Parent-Child Interaction Therapy

Gwen Burkholder, LCSW, CAADCburkholderg@csgonline.org

October 9, 2013

A Network of Services. A World of Possibilities.

Welcome and Introductions!

Photos are courtesy of Amy Herschell, Ph.D.

Thank you to the following people:

•Cheryl Bodiford McNeil, Ph.D., Department of Psychology, West Virginia University, who provided my initial five-day training to become a PCIT clinician in November 2010

•Amy D. Herschell, Ph. D., University of Pittsburg School of Medicine, who has provided ongoing supervision and consultation to me regarding providing PCIT in Lancaster, PA over the past three years.

What is PCIT?• Work with the parent (birth, kin, foster, adoptive) and child

together• Designed to treat children age 2 to 7 years exhibiting

disruptive behaviors • Use of coaching with a ‘bug-in-the-ear’ from a one-way

mirror• Consists of two phases of treatment:

– Relationship Enhancement – Behavior Management

• Initially developed by Sheila Eyberg, University of Florida.

McNeil, C.B., & Hembree-Kigin, T. (2010). Parent-Child Interaction Therapy. Second edition. New York: Springer.

PCIT Set-up

Photos are courtesy of Amy Herschell, Ph.D.

What is PCIT?• Elements of family systems, social learning

theory, and traditional play therapy• Emphasis on restructuring parent-child patterns,

not modifying target behaviors• Parents are not blamed, but are given

responsibility for improving the child's behavior • Program is completed in 12-20 sessions,

depending on the needs of the family• Empirically evaluated in over 30 controlled

studies

McNeil, C.B., & Hembree-Kigin, T. (2010). Parent-Child Interaction Therapy. Second edition. New York: Springer.

Critical Components of PCIT• Parent and Child are seen together• Relationship Focused• Not Time Limited• Coaching Model – Active, Directive• Assessment Driven• Scientifically Based• Empirically Supported• Clinically Validated

Information provided by Amy Herschell, Ph. D.

Who is PCIT Appropriate For?• Young Children (Age 2-7)

• Children exhibiting externalizing behavior problems (e.g., verbal and physical aggression, defiance, noncompliance, temper tantrums)

• Parents who could benefit from enhanced relationship and/or behavior management skills with young children

Information provided by Amy Herschell, Ph. D.

Who is PCIT Appropriate For?

• Extensive contact with Primary Caregiver (or person completing PCIT with child)

• Families with young children and who have experienced violence

• Families with young children and relationship difficulties

Information provided by Amy Herschell, Ph. D.

Developmental Progression of Conduct Disordered Behaviors

OppositionalArgues Temper tantrums BraggingStubborn Demands attention TeasesLoud Disobeys at home Impulsive

OffensiveCruelty Disobeys at School FightsSulks Screams Lying/cheatingSwears Poor peer relations

AggressiveDestroys Bad friends Steals at homeAttacks Threatens Others

DelinquentSets fires Steals Outside/Home Runs away Truancy Alcohol/drug use Vandalism

Information provided by Amy Herschell, Ph.D.

Sample Course of TreatmentSession Number

Session Content

Assessment of appropriateness for PCIT

1 Child Directed Interaction/Relationship Enhancement Skills Teaching Session

2-9 Coaching in Child Directed Interaction/Relationship Enhancement Skills

10 Parent Directed Interaction/Discipline Skills Teaching Session

11-19 Coaching in Parent Directed Interaction/Discipline Skills

20 Graduation SessionInformation provided by Amy Herschell, Ph. D.

Assessment of Appropriateness for PCIT – Intake ProcessAgency Intake

Supplemental PCIT Questions

Standardized, self-report measures

– Eyberg Child Behavior Inventory (ECBI)

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

– Child Behavior Checklist (CBCL)

– Parenting Stress Inventory – Short Form (PSI-SF)

Standardized, behavior observation measure

– Dyadic Parent-Child Interaction Coding System-IV (DPICS-IV)

Information provided by Amy Herschell, Ph. D.

Eyberg Child Behavior Inventory (ECBI)

• Assesses behaviors associated with the primary childhood disruptive behavior disorders (e.g., noncompliance, defiance, aggression)

• Appropriate for children aged 2-16 years• Contains 36 items and two scales – the

Intensity and Problem Scales• 10 Minutes for parents to complete, 2 minutes

to scoreInformation provided by Amy Herschell, Ph. D.

Child Behavior Checklist (CBCL)• Survey social competencies and problem behaviors• Complete by parent or regular caregiver• Separate forms for two age groups (1.5 – 5 years & 6-

18 years)• Approximately 100 items, 15 to 25 minutes to

administer• Comprised of two broad band scales and a total

problem scale – • Externalizing – disruptive or under controlled

behaviors• Internalizing – anxiety, depression, withdrawal• Total problems scale

Information provided by Amy Herschell, Ph. D.

Parenting Stress Index (PSI)-Short Form

• Composed of three subscales:– Parental Distress– Dysfunctional Parent-Child Interaction– Difficult Child Characteristics

• Added together, these subscales yield a Total Stress Score

Information provided by Amy Herschell, Ph. D.

Dyadic Parent-Child Interaction Coding System (DPICS)• Structured observational assessment

• Child-directed play• Parent-directed play• Clean-up

• Observing and coding parent-child interactions for PCIT specific Skills• Labeled Praise, Behavioral Descriptions,

Reflections• Questions, Commands, Criticism

Information provided by Amy Herschell, Ph. D.

Recognition as an Evidence-Based Practice

Closing the Quality Chasm in Child Abuse Treatment: Identifying and Disseminating Best Practices (Chadwick Center, 2004)     www.chadwickcenter.org/kauffman.htm

 The National Child Traumatic Stress Network (Empirically Supported Treatments

and Promising Practices, supported by The Substance Abuse and Mental Health Services Administration, 2005)     www.nctsn.org/nccts/nav.do?pid=ctr_top_trmnt_prom  

 Child Physical and Sexual Abuse: Guidelines for Treatment (Saunders, Berliner, &

Hanson, Eds., National Crime Victims Research and Treatment Center and The Center for Sexual Assault and Traumatic Stress; Office for Victims of Crime, U.S. Department of Justice, 2004)

     www.musc.edu/ncvc/resources_prof/OVC_guidelines04-26-04.pdf  Evidence-Based Treatment for Children and Adolescents (The Society of Clinical

Child and Adolescent Psychology, a division of the American Psychological Association, and the Network on Youth and Mental Health)  www.effectivechildtherapy.com  

 Youth Violence: A Report of the Surgeon General (Elliott, Hatot, & Sirovatka, Eds.,

U.S. Department of Health and Human Services, 2001)     http://www.surgeongeneral.gov/library/youthviolence  The California Evidence-Based Clearinghouse for Child Welfare (2006)      www.cachildwelfareclearinghouse.org  

Information provided by Amy Herschell, Ph. D.

Kauffman Best Practices Project (2004)

Identified Three “Best Practices” for Children who have experienced abuse and are experiencing mental health concerns:

• Abuse-Focused CBT• Parent-Child Interaction

Therapy• Trauma-Focused CBT

Information provided by Amy Herschell, Ph. D.

Key Research Areas• Efficacy/Effectiveness• Diagnostic Classifications• Child Maltreatment Populations• Cultural Variables• Therapist Variables• Treatment Delivery• Attrition• Maintenance• Dissemination

Information provided by Amy Herschell, Ph.D.

Treatment Outcome Research with Children Experiencing Behavior Problems

Main Findings: Parent skill increases in reflective listening, physical

proximity, and prosocial verbalizationsDecreases in sarcasm and criticism of the child More positive parental attitudes toward childParent report of child behavior problems to within normal

limitsParent self-reported improvements in psychopathology,

personal distress, and parenting locus of controlHigh consumer satisfaction with process and outcomeMaintenance of treatment gains up to 6 years post-

treatmentGeneralization to untreated siblingsGeneralization to home and school

Herschell, A. D., Calzada, E. J., Eyberg, S. M., & McNeil, C. B. (2002). Research Issues In Parent-Child Interaction Therapy. Cognitive & Behavioral Practice, 9.

Studies that have demonstrated PCIT’s Effectiveness with Physical Abuse• Conceptual Stage

– Urquiza & McNeil R21 Grant Submission (1995)– Urquiza & McNeil Conceptual Paper (1996)

• Case Reports and Single Subject Designs– Borrego, Urquiza, Rasmussen, & Zebell (1999)– Fillcheck, McNeil, Herschell (in press)– Fricker, Ruggiero, & Smith (2005)– Herschell, Calzada, Eyberg, & McNeil (2002)– Urquiza, Timmer, Herschell, McGrath, Zebell, & Porter

(2005)• Treatment Outcome Studies

– Chaffin and colleages (2007, 2010)– Urquiza, Timmer, Zebell, & McGrath (in press)– McNeil, Herschell, Gurwitch, & Clemens-Mowrer (2005)

Information provided by Amy Herschell, Ph. D.

Limitations and Caveats• Focus on child behavioral problems, parenting

skill, and changing relationships, not on all aspects of family (e.g., active substance abuse, parent psychopathology)

• Continued need for coordination with other treatment/support agencies

• Limited age range

• Parent and child must have regular ongoing contact

Information provided by Amy Herschell, Ph. D.

Clinician Training in PCITTraining Requirements for Clinicians

Master’s degree or higher in the mental health field Actively working with children and families.Licensed in his or her field or receive supervision from a

licensed individual trained in PCIT.

Training Program40-hours of face-to-face contact with a PCIT trainer 4-6 months later a 2-day advanced live training Case Experience (at least 2 families, preferably 5) Regular (bi-weekly) consultation/Supervision over 1 yearSkill review

Information provided by Amy Herschell, Ph. D.

Sample Course of TreatmentSession Number

Session Content

Assessment of appropriateness for PCIT

1 Child Directed Interaction/Relationship Enhancement Skills Teaching Session

2-9 Coaching in Child Directed Interaction/Relationship Enhancement Skills

10 Parent Directed Interaction/Discipline Skills Teaching Session

11-19 Coaching in Parent Directed Interaction/Discipline Skills

20 Graduation SessionInformation provided by Amy Herschell, Ph. D.

Child Directed Interaction

In the effort to enhance the relationship between the parent and child, the therapist coaches the parent to do the behavioral and play therapy techniques of:•Reflecting what child says•Describing what child is doing•Giving specific praise for child’s positive behavior

The parent is also coached to avoid doing questions, commands, and criticism and to ignore minor annoying behavior.

Parent Directed Interaction• The therapist coaches the parent to gain

increased compliance from the child by teaching how to give direct commands and how to follow-up with consistent consequences for non-compliance, as part of the behavioral and play therapy.

Corresponds with the Parent-Child Interaction Therapy Protocol(2011 Edition)

Graduation

After special playtime, practice PDI in a 5-min clean-up situation

Practice PDI for 2-4 carefully selected direct commands each day

Use PDI as necessary for running commands throughout the day

Use PDI for House Rules

Assign at least two Public Behavior practice outings

Do two practice sessions of play with two siblings together

Practice PDI in daily 5-10 min play situation at home

How PCIT has become more common in Pennyslvania

• The Pennsylvania Department of Public Welfare and the Pennsylvania Keys in collaboration with the Heinz Foundation, solicited Requests for Applications for Licensed Outpatient Psychiatric Clinics to send clinical staff to be trained to do Parent-Child Interaction Therapy beginning in 2010. Several cohorts of training groups have been trained since that time.

2011 Pennsylvania Agencies Providing Parent-Child Interaction Therapy

2012 Pennsylvania Agencies Providing Parent-Child Interaction Therapy

2013 Pennsylvania Agencies Providing Parent-Child Interaction Therapy

Last Updated – September 20, 2012

County City Agency

Allegheny Pittsburgh Allegheny Children’s Initiative

Glade Run

Laughlin Center

Family Resources of PA

Matilda Theiss Child Development Center @ WPIC

Private Practice

The Melting Pot

University of Pittsburgh/Western Psychiatric Institute and Clinic

Wesley Spectrum

Women’s Center and Shelter

Milestone, Inc.

Armstrong Leechburg Family Counseling Center

Butler Butler Family Services of Butler Health System

Family Pathways

Kids Count/Family Psychological

Pennsylvania Agencies Providing Parent-Child Interaction Therapy (8/30/13)

Pennsylvania Agencies Providing Parent-Child Interaction Therapy (8/30/13)

County City Agency

Bedford/Somerset

Bedford Alternative Community Resource Program

Berks Fleetwood Concern Counseling

Reading Familicare Counseling Center

Reading Behavioral Health

Bucks Langhorne Penndel Mental Health Center

Carbon/Monroe/Pike

Weissport Behavioral Health Associates

Palmerton Carbon/Lehigh Intermediate Unit #21 - Behavioral Health Service

Easton Colonial Intermediate Unit #20

Centre Philipsburg Cen-Clear Child Services

Chester Phoenixville Devereux Community Services

Coatsville Child Guidance Resource Centers

Clearfield/Jefferson

DuBois Clearfield-Jefferson Community Mental Health Center, Inc.

Crawford Meadville Counseling and Child Guidance

Cumberland Carlisle NHS – The Steven’s Center

Delaware Havertown Child Guidance Resource Centers

Upland Crozer-Chester Medical Center

Erie Erie Safe Harbor Behavioral Health

Sarah A. Reed Children’s Center

Pennsylvania Agencies Providing Parent-Child Interaction Therapy (8/30/13)

County City Agency

Fayette Uniontown Chestnut Ridge Counseling Services, Inc

Connellsville Counseling

Connellsville

Stern Center for Developmental and Behavioral Health

Franklin/Fulton Chambersburg Laurel Life

Camp Hill Franklin Family Services

Huntington/Mifflin/Juniata

Huntington Universal Community Behavioral Health (UCBH)

Indiana White Family Psychological Associates

Lehigh Easton Colonial Intermediate Unit #20

Lackawanna/Susquehanna

Scranton Friendship House

Scranton Counseling Center

Carbondale NHS – Northeastern PA

Lancaster Lancaster Community Services Group, Inc

Lawrence New Castle Human Services Center

Luzerne/Wyoming Wilkes Barre Children's Service Center of Wyoming Valley

Lycoming/Clinton Williamsport Community Services Group, Inc

Mercer Hermitage Community Counseling Center

Paoletta Counseling

Northumberland Sunbury Northumberland County Counseling Services

Pennsylvania Agencies Providing Parent-Child Interaction Therapy (8/30/13)

Philadelphia Philadelphia Children’s Crisis Treatment Center

Children’s Hospital of Philadelphia

Presbyterian Children's Village

Schuylkill Pottsville Professional Counseling, Consulting & Human Services

The ReDCO group

Venango Oil City Regional Counseling Center, Inc.

Washington Fredericktown Centerville Clinic

Westmoreland Greensburg FBR

New Kensington

FBR/AERI

Making referrals for PCIT

•Refer to a behavioral health agency in your area who is providing PCIT.•Consider offering PCIT at your community health center if space is available, and the necessary licensure and billing issues can be worked out for the provision of behavioral health care on site.

Recommended books on PCIT

Available on Amazon.comAvailable on www.pcit.org