Parent-Child Interaction Therapy

1. Parent-Child Interaction Therapy Rhea M. Chase, M.S. Daniel Bagner, M.S. University of Florida

2. Disruptive Behavior Disorders • Most common reason for referral of young children to mental health services • Prevalence of Oppositional Defiant Disorder and Conduct Disorder estimated to be between 2% and 16% of all children • Poor prognosis

3. Parent-Child Interaction Therapy (PCIT) • Designed for young children (3-6) and their parents/caretakers • Work with parents and child together • Live coaching of skills • Emphasis on restructuring parent-child interaction patterns

4. Child-Directed Interaction CDI Parent-Directed Interaction PDI • Parents follow • Play therapy skills • Differential attention • Increase warmth of parent-child relationship • Parents lead • Limit-setting • Consistency • Predictability • Follow through

5. Structure of PCIT • Assessment • Measures that guide treatment • Teaching sessions • Presentation of skills • Modeling and role-playing • Coaching sessions • Check in • Therapist codes and coaches • Assign homework

6. How does coaching work? • Parent wears a Bug-in-the-Ear receiver while playing with child in playroom (therapist can coach while in the room with the parent) • Therapist coaches specific skills • Spouses take turns playing and observing

7. What families might benefit from PCIT? • Children with conduct problem behavior • Preschool age (3-6) • At least one parent able to attend weekly sessions with child • Parent(s) willing to practice skills at home

8. Effectiveness of PCIT

9. Effect Size Interpretations • Small = 0.20 - 0.40 • Medium = 0.40 - 0.60 • Large = 0.60 - 0.80 • Very large = 0.80 – 1.00 • Astronomical = > 1.00

10. Child Problem Behavior and 2-Year Effect Size 2.32 Eyberg et al.

11. Child Complianceand 2 Year Effect Size .85 Eyberg et al.

12. Child Deviant Behavior Compositeand 2 Year Effect Size .54 Eyberg et al.

13. DPICS Parent Verbal and Physical Negative 1.11 Eyberg et al.

14. CDI Child-Directed Interaction

15. The CDI Teaching Session • Parents alone • Presentation of skills • Reasons • “Rules” • Examples • Modeling/demonstration • Role-play with parent What exactly are they taught?

16. CDIThe Basic Rule Follow the Child’s Lead

17. CDI: The DON’T Rules • No commands • No questions • No criticism

18. CDI: The DON’T Rules Direct : Sit here Indirect : Could you sit here? • Commands attempt to lead • Risk negative interaction No Commands

19. CDI: The DON’T Rules Questions ask for an answer • Often hidden commands • Take lead from the child • Can suggest disapproval • Can suggest not listening No Questions

20. CDI: The DON’T Rules No Criticism • Examples • You’re a bad girl • That doesn’t go that way • No Stop Quit Don’t • Points out mistakes rather than correcting them • “That’s wrong” is a criticism • “It goes like this” allows correction without criticism • Lowers self-esteem • Creates unpleasant interaction

21. What’s left?

22. CDI: The DO RulesThe PRIDE Skills • Praise • Reflect • Imitate • Describe • Enthusiasm!

23. CDI: The DO Rules Praise Unlabeled praise is nonspecific • Good! • That's great! Labeled praise tells child specifically what is good • Thank you for sitting so quietly. • Increases the specific behavior • Increases child's self-esteem • Increases positive parent-child interaction

24. CDI: The DO Rules Reflection “The moo-moo is in the barn.” “Yes, the cow is in the barn.” • Allows child to lead the conversation • Shows that parent is listening • Shows that parent understands • Improves and increases child’s speech • Repeating or paraphrasing Child Parent

25. CDI: The DO Rules Imitation Doing the same thing the child is doing • Lets the child lead • Teaches parent how to “play” • Shows approval of child’s activity • Teaches child how to play with others • Sharing • Taking turns

26. CDI: The DO Rules Description • Telling the child exactly what he or she is doing • “You’re drawing a sun.” • Lets the child lead • Lets child know you are paying attention and are interested • Shows approval of child’s activity • Models speech • Teaches vocabulary and concepts • Holds child’s attention to the task

27. CDI: The DO Rules Enthusiasm • Conveying excitement by voice and gesture • “Wow!! You finished that SO quickly!” • Lets the child know the parent enjoys being with the child • Makes the play more fun for the child (and parent) • Adds a quality of warmth to the interaction

28. Child-Directed • Interaction • DO • Praise • Reflect • Imitate • Describe • Enthusiasm • DON’T • Give Commands • Ask Questions • Criticize Use • IGNORE annoying, obnoxious behavior • STOP THE PLAY for dangerous or destructive behavior

29. Homework • “Special time” • 5 minutes a day • Practice, play, and therapy

30. Homework

31. COACHING

32. CDI Coaching • PRIDE (basic) • Great reflection! • Good labeled praise! • Following • Good following his lead. • Describe what she’s doing. • Be sure to watch what she’s doing closely.

33. CDI Coaching • Noticing positive behaviors • Wow -- she picked up the one she dropped • Attending to positive behavior • Wow -- you caught her being good! • Ignoring negative behavior • That was great ignoring his back talk

34. CDI Coaching • Catching child doing positive opposites • NICE praising his polite talk • Touch, proximity • That’s nice the way you touch him when you praise him • Genuineness • That sounded like you meant it • Parent self-efficacy • You got him to play quietly! • Nice job of getting him back to the table.

35. CDI Coaching • The treatment goals • Good teaching! • He seems a lot calmer today • She seems to be sharing more -- that will help her make friends at school. • You seem be having fun playing with your son. • You’ve got these skills down pat!

36. CDI Coaching • Developmental expectations • Describe the colors so he can learn them. • He’s still too young to understand logic • Child’s motivations -- or lack of motivations • He seems to throw the puzzle pieces when doesn’t understand where they go. • I think he just doesn’t know how to ask for your help.

37. Why Coach? • Parents think they already do these things • Verbal habits are ingrained • Coaching (therapist feedback) makes parents aware of what they say • Coaching (child’s feedback) makes parents aware of the immediate effects • Coaching heightens parent’s attention and motivation

38. Why Coach? • Coaching provides parent support in actual difficult situations • Coaching demonstrates to parents (convinces parents) that change is possible • Coaching can help parents not to give up • Coaching is efficient -- makes it possible to address relevant problem areas and not spend time on areas that are not problems

39. CDIROLE PLAY

40. Parent-Directed Interaction

41. PDI:Effective Commands • Direct (telling, not asking) • Positive (what to DO, not stop doing) • Single (one at a time) • Specific (not vague) • Age-appropriate • Given in a normal tone of voice • Polite and respectful (Please... ) • Explained before given or after obeyed • Used only when really necessary

42. The Command ... Command No Opportunity Obey Disobey Whoops! (Start over) Labeled Praise Back to Play YEA!

43. The Warning ... If you don’t [original command], you’ll have to go to the time out chair Obey Disobey (UH-OH!) Labeled Praise Back to Play YEA!

44. TheChair

45. TheChair Child stays on chair 3 min plus 5 sec quiet Or doesn’t (OH-OH!) No Are you ready to [obey original command]? Command Obey Acknowledge

46. The Backup CHILD GETS OFF CHAIR ROOM WARNING “You got off the chair before I said you could. If you get off again, you’ll go to the Time Out Room .” CHILD GETS OFF AGAIN CHILD GOES TO TIME OUT ROOM 1 MIN + QUIET BACK TO CHAIR

47. The First Obey Child Stays on Chair 3 Min plus 5 Sec Quiet No Are you ready to [Obey Original Command]? Yes Acknowledge Obey

48. Finally! Command Obey Praise Back to play!!!

49. House Rules • PDI uses running commands • House rules are standing commands • Aggressive behavior • Destructive behavior • The Procedure • Label behavior for child • Explain rule to child • No chair warnings

50. Public Misbehavior • Procedure • Make plan before leaving home • Describe desired behavior • Take along “time out chair” • Discuss back-ups