish-speaking families approach addressing: (Borrego, Anhalt, Terao, Vargas, & Urquiza, 2006; McCabe & Yeh, 2009) 1. Relationship enhancement • Native American families (Bigfoot & 2. Discipline and compliance Funderburk, 2011) Initially, the therapist discusses the key principles and skills of each phase with the Limitations of PCIT parents. Then, the parents interact with their While PCIT is very effective in addressing children and try to implement the particular certain types of problems, there are clear skills. The therapist typically observes from limitations to its use. For the following behind a one-way mirror while communicating populations, PCIT may not be appropriate, with the parent, who wears a small wireless or specific modifications to treatment may be earphone. Although not optimal, clinicians needed: who do not have access to a one-way mirror and ear bug may provide services using • Parents who have limited or no ongoing in-room coaching. Specific behaviors are contact with their child tracked on a graph over time to provide • Parents with serious mental health problems parents with feedback about the achievement that may include auditory or visual of new skills and their progress in positive hallucinations or delusions interactions with their child.

• Parents who are hearing impaired and Phase 1: Relationship Enhancement would have trouble using the ear bug device, or parents who have significant (Child-Directed Interaction) expressive or receptive language deficits The first phase of treatment focuses on improving the quality of the relationship • Sexually abusive parents, or parents between the parent and the child. This phase engaging in sadistic physical abuse, or emphasizes building a nurturing relationship parents with substance abuse issues and secure bond between parent and child. Phase I sessions are structured so that the child selects a toy or activity, and the parent plays along while being coached by the

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therapist. Because parents are taught to follow each day to practice newly acquired skills with the child’s lead, this phase also is referred to their child. Once the parent’s skill level meets as child-directed interaction (CDI). the program’s identified criteria, the second phase of treatment is initiated. During Phase I sessions, parents are instructed to use positive reinforcement. In particular, Phase II: Discipline and Compliance parents are encouraged to use skills represented in the acronym “PRIDE”: (Parent-Directed Interaction) The second phase of PCIT concentrates • Praise. Parents provide praise for a child’s on establishing a structured and consistent appropriate behavior—for example, approach to discipline. During this phase, also telling them, “good job cleaning up your known as parent-directed interaction (PDI), crayons”—to help encourage the behavior the parent takes the lead. Parents are taught and make the child feel good about his or to give clear, direct commands to the child her relationship with the parent. and to provide consistent consequences for • Reflection. Parents repeat and build upon both compliance and noncompliance. When what the child says to show that they are a child obeys the command, parents are listening and to encourage improved instructed to provide labeled or specific praise communication. (e.g., “Thank you for sitting quietly”). When a child disobeys, however, the parents initiate • Imitation. Parents do the same thing that a timeout procedure. The timeout procedure the child is doing, which shows approval typically begins with the parent issuing the and helps teach the child how to play with child a warning and a clear choice of action others. (e.g., “Put your toys away or go to timeout”) • Behavioral Description. Parents describe and may advance to sending the child to a the child’s activity (e.g., “You’re building a timeout chair. tower with blocks”) to demonstrate interest Parents are coached in the use of these skills and build vocabulary. during a play situation where they must • Enjoyment. Parents are enthusiastic and issue commands to their child and follow show excitement about what the child is through with the appropriate consequence doing. for compliance/noncompliance. In addition, parents are provided with strategies for Parents are guided to praise wanted managing challenging situations outside of behaviors, like sharing, and to ignore therapy (for example, when a child throws a unwanted or annoying behaviors, such as tantrum in the grocery store or hits another whining (unless the behaviors are destructive child). Parents also are given homework in this or dangerous). In addition, parents are taught phase to aid in skill acquisition. to avoid criticisms or negative words—such as “No,” “Don’t,” “Stop,” “Quit,” or “Not”— Assessments and instead concentrate on positive directions. In addition to clinical interviews, PCIT In addition to the coached sessions, parents uses a combination of observational and are given homework sessions of 5 minutes

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standardized assessment measures to assess parents attending a typical community interactions between parent and child, child parenting group (Chaffin et al., 2004). behaviors, and parental perception of stress Reductions in the risk of abuse following related to being a parent, as well as parents’ treatment have been confirmed in other own perceptions of the difficulty of their child’s studies among parents who had abused behaviors and their interactions with their their children (e.g., Hakman et al., 2009; child. Assessments are conducted before, Chaffin et al., 2011). during, and after treatment. • Improvements in parenting skills and attitudes. Research reveals that parents and caretakers completing PCIT typically Effectiveness of PCIT demonstrate improvements in reflective listening skills, use more prosocial The effectiveness of PCIT is supported by a verbalization, direct fewer sarcastic growing body of research and increasingly comments and critical statements at their identified on inventories of model and children, improve physical closeness to their promising treatment programs. children, and show more positive parenting attitudes (McNeil & Hembree-Kigin, 2010). Demonstrated Effectiveness • Improvements in child behavior. A review in Outcome Studies of 17 studies that included 628 preschool- At least 30 randomized clinical outcome aged children identified as exhibiting a studies and more than 10 true randomized disruptive behavior disorder concluded that trials have found PCIT to be useful in treating involvement in PCIT resulted in significant at-risk families and children with behavioral improvements in child behavior functioning. problems. Research findings include the Commonly reported behavioral outcomes following: of PCIT included both less frequent and less intense behavior problems as reported • Trauma adaptation. PCIT is now commonly by parents and teachers, increases in referred to in the cluster of trauma- clinic-observed compliance, reductions in informed strategies. Trauma adaption to inattention and hyperactivity, decreases the model was examined in a study of PCIT in observed negative behaviors such as in meeting the needs of mother-child dyads whining or crying, and reductions in the exposed to Interpersonal Violence (IPV) by percentage of children who qualified for a reducing children’s behavior problems and diagnosis of disruptive behavior disorder decreasing mothers’ distress (Timmer, Ware, (Gallagher, 2003). Urquiza, & Zebell, 2010). • Benefits for parents and other caregivers. • Reductions in the risk of child abuse. In Examining PCIT effectiveness among a study of 110 physically abusive parents, foster parents participating with their foster only one-fifth (19 percent) of the parents children and biological parents referred participating in PCIT had re-reports of for treatment because of their children’s physically abusing their children after 850 behavioral problems, researchers found days, compared to half (49 percent) of the

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decreases in child behavior problems and • National Crime Victims Research and caregiver distress for both groups (Timmer, Treatment Center and The Center for Urquiza, & Zebell, 2005). Sexual Assault and Traumatic Stress; Office for Victims of Crime, U.S. Department • Lasting effectiveness. Follow-up studies of Justice (http://academicdepartments. report that treatment gains are maintained musc.edu/ncvc/resources_prof/OVC_ over time (Eyberg et al., 2001; Hood & guidelines04-26-04.pdf) Eyberg, 2003). • Usefulness in treating multiple issues. Adapted versions of PCIT also have Implementation of PCIT in a been shown to be effective in treating Child Welfare Setting other issues such as separation anxiety, depression, self-injurious behavior, When introducing PCIT as a referral option attention deficit hyperactivity disorder that child welfare workers may consider (ADHD), and adjustment following divorce for children and families in their caseload, (Johnson, Franklin, Hall, & Preito, 2000; administrators will want to ensure that workers Pincus, Choate, Eyberg, & Barlow, 2005). have a clear understanding of how PCIT works, • Adaptability for a variety of populations. the values that drive it, and its effectiveness. Studies support the benefits of PCIT across Training for child welfare staff on the basics genders and across a variety of ethnic of PCIT, how to screen at-risk children groups (Capage, Bennett, & McNeil, 2001; with behavior problems, and how to make Chadwick Center on Children and Families, appropriate referrals can expedite families’ 2004; McCabe, 2005). access to effective treatment options.

Recognition as an Evidence- A free online training on the fundamentals of PCIT, the “PCIT for Traumatized Children Based Practice Web Course” can be accessed from the UC Based on systematic reviews of available Davis PCIT Training Center website (http:// research and evaluation studies, a number pcit.ucdavis.edu/). This is a 10-hour web of expert groups have highlighted PCIT as course with eight separate modules that a model program or promising treatment discuss and show the basics of PCIT treatment practice, including: and three supplemental modules on cultural considerations of treatment, parent factors • The California Evidence-Based affecting PCIT provision, and strategies for Clearinghouse for Child Welfare engaging parents in treatment. Module 2, (http://www.cebc4cw.org/program/ “Overview of PCIT,” was designed to educate parent-child-interaction-therapy) professionals who work with children in the • The National Child Traumatic Stress child welfare system. This training may help a Network (http://www.nctsn.org/sites/ child welfare professional decide whether to default/files/assets/pdfs/pcit_general.pdf) refer a family to a qualified therapist for PCIT.

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Finding a Therapist confidence in, the therapist with whom they will work. Caseworkers should become knowledgeable about commonly used treatments before Some specific questions to ask a potential recommending a treatment provider to therapist regarding PCIT include: families. Caregivers should receive as much • How will the parent be involved in this information as possible on the treatment process? options available to them. If PCIT is an appropriate treatment model for a family, • What is the nature of your PCIT training? seek a provider who has received adequate When were you trained? By whom? How training, supervision, and consultation in the long was the training? Do you have access PCIT model. If feasible, both the caseworker to follow-up consultation? What resource and family should have an opportunity to materials on PCIT are you familiar with? interview potential PCIT therapists before Are you clinically supervised by (or do you beginning treatment. participate in a peer supervision group with) others who are PCIT trained? PCIT Training • Why do you feel that PCIT is the Mental health professionals with at least a appropriate treatment model for this master’s degree in psychology, social work, or child? Would the child benefit from other a related field are eligible for training in PCIT. treatment methods after they complete Training involves 40 hours of direct training, PCIT (i.e., group or individual therapy)? with ongoing supervision and consultation for approximately 4 to 6 months, working with • What techniques will you use to help the at least two PCIT cases through completion. child manage his or her emotions and Fidelity to the model is assessed throughout related behaviors? the supervision and consultation period. • Do you use a standard assessment process to gather baseline information on the Questions to Ask functioning of the child and family and to Treatment Providers monitor their progress in treatment over In addition to the appropriate training, it is time? important to select a treatment provider who • Do you have access to the appropriate is sensitive to the individual and cultural needs equipment for PCIT (one-way mirror, ear of the child, caregiver, and family. Caseworkers bug, video equipment)? If not, how do you recommending a PCIT therapist should ask plan to structure the sessions to ensure that the treatment provider to explain the course the PCIT techniques are used according to of treatment, the role of each family member, the model? and how the family’s cultural background will be addressed. Family members should • Is there any potential for harm associated be involved in this discussion to the extent with treatment? possible. The child, caregiver, and family should feel comfortable with, and have

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Conclusion References

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Schuhmann, E. M., Foote, R., Eyberg, S. M., Urquiza, A. J., & McNeil, C. B. (1996). Parent- Boggs, S., & Algina, J. (1998). Parent- child interaction therapy: An intensive child interaction therapy: Interim report dyadic intervention for physically abusive of a randomized trial with short-term families. Child Maltreatment, 1, 134–144. maintenance. Journal of Clinical Child Psychology, 27, 34–45. Acknowledgment: The original (2007) and current versions of this issue brief were Timmer, S. G., Urquiza, A. J., Zebell, N. developed by Child Welfare Information M., & McGrath, J. M. (2005). Parent- Gateway, in partnership with the Chadwick child interaction therapy: Application to Center for Children and Families at Rady maltreating parent-child dyads. Child Abuse Children’s Hospital San Diego. Contributing & Neglect, 29(7), 825–842. Chadwick authors include Daniel M. Bagner, Ph.D., A.B.P.P., Charles Wilson, M.S.S.W., Timmer, S. G., Urquiza, A. J., & Zebell, N. and Blake Zimmet, L.C.S.W. The conclusions M. (2005). Challenging foster caregiver- discussed here are solely the responsibility of maltreated child relationships: The the authors and do not represent the official effectiveness of parent-child interaction views or policies of the funding agency. The therapy. Child and Youth Services Review, Children’s Bureau does not endorse any 28, 1–19. specific treatment or therapy.

Timmer, S. G., Ware, L. M., Urquiza, A. J., & Suggested citation: Zebell, N. M. (2010). The effectiveness of Child Welfare Information Gateway. (2013). parent-child interaction therapy for victims Parent-child interaction therapy with at-risk of interparental violence. Violence and families. Washington, DC: U.S. Department of Victims, 25(4), 486–503. Health and Human Services, Children’s Bureau.

Urquiza, A. J. (2010, October). Child trauma and the effectiveness of PCIT. Presentation at the 10th Annual Conference on Parent- Child Interaction Therapy. Davis, CA.

U.S. Department of Health and Human Services Administration for Children and Families Administration on Children, Youth and Families Children’s Bureau