Parent-Child Interaction Therapy

Parent-Child Interaction Therapy (PCIT) is an intervention for children (ages 2-12 years) and their parents or caregivers that focuses on decreasing externalized child behavior problems (e.g., defiance, aggression), increasing positive parent behaviors, and improving the quality of the parent-child relationship. It teaches parents traditional play-therapy skills to improve parent-child interactions and problem-solving skills to manage new problem behaviors. Parents are taught and practice communication skills and behavior management with their children in a playroom while coached by therapists. Most parenting programs for abusive parents treat parents separately from their children and use an instructive approach, but PCIT treats parents with their children. Skills are behaviorally defined, directly coached, and practiced in parent-child sessions. Parents are shown directly how to implement specific behavioral skills with their children. Therapists observe parent-child interactions through a one-way mirror and coach the parent using a radio earphone. Live coaching and monitoring of skill acquisition are cornerstones of PCIT.

The PCIT intervention is composed of three phases. The first phase consists of orientation sessions focused on increasing parent motivation for active participation. Following the motivational enhancement orientation module, parents begin a course of approximately 12 PCIT sessions that consists of two more phases. In the child-direct interaction phase, parents allow their child to lead the play activity while they describe, imitate, and praise the child’s appropriate behavior and ignore inappropriate behavior. In the parent-directed interaction phase, parents direct children’s activity by using clear, positively stated direct commands and consistent consequences for their children’s behavior (praise or time-outs). The goal is to enhance relationships while improving compliance.

The length of treatment can vary, but the standard treatment consists of 12 one-half hour weekly sessions, with a one-hour booster session one month after treatment ends.

Blueprints certification is based on three studies: (1) Nixon et al. (2003); (2) Matos et al. (2009); and (3) Chaffin et al. (2011). Nixon et al. (2003) conducted an experimental study with preschool-aged children exhibiting behavioral difficulties. Researchers randomly assigned 63 families to three groups: 1) the standard PCIT (n = 22), 2) the abbreviated PCIT (n = 23 families), and 3) a waitlist control group (n = 18 families). Findings showed both a standard 12-session treatment and an abbreviated 5-session treatment similarly reduced posttest measures of behavior problems among preschool children with oppositional defiant disorder. In addition, parents benefitted from the treatment in developing a stronger sense of competence and control in their childrearing.

Matos et al. (2009) conducted a randomized control trial involving 32 families with a child (ages 4-6 years) exhibiting hyperactivity and behavior problems in which families were randomly assigned to treatment (n = 20) or a waitlist control condition (n = 12). Results indicated significantly greater improvement for the treatment group compared to the control group on posttest measures relating to hyperactivity, aggression, disruptive behavior, and positive parental practices.

Chaffin et al. (2011) evaluated PCIT using a randomized control design involving parents referred to the program by a child welfare agency for neglect and/or physical abuse. Randomization occurred in two steps, first for the orientation conditions and then for the therapy conditions. The first randomization assigned 192 parents to either a self-motivation orientation condition or a usual orientation condition. The self-motivation orientation involved meetings without the children and included activities to highlight the benefits of the program; the usual orientation was primarily informational and educational. The second randomization assigned the 153 parents remaining after the orientation to a PCIT condition or a service-as-usual condition. The PCIT condition followed program guidelines to promote positive interaction between both parent and child; the service-as-usual sessions provided information to the parent on child development, reasonable expectations, compassionate parenting, and the value of empathy. The sequential randomization thus defined four conditions: 1) self-motivation orientation and PCIT; 2) usual orientation and PCIT; 3) self-motivation orientation and service-as-usual; and 4) usual orientation and service-as-usual (i.e., control). The design allowed for the analysis to disentangle the benefits of the orientation from the benefits of the therapy.

The PCIT program included six orientation sessions and 12 parenting sessions. Assessments occurred at baseline, after the six-session orientation, and after the 12 sessions of the parenting program. The length of the intervention varied across subjects, making it difficult to pinpoint a specific end, but the median time from baseline to collection of post-treatment data was 247 days. The period of follow-up differed as well, but the median was 2.5 years.

Study outcomes revealed the package of PCIT combined with a self-motivational orientation significantly reduced the incidence of recidivism among a sample of parents referred to child welfare for child abuse.

In terms of cost-benefit analysis, Washington State Institute for Public Policy (December 2018) reports $15.97 in measured benefits per $1 spent in implementing Parent-Child Interaction Therapy (PCIT) for families in the child welfare system, and $0.57 per $1 spent in implementing PCIT for children with disruptive behavior.

References:

Chaffin, M., Funderburk, B., Bard, D., Valle, L. A., & Gurwitch, R. (2011). A combined motivation and Parent-Child Interaction Therapy package reduces child welfare recidivism in a randomized dismantling field trial. Journal of Consulting and Clinical Psychology, 79(1), 84-95.

Matos, M., Bauermeister, J. J., & Bernal, G. (2009). Parent-Child Interaction Therapy for Puerto Rican preschool children with ADHD and behavior problems: A pilot efficacy study. Family Process, 48(2), 232-252.

Nixon, R. D. V., Sweeney, L., Erickson, D. B., & Touyz, S. W. (2003). 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.

Nurse-Family Partnership

Nurse-Family Partnership (NFP) is a home visitation program that provides first time mothers with guidance and support in developing effective childrearing practices with the goal of improving long-term outcomes for mother and child. The program begins in pregnancy, when NFP nurses initiate home visitations with pregnant women who are predisposed to infant health and developmental problems (e.g. preterm delivery, low birth weight). NFP nurses educate parents on fetal and infant development, engage other family members and friends in supporting the mother during pregnancy and post-partum, and assist families in using formal health and social services.

Visitations typically begin in the second trimester, lasting 60-90 minutes every other week, and continue through the child’s second birthday. NFP nurses possess all standard medical training and certifications and are equipped with a visit-by-visit protocol for guiding first-time mothers through improving health behaviors, developing parenting skills, and creating plans for education and employment.

The Blueprints certification of Nurse-Family Partnership is based on three randomized controlled trials from implementation sites in New York, Tennessee, and Colorado. Each study involved samples of pregnant, first-time mothers facing exceptional challenges including low income, teen pregnancy, or single parenthood.

The first certified study produced several articles over a span of decades (Eckenrode et al., 2010; Olds et al., 1986a, 1986b, 1997, 1998) and began in 1978 with 400 pregnant women from the rural Appalachian region of New York State. The women, who were recruited from private obstetrics offices and a free antepartum clinic, were randomly assigned to one of three groups: a treatment group receiving home visits during pregnancy (n = 100); a second treatment group receiving home visits up to 24 months after birth (n = 116); or a comparison group (n = 184). Relative to women in the comparison group, nurse-visited women were significantly healthier – fewer hypertensive disorders and kidney infections, improved diet, reductions in cigarette use – during pregnancy and for two years after the child’s birth. Compared to children in the comparison group, children of nurse-visited mothers displayed improved emotional and cognitive development in early childhood, experienced fewer instances of child abuse and neglect through age 15 and had fewer arrests and convictions through age 19.

The second Blueprints-certified study (Olds et al., 2002, 2004) involved low-income pregnant women receiving antepartum care in Denver, Colorado. The women were predominantly Black or Hispanic and were randomly assigned to one of two treatment groups (received home visits from a nurse, n = 235, or a paraprofessional, n = 245), or a comparison group (n = 255) receiving standard care. For four years after giving birth, nurse-visited women experienced better outcomes in general and reproductive health, including smoking cessation and pregnancy intervals, than women in the comparison group or the paraprofessional-visited group. Children of nurse-visited mothers, relative to comparison group children, displayed improved emotional coping and reduced likelihood of developmental delays in early childhood through age 4.

The third Blueprints-certified evaluation (Kitzman et al. 1997; Olds et al., 2004, 2007, 2014) was a scaled-up replication of the program and recruited low-income pregnant women in Memphis, Tennessee. The women were randomly assigned to one of four groups: a high exposure treatment group (n = 228), a low exposure treatment group (n = 230), a usual care comparison group (n = 166), or a slightly enhanced usual care comparison group (n = 515) offering developmental screening and referral services. All women in the nurse-visited treatment groups received intensive home visits during pregnancy, but the low exposure group received only two post-partum visits while the high exposure group continued receiving visits for 24 months after birth. Relative to the comparison groups, nurse-visited women had better mental, physical, and reproductive health outcomes and more economically stable households for six years after birth. Over the first two years of life, children born to nurse-visited mothers had fewer injuries and hospitalizations compared to children of control group mothers. Program benefits of higher test scores and fewer behavior problems extended to age six for all children of nurse-visited women, and to age nine for a high-risk subgroup. Maternal and child mortality rates were also significantly lower for nurse-visited mothers and their children through 20 years after birth.

In terms of cost-benefit analysis, Washington State Institute for Public Policy (December 2018) reports $1.40 in measured benefits per $1 spent in implementing Nurse-Family Partnership (NFP).

References:

Eckenrode, J., Campa, M., Luckey, D. W., Henderson, C. R., Cole, R., Kitzman, H., … Olds, D. (2010). Long-term effects of prenatal and infancy nurse home visitation on the life course of youths: 19-year follow-up of a randomized trial. Archives of Pediatrics & Adolescent Medicine, 164, 9-15.

Kitzman, H., Olds, D. L., Henderson, C. R., Hanks, C., Cole, R., Tatelbaum, R., … Barnard, K. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing. Journal of the American Medical Association, 278(8), 644-652.

Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., … Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: 15-year follow-up of a randomized trial. Journal of the American Medical Association278(8), 637-643.

Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78, 65-78.

Olds, D. L., Henderson, C. R., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., … Powers, J. (1998). Long-term effects of nurse home visitation on children’s criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. Journal of the American Medical Association, 280(14), 1238-1244.

Olds, D. L., Henderson, C. R., Tatelbaum, R., & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77,16-28.

Olds, D. L., Kitzman, H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K., … Bondy, J. (2007). Effects of nurse home visiting on maternal and child functioning: Age 9 follow-up of a randomized trial. Pediatrics, 120, 832-845.

Olds, D. L., Kitzman, H., Knudtson, M. D., Anson, E., Smith, J. A., & Cole, R. (2014). Effect of home visiting by nurses on maternal and child mortality: Results of a 2-decade follow-up of a randomized clinical trial. JAMA pediatrics168(9), 800-806.

Olds, D. L., Robinson, J., O’Brien, R., Luckey, D. W., Pettitt, L. M., Henderson, C. R., … Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110, 486–496.

Olds, D. L., Robinson, J., Pettitt, L., Luckey, D. W., Holmberg, J., Ng, R. K., … Henderson Jr., C. R. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114, 1560-1568.