Parent–Child Interaction Therapy for Child Disruptive Behaviour Disorders: A Meta-analysis

Effect of Providing Evidence-Based Mental Health Treatment on Retention in Care Among Medicaid-Enrolled Youths

OBJECTIVE

Youths who start behavioral health treatment often stop before completing a therapeutic course of care. To increase treatment engagement and quality of care, the Evidence-Based Practice and Innovation Center in Philadelphia has incentivized use of evidence-based practices (EBPs) for mental health care of youths. The authors aimed to compare treatment outcomes between youths who received EBP care and those who did not.

METHODS

Using EBP-specific billing codes and propensity score matching, the authors compared treatment retention among youths who received trauma-focused cognitive-behavioral therapy (TF-CBT; N=413) or parent-child interaction therapy (PCIT; N=90) relative to matched samples of youths in standard outpatient therapy (N=503).

RESULTS

Youths with a minimum of one session of TF-CBT or PCIT attended a second session at higher rates than did youths in the matched control group (TF-CBT: 96% vs. 68%, p<0.01; PCIT: 94% vs. 69%, respectively, p<0.01). On average, these returning youths attended more sessions in the EBP groups than in the control group (TF-CBT: 15.9 vs. 11.5 sessions, p<0.01; PCIT: 11.2 vs. 6.9 sessions, p<0.01).

CONCLUSIONS

These findings indicate that, in addition to improving quality of care, EBP implementation helps address the major challenge that most youths who engage with treatment are not retained long enough for care to have therapeutic effects. Future research should examine the mechanisms through which EBPs can improve treatment retention.

Synergistic Interventions for Silencing Oppositional Defiant Disorder and Dyslexia in a Child With Attention-Deficit/Hyperactivity Disorder: A Case Report From Albania

To the best of the authors' knowledge, this article is the first of its kind in Albania and neighboring countries to investigate the transformative synergistic intervention approach through cognitive behavioral therapy, parent-child interaction therapy (PCIT), and heavy metal detoxification on a child with attention-deficit/hyperactivity disorder (ADHD) and comorbid oppositional defiant disorder (ODD) and dyslexia. The limited mental health awareness in Albania, particularly regarding PCIT and similar treatments, highlights the importance of the applicability and adaptability of such interventions. This study suggests that the rapid management of comorbidities in ADHD, such as ODD and dyslexia, is better achieved by a combined intervention approach and by investigating the biological aspects. Further research with a large sample size is needed to assess the long-term sustainability and scalability of such an approach.

An Exposure-Based Cognitive-Behavioral Therapy for Youth with Severe Irritability: Feasibility and Preliminary Efficacy

OBJECTIVE

Clinically impairing irritability and temper outbursts are among the most common psychiatric problems in youth and present transdiagnostically; however, few mechanistically informed treatments have been developed. Here, we test the acceptability, feasibility, and preliminary efficacy of a novel exposure-based treatment with integrated parent management skills for youth with severe irritability using a randomized between-subjects multiple baseline design.

METHOD

N = 41 patients (Age, Mean (SD) = 11.23 years (1.85), 62.5% male, 77.5% white) characterized by severe and impairing temper outbursts and irritability were randomized to different baseline observation durations (2, 4, or 6 weeks) prior to active treatment; 40 participants completed the 12 session treatment of exposure-based cognitive-behavioral therapy for irritability with integrated parent management skills. Masked clinician ratings were acquired throughout baseline and treatment phases, as well as 3- and 6-months post-treatment. To examine acceptability and feasibility, drop-out rates and adverse events were examined. Primary clinical outcome measures included clinician-administered measures of irritability severity and improvement. Secondary clinical outcome measures included multi-informant measures of irritability, depression, anxiety, and attention-deficit/hyperactivity disorder symptoms.

RESULTS

No patients dropped out once treatment began, and no adverse events were reported. Irritability symptoms improved during the active phase of treatment across all measurements (all βs > -0.04, ps < .011, Cohen's d range: -0.33 to -0.98). Treatment gains were maintained at follow-up (all βs(39) < -0.001, ps > .400). Sixty-five percent of patients were considered significantly improved or recovered post-treatment based on the primary clinician-rated outcome measure.

CONCLUSIONS

Results support acceptability, feasibility, and preliminary efficacy of this novel treatment for youth with severe irritability. Limitations and future directions are also discussed.

The Efficacy of Parent Management Training With or Without Involving the Child in the Treatment Among Children with Clinical Levels of Disruptive Behavior: A Meta-analysis

A systematic review and meta-analysis was conducted where we evaluated the effects of Parent Management Training (PMT), Parent-Child Interaction Therapy (PCIT) and PMT combined with child cognitive behavioral therapy (CBT) using data from 25 RCTs on children with clinical levels of disruptive behavior (age range 2-13 years). Results showed that PMT (g = 0.64 [95% CI 0.42, 0.86]) and PCIT (g = 1.22 [95% CI 0.75, 1.69]) were more effective than waiting-list (WL) in reducing parent-rated disruptive behavior, and PMT also in improving parental skills (g = 0.83 [95% CI 0.67, 0.98]) and child social skills (g = 0.49 [95% CI 0.30, 0.68]). PCIT versus WL had larger effects in reducing disruptive behavior than PMT versus WL. In the few studies found, the addition of child CBT to PMT did not yield larger effects than PMT or WL. These results support offering PMT to children with clinical levels of disruptive behavior and highlight the additional benefits of PCIT for younger ages.

Early Emotion Development Intervention Improves Mental Health Outcomes in Low-Income, High-Risk Community Children

Children living in poverty and facing related forms of adversity are at higher risk for experiencing concurrent and later psychopathology. Although negative psychological outcomes can be improved by enhancing sensitive and responsive caregiving early in development, interventions targeting the caregiver-child dyad are not readily accessible. The present study investigated the feasibility and effectiveness of delivering a shortened eight-session form of Parent-Child Interaction Therapy-Emotion Development (PCIT-ED) in-person or remotely as an early intervention for 3-6-year-old children (N = 62) at elevated risk for psychopathology who were growing up in low-income communities. Caregiver-child dyads were randomized to eight-sessions of PCIT-ED or online parenting education. Relative to parenting education, children receiving PCIT-ED exhibited lower externalizing symptoms and functional impairment and more positive peer relationships following the intervention. Findings support the effectiveness of this shortened form of PCIT-ED, delivered in-person or remotely, as an early intervention to improve symptoms of psychopathology and functioning in high-risk children living in poverty.Trial registration Clinicaltrials.gov; NCT04399629.

Community-based Agency Delivery of Parent-Child Interaction Therapy: Comparing Outcomes for Children with and Without Autism Spectrum Disorder and/or Developmental Delays

While externalizing behaviors are common among children with autism spectrum disorder (ASD), there is a shortage of specialist community-based clinicians to provide treatment. Parent-Child Interaction Therapy (PCIT), an intervention designed to reduce child disruptive behaviors, may be effective for families of children with ASD but has rarely been studied outside of university-based research settings. We examined the effectiveness of PCIT delivered for children with (N = 109) and without (N = 2,324) ASD/developmental delays (DD) across community-based agencies in Oregon. Findings revealed significant reductions in disruptive behavior and positive changes in the parent-child relationship in both groups. These findings support PCIT as an efficacious intervention for children with ASD/DD and demonstrate PCIT's promise in community-based agencies with non-specialized clinicians.

Caregiver adverse childhood experiences and preschool externalizing problems: The role of factors that contribute to caregiver resilience

BACKGROUND

Preschool children with externalizing problems are at risk for short- and long-term difficulties and preschool externalizing problems (PEP) are influenced by several caregiver factors. One such factor is caregiver adverse childhood experiences (ACEs). Researchers have investigated how caregiver ACEs are related to PEP by identifying risk factors to account for this association. However, research on caregiver factors associated with fewer PEP is limited. Particularly, factors that contribute to caregiver resilience may be adaptive caregiver characteristics that negatively relate to PEP, even when adjusting for caregiver ACEs.

OBJECTIVE

The present study sought to address a gap in the literature by examining the impact of different types of factors that contribute to caregiver resilience (e.g., caregiver social-ecological factors or caregiver positive childhood experiences) as promotive factors of lower PEP.

PARTICIPANTS AND SETTING

Participants included 125 caregiver-child dyads recruited from the community.

METHOD

Participating caregivers completed measures of their own and their child's demographic information, caregiver ACEs, caregiver social-ecological factors, caregiver positive childhood experiences, and PEP.

RESULTS

Overall, positive caregiver childhood experiences (r = -0.25, p < .01), and not caregiver social-ecological factors (r = -0.13, p = .15), demonstrated a significant negative association with PEP. However, this relation became statistically non-significant when adjusting for caregiver ACEs (β = -0.12, p = .20).

CONCLUSIONS

Given the association between caregiver ACEs and PEP, this study highlights the importance of assessing a caregiver's ACEs, specifically when working with caregivers seeking parent training for disruptive child behaviors. There should be a continued focus on ecological and family strengths and differential impacts as they relate to PEP.

Behavior Management in Young Children Exposed to Trauma: A Case Study of Three Evidence-Based Treatments

Young children are particularly vulnerable to traumatic events and the development of posttraumatic stress symptoms, including comorbid disruptive behaviors. Fortunately, several evidence-based interventions have been shown to be effective at decreasing both posttraumatic stress symptoms and disruptive behaviors in young children. This paper provides an overview of three such interventions-Child-Parent Psychotherapy (CPP), Parent-Child Interaction Therapy (PCIT), and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). An illustrative case study is used to compare how each intervention addresses disruptive behaviors, with a focus on theoretical underpinnings, model similarities, and model differences. The models each have empirical evidence for the treatment of disruptive behavior in young children, and therefore, may be appropriate for treating children with a history of trauma exposure and comorbid disruptive behaviors. Child, caregiver, and environmental factors are essential to consider when identifying an evidence-based intervention for this population.

Applying the Theoretical Domains Framework to Develop an Intervention to 'Re-implement' Parent-Child Interaction Therapy (PCIT)

Parent-Child Interaction Therapy (PCIT) is an empirically supported treatment for childhood conduct problems, with increasing numbers of clinicians being trained in Aotearoa/New Zealand. However, ensuring sustained delivery of effective treatments by trained clinicians in routine care environments is notoriously challenging. The aims of this qualitative study were to (1) systematically examine and prioritise PCIT implementation barriers and facilitators, and (2) develop a well specified and theory-driven 're-implementation' intervention to support already-trained clinicians to resume or increase their implementation of PCIT. To triangulate and refine existing understanding of PCIT implementation determinants from an earlier cross-sectional survey, we integrated previously unanalysed qualitative survey data (54 respondents; response rate 60%) with qualitative data from six new focus groups with 15 PCIT-trained clinicians and managers in Aotearoa/New Zealand. We deductively coded data, using a directed content analysis process and the Theoretical Domains Framework, resulting in the identification of salient theoretical domains and belief statements within these. We then used the Theory and Techniques Tool to identify behaviour change techniques, possible intervention components, and their hypothesised mechanisms of action. Eight of the 14 theoretical domains were identified as influential on PCIT-trained clinician implementation behaviour (Knowledge; Social/Professional Role and Identity; Beliefs about Capabilities; Beliefs about Consequences; Memory, Attention and Decision Processes; Environmental Context and Resources; Social Influences; Emotion). Two of these appeared to be particularly salient: (1) 'Environmental Context and Resources', specifically lacking suitable PCIT equipment, with (lack of) access to a well-equipped clinic room appearing to influence implementation behaviour in several ways. (2) 'Social/Professional Role and Identity', with beliefs relating to a perception that colleagues view time-out as harmful to children, concerns that internationally-developed PCIT is not suitable for non-Māori clinicians to deliver to Indigenous Māori families, and clinicians feeling obligated yet isolated in their advocacy for PCIT delivery. In conclusion, where initial implementation has stalled or languished, re-implementation may be possible, and makes good sense, both fiscally and practically. This study suggests that re-implementation of PCIT in Aotearoa/New Zealand may be facilitated by intervention components such as ensuring access to a colleague or co-worker who is supportive of PCIT delivery, access to suitable equipment (particularly a time-out room), and targeted additional training for clinicians relating to the safety of time-out for children. The feasibility and acceptability of these intervention components will be tested in a future clinical trial.

Components of Behavioral Parent Training for Children With Attention-Deficit/Hyperactivity Disorder: A Series of Replicated Single-Case Experiments

Behavioral parent training (BPT) is an evidence-based treatment for children with attention-deficit/hyperactivity disorder (ADHD). Stimulus control techniques (antecedent-based techniques, e.g., clear rules, instructions) and contingency management techniques (consequent-based techniques, e.g., praise, ignore) are the most common ones that are being taught to parents in BPT. However, research into the additive effects of these techniques is scarce. In this replicated single-case experimental ABC phase design, including six children on stable medication for ADHD (8-11 years) and their parents, the added efficacy of consequent-based techniques on top of antecedent-based techniques was evaluated. After a baseline period (phase A), we randomized the commencement time of two sessions parent training in antecedent-based techniques and two sessions parent training in consequent-based techniques for each child. Children's behaviors were assessed by daily parent ratings of selected problem behaviors and an overall behavior rating. Although visual inspection showed that behavior improved for most children in both phases, randomization tests did not demonstrate the added efficacy of the consequent-based techniques on top of the antecedent-based techniques. Limitations of the study and recommendations for future single-case experiments in this population are discussed.

Interventions for Young Children's Mental Health: A Review of Reviews

To determine the efficacy of intervention programs for young children (4-9 years) with emerging mental health needs, we conducted a review of meta-analytic and systematic reviews of the intervention literature. Of 41,061 abstracts identified and 15,076 screened, 152 review articles met the inclusion criteria. We reviewed interventions across multiple disciplines targeting: (1) general mental health concerns; (2) internalizing symptoms; (3) externalizing symptoms; (4) anxiety; (5) depression; (6) trauma; (7) symptoms of attention-deficit/hyperactivity disorder; and (8) mental health concerns associated with autism spectrum disorder. Substantial evidence was found for the efficacy of behavioral and cognitive behavioral interventions for general mental health concerns, externalizing symptoms (generally, as well as ADHD, conduct, and other behavioral symptoms) and internalizing symptoms (generally, as well as anxiety) aged 4-9 years. Emerging evidence was identified for interventions targeting trauma symptoms, depression symptoms, and social, emotional and behavioral symptoms in autism spectrum disorder in children aged 4-9 years. Currently there is only limited emerging evidence regarding non-behavioral or non-cognitive behavioral interventions for programs targeting children ages 4-9 years where the aim is to deliver an evidence-based program to improve child social, emotional and/or behavioral functioning. Given the recent rises in mental health needs reported in children, targeted behavioral-and/or cognitive behavior therapy-based interventions should be made widely available to children (and their families) who experience elevated symptoms.

Adapting to Unprecedented Times: Community Clinician Modifications to Parent-Child Interaction Therapy during COVID-19

Parent-Child Interaction Therapy (PCIT) is an evidence-based practice that effectively prevents and treats child disruptive behaviors and child physical maltreatment and reduces parenting stress. PCIT was adapted for telehealth delivery, internet-delivered PCIT (iPCIT), before the COVID-19 pandemic but was not widely implemented until the rapid transition to telehealth during stay-at-home orders. To understand how clinicians adapted PCIT during COVID-19, we followed up on a previous study investigating community clinician adaptations of PCIT pre-COVID-19 using the Lau et al. (2017) Augmenting and Reducing Framework. Clinicians (N = 179) who responded to the follow-up survey and reported delivering PCIT remotely completed a quantitative measure of adaptations at both time points (Fall 2019; Summer 2020) to assess how adaptations to PCIT changed following lockdown measures. Clinicians (n = 135) also provided qualitative descriptions of adaptations made early in the COVID-19 pandemic. Clinicians in the full sample were 74.3% Non-Hispanic White and 14% Latinx. Most clinicians had a master's degree (66.5%), were licensed (80.4%), and were PCIT-certified (70.4%). Paired samples t-tests showed that clinicians reported similar levels of augmenting t(179) = -0.09, p=.926) and reducing adaptations t(179) = -0.77, p=.442) at both time points. Unlike quantitative findings, qualitative findings indicated that clinicians described engaging in many types of adaptations in response to the pandemic. Clinicians discussed engaging in augmenting adaptations by extending treatment length and integrating other practices into treatment. Clinicians also discussed engaging in reducing adaptations. Implications and future directions will be discussed.

Evidence-Based Treatment in Practice: PCIT Research on Addressing Individual Differences and Diversity Through the Lens of 20 Years of Service

Parent-Child Interaction Therapy (PCIT) is an intensive parent support program for caregivers and their children who exhibit difficult-to-manage disruptive behaviors. After more than four decades of research supporting its efficacy for reducing children's disruptive behaviors and improving parent-child relationships, PCIT has become one of the most popular and widely disseminated parenting support programs in the world. The evidence for the efficacy of PCIT can be found in many reviews of randomized clinical trials and other rigorous studies. To add to those reviews, our aim was to provide practical guidance on how PCIT can be part of an evidence-based program for families that depends on practitioner expertise, as well as attention to families' diverse needs. To do this, we describe the evolution of PCIT as practiced in a university-community partnership that has continued for over 20 years, alongside a narrative description of selected and recent findings on PCIT and its use in specific client presentations across four themes. These themes include studies of 1) whether the standard manualized form of PCIT is efficacious across a selection of diverse family situations and child diagnoses, 2) the mechanisms of change that explain why some parents and some children might benefit more or less from PCIT, 3) whether treatment content modifications make PCIT more feasible to implement or acceptable to some families, at the same time as achieving the same or better outcomes, and 4) whether PCIT with structural modifications to the delivery, such as online or intensive delivery, yields similar outcomes as standard PCIT. Finally, we discuss how these directions in research have influenced research and practice, and end with a summary of how the growing attention on parent and child emotion regulation and parents' responses to (and coaching of) their children's emotions has become important to PCIT theory and our practice.

Protocol for a randomised pilot study of a novel Parent-Child Interaction Therapy (PCIT) 're-implementation' intervention

BACKGROUND

Despite a number of clinicians having been trained in Parent-Child Interaction Therapy (PCIT) in Aotearoa/New Zealand, few are regularly delivering the treatment, with barriers to use including a lack of suitable equipment and lack of professional support. This pragmatic, parallel-arm, randomised, controlled pilot trial includes PCIT-trained clinicians who are not delivering, or only rarely utilising, this effective treatment. The study aims to assess the feasibility, acceptability and cultural responsivity of study methods and intervention components and to collect variance data on the proposed future primary outcome variable, in preparation for a future, larger trial.

METHODS

The trial will compare a novel 're-implementation' intervention with a refresher training and problem-solving control. Intervention components have been systematically developed to address barriers and facilitators to clinician use of PCIT using implementation theory, and a draft logic model with hypothesised mechanisms of action, derived from a series of preliminary studies. The intervention includes complimentary access to necessary equipment for PCIT implementation (audio-visual equipment, a 'pop-up' time-out space, toys), a mobile senior PCIT co-worker and an optional weekly PCIT consultation group, for a 6-month period. Outcomes will include the feasibility of recruitment and trial procedures; acceptability of the intervention package and data collection methods to clinicians; and clinician adoption of PCIT.

DISCUSSION

Relatively little research attention has been directed at interventions to resurrect stalled implementation efforts. Results from this pragmatic pilot RCT will refine and shape knowledge relating to what it might take to embed the ongoing delivery of PCIT in community settings, providing more children and families with access to this effective treatment.

TRIAL REGISTRATION

ANZCTR, ACTRN12622001022752, registered on July 21, 2022.

Examining the Efficacy of Online Administration of a Time-Limited School Readiness Intervention in the Face of COVID-19

Although the efficacy of online administration of behavioral parent training (BPT) programs is well-established, such programs address a single risk factor (behavioral functioning) for school readiness difficulties (comprised of academics, cognitive skills, and social, emotional, and behavioral functioning). The current study aims to examine the feasibility, acceptability, and efficacy of a telemedicine delivery of the School Readiness Parenting Program (SRPP), an integrative adaptation of PCIT designed to address the behavioral and academic domains of school readiness. The present study takes the first step towards validating an online administration of the SRPP as a treatment for early childhood disruptive behavior. Data were collected for 64 children ages 2-6 years (Mage = 4.63, SD = 0.86; 78.1% Hispanic/Latinx) and their families, who received either in-person administration of time-limited PCIT (PCIT-TL; n=30) or online administration of SRPP (n=34). A series of repeated measures ANOVAS were conducted to examine within and between group effects. Results revealed that both SRPP and PCIT-TL significantly reduced inattention (d's = -0.54 to -0.88), aggression (d's = -0.55 to -1.06), and behavioral symptomology (d's = -0.55 to -0.85) and produced significant gains in parental skills (d's = -1.47 to 2.99). Notably, online SRPP demonstrated greater improvement in positive parental verbalization, whereas PCIT-TL demonstrated greater reductions in parental stress. Overall, findings support the utility of online SRPP for addressing behavioral school readiness concerns.

Effectiveness of Group Parent-Child Interaction Therapy on Problem Behaviors in Chinese Kindergartners

Problem behaviors in early childhood may put young children at risk for negative behavioral and psychosocial problems. This study examined the effectiveness of group PCIT on Chinese young children's externalizing and internalizing problems. The participants were 58 mothers with their children aged 2-3 years (M = 2.95 years, SD = 0.22), assigned to an immediate treatment (n = 26) group or to a waitlist (n = 32) control group. The program involved comprehensive group intervention and featured weekly 60-90-min sessions, totaling ten sessions over three months. Results indicate that group PCIT not only significantly improved teacher-reported problem behaviors in children, but also improved observed maternal parenting behavior. These findings support the use of group PCIT in Chinese children and provide mothers with an evidence-based tool to address problem behaviors in a non-clinical population.

Targeted community-based programmes for children's mental health: A systematic review and meta-analysis of the Australian literature

OBJECTIVE

No synthesis of the Australian evidence regarding targeted prevention and early intervention for mental health concerns among young children exists. This review aimed to (1) describe the types of targeted community-based mental health programmes evaluated in Australia to support children aged 1-9 years exhibiting internalising and/or externalising symptoms and (2) examine their impact on children's internalising and externalising symptoms and disorder diagnosis.

METHOD

A systematic review and meta-analysis was conducted (PROSPERO: CRD42021255257). Four databases (PsycINFO, PsycArticles, MEDLINE and CINAHL) were searched for Australian studies published in the past 10 years that quantitatively evaluated the impact of a targeted programme on children's mental health. The National Institute of Health Quality Assessment Tools were used to evaluate the study quality.

RESULTS

Forty-two studies were included; the majority (67%) were medium quality. The mean sample size was 142 (SD = 170), children's average age was 5.78 years (SD = 2.44) and 58% were male. Aboriginal and Torres Strait Islander children were underrepresented. Studies evaluated 16 programmes that targeted (1) externalising symptoms (n = 20 studies, n = 6 programmes), (2) internalising symptoms (n = 14 studies, n = 7 programmes) or (3) both, termed transdiagnostic programmes (n = 8 studies, n = 3 programmes). Externalising programmes achieved a significant moderate mean reduction in externalising behaviours (standardised mean differences = -0.56), internalising programmes yielded a small mean improvement in anxiety symptoms (standardised mean differences = -0.25) and 57% reduced odds of anxiety disorder diagnosis. Evidence supporting transdiagnostic programmes was inconclusive.

CONCLUSION

Parenting-focused programmes targeting young children's internalising or externalising behaviours have the largest local evidence base supporting their effectiveness. Limitations include a lack of engagement with fathers, triangulation of outcomes, homogeneity and implementation reporting. Greater implementation and evaluation of community-driven integrated and systemic approaches that identify, engage and support Australia's most disadvantaged cohorts of young children and their families are needed.

Personalizing PCIT for culturally diverse families: Outcomes from a pilot trial utilizing the PersIn framework

Culture-specific versions of evidence-based interventions are critically important to meeting the needs of underserved and minoritized populations but may also face significant barriers to large-scale implementation when there are settings with multiple cultural groups and within-group heterogeneity. The PersIn framework is a proposed approach for personalizing an evidence-based intervention to facilitate cultural responsiveness concurrent with fidelity to the original intervention, flexibility in individual implementation, and administration that is standardized, feasible, and replicable. This study describes pilot feasibility outcomes for MY PCIT (n = 32), a personalized version of Parent-Child Interaction Therapy for culturally diverse families that was developed as a proof-of-concept of the PersIn framework. This application of the PersIn framework was designed to enhance cultural responsiveness by increasing alignment between parent explanatory models and the presentation and delivery of PCIT. MY PCIT produced both statistically and clinically significant changes in pre-to post-treatment child outcomes and parent outcomes. Child behavior change outcomes were comparable to those reported by three benchmark studies, supporting the potential of this approach.

Outcomes of Parent-Child Interaction Therapy (PCIT) for families presenting with child maltreatment: A systematic review

BACKGROUND

The developmental consequences of childhood trauma for young children are extensive and impact a diverse range of areas. Young children require treatments that consider their developmental stage and are inclusive of caregiver involvement. Parent-Child Interaction Therapy (PCIT), with its dyadic focus and developmental sensitivity, is uniquely positioned to offer therapeutic support to young children and their families.

AIM

The current study aimed to conduct a systematic review of the current literature on PCIT and trauma and determine treatment outcomes for children and caregivers.

METHOD

A systematic review of five electronic databases was undertaken. Studies that utilized PCIT to treat a population who had experienced trauma were included in the review regardless of study design.

RESULTS

PCIT was used to treat a population who had experienced trauma in 40 studies. PCIT was an effective treatment in improving a variety of child and parent outcomes in this population including reduced parenting stress, child behavior problems, child trauma symptoms, parental mental health concerns, negative parenting strategies, and reducing potential risk of recidivism of abuse and neglect. These findings should be taken with caution given attrition rates and potential for bias in the study samples.

DISCUSSION

Clinicians should consider PCIT as a potential treatment for children who have experienced trauma and their families. Future research should incorporate corroborative sources of information, assessment of caregiver and child trauma symptoms, examination of permanency outcomes, and consider standardization of PCIT modifications for child trauma to determine treatment in this population of children.

A Qualitative Analysis of Attrition in Parent-Child Interaction Therapy

Parent-child interaction therapy (PCIT) is one of the strongest evidence-based treatments for young children with behavior problems. Despite the efficacy of PCIT, many families fail to complete treatment, with attrition rates ranging from 30 to 69 percent. Preliminary research on attrition in PCIT treatment studies has linked maternal distress, negative verbal behavior (critical and sarcastic comments towards the child), lower socioeconomic status (SES), and fewer child major depressive disorder (MDD) diagnoses with premature termination from PCIT. However, more research is still needed to identify the range of reasons for treatment discontinuation. The purpose of the present study was to explore the range of reasons for premature termination from PCIT by conducting in-depth interviews with parents who discontinued PCIT using a qualitative design methodology. Results yielded eight themes, which were organized into three constructs: child-directed interaction (CDI) successes, difficulties with treatment, and the need for more clarity and orientation. Several existing treatment strategies that emerged from the data could be applied to PCIT to further enhance it and potentially reduce dropout (e.g., reconceptualizing dropout from PCIT, micro-orienting strategies used in other cognitive and behavioral therapies and dialectical behavior therapy). Understanding the reasons why parents drop out of PCIT and exploring different adaptations that can be made can further enhance this evidence-based treatment and increase its accessibility.

Environmental Conditions to Promote Healthy Childhood Brain/Behavioral Development: Informing Early Preventive Interventions for Delivery in Routine Care

Environmental experiences early in life have strong and enduring consequences for cognitive, emotional, and neurobiological development and related physical and mental health trajectories. The powerful influence of early caregiver nurturance and stimulation on promoting positive neurodevelopmental outcomes has been demonstrated across species. These findings elucidate the environmental conditions known to facilitate healthy neurodevelopment and underscore the potential for modifiable psychosocial factors in the environment to be harnessed to inform early preventive interventions to promote health and adaptive development. A framework for early preventive interventions to enhance nurturing and responsive caregiving for implementation during early sensitive periods of brain development delivered within existing health or educational infrastructures is proposed. Emotional development during sensitive periods is an important, under-recognized, and abundantly modifiable predictor of mental and physical health outcomes that warrants investment of resources and integration of interventions into public health infrastructure for children worldwide. Future studies are needed to further clarify whether and when sensitive periods are present for key developmental domains to inform the optimal timing and targets of these interventions. Numerous available empirically supported early interventions may be modified and applied in briefer and more feasible modalities of delivery to broader populations of developing children. As well established in growth and development across species, essential environmental inputs that are particularly important at specified developmental periods facilitate optimal growth trajectories. Such principles hold great potential in application to early child neurodevelopment to facilitate a thriving and resilient human population.

A Mixed-Methods Study of Clinician Adaptations to Parent-Child Interaction Therapy - What about Culture?

Parent-Child Interaction Therapy (PCIT) is an evidence-based practice (EBP) for young children with challenging behaviors. PCIT has been adapted to treat varying presentations and culturally diverse families. Although efforts have been made to disseminate PCIT into community settings, which often serve clinically complex, socio-culturally diverse, and marginalized communities, barriers to disseminating adapted models remain. An alternative strategy to understanding how to increase access to appropriately adapted PCIT is to learn from community clinicians' practice-based adaptations to meet their clients' diverse needs related to clinical presentation, culture, and language. This mixed-method study investigated community clinician adaptations of PCIT. Clinicians (N = 314) were recruited via PCIT listservs to complete a survey collecting background information, and adaptations to PCIT. Most clinicians had a master's degree (72.1%), were licensed (74.2%), and were PCIT-certified (70.7%). Qualitative interviews were conducted with a purposeful sample of 23 community clinicians, who were 39% Spanish-speaking, were 30% Latinx, and 30% reported serving a ≥50% Latinx clientele. Clinicians reported engaging in adaptations aimed at augmenting PCIT more extensively than adaptations involving removing core components. Themes from qualitative interviews converged with quantitative findings, with clinicians most frequently describing augmenting adaptations, and highlighted reasons for adapting PCIT. Clinicians primarily augmented treatment to address clients' clinical presentations. Clinicians rarely adapted treatment specifically for culture, but when mentioned, clinicians discussed tailoring idioms and phrases to match clients' culture for Spanish-speaking clients. Implications for training PCIT clinicians in intervention adaptations will be discussed.

Clinician adoption of Parent-Child Interaction Therapy: A systematic review of implementation interventions

Background

Parent-Child Interaction Therapy (PCIT) is a parent training intervention for childhood conduct problems, distinctive in its use of live clinician coaching of the parent-child dyad via a one-way mirror and discrete earpiece. However, despite a compelling evidence base, uptake of evidence-based parent training programmes such as PCIT by clinicians in routine care settings remains poor. This systematic review aimed to identify and synthesise implementation interventions that have sought to increase clinician adoption of PCIT in usual care settings.

Methods

We searched MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), CINAHL (EBSCO), Science Citation Index and Social Sciences Citation Index, and Web of Science Core Collection from inception to October 2020. Articles were included if they tested (by way of randomised controlled trials, controlled clinical trials, interrupted time series and controlled before and after trials) implementation interventions across any and all of the patient, clinician, clinic, system or policy domains. Two independent reviewers screened and selected studies, assessed risk of bias and extracted data - summarising implementation intervention components according to items from the Template for Intervention Description and Replication (TIDieR) checklist ( Hoffmann et al., 2014).

Results

Of the 769 articles identified once duplicates were removed, 13 papers relating to three studies met the inclusion criteria - all were quantitative or mixed-methods examinations of the effectiveness of different PCIT clinician training or training-related consultation methods. A narrative description of interventions was provided, as quantitative synthesis was not possible.

Conclusions

Research attention has to date been focussed on the establishment of an evidence-base for PCIT's effectiveness, with relatively little attention to the dissemination, implementation and sustainment of this treatment. Those studies that do exist have focused on training methods and training-related expert consultation. Research attention could usefully turn to both adoption and sustainment of this effective treatment in usual care settings.

Plain language summary

In this review, we aimed to summarise what is already known about how to implement PCIT in community settings after clinicians have received training in the approach. While research relating to the implementation of other parent training programmes is interesting and informative, implementation efforts are most effective when tailored to a specific programme in a specific context. As such, it was important to review published studies relating to PCIT specifically. We identified three relevant studies, one of which is yet to publish its main implementation findings. The three studies have focused on how best to train clinicians in PCIT, including how best to provide post-training support from expert trainers. We concluded that a fruitful line for future research would be to focus on the post-training period, particularly how best to support clinicians to adopt and sustain PCIT in their practice.

Systematic review registration

The study was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 01/10/2020 (CRD42020207118).

Barriers to Clinician Implementation of Parent-Child Interaction Therapy (PCIT) in New Zealand and Australia: What Role for Time-Out?

BACKGROUND

Parent-Child Interaction Therapy (PCIT) is an effective parent training approach for a commonly occurring and disabling condition, namely conduct problems in young children. Yet, despite ongoing efforts to train clinicians in PCIT, the intervention is not widely available in New Zealand and Australia.

METHODS

We undertook a cross-sectional online survey of clinicians in New Zealand and Australia who had completed at least the 40-h initial PCIT training, to understand the barriers they encountered in their implementation efforts, and the extent to which attitudes toward time-out influenced implementation. The overall response rate was 47.5% (NZ: 60%; Australia: 31.4%).

RESULTS

Responses suggested that participants generally viewed PCIT as both acceptable and effective. Australian participants reported seeing significantly more clients for PCIT per week than those in NZ (Medians 0 and 2, respectively; χ2(1) = 14.08, p < 0.001) and tended to view PCIT as more effective in treating disruptive and oppositional behaviour (95% CI: -0.70, -0.13, p = 0.005). Participants currently seeing PCIT clients described it as more enjoyable to implement than those not using PCIT (95% CI: -0.85, -0.10, p = 0.01). Thirty-eight percent of participants indicated that they adapt or tailor the standardised protocol, primarily by adding in content relating to emotion regulation, and removing content relating to time-out. Participants generally felt that they had fewer skills, less knowledge, and less confidence relating to the Parent-Directed Interaction phase of PCIT (which involves time-out), compared with the Child-Directed Interaction phase.

CONCLUSION

While we had hypothesised that time-out represented an intra-intervention component that detracted from implementation success, results suggested that clinician concern over the use of time-out was present but not prominent. Rather, the lack of access to suitable equipment (i.e., one-way mirror and ear-piece) and difficulties associated with clients attending clinic-based sessions were barriers most commonly reported by clinicians. We suggest that future research might consider whether and how PCIT might be "re-implemented" by already-trained clinicians, moving beyond simply training more clinicians in the approach.

The Cost-Effectiveness of Parent-Child Interaction Therapy: Examining Standard, Intensive, and Group Adaptations

This study examined the cost-effectiveness of standard parent-child interaction therapy (PCIT) and three adaptations: intensive-PCIT (I-PCIT), small group PCIT, and large group PCIT. This study used cost-effectiveness analyses to calculate average cost-effectiveness ratios, which represents the average cost for one family to change one standard deviation on each outcome measure: externalizing behavior problems, positive parenting skills, negative parenting skills, child compliance, and parenting stress. While it had the lowest initial set up cost, results indicated that standard PCIT was the least cost-effective option in reducing child disruptive behaviors and in increasing child compliance. Large group PCIT was the most cost-effective in increasing positive parenting skills and child compliance and in reducing negative parenting skills and parenting stress. I-PCIT was the most cost-effective in reducing child disruptive behaviors and the second most cost-effective option in increasing positive parenting skills and child compliance and in decreasing negative parenting. As large group and I-PCIT were the most cost-effective in different domains, both could be recommended to parents as treatment options. Future research should confirm our cost-effective results within community settings.

Peer Influence during Adolescence: The Moderating Role of Parental Support

Although many studies show that peers influence the development of adolescent internalizing and externalizing difficulties, few have considered both internalizing and externalizing difficulties in the same study, and fewer have considered the contributions of parents. Using a longitudinal sample of 385 adolescents, the contributions of best friends' internalizing and externalizing difficulties (as assessed in Grade 6; G6: M_age = 13.64 years; 53% female; 40% ethnic or racial minority) were examined as they predicted subsequent adolescent internalizing and externalizing difficulties (at G8); in addition, the moderating role of both maternal and paternal support (at G6) was explored. Structural equation modelling revealed that best friend internalizing difficulties predicted decreases, but that best friend externalizing difficulties predicted increases in adolescents' externalizing difficulties over time. Significant interactions involving both maternal and paternal support revealed that the negative impact of a G6 best friend having internalizing problems on later G8 adolescent externalizing problems was stronger at low levels of maternal and paternal support. The findings highlight the complex, and interactive, influences of friends and parents on the development of internalizing and externalizing symptomatology during adolescence, and underscore the importance of targeting both sources of social influence in research and clinical work.

Moderators of Psychosocial Intervention Response for Children and Adolescents with Conduct Problems

Objective: The purpose of this Brief Report is to synthesize the current evidence base examining moderators of psychosocial intervention response for children and adolescents with conduct problems (CP). We also provide directions for future research.Method: We focused on four categories of psychosocial interventions for the prevention and/or treatment of CP: (1) parent management training (PMT) for children, (2) other family-based interventions for adolescents, (3) youth skills training, and (4) multicomponent interventions (i.e., family-based intervention plus skills training). Emphasis is placed on findings from meta-analyses.Results: Moderation analyses have occurred more frequently for PMT than for other types of interventions. Variables for which there was consistent evidence for positive moderation included higher initial severity of CP, father engagement, higher maternal depressive symptoms, individual administration (vs. group), and treatment/targeted prevention approaches (vs. universal prevention). Variables where there was evidence for no moderation (demonstrating generalizability) included child diagnostic status and family risk in PMT, and diagnostic status and intervention setting for skills training. However, for some variables, evidence of moderation was dependent on intervention type.Conclusions: Future research should examine multiple moderators in combination; incorporate innovative techniques such as integrative data analyses, individual participant data, and class-based modeling, which may identify moderator effects that are undetected by more traditional variable-oriented moderation analyses; and conduct moderated mediation models for informing developmental theory on the interplay of risk and protective factors.

Caregiver engagement in youth partial hospitalization treatment

Although the importance of caregiver engagement in a child's psychological treatment is well established within outpatient treatment settings, the question remains whether these findings can be generalized to more intensive treatment settings where caregiver engagement may be more challenging to facilitate. A correlational, multi-informant design was used to collect data by caregiver self-report and therapist-report from a sample of 64 caregivers of youth referred for partial hospitalization. Results show that caregivers' attitudinal self-assessment of engagement was not significantly related to their self-report of behavioral engagement (e.g. number of family sessions attended) or therapists' report of caregiver engagement. After controlling for caregiver expectations and therapist ratings of caregiver engagement, only caregiver ratings of attendance at family sessions marginally predicted treatment outcomes, but in the negative direction. Implications for adapting measures of caregiver engagement to intensive treatment settings and its impact on treatment outcomes are discussed.

Integrated CARE: Adaptation of Child-Adult Relationship Enhancement (CARE) Model for Use in Integrated Behavioral Pediatric Care

The authors adapted the established Child-Adult Relationship Enhancement (CARE) interaction model for use in integrated behavioral health clinics. CARE was modified for delivery in the examination room, during routine primary care visits. Adopting a real-world implementation approach, clinical social workers were trained in the new model-IntegratedCARE-and provided the brief, 3-session treatment to 30 different parent-child dyads. Measurements included the Parental Stress Index-4 Short Form (PSI 4-SF), the Eyberg Childhood Behavior Inventory (ECBI), and the Therapy Attitude Inventory (TAI). There was a statistically significant mean score decrease on the both subscales of the ECBI at pre- and posttreatment. Scores on the TAI indicated that participants were satisfied with the treatment. Attrition rates were somewhat lower than similar studies. Findings indicate the IntegratedCARE model is feasible for sustainable delivery by trained behavioral health professionals in primary care.

Keeping an "I" on PRIDE: Measuring Imitation in Parent-Child Interaction Therapy

In parent-child interaction therapy (PCIT), therapists encourage parents to imitate child behaviors in order to convey approval of the child's actions and promote the development of linguistic and social-cognitive skills. However, the Dyadic Parent-Child Interaction Coding System (DPICS-IV), used to measure skills taught during PCIT, does not include guidelines for coding parent-child imitation, making it difficult to determine how PCIT affects it. The current study addresses this problem by developing guidelines for coding imitation, which were then used to code DPICS-IV segments from 58 Mexican American families that participated in a past clinical trial. Results suggest that these coding guidelines can be used to reliably measure parent and child imitation. A series of additional analyses supported the construct validity of the codes. Specifically, there was a trend for parent imitation, but not child imitation, to increase more from pre-post treatment in PCIT relative to treatment as usual. In addition, parents who imitate their children were found to have children who imitate them more in return. Finally, improvement in parent imitation, but not child imitation, was significantly related to a decrease in child behavior problems. Further study is needed to determine the optimal frequency of imitation, and findings suggest that additional attention to coaching imitation may be warranted.

Conduct Disorders and Empathy Development

Childhood conduct disorders, a serious mental health concern, put children at risk for significant mental health problems throughout development. Elevations on callous-unemotional (CU) traits designate a subgroup of youth with conduct disorders who have unique causal processes underlying their problem behavior and are at a particularly high risk for serious impairment relative to others with these disorders. As a result, these traits have recently been integrated into major diagnostic classification systems for conduct disorders. Given that CU traits are partly defined by deficits in empathy, we review research on empathy development in typically developing children and use this research to (a) advance theories on the specific emotional deficits that may be associated with CU traits, (b) explain the severe pattern of aggressive behavior displayed by children with elevated CU traits, and (c) suggest possible ways to enhance prevention and treatment for children with conduct disorders and elevated CU traits.

Comparative Effectiveness of Parent-Child Interaction Therapy for Children with and Without Autism Spectrum Disorder

Youth with autism spectrum disorder (ASD) often display disruptive behavior and noncompliance. Disruptive behavior in youth with ASD may limit their participation in educational and therapeutic activities and impact family functioning. Several evidence-based interventions are available for typically developing children, such as Parent-Child Interaction Therapy (PCIT). The current study examined the comparative effectiveness of PCIT for youth with ASD and without ASD. Results indicate that PCIT significantly improves parent-reported disruptive behavior in children with ASD at levels comparable to children without ASD. Additionally, improvements in ASD-related symptoms were noted for youth with ASD. These findings support the use of PCIT for children with ASD and provide clinicians with an evidence-based tool to address disruptive behavior in a wide spectrum of presenting children.

A randomized controlled trial comparing parent child interaction therapy - toddler, circle of security- parenting™ and waitlist controls in the treatment of disruptive behaviors for children aged 14-24 months: study protocol

BACKGROUND

It is common for toddlers to display disruptive behaviors (e.g., tantrums, aggression, irritability) but when these become severe and persistent they can be the start of a trajectory towards poor outcomes in childhood and adolescence. Parent Child Interaction Therapy - Toddler is an intervention model designed to meet the specific developmental needs of toddlers aged 12-24 months presenting with disruptive behaviors.

METHODS

This study will use a randomized controlled design to evaluate the efficacy of the Parent Child Interaction Therapy - Toddler intervention for children aged 14-24 months with disruptive behaviors. Ninety toddlers with parent-reported disruptive behavior will be randomly allocated to either Parent Child Interaction Therapy - Toddler, Circle of Security- Parenting™ or a waitlist control group. Key parenting capacity outcome variables will include positive and negative parenting, parenting sensitivity, parental sense of competence in managing negative toddler emotions, parent sense of caregiving helplessness, parent mentalizing about the child, parent emotion regulation, child abuse potential and parental stress. Key outcome variables for children will include child social-emotional functioning (initiative, relationship functioning, self-regulation), child emotion regulation, child attachment security, and child behavior.

DISCUSSION

Delivered in the early intervention period of toddlerhood, Parent Child Interaction Therapy - Toddler has the potential to bring about significant and lasting changes for children presenting with early onset behavioral issues.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), 12618001554257 . Registered 24 September 2018 - retrospectively registered.

Treatments for Early Childhood Trauma: Decision Considerations for Clinicians

The period from birth to age six represents a time of significant risk for exposure to trauma. Following trauma exposure, children may experience significant negative and lasting psychological, cognitive, and physical effects. Over the last two decades, the demand for and availability of evidence-based treatments (EBTs) for children under the age of six who have experienced trauma has dramatically increased. Three of the most well-supported and widely disseminated EBTs for early childhood trauma are Trauma-Focused Cognitive Behavioral Therapy, Parent-Child Interaction Therapy, and Child-Parent Psychotherapy. Increasingly, clinicians are receiving training in more than one EBT. This paper provides an overview of each intervention; presents clinicians with various child, caregiver, and environmental factors to consider when deciding amongst these three EBTs; and applies these considerations to three composite cases.

Evidence Based Dyadic Therapies for 0- to 5-Year-Old Children With Emotional and Behavioral Difficulties

As many as one in four preschool-aged children are estimated to struggle with psychosocial stress and social-emotional issues; yet, interventions are often postponed until older ages when change is actually more difficult. Reasons for this include limited interventions, paucity of FDA approved medications for young children, as well as the dearth of clinicians adequately trained in psychotherapeutic approaches for young children. This commentary outlines indications of the four most commonly used evidence-based dyadic psychotherapies for young children: Child-Parent Psychotherapy (CPP) and Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), used primarily for young children with trauma, and Parent-Child Interaction Therapy (PCIT) and Child Parent Relationship Therapy (CPRT), used mostly for children with behavioral issues. Rooted in attachment theory and further supported by the premise that the quality of the child-caregiver dyad is paramount to psychological wellbeing, these therapies focus on strengthening this relationship. Literature indicates that insecure or disorganized early attachments adversely affect an individual's lifelong trajectory. These therapies have demonstrated efficacy leading to positive behavioral changes and improved parent-child interactions. The major challenges of clinical practice focused on young children and their families include proper diagnosis and determining the best therapeutic strategy, especially for families who have not benefited from prior interventions. At this time, it is still unclear which therapy is best indicated for which type of patients and it mostly has been driven by convenience and provider preference or training. Further research is required to tailor treatments more successfully to the child's needs.

Building Bridges Triple P: Pilot study of a behavioural family intervention for adolescents with autism spectrum disorder

BACKGROUND

Many parents of adolescents with autism spectrum disorder (ASD) report that they are ill-equipped to support their children's behaviour, and these youths are known to be at substantially greater risk of emotional or behavioural problems compared to their typically developing peers. There is a need for an efficient and tailored parenting program for parents of adolescents with ASD that includes guidance on how to best support these youths' development and well-being.

AIMS

The current study examined the feasibility of Building Bridges Triple P (BBTP), an eight-week (11.5 h) parenting program specifically targeted to the needs of parents of adolescents with a developmental disability.

METHODS

A pretest-posttest single group design was used to evaluate the feasibility and acceptability of BBTP, and the potential of the program to have desired intervention effects, with nine parents of adolescents with ASD.

RESULTS

After participating in BBTP, parents reported significant reductions in their adolescent's behaviour problems, increased parenting confidence, decreased lax and overreactive responding, and decreased symptoms of depression and stress. These effects were mostly observed at post-test but were more pronounced at 3-month follow-up. Parents reported that they were satisfied with the content and format of BBTP.

CONCLUSIONS

Results provide preliminary support for the feasibility and acceptability of BBTP, and that the program has a number of desired intervention effects.