Parent-Child Interaction Therapy: Application to maltreating parent-child dyads
Introduction
Child maltreatment by parents continues to be a major social problem in the United States. Recent official reports of child maltreatment indicate a victimization rate of 12.4 per 1000 (U.S. Department of Health and Human Services, 2005). In June 1992, the National Institute of Mental Health held a “National Workgroup on Violence” to develop a research agenda for the study of interventions for violence and its consequences (National Academy of Sciences, 1993). This workgroup identified the development of treatments for maltreated children as a high priority. This study investigates the usefulness of Parent-Child Interaction Therapy (PCIT) for training maltreating parent-child dyads in an effort to reduce the risk of further abuse.
Empirical literature indicates that abusive parents engage in more negative interactions (Bousha & Twentyman, 1984) and fewer positive interactions with their children than non-abusive parents (Allesandri, 1992; Bousha & Twentyman, 1984). Wolfe (1987) noted that “it appears to be the relative absence of positive interactions that sets members of abusive families apart from matched, non-abusive controls rather than the dramatic display of open conflict and aggression” (p. 77). Milner and Chilamkurti (1991) provided support for this observation, finding that relatively low rates of positive interactions (e.g., cohesion, expressiveness) appeared to characterize abusive families more accurately than observed differences in negative interactions. For these reasons, a popular approach to the treatment of abusive families has been parent-training interventions (Dore & Lee, 1999). By training parents, it is possible to enhance abusive parents’ functioning, reduce negative parenting, and increase the numbers of positive interactions (Milner, 2000), resulting in better outcomes for children. Also, this format makes it possible to educate parents about appropriate developmental expectations (Fox, Fox, & Anderson, 1991), child management strategies (Azar, 1989), and increase parents’ self-awareness (Thomas, 1996).
Children also contribute to abusive parent-child dyadic interactions. Maltreated children have high rates of physical aggression, noncompliance, and antisocial behaviors (see Cicchetti & Toth, 2000; Kolko, 1992 for reviews). Additionally, these children exhibit an array of problem social behaviors, including poor emotional regulation, distractibility, negative affect, and a resistance to following directions (e.g., Rogosch, Cicchetti, & Aber, 1995; Shields & Cicchetti, 1998). The seriousness of abused children's behavior problems prompted Kolko (1996a) to propose including the children as participants in any treatment targeting problems of abuse in the family. For example, individual cognitive behavioral therapy for both the parent and the child has been found to reduce parent and child problems (e.g., Kolko, 1996a). Family therapy and family-centered treatments have also been used to treat problems in abusive family systems, pointing to the effectiveness of including both the parent and child in treatment.
The argument for using PCIT with children who have been maltreated is founded on a family systems perspective, which supports the view that problem behaviors in children are outward manifestations of dysfunction in the parent-child relationship (e.g., Cerezo & D’Ocon, 1999; Patterson, 1976). In an effort to deconstruct this process, Patterson (1982) described a ‘coercion hypothesis’ to account for the development and maintenance of deviant behaviors in the child and the disrupted parent-child relationship. According to this hypothesis, parents and children establish a pattern of interaction in which parents escalate their disciplinary strategies over time to include harsh and abusive actions (e.g., yelling, threatening, spanking, hitting) to keep pace with their children's similarly escalating aversive responses (e.g., back-talk and sassing, swearing, hitting, defiance). Urquiza and McNeil (1996) extend this hypothesis to include physically abusive parent-child dyads, stating that participation in hostile and coercive interactions with their children may lead some parents to engage in physical aggression as a means to get their children to comply with a command. If parents’ physical abuse results in their children's compliance, then their abusive behavior is reinforced, and thus has a greater likelihood of being re-enacted in future parent-child conflicts (Cerezo, 1997). Over time, if this abusive interaction style becomes stable, then both parent and child “co-regulate” the other in their relationship (Fogel, 1993; defined co-regulation as “a social process by which individuals dynamically alter their actions with respect to the ongoing and anticipated actions of their partners,” p. 34). Hence, we argue that the abusive parent-child relationship will be resistant to change, and to effect change will require more than parents’ and children's understanding of the mechanism of violence. Parents’ and children's habitual behaviors that serve to trigger negative behavior in the other must be eradicated and replaced by neutral and positive behaviors. To accomplish this, the interaction must be the focus of treatment. In PCIT, therapists coach caregivers remotely, teaching them to interact with their children in ways that support a more positive relationship.
Parent-Child Interaction Therapy (PCIT) is an intervention founded on social learning principles. PCIT is designed for children between 2 and 7 years of age who have externalizing disorders (Eyberg & Robinson, 1983; Hembree-Kigin & McNeil, 1995). The underlying model of change is similar to that of a parent-training program, that is, that modifying the way parents interact with their children diminishes child behavior problems, which in turn promotes more positive parenting (Chaffin et al., 2004). However, PCIT is unique in that it incorporates both parent and child within the treatment session, and uses live and individualized therapist coaching to change aspects of the interaction that cause dysfunction in the parent-child relationship.
PCIT is conducted in two phases. The first phase focuses on enhancing the parent-child relationship (often described as Child-Directed Interaction (CDI)), and the second focuses on improving child compliance (often described as Parent-Directed Interaction (PDI)). Both phases of treatment begin with an hour of didactic training, followed by a therapist's coaching parents while they play with their children. The coaching is conducted from an observation room via a “bug-in-the-ear” receiver that the parent wears. Parents are taught and practice specific skills of communication and behavior management with their children. In CDI (typically 7–10 sessions), the primary goal is to create or strengthen a positive and mutually rewarding relationship between parents and their children by modifying the way parents interact with their children. Parents are taught to follow their children's lead in play by describing their activities and reflecting their appropriate verbalizations. They are also taught to praise their children's positive behavior, telling them specifically what is laudable about their actions, products or attributes. By the end of CDI, parents generally have shifted from rarely attending to their children's positive behavior to frequently and consistently praising appropriate child behavior. Also, they shift from using more controlling methods of getting their children to engage them in play (e.g., questions, commands) and begin reflecting their children's speech, and describing their play in a way that conveys their non-controlling interest in the child's activity. During this time, parents learn to shape their children's behavior by using “selective attention.” By using this strategy, parents signal their disapproval of their children's inappropriate behavior by withdrawing their attention. Parents let the children know what behavior they want to see by telling children that when they are behaving appropriately, they will regain their parents’ attention (e.g., “When Joshua's bottom is in the chair, then I’ll be able to play with him”). When the children behave appropriately again, they are rewarded with their parents’ attention and praise. Mastering selective attention provides parents a foundation for obtaining compliance. It teaches parents patience (it is difficult to ignore annoying behaviors), and that maintaining a positive context for play may not require high levels of parental discipline.
In the second phase, PDI (typically 7–10 sessions following CDI), the primary goal is to teach effective parenting skills for use in managing children's behavior. In PDI, therapists maintain the focus of parents’ attention to their children's positive behaviors while training them to give clear, direct commands. Once parents master giving effective commands, they learn to provide praise for compliance, and strategies for dealing with noncompliance. Consistent with child welfare regulations, the time-out procedure used at this clinic does not use a spank or any physical restraint. Instead, parents are taught to give a command, count to five, give a two-choice warning (comply vs. time-out), followed by another count to five, thereby giving the child a chance to comply before receiving the time out. If a child refuses to comply with a time-out (e.g., gets off the chair), parents are taught a strategy to provide children an incentive to comply with the time-out (e.g., removal of privileges, time-out room), and finally to gain compliance (and to follow through). Parents are taught to always praise the child's ultimate compliance, even if it takes a long time to obtain. By the end of PDI, the process of giving commands and gaining compliance are predictable and safe for both the parents and children (Eyberg, 1988). At this time in the treatment process, parents are generally able to obtain compliance without giving a time-out. But if they need to give a time-out, it is a comfortable and well-practiced process for which the parent has acquired mastery (see Hembree-Kigin & McNeil, 1995, for a full description of the PCIT program).
There have been numerous studies demonstrating the efficacy of PCIT in reducing child behavior problems (e.g., Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993; Eyberg, 1988; Eyberg & Robinson, 1982; Eyberg et al., 2001), and maintaining these positive effects up to 6 years post-treatment (Hood & Eyberg, 2003). Treatment effects also have been shown to generalize to school settings (Funderburk et al., 1998; McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991), and to untreated siblings (Brestan, Eyberg, Boggs, & Algina, 1997; Eyberg & Robinson, 1982). In addition, PCIT also has been shown to be as effective for foster parents as biological parents (Timmer, Urquiza, & Zebell, in press). Given the documented effectiveness of PCIT in helping non-maltreating parents manage their behavior-problem children, we expect that it also will be effective in treating parent-child dyads, even when the children have a history of maltreatment.
The purpose of this study is to determine the effectiveness of PCIT in reducing maltreated children's negative behaviors when they are in treatment with their maltreating or non-maltreating biological parents. Based on the empirical evidence supporting the efficacy of PCIT in treating conduct problems of young children, we expect to observe significant decreases in maltreated children's behavior problems from pre- to post-treatment. However, it is possible that the trauma of the abuse experience, or that maltreating parents’ problems and the well-established negative qualities of maltreating parent-child dyads will reduce the effectiveness of PCIT. To determine the effectiveness of PCIT in this high-risk population, we will compare pre- and post-treatment measures of functioning in maltreated and non-maltreated dyads. To evaluate the further effects of parents’ maltreatment status on PCIT's effectiveness, we will compare pre- and post-treatment measures of functioning in the group of maltreated children participating with maltreating and non-maltreating parents.
Section snippets
Selection
Sample selection and data analysis were conducted in two phases. The first phase of sample selection was designed to allow us to determine whether dyads that completed treatment were systematically different from those who were referred and began treatment. Included in this phase were biological parent-child dyads referred to a university-based clinic primarily serving children with a history of maltreatment between November 1994 and May 2004. All dyads were assessed by clinical interview, and
Phase I analyses
Table 1 shows the results of the analyses for determining predictors of early termination from treatment. Coefficients presented in Table 1 are odds ratios. They reflect the degree to which the odds of an event occurring (i.e., dropping out of treatment) are increased by each unit increase in the predictor variable. For example, in Model 1, when only demographic variables are entered into the model, African American children were twice as likely as Caucasian children to end treatment early.
Discussion
The primary goal of this study was to determine whether PCIT was an effective intervention for maltreated children and their offending or non-offending parents. The first step in testing PCIT's effectiveness was to determine whether the therapy was engaging and rewarding enough to keep high-risk dyads in treatment. Results of our analyses predicting early treatment termination showed that among maltreated children, the more behavior problems parents reported, the less likely they were to
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