One of the greatest struggles for any parent is figuring out what to do when one of their children starts acting out, especially at a very young age. If the problem isn’t effectively addressed early on, it can turn into a much bigger issue as the child gets older. It can also become a vicious circle that perpetually exacerbates the problem. This is because even the best parents – being human and infallible – can become worn down and increasingly frustrated with the child’s behavior. The growing frustration can make it difficult to keep emotions aside and respond in an appropriate manner. Well-intended but misguided attempts to curtail the behavior can inadvertently fuel the child’s frustration, causing him or her to act out even more.
Although most experienced child and adolescent therapists can help parents deal with acting out behaviors, it can be more expedient to utilize a therapy specifically targeted to young children with externalizing behavior disorders and emotional problems. One of the therapies that has been found to be quite effect is Parent-Child Interaction Therapy or PCIT for short.
The Importance of Early Treatment for Behavioral Problems
It’s a well-known fact – not to mention, common sense – that the best time to treat any type of disorder (mental or physical) is early on. Unfortunately, in addition to having busy lives and countless demands to juggle, many parents want to believe that their child is “just going through a phase” when serious behavioral problems start to appear. Not to mention, it can be difficult for any parent to admit that their child may have a “disorder”. These tendencies often play a role in putting off seeking much-needed professional help. Also, many parents fear that they’ll be judged or blamed – labeled with the shame-inducing title “bad parents” – for their child’s behavioral issues.
Disorders that fit into the externalizing behavior category include attention deficit hyperactivity disorder (ADHD), which is one of the most common psychiatric disorders in children, as well as conduct disorder and oppositional defiant disorder (ODD). Children with ADHD can exhibit a wide range of behavioral problems, but the most prominent are hyperactivity (e.g. constantly being in motion, difficulty sitting still, incessant talking, fidgeting, and extreme restlessness), impulsive behavior, and difficulty paying attention. Children with conduct disorder and ODD frequently exhibit aggressive behavior, temper tantrums, irritability, and defiance (e.g. talking back to parents and other authority figures, and refusal to obey). Telling lies and being argumentative are also common traits of conduct disorder and ODD.
Children with behavioral disorders often struggle with or develop emotional issues and disorders as well, especially as they get older. They are particularly vulnerable to developing depression, low self-esteem, and various anxiety disorders. Their behavioral problems will inevitably have a serious negative impact on their social interactions and academic performance. Problems at school and in their social life can trigger and / or reinforce poor self-esteem and depressive symptoms. If these issues aren’t addressed by adolescence (or even worse, by adulthood), these individuals also become increasingly at risk for substance abuse and addiction – sometimes at a very young age. In today’s society, far too many kids are exposed to and start experimenting with substances before they reach middle school. Their acting out behavior can also lead to legal issues. Many children with conduct disorder, in particular, wind up in juvenile detention at some point during their adolescent years.
Needless to say, the sooner parents seek professional help for their child’s behavioral issues the better it will be – especially for the child. The consequences of delaying or, even worse, never getting treatment, can be very serious.
Basic Premise of PCIT
Parent-Child Interaction Therapy was developed to treat young children (between the ages of 2 and 7 years) with behavioral and emotional problems. As the name suggests, the focus of treatment is on the relationship between the parents (or parent) and the child. By improving the ways in which children and their parents interact, PCIT helps reduce dysfunctional patterns that cause and / or contribute to the child’s problems. Its primary goal is to foster healthy family interactions and improve family functioning overall.
Baumrind’s Parenting Styles
PCIT is strongly influenced by social learning theory and attachment theory. It is based largely on the work of American psychologist and researcher, Diana Baumrind. Baumrind has done extensive research on child development and the impact of parenting styles. She described four primary types of parenting styles – authoritative, authoritarian, permissive, and uninvolved.
Following is a brief look at these four very different styles:
Authoritative parenting – Parents who follow an authoritative parenting style believe in setting clear rules, boundaries, and guidelines for their children to follow. When children disobey, these parents focus more on understanding and forgiving the behavior than punishing it. This doesn’t mean they don’t discipline their children; they do, but with the goal of teaching and supporting their children (i.e. helping their children learn and grow from it) rather than breaking their will. Children aren’t discouraged from (or punished for) asking questions (e.g. about a rule or means of discipline) or expressing their feelings about something, and the parents are willing to hear what they have to say. Authoritative parents strive to be responsive to their children.
Children of authoritative parents are more likely to develop a healthy level of assertiveness, self-esteem, and social responsibility. They don’t rely solely on authority to guide them, and are more inclined to question authority when appropriate (e.g. when they know something is immoral, unacceptable, or unjust). These children also have the greatest chance of being successful in life.
Authoritarian parenting – Parents who adhere to this style of parenting understand that children are inherently self-indulgent and strong-willed. This viewpoint naturally impacts how the parents respond to their children. Authoritarian parents see their primary role as “making children learn to obey authority”, which is done by breaking their children’s strong will. Obedience and following the rules – without explanation – are top priorities to these parents, and punitive means are used to reinforce them. They tend to be controlling, demanding, and strict, and believe disobedience must be punished. Interactions with their children tend to be one-sided (e.g. “I speak, you listen”; “Because I said so”) rather than give and take. Their ability to be nurturing and responsive to the emotional needs of their children is generally lacking.
Children of authoritarian parents tend to have more self-esteem issues than other children. Being spontaneous can be a challenge for them. They also tend to be less socially competent than other children. They tend to be very compliant and proficient.
Permissive parenting – On the surface, having a permissive parent seems like every child’s dream. Also known as indulgent parents, these parents make few demands and have few rules. They are generally very lenient when it comes to reinforcing any rules they do have. They are often overly accommodating to their children’s wants. They frequently view their role as more of a friend than parent to their child, and as such, tend to be nurturing, responsive, and communicative. Some permissive parents have good intentions in that they want to ensure their child’s happiness and encourage their child’s creativity, spontaneity, and free spirit. Other permissive parents try to over-compensate for the strict parenting they were subjected to as children. Discipline is rare or non-existent, as these parents prefer to avoid confrontation.
The children of permissive parents, unfortunately, often don’t fare very well. They often have problems with authority, struggle with being mature and responsible, and tend to be less happy than their peers. Academic performance often suffers as well. Children do best with appropriate limits; permissive parents fail to set them.
Uninvolved parenting – Uninvolved parents, also sometimes referred to as neglectful parents, have little interest in taking on the demands and responsibility of being a parent. Although they provide for their children’s basic needs, these parents have little if any actual involvement in their children’s day-to-day lives. They are emotionally detached from their children, and, in some cases, may even go out of their way to avoid them. They provide little, if any, guidance, supervision, or discipline. They don’t make demands on their children, and any expectations they might have are very low. Children of uninvolved parents receive very little, if any, love, nurturing, warmth, or affection. Some uninvolved parents often never wanted to be parents in the first place, while many others are too overwhelmed with the challenges in their own lives to exert any energy towards parenting.
Of all the parenting styles, children of uninvolved parents generally fare the least well in life overall. They often struggle with anxiety, low self-esteem, poor self-control, and are at risk for substance abuse and addiction.
Baumrind’s research showed that that the best outcomes (in terms of child development) were with parents who used an authoritative approach to parenting. Part of the reason this particular parenting style is superior to the other three is because children are more likely to follow rules and comply with their parents’ requests when they make sense to them; when they seem reasonable and fair (which is reinforced by the give-and-take and ability to express feelings and ask questions of their parents in this parenting style). Also, when the rules and requests make sense and feel reasonable, children can adopt those reasons as their own. This helps them learn to appropriately regulate their emotions and control their behavior from within, which is healthy. Additionally, children respond more positively to parents who are sensitive and responsive to their needs, and thrive when appropriate limits are set within a nurturing environment.
PCIT is designed to 1) help children develop secure attachments to the parents and 2) help parents learn and establish an effective and healthy style of parenting.
Structure of PCIT
Parent-Child Interaction Therapy typically consists of an average of 15 weekly sessions that last for approximately one hour each. The therapy is geared towards young children, between the ages of 2 and 7 years, who have a behavioral disorder. Sessions are conducted by a licensed mental health professional. In most cases, the biological or adoptive parents are involved in the sessions. However, it can also be used with other primary caregivers, such as foster parents. Sessions follow the guidelines and structure outlined in the PCIT treatment manual.
PCIT has been used to help families and children from a variety of situations and backgrounds. These include:
- Children with developmental disorders
- Children who were exposed to substances in utero (i.e. during the mother’s pregnancy)
- Families with a history of physical abuse
Unlike some forms of child therapy, PCIT is dyadic in nature. This means that, rather than working with the parent or child individually throughout therapy, or focusing primarily on one or the other, PCIT involves both the child and parent(s) throughout the course of treatment. This is because the focus is specifically on improving the way they interact with each other.
How PCIT Works
PCIT is comprised of two treatment phases.
The first phase is the child-directed interaction (CDI) phase, which focuses on enhancing the parent-child relationship. During this phase of therapy, the therapist focuses on teaching the parents the necessary skills to establish or enhance a positive, secure, and nurturing relationship with the child. This phase helps parents:
- Be more supportive, consistent, and predictable in their interactions with the child
- Promote the child’s positive social behavior
- Discourage the child’s negative behaviors
The therapist teaches parents to play with their child in a nondirective way. This type of play helps parents and children develop a stronger, more positive relationship. The skills taught during this phase stem from traditional play therapy. Parents can use them to reinforce positive behavior on the part of the child.
The second phase of PCIT is the parent-directed interaction (PDI) phase. The focus of this phase is to help parents improve their child’s compliance. The therapist teaches them how to establish rules and boundaries that are age-appropriate and clear. They are taught appropriate and effective discipline, traditional skills for managing behavior, and the importance of providing consistent consequences for the child.
For both phases, the parents meet with the therapist for an instructional session in order to learn the skills for that specific phase. The parents use the following sessions in each phase to practice the new skills in a playroom with the child. The therapist assumes a coaching role, helping the parents apply what they’ve learned in an effective and appropriate manner. The practice sessions are preferably done with the therapist observing the interactions through a one-way mirror. The parents use an in-ear listening device which enables the therapist to give them immediate feedback as they interact with the child during these sessions. The immediate feedback from the therapist helps expedite the learning and mastery process.
Although PCIT typically lasts around 15 sessions, this timeframe isn’t set in stone. The goal is for parents to continue in therapy with their child until two things are accomplished. First, the parents need to show that they have truly mastered the skills they’ve been learning. Second, the parents must indicate, by way of a standardized measure of child behavior, that their child’s behavior at the end of treatment now falls within the normal range (per the rating scale). Once these two goals have been satisfied, treatment is ended.
The goals of Parent-Child Interaction Therapy include the following:
Phase I goals for parents:
- Learn how to communicate effectively with a child who has a short attention span
- Learn how to teach the child in a way that doesn’t cause frustration (for them or the child)
- Learn how to give the child positive attention in order to strengthen the parent-child relationship
- Interact in a warm, nurturing way so the child feels safe and calm
Phase I goals for children:
- Improved play skills
- Enhanced organizational skills
- Reduction in temper tantrums, anger outbursts, and frustration
- Improved social skills (e.g. being more cooperative, sharing with others)
- Increase in self-esteem
- More positive relationship with / stronger attachment to the parent(s)
Phase II goals for parents:
- Learn effective and appropriate ways to discipline the child
- Learn how to be consistent and predictable in their interactions with the child
- Increased confidence in their ability to manage the child’s behavior at home as well as in public
Phase II goals for children:
- Increased cooperation and compliance with the parents’ requests
- Improved ability to follow directions
- Improved listening skills
- Significant decrease in negative behaviors
Presenting problems that can benefit from PCIT
PCIT is particularly effective for children who frequently and chronically display any of the following problematic behaviors in any setting (i.e. home, preschool or kindergarten, school, daycare, or any other public place)
- Aggressive behavior towards peers, siblings, pets, and / or parents
- Defiant behavior
- Disruptive behavior at school
- Acting out behavior
- Oppositional behavior
- Frequent anger outbursts or temper tantrums
- Refusal to cooperate with established rules and / or parent’s requests
- Argumentative behavior, especially towards parents and others in authority
PCIT can be used with children who are currently living in foster care. Children who are on medication intended to help manage their behavior (e.g. methylphenidate for ADHD) are also appropriate for PCIT, as proper therapy can help enhance the medication’s effectiveness. It may also reduce the need for medication.
Benefits of PCIT
In addition to the obvious benefits of PCIT (e.g. decrease in acting out, defiance, and other negative child behaviors, and improvement in the parent-child relationship), children and parents who participate in PCIT often reap many other benefits as well. These may include:
- Happier family atmosphere
- Less stress for both children and parents
- Less conflict in the home
Parental benefits may include:
- Increased confidence in parenting skills
- Greater satisfaction from parenting
- Less personal distress
- Stronger internal locus of control (i.e. feeling they can have a positive impact on situations in their life, rather than feeling powerless, as if they have no ability to steer situations toward a positive outcome)
- Improved communication skills (e.g. reflective listening, less use of sarcasm)
- Improved self-esteem stemming from being a better, more effective parent
Child benefits may include:
- Improved performance at school
- Improved social skills
- Increase in overall happiness
- Decrease in frustration
- A stronger sense of security
- Improved self-esteem
- Reduced risk for depression, anxiety, substance use disorders, and many other mental health conditions and emotional problems down the road
- More positive interactions with others
Finding a Qualified PCIT Therapist
One of the best ways to find a therapist in your area who has been trained in PCIT is to use the PCIT International website. They have a directory of certified therapists (and trainers), listed according to their state (if in the U.S.) or country (for international therapists).
If your young child has a history of frequent and chronic acting out, or has been diagnosed with a behavioral disorder such as oppositional defiant disorder, ADHD, or conduct disorder, PCIT is definitely looking into. Behavioral problems don’t mean you’re a bad parent. They don’t automatically suggest that you’ve somehow failed your child. Parenting is hands down the toughest job in the world, and it’s not as if your child was born with his or her own tailor-made instruction manual. However, it may be that your parenting style and interactions with your child could use some improvement (just about every parent has room for improvement, so you’re not alone). Children act out for a variety of reasons, and the more it occurs, the more vulnerable you – the parent – are to respond with frustration and exasperation. It can quickly become a vicious cycle in which negative behavior is reinforced on both sides.
Parent-Child Interaction Therapy will give you the opportunity to work with a very experienced therapist – someone who knows how to help you improve the way you interact and communicate with your child, use play time and skills to enhance your relationship, and manage your child’s behavior effectively. There’s no better time than the present to address your young child’s behavioral issues. Not only will you save yourself a lot of headaches and heartache now and down the road, helping your child today will have a significant positive impact by giving him or her the best chance for a bright future.