clinical issues in parent-child interaction therapy

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Address correspondence to Sheila M. Eyberg, Ph.D., Department of Clinical and Health Psychology, University of Florida, Gainesville, FL 32610; e-mail: [email protected].

Received: January 21, 2000 Accepted: March 6, 2000

• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Clinical I s sues in Parent-Child Interaction Therapy

A m y D. H e r s c h e l l , West Virginia University

E s t h e r J . C a l z a d a , N ew York University S h e i l a M. E y b e r g , University o f Florida

C h e r y l B. M c N e i l , West Virginia University

The scientist-practitioner model depends on the interplay of research and clinical work. Just as research informs and improves clinical practice, clinical practice leads to the generation of important and practical research questions. The purpose of this article is to de- scribe the clinical application of Parent-Child Interaction Therapy (PCIT), detailing its essential clinical components and presenting a case example that illustrates the application of PCIT to the treatment of child physical abuse. Recommendations for common imple- mentation difficulties are presented through the case example.

p ARENT-CHILD INTERACTION THERAPY (PCIT) is a the-

oret ical ly g r o u n d e d , scientifically based, empir ica l ly

suppor t ed , a n d clinically va l ida ted t r e a t m e n t p r o g r a m

for famil ies with y o u n g ch i l d r en e x p e r i e n c i n g behav iora l

and e m o t i o n a l p rob lems . Or ig ina l ly d e v e l o p e d approxi -

mate ly 25 years ago, PCIT was i n f l u e n c e d by B a u m r i n d ' s (1967) d e v e l o p m e n t a l r esearch d e m o n s t r a t i n g y o u n g

ch i ld r en ' s dual needs for pa ren ta l n u r t u r a n c e and limits

in o r d e r to ach ieve op t ima l ou t comes . To de f ine its focus,

P C I T was s t ruc tu red a c c o r d i n g to the two-stage t r e a t m e n t

m o d e l desc r ibed by H a n f (1967) a n d drew f r o m b o t h

a t t achmen t and social l ea rn ing theories (see Foote, Eyberg,

Cognitive and Behavioral Practice 9, 16-27, 2002 1077-7229/02/16-2751.00/0 Copyright © 2002 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

C o n t i n u i n g E d u c a t i o n Q u i z l o c a t e d o n p . 8 1 .

& S c h u h m a n n , 1998). T h e empi r i ca l suppo r t for PCIT

has b e e n desc r ibed in a separa te ar t icle in this issue (Her-

schell , Calzada, Eyberg, & McNeil , 2002). T h e p u r p o s e o f this ar t icle is to descr ibe the cl inical app l ica t ion o f PCIT

by e x a m i n i n g its essential cl inical c o m p o n e n t s a n d illus-

t rat ing, t h r o u g h a case e x a m p l e o f ch i ld physical abuse, how this t r e a t m e n t m o d e l may be app l i ed to diverse chi ld

cl inical p r o b l e m s that have in c o m m o n dysfunc t iona l

pa ren t -ch i ld in t e rac t ion pa t te rns tha t serve to ma in t a in

a n d exace rba t e the behav iora l and e m o t i o n a l distress o f

the p a r e n t as well as the child.

In PCIT, pa ren t s a re t augh t specific skills tha t fos ter a

close, secure re la t ionsh ip with the i r chi ld, as well as skills

that facil i tate const ruct ive , consis tent , and p red ic t ab le

l imits and discipl ine. T h e r e are two phases in the treat-

m e n t p rog ram: Chi ld -Di rec ted In t e r ac t i on (CDI) a n d

Pa ren t -Di rec ted In t e r ac t ion (PDI). In the first phase ,

CDI, pa ren t s are t augh t to use t rad i t iona l play the rapy

Clinical Issues: Parent-Child Interaction Therapy 17

Table I Child-Directed Interaction Skills

Examples Therapist Coaching Responses

The PRIDE Skills Praise (labeled) Reflection

Imimtion

Description of behavior

Enthusiasm

Verbalizations to Avoid Questions

Commands

Critical statements

"Great job sitting in your seat." Child: "I maded a heart." Parent: "Yes, a big heart." Child: (picks up blocks and begins building a tower) Parent: (picking up blocks) "I'm going to build a

tower just like you." Child: (squishing down Play-Doh) Parent: "You're making that Play-Doh flatter and flatter." Child: (finishes a drawing) Parent: (smiles and speaks in an animated voice)

"What a beautiful picture you've drawn!"

Parent: "What are you drawing?"

Parent: "Let's play with the toy spaceship nOW."

Child: (picking up a blue crayon) "Look, I have a red crayon."

Parent: "No, that's not red. That's blue."

May prompt parent to say, "It looks like you're drawing a house."

May suggest that parent say, "We can play with whatever you want."

May teach positive correction of child by prompting parent to say, '`you have a blue crayon."

skills while they play with their child, with the goals of s t rengthening the parent-child relationship, bui lding the child's self-esteem, and increasing the child's prosocial behaviors. The parent ing skills taught dur ing CDI are shown in Table 1. In the second phase, PDI, parents are taught behavior modification principles and are guided in the use of specific techniques such as giving effective commands and using time-out; these parent ing skills are listed in Table 2. Typically, the two phases of t reatment are completed in 10 to 14 weeks, al though the speed at which t reatment progresses is based on the severity of the child's behavior problems and the parents ' rate of mastery of skills. Families may complete PCIT in as few as 5 sessions or they may require as many as 25 sessions. A sample course of t reatment is provided in Table 3.

Crit ical Cl in ica l C o m p o n e n t s

The clinical validation of PCIT is due in part to certain critical components that are buil t into the protocol. Spe- cifically, PCIT actively involves parents and their child in treatment, uses coaching as the key therapeutic tool, tailors skill application to the individual needs of each family, relies on assessment to guide each family's progress, and cont inues unt i l mastery of the skills is achieved and the child's behavior is within normal limits.

Involving Child and Parents Together in Treatment Parents have a t remendous inf luence over their young

child's behavioral and emotional development. They can

foster healthy, constructive child development or inad- vertently create or exacerbate behavior problems. Par- ents also spend a large amoun t of time with their child relative to the 1 hour a week allotted to therapy. For these reasons, rather than meet ing individually with a child, as in play therapy, or meet ing with the parents alone, as in many parent training programs, the PCIT therapist meets with the parents and child together for most t rea tment sessions. Involvement of both the child and parents places emphasis on changing parent-child interactions rather than individual behaviors of the parents or child in isolation.

Each of the two phases of PCIT, CDI and PDI, begins with one didactic session that parents a t tend without their child. During this session, the therapist provides detailed instruct ion on PCIT skills (see Tables 1 and 2), and tailors these skills to meet the parents ' ability level and specific child behavioral concerns. For example, if a paren t is concerned about her son whining, the therapist may role-play a situation in which the parent practices ig- nor ing whining behavior. Following the didactic session in each phase, parents and their child at tend coaching sessions together, in which parents are directly coached in the application of the skills as they interact with their child in a playroom. As one parent interacts with the child, the other participating caregiver (e.g., spouse, grandparent) and the therapist view the parent-child interaction from beh ind a one-way mirror. The therapist provides specific, immediate feedback to the paren t interact ing with the child via a bug-in-the-ear device.

18 Herschel l e t al.

Table 2 Parent-Directed Interaction Skills

Skill Giving Effective Commands

Commands should be: • given only if they are really important • direct rather than indirect • positively stated • simple • given one at a time • developmentally appropriate • specific, not vague

Determining Whether Compliance or Noncompliance Has Occurred

It is noncompliance if." • the child is doing something slightly different than told • the child is ignoring the command • the child complies with a negative attitude • the child complies and then undoes the requested action

Applying Appropriate Consequences for Compliance and Noncompliance

After compliance: • give labeled praise and include an explanation of why it is

good that the child obeyed (e.g., "Great.job following instructions. When you follow instructions you don' t have to go to time-out")

• give full attention to child (show enthusiasm, appreciation, use positive touch)

After noncompliance: • Initiate the time-out procedure: After giving a direct

command, the parent waits 5 seconds for compliance, if necessm T. If the child does not comply alter 5 seconds, the parent provides a warning (e.g., "If you don' t [follow the initial instruction], you will have to go to time-out") and again waits 5 seconds. If the child continues to noncomply, a 3-minute time-out is given as a punishment tot disobeying.

• Ignore all extraneous child behavior • If child refuses to stay or engages in dangerous behavior

in time-out, implement a back-up consequence (i.e., time- out room). Ifa back-up consequence is used, the child must sit in the time-out chair immediately after getting out of the time-out room.

• Time-out (initially) is provided only as a consequence for noncompliance. To complete time-out, the child must comply with the original command that resulted in time- out as well as one additional similar command.

• CDI skills are incorporated into the parent-child interaction after the time-out is completed and used to cahn both the parent and the child.

F i g u r e 1 i l lus t ra tes t he typical s t r u c t u r e o f a P C I T coach -

i ng sess ion.

C o a c h i n g P arent s

E a c h c o a c h i n g sess ion b e g i n s a n d e n d s wi th b r i e f

check- ins a n d always i n c l u d e s o b s e r v a t i o n a l a ssessment ,

c o a c h i n g , a n d f e e d b a c k to p a r e n t s o n t h e i r skill use a n d

its e f fec t o n t h e i r chi ld . T h e ini t ia l check - in is g e n e r a l l y

l i m i t e d to 10 m i n u t e s at t he b e g i n n i n g o f t he sess ion a n d

is u s e d to discuss t he p r i o r week ' s h o m e w o r k , t he ch i ld ' s

p rogress , any e v i d e n c e o f g e n e r a l i z a t i o n o b s e r v e d by t h e

p a r e n t s , a n d any se tbacks t h a t may have o c c u r r e d d u r i n g

t he week. T h e t h e r a p i s t p r o v i d e s s u p p o r t a n d e n c o u r a g e -

m e n t to t he p a r e n t s a n d assists in p r o b l e m - s o l v i n g diffi-

cu l t family s i t ua t ions as n e e d e d . Check - in e n d s wi th a

b r i e f review of t he skills t he p a r e n t s have a l r eady mas-

t e r e d a n d those they w o u l d l ike p a r t i c u l a r h e l p wi th dur-

i ng t he session. Fo l lowing t he check- in , t he t h e r a p i s t

codes a 5 - m i n u t e b e h a v i o r a l o b s e r v a t i o n o f t he p a r e n t -

c h i l d i n t e r a c t i o n to assess t he p a r e n t s ' c u r r e n t level o f

m a s t e r y o f t he skills. T h e o b s e r v a t i o n a l da t a a re u s e d to

assess t he p a r e n t s ' p rogress , to g u i d e t h e c o a c h i n g w i t h i n

t he sess ion a n d t h e h o m e w o r k , to m o n i t o r p r o g r e s s

across sessions, a n d to d e t e r m i n e w h e n t he p a r e n t s have

m e t t h e p r e d e t e r m i n e d skill a cqu i s i t i on cr i ter ia . T h e d a t a

f r o m e a c h sess ion a re g r a p h e d so t h a t t he p a r e n t s c an re-

view t h e i r p r o g r e s s wi th t he t h e r a p i s t a t t he e n d o f e a c h

sess ion a n d se lec t t he specif ic skills they wish to focus o n

d u r i n g t h e i r daily p r a c t i c e sess ions a t h o m e . E a c h sess ion

e n d s wi th a b o u t 10 m i n u t e s o f d i scuss ion in w h i c h t he

p r o g r e s s m a d e d u r i n g t he t r e a t m e n t sess ion a n d s ince

t r e a t m e n t s t a r t ed is r ev iewed a n d t he goals for t he follow-

i ng week are set.

P r o b a b l y the m o s t i m p o r t a n t c o m p o n e n t o f t he coach-

ing sess ion is t he live c o a c h i n g o f the p a r e n t i n g skills. T h e

c o a c h i n g p rov ides t he p a r e n t specific, i m m e d i a t e feed-

b a c k a n d r e d i r e c t i o n d u r i n g t he p a r e n t - c h i l d i n t e r a c t i o n .

It also offers several a d v a n t a g e s over i n d i r e c t m e t h o d s o f

t e ach ing . First, p a r e n t i n g mis takes c a n b e c o r r e c t e d t he

i n s t a n t they h a p p e n , b e f o r e the ch i ld c an r e s p o n d to t he

mis take and , m o r e impor tan t ly , b e f o r e a n i nco r r ec t l y ap-

p l i ed new t e c h n i q u e is l e a r n e d . Second , skill a cqu i s i t i on is

h a s t e n e d b e c a u s e o f the i m m e d i a c y a n d in tens i ty o f t he

f e e d b a c k received. T h i r d , t he c l in ic ian is a f f o r d e d t he op-

p o r t u n i t y to ta i lor t he skill a p p l i c a t i o n to t h e family 's

u n i q u e p r o b l e m s as they o c c u r in session. For e x a m p l e ,

h e s i t a n t p a r e n t s a re p r o v i d e d wi th s u p p o r t a n d e n c o u r -

a g e m e n t to b e c o m e m o r e active p a r t i c i p a n t s in t h e i r

ch i ld ' s p la b w h e r e a s cr i t ical o r aggressive p a r e n t s a re

c o a c h e d d i rec t ly in a n g e r - c o n t r o l t e c h n i q u e s .

T h e t h e r a p i s t ' s c o a c h i n g o f t he p a r e n t may b e v iewed

as a t r a i n i n g p roce s s s imi la r to t he o n e o c c u r r i n g be-

tween t h e p a r e n t a n d c h i l d . J u s t as t he p a r e n t is t a u g h t to

s h a p e the ch i ld ' s b e h a v i o r t h r o u g h posi t ive social r e in -

f o r c e m e n t , so too t he t h e r a p i s t s h a p e s t h e p a r e n t ' s be-

h a v i o r ( B o r r e g o & U r q u i z a , 1998) . Th i s e n a b l e s t he

t h e r a p i s t to m o d e l t h e c o n t i n u o u s use o f a p p r o p r i a t e

c o m m u n i c a t i o n skills. C o a c h i n g s t a t e m e n t s a re mos t ly

br ie t , p rec ise , l a b e l e d p ra i ses fo r use o f t h e skills, a n d

ear ly in t r e a t m e n t they a re o f t e n a c c o m p a n i e d by a b r i e f

r e a s o n e x p l a i n i n g t h e i r e f fec t o n t he ch i ld ' s behav io r .

C o a c h i n g s t a t e m e n t s also may i n c l u d e r e d i r e c t i o n , n o n -

Clinical Issues: Parent-Child Interact ion Therapy 19

Table 3 Sample Course of Treatment

Session Abbreviated Session Content and Homework Assignments

Session 1

Session 2

Session 3

Session 4

Session 5

Session 6*

Session 7

Session 8

Session 9

Session 10

Session 11

Session 12"*

Session content: Intake assessment (parent and child) Homework: None

Session content: CDI teaching session (parents only) Homework: 5 minutes of CDI/special time each day

Session content: CDI coding to guide session; first CDI coaching session (parents and child) Homework: 5 minutes of CDI/special time each day

Session content: CDI coding to guide session; second CDI coaching (parents and child) Homework: 5 minutes of CDI/special time each day

Session content: CDI coding to guide session; third CDI coaching (parents and child) Homework: 5 minutes of CDI/special time each day

Session content: PDI teaching session (parents only) Homework: Parents must not use PDI skills before next session so that they are supervised and coached in procedures

before trying them at home; review and learn the time-out procedure; 5 minutes of CDI/special time each day

Session content: CDI and PDI coding to guide session, PDI coaching (parents and child) Homework: 5 to 10 minutes of PDI each day in which parents practice PDI in play situation (parents are encouraged to call

the therapist immediately if any problems arise with PDI at home) ; 5 minutes of CDI/special time each day

Session content: CDI and PDI coding to guide session, PD1 coaching (parents and child) Homework: 5 to 10 minutes of PDI during a clean-up situation plus 3 to 5 carefully selected direct commands throughout

the day to begin practice in generalizing PDI skills; 5 minutes of CDI practice/special time each day

Session content: CDI and PDI coding to guide session; third PDI coaching, CDI coaching as needed, first PDI clean-up (parents and child)

Homework: Use PDI skills for all noncompliance; note misbehaviors that are difficult to eliminate through the use of positive commands; 5 minutes of CDI/special time each day

Session content: CDI and PDI coding to guide session, fourth PDI coaching, CDI coaching as needed, PDI clean-up; introduce the use of house rules (parents and child)

Homework: 5 to 10 minutes of PDI during clean-up situation; PDI skill use throughout the day; establish and practice one house rule (if necessary); 5 minutes of CDI/special time each day

Session content: CDI and PDI coding to guide session, fifth PDI coaching, CDI coaching as needed, PDI clean-up; managing inappropriate behavior in public (parents and child)

Homework: 5 to 10 minutes of PDI during clean-up; PDI skill use throughout the day; practice house rule (if necessary at home); practice PDI skills in public; 5 minutes of CDI/special time each day

Session content: Termination (parents and child) Congratulate the family, view videos of pre-post treatment parent-child interactions, give parent and child a "certificate of

completion," provide parent with information on handling future behavior problems, and arrange follow-up calls to determine necessity of booster sessions

Homework: Continue 5 minutes of CDI practice/special time each day and use of PDI skills whenever a command is needed

* If parents have not met mastery criteria, CDI continues. Conversely, if criteria have been met in an earlier session, the family would have pro- gressed to the PDI phase of treatment. ** This will be the last session if mastery criteria are met and the child's behavior problems have improved to within normal limits. If criteria are not met or the child's behavior is not within normal limits, treatment will continue.

crit ical c o r r e c t i o n , i n s t ruc t i on o n the d e v e l o p m e n t a l ap-

p r o p r i a t e n e s s o f ch i ld behavior , o r an i n t e r p r e t a t i o n o f

t he ch i ld ' s specif ic behaviors .

In the first o n e or two c o a c h i n g sessions, the t he r ap i s t

pra ises the p a r e n t fo r all a p p r o p r i a t e s t a t e m e n t s a n d be-

havior. A typical initial c o a c h i n g sess ion m i g h t p r o c e e d as

follows:

PARENT (to child): You ' re b u i l d i n g a house .

THERAPIST: G o o d behav io ra l desc r ip t ion . T h a t shows

h i m y o u ' r e i n t e r e s t e d in wha t he ' s do ing .

PARENT (t0 child) : It looks like the h o u s e is g o i n g to be

tall a n d s t rong .

THERAPIST: G o o d i n f o r m a t i o n d e s c r i p t i o n . H e likes

your a t t en t ion .

PARENT (to child): G o o d j o b , Aaron!

THERAPIST: Nice praise .

PARENT (to child): You ' re m a k i n g tha t h o u s e n ice a n d

s t rong .

THERAPIST: Grea t labeled praise! It 's g o o d to tell h i m

exact ly wha t you like.

5 minutes -Write-up/documentation of session (e.g., progress note)

10 minutes - Brief check in

5 minutes - Behavior observations

10 minutes- Review data obtained from behavior observation, discuss homework, and target skills for focus during homework completion

20 Herschell et al.

30 minutes - Coaching

Figure 1. Structure of 60-minute coaching session with one parent.

Once parents are comfortable with the coaching, the therapist may introduce some redirection or noncrit ical correction along with the praise:

CHILD: This is where the trucks go. PARENT (to child) : The trucks will go in that garage. THERAPIST: Very nice reflection! Good job following

his lead. PARENT (to child) : There goes the red truck. THERAPIST: Nice following. What is he doing that you

can praise him for? PARENT (to child): You're driving that truck. THERAPIST: Yes! Good behavioral description. Now

tell him, "I like how quietly you're driving the trucks today."

Later coaching sessions are less directive, and require parents to use more advanced skills and generate solutions as problems arise. An example follows:

PARENT: Thanks for using an inside voice. [After parent praises, child immediately begins yelling.]

THERAPIST: Great praise. He's really trying to get a reaction out of you. What can you do? [Therapist pauses to allow parent time to determine an appropriate response to the misbehavi~ ]

PARENT: [ Turns away from the child, ignores the screaming, and begins building a tower. As soon as the child stops yeUingfor a moment to look at the tow~ the parent returns attention and speaks.] Now that you are quiet, we can play together!

THERAPIST: Perfect! You knew that was an attention- seeking behavior so you ignored him until he be- haved appropriately. You just taught him a valuable lesson. When he behaves well, he gets lots of attention. When he misbehaves, he gets no attention. Great job!

In all cases, the therapist matches the coaching to the needs of the individual parent and child. Therapists must

be a t tuned to the parent 's cognitive, emotional , and interpersonal style, as well as the child's developmental and social history and current emotional and behavioral functioning.

Tailoring coaching to the child's developmental level. PCIT is appropriate for use with chi ldren between the ages of 2 and 6, bu t is sensitive to the developmental changes that occur between these ages. Parent-child interactions with a 2-year-old must be approached differently than those with a 6-year-old. PCIT coaching takes into account these developmental differences and includes variations based on the child's age. First, of course, the toys that are provided must be appropriate for the child's developmental stage. Toddlers are provided with toys such as soft blocks and stacking rings, and parents are coached to play hand games like pat-a-cake and to sit on the floor with the child. They are also provided more toys than the older preschoolers because of their shorter at tent ion spans. Older preschoolers are given toys that allow for more elaborate play such as bui ld ing blocks, crayons, train sets, doll houses, and people or animal figures, and parents are coached in how to mainta in play at a table.

The parents also are trained to use age-appropriate verbal communica t ion with their child. Parents of toddlers are coached to keep their descriptions short and simple ("That's the red one!") and to pair their verbalizations with animated gestures such as hand-clapping. They also are encouraged to praise effusively and to reflect all of their child's attempts at verbal communica t ion because speech is developing rapidly at this age. In contrast, older chi ldren might interpret their parents ' exagger- ated use of praise or reflection as condescending or arti- ficial. Thus, parents of older chi ldren are coached to use a more natural and empathic tone of voice and are encouraged to issue reflections that paraphrase and sum- marize rather than repeat the child's statements.

Useful but nonessential technologies for coaching. The PCIT therapist typically coaches the parent from an ob- selwation room accessing the playroom by a two-way mirror and sound system. The parent wears a bug-in-the-ear device through which the therapist communicates with the parent as he or she plays with the child. With this technology, the child can play "alone" with the parent while the therapist coaches the paren t in PCIT skills. The aim is to create a naturalistic env i ronment within the laboratory setting so as to elicit the parents ' and child's everyday behavioi: In settings where these tools are not available to the PCIT therapist, in-room coaching is rec- ommended . To coach from inside the therapy room, the therapist sits slightly beh ind and to the side of the parent opposite the child so that the therapist can speak quietly to the parent while remaining unobtrusive and out of view of both the parent and child. Although there are many advantages to coaching with the bug-in-the-ear de-

Clinical Issues: Parent -Chi ld In te rac t ion Therapy 21

vice, p r e l i m i n a r y d a t a sugges t t h a t i n - r o o m c o a c h i n g is

also effect ive w i t h i n t h e b r o a d e r P C I T p r o t o c o l (Rayfield

& Sobel , 2000) .

A s s e s s m e n t

A s s e s s m e n t is a cr i t ical e l e m e n t o f P C I T in t h a t i t

g u i d e s c l in ica l d e c i s i o n m a k i n g t h r o u g h o u t t he t rea t -

m e n t p r o g r a m . A m u l t i m e t h o d a p p r o a c h t h a t i n c l u d e s

s t r u c t u r e d c l in ical in terv iews, p a r e n t a n d t e a c h e r r a t i n g

scales, b e h a v i o r o b s e r v a t i o n s in t h e c l in ic a n d t he schoo l ,

a n d speci f ic m e a s u r e s o f p a r e n t f u n c t i o n i n g a n d satisfac-

t i on wi th t r e a t m e n t a re all u s e d to i n f o r m c l in ica l deci-

s ions r e g a r d i n g t he focus a n d o u t c o m e o f t r e a t m e n t (see

Tab le 4 fo r a s u m m a r y o f t h e a s s e s s m e n t i n s t r u m e n t s de-

v e l o p e d fo r use in PCIT) .

In pa r t i cu la r , t h e Dyadic P a r e n t - C h i l d I n t e r a c t i o n

C o d i n g S y s t e m - I I (DPICS-II; Eyberg , Bessmer , N e w c o m b ,

Edwards , & R o b i n s o n , 1994) is i n t e g r a l to PCIT. T h i s be-

hav io ra l o b s e r v a t i o n sys tem m e a s u r e s t h e qua l i ty o f t h e

pa r en t - ch i l d i n t e r ac t i ons a t t r e a t m e n t en t ry a n d at t he s tar t

o f e a c h c o a c h i n g sess ion to d e t e r m i n e t h e focus o f t h e

sess ion a n d t h e m o v e m e n t f r o m o n e p h a s e o f t r e a t m e n t

to t h e nex t . P a r e n t s rev iew g r a p h s o f t h e DPICS-II d a t a

e a c h w e e k to d e t e r m i n e w h i c h skills n e e d m o s t a t t e n t i o n

in t h e i r h o m e p r a c t i c e sess ions a n d to eva lua t e t h e i r

p r o g r e s s t o w a r d skill m a s t e r y a n d t r e a t m e n t t e r m i n a t i o n .

T h e CDI c r i t e r i a fo r skill m a s t e r y r e q u i r e t h a t in t h e

5 - m i n u t e o b s e r v a t i o n o f CDI at t he b e g i n n i n g o f a session,

t he p a r e n t m u s t give a t leas t 10 b e h a v i o r a l d e s c r i p t i o n s ,

10 r e f l e c t i ons (g iven t h e o p p o r t u n i t y to d o so) a n d 10

T a b l e 4 Assessment Measures

Measure and Brief Description Relevant References

Semistructured Clinical Interview PCIT Intake Interview

• Includes developmental, social, medical, and educational history • Focuses on family's goals, treatment expectations, strengths, and challenges • Incorporates a detailed behavioral analysis (e.g., determining antecedents, consequences, and coercive

parent-child interactions) • Includes an assessment of discipline strategies

Parent Rating of Child Behavior and Treatment Satisfaction The Eyberg Child Behavior Inventory (ECBI)

• 36-item measure of behaviors associated with the primary childhood disruptive behavior disorders • Appropriate for children aged 2 to 16 • Contains two scales (Intensity and Problem)

Therapy Attitude Inventory (TAI) • Assesses consumer satisfaction with behavior management programs • Provides information about parent perceptions of the treatment process and outcome with regard to

practicality, acceptability, and efficacy

Teacher Rating of Child Behavior The Sutter-Eyberg Child Behavior Inventory-Revised

• 38-item scale designed to assess school behavior problems for students between the ages of 2 and 16 • Similar to the ECBI in format • Yields two scores: Intensity and Problem Scale • Contains two factors: oppositional behavior and attentional difficulties

Behavioral Observation The Dyadic Parent-Child Interaction Coding System-II (DPICS-II)

• Allows for efficient observation of parent-child interactions during three standardized laboratory situations (child-directed interaction, parent-directed interaction, clean-up)

• Records a large number of parent and child verbalizations, vocalizations, physical behaviors, and behavioral sequences

• Examples of parent behaviors--direct and indirect commands, behavior descriptions, information descriptions, reflections, labeled and unlabeled praise, physical positive and negative, and critical statements

• Examples of child behaviors--compliance and noncompliance, physical positive and negative, yell, whine, smart talk, laugh, and destructive behavior

School Observation Coding System (REDSOCS) • Uses interval recording • Includes three categories of behavior: appropriate vs. opposifional, on-task vs. off-task vs. not applicable,

and compliance vs. noncompliance • Compares target child to classroom controls

Eyberg & Calzada (1998)

Eyberg&Pincus (1999)

Brestan,Jacobs, Rayfield, & Eyberg (1999)

Eyberg & Pincus (1999)

Eyberg et al. (1994)

Jacobs et al. (2000)

22 Herschell et al.

l abe led praises. In addi t ion, no more than 3 verbalizations that are commands , criticisms, or questions may be issued dur ing the same 5-minute per iod. Once the child 's parents meet these criteria, the second phase of PCIT, PDI, is init iated.

The PDI cri teria for skill mastery require that dur ing a 5-minute observat ion of PDI at the beg inn ing of a session, the pa ren t must give at least 4 commands , of which at least 75% must be "effective" (i.e., direct, positively stated, single c o m m a n d s that provide an oppor tun i ty for the child to comply), and parents must show at least 75% correct fol low-through after effective commands ( labeled praise after compl iance and warning after noncompl i - ance). In addi t ion, if the child requires a t ime-out that begins dur ing the observation, the pa ren t must successfully follow th rough with the PDI p rocedure and the interact ion must end with compl iance to the original command. Successful mastery of both CDI and PDI skills is requi red to comple te the t rea tment program.

C a s e Examp le o f a Phys ica l ly A b u s e d Child

Rationale for PCIT In 1997, approximate ly 984,000 chi ldren or 13.9 pe r

1,000 ch i ldren were victims of substant iated or indica ted mal t rea tment , of whom about 25% were physically abused, most of ten (approximate ly 75%) pe rpe t r a t ed by their parents (U.S. Depa r tmen t of Heal th and H u m a n Services, 1999). Many research efforts to examine child physical abuse have been ini t iated and general ly have focused on descr ibing chi ldren and families who have expe r i enced abuse (e.g., Becker et al., 1995; Kolko, 1992; Oates & Bross, 1995). Less research a t tent ion has been devoted to t rea tments to prevent or remedia te the effects of abuse (Urquiza & McNeil, 1996). The empir ical suppor t for PCIT has been establ ished for families with children with disruptive behavior disorders, but this treat- men t also has been successfully appl ied to families exper ienc ing o the r difficulties, inc luding child physical abuse (see research review, this issue; Herschel l et al., 2002).

PCIT offers a promis ing t rea tment approach to child physical abuse for several reasons (see Filcheck, McNeil, & Herschell , in press; Urquiza & McNeil, 1996, for more deta i led discussions). First, the format of PCIT may be part icularly appropr i a t e for t r ea tment of physically abusive families. Physically abusive parents may benefi t f rom a more concrete , p rob lem-or ien ted , behavioral t ra ining approach in which parents must practice in teract ing positively while s imultaneously control l ing their anger with their child (Azar & Wolfe, 1998; Wolfe & Sandler, 1981). As no ted by Bonnet , Kaufman, Harbeck, and Brassard (1992), PCIT therapists utilize concre te t ra ining strategies (e.g., d i rect coaching) , model and role-play specific

skills, assign daily homework, and require pract ice of skills unti l mastery is achieved. Second, the p rob lems under lying physical abuse (e.g., coercive parent-chi ld interaction) also are c o m m o n among chi ldren exper ienc ing disruptive behavior. PCIT targets and works toward correct ing such coercive in teract ion patterns. Third, disruptive behavior disorders and physical abuse often co-occur. Many families seen clinically in PCIT have been physically abusive families. Fourth , abusive families general ly exper ience fewer positive interact ions and a grea ter number of negative interact ions than nonabusive families (Azar & Wolfe; DePanfilis & Salus, 1992). PCIT places a s t rong emphasis on developmenta l ly sensitive, positive pa ren t ing skills in an effort to increase positive interactions and decrease negative affect and control between the parents and child. Finally, child ma l t r ea tmen t is likely a result of mul t ip le factors in the parent-chi ld dyad that can best be r emed ia t ed when working with the pa ren t and child toge ther as is done in PCIT (Filcheck et al.; Urquiza & McNeil).

Case Background Information Ms. W was cour t o rde r e d to par t ic ipate in PCIT with

he r 6-year-old son, Tyler. Tyler and his 2-year-old brother, Thomas, had been removed from their mother ' s care approximate ly 14 months pr ior to the PCIT referral due to a substant iated inc ident of physical abuse by Ms. W. Ms. W descr ibed the inc iden t as beg inn ing when she saw Tyler push Thomas to the g round and hit him. In response, she g rabbed a bel t and went to "spank" Tyler for hur t ing Thomas. When Tyler saw his m o t h e r coming, he ran from her. As he was running, Ms. W hit h im on the back and shoulders with the belt. She r epor t ed that the belt also must have struck his face because later she saw a mark on his face. Ms. W's sister, who also not iced the mark, r epo r t ed the inc ident to Child Protective Services (CPS). A CPS investigation was init iated, and the abuse was substantiated. Both chi ldren were p laced in foster care, and Ms. W was sen tenced to 3 months in jail . Follow- ing the ja i l term, Ms. W was requ i red to comple te 100 hours of communi ty service, a t tend 14 weekly 1.5-hour anger m a n a g e m e n t classes, a t tend 12 weekly 1-hour paren t ing classes, a t tend individual therapy, comple te a psychological evaluation, and par t ic ipate in PCIT. These requirements , as well as ob ta in ing appropr ia t e hous ing and furnishings, were specified in her CPS family service plan and proba t ion guidelines. PCIT was ini t ia ted after successful comple t ion of all o the r family service plan and proba t ion requirements , and approximate ly 1 mon th pr ior to ant ic ipated reunificat ion.

Assessment Ms. W failed to a t tend or cancel her first two sched-

uled intake sessions. After the second no-show, the thera-

Clinical Issues: Parent-Child Interaction Therapy 23

pist (A.H.) contacted Ms. W and her CPS social worker by phone and mail. Each was informed that if Ms. W did not attend a third scheduled appointment, she would be placed at the end of the wait list. The therapist explained that placement on the wait list would place Ms. W in vio- lation of the court order, delay her complet ion of the family service plan, and thereby delay reunification. The social worker strongly encouraged Ms. W to attend the session.

Ms. W arrived on time for the third scheduled intake session and brought with her a completed Child Behavior Checklist (CBCL), Eyberg Child Behavior Inventory (ECBI), Parenting Stress Index (PSI), and Child Abuse Potential Inventory (CAPI) (see Table 4), all of which had been previously mailed to her. During the session, a clinical interview was conducted, and Ms. W and Tyler were observed in the three parent-child interaction tasks (child-directed interaction, parent-directed interaction, and clean-up situations) of the DPICS-II.

In that Tyler had not been in Ms. W's care for 14 months, results of this formal assessment were inter- preted with caution. Both Ms. W and Tyler seemed happy but tentative during this reunion, and it is unlikely that their behavior represented a normal pattern of interaction for them. There also was a high likelihood (under- standably) that Ms. W would want to present herself and her child favorably, considering the involvement of CPS and the legal system as well as her desire to have the children returned to her care. Therefore, Tyler's current foster mother was asked to complete the same question- naires (i.e., CBCL, ECBI, PSI, CAPI). Results of the assessment revealed that Tyler exhibited some conduct problems. Both his biological and foster mothers ' CBCL Tscores were clinically elevated on the Externalizing and Total Problems scales. On the Externalizing scale, Ms. W's score was T = 71 and the foster mother 's score was T = 75. These scores were consistent with their scores on the ECBI. Ms. W obtained an Intensity Score of 135 and a Problem Score of 16; the foster mother obtained an In- tensity Score of 140 and a Problem Score of 18, indicating moderate conduct problems. Tyler's classroom teacher completed a Sut ter-Eyberg Child Behavior Inventory- Revised (SESBI-R; Eyberg & Pincus, 1999) that indicated an Intensity Score of 147 and a Problem Score of 21. These scores were consistent with the biological and foster mothers ' reports that Tyler was experiencing a clinically significant level of disruptive behavior.

Results of Ms. W's completed CAPI revealed an elevated "Faking-Good index," render ing the results invalid and prohibiting further interpretation. Results of the foster mother 's completed CAPI indicated no clinically significant scores.

During the DPICS-II baseline behavioral observations, Ms. W appeared uncomfortable interacting with Tyler.

Rather than playing with him, she sat quietly and observed his play. Her attempts to interact with him generally began with questions or indirect commands. In fact, in all three observed situations, approximately 75% of Ms. W's verbalizations were questions or indirect commands. In the CDI observations, Ms. W gave 4 descriptive statements, 2 reflective statements, 12 questions, 6 indirect commands, and no praise. Similar patterns were noted during observation of the PDI and clean-up situations. Tyler complied with approximately 33% of Ms. W's commands. In spite of Ms. W's difficulty dur ing the interaction, Tyler seemed to enjoy the individual time with his mother.

Through the intake and course of additional sessions, it was learned that Ms. W was brought up by her single mother, who abused substances regularly (almost daily). During her childhood, Ms. W experienced extreme family conflict, periodic homelessness, and both neglect and physical abuse perpetrated by her mother. Ms. W was 15 years old when she gave birth to Tyler. Shortly thereafter, she dropped out o f high school (9th grade) to care for him. Ms. W reported having had three intimate relation- ships, which all involved domestic violence and ended in extreme conflict. A CPS history provided by the social worker confirmed Ms. W's report.

The therapist helped Ms. W to unders tand her parenting difficulties in the context of her past experiences and stressors and was supportive and nonjudgmenta l while maintaining the focus of the assessment and t reatment goals. The session proved to be instrumental in establishing rapport with Ms. W, who was generally suspicious of mental health professionals. Also dur ing this session, the therapist completed an assessment of the services already received by Ms. W, particularly previous parenting classes, to ensure consistency in treatment.

Treatment CDI teaching session. The first t reatment session, at-

tended by Ms. W alone, was a valuable opportuni ty for cont inuing to build rapport, obtaining additional information relevant to treatment, and establishing Ms. W's expectations for future t reatment sessions. During this highly interactive session, the therapist presented each skill individually (see Table 1), providing its description and rationale, and then requested Ms. W's feedback, incorporated her appropriate suggestions, and provided many examples of the application of the skill to Tyler's specific behaviors. Th roughou t this session, modeling, role-plays, and h u m o r were used to engage Ms. W. Special effort was made to avoid blaming Ms. W or minimizing her parent ing abilities. Instead, the therapist emphasized Ms. W's strengths, compl imented the parent ing successes she had already experienced (e.g., complet ing parent ing classes), and discussed how she and the therapist could

24 Herschell e t al.

work toge ther to improve Tyler's behavior. Following interactive instruct ion on the skills, Ms. W was asked and agreed to comple te 5 minutes of homework (i.e., CDI play) dur ing her visits with Tyler dur ing the week. She was given a form to use for r ecord ing whether or not she comple ted the homework at each visitation and to note any concerns or quest ions that came up.

CDI coaching sessions. Both Ms. W and Tyler a t t ended the next session, the first coaching session. The therapist began the session by talking with Tyler about why he and his morn were a t t end ing sessions and what he could expec t f rom therapy, and then showed him the t rea tment room. Next, Tyler was given toys to play with while the therapis t reviewed with Ms. W her comple ted homework sheet. She had comple ted homework dur ing each visit with Tyler as promised, and she r epor t ed no questions or concerns. The therapis t comp l imen ted Ms. W on comple t ion of homework, no t ing that it would he lp treat- men t progress more swiftly. The therapis t devoted t ime to facili tating a discussion a r o u n d how Ms. W was able to fit the homework into visits, and its effects on her and Tyler. Together, the therapis t and Ms. W dec ided to focus the session on increasing behavioral descriptions. The therapist he lped Ms. W secure the "bug" (bug-in-the-ear ear- piece), exi ted the playroom, and went into the observation room. During the 5-minute DPICS-II coding conducted before coaching, Ms. W demons t ra t ed a slight increase in reflections and a slight decrease in commands from the basel ine assessment. She was given labe led praise for the improvements seen dur ing coding, followed by 30 minutes of coaching focusing only on the positive skills that Ms. W demons t ra t ed in this first coaching session.

THERAPIST: W o w - - w e are off to a great start! You already are increasing the n u m b e r of reflections and decreas ing the n u m b e r of commands that you give Tyler. This is exactly what we talked a b o u t - - I can tell that you worked hard dur ing the week on your homework. Good job!

Ms. W (t0 Tyler) : What are you making with that Play- Doh?

THERAPIST: [Silent--ignoring the question and waiting for a statement]

Ms. W (to Tyler): It looks like you ' re going to make a snake.

THERAPIST: Excel lent behavioral description! Ms. W (t0 Tyler) : You are making a very scary snake. THERAPIST: There is ano the r great behavioral descrip-

tion.

After coaching, the therapist met with Ms. W and Tyler to process thei r react ions to the session and to review a graph of the skills assessment coded at the beg inn ing of the session. Again, the therapis t focused only on the skill categories showing improvement . Together, the therapis t

and Ms. W agreed on specific homework goals for the next week.

Subsequent CDI coaching sessions followed a similar format (see Figure 1). For each, the therapis t conduc ted a 10- to 15-minute check-in to review t rea tment progress, discuss homework comple t ion , and assess relevant life events and stressors. Next, a 5-minute behavior observation was coded, followed by coaching for 30 minutes and a 10-minute review of skill use and homework planning.

With each coaching session, Ms. W's skills improved, and she expressed great pr ide in he r accomplishments . She also seemed more invested in t rea tment as it pro- gressed. For example , dur ing check-ins she frequent ly asked questions about par t icular behavioral difficulties with Tyler and how the PCIT skills could be appl ied with her younger son, Thomas. Through these questions, the therapis t taught Ms. W a s tandard problem-solving tech- nique for appl icat ion to child issues that arose. They re- co rded the solutions on the homework sheet and reviewed their success the following week. Unsatisfactory solutions were resolved toge ther when they occurred. A second example of Ms. W's investment in t r ea tment was he r curiosity and high interest in reviewing her skill ac- quisit ion chart. A part icularly difficult skill for Ms. W was labeled praise, which became the focus of intensive coaching and was a part icularly impor t an t victory for Ms. W once she achieved the chal lenging mastery cri teria of 10 labe led praises in 5 minutes.

After he r fifth coaching session, Ms. W met mastery cri ter ia for CDI and was eager to advance to PDI, the second phase of PCIT; however, advancing to PDI was de- layed because of p l acemen t concerns . Tyler had no t yet been r e tu rned to Ms. W's full-time care, so she and the therapis t d e t e r m i n e d that it would be best to wait unti l reunif icat ion to begin PDI. The therapis t contac ted the CPS social worker to check on reunif icat ion status and l ea rned it was ext remely likely that Tyler would be re- tu rned at the end of the month . Therefore , sessions were scheduled every o ther week to assure main tenance of the CDI skills in the in ter im and to provide suppor t for Ms. W dur ing this part icularly stressful t ime. The t ime also was used to help her secure adequa te child care in anticipa- t ion of n e e d e d respite once her ch i ldren were re turned .

T h r o u g h o u t the first phase of t rea tment , the therapis t had been in f requent contact with Ms. W's social worker. In fact, the social worker had a t t ended a session to observe the progress and discuss coord ina t ion of services. That mee t ing he lped to establish a working re la t ionship between the therapis t and social worker and facili tated coord ina t ion of t rea tment efforts. For example , when Ms. W had exhausted her available opt ions for adequa te housing and men t ioned this to the therapist , the therapist was able to work with the social worker to advocate ef- fectively for new hous ing opt ions for Ms. W.

Clinical Issues: Parent-Child Interaction Therapy Z5

One week pr ior to ini t iat ing the PDI teaching session (the t ime of the mid t r ea tmen t assessment), the therapis t asked both Tyler's foster m o t h e r and Ms. W to comple te ECBIs again. Ms. W's scores suggested that she perceived some improvemen t in Tyler's b e h a v i o r - - h i s scores came to within normal limits (Intensity Score = 129; Problem Score = 11), a l though his foster mother ' s r epor t showed no change f rom he r ear l ier r epor t indicat ing modera t e conduc t p roblems (Intensity Score = 141; Problem Score = 16).

PDI teaching session. After comple t ion of the midtreat- m e n t quest ionnaires , and 1 week before the expec ted reunif icat ion date, the therapis t taught the PDI skills (Ta- ble 2) to Ms. W, using a highly interactive teaching format, similar to the CDI teaching session. Following an overview of PDI, the therapis t descr ibed the use of effective commands (e.g., "Please give me the hammer") , how to de te rmine child compl iance versus noncompl iance , and how to provide consistent, appropr ia te consequences for child compl iance and noncompl iance . In this session, she role-played giving enthusiastic labe led praise after compl iance and giving a clear t ime-out warning after noncompl i ance ("If you don ' t [e.g., give me the hammer] , you will have to sit on the t ime-out chair"). The therapis t mode led the s t ructured PDI t ime-out procedure using a child-sized teddy bear as the child, and then role-played the p rocedure with Ms. W. Together, the therapist and Ms. W tr ied to ant icipate the p rob lems Tyler might p resen t dur ing time-out, and they discussed how different p rob lems could be managed. One concern Ms. W ment ioned was the high l ikel ihood that Tyler would refuse to stay on the t ime-out chair. The therapis t then descr ibed the back-up p rocedure that would be used to teach Tyler to stay on the chair. When Tyler got off the t ime-out chair, he would have to go to the t ime-out room for 1 minute. After the t ime-out room, Tyler would still have to sit on the chair for 3 minutes, which is the punish- men t for noncompl iance . Ms. W agreed not to practice PDI dur ing the next week when she visited Tyler. That way, the therapis t could coach her in the p layroom the first t ime that she used the t ime-out p rocedure with Tyler, which she expec ted would be difficult. Ms. W also agreed to review the t ime-out h a n d o u t every day so that she could r e m e m b e r the p rocedu re when she and Tyler came to the next session. The therapis t and Ms. W also discussed how they would present the new procedures to Tyler, who would be moving back home only 2 or 3 days after the next session.

PDI coaching sessions. At the beginning of the first PDI coaching session, the therapist reviewed the PDI procedure with Ms. W and expla ined it briefly to Tyler. After all of their questions were answered, the therapist began coaching CDI until Ms. W and Tyler were comfortable and engaged in the play. Then Ms. W was coached to explain

to Tyler that today's session would be different than before. She told him that when he re tu rned home, the rules would be different than before. Ms. W explained,

'~Zou know that we have come here to learn how we can get a long better. One way you can he lp us is by listening. Today we are going to pract ice listening. So, it 's really impor t an t that when I tell you to do something, you do it. When you listen, I ' l l be very happy and p r o u d of you. In fact, I 'm going to tell you how glad I am when you listen. But if you choose no t to listen, I ' m going to r emind you o f how impor t an t it is by r emind ing you that you have to do what I told you to do or you will have to sit on the t ime-out chair, and that is no fun. From now on, this is what we will do here, and we will also pract ice this when you come home."

With all families, coaching dur ing the first PDI session must be fast-paced and directive to ensure pa ren t and child success. The therapis t also must be especially sensitive to the parent ' s feelings and needs. Dur ing Tyler's first exper ience on the t ime-out chair, he began screaming, "I hate you. I know you d o n ' t love me. I never want to come home." Over the bug, the therapist immediately responded:

"I know that must be ha rd to hear, but it 's pret ty c o m m o n for kids to say things they don ' t mean when they ' re angry. R e m e m b e r we ta lked abou t how this change would be ha rd for Tyler, and you said he would probably be angry with you for changing the rules [Ms. W nods]. We dec ided then that it is impor t an t to ignore that behavior because you will teach h im that you are consistent and pre- dictable and that you will r e spond to his misbehav- ior in a calm way. Keep it up; you ' r e do ing a great job."

The therapis t used a calm and soothing voice and coached Ms. W to use a deep b rea th ing strategy focusing on slow, cont ro l led b rea th ing to he lp Ms. W decrease he r he igh tened stress response.

After 70 minutes, the first PDI session ended . Dur ing the session, Tyler had to go to the t ime-out chair twice and the t ime-out room once, but by the end of the session, he was following his mother ' s commands easily. With the therapist ' s assistance, Ms. W improved her commands and gradually became comfor table with the procedure . She l ea rned to state t ime-out warnings matter-of- factly after commands when Tyler a t t empted to side-track ra ther than obey, and every t ime that Tyler obeyed, she r e m e m b e r e d to give him a labe led praise. Ms. W devel- oped a good pace in he r practice, and used all of he r CDI skills between the c o m m a n d - o b e y - p r a i s e sequence of PDI. At the end of the session, she descr ibed herself as exhausted but elated. The therapis t stressed how impor t an t

26 Herschell et al.

it would be to have CDI special t ime with Tyler every day as soon as he moved home, and she assigned daily 10- minute PDI practice. She asked Ms. W to call immedia te ly if she had any difficulties with PDI dur ing their practice at home.

In subsequent PDI sessions, Tyler rarely needed to go to time-out, and the intensity of his react ions to t ime-out decreased immedia te ly after the first coaching session, even as the commands were made more difficult. Specific a t tempts were made to general ize gains in the clinic to o the r settings by (a) incorpora t ing a clean-up task, (b) establishing house rules, and (c) providing instructions and in vivo coaching on the use of the PDI skills in public places. By the sixth PDI coaching session, Ms. W demon- strated mastery of both the CDI and PDI skills. The social worker r epor t ed visiting the home and be ing impressed with the mother ' s behavior with the boys. Ms. W repor ted conf idence in manag ing Tyler's behavior one-on-one, but no ted that it was still difficult to manage the two boys together, despi te a house rule for hitting. Ms. W brough t Thomas a long to two of the last sessions so that the therapist could observe and coach Ms. W in interact ions with both ch i ld ren simultaneously.

Treatment completion. At the 14th session, the therapis t and Ms. W discussed t rea tment progress and agreed that t r ea tment goals had been met. The therapis t recom- m e n d e d they mee t for 2 more sessions to consol idate the gains and plan main tenance strategies. She men t ioned that after sessions ended, Ms. W would be welcome to contact he r with any concerns. The therapis t also men- t ioned that she would call in about 4 weeks to schedule a boos ter session with the family. Ms. W expla ined to Tyler that t r ea tment would soon end and that both she and the therapist were very p roud of Tyler for he lp ing them to learn how to get a long be t te r by l istening so well .Just before the 16th session, Ms. W comple ted ano the r ECBI. The scores were within normal limits (Intensity Score = 94; Problem Score = 6). Behavioral observations dur ing the session showed con t inued mastery of Ms. W's CDI and PDI skills. Tyler was compl ian t to 91% of his mother ' s 11 di rec t commands . On the one occur rence of noncompliance, Ms. W appropr ia te ly gave a warning, and praised Tyler when he then obeyed. After discussing all of the assessment results, Ms. W and the therapis t agreed that this would be the final session.

To mark the end of therapy, the family reviewed pre- and pos t t r ea tment videotapes of DPICS-II interactions. Together; the therapis t and Ms. W discussed changes made in the re la t ionship between Ms. W and Tyler, attrib- ut ing these gains to Ms. W's behavioral changes. They also discussed Ms. W's ability to manage Tyler's behavior without "spanking" him and her PRIDE in he r own behavior as well as his. Ms. W was given a certificate of complet ion, and Tyler was given a blue r ibbon for good be-

havior. The therapis t emphas ized that con t inued daily practice of the PCIT skills th rough the CDI special t ime and con t inued use of PDI whenever Ms. W n e e d e d to direct Tyler would help to mainta in and cont inue improv- ing Tyler's behavior and the gains made in t rea tment . Ms. W was again r e m i n d e d that she could contact the therapis t at any t ime and that the therapis t would contact he r in 4 weeks to schedule the follow-up visit.

Booster session. Six weeks after t r ea tment ended , Ms. W and Tyler a t t ended a booster session. Ms. W repor t ed that Tyler was do ing well. He had expe r i enced no behavioral difficulties at home or school o the r than occasional noncompliance, which Ms. W quickly po in ted out led to a time-out. She also r epor t ed that Tyler had started back- talking her at times. In response, she had begun giving labe led praise for the "positive opposites" (e.g., using po- lite words, speaking respectfully) and ignor ing the sassy behavior. She expressed concern that he was learn ing this behavior from the o the r ch i ldren and families in he r neighborhood. As before, the therapist and Ms. W problem- solved possible solutions to the dilemma. A DPICS-II assess- men t revealed that Ms. W's CDI skills were slightly below mastery level, but her PDI skills were excellent , and Tyler's compl iance (88%) r ema ined high. When asked if she had con t inued to pract ice the CDI skills with Tyler, Ms. W repor ted not pract ic ing as often as when she and Tyler a t t ended weekly therapy sessions. The therapis t rec- o m m e n d e d that she resume daily CDI, emphasiz ing the impor tance of main ta in ing t rea tment gains. Ms. W expressed concern over he r slight d rop in CDI skills and in- d ica ted that she would make a greater effort. The booster session e n d e d with the therapis t prais ing the family for their con t inued success and Ms. W agreeing to contact the therapis t in the future if needed .

C o n c l u s i o n

The clinical validation of PCIT is, in large part, a result of critical componen t s buil t into the protocol . Specifi- cally, these componen t s include actively involving parents and their ch i ld( ren) in t rea tment , relying on assess- men t to guide each family's progress, using coaching as the key therapeut ic tool, tai loring skill appl ica t ion to the family's individual needs, and cont inu ing in t rea tment unti l mastery of skills is achieved and the child 's behavior is within normal limits. These same componen t s allow the t rea tment model to t ranscend the t r ea tment of families with young conduc t -d i sordered chi ldren to the treat- men t of families with young chi ldren who have experienced a wide range of emotional and behavioral disorders as well as ch i ldren who have expe r i enced physical abuse. For physically abusive families, PCIT offers a promis ing approach to r emedia t ing the negative effects of abuse, an unfor tunate ly c o m m o n p h e n o m e n o n in our society.

Clinical I s s u e s : P a r e n t - C h i l d I n t e r a c t i o n T h e r a p y 27

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Address correspondence to Cheryl B. McNeil, Ph.D., Depar tment of Psychology, West Virginia University, Morgantown, WV 26506-6040; e-mail: [email protected].

Received: July 9, 2001 Accepted: July 30, 2001