A Community Mental Health Implementation of Parent–Child Interaction Therapy (PCIT

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Parent–Child Interaction Therapy (PCIT) has been identified as an evidence-based practice in the treatment of externalizing behavior among preschool-aged youth. Although considerable research has established its efficacy, little is known about the

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  ORIGINAL PAPER A Community Mental Health Implementation of Parent–ChildInteraction Therapy (PCIT) Aaron R. Lyon  • Karen S. Budd   Springer Science+Business Media, LLC 2010 Abstract  Parent–Child Interaction Therapy (PCIT) hasbeen identified as an evidence-based practice in the treat-ment of externalizing behavior among preschool-agedyouth. Although considerable research has established itsefficacy, little is known about the effectiveness of PCITwhen delivered in a community mental health setting withunderserved youth. The current pilot study investigated animplementation of PCIT with primarily low-socioeconomicstatus, urban, ethnic minority youth and families. Thefamilies of 14 clinically referred children aged 2–7 yearsand demonstrating externalizing behavior completed PCITinitial assessment, and 12 began treatment. Using standardPCIT completion criteria, 4 families completed treatment;and these families demonstrated clinically significantchange on observational and self-report measures of parentbehavior, parenting stress, and child functioning. Althoughtreatment dropouts demonstrated more attenuated changes,observational data and parent-reported problems acrosssessions indicated some improvements with lower doses of intervention. Attendance and adherence data, referralsource, barriers to treatment participation, and treatmentsatisfaction across completers and dropouts are discussedto highlight differences between the current sample andprior PCIT research. The findings suggest that PCIT can bedelivered successfully in an underserved community sam-ple when families remain in treatment, but that prematuredropout limits treatment effectiveness. The findingssuggest potential directions for research to improve uptakeof PCIT in a community service setting. Keywords  Disruptive behavior   Parent–Child Interaction Therapy   Community mental health    Engagement Introduction Disruptive behavior disorders (e.g., attention-deficithyperactivity disorder, oppositional defiant disorder, con-duct disorder) are among the most common reasons chil-dren are referred for mental health services (Kazdin et al.1994; Reid 1993). This fact is unsurprising in light of the reported prevalence rates for these disorders, which are ashigh as 7% for ADHD, 10% for conduct disorder, and 16%for ODD (American Psychiatric Association 2000). TheDSM-IV criteria for ODD and CD may even exclude some‘‘sub-clinical’’ externalizing youth who are neverthelessexperiencing functional impairment (Rowe et al. 2005), which suggests that prevalence rates of children in need of treatment for disruptive behavior might be higher still.These findings are sobering considering the likelihood foruntreated disruptive behavior problems to persist and theassociation between childhood disruptive behavior andnegative outcomes, such as delinquency and criminality(Farrington 1995; Loeber et al. 1995; Vitelli 1997). Following the pattern displayed by research on a rangeof clinical issues (Bernal and Scharro´n-Del-Rı´o 2001),controlled clinical trials of treatment programs for disrup-tive behavior disorders have typically included low num-bers of ethnic minorities, resulting in multiple calls forincreased representation (e.g., Kazdin 2003; Miranda et al. 2005). In a recent meta-analytic review of controlled K. S. Budd ( & )Department of Psychology, DePaul University, 2219 N.Kenmore Ave, Chicago, IL 60614, USAe-mail: kbudd@depaul.eduA. R. LyonPsychiatry and Behavioral Sciences, University of Washington,6200 NE 74th St., Suite 100, Seattle, WA 98115, USA  1 3 J Child Fam StudDOI 10.1007/s10826-010-9353-z  studies of evidence-based treatments for ethnic minorityyouth, Huey and Polo (2008) were unable to identify anyinterventions that could be categorized as well-establishedfor those populations using the efficacy criteria delineatedby the Task Force of Division 12 of the American Psy-chological Association (Chambless et al. 1996). Never-theless, the full extent to which ethnic minority youth havebeen excluded from evidence-based practice researchremains unclear due to inconsistent reporting of participantdemographics within the literature (Weisz et al. 2005a). Part of the clinical research disparity between ethnicminority and white populations appears to stem from thesettings in which the groups are most likely to seek services.Ethnic minority youth are less likely to initiate or completepsychosocial treatment (Rawal et al. 2004; Snowden 1999; Sue et al. 1991) and, when they do, treatment is most likelyto occur in a community setting (Takeuchi et al. 1993; Weersing and Weisz 2002). Indeed, the majority of efficacy trials with youth have been conducted in highly controlledsettings that do not closely resemble service clinics (Sou-tham-Gerow et al. 2003; Weisz et al. 2005a). Simulta- neously, treatment received in community mental healthclinics is less likely to include evidence-based ‘‘best prac-tices’’ (Weisz et al. 1997). It is essential that clinical studies of evidence-based practices move beyond controlledresearch settings and into the settings where ethnic minorityyouth routinely receive treatment, such as communitymental health centers (CMHCs).Provision of treatment in CMHCs presents a new set of challenges for the use of evidence-based practices, in thatattrition from treatment is higher in CMHCs (Garcia andWeisz 2002). At present, the reasons for these attritionlevels are unclear; however, high rates of client dropoutand other aspects of engagement, such as attendance andadherence, represent a significant concern when assessingtreatment effects. Engagement is a particularly complexissue in child and family treatment due to the influence of multiple individuals (e.g., child, parents, teachers) whomay not share a common conceptualization of the problemor equal motivation for change. Among low-SES, ethnicminority children and families, a range of physical (e.g.,service accessibility, scheduling) and psychosocial barriers(e.g., stigma, social support) have been identified in theliterature (Gross et al. 2001; Harrison et al. 2004; McKay et al. 1998). Nevertheless, findings have often beeninconsistent across studies with regard to the presence of any particular set of client characteristics or barriers forclients who discontinue services (McKay and Bannon2004). Investigation of barriers to parental treatmentengagement is of particular concern for the families of children who display externalizing behavior since parenttraining has emerged as a efficacious ‘‘best practice’’ forthose problems (Eyberg et al. 2008; Serketich and Dumas 1996). In behavioral parent training models, the skills andbehaviors of caregivers are the primary focus of treatment,placing considerable importance on their engagement intherapy.Parent–Child Interaction Therapy (PCIT; Eyberg andRobinson 1982; Zisser and Eyberg 2008) is a manualized parent training intervention that has received substantialempirical support in the treatment of disruptive behavioracross multiple reviews (e.g., Brestan and Eyberg 1998; Gallagher 2003; Thomas and Zimmer-Gembeck  2007). PCIT draws heavily from established parenting, sociallearning, and attachment theories and proceeds along twosuccessive phases: Child-Directed Interaction (CDI) andParent-Directed Interaction (PDI). In CDI, goals includestrengthening the parent–child relationship by coachingparents in their use of nondirective play therapy skillsdesigned to support social interaction and increase positiveparent behaviors, such as praise. The PDI phase builds onCDI skills with the introduction of unambiguous parentalcommands, limit-setting, and consistent follow-throughwith consequences (e.g., timeout) to increase complianceand decrease disruptive behavior.A wealth of research has established empirical supportfor the efficacy of PCIT in children with disruptivebehavior disorders immediately following treatment and atfollow-up (e.g., Hood and Eyberg 2003; Nixon et al. 2004; Schuhmann et al. 1998). Among other changes, PCIT hasbeen documented to result in substantial increases inpositive parental attention and child compliance anddecreases in children’s externalizing behavior. In PCITefficacy studies, attrition rates have typically ranged from27 to 47% (Bagner and Eyberg 2007; Boggs et al. 2004; Fernandez and Eyberg 2009; Schuhmann et al. 1998; Werba et al. 2006). Data from other community-basedapplications of PCIT (Chaffin et al. 2009; McNeil 2007; Phillips et al. 2008; Timmer et al. 2005) suggest wide variability in rates of attrition, from 12 to 77%.Research has also provided some support for the use of PCIT with ethnic minority populations (e.g., Capage et al.2001; Chaffin et al. 2004; McCabe and Yeh 2009). Despite this progress, a majority of PCIT research with ethnicminority clients has been conducted within controlledclinical trials rather than in service clinics, and one studywas retrospective. Due to insufficient evidence, Eyberg(2005) has concluded that PCIT cannot yet be identified asan empirically-supported treatment for African Americanchildren. For the current study, we used the standard PCITprotocol, which allows for individualized tailoring to theneeds of each client. Further investigation remains neces-sary before PCIT can be recognized as an empirically-supported treatment across ethnic minority groups.In a review of youth psychotherapy outcome research,Weisz et al. (2005a) identified striking differences between J Child Fam Stud  1 3  the existing research base and characteristics of typicalclinical practice with regard to (1) enrollment of samples,(2) service providers, and (3) settings in which treatmentwas provided. Although intervention studies for conductproblems fared slightly better than those for some othercategories (e.g., anxiety, ADHD), only 2% of the conductproblems studies reported representative characteristicsacross all three dimensions, suggesting distressingly lowrepresentativeness. Most often, studies of interventions forconduct problems included youth who were recruitedrather than independently treatment-seeking, were treatedby researchers or graduate students, and occurred in con-trolled research settings. Although, as cited above, PCIThas received strong empirical support regarding its effi-cacy, the majority of the outcome research on PCIT hasbeen conducted with predominantly Caucasian familiesseen at university or hospital-based clinics (Gallagher2003).The current research strives to bridge the gap betweenthe existing PCIT research base and the settings in whichethnic minority youth are likely to receive services byassessing a PCIT program established in a communitymental health center (CMHC). Our program represents auseful transition point between the highly controlledresearch settings that are typical of PCIT research and realworld service settings. The program satisfies Weisz et al.(2005b) criteria for clinical representativeness with regardto participant enrollment and treatment setting because itprovides intervention to treatment-seeking, clinic-referredyouth in a clinical service setting. However, unlike typicalclinical treatment providers, who usually consist of prac-ticing clinicians (or even paraprofessionals), our serviceproviders included the study’s principal investigator andgraduate students in a clinical psychology doctoral pro-gram, a characteristic more common to the existing evi-dence base.In addition to the dimensions identified by Weisz and hiscolleagues, the clinical characteristics of children includedin PCIT research also warrant attention. Eligibility criteriain the majority of PCIT studies have included a diagnoseddisruptive behavior disorder and/or clinical elevations onstandardized behavioral measures (e.g., Bagner and Eyberg2007; Boggs et al. 2004; Eisenstadt et al. 1993; Funderburk  et al. 1998). In contrast, community treatment settingscommonly provide services to individuals who do notnecessarily meet diagnostic criteria for major DSM diag-noses but are nevertheless presenting with problems sub-stantial enough to result in clinical referral (Snowden et al.1989). The effectiveness of and barriers to evidence-basedtreatments such as PCIT within community-based popula-tions become important questions as the field movesincreasingly toward dissemination of empirically-derived‘‘best practices’’ (Weisz et al. 2005b). The aim of the current study was to conduct a detailedcase analysis of treatment effectiveness, engagement,treatment acceptability, and barriers to successful com-pletion in a pilot community-based application of PCITserving a predominantly low-SES, urban, ethnic minoritypopulation. The article reports on families seen in the first30 months (July 2005 to February 2008) of the program’soperation. Due to the small size of the pilot sample, weused descriptive rather than statistical analysis to examinevariables that may relate to success of PCIT in a CMHC.Client engagement in treatment is conceptualized usingNock and Ferriter’s (2005) descriptions of   attendance  and adherence  in parent training studies. Especially in popu-lations who are at high risk for low treatment engagement,research investigating the role of treatment attrition,attendance, and adherence is essential. Method ParticipantsStudy participants included 14 children and their caregiv-ers, who sought treatment at an urban CMHC, were eligiblefor PCIT based on their clinical presentations, completedinitial assessment, and provided research consent. (Threeadditional potential study participants did not completeinitial assessment, and a fourth family did not provideresearch consent.) The 14 families were referred fortreatment from multiple sources including schools andexternal agencies, CMHC outreach workers, and, in 4cases, self-referral. Participating caregivers consisted of 12single mothers (or, in one case, a grandmother), 1 singlefather, and 1 married couple. In addition, one father wholived separately from the mother and child began treatmentbut left soon after the initial assessment session. Due tolack of research consent, his data were not included in ouranalyses. Two of the single-parent participants were fosterparents, who each had been caregivers for their child forover a year and were in the process of adopting them.Study children were 64% male with a mean age of 3.7 years (SD  =  1.4; range: 2–7). Child ethnicity was 50%African American, 29% Multiracial (1 Latino and Cauca-sian, 3 Latino and African American), and 21% Latino. Inthe case of the two foster children, ethnicity of parent(Caucasian) differed from ethnicity of child (1 AfricanAmerican and 1 Latino and African American). Primarychild diagnoses were Oppositional Defiant Disorder (ODD;36%); Attention-Deficit Hyperactivity Disorder (ADHD),Combined Type (29%); Disruptive Behavior Disorder NotOtherwise Specified (DBD NOS; 21%); ADHD, PrimarilyInattentive Type (7%); and combined DBD NOS andAutistic Disorder (7%). Although specific data on parental J Child Fam Stud  1 3  income were not available, 79% of clients received publicassistance (e.g., Medicaid) and 14% were charged areduced fee for treatment, based on their financial status.On the basis of their ethnic and socioeconomic character-istics, participating youth were from demographic groupsless likely to receive high-quality mental health services.Of the 14 families, 2 only attended assessment sessionsbefore discontinuing. Therefore, the data described belowinclude only the 12 families who received at least onetreatment session.SettingThe CMHC in which the study was conducted has beenoffering a range of preventive and mental health servicesfor high-risk youth and their families for over 30 years.Services focus on families with limited means (i.e., onpublic aid, non-insured, or under-insured). In 2007, 85% of clientele were non-white and 84% were on public assis-tance. Unlike most CMHCs, which are free-standing ser-vice centers, the CMHC in this research is located on auniversity campus and serves as a primary training clinicfor doctoral clinical psychology students. In addition to 27part- and full-time staff, 15–20 student therapists provideservices.For the majority of families (9 of 12), sessions were heldin two CMHC therapy rooms. The rooms were equippedwith living room furniture, a table, and chairs. Both wereconnected by an observation room with one-way mirrorsfor monitoring the rooms. One room served as the primarytherapy room for meetings with families and observationsof parent–child interactions. Following the beginning of PDI, the second room functioned as the timeout room withslight modifications to remove potentially dangerous oreasily damaged items (e.g., lamps, low-hanging pictures,easily movable chairs). For the other three families, ses-sions were held with a similar configuration (including aroom with a one-way mirror but no living room furniture)at a local daycare center (their referring agency).Measures Child and Parent FunctioningChild Behavior Checklist   ( CBCL  ; Achenbach and Rescorla2000, 2001). The CBCL is a caregiver-report form designed to measure the severity of behavioral and emo-tional symptoms in children. Two versions were used, theCBCL 1  -5 and the CBCL 6–18, to cover the age range of clients (2–7 years). The measures contain 99 and 112items, respectively, and yield Internalizing, Externalizing,and Total Problems scale scores. Inter-item consistency forthese three subscales is strong for both the CBCL 1  -5( a  =  .89, .92, .95; Achenbach and Rescorla 2000) and the CBCL 6–18 ( a  =  .91, .92, .94; Achenbach and Rescorla2001). In addition, recent research has supported the con-struct validity and use of the CBCL 1  -5 scales with low-income African American and Latino parents, especiallyfor the externalizing scale (Gross et al. 2006). Eyberg Child Behavior Inventory  ( ECBI  ; Eyberg andPincus 1999). The ECBI is a 36-item disruptive behaviorrating instrument completed by children’s caregivers. TheECBI Intensity Scale measures the frequency of disruptivebehaviors on a 7-point scale and the Problem Scale mea-sures whether or not parents find those behaviors prob-lematic. Intensity Scale scores of   C  132 are above theclinical cutoff (Eyberg and Pincus 1999). In their recentassessment of the ECBI’s utility in a sample of low- andmiddle-income African American and Latino parents,Gross et al. (2007) found inter-item correlations ranging from  a  =  .92 to .95 for the Intensity Scale and from a  =  .90 to .94 for the Problem Scale. Parenting Stress Index-Short Form  ( PSI-SF  ; Abidin1995). The PSI-SF is a 36-item parent-report measure of strain experienced in parenting responsibilities and inter-actions with children. The measure contains three sub-scales: Parental Distress, Parent–Child DysfunctionalInteraction, and Difficult Child, as well as a Total Stressscore. In an investigation of the psychometrics and utilityof the PSI-SF in a low-SES, African American sample,Reitman et al. (2002) found good inter-item consistency within each subscale and evidence for the construct validityof the three factor solution described above.  Dyadic Parent–Child Interaction Coding System III  (  DPICS III  ; Eyberg et al. 2005). The DPICS is an obser-vational method of measuring the content and quality of parent–child interactions during a series of standardizedsituations. Initial assessment and post-treatment assessmentsituations consist of child-led play, parent-led play, andclean-up, which are presented in increasing order of parental direction and control. The initial and post-treat-ment DPICS assessments last 25 min, including a 5-minwarm-up period for child-led play and parent-led playbefore 5 min of coding and ending with 5 min of clean-up.In addition to assessing parent–child interactions in theinitial and post-treatment assessments, we conducted 5-minassessments of the parent and child in play at the beginningof most CDI and PDI treatment sessions in order to assessparental mastery of PCIT skills. All assessment observa-tions were videotaped and audiotaped to allow for laterDPICS coding.The DPICS system provides standard definitions forcoding parent verbalizations and child responses to com-mands in real time. Parent verbalizations consist of thefollowing categories: Praise, including both specific(Labeled) and general (Unlabeled) positive evaluations of  J Child Fam Stud  1 3  child behavior; Reflections, involving the repetition of achild’s speech or paraphrasing its meaning; BehaviorDescriptions, where parents describe a child’s currentactivities; Criticisms, which include correcting, disap-proving, or sarcastic speech directed toward the child;Direct Commands, consisting of specific statements for thechild to do something; Indirect Commands, consisting of suggestions or requests for the child to do something;Questions, which ask for information or add a ‘‘question’’tag to a comment; and Neutral Talk, which includes anyother verbalization that does not fit one of the previouscategories. The child’s response to parent commands iscoded as compliance or noncompliance to each commandfor which there was an opportunity to comply.Graduate and undergraduate psychology students codedDPICS assessments. They received extensive training inthe system, including reading the DPICS manual, review-ing definitions in didactic sessions, completing homework exercises, practicing coding with experienced coders, andthereafter meeting regularly to review discrepancies andreduce observer drift. An undergraduate student first tran-scribed video segments into an Excel spreadsheet bywatching the videotape and listening to the audiotape. Asecond student then rechecked the transcripts for accuracy.Next, one observer coded parent and child behaviors usingthe DPICS system. A second observer independently coded75% of segments to assess interobserver agreement. Kappareliabilities for individual behaviors were .77 (negativetalk), .88 (direct commands), .77 (indirect commands), .86(labeled praise), .84 (unlabeled praise), .92 (questions), .80(reflections), .83 (behavior descriptions), .81 (neutral talk),.68 (child compliance), .56 (child noncompliance), and .63(no opportunity for compliance). According to Landis andKoch (1977), Kappa values between .41 and .60 are con- sidered moderate, between .61 and .80 substantial, andabove .81 ‘‘almost perfect.’’  Attendance and AdherenceSession attendance.  Parents’ attendance at scheduledtreatment sessions served as one measure of clientengagement and treatment dose. Nock and Ferriter (2005) defined treatment  attendance  as ‘‘delivery of the agreedupon treatment participants … to the treatment setting forscheduled appointment’’ (p. 151). In our study, treatmentsessions were considered scheduled if the meeting wasarranged during the previous session or if they werescheduled between sessions by phone. Non-treatment ses-sions (e.g., those devoted primarily to assessments orscheduling issues) were not included in our counts. Typi-cally, client attendance at the next session was confirmedat the conclusion of each week’s meeting. Clientcancellations (by telephone) and no-shows were bothconsidered nonattendance but were tracked separately.  Homework completion.  Homework completion provideda measure of parental treatment  adherence  outside of thetherapy sessions. As a standard part of PCIT, parents arerequested to complete daily 5-min practice sessions duringCDI and an additional 10-min practice session during PDI(15 min total) in order to solidify PCIT skills and promotegeneralization of the skills. Parent completed homework sheets from the treatment manual (Eyberg and Child StudyLab 1999), on which they recorded the date, activity, andany problems or questions that arose. We calculatedhomework completion by tallying the number of days of homework completed per week of treatment. CDI home-work occurred during both the CDI and PDI phases,whereas PDI homework occurred only during PDI.Therefore, we calculated separate tallies for CDI and PDIhomework.  Dropout.  We defined dropout as occurring when acaregiver explicitly told the therapist that s/he wished toend treatment or quit coming to all further scheduled parenttraining sessions and failed to return calls despite 6 or moreweeks of repeated, weekly documented staff efforts tore-contact and re-engage the parent by phone or mail. Satisfaction and BarriersTherapyAttitudeInventory ( TAI; Eyberg1993).TheTAIisa10-itemparent-reportmeasurethatassessessatisfactionwiththe therapy process and its outcomes. Parents rate items on a1 to 5 scale, with higher ratings indicating greater satisfac-tion.Itemsassessconstructsincludingparents’confidenceincarrying out discipline and satisfaction with the parenttraining intervention. Previous research with the TAI hasyielded high internal consistency and 4-month test–retestreliability (Brestan et al. 1999). TAI data were available for 10 of the 12 families who attended at least one treatmentsession (3 completers and 7 noncompleters).  Barriers to Treatment Participation Scale  (  BTPS  ; Kaz-din et al. 1997). The BTPS is a 58-item measure parentscompleted at the end of treatment regarding psychologicaland practical barriers to client engagement. The first 44items list potential barriers to treatment (e.g., ‘‘Treatmentdid not seem necessary,’’ ‘‘I felt that treatment cost toomuch’’) and are rated on a 5-point scale (1  =  never aproblem, 5  =  very often a problem). Consistent with thepractices of the measure authors (Kazdin et al. 1997), we used a total barriers score in the current study. Kazdin et al.(1997) reported acceptable levels of inter-item consistency for total barriers. Items 45–58 list 14 critical events (e.g., ‘‘Ilost my job or had a change in income’’) that might affecttreatment participation. Respondents indicate which of theevents (if any) they experienced while receiving treatment. J Child Fam Stud  1 3
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