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Parent Child Interaction Therapy:

An Introduction to an Evidenced-based Practice for Treating Children with Disruptive

Behavior Problems

Tennessee Psychological Association

Annual Convention| Nashville, TN

October 30, 2010

Presenter Contact Information & Affiliations

John-Paul Abner, Ph.D.

[email protected]

Christina Warner-Metzger, Ph.D.

[email protected]

Acknowledgements• Dr. Sheila Eyberg

• Centers of Excellence for Children in State Custody

– Dr. Janet Todd

– Dr. Michele Moser

– Dr. Colby Butzon

• Governors Office of Children’s Care Coordination and the Bureau of TennCare

University of Tennessee | East Tennessee State University

http://www.uthsc.edu/

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PCIT Internationalwww.pcit.org

University of Florida Labhttp://pcit.phhp.ufl.edu/

UTHSC PCITwww.uthsc.edu/pcit


Target Population

• Disruptive Behavior Disorders (DBDs) most common referral for children

– Oppositional Defiant Disorder (ODD)

– Conduct Disorder (CD)

– Attention-Deficit/Hyperactivity Disorder (ADHD)

• Several factors contribute to development of DBDs


Target Population (cont.)

• Examples of disruptive behaviors

– Whining

– Noncompliance

– Lying

– Hyperactivity

– Verbal aggression

– Classroom conduct problems


– Physical aggression

– Cruelty to animals

– Destructive behavior

– Fire-setting

– Stealing

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Target Population (cont.)

• Other behaviors

– Bonding in blended families

– Self-injurious behavior

– Abuse sequela

– Low self-esteem

– Sad mood

– Perfectionism


– Developmental delays

– Generalized anxiety

– Post-divorce adjustment

– Separation anxiety

Behaviorism Meets Tradition

• Behavioral Theory (Greco, Sorrell, & McNeil, 2001)

• Play Therapy (Virginia Axline)

– Child-focused

– Therapist interacting with child

• Limitations

– Children bond to therapist, but not caregiver

– No measurable change in children’s behavior at home


A Mentor’s Work

• Based largely on work of Constance Hanf (1969)

– Targeted oppositional behavior of young children

– Two-stage model

• Stage 1: Differential reinforcement

• Stage 2: Clear directions, consistent rewards, and time-out for noncompliance

– Worked with parent-child dyad

– Live coaching


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Enter Eyberg

• Eyberg’s PCIT

– Added Baumrind’s (1967, 1991) parenting styles theory to Hanf’s approach

– Incorporated attachment and social learning theory

– Taught parents specific behavioral play skills (PRIDE Skills)


Parenting Styles

• Baumrind (1967, 1991) & Maccoby & Martin (1983)

– Two dimensions of parenting

• Responsivity (warmth)

• Demandingness (control)

– Results in 4 Parenting Styles


Authoritarian Authoritative

Rejecting-

Neglecting

Permissive

Lo Responsivity Hi

Dem

an

din

gn

ee

ss

Lo

Hi

More Theory

• Attachment Theory

– Sensitive and warm parenting leads to secure attachment

– Insecure attachment• Related to child aggressive behavior, low social competence, poor

coping skills, low self-esteem, and poor peer relationships

• Related to increased maternal stress and occurrence of CAN

• Social Learning Theory

– Emphasizes contingencies that shape dysfunctional interactions of parents/children

– Patterson’s Coercion Theory (next page)


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Patterson’s Coercion Theory

• (Patterson 1982, 2002; & colleagues, 1992)


Child wins!

Child

noncompliance

Parent gives

command

Nonresponsive

discipline

Or the Parents Respond Aggressively


Parent wins!

Child

noncompliance

Parent gives

command

Parent

responds

aggressively

EBPs

• Evidence-Based Practices (EBPs)

– Use best evidence available & consult with client to determine which treatment option is best for them

– Treatments validated by some form of documented scientific evidence

– What counts as “evidence” varies

– But not based on tradition, convention, belief, or anecdotal evidence alone


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Efficacy of PCIT

• Statistically and Clinically Significant

– improvements in the interactional style of parents

– improvements in the behavior problems of children at home and at school

– parents report less personal distress and more confidence in their ability to control their child’s behavior

– generalizes to other family members, including siblings


Empirically-Support Treatment

• Named one of two “well-supported and efficacious treatments for child abuse” (U.S. Department of Justice – Office for Victims of Crimes)

• Kaufman Best Practices Project and National Child Traumatic Stress Network “supported and probably efficacious”– http://www.chadwickcenter.org/kauffman.htm

– http://www.nctsnet.org/


Pre/Post Treatment Video


http://www.chadwickcenter.org/kauffman.htm

http://www.nctsnet.org/

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ECBI Intensity Scale1 – 3 Year Follow-Up

120

130

140

150

160

170

180

190

Pre-treatment Follow-up

Inte

nsit

y S

co

res Dropouts

Completers

p < .01

Boggs et al., 2004

Evidence of Effectiveness, cont.

• Father participation in treatment may not affect immediate treatment outcome, but may help to maintain the beneficial effects of PCIT (Bagner & Eyberg, 2003)

• Abusive parents completing PCIT had a 19% re-report for physical abuse compared with 49% of parents assigned to a standard community group (Chaffin, et al., 2004)


Evidence of Effectiveness, cont.

• 1 & 2 year FU found tx gains maintained for standard and abbreviated PCIT by measure of parent reports and independent observations (Nixon, et al., 2004)

• 6 year FU found tx gains maintained according to mothers’ reports (Hood & Eyberg, 2003) (graph next slide)


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ECBI Intensity Scale~ 4-6 Year Effect Size

100

110

120

130

140

150

160

170

180

190

200

Pre Post 4-6 Year

Follow-Up

Inte

nsit

y S

co

re

1.43

Hood & Eyberg, 2003

Factors Increasing Effectiveness


PARENT FACTORS

FAMILY FACTORSCHILD FACTORS

Average IQ

Strong Motivation

Age 2-7

Good receptive

language skills

Good marital

adjustment

Extended family

support

Factors Decreasing Effectiveness


Severe marital

discord

Extended family

support

Under age 2

over age 7

PDD

PARENT FACTORS ID

Severe

psychopathology

Active substance

abuse

Court-ordered/

unmotivatedCHILD FACTORS FAMILY FACTORS

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PCIT withDiverse Populations

• PCIT has been shown to be effective for children with

– Comorbid DBD and ID (Bagner & Eyberg, 2007)

– Developmental disabilities, with little modification (receptive language must be >2 years old) (McDiarmid & Bagner, 2005)

– Autism Spectrum Disorder (Masse, McNeil, Wagner, & Chorney, 2007; Solomon, Ono, Timmer, & Goodlin-Jones, 2008)

– Separation Anxiety Disorder (Pincus, Eyberg, & Choate, 2005) (Bravery-Directed Interaction)


Additional Populations/Settings

• Adaptations for Mexican-Americans: GANA

• Evidence for generalization to the school setting

• Foster parent training


Tenets of PCIT

• Structure of PCIT

– Geared toward ages 2-7 years

– Children with disruptive behaviors

– 12-20 sessions

– Live coaching

• One-way mirror

• Bug-in-the-ear

– Mastery-based


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Ignore the Person Behind the Glass (okay, not really)

• Therapist as a Coach

– Coaches parent in using techniques during interaction with child

– Therapist uses same PRIDE skills to encourage learning in parents

– Immediate feedback

– Consistent delivery

– Shape parent’s behavior with practice


One Step at a Time

• Two stage process

– Stage 1: Child-Directed Interaction (CDI)

• Relationship enhancement phase

• Create mutually rewarding relationship

• Decrease the “I love my child, I just don’t like them very much” syndrome

– Stage 2: Parent-Directed Interaction (PDI)

• Discipline phase

• Consequences for behavior


CDI

• The Setting

– Preferably plain room, with few distractions

– Parent and child at table in room

– 2-3 appropriate toys

– Parent has bug-in-the-ear

– Therapist (“coach”) watches through one-way mirror


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Necessary Equipment

• Bug-in-the-ear devices

• One-way mirror (or closed circuit viewing)

• Audio from therapy room to observation room

• Time out room (or swoop & go)

• Video camera and tapes

• Appropriate PCIT toys


One-Way Mirror Set-up


Family’s View

Therapist’s View

Audio Equipment


Microphone in

therapy room

Attached to speaker

in observation room

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Bug-in-the-Ear Devices


Therapist’s

Speaker/Microphone

Client’s

earpiece

Pulling It All Together

Centers of Excellence for Children in State Custody

Promotional Video


CDI Teach

• Therapist teaches parent the CDI skills (PRIDE and selective attention)

• Uses modeling, role-playing, and homework

• Weekly behavioral homework

– Explain Special Time

– Appropriate Toys

– Special Time is NOT a privilege


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The Don’t Skills

• Avoid using these during Special Time

– Commands

– Questions

– Criticisms


Commands• Definition: directs the vocal or motor behavior

of the child

• Commands lead the play

• Commands can lead to unpleasant interactions if child disobeys

• Two types of commands

– Direct: “Sit down” “Put that away”

– Indirect:

• “Why don’t you sit here?

• “Let’s clean up the room.” University of Tennessee | East Tennessee State University

Questions

• Definition: verbal inquiries that request an answer but do not suggest that a behavior is to be performed

• May have a rising inflection at the end

• Leads the play instead of following it

• Questions are often hidden commands or suggestions

• May seem like you aren’t listening or disagree with the child

• May suggest disapprovalUniversity of Tennessee | East Tennessee State University

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Criticisms

• Definition: disapproval of the child or the child's attributes, activities, products, or choices

• Sarcastic or rude speech

• Doesn’t work to decrease bad behaviors (actually might increase them!)

• May lower the child’s self-esteem

• Creates an unpleasant interaction


The Do (PRIDE) Skills

• Use the following during Special Time

– Praise

– Reflect

– Imitate

– Describe

– Enthusiasm!!


Labeled Praise

• Definition: positive evaluation of a specific behavior, activity, or product of the child

• Praise appropriate behavior

• Causes the behavior to increase

• Lets the child know what you like

• Increases the child’s self-esteem

• Adds to warmth of the relationship

• Makes both parent and child feel goodUniversity of Tennessee | East Tennessee State University

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LP Examples

• “That’s terrific counting”

• “I like the way you are playing so quietly”

• “You did a nice job building the wall”

• “Your design is pretty”

• “Thank you for showing the colors to me”


Reflections

• Definition: statement that has the same meaning as the child verbalization

• Shows the child you are really listening

• Demonstrates acceptance and understanding of the child

• Improves child’s speech

• Increases verbal communication


RF Examples

• Child: “I made a star.”

• Parent: ”Yes, you made a star.”

• Child: “I have a choo-choo.”

• Parent: “You have the train.”


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Imitation

• Definition: mimicking the child’s behaviors at a developmentally appropriate level

• Lets child lead

• Approves child’s choice of play

• Shows child that you are involved

• Teaches child how to play with others (e.g. basis of taking turns)

• Tends to increase the child’s imitation of what you do


Imitation Examples

• Child: “I’m putting baby to bed”

• Parent: “I’ll put sister to bed, too” (Parent puts the sister to bed)

• Child: (Child draws a sun)

• Parent: (Parent draws a sun in their

picture)


Behavioral Descriptions• Definition: non-evaluative, declarative statements

describing the child’s ongoing or immediately completed observable verbal or nonverbal behavior

• Describe appropriate behavior, shows interest

• Allows child to lead

• Teaches concepts, models speech

• Holds child’s attention

• Organizes child’s thoughts about play


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BD Examples

• “You picked up an orange block.”

• “You are making a tower.”


Enthusiasm

• Let’s child know that you enjoy spending time with them.

• Increases the warmth of play

• Includes positive touch


I’m Not Looking!

• Selective Attention (Ignoring)

– Distinguishes attention given for positive vs. negative behaviors

– Behavior likely to increase before decreases (extinction)

– Decreases minor annoyances

– Ignore every occurrence

– Do not ignore dangerous or destructive behavior


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I’m Looking!!!!!!!!!!!

• Strategic Attention

– Desirable or prosocial behaviors

– Praise and attention


Ignoring Examples

• Child: (Whining) I want the toy you have.

• Parent: (Continues to play with toy)

• Child: (Hits parent)

• Parent: (Ends Special Time)


CDI Mastery Criteria

• 10, 10, & 10

– 10 Labeled Praises

– 10 Behavioral Descriptions

– 10 Reflections (given opportunity)

• No more than 3 combined

– Questions

– Commands

– CriticismsUniversity of Tennessee | East Tennessee State University

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Special Time

• What is it?

– 5-minute daily home practice

• Where is it?

– May start at a table, but should follow child’s play within the room

– Somewhere free from distractions

• When is it?

– At the same “event” time each day

– Parent watches clock for start/end timeUniversity of Tennessee | East Tennessee State University

Appropriate Toys for Special Time

• Construction toys

• Creative toys

• Non messy art activities (crayons, etc.)

• Playskool barns, house, etc.


Toys to avoid during CDI

• Board games, puzzles

• Pretend talk toys

• Toys that encourage rough/

aggressive play

• Toys that encourage messy play


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Beginning & EndingSpecial Time (CDI)

• To Begin

– “We’re going to have special time now. You have to play gently with the toys. There’s no hitting and there’s no hurting. You can play with any of these toys and I will play with you.”

• To End

– “Special time is over. I am going to clean up. You can help me if you want.” (praise if child helps)• OR “You can continue playing, but I have some other things that I

have to do now.“ (leave the table and begin doing something else)


CDI Video Demonstration

• Colby and 3yo girl


Time to Play

• Parent

• Child


• Pick a toy

• Role play for 5 minutes each in each role

• Child misbehaves in final minute on the cue of the presenters

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Measuring Behavioral Change

• Dyadic Parent-Child Interaction Coding System (DPICS)

– Systematic coding of parent verbalizations during interaction with child, as well as physical positives and negatives

• Time points

– Baseline (pre-treatment)

– Beginning of each session

– Post-treatment


CDI Coding Sheet DPICS III (v3.08)

Child’s Name Date Caregiver: Mother Session: Intake Father CDI # Other: PDI # Final session

Positive Tally Codes Total Mastery

Talk (TA) (ID +AK)

___

Behavior Description (BD) 10

Reflection (RF) 10

Labeled Praise (LP) 10

Unlabeled Praise (UP) ___

Avoid Tally Codes Total Mastery

Question (QU)

≤3 Commands (DC+IC) DC IC

Negative Talk (NTA) (CR+ST)

Positive Circle One (1 = Very Low; 5 = Very High)

Imitate 1 2 3 4 5

Use Enthusiasm 1 2 3 4 5

Ignore Disruptive Behavior 1 2 3 4 5

Other (Specify)

Child Behavior Measures

• Required

– Eyberg-Child Behavior Inventory (ECBI)

– DPICS

• Recommended

– Sutter-Eyberg Student Behavior Inventory – Revised (SESBI-R)

– Behavior Assessment System for Children (BASC-2)

– Parenting Stress Inventory (PSI) (available in short form)

• Free Screening Measure

– NICHQ Vanderbilt Assessment Scale – Parent

and Teacher Informant


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PCIT International Training Standards

• Masters degree or higher in a mental health field and licensed (or supervised by a licensed individual trained in PCIT)

• Minimum 40 hours of direct training with ongoing supervision and consultation for approximately 4 to 6 months

• Complete a minimum of 2 cases as primary therapist or co-therapist

• Fidelity of model and mastery of skills assessed throughout learning sessions, supervision, and consultation phases


Recommendations for Optimal Training

• A minimum of 2 clinicians within a single agency trained at one time

• Identify 2 or 3 families as possible PCIT clients prior to initiating training

• Weekly supervision initially that tapers to no less than monthly through completion of 2 cases

• May have in-home adjunct services, but must have in-clinic services


Why This Training Model?PRACTITIONER TRAINING OPPORTUNITY

TRAINING

COMPONENT

KNOWLEDGE DEMONSTRATE

SKILLS

ACTUALLY USE

SKILLS

Theory Discussion 10% 5% 0%

Demonstrate in

Training

30% 20% 0%

Practice & Feedback

in Training

60% 60% 5%

Coaching in

Actual Practice

Setting

95% 95% 95%


Source: Joyce & Showers, 2002

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Final Questions/Comments

• Everyone did a very nice job of sitting quietly in their chairs.

• You also did a fantastic job participating today.


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