Parent Child Interaction Therapy (PCIT)

Parent ChildInteraction Therapy(PCIT) The Future of School Psychology Task Force on Family-School PartnershipsKathryn Woods, Stephanie Bieltz, and Amanda Clinton

Definition PCIT is a short-term, empirically validated intervention that is designed for families with young children. This form of treatment may be used for externalizing and internalizing problems and a broad range of behavioral, emotional, and developmental problems exhibited in childhood. See PCIT Handout 1 for More Information

Rationale for a Multi-Tiered Approach to Family-School Partnerships • Family-school partnerships provide a context for families and educators to collaboratively identify and prioritize concerns across a continuum of opportunities and intensities • Prevention and intervention efforts and supports are delivered toward a universal and targeted audience • A multi-tiered approach enables families and educators to provide services based on a student’s responsiveness to previous preventions, interventions, and supports See PCIT Handout 2 for More Information

Explanation for a Multi-Tiered Approach to Family-School Partnerships • Provides various levels of family-school supports based on a student’s identified need and responsiveness to previous efforts • Universal – Family-school collaboration provided to support all students and families (e.g., 4 As, Parent-School Collaboration, Parent Involvement, Parent Education) • Targeted – Family-school collaboration provided to support identified students and families unresponsive to previous universal efforts (e.g., Parent Education and Intervention, Parent Consultation) • Intensive – Family-school collaboration provided to students and families unresponsive to previous targeted efforts (e.g., Parent Consultation [conjoint behavioral consultation] and Parent Intervention)

The Multi-Tiered Approach to Family-School Partnerships Tier 3: Intensive, Individual Interventions Individualized supports for families and students unresponsive to the first two tiers (e.g., Parent Consultation [conjoint behavioral consultation] and Family Intervention) Tier 3 1-7% Tier 2: Targeted Group Interventions Specific preventions and remedial interventions for targeted groups of families and students identified as “at risk” and unresponsive to the first tier (e.g., Parent Training and Intervention, Parent Consultation) Tier 2 5-15% Tier 1: Universal Interventions Engaging all families as collaborative partners (e.g., 4 As, Family-School Collaboration, Parent Involvement, Parent Education) Tier 1 80-90%

Rationale for Using PCIT • Early intervention is critical to prevent negative developmental trajectories and outcomes • Unlike other techniques used to improve child behavior, PCIT emphasizes a comprehensive treatment approach that is focused on increasing positive behavior, decreasing negative behavior, and improving the parent-child relationship (McDiarmid & Bagner, 2005) • Parent-child relationships are at the heart of many intervention efforts and intervention efforts that focus on improving this relationship enable families to interact with their children and achieve satisfying relationships and positive outcomes for children and their families for years to come (Epps & Jackson, 2000) See Overview Module for More Information on Partnering with Families

PCIT Research • Research examining the effectiveness of PCIT has found: • Statistically and clinically significant improvements in child disruptive behaviors and noncompliance • Treatment effects that generalize to home, daycare, preschool, early elementary classroom settings, and untreated siblings • Significant improvements in parent reported activity and stress levels, child internalizing problems, and self-esteem • High degree of participant satisfaction • Clinically significant improvements maintained at one and two-year follow-up evaluations See PCIT Implementation Guidelines for Factors that Influence the Effectiveness of PCIT

Treatment Goals • Goals for treatment include: • An improvement in the quality of the parent-child relationship • An increase in parenting skills • An increase in child prosocial behaviors • A decrease in child behavior problems • A decrease in parenting stress (Hembree-Kigin & McNeil, 1995)

Steps in PCIT • Step 1: Pretreatment Assessment of Child and Family Functioning and Feedback • Step 2: Teaching Behavioral Play Therapy Skills • Step 3: Coaching Behavioral Play Therapy Skills • Step 4: Teaching Discipline Skills

Steps in PCIT cont. • Step 5: Coaching Discipline Skills • Step 6: Posttreatment Assessment of Child and Family Functioning and Feedback • Step 7: Boosters (Information on steps and session content gathered from Hembree-Kigin & McNeil, 1995)

Session #1 - Intake • Average Length: 1-2 Sessions • Process: • Information is gathered on concerns, developmental history, family functioning, and family stressors • Formal testing is conducted which will serve as a baseline measure of a child’s behavior and parenting skills • Therapist observes and may videotape how the parent and child interact with one another • Feedback on these interactions will be provided during the next session See PCIT Implementation Guidelines for More Information on PCIT Sessions

Session #1 – Intake • Process cont.: • Information is also collected regarding the family’s experience using time-out • Time-out is described in later sessions so it is important to inform the family that the time-out that will be described is different from the one that may have been used unsuccessfully in the past • Feedback regarding assessment results and treatment planning is provided • Preliminary feedback on observations is discussed along with results from formal testing • Parents are asked why they believe their child is experiencing problems • Therapist tries to reduce any feelings of guilt the parents may have for their child’s behavior problems while also encouraging them to take responsibility for successfully resolving them

Available Resources • Assessment tools that may be used during intake: • Parent Report Measures: • Child Behavior Checklist – Parent Form • Eyberg Child Behavior Inventory • Parenting Stress Index • Social Skills Rating System • Conners Parent Rating Scale – Revised • Vineland Adaptive Behavior Scales • Childhood Autism Rating Scale • Minnesota Multiphasic Personality Inventory – 2 • Beck Depression Inventory See PCIT Handout 3 for References

Available Resources cont. • Assessment tools that may be used during intake: • Teacher Report Measures: • Sutter-Eyberg Student Behavior Inventory • Child Behavior Checklist • Social Skills Rating System • Conners Teacher Rating Scale • Child Report Measures: • Harter Pictoral Scale of Perceived Competence and Social Acceptance for Young Children • Peabody Picture Vocabulary Test – Revised See PCIT Handout 3 for References

Session #2 – Teaching BehavioralPlay Therapy • Average Length: 1 Session • Process: • Goals of behavioral play therapy are described • Rationale for the use of brief daily home “play therapy” sessions is presented • “Do” and “Don’t” skills of behavioral play therapy are described • Use of strategic attention and selective ignoring are discussed • All skills are modeled together • Parents are coached as they role-play skills • Logistics of play therapy at home are discussed

Session #2 – Teaching Behavioral Play Therapy • Goals of Behavioral Play Therapy • Goals based on presenting concerns • Important to convey that playtime is a therapeutic intervention and not “just playing” with the child • Daily Home Play Therapy Practice • To be done for at least 5 minutes everyday with the child leading the activity • Play therapy should not be viewed as a privilege that the child can earn or lose • Playtime is often more important on days when the child has misbehaved

Session #2 – Teaching Behavioral Play Therapy • “Do” Skills (DRIP) • Describe appropriate behavior • Reflect appropriate verbalizations • Imitate appropriate play • Praise prosocial behavior • “Don’t” Skills • Give commands or make requests • Ask questions • Criticize or correct in a negative way

Session #2 – Teaching Behavioral Play Therapy • Using Strategic Attention • Involves using the “Do” skills of behavioral play therapy • Used to reward the behaviors adults would like to see the child display more often • First, identify the behaviors or qualities that the parent sees as desirable and prosocial even if infrequent at first • Parents may want to think of the behaviors they would like to see their child display as opposed to their inappropriate behaviors • Once behaviors are identified, parents are to lookout for targeted behavior • “Catch the child being good” • Parents are encouraged to use strategic attention and praise appropriate behavior as much as possible throughout the day

Session #2 – Teaching Behavioral Play Therapy • Using Selective Ignoring • Parents are to identify behaviors or qualities they would like to see diminished • In order for ignoring to be effective the child must be doing the problem behavior to get a reaction or attention from the parent • Therapist then helps the parents analyze whether or not their attention rewards the child for engaging in each of the behaviors and whether the removal of attention should be expected to impact the behavior • Important for parents to understand that a behavior that is ignored will get worse before it gets better • Parents should determine if they can tolerate having the behavior get worse before it gets better • Parents must also understand that once they begin to ignore a behavior they must continue to ignore the behavior until it stops occurring

Session #2 – Teaching Behavioral Play Therapy • Modeling Skills Together • The therapist may model the skills with the parent pretending to be the child or show a videotaped segment of a parent with a child who presented with similar problems • After demonstrating the combined skills the parent performs a role-play • The therapist should encourage parents to perform the “Do” skills and may suggest specific phrases for the parent to repeat • Purpose is to show the parent how it feels to do the skills and what it is like to have someone providing frequent feedback on their performance

Session #2 – Teaching Behavioral Play Therapy • Considerations: • Behavioral play therapy is particularly helpful for one-parent families • These parents may often feel stressed and overburdened and this playtime provides them with positive interactions and time with their children • Two-parent families should consider alternating days in which each parent engages in play therapy with the child • Parents can also do play therapy at home with all of their children between the age of 2 and 7 • Before leaving the session, parents should know when and where they will conduct play therapy in their home • Should be done in a place that is quiet, private, and free of distractions and should occur at about the same time everyday • Parents are reminded to practice for 5 minutes a day and are given a recording sheet to note whether or not they practiced and any difficulties or problems that came up during playtime

Session #3 – Coaching Behavioral Play Therapy Skills • Average Length: 2 – 4 Sessions • Process: • Check-in and review homework • Recording of play therapy skills • Coaching of play therapy skills • Feedback on progress and homework assignment • Individual time with child (optional)

Session #3 – Coaching Behavioral Play Therapy Skills • Observing Behavioral Play Therapy Skills • The parent and child play together for five minutes and the therapist records the parent’s progress on a chart that is updated on a weekly basis • Progress is compared to mastery criteria • Criteria is based on concept of overlearning principles taught by therapists

Session #3 – Coaching Behavioral Play Therapy Skills • Coaching the “Do” and “Don’t” Skills: Tips for Therapists • Make coaching brief and precise • Should take the form of labeled praise, gentle correction, directives, and observations • Coach after nearly every parent verbalization • Give more praise than correction • Coach easier skills first • Incorporate observations into feedback • Make use of humor • Move from more directive to less directive coaching

Session #3 – Coaching Behavioral Play Therapy Skills • Qualitative Aspects of Parent-Child Interactions • Physical closeness and touching • Eye contact, facial expressions, vocal qualities • Turn-taking, sharing, polite manners • Developmentally sensitive teaching • Task persistence

Session #4 – Teaching Discipline Skills • Average Length: 1 Session • Process: • Explain use of compliance exercises • Discuss how to give effective directions • Discuss how to determine if child has obeyed • Discuss consequences for obeying • Discuss consequences for disobeying • Present backups for time-out • Coach parents as they role-play discipline skills

Session #4 – Teaching Discipline Skills • Importance of Compliance Exercises • Parents are informed of the importance of consistency, predictability, and follow-through • Parents are taught to view all misbehavior as falling into two categories: noncompliance and disruptiveness • Noncompliance – refusing to do what one is told • Disruptiveness – doing things that one is told not to do

Session #4 – Teaching Discipline Skills • Importance of Compliance Exercises cont. • Best way to teach compliance is through practice • By receiving a great deal of enthusiastic praise for small accomplishments, the child views minding in a more positive light and the habit of defying simple requests is weakened • Once compliance is improved within these exercises parents are coached in more real-life situations such as getting their child to come in from outside

Session #4 – Teaching Discipline Skills • Determining Compliance: • Even with well-stated commands it is sometimes difficult to determine if a child has obeyed • The following situations should be discussed with the parent to determine if the child complied with the parent’s direction • Doing something slightly different from the parent’s request • Dawdling • “Playing Deaf” • Partially complying • Minding with a bad attitude • Undoing

Session #4 – Teaching Discipline Skills • Consequences for Obeying • Parents are taught to praise their child as specifically as possible when their child complies with a request • Labeled praise such as: “Thanks for minding,” “I like it when you do what I ask,” or “Good following instructions!” • When enthusiastic labeled praises are given for listening children begin to view compliance in a more positive light • In addition to labeled praise, the parent should mention that they are happy that the child did not have to go to time-out

Session #4 – Teaching Discipline Skills • Consequences for Disobeying • If a child does not follow a parent’s command, parents are instructed to not repeat the command, but make a “two-choices statement” • Parents hold up two fingers and says in a neutral tone of voice, “You have two choices. You can put Mr. Potato Head back in the box or go to time-out.” • It is critical that a parent never provides a two-choices statement without being prepared to follow through with time-out • After giving the statement, parents are taught to watch closely to determine whether their child has complied • If so, enthusiastic praise is given • If not, the parent should proceed with time-out

Session #4 – Teaching Discipline Skills • Time-Out • Parent should escort child to time-out and then explain that the child is to sit in the chair until they can get off • The time-out chair should be in a specific, “boring” location that is free from distractions or attention from others • Time-out is over after the child has spent three minutes in time-out chair • More time may be added if child misbehaves in time-out chair

Session #4 – Teaching Discipline Skills • Backups for time-out • Isolation in another room • Restriction of privileges • Ways to handle time-out escape • Stand by time-out chair • Place hand on child’s shoulder as they sit in time-out • Repeatedly place child back in time-out chair • Add additional time for time-out escapes • Explain to child that time-out does not begin until they sit appropriately • Parents role-play discipline skills • Time-out procedures are reviewed • Parents should not use time-out until after the next session with additional coaching by the therapist

Session #5 – Coaching Discipline Skills • Average Length: 4-6 Sessions • Process: • Rehearse time-out with family • Coach discipline skills • Combine play therapy and discipline skills • Coach time-out

Session #5 – Coaching Discipline Skills • Guidelines for Coaching Discipline Skills • Give one instruction at a time • Use positively stated instructions • Coach both verbal and nonverbal communication • Praise parental compliance • Offer support and reassurance • Use relaxation training strategies

Session #6 – Posttreatment Assessment of Child and Family • Average Length: 1 – 2 Sessions • Process: • Therapist and family review therapy progress • Discuss strategies for addressing any remaining problems • Decide on a schedule for maintenance or “booster” sessions

Session #6 – Posttreatment Assessment of Child and Family • Measures that were administered before treatment are repeated • Changes on formal measures and videotaped interactions of the family from pretreatment to posttreatment are reviewed • Problem-solving skills are reviewed with the parents so that they can apply their new parenting strategies to a variety of problems that may come up • Parents are asked to identify at least one remaining concern and formulate a plan to address this concern

CASE EXAMPLE

Background • Tommy is a 5-year, 3 month-old English-speaking African-American male who demonstrates behavioral difficulties including talking back to adults, ignoring directions, and hitting other children when frustrated • He is the child of an older single mother and has two siblings in their early twenties

Step 1 – Pretreatment Assessment • Interview: • Mrs. Smith, Tommy, and Tommy’s siblings attend the session • First, the limits of confidentiality are explained to the family • During a semi-structured interview, Mrs. Smith describes Tommy’s developmental history, which is significant for slight language delays. She shares that the family is under considerable stress given her long work days, the absence of Tommy’s father, and the need to rely on her adult children to care for Tommy after preschool

Step 1 – Pretreatment Assessment, cont. • Interview, cont.: • During the interview, Tommy is permitted to play with toys in the room. He is observed by the therapist to select plastic dinosaurs which he has ‘run’ in the air and often strikes against one another with loud crashing sounds • As Tommy becomes increasingly louder and more active, Mrs. Smith responds to his behavior by yelling, “Stop!” Similar techniques are employed by Tommy’s elder sister, while his brother ignores Tommy • The therapist is careful to encourage Mrs. Smith to feel comfortable managing her son’s behavior as best she can and does not intervene

Step 2 – Formal Assessment • Formal Assessment: • Tommy is observed for a few minutes while the therapist speaks to his mother about the questionnaires she will complete • Next, formal assessment is conducted • Tommy is administered the Peabody Picture Vocabulary Test due to reported concerns about his language development • While Tommy is being evaluated, Mrs. Smith responds to the items on a series of behavioral checklists, including the Child Behavior Checklist – Parent Form, Eyberg Child Behavior Inventory, and Parenting Stress Index, in order to establish baseline information

Step 2 – Teaching Behavioral Play Therapy • Teaching Play Therapy: • Mrs. Smith receives information about the goals of play therapy • Mrs. Smith learns that the interventions are designed to improve her relationship with her son while reducing Tommy’s aggression and anger and increasing his self-esteem • Daily home therapy is explained to her as being done for at least 5 minutes each day and that the child should lead the activity • She expresses understanding, along with doubts, that this 5 minute play activity must take place even on days when Tommy has been non-compliant because it can break the negative cycle of behavioral non-compliance

Step 2 – Teaching Behavioral Play Therapy, cont. • Teaching Play Therapy, cont.: • The therapist explains the acronym “DRIP” to Mrs. Smith. • Mrs. Smith practices with the therapist, starting out by saying, “You play with the dolls.” The therapist reminds her it is important to describe, reflect, imitate, and praise. Mrs. Smith then says, as the therapist picks up a car and starts to play with it, “You picked a red car and you are driving it along the street.”

Step 2 – Teaching Behavioral Play Therapy, cont. • Teaching Play Therapy, cont.: • When Mrs. Smith demonstrates a solid grasp of the use of “DRIP” techniques through role plays with the therapist, she and the therapist make plans for follow-up play sessions at home • Mrs. Smith decides that the most convenient place and time to practice behavioral play therapy will be just after dinner each day. She plans to play with Tommy in his room, since it is a relatively quiet location

Step 3 – Coaching Behavioral Play Therapy • Coaching Play Therapy: • Mrs. Smith shares her record of play therapy sessions • She demonstrates that she engaged in play therapy 5 of the 7 days between sessions • Her efforts and consistency are praised by the therapist

Step 3 – Coaching Behavioral Play Therapy • Coaching Play Therapy, cont.: • Next, Mrs. Smith and Tommy play together for 5 minutes in a therapy room while the therapist observes behind a one-way mirror • Mrs. Smith is reminded to praise Tommy when he shares his toy with her and to avoid asking questions and giving commands

Step 3 – Coaching Behavioral Play Therapy, cont. • Coaching Play Therapy, cont.: • Mrs. Smith shares her record of play therapy sessions indicating that she engaged in play therapy 6 of the 7 days between sessions • During this 2nd session, focused on coaching behavioral play therapy, Mrs. Smith is encouraged to ignore behaviors that continue to be of concern to her. Specifically, when Tommy grabs toys away from her or bangs them together, she attends to another toy and does not say anything • As soon as Tommy realizes that his mother is not attending to his acting out, he offers to share with her. Mrs. Smith reflects on this behavior and praises him

Step 3 – Coaching Behavioral Play Therapy, cont. • Coaching Play Therapy, cont.: • Mrs. Smith shares that she engaged in play therapy 4 of the 7 days between sessions • During this session, qualitative aspects of PCIT are the focus • Mrs. Smith is encouraged to make eye contact with Tommy and sit close to him or give him a hug when he engages in appropriate behaviors, especially when he persists on a task that is difficult for him • Tommy responded to attention from his mother by continuing to engage in appropriate behaviors

Step 4 – Teaching Discipline Skills • Teaching Discipline: • This session explains to Mrs. Smith how to effectively implement consequences for Tommy’s inappropriate behavior • The therapist focuses on increasing Tommy’s compliance during play by helping Mrs. Smith give effective directions to Tommy • When they are not followed, Mrs. Smith identifies and responds to non-compliant behavior

Parent Child Interaction Therapy (PCIT)