• By Dartington SRU
• Posted on Thursday 29^th May, 2014

From innovation to impact: the case of PCIT

Sheila Eyberg, the developer of Parent-Child Interaction Therapy (PCIT), was interviewed for a series of articles in Prevention Action in May 2012. Here we provide a précis of her comments about the development of the programme.

A marriage of the old and the new

Parent-Child Interaction Therapy (PCIT) is a treatment programme for young children with significant behavioural and emotional difficulties and their parents. Eyberg began developing it in the 1970s as a young clinical psychologist.

An early inspiration was Diana Baumrind. While Eyberg was at graduate school in the late 1960s, Baumrind’s research was challenging the traditional focus on individual play therapy. The idea of parent training, now a mainstay of treatment for child behaviour problems, was novel. Baumrind found that a nurturing and responsive parenting style accompanied by clear communication and firm limit-setting (what she called “authoritative parenting”) led to the best outcomes for children.

However, in her first clinical posting at Oregon Health Sciences University (OHSU), Eyberg was encouraged to set aside the novel parent training approach and instead explore the more traditional play therapy. She immersed herself in the literature and was inspired by the work of two more researchers: Virginia Axline and Bernard Guerney.

Axline argued that play therapy was successful not only because it gives parents and children time to bond, but also because children can vent their emotions through play. Guerney agreed, and developed a structured training programme in which parents, under the observation of a therapist, took part in play sessions with their children in their own homes.

Beyond play therapy

Eyberg hypothesised that the main problem with play therapy was that “the therapy hour couldn’t overcome the many other hours in each week filled with powerful negative interactions that kept the child’s negative behaviours in place.”

Play therapy clearly had some short-term benefits, but how could these be sustained outside of the therapy session? Eyberg thought a more effective strategy would combine traditional play therapy with innovations around training parents in a more authoritative parenting style. Parent-child relationships could be strengthened in play therapy, and then parents could learn more effective techniques of managing behaviour in parent training sessions.

The birth of PCIT

Eyberg was inspired by the work of Constance Hanf, also at OHSU, and adopted a similar two-phase structure, dividing her intervention into a Child-Directed Interaction (CDI) phase and a Parent-Directed Interaction (PDI) phase.

The first phase, CDI, draws on the strengths of play therapy: the child takes the lead while the parent practices giving praise and avoiding criticism. The second, PDI, adds parent training: parents take the lead in setting expectations and limits.

The intervention was officially named “Parent-Child Interaction Therapy” in 1974. Since then, studies have shown that PCIT often results in more positive interactions between the parent and child. Parents are better able to be nurturing and set effective limits – both hallmarks of an “authoritative” parenting style – and children themselves engage in better behaviour.

PCIT: the scientific method in action

In graduate school, Eyberg’s mentors instilled the notion that a “good therapist” is one who views each client’s treatment plan as a hypothesis to be tested. If the hypothesis can’t be confirmed quickly, the therapist revises and tests the treatment plan again and again – until it works.

Looking back, Eyberg explains: “When translated into the graduate student’s bottom line, we would be ‘good therapists’ if our cases were successful – defined by the data points on graphs. And it was our responsibility – not the child or family’s – to make this happen.”

Staying faithful to her scientist-practitioner training, Eyberg established a requirement for PCIT therapists to formally identify change in parents and their children through the collection and analysis of data at the beginning, during and at the end of the course of treatment. The gathering of data as part of this ongoing assessment and hypothesis-testing process is a core component of PCIT. The information contributes to decisions about the focus of the treatment and the desired outcomes. The data is used to test the therapist’s hypotheses and inform amendments in treatment plans.

What is more, evidence that the child’s and parents’ situation is improving is required before families can transition from the first phase of the treatment (CDI) to the second stage (PDI). The PCIT treatment is not complete until the child’s behaviour is reported to be back within the normal range for children of a similar age and stage of development.

Measuring change

But if PCIT was to be based on reliable evidence, therapists had to have a consistent way to assess parents’ and children’s progress. So Eyberg and her colleagues developed several assessment tools.

The first is a behavioural coding system known as the Dyadic Parent-Child Interaction Coding System (DPICS), which the therapist uses to quantify changes in children’s behaviour and parents’ skills observed during therapy sessions. A second is the Therapy Attitude Inventory (TAI), which explores the family’s perceptions of the acceptability of the treatment and general client satisfaction.

The third, and most widely known, is the Eyberg Child Behaviour Inventory (ECBI), a scale that measures parent reports of child conduct problems at home. It measures both the frequency of disruptive behaviours and the extent to which the parent perceives the child’s behaviour to be a problem. The ECBI (along with the DPICS) is completed every week throughout treatment to highlight areas for PCIT therapists to focus on and to capture changes that might indicate the treatment plan is working.

What next for PCIT?

What next for PCIT? Two things, according to Eyberg. The first is a commitment to expanding the research base for PCIT.

A lot of research has been done on PCIT, but gaps remain. How long, for instance, does PCIT continue to have an effect? Current data suggest that positive effects can be detected up to six years after treatment, “but we need longer and more tightly controlled studies,” says Eyberg.

Another focus for future research is retention and drop-out rates. A defining feature of the intervention is that families should be discharged only when the child’s behaviour is back in a “normal” range. Those who drop out sooner do not receive the full treatment, and the concern is that PCIT won’t work for them. Eyberg argues that understanding what factors influence drop-out is important to ensure that those who need treatment, but who struggle to remain engaged, get the help they deserve.

The second area for development involves training a new generation of PCIT clinicians. In the early stages of PCIT’s development, graduate programmes in clinical psychology were the primary vehicle for training PCIT therapists. Since then, the training has become increasingly sophisticated.

The deployment of modern communications technology, for example, has transformed the training process, enabling trainers to provide immediate, live feedback to trainee therapists without being physically present during the therapy session. This coaching relationship parallels the “bug-in-the-ear” device that PCIT therapists use to coach parents during therapy sessions.

A learning collaborative has also been formed, in partnership with the US National Center for Child Traumatic Stress (NCCTS). Its goal is to foster clinical competence as well as organisational support and readiness in order to break down barriers to implementing evidence-based programmes in the community.

The collaboration emphasises learning by doing. Trainees participate in face-to-face sessions and consultation calls, and practice their newly-developed skills between sessions. Between sessions they are encouraged to share learning so that everyone can benefit from others’ successes and failures. This innovative training model is subject to an ongoing evaluation. Preliminary findings suggest that it results in levels of fidelity and outcomes that are comparable to those found in the strict conditions of randomised controlled trials.

The full articles can be read here:PCIT: The birth of an innovationPCIT: The scientific method in actionPCIT: What next for the popular intervention?