Global dissemination of parent-child interaction therapy: The perspectives of Dutch trainees

Highlights

• Clinicians offer valuable perspectives on the global implementation of behavioral parent training programs.

• Dutch clinicians perceive parent-child interaction therapy to be an acceptable treatment.

• Dutch clinicians experience significant barriers to the implementation of PCIT.

• PCIT trainers must consider ways to address barriers experienced by Dutch and US clinicians.

Abstract

Robust evidence of the efficacy of behavioral parent training (BPT) programs for the treatment of childhood conduct problems has led to increasing international dissemination. As BPT programs are transported out of the countries in which they were developed, it is important to consider how barriers to therapist training vary—or do not vary—across countries and cultures in order to determine how the training process may need to be adapted. Using a systematic qualitative approach, we interviewed 75% (18) of all Dutch therapists trained in the BPT program parent-child interaction therapy (PCIT) to explore their perceptions of the PCIT model, training, and acceptability in the Netherlands. Dutch therapists reported numerous positive experiences with PCIT training and the treatment model, but also described significant barriers related to family, therapist, protocol, and agency factors. Therapists' perceptions of barriers to training and implementation overlapped substantially, though not comprehensively, with a sample of PCIT therapists in the US, suggesting that while PCIT training may be transported from the US to the Netherlands, some barriers exist that are not being addressed in the global dissemination.

Introduction

Conduct problems in young children are a highly prevalent and serious public health concern (Lavigne, LeBailly, Hopkins, Gouze, & Binns, 2009; Loeber, Burke, Lahey, Winters, & Zera, 2000). Intervention is often required to prevent children from experiencing a developmental trajectory that leads from conduct problems in early childhood to multiple, significant negative outcomes in later childhood and adolescence (Masten & Cicchetti, 2010). Behavioral parent training (BPT) has been established as the best-practice intervention to ameliorate childhood conduct problems (Eyberg, Nelson, & Boggs, 2008; McCart, Priester, Davies, & Azen, 2006). Based on behavioral principles, BPT programs focus on the development of caregivers' abilities to alter behavioral contingencies for their children. BPT programs that are associated with larger effect sizes in the reduction of child conduct problems and the development of effective parenting skills include several key components: parents' active practice with their children in sessions; development of nurturing interactions between parents and children; and parents' effective use of time-out and consistent discipline (Kaminski, Valle, Filene, & Boyle, 2008).

With the strong empirical support for BPT programs has come an increase in their dissemination internationally (Gardner, Montgomery, & Knerr, 2016). International dissemination includes significant challenges, not only related to the transfer of client outcomes (e.g., effectiveness of the intervention in a new culture) but also related to the process of implementation (e.g., training therapists in the new setting). In order to implement a program successfully, training must be acceptable to trainees, feasible to transport, and effective in developing therapists' competencies. These challenges may be exacerbated when transporting training from the country in which it was developed to a new country. Although increasing evidence suggests that BPT programs generally maintain positive client outcomes (e.g., reduction of child conduct problems) when transported from the US or Australia to other countries (Gardner et al., 2016; Leijten, Melendez-Torres, Knerr, & Gardner, 2016), the literature on implementation outcomes (e.g., acceptability, sustainability, feasibility) remains sparse (Baumann et al., 2015; Proctor et al., 2011). Further, the existing work on implementation has generally neglected the perspectives of one of the key stakeholders in the global dissemination of BPT programs: that is, the perspectives of the therapists being trained.

PCIT is a manualized BPT intervention developed to address childhood conduct problems in children aged two- to seven-years-old. Extensive research supports the model's efficacy (e.g., Niec, Barnett, Prewett, & Shanley, 2016; Nixon, Sweeney, Erickson, & Touyz, 2003; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998) and long-term maintenance of gains (e.g., Eyberg, Boggs, & Jaccard, 2014; Nixon, Sweeney, Erickson, & Touyz, 2004). In two phases of treatment—Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI)—parents learn to use child-centered skills, differential attention, and consistent, age-appropriate discipline to enhance the parent-child relationship and to reduce child behavior problems. Two components of PCIT that are key to changing parent and child behaviors are (1) assessment throughout treatment that includes not only parents' perceptions of their children's behaviors but also direct behavior observations of parents' skills to guide treatment, and (2) the use of in vivo coaching during which therapists use behavioral principles to shape parents' interactions with their children (Barnett et al., 2017; Eyberg & Funderburk, 2011; Shanley & Niec, 2010). These core components are important mechanisms of change in the PCIT model (Shanley & Niec, 2010) and have been linked to parents' skill acquisition (Barnett et al., 2017; Barnett, Niec, & Acevedo, 2013). Live practice of skills with parents and children in session has also been found to relate to larger effect sizes in the reduction of child conduct problems (Kaminski et al., 2008). Although these components are specific strengths of the PCIT model, they require therapists to use strategies not commonly used in other interventions. Thus, it is possible that these key components of the PCIT model may also create barriers to implementation.

PCIT has been disseminated into community mental health settings (e.g., Lanier, Kohl, Benz, Swinger, & Drake, 2014; Lyon & Budd, 2010; Pearl et al., 2012) and has demonstrated efficacy with families from diverse ethnic backgrounds (Fernandez, Butler, & Eyberg, 2011; Matos, Bauermeister, & Bernal, 2009; McCabe, Yeh, Lau, & Argote, 2012). The intervention is increasingly being disseminated internationally. Currently, it is implemented in Australia, China (Hong Kong), Germany, Japan, New Zealand, the Netherlands, Norway, South Korea, Switzerland, and Taiwan (Niec, 2018) with training also underway in France. Although effectiveness studies have been conducted in a few countries outside of the US (e.g., Netherlands; Abrahamse, Junger, Van Wouwe, Boer, & Lindauer, 2016; Norway; Bjørseth & Wichstrøm, 2016; Hong Kong; Leung, Tsang, Sin, & Choi, 2015), little is known about the success of the broader dissemination efforts in any country outside of the US.

In the US, factors related to the implementation of PCIT have been explored among PCIT trainers (Scudder & Herschell, 2015) and among community PCIT clinicians (Christian, Niec, Acevedo-Polakovich, & Kassab, 2014). A qualitative investigation of the perceptions of PCIT therapists in the US suggest that they view the core components of PCIT as acceptable and valuable (Christian et al., 2014). However, US clinicians also identified a number of barriers at various levels of implementation (e.g., family, therapist, protocol, and agency factors). Some of the most frequently identified barriers included the costs associated with starting a PCIT program, difficulties managing the audio/visual equipment often used in PCIT, and difficulties engaging parents or managing the complexities of highly stressed families within the treatment model. US clinicians also expressed a need for more frequent or longer consultation during the training process. These barriers have implications for the implementation and maintenance of PCIT programs; thus, it is important to understand the experiences of international PCIT therapists, such as those in the Netherlands.

As the international dissemination of PCIT and other BPT programs continues to expand, it is important to consider how barriers to training vary—or do not vary—across cultures to determine in what ways training may need to be adapted to the context in which it is delivered. Differences in mental health systems and other contextual factors may influence clinicians' experiences with training and the implementation of the PCIT model. If PCIT and other parenting programs are to be successfully transported and sustained in other countries, it is important to understand differences in the experiences of international trainees.

PCIT was first implemented in the Netherlands in 2007. Since that time, research has supported the validity of PCIT-related measures in that country (e.g., Eyberg Child Behavior Inventory; Abrahamse et al., 2015), and has shown preliminary support for the effectiveness of PCIT among Dutch families (Abrahamse et al., 2012; Abrahamse et al., 2016). Although implementation has not been a focus of investigation, some challenges to the dissemination of PCIT are evidenced within existing work. For example, attrition rates among Dutch families are significant (40%; Abrahamse, Niec, Junger, Boer, & Lindauer, 2016) and the spread of the model within the country has been slow (F. Coelman, personal communication, June 26, 2017). It is not yet known what barriers might play a part in these challenges.

There is reason to expect that some barriers experienced by PCIT therapists in the US may also be experienced by Dutch therapists. This is due, in part, to similarities that exist between the Dutch and US community mental health care systems. For example, in both countries, the pathways to reaching mental health care can be complicated, leading to families having difficulty accessing care (Mental Health America, 2018; Prinz, 2014). Attrition from treatment is also a significant issue in both systems (de Haan, Boon, Vermeiren, Hoeve, & de Jong, 2015; Zwaanswijk, Verhaak, Bensing, van der Ende, & Verhulst, 2003). In the Netherlands, as in the US, underutilization of services in the child mental health care system is a concern (Garland et al., 2005; Zwaanswijk et al., 2003). In particular, children from ethnic minority populations in the Netherlands, as in the US, are less likely to receive treatment for conduct problems (Zwirs, Burger, Schulpen, & Buitelaar, 2006).

Despite some common concerns, differences in cultures and systems across the US and the Netherlands may lead to unique barriers experienced by Dutch PCIT therapists. For example, differences in the education system of mental health professionals mean that it is not uncommon for behavioral interventions to be administered in the Netherlands by individuals with the equivalent of a bachelor's degree, whereas most BPT programs implemented within the community mental health system in the US are administered by masters-level clinicians. This may lead to diverse perceptions of the PCIT training process. Differences across cultures have also been shown in parenting styles in that Dutch parents are less directive, engage their children with fewer questions, and use fewer negative verbalizations to modify their children's behavior than a US sample of parents (Abrahamse, Niec, Solomon, Junger, & Lindauer, 2018).

Although BPT programs generally demonstrate comparable effectiveness when transported outside of their countries of origin (Gardner et al., 2016), problems remain in sustaining fidelity and effect sizes when programs are disseminated broadly (Michelson, Davenport, Dretzke, Barlow, & Day, 2013; Piquero, Farrington, Tremblay, & Jennings, 2009; Weisz, Doss, & Hawley, 2005). It is important, therefore, to investigate the perspectives of the therapists who are receiving PCIT training and implementing the program. We interviewed PCIT therapists in the Netherlands in order to investigate their perspectives on PCIT training and the PCIT treatment model as implemented within their own country. Using a systematic qualitative approach based on the recommendations of Marshall and Rossman (2010), we sought to answer two primary questions: (1) Do Dutch therapists experience PCIT as an acceptable, effective, and sustainable approach to the treatment of children's conduct problems? (2) What barriers do Dutch therapists experience that may impede the long-term success of PCIT in the Netherlands?