Topic:
Parent-Child Interaction Therapy and preschool-age children with disruptive behavior disorders.

Research tells us:
The disruptive behaviors of unruly preschoolers decrease when their parents use the techniques taught in Parent-Child Interaction Therapy. There is also some evidence, although it is less clear, that PCIT may have benefits for their social-emotional functioning, as well.

Acting on the evidence:
Parents and others who work with preschoolers can adopt PCIT's basic relationship-building and disciplinary techniques:

Employ "PRIDE" skills during child-led playtimes: Praise appropriate behavior; Reflect appropriate talk, restating and expanding on the child's comments; Imitate appropriate play; Describe appropriate behavior; and be Enthusiastic.

Use "Minding" techniques during brief adult-led playtimes:

• Teach the child to comply with instructions by giving simple commands that are direct, specific, age appropriate, and stated in a manner that's calm, positive, and respectful.
• When the child follows your directions, give specific praise; and when he or she doesn't do so, give a reminder and follow it with time-out, if necessary.

In the early 1980s, Sheila Eyberg at the Oregon Health Sciences University developed an intensive treatment method for preschoolers with disruptive behavior disorders and their parents. Because poor parent-child interaction is an important source of disruptive behavior problems, Eyberg's Parent-Child Interaction Therapy (PCIT) focuses on teaching parents a set of specific behavior management techniques within a play therapy setting, and then coaching them as they use the techniques with their child.

Natalie G. Gallagher, Ph.D., of the Research and Training Center on Early Childhood Development, analyzed 17 research studies to determine whether PCIT brings about positive behavioral and/or social-emotional change in preschoolers. Considered as a whole, the available study findings provide strong evidence that involvement in PCIT produces significant improvements in child behavior. The practice of PCIT may also have a positive impact on the social-emotional behavior of participants, although the evidence for this is less certain. In reporting these positive findings, Dr. Gallagher notes that the large majority of study participants were Caucasian mother-son pairs, however she found that PCIT's benefits extend across genders.

What are the key characteristics of PCIT? Let's take a look at the practice as both described and carried out in the research studies.

In PCIT, a trained practitioner uses a combination of teaching, modeling, and coaching to train parents in behavior-management techniques that they practice using while their children are at play. Parents learn one set of skills that promote a nurturing and secure parent-child relationship. They also learn a second set of skills to increase their child's positive social behavior and decrease negative behavior.

In each of PCIT's two treatment phases, the parent first attends a learning session without the child. During this session, the practitioner introduces the skills to be learned for that phase and uses role-playing to help the parent practice each skill. In the following sessions, parent and child interact in a playroom while the practitioner observes through a one-way mirror and uses a parent-worn earpiece to coach the parent in applying the newly learned skills.

Skills emphasized in the first, or Child-Directed Interaction (CDI) phase of PCIT, strengthen the parent-child relationship and increase the child's positive social behaviors. Parent and child take part in a "special play time" where toys that encourage creativity (building blocks, art materials, etc.) are readily available. Parents allow their child to lead the play session. Parents avoid asking questions, giving commands, or criticizing the child. Parents are coached to use "PRIDE skills" frequently: Praise appropriate behavior (" I like the way you're playing so gently with the toys"), Reflect appropriate talk (Child: "I like to play with blocks," Parent: "These blocks are fun"), Imitate appropriate play (Parent draws a circle on paper after child performs the same action), Describe appropriate behavior ("You are building a tower"), and be Enthusiastic ("You really are being gentle with the toys!"). Parents ignore negative behavior that does not place the child in immediate danger.

Once the CDI skills are mastered, therapy moves to the Parent-Directed Interaction (PDI) phase. The practitioner teaches parents to give clear commands and to deliver a response following every instance of child compliance or noncompliance. Parents learn to give direct, specific, age-appropriate commands in a positive, calm, and respectful manner. Commands are given one at a time and only when necessary.

In this phase, the child is given "minding exercises" that begin by teaching how to follow simple instructions ("Please put the red crayon in my hand") and move to more "real-world" commands ("Please pick up the crayon that you dropped"). Parents are coached to give specific praise after the child obeys ("Thank you for picking up the crayon. Because you listened to me, you do not have to go to time-out. We will keep playing").

Let's watch as a mother and her preschooler put these skills into practice:

Carol Harmon and her son Jason often spend spring mornings on their home's screened porch, where they've moved 3-year-old Jason's toybox, building sets, and art supplies, as well as Carol's floor loom, for the warm-weather months. This morning, Carol looks up from a complex tapestry she's creating for a new client. Before re-loading her shuttle with a new shade of homespun yarn, she speaks to her son.

"Jason, you're playing so nicely with your trains this morning. I sure appreciate it. I really like the way you're moving them along so carefully!"

"This one is the best engine," comments Jason, waving one of his toys. "He's the boss of every engine!"

"Some trains are especially fun, aren't they?" Carol responds, stepping across the porch to kneel next to her young railroader. Carol settles comfortably into a pattern of interaction that has transformed a once chaotic, frustrating relationship with her young son into times of enjoyable companionship-times when Jason plays contentedly and Carol can actually get some work done!

Carol selects one of the little trains and moves it slowly along the wooden track as Jason has done, imitating his enthusiastic "Chuga-chuga-choo-choos!"

"I see you're hooking more cars onto your train now," Carol comments as she watches Jason. "It's lots longer than mine. Now your best engine will really show what it can do!"

Soon Carol returns to her work, and Jason continues playing. Before long he tires of the trains. Jason dumps his remaining railroad toys on the floor and uses the upside-down storage basket as a pretend garage for his assortment of toy vehicles.

After a few minutes, Carol says, "Jason, I see you've made a garage for your cars and trucks. Pretty cool idea."

"Race cars, too," notes Jason, without looking up.

"It's okay to use that basket for a garage," Carol continues, "but I need you to stop and find another box to put your train things in now. The mess on the floor has gotten too big and everything is getting mixed up.Go get that other box and put the trains in there now."

Jason hesitates only a moment, looks around, and reaches for an empty plastic crate. Watching all the while, Carol says cheerfully, "Jason, thanks so much for listening and clearing away the trains. No time-out for you! You can keep having fun with that terrific new garage."

Take another look:
Read or download the complete research synthesis in the Bridges section of http://www.researchtopractice.info/: Gallagher, N. (2003). Effects of parent-child interaction therapy on young children with disruptive behavior disorders. Bridges, 1 (7).

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