Creating ConnectionsA Comparison of Two Treatment Models Addressing Parent-Child Relationships

Dorothy Denny, MSW, LCSW

Welcome!

• Presentation overview:• Description of PCIT and CPP• Comparison of the two models• Demonstrations• Guidelines for selecting treatment modality• Discussion and questions

Parent Child Interaction Therapy (PCIT)

• Developed for families with young children experiencing behavioral and emotional problems• Therapists coach parents during interactions with

their children to teach new parenting skills• Skills are designed to enhance parent-child bond,

reduce child negative behaviors, and increase parenting efficacy

Child-Parent Psychotherapy

• Developed for young children exposed to trauma, especially domestic violence• Typically sessions conducted with child and

parent or significant caregiver together• Therapist aims to engage with parent/child dyad

to create safety, promote attunement and change negative interactional patterns• Parent and child create joint trauma narrative

that identifies and addresses trauma triggers

Theoretical Underpinnings

PCIT• Behavior theory• Attachment theory• Social learning theory

CPP• Integrates psycho-

analysis and attachment theory• Includes

developmental theory, cognitive-behavioral and social learning approaches

Target population

PCIT

• Ages 2.5 to 6• Has been adapted for

older kids (up to age 12)• Presenting concerns• Child disruptive

behavior• Parent coercive

discipline

CPP• Ages Birth to 5• Presenting concerns• Exposure to domestic

violence• Separation anxiety• Emotional dysregulation• Parental depression• Chronic stress• Bereavement• Attachment “fit”

Treatment Length and Structure

PCIT• Clinic-based (has been

adapted for home-based treatment)• Average 12-20 weekly

sessions• Highly structured• Phase-based treatment:• Child Directed Interaction• Parent Directed Interaction

CPP• Clinic or home based• Average: 50 weekly

sessions• Flexible• Non linear• 3 general treatment

phases:• Relationship /process building• Targeting problem areas• Recapitulation/termination

Client Constellation

PCIT• Parent and child• Parents can be foster

or kinship caregivers• Parents must have

daily access to child for home practice

CPP• Parent/caregiver and

child• Parents can be foster

or kinship caregivers• Can be implemented

during supervised visitation for children in child welfare system

Therapist Role/ Alignment

PCIT• Therapist = Coach

• Therapist is aligned with the parent

CPP• Therapist = Facilitator

• Observer/Interpreter

• Therapist is aligned with the child-parent dyad

Necessary Resources for Implementation

PCIT

• AV equipment• Space• Toys

CPP• Toys to evoke child’s

memory or emotion about a traumatic event

Training/Supervision Requirements

PCIT

• 40 hours of face-to-face training with a PCIT trainer• 6 months phone

consultation with trainer while seeing cases• No specialized

supervision required

CPP• Varies according to

setting and need• In-person training or

learning collaborative models• Consultation and

reflective supervision

Assessment ProcessPCIT

• Clinical interview• ECBI • PSI• DPICS observation• Other standardized

measures as appropriate

CPP• Observations across

conditions• Developmental history• Caregiver perspective on

child and family situation• Caregiver history and

psychological functioning• Cultural “niche”• Standardized

assessment measures

Evidence Base

PCIT

• Several RCTs showing long-term maintenance of treatment gains• CEBC rating of 1

(“well-supported by research evidence”) on scale 1-5

CPP• 3 RCTs with trauma-

exposed young children • CEBC rating of 2

(“supported by research evidence”) on scale 1-5

AdaptationsPCIT

• Families and children with prenatal exposure to alcohol and other drugs• Group treatment• Children 8-to-12 years of

age• Children with medical

conditions.• Physically abusive

families• Native American families

CPP• Latino families• African American families• Native American families• Asian families• Recent immigrants• Anxiously attached dyads• Depressed mothers• Chronically stressed

families

Possible Barriers to TreatmentPCIT

• Lack of home practice opportunities (e.g., when parents do not live w/ child)• Inability to attend

weekly sessions makes skill acquisition much more difficult• Cognitive impairment

of caregiver• Lack of AV equipment

CPP• Parents unwilling to

engage in emotionally laden and trauma focused work• Cognitive impairment

of caregiver• Ongoing domestic

violence or otherwise unsafe environment• Lack of clinician access

to reflective supervision

Therapist Anxieties PCIT

• Too manualized• Degree of therapist

direction• Lack of comfort with

time out procedures

CPP• Not manualized

enough• Alignment issues • Reluctance to process

traumatic material• Less comfort or

familiarity with psychodynamic theory • Fewer family therapy

skills • Reflective supervision

Essential Elements-PCIT

• Coding• Coaching• Home practice

DPICS CODING SHEET FOR PRIDE SKILLS (CDI CODING SHEET)

Date:______________ Session:________________

Child’s Name:____________________ Caregiver Name:____________________

Child Directed Interaction

Positive Tally Total Mastery

Talk (TA)

Behavior Description (BD)

Reflection (RF)

Labeled Praise (LP)

Unlabeled Praise (UP)

Avoid Tally Total Mastery

Question (Q)

Commands (DC + IC)

Negative Talk (NTA)

Positive Check One

Imitate Satisfactory Needs Practice

Use Enthusiasm Satisfactory Needs Practice

Ignore Disruptive Behavior Satisfactory Needs Practice Not Applicable

Other (specify)

Essential Elements-CPP

• Developmental guidance• Attunement• Curiosity and empathy• Ports of Entry•Moments of meaning• Reflective supervision

Domains of Intervention- PCIT

• Parent-child “special playtime” at home• Weekly coaching sessions of parent utilizing skills

in play situations • Parent’s discipline of child• Parent’s communication with child

Domains of Intervention-CPP

• Play• Biological disruptions• Child’s behaviors• Child’s aggression• Physical punishment• Derogation, threats, criticism• Relationship with absent parent/perpetrator• Ghosts/Angels in the nursery

Treatment Goals-PCIT

• Improve parent-child attachment relationship • Increase parent’s warmth and responsivity to child• Reduce frustration/anger on part of both parent

and child• Help parent and child view one another more

positively• Increase child’s social skills, attention, and self-

esteem

Treatment Goals-PCIT

•Decrease child’s disruptive behaviors• Increase parent’s use of effective discipline skills• Increase parent’s predictability, consistency, and follow through• Enable parent to generalize discipline skills to other settings

How Treatment Goals are Achieved-PCIT

• PRIDE skills• Daily parent-child “Special Time” at home• Command training – giving good instructions• Coaching parent to implement detailed discipline

procedure• Planned responses to• Refusal to stayy in time-out• Impulsive or dangerous behaviors• Behavior disruptions in public settings

• Gradual generalization from clinic minding exercixes to “real life” discipline

Treatment Goals - CPP

• Return to normal development• Respond realistically to threat• Regulate levels of emotional arousal• Re-establish trust in body sensations• Restore relational reciprocity• Normalize traumatic response• Differentiate remembering from reliving• Place traumatic experience into perspective

How Treatment Goals are Achieved - CPP

• Using child’s play and language to explore themes• Conveying developmental guidance• Modeling protection• Interpreting feelings and actions• Providing emotional support and empathic

communication• Offering material help

Determining best treatment option: PCIT or CPP??Questions to Consider:• Age of child• Child’s relationship with caregiver• CPS or Court priorities• Trauma history of child• Trauma history of caregiver• Symptom presentation• Safety concerns• What else??

Questions & Answers

Bibliography• Bodiford McNeil, C, & Hembree-Kigin, T. L. (2010). Parent-child

interaction therapy 2nd ed.) New York: Springer. • Lieberman, A. (2004). Traumatic stress and quality of

attachment: Reality and internalization in disorders of infant health. Infant Mental Health Journal, 25(4), 336-351.

• Lieberman, A., & Van Horn, P. (2005). Don't hit my mommy: A manual for child-parent psychotherapy with young witnesses of family violence. ZERO TO THREE Press.

• And special thanks to our CASGSL staff and children for participating in the videos.