When parents need skills, PCIT can help


By Dr. Andrew Clark

Effective parenting may be in fact the best form of prevention for childhood mental health issues. Many parents interact and communicate with their children in ways that are consistent with their own experiences growing up. Unfortunately, some parents have multiple adverse childhood experiences and have not experienced the positive consistency, warmth and limit-setting needed to support the development of their parenting skills. Effective parenting is difficult even when it has been experienced because our daily modern life limits our time to commit to this. Like any set of skills, it needs to be practiced and maintained by setting aside time for undisturbed one-on-one play between a parent and a child. The dwindling regional connections of extended families in the United States may have decreased the generational transfer of parental skills, and inconsistent and competing “pop psychology” parenting trends in the media may confuse more than help. These factors all contribute to inconsistent parental models and can erode parents’ skills.

The relationship between a child and a caregiver sets the foundation for internal psychological associations. Many adverse genetic and biological risks may be overcome or improved by the effects of consistent parental supervision, positive warm regard and empathic interactions. Inconsistent expectations and stressful parenting styles may actually damage the brain. For example, perceived stress from high emotion such as screaming at a child will increase cortisol, a stress hormone with effects on genetic expression and ultimately brain pathways. Eventually, neural network pathways are influenced by these multi-factorial hormonal and genetic influences, so poor parenting may lead to mental health issues such as heightened anxiety, mood dysregulation and attention problems. In addition, the behavioral reinforcement of aggressive, avoidant or anxious parenting styles can lead to poor social skills and aggressive and isolative behaviors in children.

Parent Child Interaction Therapy (PCIT) is a form of behavioral training developed by Dr. Sheila Eyberg for children ages 2 through 7 and their caregivers that has been well studied and validated. It is an evidence-based treatment directed at improving the parent-child relationship by developing communication skills that change the parent-child interaction patterns. PCIT draws from both attachment and social learning theories to achieve authoritative parenting. The authoritative parenting style is marked by consistent, warm limit setting and has been associated with fewer child behavior problems. Don’t confuse authoritative for authoritarian. Authoritarian is a controlling, demanding and one-sided directive parenting style, as opposed to a permissive parenting style, which gives the primary control to the child and fails to set limits or offer direction. The breakdown of respect, listening skills and enjoyable time together due to frustration from poor parenting styles can lead to aggressive and oppositional interactional styles. Disruptive behavior is the most common reason for referral of young children for mental health services and can vary from relatively minor infractions such as talking back to significant acts of aggression. For many parents who feel exhausted and hopeless in their relationships with their young children, PCIT can help.

So how does it work? Basically, it breaks down into two skill building parts; Child-Directed Interaction and Parent-Directed Interaction, then it has three assessments to ensure the skills are acquired – the pre-treatment, mid-treatment, and post-treatment assessments. First, the parents are taught DOs and DON’Ts. The DOs includes the PRIDE skills:

P – Praise
R – Reflect
I – Imitate
D – Describe
E – Enjoyment

The parents are taught play therapy techniques to describe the actions of their child, reflect upon what their child says, imitate the play of their child, praise their child’s positive actions and try to enjoy the special time together. The DON’Ts include giving commands, asking questions or criticizing the child. Parents are to ignore obnoxious and provocative behaviors and not stop special time unless there is dangerous or destructive behavior. Essentially, the special time is the child’s turn to be so special the parent lets them lead unstructured play. Special time is assigned for 20 minutes daily to be done regardless of busy schedules and is never to be taken away as a consequence.
The parent-directed interaction is to empower parents to lead with consistency, limit setting, clear expectations and contingency management. The skills are taught to effectively give consequences linked directly to disobedient behaviors such as time-outs or losing privileges. The COPE skills provide positive reinforcement of obedient behavior:

C – Command
O – Obey
P – Praise
E – Explain

Giving commands is an art. Be specific, short and positive, meaning that you tell the child what to do rather than what not to do. A polite and normal tone of voice is crucial. Reasons should only be given before a command or after a command is obeyed. For PCIT, the most effective training involves the use of a one-way mirror with coaching done by a PCIT-trained therapist using an objective scoring instrument to show successful improvement in skills during the assessments. Typically, the PCIT can be six to 12 weeks long depending on the parent-child relationship.

Prevention can come in many forms. PCIT has been shown to reduce disruptive behaviors in children with oppositional defiant disorder and children with autism. PCIT has been shown to be effective with physically abusive parents, aiding in reuniting families. The healthy and secure attachment to a primary caregiver may be the best form of mental health prevention.

Dr. Andrew Ryan Clark, a native of Northeastern Pennsylvania, serves as the Medical Director for KidsPeace Hospital and Residential Services. He is a board-certified Child and Adolescent Psychiatrist who completed his residency training and child and adolescent fellowship at Medical University of South Carolina in Charleston, S.C. He completed medical school at Drexel University College of Medicine and undergraduate studies at Wilkes University. He participated in a National Institute of Drug Abuse research track where he received a competitive National Institute of Health research award. He has numerous peer-reviewed presentations and publications in the field of adolescent substance abuse and problematic Internet use. He is married with three children ages 1, 3, and 7 years old.