Standard Parent-Child Interaction Therapy Research Articles

Evidence-Based Treatment in Practice: PCIT Research on Addressing Individual Differences and Diversity Through the Lens of 20 Years of Service.

Parent-Child Interaction Therapy (PCIT) is an intensive parent support program for caregivers and their children who exhibit difficult-to-manage disruptive behaviors. After more than four decades of research supporting its efficacy for reducing children's disruptive behaviors and improving parent-child relationships, PCIT has become one of the most popular and widely disseminated parenting support programs in the world. The evidence for the efficacy of PCIT can be found in many reviews of randomized clinical trials and other rigorous studies. To add to those reviews, our aim was to provide practical guidance on how PCIT can be part of an evidence-based program for families that depends on practitioner expertise, as well as attention to families' diverse needs. To do this, we describe the evolution of PCIT as practiced in a university-community partnership that has continued for over 20 years, alongside a narrative description of selected and recent findings on PCIT and its use in specific client presentations across four themes. These themes include studies of 1) whether the standard manualized form of PCIT is efficacious across a selection of diverse family situations and child diagnoses, 2) the mechanisms of change that explain why some parents and some children might benefit more or less from PCIT, 3) whether treatment content modifications make PCIT more feasible to implement or acceptable to some families, at the same time as achieving the same or better outcomes, and 4) whether PCIT with structural modifications to the delivery, such as online or intensive delivery, yields similar outcomes as standard PCIT. Finally, we discuss how these directions in research have influenced research and practice, and end with a summary of how the growing attention on parent and child emotion regulation and parents' responses to (and coaching of) their children's emotions has become important to PCIT theory and our practice.

PISTACHIo (PreemptIon of diSrupTive behAvior in CHIldren): real-time monitoring of sleep and behavior of children 3–7 years old receiving parent–child interaction therapy augment with artificial intelligence — the study protocol, pilot study

BackgroundEmotional behavior problems (EBP) are the most common and persistent mental health issues in early childhood. Early intervention programs are crucial in helping children with EBP. Parent–child interaction therapy (PCIT) is an evidence-based therapy designed to address personal difficulties of parent–child dyads as well as reduce externalizing behaviors. In clinical practice, parents consistently struggle to provide accurate characterizations of EBP symptoms (number, timing of tantrums, precipitating events) even from the week before in their young children. The main aim of the study is to evaluate feasibility of the use of smartwatches in children aged 3–7 years with EBP.MethodsThis randomized double-blind controlled study aims to recruit a total of 100 participants, consisting of 50 children aged 3–7 years with an EBP measure rated above the clinically significant range (T-score ≥ 60) (Eyberg Child Behavior Inventory-ECBI; Eyberg & Pincus, 1999) and their parents who are at least 18 years old. Participants are randomly assigned to the artificial intelligence-PCIT group (AI-PCIT) or the PCIT-sham biometric group. Outcome parameters include weekly ECBI and Pediatric Sleep Questionnaire (PSQ) as well as Child Behavior Checklist (CBCL) obtained weeks 1, 6, and 12 of the study. Two smartphone applications (Garmin connect and mEMA) and a wearable Garmin smartwatch are used collect the data to monitor step count, sleep, heart rate, and activity intensity. In the AI-PCIT group, the mEMA application will allow for the ecological momentary assessment (EMA) and will send behavioral alerts to the parent.DiscussionReal-time predictive technologies to engage patients rely on daily commitment on behalf of the participant and recurrent frequent smartphone notifications. Ecological momentary assessment (EMA) provides a way to digitally phenotype in-the-moment behavior and functioning of the parent–child dyad. One of the study’s goals is to determine if AI-PCIT outcomes are superior in comparison with standard PCIT. Overall, we believe that the PISTACHIo study will also be able to determine tolerability of smartwatches in children aged 3–7 with EBP and could participate in a fundamental shift from the traditional way of assessing and treating EBP to a more individualized treatment plan based on real-time information about the child’s behavior.Trial registrationThe ongoing clinical trial study protocol conforms to the international Consolidated Standards of Reporting Trials (CONSORT) guidelines and is registered in clinicaltrials.gov (ID: NCT05077722), an international clinical trial registry.

Utilizing Parent-Child Interaction Therapy with Trauma-Directed Interaction in a Young Male in Out of Home Care Who Had Experienced Trauma

Child abuse and neglect in young children can lead to trauma-related stress symptoms that can be challenging to manage. Parent-Child Interaction Therapy (PCIT), a strong evidence-based behavioral parent training program used for young children with behavior issues, has been used in its traditional form with increasing frequency with children and families who have trauma histories, with clinicians tailoring PCIT to use with children who have experienced trauma. Trauma-Directed Interaction (TDI) is a new systematic adaption to the standard PCIT parent training program that has the potential to help treat trauma in younger children. TDI includes several trauma-informed techniques that are added to a course of standard PCIT treatment including psychoeducation regarding trauma, recognition of feelings, and emotional regulation. This case study illustrates the use of a manualized trauma adaptation to PCIT (TDI) with a three-year-old boy who had a history of child maltreatment and his caregiver. This case provides a summary of the progression of this intervention and the results obtained. Results from the case indicated that TDI treatment was effective in not only reducing child trauma and behavioral symptoms but also in reducing mild caregiver mental health concerns. The next steps for TDI treatment and need for further research are discussed.

PARENT-CHILD INTERACTION THERAPY (PCIT) FOR ASD AND PCIT-T FOR TODDLERS: KNOW-HOW OF IMPORTANT THERAPY ADAPTATIONS FOR PRESSING MENTAL HEALTH ISSUES

Standard parent-child interaction therapy (PCIT) was developed as a treatment of disruptive, externalizing behavior disorders in developmentally normal children ages 3 to 6 years old. PCIT integrates operant conditioning techniques and play therapy to encourage a secure caregiver-child relationship through 2 phases of treatment: child-directed interaction (CDI) and parent-directed interaction (PDI). Over the years, PCIT has been able to use adaptations and tailoring to treat new diagnostic conditions and target more populations.

Parent-Child Interaction Therapy Supports Healthy Eating Behavior in Child Welfare-Involved Children.

Objective: We tested the efficacy of standard Parent–Child Interaction Therapy (PCIT), a live-coached, behavioral parent-training program, for modifying problematic eating behaviors in a larger effectiveness trial of PCIT for children involved in the child welfare system. Method: Children ages 3–7 years and their parents were randomly assigned to PCIT intervention (n = 120) or services as the usual control (SAU; n = 84) groups in a randomized clinical trial. Children’s eating behaviors were assessed pre- and post-intervention via the Child Eating Behaviors Questionnaire (CEBQ). Intention-to-treat analyses were conducted, followed by per-protocol analyses, on treatment-engaging families only. Results: PCIT led to reductions in child welfare-involved children’s food responsiveness, speed of food consumption, and tendency to engage in emotional overeating relative to children in the services-as-usual control condition. Standard PCIT may be an effective intervention to promote healthy child eating behaviors in families involved with child welfare, even when food-related behaviors are not directly targeted by the intervention. Public Health Significance: This clinical trial provides evidence that child welfare-involved children who received PCIT experienced significant reductions in maladaptive eating-related behaviors, namely food responsiveness, emotional overeating, and speed of eating. These findings were observed in relation to children in a comparison control group who had access to child welfare services-as-usual.

Parent Training Adapted to the Needs of Children With Callous–Unemotional Traits: A Randomized Controlled Trial

Callous–unemotional (CU) traits designate a distinct subgroup of children with early-starting, stable, and aggressive conduct problems. Critically, traditional parenting interventions often fail to normalize conduct problems among this subgroup. The aim of this study was to test whether parent–child interaction therapy (PCIT) adapted to target distinct deficits associated with CU traits (PCIT-CU) produced superior outcomes relative to standard PCIT. In this proof-of-concept trial, 43 families with a 3- to 7-year-old child (M age = 4.84 years, SD = 1.12, 84% male) with clinically significant conduct problems and elevated CU traits were randomized to receive standard PCIT (n = 21) or PCIT-CU (n = 22) at an urban university-based research clinic. Families completed five assessments measuring child conduct problems, CU traits, and empathy. Parents in both conditions reported good treatment acceptability and significantly improved conduct problems and CU traits during active treatment, with no between-group differences. However, linear mixed-effects models showed treatment gains in conduct problems deteriorated for children in standard PCIT relative to those in PCIT-CU during the 3-month follow-up period (ds = 0.4–0.7). PCIT-CU shows promise for sustaining improvements in conduct problems for young children with conduct problems and CU traits, but requires continued follow-up and refinement.

Treatment Readiness among Primarily Latine Families Seeking Parent-Child Interaction Therapy (PCIT) in an Urban Setting.

(1) Background: Given the high prevalence of childhood mental health problems and their long-lasting negative consequences if left untreated, it is important to investigate factors that affect family engagement in psychological interventions such as Parent–Child Interaction Therapy (PCIT), including caregiver treatment readiness and readiness for change (RFC). Specifically, Latine families experience greater mental health disparities and have unique cultural factors that affect engagement. The current project examined caregiver pretreatment readiness among primarily Latine Spanish- and English-speaking families. (2) Methods: Participants were 100 caregivers (96% female) of young children ages 2 to 7 who sought PCIT services from a community mental health center in Washington, D.C. Families completed written and observational assessment measures at pretreatment and throughout PCIT, which were used for the current study. (3) Results: Caregivers reported high readiness and importance of treatment at intake, with higher RFC among Spanish-speaking caregivers. Regardless of language, caregivers who reported more frequent and problematic child misbehavior and who were from a multi-caregiver household tended to report more RFC and treatment importance at intake. Pretreatment RFC also predicted family completion of the first phase of PCIT although there was a high attrition rate for the sample as only 18% of families completed treatment. (4) Conclusions: These findings provide insight into the implementation of standard PCIT among Spanish- and English speaking families and highlight the benefits of assessing pretreatment caregiver readiness to inform clinical decision-making.

51.1 I-PCIT: INTERNET-DELIVERED PARENT-CHILD INTERACTION THERAPY

Objectives: Parent-child interaction therapy (PCIT) is an evidence-based behavioral parent-training program that was initially developed for families with young children (ages 2-7 years) who exhibited socially disruptive behaviors (aggression and noncompliance). It is a dyadic parent-child therapy with unique elements of in vivo parent coaching via a bug in the ear by the therapist who works from behind a one-way mirror. Most important, PCIT allows for individually tailored coaching that can address unique difficulties of particular parent-child dyads. Despite the effectiveness of PCIT, a high dropout rate (in some studies as high as 50%) prior to completion of the treatment remains a significant problem. The use of new technologies such as telehealth to remotely deliver real-time therapy to the patient’s home has shown to overcome the many barriers including treatment availability, accessibility, and acceptability. During the COVID-19 pandemic, internet-PCIT (I-PCIT) became the treatment of choice for many centers around the country. Methods: This presentation will introduce the basic concepts of I-PCIT. We will focus on the similarities and differences between standard PCIT delivered in the office setting and I-PCIT. We will show video clips of I-PCIT sessions to illustrate the novel aspects of the treatment. Results: Participants will learn how to conduct PCIT using remote technology. They will be able to discuss various aspects of the PCIT treatment done in the home environment. They will be able to review problem-solving strategies such as ways to keep the young child in the room, time-out routine practice, and siblings needing to be present in the session, and other challenging situations will be discussed. Participants will have an opportunity to present their challenging cases and ask questions. Conclusions: A small but growing literature shows that I-PCIT is an acceptable adaptation of PCIT. It allows for expansion of the reach of mental health services, helps with compliance, and allows for continuation of treatment for many families during the COVID-19 pandemic. DBD, EC, P

The Cost-Effectiveness of Parent-Child Interaction Therapy: Examining Standard, Intensive, and Group Adaptations.

This study examined the cost-effectiveness of standard parent-child interaction therapy (PCIT) and three adaptations: intensive-PCIT (I-PCIT), small group PCIT, and large group PCIT. This study used cost-effectiveness analyses to calculate average cost-effectiveness ratios, which represents the average cost for one family to change one standard deviation on each outcome measure: externalizing behavior problems, positive parenting skills, negative parenting skills, child compliance, and parenting stress. While it had the lowest initial set up cost, results indicated that standard PCIT was the least cost-effective option in reducing child disruptive behaviors and in increasing child compliance. Large group PCIT was the most cost-effective in increasing positive parenting skills and child compliance and in reducing negative parenting skills and parenting stress. I-PCIT was the most cost-effective in reducing child disruptive behaviors and the second most cost-effective option in increasing positive parenting skills and child compliance and in decreasing negative parenting. As large group and I-PCIT were the most cost-effective in different domains, both could be recommended to parents as treatment options. Future research should confirm our cost-effective results within community settings.

Real-world Outcomes of PCIT for Children at Risk of Autism or Developmental Delay

Disruptive behaviors in children with Autism Spectrum Disorder (ASD) or developmental delay are common, persistent and cause distress to families. Parent–Child Interaction Therapy (PCIT) may be an effective intervention with emerging evidence to support its use for children with at-risk development. We aimed to investigate the effectiveness of standard PCIT for young children (2–4 years) with disruptive behaviors and signs of ASD and/or developmental delay, treated in a real-world clinical setting. We hypothesized that there would be a reduction in disruptive behaviors and for parents, a reduction in depressive symptoms. This was a retrospective file-review study of 236 referrals to a toddler clinic over a 17-month period (January 2016 to May 2017). Disruptive child behavior (EBCI Intensity scale and ECBI Problem scale) and maternal depression (EDS score) severity were analyzed across two time conditions (pre-treatment and post-treatment) using linear mixed models with repeated measures, including time, child ASD risk status and their interaction as main effects. An identical linear mixed models with repeated measures analysis was subsequently conducted using clinician identified concern about the child’s development as the between subjects factor. Disruptive child behavior for children at-risk of autism (high SCQ score) and for those with low SCQ scores, improved on average into the non-clinical range. Parental EDS scores reduced in the both groups, but reduced by a greater degree in the children at-risk of autism (high SCQ) group. This study suggests that children at-risk of autism and developmental delay should not be excluded from PCIT, an evidence-based intervention for disruptive behaviors, as there is potential benefit for both children and parents.

The Differential Contribution of the Components of Parent-Child Interaction Therapy Emotion Development for Treatment of Preschool Depression

An adaptation of Parent-Child Interaction Therapy (PCIT) with a novel Emotion Development (ED) module has shown efficacy for the treatment of early childhood depression. Children who received PCIT-ED also showed healthy alterations in neural response to reward. We investigated whether the novel ED module made a unique contribution to the treatment of depression and neural response to reward, and whether child-directed intervention (CDI) and parent-directed intervention (PDI) modules (standard elements of PCIT) were also effective. Dyads who participated in a randomized controlled trial of PCIT that compared the active PCIT-ED to a wait list (WL) condition were assessed at the completion of each module of PCIT-ED (CDI, PDI, ED) or WL time equivalent for child depression and other symptoms, parenting styles, stress, and depression. Event-related potentials during a reward task were obtained at the end of standard PCIT and after the novel ED module. Study findings showed that the ED module as well as some elements of standard PCIT were effective in reducing child depression and other forms of psychopathology. Changes in the child's neural response to reward and parental response to child emotional expression were specific to the ED module. Study findings suggest that the novel ED module has added efficacy for the treatment of early childhood depression, as well as unique efficacy in changing neural responses to reward and parenting response to child emotional expression. These findings can inform clinical uses of this treatment in a modular fashion. Future studies are needed that control for session number and order of PCIT-ED modules. A Randomized Controlled Trial of PCIT-ED for Preschool Depression; https://clinicaltrials.gov/; NCT02076425.

Effectiveness of Community-Delivered Parent-Child Interaction Therapy Compared to Usual Care

This study used a quasi-experimental design to explore implementation of Parent-Child Interaction Therapy (PCIT) by community therapists after they completed their standard PCIT training. Child outcomes were compared to children in usual care. PCIT significantly differed from usual care in all aspects of treatment including that families in the PCIT group received significantly fewer hours of service. Children in PCIT had larger reductions in disruptive behavior. However, intent-to-treat analyses of child outcomes found no significant between-group differences. Limitations included cross contamination of participants between conditions and small sample size. More research is needed to examine the effectiveness of PCIT in the community, including its cost-effectiveness and long-term follow-up.

An Evaluation of Parent–Child Interaction Therapy With and Without Motivational Enhancement to Reduce Attrition

Although many interventions for child externalizing behavior report promising outcomes for families, high attrition prior to program completion remains a problem. Many programs report dropout rates of 50% or higher. In this trial we sought to reduce attrition and improve outcomes by augmenting a well-known evidence-based intervention, Parent–Child Interaction Therapy (PCIT), with a 3-session individual motivational enhancement component. Participants were 192 Australian caregivers (91.7% female; Mage = 34.4 years) and their children (33.3% female; Mage = 4.4 years). Families (51% referred from child welfare or health services for risk of maltreatment) were assigned to PCIT or a supported waitlist, with families assigned to PCIT receiving either standard PCIT (S/PCIT) or motivation-enhanced PCIT (M/PCIT), depending on their time of entry to the study. Waitlist families received phone calls every week for 12 weeks. Parents in M/PCIT reported more readiness to change their behavior from preassessment to after the motivation sessions. Also, parents who reported high, rather than low, motivation at preassessment did have a lower attrition rate, and there was some evidence that enhancing motivation was protective of premature attrition to the extent that caregivers achieved a high degree of change in motivation. Yet comparison of attrition rates and survival analyses revealed no difference between M/PCIT and S/PCIT in retention rate. Finally, there were greater reductions in externalizing and internalizing child behavior problems and parental stress among families in S/PCIT and M/PCIT compared with waitlist, and there was generally no significant difference between the two treatment conditions.

Parent–Child Interaction Therapy With Emotion Coaching for Preschoolers With Attention-Deficit/Hyperactivity Disorder

Preschoolers with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for the development of comorbid conduct disorder (CD) and depression. Early predictors of serious adverse outcomes within this population include parenting characterized by high levels of negativity and low levels of positivity, maternal depression, and child emotion regulation (ER) difficulties. Parent–child interaction therapy (PCIT) is an evidence-based treatment for oppositional defiant disorder and CD that has also been shown to improve comorbid child internalizing symptoms and maternal depression by enhancing parenting and improving the parent–child relationship. PCIT-emotion development (PCIT-ED) is an adaptation for depressed preschoolers, grounded in developmental literature, which teaches parents to become “emotion coaches” for their children, in an effort to build child ER skills. In this paper, we describe the iterative process by which we implemented and adapted PCIT-ED based on our experiences treating nine children with ADHD. We present three case examples that exemplify our process in adapting the PCIT-ED manual. This work suggests that PCIT with parent emotion coaching (PCIT-ECo) may be a promising treatment approach for young children with ADHD. Future research will need to examine this adaptation relative to standard PCIT to determine whether our integration of parent emotion coaching results in added improvement in child ER, internalizing and externalizing problems, and functional impairment.

Parent–Child Interaction Therapy

It is common practice to augment efficacious treatment protocols for special populations (Durlak & DuPre, 2008), but this is often done before establishing that standard services are not appropriate. In this randomized controlled trial with families at risk or with a history of maltreatment (N = 151), we investigated the effectiveness of standard 12-session Parent-Child Interaction Therapy (PCIT). This is in contrast to other PCIT studies with similar parents, which have allowed for longer and sometimes variable treatment length and with modifications to PCIT protocol. After treatment and compared to Waitlist, mothers reported fewer child externalizing and internalizing behaviors, decreased stress, and were observed to have more positive verbalizations and maternal sensitivity. These outcomes were equivalent or better than outcomes of our previous PCIT trial with high-risk families (Thomas & Zimmer-Gembeck, 2011) when treatment length was variable and often longer. These findings support standard protocol PCIT as an efficacious intervention for families in the child welfare system.

The Effectiveness of Group Parent–Child Interaction Therapy with Community Families

Parent–Child Interaction Therapy (PCIT) is a behavioral, parent-training program that incorporates both operant learning and play therapy techniques to treat child disruptive behavior problems. The present pilot study examined the use of a group PCIT protocol with a mixed clinical sample of primarily low-socioeconomic status community families. Forty families with a child between the ages of 2 and 8 years old were either self-referred to the group or referred by child protective services, and 27 began treatment. Following a standard group PCIT protocol, 17 families completed treatment. Caregivers who completed the PCIT group reported a significant decrease in child disruptive behavior and parenting stress following completion of the 12-week group. Behavior observations of the treatment completers revealed a significant increase in parent prosocial behavior and a decrease in inappropriate parent behavior from pre- to post-treatment. As there have been no demonstrations, to date, of group PCIT in a community-based setting, this study presents evidence that PCIT is a promising treatment format for dissemination research and practice. The benefits and challenges of using a group PCIT format for delivery of clinical services are discussed.

Parent-Child Interaction Therapy for Mexican Americans: Results of a Pilot Randomized Clinical Trial at Follow-up

We examined treatment effects over a 6- to 24-month period posttreatment for 3 different interventions for externalizing behavior problems in young Mexican American (MA) children: a culturally modified version of Parent–Child Interaction Therapy (PCIT), called Guiando a Niños Activos (GANA), standard PCIT, and treatment as usual (TAU). Fifty-eight MA families with a 3- to 7-year-old child with clinically significant behavior problems were randomly assigned to GANA, standard PCIT, or TAU. As previously reported, all three treatment approaches produced significant pre-post improvement in conduct problems across a wide variety of parent-report measures, and those effects remained significant over the follow-up period. GANA produced results that were significantly superior to TAU on 6 out of 10 parent-report measures 6 to 24months posttreatment, and GANA significantly outperformed PCIT on child internalizing symptoms. However, PCIT and TAU did not differ significantly from one another. These data suggest that both PCIT and GANA produce treatment gains that are maintained over time, and that GANA continues to outperform TAU over the long term.

A Community Mental Health Implementation of Parent–Child Interaction Therapy (PCIT)

Parent-Child Interaction Therapy (PCIT) has been identified as an evidence-based practice in the treatment of externalizing behavior among preschool-aged youth. Although considerable research has established its efficacy, little is known about the effectiveness of PCIT when delivered in a community mental health setting with underserved youth. The current pilot study investigated an implementation of PCIT with primarily low-socioeconomic status, urban, ethnic minority youth and families. The families of 14 clinically referred children aged 2-7 years and demonstrating externalizing behavior completed PCIT initial assessment, and 12 began treatment. Using standard PCIT completion criteria, 4 families completed treatment; and these families demonstrated clinically significant change on observational and self-report measures of parent behavior, parenting stress, and child functioning. Although treatment dropouts demonstrated more attenuated changes, observational data and parent-reported problems across sessions indicated some improvements with lower doses of intervention. Attendance and adherence data, referral source, barriers to treatment participation, and treatment satisfaction across completers and dropouts are discussed to highlight differences between the current sample and prior PCIT research. The findings suggest that PCIT can be delivered successfully in an underserved community sample when families remain in treatment, but that premature dropout limits treatment effectiveness. The findings suggest potential directions for research to improve uptake of PCIT in a community service setting.

Parent–Child Interaction Therapy for Mexican Americans: A Randomized Clinical Trial

This study compared the effectiveness of a culturally modified version of Parent–Child Interaction Therapy (PCIT), called Guiando a Niños Activos (GANA), to the effectiveness of standard PCIT and Treatment as Usual (TAU) for young Mexican Amerian children with behavior problems. Fifty-eight Mexican Amerian families whose 3- to 7-year-old child had a clinically significant behavior problems were randomly assigned to GANA, standard PCIT, or TAU. All three treatment approaches produced significant pre–post improvement in conduct problems across a wide variety of parent-report measures. GANA produced results that were significantly superior to TAU across a wide variety of both parent report and observational indices; however, GANA and PCIT did not differ significantly from one another. PCIT was superior to TAU on two of the parent report indices and almost all of the observational indices. There were no significant differences between the three groups on treatment dropout, and families were more satisfied with both GANA and PCIT than with TAU.