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

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.

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.

Utilizing Parent-Child Interaction Therapy with Trauma-Directed Interaction in a Young Male in Out of Home Care Who Had Experienced Trauma

Child abuse and neglect in young children can lead to trauma-related stress symptoms that can be challenging to manage. Parent-Child Interaction Therapy (PCIT), a strong evidence-based behavioral parent training program used for young children with behavior issues, has been used in its traditional form with increasing frequency with children and families who have trauma histories, with clinicians tailoring PCIT to use with children who have experienced trauma. Trauma-Directed Interaction (TDI) is a new systematic adaption to the standard PCIT parent training program that has the potential to help treat trauma in younger children. TDI includes several trauma-informed techniques that are added to a course of standard PCIT treatment including psychoeducation regarding trauma, recognition of feelings, and emotional regulation. This case study illustrates the use of a manualized trauma adaptation to PCIT (TDI) with a three-year-old boy who had a history of child maltreatment and his caregiver. This case provides a summary of the progression of this intervention and the results obtained. Results from the case indicated that TDI treatment was effective in not only reducing child trauma and behavioral symptoms but also in reducing mild caregiver mental health concerns. The next steps for TDI treatment and need for further research are discussed.

Bringing Parent-Child Interaction Therapy to South Africa: Barriers and Facilitators and Overall Feasibility-First Steps to Implementation

There is a large assessment and treatment gap in child and adolescent mental health services, prominently so in low- and middle-income countries, where 90% of the world's children live. There is an urgent need to find evidence-based interventions that can be implemented successfully in these low-resource contexts. This pre-pilot study aimed to explore the barriers and facilitators to implementation as well as overall feasibility of Parent-Child Interaction Therapy (PCIT) in South Africa. A reflective and consensus building workshop was used to gather South African PCIT therapist (N = 4) perspectives on barriers, facilitators, and next steps to implementation in that country. Caregiver participants (N = 7) receiving the intervention in South Africa for the first time were also recruited to gather information on overall feasibility. Facilitators for implementation, including its strong evidence base, manualisation, and training model were described. Barriers relating to sustainability and scalability were highlighted. Largely positive views on acceptability from caregiver participants also indicated the promise of PCIT as an intervention in South Africa. Pilot data on the efficacy of the treatment for participating families are a next step. These initial results are positive, though research on how implementation factors contribute to the longer-term successful dissemination of PCIT in complex, heterogeneous low-resource settings is required.