Predictors of treatment attrition and treatment length in Parent‐Child Interaction Therapy in Taiwanese families☆,☆☆
Introduction
Maladaptive parenting styles or practices have been found to be associated with the development of behavior problems in children (e.g., Dishion et al., 1995, Patterson and Stouthamer-Loeber, 1984). Children with behavior problems, in turn, are at risk for academic failing and social difficulties in childhood and serious antisocial behavior and criminal activity in adolescence and adulthood (e.g., Werba, Eyberg, Boggs, & Algina, 2006). Behavioral parent training (BPT) programs, including Parent–Child Interaction Therapy (PCIT), are often successful at improving parenting skills and helping parents address child behavior problems (e.g., Maughan et al., 2005, Thomas and Zimmer-Gembeck, 2007). PCIT is an intensive, evidence-based parent–child dyadic treatment program that has been evaluated in over 30 controlled studies and has been classified as an empirically supported treatment used primarily and successfully for 2- to 7-year-old children with disruptive behavior problems (e.g., Chambless and Ollendick, 2001, Eyberg et al., 2008). Past PCIT research (e.g., Chaffin et al., 2004, Galanter et al., 2012) has included children up to the age of 12 and suggests that PCIT may work for older children.
The goal of PCIT is to promote positive parenting skills and alter specific patterns of the interaction that cause dysfunction in the parent–child relationship (Eyberg and Funderburk, 2011, McNeil and Hembree-Kigin, 2010). PCIT is conducted in two phases: child-directed interaction (CDI) and parent-directed interaction (PDI). During the CDI phase, the focus is on teaching parents to provide positive consequences (e.g., praise) for children's appropriate behaviors (e.g., sharing), while ignoring minor disruptive behaviors. During the PDI phase, parents are taught to implement effective and consistent discipline strategies (e.g., ignoring, time-out) that specifically address children's inappropriate behaviors (e.g., whining, non-compliance; Eyberg and Funderburk, 2011, McNeil and Hembree-Kigin, 2010). PCIT has several defining features that distinguish it from most other BPT interventions: 1) it uses a parent–child dyadic delivery format in which the parent and the child both attend treatment sessions, 2) it uses direct, in vivo coaching whereby parents practice new skills and get immediate feedback about performance, 3) it requires continuous observation and coding of parent–child interactions throughout treatment to assess progress, and 4) it is a performance-based treatment that continues until parents demonstrate skill mastery criteria and the child no longer exhibits clinically elevated behavioral problems (Driskell et al., 1992, McNeil and Hembree-Kigin, 2010).
Although BPTs are effective in reducing child behavior problems, the intensive treatment inevitably leads to attrition in some cases. Unfortunately, attrition affects treatment outcomes, as families do not receive the benefits of improved child disruptive behavior, reduced parenting stress, or enhanced parenting skills associated with BPTs (Boggs et al., 2004). Attrition rates during PCIT have ranged from 10% (Matos, Torres, Santiago, Jurado, & Rodriguez, 2006) to 69% (Lanier et al., 2011). Pretreatment variables that have predicted attrition include assignment to the waiting list control group and young maternal age (Werba et al., 2006). Other variables that have predicted attrition include single parenthood (Bagner, 2013), high parental stress (Capage et al., 2001, Werba et al., 2006), more negative or inappropriate maternal talk toward the child (e.g., criticism, sarcasm, smart talk; Fernandez and Eyberg, 2009, Werba et al., 2006), less maternal positive talk (labeled and unlabeled praises; Fernandez & Eyberg, 2009), lower maternal intellectual functioning (Fernandez & Eyberg, 2009), and depressive symptoms (Fernandez & Eyberg, 2009). Child factors that have predicted dropout include having a young child, having a child with comorbid behavior problems, and having a child with developmental delay (Bagner, 2013).
The treatment length of PCIT may be a barrier to treatment completion, as families are requested to stay in treatment until the caregiver reaches pre-set skill levels and rates their child's behavior within normal limits. Treatment typically lasts for 10 to 16 sessions (Gallagher, 2003, Herschell et al., 2002), although some variability has been observed in other cultures, with more sessions required (Matos et al., 2006, McCabe and Yeh, 2009). For example, McCabe and Yeh (2009) examined the efficacy of PCIT with Mexican American parent–child dyads whose 3- to 7-year-old child had a clinically significant behavior problem and found that 18.7 sessions were needed for these families in the standard format of PCIT, while Matos et al. (2006) found a 16-session average when using PCIT with Puerto Rican families. In a sample of Chinese families in Hong Kong, parents with more personal and family difficulties required more than 20 sessions (Leung, Tsang, Heung, & Yiu, 2009). As can be discerned from prior research, some families require 16 or more sessions to complete PCIT, which can contribute to attrition if not addressed properly.
Studies have been conducted to confirm the effectiveness of PCIT for families in countries outside of the United States such as Australia (Nixon et al., 2003, Thomas and Zimmer-Gembeck, 2012), The Netherlands (Abrahamse et al., 2012), and the People's Republic of China, Hong Kong (Leung et al., 2009, Leung et al., 2015). These studies have found that PCIT is effective in other cultures when it is delivered as stipulated in the PCIT protocol (Leung et al., 2009, Leung et al., 2015, Nixon et al., 2003), with some minor tailoring for cultural appropriateness. In the study with Chinese families in Hong Kong, culturally appropriate examples were provided for various techniques (e.g., labeled praise, ignoring); otherwise, standard PCIT was delivered (Leung et al., 2009, Leung et al., 2015).
Although prior research has examined the use of PCIT with Chinese families in Hong Kong (Leung et al., 2009, Leung et al., 2015), the present study is the first of its kind to examine the use of PCIT with Taiwanese families. The first goal of the present study was to examine the predictors of treatment attrition and length in PCIT. Predictors used in the analyses for treatment attrition and length included those assessed in this study that have predicted these outcomes in past research. The second goal was to determine whether PCIT resulted in changes in child and parent behaviors in a sample of Taiwanese families whose children had disruptive behavior or conduct problems. Based on past research, we predicted that positive parenting behaviors would increase while negative parenting behaviors and child behavior problems would decrease.
Section snippets
Participants
Sixty-one Taiwanese caregivers and their children were recruited for participation in the current study. Forty-four children, ranging in age from 3 to 11 years, and their caregivers were enrolled in PCIT after they completed a pre-treatment assessment. The age of caregivers ranged from 23 to 66 years. Of the 44 parent–child dyads, 32 children and their caregivers completed treatment. Twelve children and their caregivers dropped out of treatment. Socio-demographic characteristics of all
Demographic data
When comparing the child, parent, and family characteristics of treatment completers and treatment dropouts, significant differences were observed for caregiver's gender, education, family status and psychological problems/disorders. Compared to caregivers who completed treatment, caregivers who dropped out of treatment were more likely to be female (100% vs. 71.9%), χ2(1, N = 44) = 4.24, p < .05, and to have completed high school or less (75% vs. 18.8%), χ2(6, N = 44) = 15.39, p < .05. Moreover, compared
Discussion
This study on the use of PCIT with Taiwanese children with disruptive behavior problems and their caregivers had two main goals. The first goal was to explore predictors that contribute to treatment attrition and length in PCIT for these Taiwanese families. The second goal was to examine the treatment effects of PCIT in a Taiwanese sample. Several factors were found to predict treatment attrition and length and were consistent with those identified as predictors in US samples (Fernandez and
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Funding for this research was provided by Grant NSC 100-2410-H-194-044-MY2 from the National Science Council, Taiwan. The authors would like to thank the several research assistants who devoted valuable time and assistance in data collection and entry: Chia-Jung Chang, Xiao-Ru Cheng, Chao-Xian Wu, Kai-Wen Tseng, and Yao-Chung Tseng.
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The findings and conclusions in this manuscript are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.