1. Child Adult Relationship Enhancement CARE
Curriculum Developed by
Erica Pearl, PsyD; Barbara W. Boat, PhD; Erna Olafson, PhD/PsyD at
Cincinnati Children’s Hospital
Trauma Treatment Training Center

2. CARE Presented by Dianne Jandrasits, PsyD Teri Pentz, MS
Kristen Schaffner, MSEd, PhD Candidate
Matilda Theiss Child Development Center
Of Western Psychiatric Institute and Clinic of UPMC
Pittsburgh, PA

3. Child Adult Relationship Enhancement: Two Parts
Part I
Involves following the child’s lead in order to connect with the child
Part II
Involves discipline, including specific techniques to improve compliance

4. Evidence Based Promising Practice
Developed from empirically validated treatment called Parent Child Interaction Therapy (PCIT) developed by Sheila Eyberg
Adopted by National Child Traumatic Stress Network as a “Promising Practice”

5. What is PCIT?
PCIT
Developed for children ages 2-8 with Disruptive Behavior Disorder(s)
Play-based Dyadic Intervention
Brief treatment (14-20 weeks to complete)
Changes behavior from clinicilly significant problem to non-problematic levels
Evidence shows results last up to 6 years

6. Empirical Evidence for PCIT
PCIT International website ( provides an extensive list of over one-hundred and fifty research studies related to PCIT
Outcomes of PCIT
Decreased parental stress, more positive parent-child interactions, more internal locus of control for parents, as well as higher parental tolerance for their child’s behaviors (e.g., Boggs et al., 2004; Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998)
Significant decrease in child noncompliance, disruptive behaviors, and activity level (Eisenstadt et al., 1993)
A significant reduction in symptoms associated with Oppositional Defiant Disorder, Conduct Disorder, and Attention-Deficit Hyperactivity Disorder (Eisenstadt et al., 1993).

7. Empirical Evidence for PCIT (continued)
PCIT has demonstrated efficacy with a variety of clinical and cultural populations. (e.g., Bagner & Eyberg, 2007; Baurermeister, & Bernal, 2009; Chaffin et al., 2004; Choate, Picnus, Eyberg, & Barlow, 2005; Matos, McCabe & Yeh, 2009; Timmer et al., 2006)
Treatment gains have been maintained for one to six years (Boggs et al., 2004; Hood & Eyberg, 2003).

8. Child Adult Relationship Enhancement (CARE)
Trauma-informed, field-initiated modification of specific PCIT skills
For general usage by non-clinical adults who interact with traumatized children in a variety of settings
Supported by pragmatic evidence of effectiveness
(CARE Manual)

9. Evidence Base for CARE
According to the National Child Traumatic Stress Network, although CARE has not been studied extensively, due to the substantial research base supporting PCIT (treatment from which CARE was derived) the intervention is considered a promising practice with a sound theoretical basis.

10. Who Should Be Trained? Child Care Providers
Early Intervention Service Providers
Home Visitors
Educators and School Staff
Medical Professionals (Nurses, Pediatricians, Emergency Care Specialists, Dentists)
Adoptive Parents
Residential and Day Treatment Staff (including non-clinical staff)
Child Advocates
Foster Care Case Workers
Child Protection Workers
Police
Transportation Providers

11. What Does CARE Training Include?
Lecture, Demonstrations, Practice
(3 hours)
Lecture, Demonstrations, Practice, Live Coaching for mastery of skills (6 hours)
Training choice depends on setting, client population, and agency goals.

12. Toys for Connecting with Children
Creative, constructive toys
Building Blocks
Legos, Duplos, Tinker Toys
Mr/Mrs Potato Head
Dollhouse with miniatures
Crayons, paper, stencils, scissors
Pretend toys: food, farm, garage, cars
Play Dough and molds
Dolls/stuffed animals

13. Toys

14. Part I: Following the Child’s Lead
Research shows these skills help adults build good relationships with children, helping them feel safe and calm
Following a child’s lead can help adults communicate with all children, esp. those who are very active, oppositional, or shy
Using these skills helps adults teach children effectively
The interaction can improve a child’s willingness to comply
Following the child’s lead tends to improve the child’s social skills, e.g. sharing

15. Part II: Adult Directed Interaction
Discipline
Involves specific techniques to improve child’s compliance
Not recommended for dangerous, destructive behavior

16. Part I Skills: Minding Your “P’s and Q’s”
Two sets of Rules
“Do” Skills (P)
Can be used in many interactions with children throughout the day
“Avoid” Skills (Q)
Can be used in a variety of settings but there are some limits

17. “Do” Skills: P’s Praise (Labeled) appropriate behavior
Paraphrase appropriate talk
Point Out child’s appropriate behavior

18. Praise (Labeled) Appropriate Behavior
Praise is a compliment about a child or his/her behavior
Two Types of Praise
Labeled: Specific about what you like
“You chose such pretty colors!”
“ I like how you write so neatly.”
Unlabeled: Nonspecific praise
“Good!”
“Nice job.”
“You’re so smart.”

19. Praise
Labeled is better than Unlabeled because it lets the child know exactly what the adult likes
Increases the likelihood that the behavior will occur again
Adds more warmth to a relationship with a child
Makes both adult and child feel good!

20. Praise (Labeled) You’re very good at remembering your supplies.
Great job getting your homework done!
You’re doing such a great job of working hard.
Great idea to draw it that way.
That was kind of you to ask her to join in.
This is a terrific cake we made together.
That is a wonderful story you told.
I appreciate how clearly you explained that.
Good job finding that puzzle piece!
You’re doing a great job playing calmly.

21. Paraphrase Appropriate Talk
Paraphrasing is reflecting or repeating back all or part of what the child says
Examples
Child: “Big train.” Adult: “Yes, that IS a big train.”
Child: “Give me the car.” Adult: “You want the car.”
Child: “The clown makes me laugh.”
Adult: “The clown is funny.”
Child: “This piece don’t fit.” Adult: “That piece doesn’t fit.”

22. Paraphrase Appropriate Talk
Allows the child to lead conversation
Shows the child you’re really listening
Shows you accept and understand what s/he is saying
Improves and increases the child’s speech and conversational skills
May feel awkward at first but children LOVE it!

23. Paraphrase You did make dinner! You’d like to see that movie…
You feel overwhelmed with work.
The show is funny!
You had to run more than usual today.

24. Point Out Child’s Appropriate Behavior
States exactly what the child is doing
A running commentary, like a sports announcer on the radio
Describe each little thing and include the words, “you are…”

25. Point Out Child’s Appropriate Behavior
Let’s the child lead
Let’s the child know you’re interested & paying attention to him or her
Let’s the child know you approve of what he or she is doing
Models speech and teaches vocabulary and concepts
Keeps the child’s attention on the task & teaches child how to keep his or her own attention on a task
Helps organize the child’s thoughts

26. Point Out Behavior You’re making brownies for the party.
You’re sitting very quietly.
You’re drawing a picture.
You lined up all the blocks.
You’re getting organized.
You put them together.
You put the girl inside the truck.

27. “Avoid” Skills: Q’s Avoid Unnecessary Questions
Quash the Need to Lead by Avoiding Commands
Avoid words like
Quit No
Don’t
Stop
Not

28. Avoid Unnecessary Questions
Two Types of Questions
Information
Who, what, where, when, how
Tone-of-Voice
When the voice goes up at the end of the sentence but the person is not really asking for information (lilt)

29. Questions
Take the lead away from the child because they require an answer
Are often hidden or indirect commands, such as, “Would you like to build a house?”
Sometimes suggest disapproval
May leave child feeling that the adult is not really listening

30. Quash the Need to Lead by Avoiding Commands
Statements that try to direct play or conversation by suggesting what a child should do or what s/he should talk about
Two Types of Commands:
Direct: “Sit down.” “Tell me what you did today.”
Indirect: “Would you like to___?” “Let’s put the cars away.”

31. Quash Need to Lead by Avoiding Commands
Commands take the lead away from the child
If the child doesn’t obey the command, the connection can be lost because the play is no longer fun
Commands will be discussed in greater detail when we discuss discipline phase of CARE

32. Avoid Negative Talk: Quit, No, Don’t, Stop, Not
Negative or contradictory statements about the child or his/her actions that usually include the words, “Quit - ,” “No –,” “Don’t - ,” “Stop - ,” and “Not - .”
Examples
“Quit bothering your friend at circle.”
“No, that’s not how we do it.”
“Don’t forget to throw away your milk carton.”
“Stop banging the blocks on the table.”
“That’s not nice.”

33. Negative Talk: Quit No Don’t Stop Not
Often creates an unpleasant interaction
May make the child feel bad about herself or himself
Rarely works to decrease undesired behavior and often increases the criticized behavior
Points out mistakes

34. Negative Talk Exercise VERY difficult habit to break
Recall familiar negative talk typically heard as a child
VERY difficult habit to break
What should I say to a child?
Lots of other things to do & say
We’re not eliminating “Avoid” skills entirely, but the following skills are emphasized to enhance connection with children
These skills can be utilized during playtime and times when it is not imperative for the adult to be in charge

35. What About Inappropriate Behavior?
When adults apply P’s and Q’s children often display good behavior…but not always
What do we do if a child misbehaves?

36. Strategic Ignoring
Strategic (planned) ignoring is a powerful tool for decreasing or eliminating undesired attention – seeking behaviors
What behavior cannot be ignored?
What behavior can be ignored?

37. Strategic Ignoring
Any attention, positive or negative, can increase the negative behavior
Avoid any verbal or nonverbal reaction to the behavior (e.g. looking at the child, smiling, frowning, etc.).
Once you begin ignoring, it is essential that you continue to ignore until the behavior stops (e.g. tantrum at check-out)
Continue ignoring until the child is doing something appropriate
Praise the child immediately for the appropriate behavior. This helps the child notice the difference between responses to good vs. bad behavior.
CAUTION: behavior gets worse before it gets better
Consistent ignoring eventually decreases many undesired behaviors

38. Strategic Ignoring Change negative behavior to positive by
Praising Positive Opposites
While ignoring (-) behavior, look for any (+) behavior occurring at the same time and comment on it
Any time you see behavior that is the opposite of problem behavior you have to ignore, give the child a BIG labeled praise for the “positive opposite”
If a negative behavior stops, comment immediately on what the child is doing that is the opposite of the negative behavior

39. Mastery of P’s & Q’s Purpose of Mastery Testing
For trainees to practice skills and receive helpful feedback
Information practiced soon after learning is remembered best
Coding
See CARE skills coding sheet
Code for 3 minutes
Goal:
5 Praises (Labeled), 5 Paraphrases, and 5 instances of Pointing out Behavior
3 or fewer total Questions, Commands & Negative Talk

40. Part II Skills: Giving Good Commands
Make Commands Direct
State Positively
One at a Time
Make Commands Specific
Use Age-Appropriate Commands
Give Commands Politely and Respectfully
Use Neutral Tone of Voice
Offer Developmentally Appropriate Choices
Limit Explanations
Use “5 Second Rule” to Give Time to Comply

41. Use “5 Second Rule” to Give Time to Comply
Giving Good Commands
Use “5 Second Rule” to Give Time to Comply

42. Giving Good Commands: 5 Seconds for Compliance
When a child is dawdling, we must decide whether he or she is making a move toward compliance
While trying to decide, say nothing to the child and SILENTLY count to 5 in your head. If he or she doesn’t comply by the end of 5 seconds, this is considered noncompliance
Always provide labeled praise for compliance with commands

43. Determining Compliance vs. Noncompliance
Do I praise a child if they write their name at the bottom of the page but I told them to write it at the top?
Even though the child did write his or her name, the specific command was to write it at the top of the page. When a child does something slightly different from your command, it is noncompliance and does not get a Labeled Praise.
If I have told the child, “Please put the box on the shelf” and she slams it down while yelling, “I put the stupid box away!” what do I do?
The command was to put the box on the shelf and the child did so. The best thing to do is to ignore the attitude and praise the compliance. Bad attitudes will disappear when you give them no attention.

44. Broken Record
Technique for adults to practice giving a direct, positively stated command while keeping a neutral, consistent tone of voice

45. Broken Record
Choose a command where compliance isn’t critical (Please sit down)
Noncompliance? Give command 2nd time using EXACTLY the same words. Remain quiet (counting silently and slowly to 5), point to assist the child in understanding, and maintain neutral facial expression. If the child complies, provide enthusiastic Labeled Praise!
Noncompliance? Give command 3rd (and final time) using EXACTLY same words and neutral but firm tone of voice. Again, remain quiet (counting silently to 5), point to assist child in understanding, and & maintain neutral expression. If child complies with this 3rd command, provide Labeled Praise.
Noncompliance? Ignore him or her by turning away for walking away for 30 seconds to one minute.

46. Summary and Conclusion
CARE teaches techniques and skills which promote positive adult-child relationships while increasing compliance by use of effective commands
This presentation provides an overview of the program, but not full training
For more information on receiving training for your organization, please contact Dr. Jandrasits or Ms. Schaffner

47. Questions? ?