parent-child interaction therapy rhea m. chase, m.s. daniel bagner, m.s. university of florida

Parent-Child Interaction Therapy

Rhea M. Chase, M.S.

Daniel Bagner, M.S.

University of Florida

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

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

Child-Directed Interaction

Parent-Directed Interaction

Parents follow

Play therapy skills Differential attention Increase warmth of

parent-child relationship

Parents lead

Limit-settingConsistency Predictability Follow through

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

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

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

Effectiveness of PCIT

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

Child Problem Behavior

and 2-Year Effect Size

178

104112

121

80

100

120

140

160

180

200

Pre Post 1 Year 2 Year

Inte

nsi

ty S

core

2.32

Eyberg et al.

Child Complianceand 2 Year Effect Size

50

60

70

80

90

100

Pre Post 1 Year 2 Year

Per

cen

t

.85

Eyberg et al.

Child Deviant Behavior Composite

and 2 Year Effect Size

0

10

20

30

40

50

60

Pre Post 1 Year 2 Year

Fre

qu

ency

in

30

Min

ute

s

.54

Eyberg et al.

DPICS Parent Verbal and Physical

Negative

0

5

10

15

20

25

30

35

40

Pre Post 1 Year 2 Year

Fre

qu

ency

in

30

Min

ute

s

1.11

Eyberg et al.

Child-Directed Interaction

CDI

The CDI Teaching Session• Parents alone• Presentation of skills

Reasons “Rules” Examples

• Modeling/demonstration• Role-play with parent

What exactly are they

taught?

CDIThe Basic Rule

Follow the Child’s Lead

CDI: The DON’T Rules

• No commands• No questions• No criticism

Direct : Sit here

Indirect : Could you sit here?

• Commands attempt to lead

• Risk negative interaction

No Commands

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

CDI: The DON’T Rules

• 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

No CriticismCDI: The DON’T Rules

What’s left?

CDI: The DO Rules The PRIDE Skills

PraiseReflect ImitateDescribeEnthusiasm!

PraiseUnlabeled 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

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

Child

Parent

• Repeating or paraphrasing

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

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

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

CDI: The DO Rules

IGNORE annoying, obnoxious IGNORE annoying, obnoxious behaviorbehavior

STOP THE PLAY for STOP THE PLAY for dangerous or destructive dangerous or destructive behaviorbehavior

Child-Directed Child-Directed InteractionInteraction

DON’TDON’T– Give Give

CommandsCommands– Ask QuestionsAsk Questions– CriticizeCriticize

DODO– PraisePraise– ReflectReflect– ImitateImitate– DescribeDescribe EnthusiasmEnthusiasm

“Special time” 5 minutes a day Practice, play, and therapy

Homework

Homework

Good activities:

Toys with no rules

Construction toys

Play sets

Creative Toys

Not-so-good activities:

Board games

Messy activities (like fingerpaint)

Aggressive toys (like guns or action figures)

Pretend-talk toys

COACHING

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.

• 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

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.

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!

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.

CDI Coaching

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

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

CDIROLE PLAY

Parent-Directed Interaction

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

The Command ...

Command

No Opportunity

Whoops!(Start over)

Obey

Labeled Praise

Disobey

Back to PlayYEA!

Back to PlayYEA!

Labeled Praise

The Warning ...

Obey Disobey(UH-OH!)

If you don’t [original command], you’ll have to go to the time out chair

The Chair

Are you ready to [obey original command]?

Child stays on chair 3 min plus 5 sec quiet

Or doesn’t(OH-OH!)

ObeyAcknowledge

The Chair

Command

No

BACK TO CHAIR

CHILD GOES TOTIME OUT ROOM1 MIN + QUIET

CHILD GETS OFF CHAIR

CHILD GETS OFF AGAIN

The Backup

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 .”

Yes

Are you ready to [Obey Original Command]?

Obey

Acknowledge

The First ObeyChild Stays

on Chair 3 Min plus 5 Sec Quiet

No

Praise

Obey

Back to play!!!

Finally!Command

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

Public Misbehavior

Procedure– Make plan before leaving home– Describe desired behavior– Take along “time out chair”– Discuss back-ups

PRACTICING PDI

Further Information…

• PCIT website: www.pcit.org– Literature– Measures– Other material

Thank you!

Questions?