Intervention Summary

Parent-Child Interaction Therapy

Parent-Child Interaction Therapy (PCIT) is a treatment program for young children with conduct disorders that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns. PCIT was developed for children ages 2-7 years with externalizing behavior disorders. In PCIT, parents are taught specific skills to establish or strengthen a nurturing and secure relationship with their child while encouraging prosocial behavior and discouraging negative behavior. This treatment has two phases, each focusing on a different parent-child interaction: child-directed interaction (CDI) and parent-directed interaction (PDI). In each phase, parents attend one didactic session to learn interaction skills and then attend a series of coaching sessions with the child in which they apply these skills. During the CDI phase, parents learn nondirective play skills similar to those used in play therapy and engage their child in a play situation with the goal of strengthening the parent-child relationship. During the PDI phase, parents learn to direct the child's behavior with clear, age-appropriate instructions and consistent consequences with the aim of increasing child compliance. Ideally, during coaching sessions, the therapist observes the interaction from behind a one-way mirror and provides guidance to the parent through a "bug-in-the-ear" hearing device. PCIT is generally administered in 15 weekly, 1-hour sessions in an outpatient clinic by a licensed mental health professional with experience working with children and families. The treatment manual provides written outlines in checklist form for each session. The program has been used with families with a history of physical abuse, children with prenatal substance exposure, and children with developmental disabilities.

Descriptive Information

Areas of Interest	Mental health treatment
Outcomes	1: Parent-child interaction 2: Child conduct disorders 3: Parent distress and locus of control 4: Recurrence of physical abuse
Outcome Categories	Family/relationships Mental health Social functioning Trauma/injuries Physical aggression and violence-related behavior
Ages	0-5 (Early childhood) 6-12 (Childhood) 26-55 (Adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Asian Black or African American Hispanic or Latino White Race/ethnicity unspecified Non-U.S. population
Settings	Outpatient School
Geographic Locations	Urban Suburban Rural and/or frontier
Implementation History	It has been disseminated across the United States, primarily by practitioners who completed graduate training at the University of Florida. PCIT currently is offered at a number of university-affiliated programs and community agencies. Thousands of children and their families have participated in the treatment. Outside the United States, PCIT sites are established or are developing in Australia, Germany, Hong Kong, the Netherlands, Norway, Russia, and Taiwan. Results of some international implementations have been published.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	The program has been adapted and/or translated for use in Australia, Germany, Hong Kong, the Netherlands, Norway, Puerto Rico, Russia, and Taiwan.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Boggs, S. R., Eyberg, S. M., Edwards, D. L., Rayfield, A., Jacobs, J., Bagner, D., et al.. Outcomes of Parent-Child Interaction Therapy: A comparison of treatment completers and study dropouts one to three years later. Child and Family Behavior Therapy, 26(4), 1-22.

Schuhmann, E. M., Foote, R. C., Eyberg, S. M., Boggs, S. R., & Algina, J. Efficacy of Parent-Child Interaction Therapy: Interim report of a randomized trial with short-term maintenance. Journal of Child Clinical Psychology, 27(1), 34-45.

Study 2

Chaffin, M., Silovsky, J. F., Funderburk, B., Valle, L. A., Brestan, E. V., Balachova, T., et al.. Parent-Child Interaction Therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72(3), 500-510.

Study 3

Bagner, D. M., & Eyberg, S. M. Parent-Child Interaction Therapy for disruptive behavior in children with mental retardation: A randomized controlled trial. Journal of Clinical Child and Adolescent Psychology, 36(3), 418-429.

Study 4

Nixon, R. D. V., Sweeney, L., Erickson, D. B., & Touyz, S. W. Parent-Child Interaction Therapy: A comparison of standard and abbreviated treatments for oppositional defiant preschoolers. Journal of Consulting and Clinical Psychology, 71(2), 251-260.

Outcomes

Outcome 1: Parent-child interaction
Description of Measures	Parent-child interaction was measured using the following instruments: Dyadic Parent-Child Interaction Coding System (DPICS), which assesses parent-child interaction during a structured three-part session that includes a child-directed activity, a parent-directed activity, and clean-up. Sessions were videotaped and viewed by trained observers who used the DPICS to code the verbal behaviors (e.g., commands, praises, criticisms), vocal behaviors (e.g., laughs, whines, yells), and physical behaviors (e.g., physical positives such as hugs or pats, physical negatives such as slaps) of the parent and child. Parent behaviors were collapsed across positive behaviors (i.e., praise, reflection, description, physical positives) and negative behaviors (i.e., criticism, sarcasm, physical negatives). Total frequencies for each category were tabulated across observation times. Child compliance was defined as the percentage of parental commands that were obeyed by the child during the parent-directed and clean-up situations. Parenting Scale (PS), a self-report measure completed by parents of young children to assess dysfunctional discipline practices. The Overactivity subscale was used to assess harsh, aggressive, and authoritarian discipline behaviors.
Key Findings	In one study, parents in the PCIT group interacted more positively with their child and were more successful in gaining their child's compliance at 4-month follow-up than parents in the wait-list control group (all p values < .01). Specifically, child compliance with parental commands increased from 23% to 47% for the mothers (p < .01) and from 27% to 45% for the fathers (p < .05) in the PCIT group. In the wait-list control group, child compliance with parental commands remained unchanged. In another study, participants were assigned to a group receiving PCIT, a group receiving PCIT plus individualized enhanced services (EPCIT), or a standardized community-based parenting group. From baseline to posttreatment, the PCIT group (p < .01) and the EPCIT group (p < .01) had significant decreases in negative parental behaviors compared with the community-based parenting group, which showed no change from baseline. The scores on positive parental behavior were generally high, with no statistically significant differences between groups. In a third study, mothers who received PCIT used significantly more positive parenting skills (p < .001) and fewer negative parenting practices (p = .006) at 4-month follow-up compared with mothers in the wait-list control group. Effect sizes for both findings were large (Cohen's d = 2.06 and 1.32, respectively). In addition, children's compliance with maternal commands was significantly higher in the PCIT group than in the wait-list control group (p = .006); the effect size for this finding was also large (Cohen's d = 1.53). In an Australian study, participants were assigned to a group receiving standard PCIT, a group receiving an abbreviated form of PCIT, or a wait-list control group. At posttreatment, mothers in the PCIT and abbreviated PCIT groups praised their children more (all p values < .001) and gave their children fewer commands (all p values < .05) than mothers in the control group. In addition, PCIT mothers criticized their children less and PCIT children were more compliant than their counterparts in the control group (all p values < .01). There were no significant differences between the PCIT and abbreviated PCIT groups on any of the measures.
Studies Measuring Outcome	Study 1, Study 2, Study 3, Study 4
Study Designs	Experimental
Quality of Research Rating	3.2 (0.0-4.0 scale)

Outcome 2: Child conduct disorders
Description of Measures	Child conduct disorders were measured using the following instruments completed by parents: Eyberg Child Behavior Inventory (ECBI), which assesses the child's conduct behavior on two scales: the Intensity scale measures the frequency with which conduct problem behavior occurs, and the Problem scale measures how problematic the child's behavior is to the parent. Child Behavior Checklist (CBCL), which measures the problem behaviors of children ages 1½ to 5 years. Two scales were used: the Externalizing scale and Total scale. Home Situations Questionnaire--Modified (HSQ-M), which assesses difficult behavior of children at home. The Severity subscale was used.
Key Findings	In one study, parents in the PCIT group reported significant improvements in their child's behavior from baseline to 4-month follow-up compared with families in the wait-list control group (p < .01). In another study, mothers in the PCIT group reported significantly fewer child externalizing behaviors (p = .009) and fewer total child behavior problems (p = .003) on the CBCL and fewer disruptive behaviors on the ECBI Intensity scale (p = .002) at 4-month follow-up compared with mothers in the wait-list control group. All three findings were associated with large effect sizes (Cohen's d = 1.08, 0.97, and 1.50, respectively). In an Australian study, participants were assigned to a group receiving standard PCIT, a group receiving an abbreviated form of PCIT, or a wait-list control group. At posttreatment: Mothers in the PCIT and abbreviated PCIT groups reported fewer oppositional and conduct problem behaviors than mothers in the control group (all p values < .01). Mothers in the PCIT group reported less severe behavior problems at home compared with control mothers (p < .01), with no significant difference between reports of severe behavior problems by abbreviated PCIT and control mothers. Fathers in the abbreviated PCIT group reported less oppositional behavior than fathers in the control group (p < .05), with no significant difference between reports of oppositional behavior by PCIT and control fathers. No significant differences were found between the PCIT and abbreviated PCIT groups on any of the child behavior measures.
Studies Measuring Outcome	Study 1, Study 3, Study 4
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 3: Parent distress and locus of control
Description of Measures	Parent distress and locus of control were measured using the following instruments completed by parents: Parenting Stress Index (PSI), which assesses the stress associated with difficult qualities or characteristics of children that can lead to frustration and unfulfillment in the parenting role. The Parent Domain reflects the parent's view of his or her own functioning in the parenting role. The Child Domain measures child behavior problems that lead to frustration in trying to develop a relationship with the child. The Total Stress Scale is the sum of the Parent and Child Domain scores. Parent Locus of Control Scale (PLOC), which assesses the degree to which parents believe they can influence or control the behavior of their child. Parent Sense of Competence Scale (PSOC), which assesses parenting self-esteem and two aspects of parental competence: their feelings of satisfaction and efficacy in the parenting role. The total score was used.
Key Findings	In one study, parents who received PCIT had decreased self-reported parenting stress (p < .01) and increased self-reported internal locus of control (p < .01) from baseline to 4-month follow-up compared with parents in the wait-list control group. In a second study, when compared with mothers in the wait-list control group at 4-month follow-up, mothers who received PCIT reported significantly fewer child behavior problems that lead to frustration in trying to develop a relationship with the child (p = .04). The effect size for this finding was medium (Cohen's d = 0.59). In an Australian study, participants were assigned to a group receiving standard PCIT, a group receiving an abbreviated form of PCIT, or a wait-list control group. At posttreatment, mothers in the abbreviated PCIT group reported significantly less parenting stress than control group mothers (p < .05), but parenting stress did not differ significantly between mothers in the PCIT group and control group. Compared with mothers in the control group, mothers in PCIT and abbreviated PCIT groups reported more satisfaction (all p values < .05), more control (all p values < .01), and less overreactive discipline (all p values < .01) at posttreatment. There were no significant differences between the PCIT and abbreviated PCIT groups on these measures.
Studies Measuring Outcome	Study 1, Study 3, Study 4
Study Designs	Experimental
Quality of Research Rating	3.1 (0.0-4.0 scale)

Outcome 4: Recurrence of physical abuse
Description of Measures	Recurrence of physical abuse was measured using reports of abuse from a statewide child welfare administration database. The most common sources of reports in the database were school staff, relatives, and family members. This database uses unique identifiers for the family as well as for the abusive parent. All database matches were manually checked to confirm a positive match between the maltreatment report and the study participant identified as the perpetrator.
Key Findings	Participants in a study were assigned to a group receiving PCIT, a group receiving PCIT plus individualized enhanced services (EPCIT), or a standardized community-based parenting group. At a median follow-up of 850 days after the intervention, the rate of recurrence of physical abuse was 19% for PCIT participants, 36% for EPCIT participants, and 49% for community-based parenting group participants (p = .02).
Studies Measuring Outcome	Study 2
Study Designs	Experimental
Quality of Research Rating	3.9 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	0-5 (Early childhood) 6-12 (Childhood) 26-55 (Adult)	81% Male 19% Female	77% White 14% Black or African American 9% Race/ethnicity unspecified
Study 2	0-5 (Early childhood) 6-12 (Childhood) 26-55 (Adult)	65% Female 35% Male	52% White 40% Black or African American 4% Hispanic or Latino 2% Race/ethnicity unspecified 1% American Indian or Alaska Native 1% Asian
Study 3	0-5 (Early childhood) 6-12 (Childhood) 26-55 (Adult)	77% Male 23% Female	67% White 17% Black or African American 13% Race/ethnicity unspecified 3% Hispanic or Latino
Study 4	0-5 (Early childhood) 26-55 (Adult)	70% Male 30% Female	100% Non-U.S. population

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Parent-child interaction	3.9	3.5	4.0	2.5	2.4	3.1	3.2
2: Child conduct disorders	4.0	3.9	4.0	2.5	2.4	3.1	3.3
3: Parent distress and locus of control	3.4	3.4	4.0	2.5	2.4	3.1	3.1
4: Recurrence of physical abuse	4.0	4.0	4.0	4.0	3.5	4.0	3.9

Study Strengths

The majority of the measures used in the studies have excellent and well-tested psychometric properties. All the studies used random assignment and good methodologies to assess intervention fidelity (e.g., videotaping and review of a random sample of sessions, direct supervisor observation, use of clinical guides). Rates of adherence to the treatment protocol were high across all the studies.

Study Weaknesses

Some of the measures lack sufficient documentation of psychometric properties. Attrition rates were higher in the intervention group than the control group in some of the studies. Attempts to control for attrition and missing data were minimal to modest. The small sample size in each of the studies did not permit the use of multivariate analysis, which may have provided stronger evidence for causation and ruled out confounding variables.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Funderburk, B., Gurwitch, R., & Nelson, M. Parent-Child Interaction Therapy (PCIT) training curriculum. Oklahoma City: University of Oklahoma Health Sciences Center.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
3.8	3.9	3.9	3.8

Dissemination Strengths

The implementation materials include comprehensive instruction for implementers, with scripts and therapist prompts provided for each session. Guidance is provided to assist in planning prior to implementation, adapting the program for specific cultural groups, and incorporating quality assurance tools into regular program procedures. The required training clearly connects to and expounds on each intervention component. Quality assurance is a defined feature of the program, with thoughtful attention given to both monitoring program fidelity and assessing intervention outcomes.

Dissemination Weaknesses

Additional guidance is needed on integrating this intervention into existing organizational functions. Some implementation and training materials have not been formatted for use in nonresearch settings. It is unclear whether technical assistance is available to new implementers. Some data collection procedures for monitoring quality assurance may be too demanding for use in nonresearch settings.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Treatment materials	$1,000 per set	Yes
1-week, off-site training plus 100 hours of additional training/consultation over 12 months	$3,000-$4,000 per person	Yes

Additional Information

A study of high-risk families involved in the child welfare system estimated the cost for each parent-child pair completing the program to be $2,208-$3,638 (Chaffin et al., see Quality of Research materials reviewed).