Parent-child interaction therapy: The rewards and challenges of a group format

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<ul><li><p>113 </p><p>Parent-Child Interaction Therapy: The Rewards and Challenges of a Group Format </p><p>Larissa N. Niec, Jannel M. Hemme, and Justin M. Yopp, Central Mich igan University Elizabeth V. Brestan, Auburn University </p><p>Parent-Child Interaction Therapy (PCIT) is an evidence-based treatment for young children with severe behavior problems. Typically, it is individually administered to families by a therapist and a cotherapist. Howev~ converting PCIT to a group fo~vnat can be a cost-effective way to reach a largo number of families in need of treatment. In addition, PCIT offers techniques to facilitate parents' skill development and generalization of skills that are not commonly used in group parent training programs. This article has multi- ple goals: (a) to review the structure of a group PCIT program, (b) to discuss the empirical rationale for use of the program, and (c) to provide a case example that illustrates the rewards and challenges of group PCIZ </p><p>D ISRUPTIVE BEHAVIOR PROBLEMS in young children can lead to serious difficulties in broad areas of func- tioning, including difficulties in family, peer, school, and community interactions. Children with disruptive behav- ior disorders (e.g., opposifional-defiant disorder, conduct disorder, attention-deficit/hyperactivity disorder) have been found to be at risk for school adjustment problems (Campbell &amp; Ewing, 1990; McGee, Partridge, Williams, &amp; Silva, 1991), antisocial activity (Kratzer &amp; Hodgins, 1997; Loeber, 1990), and have higher than normal rates of sub- stance abuse and interpersonal problems (e.g., Lynskey &amp; Fergusson, 1995; Weiss &amp; Hectman, 1993). Although effec- tive treatments are available for these children (Brestan &amp; Eyberg, 1998; Chambless &amp; Ollendick, 2001), there is a current need for programs that are cost-effective and eas- ily disseminated. Providing group parent training is one way to meet that need, as it is substantially more cost- effective than individual treatment (Barldey, 1987; Webster- Stratton, Kolpacoff, &amp; Hollinsworth, 1988). One empiri- cally based treatment for individual families, Parent-Child Interaction Therapy (PCIT; Hembree-Kigin &amp; McNeil, 1995), is particularly promising as a group treatment. </p><p>PCIT is an empirically based behavioral family treat- ment program designed to address the behavior prob- lems of children 2 to 7 years of age. It is typically adminis- tered individually to each family by a therapist and a cotherapist. PCIT differs from many parent training pro- grams in its dual focus on the development of the parent- child relationship and parents' behavior management skills (Foote, Eyberg, &amp; Schuhmann, 1998; Nixon, 2002). Components of PCIT that are not commonly provided in </p><p>Cognitive and Behavioral Practice 12, 113-125, 2005 1077-7229/05/113-12551.00/0 Copyright 2005 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved. </p><p>group programs (e.g., live coaching of parent-child inter- actions and immediate feedback) make it a valuable and innovative protocol for group parent training. Despite tile potential benefits of using PCIT in groups, very few clinics have done so (e.g., Auerbach, Nixon, Forrest, Gooley, &amp; Gemke, 1999; Brestan, Valle, &amp; Funderburk, 1999; Niec &amp; Yopp, 2001), and to date, no published paper has discussed the modifications necessary to adapt PCIT from an individual to a group format. The goals of this paper are to review the structure of a group PCIT program, discuss the empirical rationale for use of the pro- gram, and provide a case example that illustrates the rewards and challenges of group PCIT. </p><p>Structure and Goals o f PCIT </p><p>Based on Hanf's (1969) two-stage parent training model, the theoretical foundation of PCIT integrates concepts from social learning theory, traditional play therapy, and attachment theory to enhance the parent- child relationship, increase children's prosocial behav- iors, and increase parents' behavior management skills (Eyberg, 1988; Hembree-Kigin &amp; McNeil, 1995; Herschell, Calzada, Eyberg, &amp; McNeil, 2002a; Herschell, Calzada, Eyberg, &amp; McNeil, 2002b). PCIT differs from many par- ent training programs in its use of live coaching to pro- vide parents with immediate feedback regarding their in- teractions with their children. Typically, therapists coach the parent from an observation room, while the parent, wearing a bug-in-the-ear device, interacts with his or her child in the therapy room. This equipment is optimal, but not required, as coaching can also be conducted in the same room with the parent and child (Herschell et al., 2002b). Whether coaching is in-room or out, the use of these immediate feedback techniques may be one component of PCIT that facilitates skill development (Eyberg &amp; Matarazzo, 1980). </p></li><li><p>114 Niec et al. </p><p>Assessment is fundamental to the PCIT program and is used throughout treatment. Ongoing assessment en- ables therapists to target specific problem behaviors, guide treatment, and provide a means of evaluating treatment efficacy and treatment satisfaction. The PCIT assessment process is a multisource, multimethod approach that in- cludes behavior ratings from caregivers and teachers, standardized behavioral observations during weekly treat- ment sessions, and parent monitoring during daily home- work practices (Bahl, Spaulding, &amp; McNeil, 1999). Assess- ment can also be a tool to initiate and maintain parents' engagement in the treatment process. For example, conducting weekly behavioral observations allows parents to see areas of behavioral improvement, which can be reinforcing. </p><p>The PCIT protocol has been described in detail else- where (Hembree-Kigin &amp; McNeil, 1995; Herschell et al., 2002b). To summarize the procedures, the two phases of PCIT are Child-Directed Interaction (CDI) and Parent- Directed Interaction (PDI). CDI, the first phase, focuses on building parents' skills to elicit children's positive behav- iors and to enhance the parent-child relationship. During CDI parents are taught child-centered play skills similar to those used by nondirective play therapists. Because parent- child interactions in families with behavior-disordered children are frequently negative and coercive in nature (e.g., Campbell, 1995; Stormont, 2002, for reviews), a critical goal of CDI is to increase positive, nurturing inter- actions. Specific relationship-enhancing skills include the PRIDE skills (Praising, Reflecting, Imitating, Describing, and Enthusiasm; Herschell et al., 2002b). Parents are also taught to avoid using criticisms, commands, and ques- tions during CDI practice sessions. In each session, the therapist conducts a brief behavioral observation, as- sesses parents' skill development, and provides feedback regarding parents' observed strengths and weaknesses. Once parents are able to use the PRIDE skills consistently to interact in a positive manner with their children, the second phase of treatment is introduced. </p><p>Skills taught during the PDI are primarily based on so- cial learning theory and include such concepts as differ- ential attention, social reinforcement, punishment, and problem-solving skills training. The primary goal of PDI is to teach parents how to discipline their children effec- tively. Appropriate discipline techniques and problem- solving skills are taught and practiced during the PDI phase, and child compliance is emphasized (Hembree- Kigin &amp; McNeil, 1995). Specifically, parents are coached during each PDI session to ignore inappropriate, attention- seeking behaviors and to provide consequences for non- compliance (Eyberg &amp; Boggs, 1989). Parents direct child behavior using age-appropriate instructions, giving effec- tively stated commands, praising appropriate behaviors, and providing consistent consequences for noncompliance. </p><p>Efficacy of Individually Formatted PCIT </p><p>Multiple studies have demonstrated the statistical and clinical efficacy of PCIT when administered in an individ- ual format (e.g., Eyberg &amp; Boggs, 1989; Gallagher, 2003; McNeil, Capage, Bahl, &amp; Blanc, 1999; Nixon, Sweeney, Erickson, &amp; Touyz, 2003; Schuhmann, Foote, Eyberg, Boggs, &amp; Algina, 1998). Schuhmann and colleagues dem- onstrated that clinic-referred families who completed PCIT reported fewer child externalizing behavior prob- lems, criticized their children less frequentl}; and praised their children more frequently" than wait-list controls. Mc- Neil and colleagues (1991) found that preschool-aged children referred for treatment secondary to problematic behaviors in the home setting were reported by teachers to have notable improvements in their school behavior fol- lowing completion of PCIT. Positive effects have been demonstrated on untreated siblings in addition to the targeted child. Specifically, parents reported an improve- ment in the untreated siblings' behaviors following treat- ment (Brestan, Eyberg, Boggs, &amp; Algina 1997; Eyberg &amp; Robinson, 1982). </p><p>PCIT has been used effectively with a variety of popu- lations, including low-income families (Querido &amp; Eyberg, 2001) and culturally diverse populations (Capage, Ben- nett, &amp; McNeil, 2001; Querido &amp; Eyberg, 2002). Case studies have provided preliminary support for the effec- tiveness of PCIT with families at high risk for physical abuse (Borrego, Urquiza, Rasmussen, &amp; Zebell, 1999; Herschell et al., 2002b). </p><p>PCIT has also demonstrated long-term maintenance of treatment gains. Follow-up assessments of families treated with PCIT demonstrate maintenance of gains in children's compliance and positive parent-child inter- actions at 4 months (Schuhmann et al., 1998), 1 year (Eyberg &amp; Robinson, 1982; Funderburk et al., 1998), 2 years (Eyberg et al., 2001), and 3 to 6 years (Hood &amp; Eyberg, 2003). </p><p>Efficacy of Group-Formatted Parent Trainin~ </p><p>To date, no published studies have investigated tee ef- ficacy of group PCIT using a well-controlled experimen- tal design. However, Auerbach et al. (1999) reported on a multimodal program for oppositional children that in- cluded group PCIT as a treatment component. Their program included group PCIT, supportive group therapy for parents, and group social skills training for children. Preliminary data reflected no reductions in children's be- havior problems as assessed by standardized measures, and parents reported high levels of stress at both the pretreatment and posttreatment assessments. Qualitative reports by parents and staff impressions of the families suggested that children's problem behaviors decreased </p></li><li><p>Group Parent-Child Interaction Therapy 115 </p><p>following the multimodal program (Auerbach et al., 1999). Although this program converted PCIT to a group format and included innovative techniques (e.g., therapist- led excursions to public areas to promote generalization of parenting skills), it is difficult to determine whether group PCIT was the change agent, as these families re- ceived several services simultaneously. In addition, 50% of the families continued to receive individual family treat- ment following the PCIT group, and the posttreatment outcome measure results were equivocal. In another study of modified PCIT, McNeil, Herschell, Gurwitch, and Clemens-Mowrer (in press) reported on a program in which foster parents were taught PCIT skills during a 2-day group workshop. Preliminary data demonstrated significant re- ductions in foster children's levels of behavior problems 1 month posttraining. Mean behavior problems moved from the clinically significant range to the normal range on the Eyberg Child Behavior Inventory (ECBI; Eyberg &amp; Pincus, 1999), and these changes remained at 5 months posttraining. This investigation of a promising PCIT workshop format suggests that behavioral change can occur following a brief 2-day group intervention. The au- thors caution, however, that such a brief treatment may not be appropriate for highly stressed families presenting with multiple problems, as families receive fewer coached sessions and have fewer opportunities to problem solve with therapists and group members. </p><p>Although no controlled studies with group PCIT have been published, parent training is frequently provided in a group format and a variety of group parent training models have demonstrated effectiveness in preventing and reducing children's externalizing behaviors (e.g., Pisterman et al., 1989; Ruma, Burke, &amp; Thompson, 1996; Sheeber &amp;Johnson, 1994; Webster-Stratton &amp; Hammond, 1997; Webster-Stratton, Hollinsworth, &amp; Kolpacoff, 1989; Webster-Stratton, Reid, &amp; Hammond, 2001). Parent train- ing groups have addressed a range of externalizing be- havioral problems such as aggression, hyperactivity, and noncompliance in children diagnosed with attention- deficit/hyperactivity disorder (Barkley, 1987; Pisterman et al., 1989), children diagnosed with oppositional de- fiant and conduct disorders (Webster-Stratton, 1981; Webster-Stratton &amp; Hammond, 1997), children with dif- ficult temperaments (Sheeber &amp;Johnson, 1994), and chil- dren with learning disabilities (Chadwick, Momcilovic, Rossiter, Stumbles, &amp; Taylor, 2001). Parent training groups typically range from 5 to 13 sessions, with weekly sessions lasting from 1 to 2 hours. Group parent train- ing programs utilize a variety of techniques to assist par- ents in improving their children's behaviors. These methods include using videotape vignettes, didactic train- ing, role-playing, modeling, group discussion, and home- work (Sampers, Anderson, Hartung, &amp; Scambler, 2001). Group parent training techniques do not commonly in- </p><p>clude live coaching of parents' interactions with their children. In fact, other group formats of parent training typically included only parents, not children, in the ses- sion. The inclusion of children in the session and live coaching are two advantages of group PCIT that may help parents to gain mastery of behavior management skills and facilitate skill generalization. Live coaching of parent-child interactions has not been empirically exam- ined in group parent training protocols. However, pro- riding continuous feedback to parents during the session is fundamental to PCIT, and this technique has been shown to be effective in producing behavior change within the context of individual family treatment relative to didactic-focused group parent training (Eyberg &amp; Mat- arazzo, 1980). </p><p>One widely researched group parent training proto- col is the videotape modeling program developed by Webster-Stratton (1981). Similar to PCIT, this program addresses externalizing behavior problems of preschool to early elementary-age children. Both the Webster-Stratton program and PCIT teach parents to interact with their children in a manner aimed at eliciting prosocial behav- ior, and both programs provide parents with discipline strategies based on behavioral principles. The Webster- Stratton program, however, is regularly administered in a group format and typically entails 10 to 14 two-hour sessions involving between 8 and 15 parents. The pro- gram uses modeling to...</p></li></ul>


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