ParentChild Interaction Therapy: An EvidencedBased Treatment for HighRisk Families

1
Parent-Child Interaction Therapy An
Evidenced-Based Treatment for High-Risk Families

• Robin H. Gurwitch, PhD
• Cincinnati Childrens Hospital Medical Center
• Beverly W. Funderburk, PhD
• Melanie M. Nelson, PhD
• University of Oklahoma Health Sciences Center
• 17th National Conference on Child Abuse and
  Neglect
• March 30-April 4, 2009
• Atlanta, Georgia
• Robin.Gurwitch_at_cchmc.org

2
Please do not reproduce without permission of the
authors

• Thank you

3
Acknowledgements

• Sheila Eyberg, Ph.D., and Steve Boggs, Ph.D.,
  University of Florida
• University of Oklahoma Health Sciences Center
  PCIT Training Team
• Mark Chaffin, Ph.D., Dolores BigFoot, Ph.D.,
  Vicki Cook, M.Ed., Elizabeth Bard, M.Ed, Amanda
  Pollock, M.A., L.P.C., David Bard, Ph.D., Janelle
  Shanley, Ph.D., Darden White, B.A., Julie Jones,
  M.A., L.P.C., Stephanie Kramer, M.A., L.P.C., and
  Carol McCoy, M.A., L.P.C.

4
What is Parent-Child Interaction Therapy (PCIT)?

• Developed by Dr. Sheila Eyberg for families of
  children aged 2-7 with disruptive behavior
  disorders
• Combines elements of attachment and learning
  theories, systems theory, and behavior
  modification
• Strong Evidenced-based treatment with over 90
  randomized controlled trials
• Short-term avgerage of 13 weekly sessions
• Direct coaching of parent with child
• Gives parent responsibility, not blame

5
Key Features

• Emphasizes restructuring the parent-child
  interaction by teaching specific parenting skills
• Involves direct practice and coaching of skills
  in sessions
• Establishes daily positive parent-child
  interaction time
• Teaches generalization of skills
• Implemented with parent and child together
• Treatment manual used
• Not time-limited
• Assessment driven

6
Eyberg Child Behavior Inventory-Intensity Scale
ES -3.41
n61 p lt .0001
7
Child Behavior Checklist Externalizing Scale
(T-score)
ES -2.11
n61 p lt .0001 for all pre-post comparisons
8
Observed Child Compliance
All subjects (n62) p lt .001 for all comparisons
9
Parent Stress Index Short Form (mother report)
p lt .0001 for all pre-post comparisons
n 60
10
Beck Depression Inventory (mother report)
p lt .0001 for pre-post comparison
n 61
11
National research findings

• Improvements in child behavior
• Improvements in parenting skills and attitudes
• Generalization to school
• Generalization to untreated siblings
• Reductions in the risk of child abuse
• Benefits for parents and other caregivers

12
What does PCIT involve?

• 12-14 weekly therapy sessions (average)
• 2 phases of treatment
• Teaching sessions (1 per phase)
• Coaching sessions (3 or more per phase)
• Homework
• Mastery
• Generalization
• Graduation

13
Assessment in PCIT

• Intake Assessment
• Assessing child behavior
• Eyberg Child Behavior Inventory (ECBI)
• Sutter-Eyberg Student Behavior Inventory (SESBI)
• CBCL
• PSI

14
Balances Two Factors
1. Positive Interaction with the Child Increase
positive attention Decrease negative
attention Addressed directly in the Child
Directed Interaction (CDI) 2. Consistent Limit
Setting Consistency Predictability Follow-Through
Addressed in the Parent Directed Interaction
(PDI) also in CDI
15
Goals of Child Directed Interaction

• Strengthen parent-child relationship
• Improve childrens willingness to accept limits
• Improve childrens self-esteem
• Improve frustration tolerance
• Improve anger management
• Increase parent confidence
• Teach children prosocial behavior
• Improve childrens speech and language
• Decrease negative behaviors

16
CDI Skills

• Parents are taught to
• Follow the childs lead
• Praise
• Reflect
• Imitate
• Describe
• Enthusiasm

17
CDI Skills

• Parents are taught to avoid
• Leading the play
• Commands
• Questions
• Criticism

18
Child Directed Interaction

• IGNORE annoying, obnoxious behavior
• STOP THE PLAY for dangerous or destructive
  behavior

19
CDI Mastery Criteria

• 10 Labeled Praises
• 10 Behavioral Descriptions
• 10 Reflections
• Less than 3 total of Questions, Commands, and
  Criticisms
• In one 5-minute observation

20
Goals of Parent Directed Interaction

• Improve parents ability to
• Set appropriate limits
• Implement contingency management
• Be consistent and predictable in their discipline
• Problem-solve in discipline situations
• Use good reasoning skills
• Improve childrens compliance
• Decrease negative child behaviors

21
Features of the Parent Directed Interaction (PDI)

• Command traininggiving good instructions
• Contingent praise or consequence (time-out)
• Gradual generalization from clinic minding
  exercises to real life discipline
• Planned responses to
• Refusing negative consequence
• House Rules
• Behavior disruptions in public settings

22
PDI Skills Criteria

• At least 4 commands in 5-minute observation
• At least 75 commands effective
• At least 75 correct follow through
• Ability to correctly follow discipline flow chart
  in role plays

23
Termination

• Collect post-treatment measures!
• Review progress (use summary sheet, ECBIs, tapes,
  etc)
• Lots of praise
• Schedule booster or follow-up as needed
• Maintain for 3-6 months
• Use of discipline ladder
• Managing future behavior problems

24
1- to 2-year follow-up

• Followed a sample of 13 PCIT completers at 1- and
  2-year post-treatment
• Treatment was time-limited
• Demographic characteristics
• 100 boys 84 Caucasian
• Mean age 4.7
• Median income 15K

Eyberg, Funderburk, Hembree-Kigin, McNeil,
Querido, Hood (2001)
25
CBCL Externalizing Scale
Eyberg, Funderburk, Hembree-Kigin, McNeil,
Querido, Hood (2001)
26
Observed Compliance
Eyberg, Funderburk, Hembree-Kigin, McNeil,
Querido, Hood (2001)
27
Observed Child Negative Behavior
Eyberg, Funderburk, Hembree-Kigin, McNeil,
Querido, Hood (2001)
28
Observed Parent Negative Behaviors
Eyberg, Funderburk, Hembree-Kigin, McNeil,
Querido, Hood (2001)
29
4- to 6-Year Follow-up

• 23 families (out of 50 completers)
• 70 boys
• 83 Caucasian
• Mean age at pre-treatment 5.0
• Mean Hollingshead Index 40

Hood Eyberg, 2002
30
ECBI Intensity Scale
6 children above the cutoff at long- term
follow-up
1.43
Hood Eyberg, 2003
31
PCIT in families with a history of abuse
32
Physical Abuse ? Behavior Problems

• Identification with the parent
• Modeling parental behavior
• Inadequate nurturance reduces empathy and
  increases aggression
• Lack of limits leads to problems accepting
  structure

33
Behavior Problems ? Physical Abuse

• High activity level leads to exhausted parents
  who give up on supervision
• Normal parenting techniques unsuccessful in
  managing behavior
• Hyperactive behavior results in high degrees of
  parental stress

34
Physically Abusive Parents

• Report high levels of child behavior problems
• Less awareness of child positive behaviorsfew
  positive interactions
• Inappropriate expectations for child
• High endorsement of corporal punishment
• Difficulty discriminating levels of misbehavior

35
Rationale for Applying PCIT to Physical Abuse

• Physical abuse usually occurs in the context of
  discipline.
• Physically abusive parents perceive their
  children as behaviorally disordered.
• Parent skills taught in PCIT are consistent with
  the intermediate goals for physical abuse
  treatment (ultimate goal is to stop abusive
  behavior)

36
Pre-treatment Scores

• Average 2 prior physical abuse reports
• 39 had severely beaten a child
• Average 2 prior neglect reports
• Diagnostic Interview (DIS)
• 32 drug or alcohol
• 39 probably antisocial personality
• Beck Depression Inventory II
• 22 moderate or higher depression score (gt19)
• No differences between groups on demographic or
  test scores

37
PCIT with Abusive Parents

• With abusive parents, some models work better
  than others. A good model can even work better
  than more intensive services (Chaffin, et al.,
  2003)

38
Study Conclusions

• PCIT is effective in reducing future child
  physical abuse reports relative to standard
  services
• PCIT outcomes can be obtained by therapists with
  a wide range of prior experience and training, if
  adequately trained in PCIT.
• PCIT is more expensive, but the cost to avert a
  single re-report is not unreasonable

39
Challenges

• Children may not be in the parents home
• Limited opportunity to practice skills outside of
  session
• Dont want to discipline during session/visits
• Treatment tends to last longer
• Treatment is often mandated
• Parents may abuse drugs/alcohol

40
PCIT in families of children with prenatal
substance exposure (PSE)
41
Caregivers of Children with PSE

• May be biological, foster, or adoptive
• Perceptions of the child are negative
• Parenting satisfaction is lower than those w/o
  substance exposure
• Higher levels of parenting stress
• Increased risk for attachment problems as many
  unrewarding child behaviors are associated with
  prenatal substance exposure

42
Rationale for Applying PCIT to families of
children with PSE

• Increased risk for behavioral difficulties as
  secondary disabilities
• Increased risk for parenting stress
• Increased risk for failed foster care placement
• OR
• Increased risk for substance abuse relapse

43
Rationale for Applying PCIT to families of
children with PSE

• Parents perceive children as behaviorally
  disordered solely due to drug/alcohol exposure
• They are more receptive to an approach offering
  effective behavior management
• Needs of caretakers with children considered at
  risk are consistent with the skill training
  focus of PCIT

44
Population

• Children (n38)
• Diagnosed with FAS/ARND or other substance
  exposure
• Functioning at a minimum of 30 months of age in
  cognitive development
• Between 2½ and 7 years of age
• Parent/Caregiver
• gt65 IQ based on KBIT

45
Rationale for Group Format

• Too many referrals, too few therapists
• Attrition
• Time efficiency
• Cost efficiency
• Vicarious learning opportunities
• Increased generalization opportunities
• Feedback and praise from others
• Support group for caregivers

46
Results of Group PCIT (n38)
47
New Directions in PCIT research

• Children with History of Physical Abuse
• Children with FASD/Substance Abuse Exposure
• Children with history of trauma
• Group PCIT Format
• Older Children (7-12)
• Children with Developmental Disabilities
• Children with Social Anxiety
• Children in Foster Care
• Children with history of domestic violence
• Children who are reunifying with parents
• Native American Families
• Mexican-American Families

48
PCIT Training Programs

• Graduate programs in clinical psychology
• University of Florida
• 1 week, for academics and researchers
• University of Oklahoma
• For community providers
• 7 week-days, plus 6-months weekly consultation
• Also 1-year practicum placements and seminar
• University of California-Davis
• For community agencies
• 1-year program