Parent–child interaction therapy (PCIT) is an intervention developed by Sheila Eyberg (1988) to treat children between ages 2 and 7 with disruptive behavior problems. PCIT is an evidence-based treatment (EBT) for young children with behavioral and emotional disorders that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns.
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. The most commonly treated Disruptive Behavior Disorders may be classified as Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD), depending on the severity of the behavior and the nature of the presenting problems. The disorders often co-occur with Attention-Deficit Hyperactivity Disorder (ADHD). It uses a unique combination of behavioral therapy, play therapy, and parent training to teach more effective discipline techniques and improve the parent–child relationship.
PCIT is typically administered once a week, with 1-hour sessions, for 10-14 sessions total and consists of two treatment phases: Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI). The CDI component focuses on improving the quality of the parent-child relationship, which will help promote changes in behavior. This sets the foundation for the PDI stage, which continues to encourage appropriate play while also focusing on a structured and consistent approach to discipline.
History PCIT was derived from several theories, including attachment theory, social learning theory, and parenting styles theory.
Attachment theory According to attachment theory by Ainsworth, “sensitive and responsive parenting” during infancy and toddlerhood leads the child to develop an expectation that their needs can be met by the parent. Thus, parents who show their young children greater warmth and are more responsive and sensitive to their needs promote a sense of security that they can later apply to relationships with others. This can also help with more effective emotion regulation. Children who are referred to clinics for externalizing behaviors are more likely than non-referred children to display distress when separated from the parent and to display indicators of an insecure attachment to their parent.
The Child Directed Interaction (CDI) component of the PCIT applies attachment theory through its goal to “restructure the parent-child relationship and provide a secure attachment for the child”. The CDI component makes use of the idea that parents can have a dramatic effect on their child's behavior, especially during the early preschool years. This is a critical period where children are more responsive to their parent's and less so to other influences such as teachers or peers.
Social learning theory Social learning theory suggests that new behaviors can be learned by watching and imitating the behaviors of others.Bandura, A., & Walters, R. H. (1977). Social learning theory (Vol. 1). Englewood Cliffs, NJ: Prentice-hall. Patterson (1975) further expands on this and proposes that child behavior problems are “inadvertently established or maintained by dysfunctional parent-child interactions”.Patterson, G. R. (1975). Families: Application of social learning to family life. Champaign, IL: Research Press. There can be a “coercive interaction cycle” between parent and child where both try to control the behavior of the other. Behaviors such as arguing and aggression in children are reinforced by parent behaviors (e.g., withdrawal of demands), but negative parent behaviors can subsequently be reinforced by negative child behaviors. In sum, children can learn many behaviors from their parents’ feedback, but this can result in negative externalizing behaviors, as well. The PDI component targets this cycle specifically by establishing consistent parenting behaviors that encourage the desired behavior in children.
Parenting style theory According to Diana Baumrind’s parenting style theory (year link citation) found that the authoritative parenting style leads to the healthiest outcomes for children transitioning into adolescence. This style combines responsive and nurturing interactions with clear communication and firm discipline. The influence of this theory can be seen particularly in the PDI treatment phase where parents are taught to use direct commands to increase desired behavior, along with other positive and nurturing behaviors.
Structure of the PCIT Eyberg’s original paper (1988) thoroughly describes each assessment and treatment phase of the PCIT and includes suggestions for applying the therapy.
First, parents attend a training session during which the therapist explains each rule and its rationale. Each parent is also taught through one-on-one role play interactions with the therapist. Parents are also given a handout at the end of the session that summarizes the basic directions so they can review it at home.
After this training session, the sessions that follow will include the child. The sessions are held in a playroom, with the child playing with one parent at a time. Meanwhile, the therapist and the other parent will be observing the play through a one-way mirror or video system. The therapist can provide immediate feedback and suggestions through a “bug-in-ear” device or sit in the room to do the coaching. At the end of the session, the therapist discusses the child's progress, using summary sheets that parents can use to guide their interactions during practice sessions at home. These practice sessions serve as a “homework assignment” for parents, during which they practice the interaction with their child for five minutes a day, using homework sheets to track progress. The treatment begins with the Child-Directed Interaction phase, then is followed by the Parent-Directed Interaction (PDI) phase.
Child-Directed Interaction (CDI) According to Eyberg (1988), the parent's goal during this stage is to follow the child's lead during play while being sure to follow the “Don’t Rules” and “Do Rules of CDI”. The child should be free to lead the activity and make their own decisions about what and how to play. By letting their children take control of the play, the parents help their child develop autonomy and independence.
Don’t rules of CDI According to Eyberg (1988), the Don't rules help parents step back and encourage child-led play by avoiding commands, questions, and criticisms. Commands, or instructions, would take the lead away from the child could also introduce potential disagreements into the play. Parents are also encouraged to not ask questions. This can include questions such as “How about putting the toys away?” which are actually implied commands. The concern about asking questions is that they may come off as accusatory (“Why did you choose that toy?”) or take the conversation to an “adult” level instead of letting the child play freely and naturally. The general idea is that questions provide little information, so they have limited usefulness in therapy. The third “don’t” rule is to avoid criticizing. Though criticisms can range from mild to blatant attacks on the child, criticisms in general can lead to damaging effects on the child's self-esteem. As children learn which behaviors are good or bad, they rely on what their parents say about them and believe it. Criticisms may also frustrate or anger the child and can lead to a counterattack. Taken together, criticisms are not only unproductive in therapy, but also are threats to the positive relationship that the PCIT emphasizes.
Do rules of CDI According to Eyberg (1988), the Do rules of CDI that promote positive behavior throughout play. The first Do is to describe what the child is doing during the activity. Doing this may seem unnatural at first, but describing serves a few purposes: it allows the child to (1) lead play, (2) improve attention towards independent activities, (3) clarify the activity and encourage the child to further elaborate the play, and (4) help teach the child different concepts in a positive way. For example, the child learns through positive feedback (“you found the red one”) instead of coercion (“find the red one”).
The second Do is imitation. Eyberg recommends that the parents “sit close and do the same thing as the child”. The parent can add to the child's play, or do something similar, but the focus should still remain on the child's style of play. The attention that imitation can demonstrate can show the child that the parent is interested and believes what they are doing is important. Imitation may even lead to the child imitating the parent. The aim is that through the parent-child play, the child can learn cooperative play skills that they can one day use with other children.
Parents are encouraged to reflect what the child says during play, the third Do of CDI. This helps parents practice listening to their child. For example, when the child says “The car is fast,” the parent might say “Yes, the car is fast”. These reflections show that the parent understands and accepts what the child is saying. Additionally, using reflective statements can improve the child's vocabulary and grammar by providing clarity to the child's thoughts. It also gives the child an opportunity to agree or disagree with the parent's understanding and elaborate if needed.
Praise is the fourth Do, and is very important because it can make children feel good and increase warmth, an important goal of the CDI. Praise statements such as “Good job!” show the child that their creations and actions are important. This is important because children tend to believe the things parents say to them, whether they be positive or negative. The manual specifies two types of praise. “Labeled praise” statements specify exactly what the parent likes about their behavior. For example, saying “You did a beautiful job of drawing that picture” not only teaches children that they did something the parent liked, but also teaches them what they did to earn that praise. Because PCIT can be used from ages 2 through 7, coaching takes into account the developmental differences at each age and teaches parents to be mindful of those differences. Parents are encouraged to praise and reflect all attempts of their child to verbally communicate, as speech skills are concurrently developing.
Parent-Directed Interaction (PDI) According to Eyberg (1988), during the PDI component, parents continue the skills learned in the CDI, but this time they are taught new skills to lead the play. These skills include giving verbal directions and applying the appropriate consequences to the child in a fair manner that the child can understand clearly. These steps are practiced at the clinic, and parents are not encouraged to practice at home until they feel confident.
Eyberg (1988) states that he first step is to give clear, direct commands for the desired behavior from the child and to avoid indirect commands, which can be too vague and confusing to the child. For example, “Put this red table in the house” is a direct command. However, an indirect command such as “Will you color the leaves green?” can be interpreted by the child as a genuine question. Another example of an indirect command is “Let’s clean up the toys”, which does not indicate clearly if both the parent and child will be doing the task or how much of the task the child will do themselves. Additionally, phrases that are too general, such as “Be good”, should be avoided, as it does not provide enough information about what exactly is expected of the child. In sum, clear statements should be used towards the child so they can understand easily without getting confused.