1. Copyright October 2007 Sheila Eyberg Adaptations of Parent-Child Interaction Therapy to Different Needs, Different Groups UF PCIT Training Workshop October, 2007

2. Copyright October 2007 Sheila Eyberg Active Skills Training PCIT Proven Effective for Large Stuffed Bears

3. Copyright October 2007 Sheila Eyberg Weekly ECBI Intensity Scores Normative mean Clinical cutoff Criterion to end treatment Treatment Completers (n = 64) And All Children Who Complete Treatment

4. Copyright October 2007 Sheila Eyberg PCIT is an “Evidence-Based Treatment” for (strictly speaking)  Young children (3 to 6)  Disruptive behavior disorders  USA or Australian residents  Without severe mental impairment (e.g., autism)  And their non-cognitively delayed parents  Designation based on two well-conducted RTCs Schuhmann et al., 1998 (US study) Nixon et al., 2003 (Australian study)

5. Copyright October 2007 Sheila Eyberg PCIT also named one of two “Well-Supported and Efficacious” Treatments for Child Abuse  Designation based on a now classic study Chaffin, M., Silovsky, J., Funderburk, B. et al. (2004). Parent-child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72, 500–510. – U.S. Department of Justice - Office for Victims of Crimes

6. Copyright October 2007 Sheila Eyberg But (strictly speaking) the Chaffin Study Presented An Adaptation of PCIT for a Special Population “Child Abusing Parents”  Extended child age range up to 12 Age-appropriate CDI activities (e.g., crafts) Age-appropriate back-ups to timeout chair (e.g., loss of privilege)  Added group modules at beginning and end Pre-PCIT motivational enhancement group – 6 session preparation for treatment involvement Follow-up group meetings –4 sessions of loosely structured problem-solving  PCIT protocol was made time-limited (14 wks)

7. Copyright October 2007 Sheila Eyberg Observed Parent Negative Behaviors (Criticism, Sarcasm, Negative Touch) Chaffin et al., 2004

8. Copyright October 2007 Sheila Eyberg PCIT (Plus 6-week Motivation Enhancement) with Abusive Parents Percent Re-Abuse During 2.5 Years After Treatment Chaffin et al., 2004

9. Copyright October 2007 Sheila Eyberg Exciting Results But…  If you learn PCIT, will it work for child abuse treatment? Or must you also use the motivation protocol? Economically important question for agencies deciding whether to adopt a treatment  Another question the study spawns – Does PCIT work for 12-year-olds? Unlikely effective for treating conduct-disordered 12-year-olds  Another question – Would the adaptations made for older children work well with young disruptive children? Empirical question – but unlikely

10. Copyright October 2007 Sheila Eyberg How Best to Develop a PCIT Adaptation  Test standard PCIT in the new population If it does not work, an adaptation unlikely to work If it does work, then you can examine if adaptation improves outcomes  Problems with testing adapted PCIT first If it does not work, you don’t know if the treatment or the adaptation was the problem If it does work, you don’t know if adaptation is needed It can waste expensive research dollars and time  First see if adaptation is needed

11. Copyright October 2007 Sheila Eyberg A Pilot Study of PCIT for Children with Comorbid ODD and Mental Retardation  3 - 6 years old  Oppositional defiant disorder DISC-IV-P and CBCL  Mild or moderate MR WPPSI-III Adaptive Behavior Scale Inclusion criteria Bagner & Eyberg, 2007

12. Copyright October 2007 Sheila Eyberg Children with Comorbid ODD and Mental Retardation  Major sensory impairments in child (deafness, blindness)  Childhood autism spectrum disorders Childhood Autism Rating Scale  Child history of psychosis  Primary caregiver not MR Wonderlic Personnel Test  Families suspected of child abuse Exclusion Criteria Bagner & Eyberg, 2007

13. Copyright October 2007 Sheila Eyberg Sample Description  Child 77 % male 67% Caucasian Mean age = 4.5 yrs Mean FSIQ = 59 (SD = 11.06)  Family 73% two-parent families Mean age of mother = 36; father = 38 Hollingshead SES = 41.30 (SD = 14.14) Bagner & Eyberg, 2007

14. Copyright October 2007 Sheila Eyberg Study Treatment Characteristics  Families randomized to PCIT (n = 15) or Waitlist Control (n = 15) conditions  Therapists Advanced graduate students Weekly supervision  Average of 12 weekly sessions CDI time limited (6 sessions) PDI not time limited Completion criteria unchanged  Treatment Integrity 97% accuracy; 97% interrater reliability  High treatment satisfaction Therapy Attitude Inventory = 46.88 Bagner & Eyberg, 2007

15. Copyright October 2007 Sheila Eyberg Clinical cutoff Disruptive Behavior Change in Children with Comorbid ODD and Mental Retardation Bagner, D.M., & Eyberg, S.M. (2007). Parent-child interaction therapy for disruptive behavior in children with mental retardation: A randomized controlled trial. Journal of Clinical Child and adolescent Psychology, 36, 1-12. n = 8 treatment completers

16. Copyright October 2007 Sheila Eyberg Mothers “Do” Skills During Child-Led Play d = 1.43 p <.001 Frequency Bagner & Eyberg, 2007

17. Copyright October 2007 Sheila Eyberg Mothers “Don’t” Skills During Child-Led Play d = 1.06 p =.014 Frequency Bagner & Eyberg, 2007

18. Copyright October 2007 Sheila Eyberg Percent Child Compliance (Alpha) During Parent-Led Play and Clean Up d = 1.10 p =.009 Percentage Bagner & Eyberg, 2007

19. Copyright October 2007 Sheila Eyberg CBCL Externalizing Scale d = 1.05 p =.01 Clinical cutoff Bagner & Eyberg, 2007

20. Copyright October 2007 Sheila Eyberg CBCL Total Score d = 1.12 p =.007 Clinical cutoff Bagner & Eyberg, 2007

21. Copyright October 2007 Sheila Eyberg Parenting Stress Index – Short Form Parental Distress Subscale d =.18 p =.703 Clinical cutoff Bagner & Eyberg, 2007

22. Copyright October 2007 Sheila Eyberg Parenting Stress Index – Short Form Parent-Child Dysfunctional Interaction d =.38 p =.099 Clinical cutoff Bagner & Eyberg, 2007

23. Copyright October 2007 Sheila Eyberg Parenting Stress Index – Short Form Difficult Child Subscale d =.77 p =.074 Clinical cutoff Bagner & Eyberg, 2007

24. Copyright October 2007 Sheila Eyberg Developmental Considerations in Applications of PCIT  Children with mild/moderate MR respond to treatment like normally developing children Treatment flexibility accommodates many individual child differences  Treatment outcomes more related to parent functioning PCIT not successful with parents who have MR

25. Copyright October 2007 Sheila Eyberg Developmental Considerations  Age 7 typically an upper limit for treating conduct problems with PCIT Children become cognitively “streetwise” –May behave perfectly until they leave the clinic Children are larger and stronger –Physical resistance could be dangerous  PCIT adapted for children up to Age 12 for treating abusive parenting Abused children not typically violent toward parent

26. Copyright October 2007 Sheila Eyberg Developmental Considerations  Age 3 likely not an important lower limit  Many 2-year-olds respond well  At 18 months even some toddlers benefit if they understand commands

27. Copyright October 2007 Sheila Eyberg Applications of PCIT to Children with New Target Problems In ternalizing Behaviors and Separation Anxiety Disorder (SAD)?  Social learning theory can be applied to any maladaptive behavior Attend to desired behavior to increase it Ignore maladaptive behavior to decrease it  Traditional attachment theory holds that insecure attachment causes SAD Current research links insecure attachment to –Behavior problems in preschoolers –Anxiety symptoms in adolescents

28. Copyright October 2007 Sheila Eyberg Internalizing Behavior Problems and Separation Anxiety Disorder (SAD)?  Parent factors in child internalizing disorders Child anxiety –Low levels of parental warmth –High levels of criticism Child depression –Low levels of parental warmth –Harsh, inconsistent discipline  PCIT targets similar parents behaviors in treatment of child disruptive behavior

29. Copyright October 2007 Sheila Eyberg Sample of ODD Children with Co-morbid Internalizing Behaviors and SAD  Sample 100 families Referred for ODD Age 4.8 years (range 3 to 6) 69% boys 14% had co-morbid SAD 14% had elevated internalizing CBCL score Race/ethnicity –76 Caucasian (76%) –8 African American (8%) –1 Asian (1%) –3 Hispanic/Latino (3%) –12 Bi-racial (12%)\ Chase & Eyberg, in press

30. Copyright October 2007 Sheila Eyberg Outcome Measures DISC-IV: parent interview of DSM criteria – Included SAD diagnosis / symptoms CBCL –included Internalizing Scale)

31. Copyright October 2007 Sheila Eyberg Separation Anxiety Disorder Pre- 14 Post- 3 SAD symptoms F (1,55) = 18.93, p <.001 Number of SAD Symptoms Number of Children with SAD Diagnosis

32. Copyright October 2007 Sheila Eyberg CBCL Internalizing Scale Internalizing Score F (1,59) = 8.36, p <.01 Above clinical cutoff  Pre-Tx 14  Post-Tx 3

33. Copyright October 2007 Sheila Eyberg Implications  PCIT may be effective for SAD A range of internalizing behaviors  PCIT recommended for Comorbid internalizing and externalizing problems Chase, R. M., & Eyberg, S. M. (in press). Clinical presentation and treatment outcome for children with comorbid externalizing and internalizing symptoms. Journal of Anxiety Disorders.

34. Copyright October 2007 Sheila Eyberg Two Model RTCs Examining PCIT Adaptations  Pincus, D.B., Eyberg, S.M., & Choate, M.L. (2005). Adapting parent-child interaction therapy for young children with separation anxiety disorder. Education and Treatment of Children, 28, 163-181.  McCabe, K.M., Yeh, M., Garland, A.F., Lau, A.S., & Chavez, G. (2005). The GANA program: A tailoring approach to adapting parent-child interaction therapy for Mexican Americans. Education and Treatment of Children, 28, 111-129.  Final RTC results submitted for publication

35. Copyright October 2007 Sheila Eyberg Pilot Study Leading to RTC of SAD Pincus & Eyberg, 2007  To examine effects of PCIT with children aged 4-8 seen for treatment of Separation Anxiety Disorder using multiple baseline experimental design Participants  Three children with a primary diagnosis of SAD  All Caucasian  Annual family income $75,000

36. Copyright October 2007 Sheila Eyberg Primary Measures  Anxiety Disorder Interview Schedule (Child and Parent Versions) (ADIS-C/P; Silverman & Albano, 1997)  Child Behavior Checklist (CBCL; Achenbach & Edelbrock, 1991)  Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999)  Weekly Record of Anxiety at Separation (WRAS; Choate & Pincus, 2000) (parent daily monitoring form of frequency and severity of 22 SAD behaviors)  Fear and Avoidance Hierarchy—list of separation situations that are avoided by the child; parents rated fear and avoidance on 0-8 scale

37. Copyright October 2007 Sheila Eyberg Case Descriptions 1 “Sam”” --7 year old male, 2 nd grader --Intense fear of being separated from parents --Continual worry about parents’ well being, crying --Somatic complaints: stomach/headache --Avoidance of all extra “fun” activities if he had to separate --Average 6 distressing separation incidents/ week at pre-treatment 2 “Jack” --5 year old male, in kindergarten --“Meltdowns” each time parents leave him, physical distress, stomachaches -- Unable to play at friends’ houses or sleep alone --Sought constant reassurance from parents, excessive clinginess --Average 8 distressing separation incidents per week at pre- treatment

38. Copyright October 2007 Sheila Eyberg 3 “Karen” --8 year old female -- Unable to play at friends’ houses or sleep alone -- Complaints of physical distress, stomachaches -- Excessive clinginess to her mother -- Parents report over 11 distressing separation incidents per week -- Parents feel intolerant of her behavior and yell at her constantly to behave herself and stop being so afraid -- Karen’s behavior causes stress and fighting for whole family Case Descriptions

39. Copyright October 2007 Sheila Eyberg Results of Pilot Study  Clinically significant decreases in separation anxiety behaviors for all three young children with diagnosed SAD  None of the 3 children met criteria for a clinical diagnosis of SAD following PCIT treatment  Incidents of separation anxiety dropped to zero within 5 weeks after beginning treatment for all three children and remained at or close to zero at short term follow up  Children’s fear and avoidance ratings decreased substantially during the CDI phase of treatment and continued to decrease during PDI phase

40. Copyright October 2007 Sheila Eyberg Severity of SAD at Pre and Post Treatment and Follow-up

41. Copyright October 2007 Sheila Eyberg Total Fear and Avoidance Ratings at Each Assessment Point

42. Copyright October 2007 Sheila Eyberg Number of Weekly Separation Incidents at Pre, Post, and Follow-up

43. Copyright October 2007 Sheila Eyberg Number of Separation Anxious Incidents

44. Copyright October 2007 Sheila Eyberg Adaptation of PCIT for Mexican-American Families McCabe et al., 2008  Randomized controlled trial  3 groups Standard PCIT Cultural adaptation (GANA) Treatment as usual (TAU)  Adaptation examples Name changed from “therapy” to “classes” “Therapist” was called “teacher” No changes in defining features of PCIT  Results consistent across multiple observational and rating scale outcome measures

45. Copyright October 2007 Sheila Eyberg CBCL Externalizing Scale

46. Copyright October 2007 Sheila Eyberg “PCIT-Lite” A Parenting Enhancement Program for Non-Clinical Families Harwood & Eyberg, in preparation  Program designed to improve parent-child relationship, communication, and discipline 4-session group parenting class Based on principles and protocol of PCIT  Some support for this PCIT modification from the clinical literature PCIT in group format (Gurwitch et al., 2005) PCIT in brief 5-session application (Nixon et al., 2003) Return-to-chair back-up to time-out chair (Schroeder & Gordon)

47. Copyright October 2007 Sheila Eyberg Protocol for PCIT-Lite 4 to 5 families per group (both mothers and fathers) Children meet in separate playroom with child care assistant (except during parent-child coaching) –Session 1 CDI Teaching and brief coaching –Session 2 CDI Coaching –Session 3 PDI Teaching and brief demonstration –Session 4 PDI Coaching Parents receive all standard CDI handouts and modified PDI handouts Daily homework similar to PCIT Post- and 6-month follow-up data collected by phone

48. Copyright October 2007 Sheila Eyberg Design and Participants  Inclusion Criteria Children between 3 and 6 years of age ECBI score within 1 SD of normative mean  Exclusion Criteria Major sensory or mental handicap  30 mother-child dyads randomly assigned PCIT parenting enhancement group –Called Primary Care PCIT (PC-PCIT) PCIT comparison group that received written PCIT handouts and directions for practice –Called Anticipatory Guidance Harwood & Eyberg, in preparation

49. Copyright October 2007 Sheila Eyberg ECBI Intensity Scale Time effect only F(2, 36) = 9.15, p =.001, f =.96

50. Copyright October 2007 Sheila Eyberg Parent Locus of Control – Short Form Time Effect Only F(2, 36) = 12.09, p <.001, f = 1.10

51. Copyright October 2007 Sheila Eyberg Parenting Scale Time Effect Only F(2, 36) = 11.05, p <.001, f = 1.05

52. Copyright October 2007 Sheila Eyberg ECBI Intensity Scale Comparing Baseline to Treatment Change (One Month Between Each Assessment Point) Screening to pre-treatment p = 1.00, d =.17 Pre to post-treatment p <.001, d =.66 Screening to post-treatment p =.007, d =.67

53. Copyright October 2007 Sheila Eyberg Summary and Conclusions of the Pilot Study  Group differences not significant – cannot draw conclusions from nonsignificant differences  Parents reported better child behavior after the classes and felt more confident and in-control in disciplining  Parent ratings suggest the changes in child behavior lasted over 6-month follow-up  Results are promising and support further study  Results cannot be generalized to children with clinical behavior problems