1. Parent-Child Interaction Therapy Rhea M. Chase, M.S. Daniel Bagner, M.S. University of Florida

2. Disruptive Behavior Disorders Most common reason for referral of young children to mental health services Prevalence of Oppositional Defiant Disorder and Conduct Disorder estimated to be between 2% and 16% of all children Poor prognosis

3. Parent-Child Interaction Therapy (PCIT) Designed for young children (3-6) and their parents/caretakers Work with parents and child together Live coaching of skills Emphasis on restructuring parent- child interaction patterns

4. Child-Directed Interaction Parent-Directed Interaction  Parents follow Play therapy skills Differential attention Increase warmth of parent-child relationship  Parents lead Limit-setting Consistency Predictability Follow through

5. Structure of PCIT Assessment –Measures that guide treatment Teaching sessions –Presentation of skills –Modeling and role-playing Coaching sessions – Check in – Therapist codes and coaches – Assign homework

6. How does coaching work? Parent wears a Bug-in-the-Ear receiver while playing with child in playroom (therapist can coach while in the room with the parent) Therapist coaches specific skills Spouses take turns playing and observing

7. What families might benefit from PCIT? Children with conduct problem behavior Preschool age (3-6) At least one parent able to attend weekly sessions with child Parent(s) willing to practice skills at home

8. Effectiveness of PCIT

9. Effect Size Interpretations Small = 0.20 - 0.40 Medium = 0.40 - 0.60 Large = 0.60 - 0.80 Very large = 0.80 – 1.00 Astronomical = > 1.00

10. Child Problem Behavior and 2-Year Effect Size 2.32 Eyberg et al.

11. Child Compliance and 2 Year Effect Size.85 Eyberg et al.

12. Child Deviant Behavior Composite and 2 Year Effect Size. 54 Eyberg et al.

13. DPICS Parent Verbal and Physical Negative 1.11 Eyberg et al.

14. Child-Directed Interaction CDI

15. The CDI Teaching Session Parents alone Presentation of skills  Reasons  “Rules”  Examples Modeling/demonstration Role-play with parent What exactly are they taught?

16. CDI The Basic Rule Follow the Child’s Lead

17. CDI: The DON’T Rules No commands No questions No criticism

18. Direct : Sit here Indirect : Could you sit here? Commands attempt to lead Risk negative interaction No Commands CDI: The DON’T Rules

19. Questions ask for an answer Often hidden commands Take lead from the child Can suggest disapproval Can suggest not listening No Questions CDI: The DON’T Rules

20. Examples  You’re a bad girl  That doesn’t go that way  No Stop Quit Don’t  Points out mistakes rather than correcting them  “That’s wrong” is a criticism  “It goes like this” allows correction without criticism Lowers self-esteem Creates unpleasant interaction No Criticism CDI: The DON’T Rules

21. What’s left?

22. CDI: The DO Rules The PRIDE Skills  P raise  R eflect  I mitate  D escribe  E nthusiasm!

23. Praise Unlabeled praise is nonspecific – Good! – That's great! Labeled praise tells child specifically what is good – Thank you for sitting so quietly. Increases the specific behavior Increases child's self-esteem Increases positive parent-child interaction CDI: The DO Rules

24. Reflection “The moo-moo is in the barn.” “Yes, the cow is in the barn.” Allows child to lead the conversation Shows that parent is listening Shows that parent understands Improves and increases child’s speech Child Parent Repeating or paraphrasing CDI: The DO Rules

25. Imitation Doing the same thing the child is doing  Lets the child lead  Teaches parent how to “play”  Shows approval of child’s activity  Teaches child how to play with others – Sharing – Taking turns CDI: The DO Rules

26. Description Telling the child exactly what he or she is doing – “You’re drawing a sun.” Lets the child lead Lets child know you are paying attention and are interested Shows approval of child’s activity Models speech Teaches vocabulary and concepts Holds child’s attention to the task CDI: The DO Rules

27. Enthusiasm Conveying excitement by voice and gesture – “Wow!! You finished that SO quickly!” Lets the child know the parent enjoys being with the child Makes the play more fun for the child (and parent) Adds a quality of warmth to the interaction CDI: The DO Rules

28.  IGNORE annoying, obnoxious behavior  STOP THE PLAY for dangerous or destructive behavior Child-DirectedInteraction DON’T DON’T –Give Commands –Ask Questions –Criticize  DO –Praise –Reflect – Imitate –Describe Enthusiasm Enthusiasm

29.  “Special time”  5 minutes a day  Practice, play, and therapy Homework

30. Good activities: Toys with no rules Construction toys Play sets Creative Toys Not-so-good activities: Board games Messy activities (like fingerpaint) Aggressive toys (like guns or action figures) Pretend-talk toys

31. COACHING

32. CDI Coaching PRIDE (basic) –Great reflection! –Good labeled praise! Following –Good following his lead. –Describe what she’s doing. –Be sure to watch what she’s doing closely.

33. Noticing positive behaviors –Wow -- she picked up the one she dropped Attending to positive behavior – Wow -- you caught her being good! Ignoring negative behavior –That was great ignoring his back talk CDI Coaching

34. Catching child doing positive opposites –NICE praising his polite talk Touch, proximity –That’s nice the way you touch him when you praise him Genuineness – That sounded like you meant it Parent self-efficacy –You got him to play quietly! –Nice job of getting him back to the table. CDI Coaching

35. The treatment goals –Good teaching! –He seems a lot calmer today –She seems to be sharing more -- that will help her make friends at school. –You seem be having fun playing with your son. –You’ve got these skills down pat! CDI Coaching

36. Developmental expectations –Describe the colors so he can learn them. –He’s still too young to understand logic Child’s motivations -- or lack of motivations –He seems to throw the puzzle pieces when doesn’t understand where they go. –I think he just doesn’t know how to ask for your help. CDI Coaching

37. Why Coach? –Parents think they already do these things –Verbal habits are ingrained –Coaching (therapist feedback) makes parents aware of what they say –Coaching (child’s feedback) makes parents aware of the immediate effects –Coaching heightens parent’s attention and motivation

38. Why Coach? –Coaching provides parent support in actual difficult situations –Coaching demonstrates to parents (convinces parents) that change is possible –Coaching can help parents not to give up –Coaching is efficient -- makes it possible to address relevant problem areas and not spend time on areas that are not problems

39. CDI ROLE PLAY

40. Parent-Directed Interaction

41. PDI: Effective Commands Direct (telling, not asking) Positive (what to DO, not stop doing) Single (one at a time) Specific (not vague) Age-appropriate Given in a normal tone of voice Polite and respectful (Please... ) Explained before given or after obeyed Used only when really necessary

42. The Command... Command No Opportunity Whoops! (Start over) Obey Labeled Praise Disobey Back to Play YEA!

43. Back to Play YEA! Labeled Praise The Warning... Obey Disobey (UH-OH!) If you don’t [original command], you’ll have to go to the time out chair

44. The Chair

45. Are you ready to [obey original command]? Child stays on chair 3 min plus 5 sec quiet Or doesn’t (OH-OH!) Obey Acknowledge The Chair Command No

46. BACK TO CHAIR CHILD GOES TO TIME OUT ROOM 1 MIN + QUIET CHILD GETS OFF CHAIR CHILD GETS OFF AGAIN The Backup ROOM WARNING “You got off the chair before I said you could. If you get off again, you’ll go to the Time Out Room.”

47. Yes Are you ready to [Obey Original Command]? Obey Acknowledge The First Obey Child Stays on Chair 3 Min plus 5 Sec Quiet No

48. Praise Obey Back to play!!! Finally! Command

49. House Rules  PDI uses running commands  House rules are standing commands –Aggressive behavior –Destructive behavior  The Procedure –Label behavior for child –Explain rule to child –No chair warnings

50. Public Misbehavior  Procedure –Make plan before leaving home –Describe desired behavior –Take along “time out chair” –Discuss back-ups

51. PRACTICING PDI

52. Further Information… PCIT website: www.pcit.orgwww.pcit.org –Literature –Measures –Other material

53. Thank you! Questions?