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    Topic review

    Home-Based Parent–Child Interaction Therapy

    Submitted by: Mariëlle Abrahamse

    Definition

    The current study evaluates the effectiveness of an adapted version of Parent–Child Interaction Therapy (PCIT). Based on theoretical foundations and increasing empirical evidence, PCIT is regarded as one of the most effective treatments in preventing child maltreatment. PCIT is a well-established parent training program originally developed for children aged between two and seven years with disruptive behavior problems, that is widely available across countries and cultures. Since child disruptive behavior problems play an important role in negative parent–child interactions, parenting stress, and parental harsh discipline, this behavior is not only a consequence of maltreatment, but also a strong factor in the risk for child maltreatment. Therefore, PCIT has been used at an increasing level in other populations including different ethnic populations and child welfare populations that are related to child maltreatment.

    1. Overview

    High treatment attrition and limited reach of mental health services for at-risk families remains an important problem in order to effectively address the global concern of child maltreatment and child disruptive behavior problems. This study evaluated the effectiveness of a home-based and time-limited adaptation of Parent–Child Interaction Therapy (PCIT). Twenty families with children (70% boys) aged between three and seven years were randomly assigned to an immediate treatment group (IT, n = 10) or a waitlist control group (WL, n = 10). After receiving treatment and compared to mothers in the WL group, mothers in the IT group reported fewer child behavior problems and more improved parenting skills. Although initial analyses revealed no significant differences, additional analyses showed a significant decrease in the primary outcome of the study, namely child abuse potential, between the baseline and follow-up assessment for the total treated sample. A low treatment attrition rate (15%) was found, indicating higher accessibility of treatment for families. Findings suggest that the brief home-based PCIT is a potentially effective intervention to prevent child maltreatment and disruptive behavior problems in at-risk families. Results also reinforce the importance of addressing the specific needs of these families to increase treatment effectiveness.

    2. Parent–Child Interaction Therapy

    Globally, over half of all children—that is one billion children, between two and 17 years of age—have been exposed to some type of physical, sexual, or emotional violence [1]. It is not a surprise that child maltreatment can lead to a range of consequences such as an increased risk for negative development including physical and mental health problems [2]. In the Netherlands, a national prevalence study showed that the rates of child maltreatment for children aged 0 to 17 years were estimated to be 3.4% [3]. Given the prevalence and high impact on child development, early prevention of child maltreatment is therefore of outmost importance. In the past decade, the best efforts of child protection services and increased government attention as well as expenditures in many countries have led to more knowledge about the signs, prevention, and interventions focusing on child maltreatment [4]. Nevertheless, there are some factors impeding the effective prevention and intervention of child maltreatment. First, recognition and help seeking seem to be more difficult for at-risk families [5][6], especially when parents experience a high level of parenting stress [6]. Second, premature treatment attrition remains a significant problem in prevention and intervention such as parent training programs [7][8].
    This entry evaluates the effectiveness of an adapted version of Parent–Child Interaction Therapy (PCIT) [9]. Based on theoretical foundations and increasing empirical evidence, PCIT is regarded as one of the most effective treatments in preventing child maltreatment [4][10][11][12]. PCIT is a well-established parent training program originally developed for children aged between two and seven years with disruptive behavior problems, that is widely available across countries and cultures. Since child disruptive behavior problems play an important role in negative parent–child interactions, parenting stress, and parental harsh discipline [13], this behavior is not only a consequence of maltreatment, but also a strong factor in the risk for child maltreatment [4]. Therefore, PCIT has been used at an increasing level in other populations including different ethnic populations [14][15][16] and child welfare populations that are related to child maltreatment. In previous research, PCIT has been found to be effective in reducing further physical abuse in families where physical abuse was present [10][17]. So far, PCIT is not tailored for the specific needs of maltreating parents, and the current discussion in the literature is what this heterogeneous group actually needs to prevent, reduce, or eliminate child maltreatment [18][19]. Therefore, the question is to which degree the improvement of positive parenting skills and the reduction in child disruptive behavior problems is enough to prevent maltreatment in the future. However, the body of empirical evidence is still growing and PCIT has even been found to be an effective treatment to prevent child maltreatment by decreasing child disruptive behavior problems, parenting stress, and by improving parenting skills [4][11][20].
    As in many parent training programs, the prevention of attrition remains a big challenge in PCIT and impacts the public health of the families involved. Families who completed PCIT showed significant improvements in the behavior of the child, parenting stress, and parental functioning, while families who dropped out did not achieve the same positive outcomes [21]. Therefore, premature drop-out is considered a serious problem in PCIT, which also affects the effectiveness of the treatment. In previous research, dropout rates ranged from 27 percent to 69 percent [21][22][23][24].
    Based on the original treatment protocol [25], PCIT is typically delivered in a playroom at the clinic, with therapists coaching the parents in vivo through a one-way mirror and with a wireless headset. PCIT is performance-based and continues until the treatment goals are met including parents reaching established criteria for both observed skills and their ratings of the child’s behavior within normal limits. Therefore, treatment completion is theoretically equal to treatment success. Delivering treatment in a clinical setting has many benefits such as high environmental control and appropriate equipment. However, it also means that families have to travel to the outpatient clinic. Thereby, in most families referred to community services, other problems are present such as financial and mental health problems, limited motivation, and having too many worries to be able to acquire new skills [26][27][28]. Additionally, simple practical problems such as not having someone to watch the other children during their visit to the clinic, could be a barrier to treatment. Particularly for these families with low resources, it is a challenge to finish a treatment successfully. The literature emphasizes the importance of meeting the needs of families with low resources [29] and a home-based treatment may be most suitable and could be a solution to increase the accessibility of treatments as well as their effectiveness. Treatment delivery in the family’s home comes with several benefits; it eliminates logistic barriers, has a stronger ecological validity since the therapist is observing the parent and child in their natural environment, and also has a faster generalization of the learned skills to other situations [28][29]. In addition, the Centers for Disease Control and Prevention identified home-based programs as the preferred treatment for families at risk for child maltreatment [30].
    Several studies have supported the utility of PCIT in the home situation. Home-based PCIT only needs some adjustments to implement and provide the treatment outside a clinical setting, but the core components of PCIT remain intact. Findings of previous studies have shown similar outcomes for home-based and clinic-based groups, suggesting that the added value for home-based PCIT is found in serving a wide range of families who may not have access otherwise. However, the results have been inconclusive about lower rates of treatment attrition [20][21][29][31][32][33][34].
    Adapting PCIT for delivery in the home situation is not the only mechanism that can be adjusted to reduce attrition. Previous research has shown positive results from a brief version of PCIT with 12 sessions conducted in families with multiple problems who were at risk for child maltreatment [12]. This protocol was based on the less-is-more principle stating that brief interventions with a moderate number of sessions and a clear end-point are more effective than interventions with a large number of sessions [35]. The clearly defined end-point will encourage families to complete the intervention. In line with the before mentioned research study, a recent meta-analysis has shown that PCIT is effective with and without a specified number of sessions [36].

    3. Conclusions

    Despite the limitations, there are promising findings in the field of the prevention of child maltreatment by creating higher accessibility of treatment through providing a brief and home-based version of PCIT for at-risk families who may not have access otherwise. The study does show some encouraging evidence that PCIT can be implemented effectively in a real-world community setting, with apparently low attrition. However, additional evaluation research is recommended to support the findings that reduced child disruptive behavior problems and improved parenting skills also effectively reduce the risk for child maltreatment. Although our study did only find indirect evidence for the prevention of child maltreatment, our findings did contribute to the knowledge on evidence-based practice in the prevention of child maltreatment.

    The entry is from 10.3390/ijerph18168244

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