Infant Parent Psychotherapy: Clinical Understanding

1
Infant / Parent Psychotherapy Clinical
Understanding Treatment

• Natalie Roth, Ph.D.
• Jessica Singleton, Ph.D.

2
Choose Your Approach Based on Need

• Emotional Support (look, listen, acknowledge, and
  show compassion)
• Concrete Resources (food, housing, clothing,
  medical care)
• Developmental Guidance (basic child care routines
  and safety needs, observation of the babys
  competencies, and anticipation of new milestones)
• Advocacy (speak for those who cannot)
• Infant-Parent Psychotherapy (when support and
  guidance are not adequate)
• Weatherston, D.J. (1995). She does love me,
  doesnt she? Zero to Three, February/March, p. 8

3
Infant-Parent PsychotherapyAn Overview of
Therapeutic Approaches

• Infant-Parent Psychotherapy
• Psychoanalytically based
• Both parents and infant are the patient
• Corrective attachment experience of the
  therapeutic relationship
• Interpretation (transference, projective
  identification)
• Increasing parents self-esteem, knowledge, and
  skills

4
Infant-Parent PsychotherapyAn Overview of
Therapeutic Approaches

• Focusing on Infant Behavior
• (Terry Brazelton and colleagues)
• As part of an evaluation process (pediatric
  examination Neonatal Behavioral Assessment
  Scale, Bailey)
• Infants response to the test situation initiates
  discussion
• Examples Overstimulated baby
• At-risk attachment situations

5
Infant-Parent PsychotherapyAn Overview of
Therapeutic Approaches

• Interaction Guidance
• Focus on mothers behavior
• Establish therapeutic alliance (home visits,
  education, advice, practical help, support, and
  intervening with other agencies)
• Positive reinforcement of maternal behaviors that
  are good (videotaping and replay, then in vivo
  interaction)
• Alternate Entire Network of Family Interactions
  (the family triad)

6
Infant-Parent PsychotherapyAn Overview of
Therapeutic Approaches

• Watch, Wait Wonder
• (Elisabeth Muir)
• Parent-child interaction is port of entry
• Parent-child play time parent follows childs
  lead
• Discussion with therapist therapist follows
  parents lead

7
Infant-Parent PsychotherapyAn Overview of
Therapeutic Approaches

• Floortime
• (Stanley Greenspan)
• Technique and philosophy centered on developing
  meaningful adult/child interactions to promote
  cognitive and social/emotional development
• 5 Step technique
• Observation
• Approach- Open the Circle of Communication
• Follow the Childs Lead
• Extend and Expand
• Child Closes the Circle

8
Meta-Analysis 101

• A study of studies
• Usefulness
• Cohens d
• Effect size interpretation
• Small .00-.32
• Moderate .33-.55
• Large .56

9
The Current Meta-Analysis

• Models Identified
• Psychodynamic
• Educational
• Infant Massage
• Eclectic

• Types of Practitioners
• Psychologists
• Psychiatrists
• Social Workers
• Nurses
• Paraprofessionals

10
Outcome Measures

• Ainsworth Maternal Sensitivity Scale (Ainsworth,
  Blehar, Waters, Wall, 1978)
• AMBIANCE (Bronfman, Parsons, Lyons-Ruth, 1999)
• Chatoor Mother/Infant/Toddler Play Scale
  (Chatoor, 1986 Chatoor, Menville, Getson,
  ODonnell, 1988)

• Crittenden Experimental Index of adult-infant
  Relations (Crittenden, 1981)
• Home Observation for Measurement of the
  Environment (Bradley Caldwell, 1977)
• Klein-Briggs Observation of Communicative
  Interaction Scales (Klein Briggs, 1987)

11
Outcome Measures

• Mother-child relationship evaluation (Roth, 1961)
• NCAST Feeding and Teaching Scales (Barnard, 1989)
• Parent/Caregiver Involvement Scale (Farren et
  al., 1986)
• Parental Attitudes Toward Childrearing (Goldberg
  Easterbrooks, 1984)

• Parenting Sense of Competence Scale (Johnston
  Mash, 1991)
• Parenting Stress Index(Abidin, 1990)
• Quality of Parental Support and Parent-Child
  Interaction Observations (Erickson et al., 1985)
• Relationship Survey (Simpson, Rholes, Nelligan,
  1992)

12
(No Transcript)
13
Moderators Large Effect Sizes

• Large ES
• Mental Health Therapists
• Psychodynamic, Interaction Guidance, Massage,
  Eclectic Models
• Brief to moderate length
• Hispanic and White clients
• Parents with ltHS education

14
Infant-Parent Psychotherapy

• Attachment Perspective/Relationship based
• Selma Fraiberg/Alicia Lieberman
• Ghosts in the Nursery
• Child-parent psychotherapy

15
Infant-Parent PsychotherapyPractitioners

• Psychologists
• Psychiatrists
• Social workers
• Family therapists
• Nurses
• Child development specialists
• Occupational therapists

16
Infant-Parent Psychotherapy Major Tenants

• The attachment system is the organizer of
  childrens responses
• Problems in infancy are addressed in the context
  of the attachment relationship
• Transactional development

17
Infant-Parent PsychotherapyAssessment

• Observations include
• Parent-child interaction
• Child-examiner interaction
• Multiple settings/times
• Developmental history
• Parent report of problem
• Parents history
• Cultural issues

18
Infant-Parent Psychotherapy Key Concepts

• Kitchen therapy
• Techniques
• Behavior-based strategies
• Play
• Verbal interpretation
• Ports of Entry

• Four Modalities
• Concrete Assistance
• Emotional Support
• Developmental Guidance
• Psychodynamic Psychotherapy

19
Infant-Parent PsychotherapyPorts of Entry

• The childs behavior
• The parent-child interaction
• The childs representations
• Parental Representations
• Intertwined parent-child representations
• Parent-therapist relationship

20
Infant-Parent PsychotherapyConcrete Assistance

• Locating resources
• Providing transportation
• Advocacy
• Completing forms

21
Infant-Parent PsychotherapyEmotional Support

• Look, Listen, Acknowledge, and Show Empathy
• Awareness of the parents and childs messages

22
Infant-Parent PsychotherapyDevelopmental Guidance

• Non-didactic
• Speak through the child
• Interpret
• She loves it when you hold her like that.
• I wonder what he is saying to us now.
• Encourage play
• Model
• Encourage eye contact, smiling, waiting,
  following
• Offer suggestions

23
Infant-Parent PsychotherapyPsychodynamic
Psychotherapy

• Understanding the parents reaction to their
  child in the context of their personal history
• Include the infant
• What was it like for you when he follows you
  around?
• How was your relationship with your parent?

24
Infant-Parent PsychotherapyReview

• Emotional support, warmth, and empathy
• The infant is always present
• Point out accomplishments
• Provide parent education
• Be on time for all sessions
• Help them increase their feeling vocabulary
• Group settings are possible
• Time issues
• Provide opportunities for positive experiences
• Always remain open, curious, and reflective

25
Infant-Parent PsychotherapyAn Overview of
Therapeutic Approaches

• Parent-Child Interaction Therapy
• (Sheila Eyberg)
• Combining play therapy and behavioral techniques
• More to come

26
Parent-Child Interaction Therapy (PCIT)

• Developed by Sheila Eyberg, Ph.D. (University of
  Florida)
• For children ages 2-6 with a range of behavioral,
  emotional, and family problems (e.g. difficult
  termperament, hyperactivity, faulty social
  information processing, genetic difficulties)

27
Parent-Child Interaction Therapy (PCIT)

• Manualized (Hembree-Kigin, T. L., McNeil, C. B.
  (1995). Parent-Child Interaction Therapy. New
  York Plenum)
• Based on attachment theory and social learning
  theory
• Short-Term (10-16, 1 hr. sessions)
• Assessment-driven
• Empirically supported
• Divided into two phases
• Child-Directed Interaction (CDI)
• Parent-Directed Interaction (PDI)

28
Theorectical Foundations of PCIT

• Baumrinds Parenting Styles
• Authoritarian (high demandingness, low warmth)
• Permissive (high warmth, low demandingness)
• Authoritative (high warmth, high demandingness)
• Nurturance and firm limits are both necessary for
  healthy outcomes

29
Theorectical Foundations of PCIT

• Attachment Theory
• Focus of CDI is to restructure parent-child
  relationship to provide a secure attachment
• Asserts that sensitive and responsive parenting
  provides the foundation for the childs knowledge
  that he/she will be responded to when necessary.
• Results in more effective emotional and
  behavioral regulation

30
Social Learning Theory

• Patterson et. al (1991)
• Coercion Theory
• Behavior problems are inadvertently established
  or maintained by dysfunctional parent-child
  interactions
• Both child and parent actively engage in the
  continuation of the cycle, which is maintained
  through negative reinforcement

31
Patterson et. al (1991) Coercion Theory
Increase in Problem Behaviors
Negative Reinforcement Increases Intensity of
Behavior Over Time
Withdrawal of Parental Request
Child Problem Behaviors (Arguing, Aggression)
32
Patterson et. al (1991) Coercion Theory
Increase in Negative Behaviors
Negative Reinforcement Increases Intensity of
Behavior Over Time
Momentary Compliance from Child
Negative Parent Behaviors (Yelling)
33
Patterson et. al (1991) Coercion Theory

• Parent of children with externalizing behaviors
  have been found to be
• Power-assertive (Authoritative) and
• Lax (Permissive)
• Its this combination of intermittent
  reinforcement that produces such a strong
  reinforcement system

34
Structure of PCIT

• Child Directed Interaction (CDI)
• Teaching Session
• One Hour Session
• Parents alone
• Presentation of skills
• Rules
• Reasons
• Examples
• Modeling/demonstration
• Role-play with parents

35
Structure of PCIT

• CDI
• Dont Rules
• Follow the Childs Lead
• No Commands (attempt to lead risk negative
  interaction)
• No Questions (are often hidden commands, take
  lead from the child, can suggest disapproval, can
  suggest not listening)
• No Criticism (Points out mistakes rather than
  correcting them, lowers self-esteem, creates
  unpleasant interaction)

36
Structure of PCIT

• CDI
• Do Rules
• PRIDE
• Praise (Labeled Thanks you for using your
  indoor voice)
• Reflect (Allows child to lead shows that parent
  is listening shows that parent understand
  improves speech)
• Imitate (Lets the child lead teaches parent
  how to play, show approval of childs activity
  teaches child how to play with others)
• Describe (sportscaster, child leads, child
  knows youre paying attention, shows interest and
  approval, teaches vocabulary, holds childs
  attention to the task)
• Enthusiasm! (Lets the child know you enjoy
  being with them, makes the play more fun, adds
  quality of warmth)

37
Structure of PCIT

• CDI
• IGNORE (talking to the wall) annoying, obnoxious
  behavior use STRATEGIC ATTENTION to increase
  desireable behavior
• STOP THE PLAY for dangerous or desctructive
  behavior and use safe discipline technique

38
Structure of PCIT

• CDI
• Suggested Toys
• Creative constructional toys (blocks, Mr. Potato
  Head, Toy farm w/ animals, crayons and paper)
• Avoid
• toys that encourage rough play
• toys that lead to aggressive play
• toys that require limit setting (scissors)
• toys that discourage conversation
• toys that lead parent or child to pretend they
  are someone else

39
Structure of PCIT

• Coaching is the primary method of parent training
  (bug in the ear)
• allows immediate feedback
• prevents miscommunication
• provides support
• enables therapist to calm and reassure parent if
  needed
• provides opportunity for reframing parent
  attributions

40
Structure of PCIT

• Common Coaching Statements
• Labeled Praises
• Good ignoring!
• Gentle correctives
• Oops, a question.
• Directives
• Can you reflect that?
• Observations
• He quiets down when you talk softly like that.

41
Structure of PCIT

• Weekly Coaching Sessions
• Homework
• Special Time
• 5-10 Minutes/day
• Reduces resistance
• Able to sustain quality
• Hart to concentrate for longer
• Reduces likelihood of problems
• Doesnt have to be rigid
• Not contingent on behavior
• Ending Im going to pick up the toys now. You
  can help me if you want

42
Structure of PCIT

• Mastery of CDI
• DPICS (Descriptive Parent Child Interaction)
  coding for 5 minutes
• 10 labeled praises
• 10 behavior descriptions
• 10 reflections
• No commands, questions, or criticisms

43
Structure of PCIT

• Parent-Directed Interaction (PDI)
• Concentrates on
• Issuing clear commands
• Providing consistent consequences for both
  compliance (labeled praise) and noncompliance
  (time-out procedure)

44
Structure of PCIT

• PDI
• Effective Commands
• Direct (telling, not asking)
• Positive (what to DO, not stop doing)
• Single (one at a time)
• Specific (not vague)
• Age-appropriate
• Given in a normal tone of voice
• Used only when really necessary
• Explained after obeyed

45
Structure of PCIT

• Command

No Opportunity
Obey
Disobey
Labeled Praise
Whoops! (Start Over)
Back to Play!
46
Structure of PCIT

• If you dont (original command), youll have to
  do to the time out chair

Obey
Disobey
Labeled Praise
Back to Play!
47
Structure of PCIT

• The Chair
• Child stays on chair 3 min. plus 5 seconds quiet

Are you ready to (obey original command?)
Doesnt Stay on Chair
Obey
Praise
48
Structure of PCIT

• Child Gets Off Chair

You got off the chair before I said you could.
If you get off again, youll go to the Time Out
Room
Child gets off again
Back to Chair
Child goes to time out room 1 minute of quiet
49
Structure of PCIT

• The Chair
• Child stays on chair 3 min. plus 5 seconds quiet

Are you ready to (obey original command?)
Obey
Acknowledge
50
Structure of PCIT

• Command
• Obey
• Praise
• Back to Play!!

51
Structure of PCIT

• House Rules
• Standing Commands
• No aggressive behavior
• No destructive behavior
• Procedure
• Label behavior for child
• Explain rule to child
• No chair warnings
• Its over when time is up

52
Structure of PCIT

• Public Misbehavior
• Procedures (time out can travel)
• Make plan before leaving home
• Describe desired behavior
• Take along time out chair (towel)
• Discuss back-ups

53
Structure of PCIT

• Last session
• Posttreatment-evaluation
• Discussion and Feedback
• Perception of reasons for change
• review measures
• show pre and post video tape
• Address remaining concerns
• Schedule boosters