parent-child interaction therapy: new directions in research

Parent-Child Interaction Therapy: N e w Directions in Research

A m y D. Hersche l l , West Virginia University E s t h e r J . Calzada, New York University Shei la M. Eyberg , University of Florida

Chery l B. McNeil , West Virginia University

Parent-Child Interaction Therapy (PCIT) is a short-term, evidence-based parent training program for families with 2- to 6-year-old children experiencing behavioral, emotional, or family problems. Based on both attachment theory and social learning theory, PCIT research has provided evidence of efficacy, generalization, and maintenance. The new directions in PCIT research are highlighted in this article.

p ARENT-CHILD INTERACTION THERAPY (PCIT) is a short-term, evidence-based intervention designed for

families with children between the ages of 2 and 6 who are experiencing a broad range o f behavioral, emotional, and family problems. This manualized parent training program has two discrete phases, Child-Directed Interac- tion (CDI) and Parent-Directed Interaction (PDI). CDI concentrates on strengthening parent-child at tachment as a foundat ion for PDI, which emphasizes a structured and consistent approach to discipline. Throughou t treatment, emphasis is placed on the interaction between the parents and their child due to the specific theoretical as- sumptions about the development and maintenance of externalizing behavior 1 in children. The protocol is assessment driven and is not time limited; progress in the parent-child interactions is coded at each session, and treatment is completed when parents have mastered the skills of CDI and PDI and the child's behavior is within normal limits.

Research indicates that externalizing behavior origi- nates from multiple child and family factors. Child factors may include difficult temperament (Bates, Bayles, Ben- nett, Ridge, & Brown, 1991), hyperactivity (Loeber & Keenan, 1994), faulty social information processing (Crick & Dodge, 1994), and genetic difficulties. These child factors interact with adverse family factors in the development and maintenance of externalizing behavior (Kazdin, 1987). Family factors may include maternal depression

1 The term "externalizing behavior" is used to refer to disruptive behavior characteristic of diagnostic criteria for oppositional<lefiant disorder or conduct disorder (e.g., noncompliance, aggression).

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(Forehand, Furey, & McMahon, 1984; Webster-Stratton & Hammond, 1990), stressful life events (Campbell, 1998), anger (Wolfe, 1987), parent conflict about childrearing (Bearss & Eyberg, 1998; Bearss, Eyberg, & Hoza, 2002), social isolation (Dumas & Wahler, 1983), single-parent status, or poverty (Forehand et al.). Family factors are thought to influence child behavior through their effect on parenting behaviors (Patterson, Reid, & Dishion, 1992; Tolan, Guerra, & Kendall, 1995). Parents' early interactions with their young child appear to be the most proxi- mal parental influence on the child's behavioral development (Campbell, 1997), and parenting practices continue to play a critical role in the maintenance of externalizing behavior throughout chi ldhood and adolescence (Mc- Mahon & Estes, 1997). The strong and consistent relations between certain parenting styles and problematic child outcomes (Azar & Wolfe, 1989; Franz, McClelland, & Weinberger, 1991; Olson, Bates, & Bayles, 1990) suggests the need to focus on parenting style and parent- child interactions in families whose young children dem- onstrate behavioral and emotional problems.

T h e o r e t i c a l F o u n d a t i o n s o f PCIT

According to at tachment theory, sensitive and responsive parent ing during infancy and toddlerhood leads the child to develop a cognitive-affective working model that predicts that the child's needs will be met by the parent. Thus, young children whose parents show greater warmth, responsiveness, and sensitivity to their signals are more likely to develop a secure working model of their rela- tionships with others and more effective emotional regu- lation (Ainsworth, Blehar, Waters, & Wall, 1978). Clinic- referred preschoolers with externalizing behavior are more likely than nonreferred children to be distressed during separations from parents and to display behavioral indicators of insecure at tachment (Greenberg & Speltz, 1988).

I0 Herschell et al.

CDI draws from a t t achment theory in its aims to re- s tructure the parent -chi ld re la t ionship and provide a secure a t t achment for the child. Parents are taught skills that foster positive, nur tu r ing in teract ion patterns. This phase of t rea tment recognizes that parents can have a part icular ly dramat ic effect on their child 's behavior during the early preschool years when chi ldren are more responsive to parenta l a t tent ion and less susceptible to the inf luence of peers, teachers, or deve lopmenta l au tonomy than in la ter years (Eyberg, Schuhmann, & Rey, 1998).

Social learn ing theory asserts that child behavior problems are inadvertent ly establ ished or main ta ined by dys- funct ional parent-chi ld interactions. According to Patter- son, each m e m b e r in the re la t ionship a t tempts to control the behavior of the o the r th rough habitual , aversive behaviors, thus establishing a coercive style of in teract ion (Patterson, 1975, 1976, 1982; Patterson, DeBaryshe, & Ramsey, 1989). The coercive interact ion cycle is main- ta ined by negative re inforcement , in which external iz ing child behaviors (e.g., arguing, aggression) are re inforced by pa ren t behaviors (e.g., withdrawal of demands) , and, in turn, negative pa ren t behaviors (e.g., yelling) are rein- forced by chi ld behaviors (e.g., momen ta ry compliance) . Parents of ch i ldren exhib i t ing external iz ing behaviors have of ten been found to be both power-assertive and lax in their discipline. This inconsistency serves to s t rengthen the young child 's external izing behavioral reper to i re (Sansbury & Wahler, 1992). PCIT specifically addresses such processes by establishing consistent con- t ingencies for the child 's behavior dur ing the PDI phase of t rea tment .

Structure of PCIT

For each phase of t rea tment , CDI and PDI, parents at- tend one didactic session dur ing which the therapis t de- scribes the skills of the interact ion and provides the ra- t ionales for their use. Model ing and role-playing are incorpora ted into these sessions to facilitate learn ing of the skills. Following the initial didactic session, parents and their child a t tend weekly coaching sessions together. Between sessions, parents are asked to devote 5 to 10 minutes a day pract ic ing the interact ions with thei r child at home.

Dur ing CDI, parents are taught to use the PRIDE skills (Praise, Reflection, Imitat ion, Descript ion, and Enthusi- asm) at high rates and to avoid questions, commands , and criticism while they play with their child. The play sit- uat ion at home and in the clinic is a r ranged so that the child may choose the toy(s) he or she would like to play with, and the pa ren t is ins t ructed to play a long with the child, following the child 's lead. Dur ing the coaching sessions, parents typically wear a bug-in-the-ear hear ing de- vice and are coached on their use of the skills by a thera-

pist who is observing the parent-chi ld in teract ion from beh ind a one-way mirror.

Once the parent ' s CDI skill level meets a predeter - mined set of criteria, the second phase of PCIT is in- itiated. Dur ing PDI, parents are taught to issue clear, developmental ly appropr ia te , direct commands and to provide consistent consequences for bo th their child 's compl iance and noncompl iance . Parents are instructed to provide labe led praise following child compl iance and to initiate a t ime-out p rocedure following child noncompliance. Parents are coached in the use of these skills during a play situation with their child in which they must issue commands and follow th rough with the appropr ia t e consequence (i.e., praise or t ime-out) .

For most families, the full course of t r ea tment is com- p le ted in 10 to 16 weekly, 1-hour sessions. A comprehen- sive PCIT t rea tment p rogram includes (a) a p re t r ea tmen t assessment of child and family funct ioning; (b) feedback, teaching, and coaching of parents in the CDI skills; (c) teaching and coaching of parents in the PDI skills; (d) teaching general izat ion skills; and (e) a pos t t rea tment assessment of child and family funct ioning. Follow-up assessments are r ecommended , and booster sessions should be provided, if needed.

Efficacy of PCIT

Outcome research on PCIT has demons t r a t ed clinically and statistically significant improvements in the in terac t ional style o f parents and in the behavior problems of ch i ld ren at home and at school (Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk , 1993; Mc- Neil, Eyberg, Eisenstadt, Newcomb, & Funderburk , 1991; Schuhmann , Foote, Eyberg, Boggs, & Algina, 1998). In add i t ion to f inding that PCIT is efficacious in he lp ing them manage the i r chi ld ' s behavior, pa ren t s r e p o r t h igh levels of satisfaction with the c on t e n t and process of PCIT, less pe r sona l distress as the i r chi ld 's behav ior improves, and more conf idence in the i r abil i ty to control the i r chi ld 's behavior ( S c h u h m a n n et al.). The effects of PCIT have been shown to genera l ize to o the r m e m b e r s of the family, i nc lud ing the behavior of un- t rea ted siblings of r e fe r red ch i ld ren and the psychological func t ion ing of the p a r e n t (Brestan, Eyberg, Boggs, & Algina, 1997; Eyberg & Robinson, 1982). These examina t ions of PCIT have i nc luded compar i sons of t rea ted ch i ld ren to wait-list cont ro ls (McNeil, Capage, Bahl, & Blanc, 1999; Q u e r i d o & Eyberg, 2001; Schuh- mann et al.), no rma l c lassroom controls , un t r ea t ed c lassroom controls (McNeil et al., 1991), modif ied treat- m e n t g roups (Nixon, Sweeney, Erickson, & Touyz, 2001), t r e a tmen t d ropou t s (Edwards et al., 2002), and cont ro l groups varying in severity of disrupt ive behav ior ( F u n d e r b u r k et al., 1998). Each c o m p a r i s o n has dem-

Parent-Child Interaction Therapy Research 11

ons t r a t ed the super io r i ty o f t r e a t m e n t over var ious con t ro l cond i t ions .

N e w D i r e c t i o n s

The progress ion of t r ea tment research is not linear; it advances like spokes in a rota t ing wheel. The spokes in- c lude t radi t ional child outcomes, outcomes for the family, outcomes across situations, and outcomes ex tend ing fur ther in time. They include c o m p o n e n t analyses, process analyses, and predic tors of t r ea tment events. They in- c lude appl icat ions of t r ea tment to ch i ldren f rom diverse backgrounds , and new variations of t r ea tment delivery. They include new methods to measure and analyze change. At its hub, the t rea tment itself is changed with the knowledge ga ined from the many direct ions of study. In the scientist-practi t ioner model , clinical pract ice sits at the hub as well. It is shaped by the research and, in turn, generates impor t an t and practical research questions. In this section, we review the new direct ions of PCIT research, and suggest ways to fur ther our under s t and ing of this t reatment .

Effectiveness Examinat ion of the efficacy of a t r ea tment is an impor-

tant first step in t r ea tment research. It is impor tan t to follow that step with an examina t ion of how, why, and for whom the t r ea tment is effective (Kazdin, 1997). For example, PCIT studies have demons t ra t ed significant changes on a group level, but less is known about the specific predic tors of t r ea tment response. There is evidence to suggest that families in which a m o t h e r is highly critical or depressed r e spond more poor ly to PCIT (Werba, Eyberg, Boggs, & Algina, 2002). Clinical exper ience suggests that parents actively abusing a drug, or exper ienc- ing s e v e r e mari tal d iscord or psychopathology also may re- spond poorly to PCIT (Hembree-Kigin & McNeil, 1995). Much more research is n e e d e d to establish for whom PCIT is most effective and to identify which families are most responsive to t r ea tment in o rde r to provide services to families that will benef i t them most and to identify less responsive groups for fur ther study a imed at t r ea tment modif icat ions to be t te r serve these families.

Translational research also is n e e d e d to examine the effectiveness of PCIT in real-world clinics where the services are provided without the intensive scrutiny of super- visors and cameras record ing the integri ty of every session as del ivered by doctora l and pos tdoctora l students. Studies conduc ted in communi ty menta l heal th centers may inform PCIT training and disseminat ion protocols as well. Finally, t r ea tment ou tcome must be examined not only for the families who comple te t rea tment , but also for intent-to-treat groups that begin PCIT. A recent follow-up study found that families who d r o p p e d out of PCIT

looked the same after 1 to 3 years as they had before treat- men t started, whereas families who had comple t ed treat- men t ma in ta ined their gains in both child and family funct ioning (Edwards et al., 2002).

Diagnostic Variables Although r igorous empir ica l examina t ion of PCIT has

been conduc ted only with chi ldren who show externalizing behavior, the t r ea tment has been app l ied to ch i ld ren with diverse ch i ldhood disorders (e.g., Urquiza & Mc- Neil, 1996). The pa ren t ing pr inciples that under l i e PCIT, from both a t t achment and social learn ing theory, have appl ica t ion to a range of dysfunctional parent -chi ld interactions, inc luding those associated with the in ternal iz ing disorders of ch i ldhood (Pincus, Choate, Eyberg, & Bar- low, in press), chronic pediatr ic illness (Miller & Eyberg, 1991), and deve lopmenta l d isorders (Eyberg & Mat- arazzo, 1975). Eisenstadt et al. (1993) showed that, in a sample of preschoolers exhibi t ing external iz ing behavior problems, the chi ldren 's scores for in ternal iz ing behavior p rob lems and symptoms of a t tent ion-def ic i t /hyperact iv- ity d i sorder decreased significantly following PCIT. It will be impor tan t to d o c u m e n t fur ther the range of comorb id diagnoses affected by PCIT and to explore the ex ten t to which PCIT can be adap ted for t r ea tment of o the r disorders of ch i ldhood.

Cultural Variables Developmenta l research has long rel ied on assump-

tions about heal thy ch i ldrear ing practices and beliefs that were based on studies of middle-class, Caucasian families and that ignored cultural variations in pa ren t ing (Zayas, 1994). So, too, the deve lopmen t of most psychosocial t rea tments for ch i ldren have been based on West- e rn theories and have been tested on p redominan t ly Caucasian samples, with less a t tent ion to the inf luence o f social and cultural diversity. Al though t r ea tment studies of ch i ldren exper ienc ing disruptive behavior disorders, inc luding PCIT studies, have had perhaps more cultur- ally he te rogeneous samples than studies of o the r child- h o o d disorders, the outcomes are rarely r epo r t ed sepa- rately by ethnic g roup and, in fact, only half of the peer- reviewed studies in this area have even r epo r t ed the ethnicity of their par t ic ipants 2 (Brestan & Eyberg, 1998).

It is not surpris ing then, that for PCIT, like o the r pa ren t ing programs (Forehand & Kotchick, 1996), very l imited data exist to indicate whether or how the values and practices of an ethnic minori ty g roup should lead to changes in pa ren t ing (Capage et al., 2001a; Hembree - Kigin & McNeil, 1995). Some evidence has suggested that

2The low percentage of treatment research articles reporting par- ticipant ethnicity is primarily due to the inclusion of early studies, when ethnicity was rarely reported.

12 Herschell et al.

cul ture largely de te rmines the inferred basis of parent- hood, so that pa ren t ing is def ined according to cultural under s t and ing and is g r o u n d e d in the past exper iences of that cul ture (Baumrind, 1995; O'Reilly, Tokuno, & Ebata, 1986). Yet, recent research with African Amer ican families suggests that pa ren t ing styles associated with op- t imal child outcomes are the same in this cul ture as in the majori ty Caucasian cul ture (Quer ido & Eyberg, 2002) and that PCIT may be equally effective with these families as with Caucasian families when the effects of socioeconomic status are cont ro l led (Capage, Bennett , & McNeil, 2001b). Werba et al. (2002) also found that ethnici ty pre- d ic ted ne i the r response nor at tr i t ion in PCIT, a l though their sample inc luded only 19 African Amer ican families. Calzada and Eyberg (2002) examined specific paren t ing practices among Dominican and Puer to Rican mothers living in the Uni ted States, and their results suggested that the pa ren t ing values of these Hispanic groups are also similar to those of U.S. Caucasian mothers. In sum, a l though the pre l iminary data are promis ing in suggest- ing that PCIT may be appl ied successfully to diverse ethnic groups, a more comple te under s t and ing of the con- struct of effective paren t ing within diverse groups is necessary. It is imperat ive that future studies identify the mechanisms of therapeut ic change and the ways that t r ea tment may be ta i lored to maximize therapeut ic gains in the t rea tment of minori ty families.

Therapist Variables There is evidence to suggest that therapist behaviors

may be more predict ive of t r ea tment ou tcome than therapeut ic techniques (e.g., Luborsky et al., 1986), yet less than 3% of the research on child therapy has addressed the therapeut ic process (Kazdin, Bass, Ayers, & Rodgers, 1990). Researchers have suggested that a more thorough examina t ion of the quality of social re inforcement , in- c luding the accuracy and consistency of the clinician's delivery of social re inforcement , is needed to he lp clini- cians systematically facilitate and unde r s t and the mechanisms of change in PCIT (Borrego & Urquiza, 1998). In a recen t study, Capage, McNeil, Bahl, and Herschel l (2001) examined the relat ion between therapis t style and materna l compl iance , skill acquisit ion, and consumer satisfaction with PCIT. They found that mothers acquired skills more efficiently when therapists ba lanced positive feedback with constructive advice, though no association was found between therapist style and maternal compliance or satisfaction with t reatment .

Delivery of Treatment Families who are most in need of services often have

l imited financial resources and face o ther stressors that interfere with t rea tment (McNeil & Herschell , 1998). The logistical considerat ions involved in a t tending weekly ther-

apy appo in tments range f rom t ranspor ta t ion difficulties to child care issues, and may interfere with a family's ability to commi t to therapy, regardless of motivat ion level, In such cases, it is necessary to f ind alternative ways to de- liver clinical services.

Quer ido and Eyberg (2001) des igned a mode l of PCIT delivery for low-income, Head Start families for whom barriers to t rea tment often include lack of t ranspor ta t ion and care for o ther ch i ld ren in the home. Developed in response to discussions with the local Head Start Policy Council and Head Start staff, several incentives, includ- ing provision of t ranspor ta t ion to and from sessions and care for siblings dur ing sessions, were inc luded in the p rogram and appea red to enhance parents ' motivat ion for t reatment . For rural families, where the distance pre- sents even greater barriers, the advances in te leheal th and o the r dis tance- learuing technologies may provide a venue for future appl icat ions of PCIT.

Bahl (1998) has p roposed a mode l for applying PCIT to the classroom, which she calls Teacher-Child Interac- tion Training (TCIT). Similar to the phases of PCIT, he r mode l focuses first on enhanc ing the teacher-chi ld rela- t ionship and later on improving child compliance. The structure of TCIT also is similar to that of PCIT in its focus on working with the teacher and chi ldren together, providing direct coaching and over learning of behavioral skills, and emphasiz ing the use of a positive approach to working with teachers. Modifications for the classroom include appl icat ion of the behavioral skills to academic lessons, the use of an ignor ing signal, and use of a school- specific back-up for t ime-out (e.g., d i rector ' s office or an- o ther classroom). The effectiveness of TCIT is current ly being investigated.

Attr i t ion Treatments for families with chi ldren who have exter-

nalizing behavior p rob lems place many effort- and time- re la ted demands on parents, and it is not u n c o m m o n for families to te rminate t rea tment early. Most studies f ind that 40% to 60% of families of ch i ld ren and adolescents who en te r t r ea tment te rminate premature ly and against the advice of t rea tment providers (Kazdin & Wassell, 1998). Data r epor t ed by Werba et al. (2002) indica ted that 33% of families re fer red for PCIT d r o p p e d out of t rea tment prematurely. Families who comple te PCIT evidence significant behavioral gains, precisely because significant behavioral gains are requ i red for terminat ion. Families who end t r ea tment p remature ly cannot be ex- pec ted to show these same gains (Edwards et al., 2002).

To address the issue of at tr i t ion, it is impor t an t to in- vestigate variables that identify or descr ibe families at risk for d r o p p i n g out of t reatment . Prinz and Miller (1994) found that families whose t rea tment focused exclusively on pa ren t t ra ining and child behavior d r o p p e d out more

Parent-Child Interaction Therapy Research 13

often than families who had oppor tuni t ies to discuss life concerns beyond child management , part icularly among families facing greater adversity. They suggested that ad- dressing b roade r contextual issues in t rea tment might be necessary to keep some families in t rea tment . A similar conclusion was reached by Werba et al. (2002), who found that materna l depress ion was a significant predic- tor of d r o p o u t f rom PCIT. They r e c o m m e n d e d that some a t tent ion to the mother ' s personal concerns be given in each session, and recent changes to the PCIT t rea tment manual (Eyberg & Calzada, 1998) reflect this concern.

Al though o ther researchers have found significant relations between attr i t ion and bo th chi ld-related variables, such as p rob lem severity (Webster-Stratton, 1997), and demograph ic variables, such as soc ioeconomic disadvan- tage (Armbruster & Kazdin, 1994), none o f these variables has been found predict ive of d r o p o u t f rom PCIT (Capage et al., 2001b; Werba et al., 2002). Further, even the significant parent - re la ted variables accounted for only a small amoun t of variance in PCIT ou tcome (Werba et al.). It will be impor tan t to examine fur ther the influence of the therapy process variables on PCIT outcome, and part icularly the therapis t -parent relat ionship.

Maintenance The presence of disruptive behavior disorders in

ch i ldhood predicts antisocial behavior in adolescence and adu l thood (Farr ington, 1995; Satterf ield & Schell, 1997), providing s t rong evidence of critical need for effective t reatments for these chi ldren. Al though many studies have d o c u m e n t e d initial t r ea tment success for ch i ldren with external iz ing behavior (Brestan & Eyberg, 1998), fewer studies have d o c u m e n t e d long-term maintenance o f t rea tment effects (Eyberg, Edwards, Boggs, & Foote, 1998). Funde rbu rk et al. (1998) provided the first evidence of long-term main tenance of PCIT. In a study of 12 boys re fe r red for behavior p rob lems bo th at home and at school, they conduc ted 12- and 18-month follow- up school assessments after comple t ion o f PCIT. Treated ch i ldren were c o m p a r e d with classroom control ch i ldren on teacher ratings and classroom observations of behavior, a t tent ion, and social adjustment . At post t rea tment , the chi ldren had shown significant improvements on teacher ratings, observat ional measures of noncompl i - ance, and inappropr ia te classroom behaviors, but no t on observed off-task behaviors or teacher ratings of social skills (McNeil et al., 1991). At the 12-month follow up, 11 of the 12 boys ma in ta ined all pos t t rea tment improvements on observat ional and teacher ra t ing measures of classroom conduc t problems. At the 18-month follow-up, ch i ld ren main ta ined improvements in compliance, but demons t ra t ed decl ines on o the r measures o f school behavior into the range of p re t r ea tmen t levels. Eyberg et al. (2001) examined the home behavior of families up to 2

years following PCIT. The families had originally com- p le ted an exper imenta l 14-week, t ime-l imited appl ica t ion of PCIT in which half of the families received the tradi- t ional sequence (CDI-first) and half of the families received the reversed sequence (PDI-first; Eisenstadt et al., 1993). One year following t rea tment comple t ion , 8 of the 13 (62%) families main ta ined t r ea tment gains, and 2 years following t reatment , 9 of 13 (69%) families main- rained their gains, as measured by behavior observat ion and pa ren t ra t ing scales. Specifically, 2 years after complet ion of PCIT, parents con t inued to r epor t child behavior problems, child activity level, and pa ren t ing stress at pos t t rea tment levels, and the majori ty of ch i ld ren (7 of 13, or 54%) r ema ined free of diagnoses of disruptive behavior disorders. Further, parents r epor t ed high satisfac- t ion with the process and ou tcome of PCIT at the 2-year follow-up. Notably, no long-term impact of phase sequence was evident at e i ther follow-up.

Edwards et al. (2002) conduc ted a long-term follow-up of 23 families from the Schuhmann et al. (1998) study who had comple ted t rea tment and c o m p a r e d them to 23 families who had d r o p p e d out. The length o f follow-up for both groups ranged from 10 to 30 months after the pre- t rea tment assessment. Mothers of chi ldren who d r o p p e d ou t o f PCIT r e p o r t e d significantly more symptoms of the disruptive behavior disorders at follow-up than d id mothers of ch i ldren in families that comple t ed treatment . Decreased pa ren t ing stress and h igher satisfaction with t rea tment were also associated with t r ea tment complet ion. These da ta provided evidence that PCIT can al- ter the deve lopmenta l pa th of external iz ing behavior p rob lems and po in ted to the critical need to keep families in t r ea tment unti l complet ion . Finally, H o o d and Eyberg (2002) ex tended the examinat ion of main tenance of t rea tment gains for the families who comple t ed PCIT and assessed the Schuhmann et al. families 3 to 6 years following t rea tment complet ion . They found that the fre- quency o f external iz ing behavior was u n c h a n g e d when c o m p a r e d to pos t t rea tment levels, as was the conf idence of the mothers in their ability to control their child 's behavior. Al though PCIT has demons t ra t ed lasting change, the g roup data mask individual families for whom the outcomes may be less positive. Individual child and family characteristics, such as comorbid i ty or pa ren t psychopathology, likely inf luence main tenance of t r ea tment gains, and it will be impor tan t to study the predic tors of long-term t rea tment outcome.

Disseminat ion In spite of moun t ing empir ical suppor t since its devel-

o p m e n t in the 1970s, PCIT is still pr imari ly used in select university t ra ining clinics, and pa ren t t ra ining has no t yet become the s tandard of care in the typical communi ty menta l heal th center, where the majori ty of young chil-

14 Herschell e t al.

d r e n e x p e r i e n c i n g ex te rna l i z ing behav io r p r o b l e m s are

t rea ted . Access to ev idence-based care is an i m p o r t a n t

p r o b l e m for o u r na t ion ' s ch i l d r en that c a n n o t be i g n o r e d

(Satcher, 2000). Fo r PCIT, d i s semina t ion mus t b e c o m e a

priority. In r e c o g n i t i o n o f this goal, a c o m p r e h e n s i v e

t r e a t m e n t m a n u a l (Eyberg & Calzada, 1998) and a text

(Hembree -Kig in & McNeil , 1995) have b e e n wri t ten that

ou t l ine P C I T and prov ide r e c o m m e n d a t i o n s for its imple-

men ta t i on . Addit ional ly, workshops have been c o n d u c t e d

at na t iona l c o n f e r e n c e s (e.g., Associa t ion for Advance-

m e n t o f Behav ior Therapy, A m e r i c a n Psychological Asso-

c ia t ion) , and in tens ive t ra in ing workshops have b e e n con-

d u c t e d in individual c o m m u n i t y men ta l hea l th centers .

It is i m p o r t a n t that d i s semina t ion results in an accu-

rate i m p l e m e n t a t i o n o f PCIT so that cri t ical c o m p o n e n t s

o f the the rapy are n o t a l t e red (e.g., c o d i n g paren t -ch i ld

in te rac t ions to gu ide t r e a t m e n t sessions; r e q u i r i n g skill

mastery b e f o r e m o v i n g to new t r e a t m e n t steps). W i t h o u t

t r e a t m e n t fidelity, the effect iveness o f any empir ica l ly

s u p p o r t e d t r e a t m e n t c a n n o t be assured (Hengge le r , Mel-

ton, B r o n d i n o , Scherer , & Hanley, 1997). Yet very little is

known a b o u t how to ach ieve such precis ion. It is uncer-

tain, for example , wha t level o f p r i o r cl inical t r a in ing and

what d e g r e e o f P C I T t r a in ing is necessary for c l inicians

wi th in the c o m m u n i t y to ob ta in t r e a t m e n t effects s imilar

to those d o c u m e n t e d in universi ty research centers . To

date, mos t PCIT t r a in ing has b e e n c o n d u c t e d us ing an

a p p r e n t i c e s h i p m o d e l with clinical psychology g radua te

s tudents a l ready t r a ined in process skills and basic indi-

vidual and family the rapy t echn iques . C o t h e r a p y and ver-

tical t eam mode l s also have b e e n used in the universi ty

sett ing. T ra in ing c o n d u c t e d in c o m m u n i t y m e n t a l hea l th

cen ters has involved Ca) in tens ive didact ic p resen ta t ions

i n c l u d i n g i n f o r m a t i o n on unde r ly ing theor ies , assess-

men t , and a p p r o a c h e s for h a n d l i n g diff icult t he rapeu t i c

si tuations, (b) in terac t ive discussions, m o d e l i n g and role-

plays, (c) superv is ion o f o n e o r m o r e cases, and (d) con-

t i n u e d consu l ta t ion . T h e r e are several mode l s o f PCIT

t ra ining, however, at varying levels o f in tensi ty (e.g., read-

ing the t r e a t m e n t manua l , pa r t i c ipa t ing in v ideo t ra ining,

a t t e n d i n g week- long workshops) , that cou ld be fu r t he r

developed . It may be that a combina t i on o f t ra ining models

will be impor tan t , regardless o f previous clinical training.

C o n c l u s i o n s

Since its beg inn ing , PCIT has b e e n empir ica l ly inves- t igated and subsequen t ly mod i f i ed to i n c o r p o r a t e the

f indings f r o m these invest igat ions. Studies have dem-

ons t r a t ed the efficacy and utility o f PCIT, bu t many ques-

t ions r e m a i n to be answered. All o f the spokes in the

PCIT assessment and t r e a t m e n t research whee l n e e d to

be addressed , a n d readdressed , as results suggest adjust-

men t s and adap ta t ions that r equ i r e f u r t h e r testing.

C o n s i d e r i n g the p o o r p rognos i s o f u n t r e a t e d ex te rna l -

izing p r o b l e m s in p reschoole rs , the n e e d for effective-

ness studies in real-world set t ings is p a r a m o u n t . H a n d in

h a n d with effect iveness r e sea rch is the n e e d for r e sea rch

on t r a in ing a n d fa i thfu l d i s s e m i n a t i o n o f PCIT. As o n e

o f few ev idence-based early i n t e rven t ion p r o g r a m s for

y o u n g ch i l d r en with ex te rna l i z ing behavior , the po ten t i a l

impac t o f PCIT is significant. PCIT scient is t -pract i t ioners

a re c o m p e l l e d to e m b a r k on the p a t h to r e f i n e d un-

d e r s t a n d i n g o f these issues because the m e n t a l hea l th

needs o f the ch i ld ren , the i r families, a n d u l t imate ly soci-

ety, a re great.

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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

parent-child interaction therapy: new directions in research

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