Recent estimates of externalizing disorders among kindergarten and first-grade children is 13.8%, with estimates for oppositional defiant disorder and conduct disorder at 8.4% and 1.2%, respectively (1), indicating the need for treatment interventions in younger age-groups. Importantly, this need must be considered in the face of rising concerns regarding the possible overuse of medications in the same age-group; these include the increasing utilization of atypical antipsychotics, which have potentially significant long-term sequelae (2). The benefits of behavioral intervention lessen the risk of psychiatric drug prescription, with the potential for providing long-term improvement in social learning. Also, despite the efficacy of stimulant medication for attention-deficit hyperactivity disorder (ADHD), the need for psychosocial treatment (including parent training) is very clear (3), especially in preschool-age children (4). For this reason, early-childhood behavioral interventions are increasingly relevant in preparing child psychiatry residents to utilize and supervise appropriate, evidence-based care for children with disruptive behavior disorders.
At our clinic, the need for a nonpharmacologic treatment for behavioral problems in young children was made evident by the increasing number of referrals for such problems made by local practitioners. There was no coherent training in place to address behavioral treatment modalities in younger children, yet our residency program director felt that this area was an identified area of concern for child and adolescent psychiatry (5).
Parent–Child Interaction Therapy (PCIT) is an evidence-based treatment model, developed by Sheila Eyberg, that combines aspects of play therapy and behavior therapy, as well as social learning and family-system theories (6). This behavioral family intervention involves highly specific, step-by-step, live coached sessions with parent/caregiver and child. PCIT has an evidence-base supporting its efficacy (7, 8) and is a recognized treatment for oppositional defiant disorder (9). Self-report studies, parent satisfaction surveys, and interactional studies also report positive outcomes (10). Its use in other populations has been described, for example, in developmental disorders (11), anxiety disorders (12), and child maltreatment (13), and in ethnic minority groups (14).
PCIT was originally developed for 2- to 7-year-old children with oppositional, defiant, and other externalizing behavior disorders. This two-phase intervention includes a child-directed interaction (CDI) component, focusing on relationship enhancement, and a parent-directed interaction (PDI) component, focusing on child-management strategies. All sessions other than introductory ones are live-coached by the therapist, ideally using an observational one-way mirror, as well as a transmitter and receiver system. Although the progress is based on skill mastery, rather than time, using observation and data collection to guide parent–child progression through the program’s components, the program typically has an anticipated time length of 12 to 20 weeks. This includes ending-sessions to consolidate and generalize what has been learned in the CDI and PDI components.
The initial hurdle in providing PCIT training within our residency program was funding a faculty therapist to provide training and supervision of the residents. Although previous attempts for teaching PCIT had included nine 1-hour didactic lectures from a local PCIT therapist, it quickly became clear that residents also needed on-site direct supervision. Funding for a part-time mental health professional was obtained through our hospital affiliate. A licensed psychologist with early-childhood experience and expertise in parenting interventions was recruited and hired with arrangements for her to receive the 40-hour PCIT training. All material used for training in PCIT is screened by her or is provided through her training sources in order to preserve treatment integrity and to ensure that treatment guidelines are followed.
Before implementing PCIT training in our program, the room and equipment needs were addressed. Although two playrooms were available, a small conference/family intake room was chosen in order to avoid the distraction of extraneous toys and play furniture. This room was already equipped with a one-way observational mirror, as well as video and audio equipment (i.e., high-digital camera, camera power supply, and high-resolution color monitor with audio reception) for observation. In order to provide PCIT, a wireless microphone/radio system was added to allow the therapist to speak to the parent through a BTE (behind-the-ear) receiver. A dedicated set of toys that are developmentally appropriate for creative, noncompetitive parent–child interaction was purchased and specified for PCIT (e.g., tinker toys, crayons and paper, “Mr. Potato Head”).
PCIT training in our program had to be coordinated with other resident-training activities. Coordinating parent, resident, and supervisor schedules constituted major planning decisions, including where to place the didactic and supervisory portion in relation to the actual parent–child therapy sessions. In the first year of implementation, nine 1-hour PCIT didactic lectures continued while PCIT therapy sessions were incorporated into each resident’s regular outpatient clinic schedule. Sessions were either observed and supervised by the psychologist or recorded for later review and supervision. In subsequent years, PCIT didactics and therapy sessions were combined into a half-day outpatient clinic. Currently, two first-year residents spend one-half day of their 6-month outpatient experience together at the PCIT clinic. This allows each resident to manage one case and observe another case during the half-day time-slot. Utilizing a defined half-day time slot once a week for the PCIT clinic has made the training process more efficient, bringing parent, child, resident, and supervisor together for instruction, service delivery, and supervision. One disadvantage to this format is that it limits the scheduling flexibility for parents and children, but we have found that motivated parents will work with this arrangement.
The supervising psychologist in our residency program screens all referrals for PCIT, which are typically made by outside providers or by residents already seeing a parent or child in our outpatient clinic. Initial screening includes reviewing the case for comorbid diagnoses (e.g., developmental disorder), which could affect the quality of the resident’s “first-case” learning experience. The parent’s commitment to weekly sessions over a 3- to 4-month period is also assessed.
Sixteen residents have completed PCIT training in the 4 years since the training began. Thirteen of those residents responded to an informal, four-question e-mail survey assessing the training. The research was reviewed by the University of South Carolina IRB and deemed to be exempt from the requirements of 45 CFR 46 Protection of Human Subjects. Eight of the responding residents had completed their training and were working or interviewing in the field of child and adolescent psychiatry; one had entered a forensic psychiatry fellowship. Four residents were still involved in completing their child and adolescent psychiatry training.
When asked “Was PCIT training worthwhile for you? Rate on a scale of 1 to 5, 1 being Not At All, 5 being Really Worthwhile,” nine residents assigned a rating of 5, and four residents assigned a rating of 4. In response to “Please state why it was worthwhile or not worthwhile to you,” residents indicated that PCIT training gave them a set of specific skills, with appropriate language, to use in parent training for behavioral modification. There was agreement that the experience of implementing a PCIT intervention produced more in-depth learning and knowledge of the techniques than just didactics alone. One resident felt that she had acquired a better platform from which to learn about attachment, specifically, parent–child attachment problems.
In their responses to the question “How have you utilized the training since you completed it?” all reported teaching of parenting skills in office sessions as a specific utilization of PCIT training. Four residents referenced their referral of parents and patients into PCIT. They felt comfortable referring parents for these services because of their knowledge of what to expect, which enabled them to give detailed information to parents about the program. Two residents appreciated having familiarity with a nonpharmacologic treatment approach for young children.
In response to the final question “How would you change the training?” residents had few recommendations for changes in the current training process. The most frequent response was a desire to observe more cases (i.e., to observe the faculty supervisor or view videos of other resident cases). Three residents commented on the importance of choosing appropriate cases for training purposes. Two residents noted that incorporation of the didactic and supervisory components into an identified clinic program was a needed improvement. It was noted that an afternoon (rather than morning) time for the clinic could increase parent participation. One resident thought there should be more time spent on advanced PCIT techniques, and one wanted to learn more about other evidenced-based parenting programs.
Implementation of an evidenced-based parent training program in child and adolescent psychiatry training appears to be a beneficial experience for residents, especially in terms of gaining specific skills and language for parent training. Certainly, the results of this brief, IRB-exempt, self-report feedback survey are limited by small sample size as well as lack of experimental design and statistical analysis. Further investigation into the long-term benefits of this type of training is warranted.
When considering the addition of PCIT to a residency training program, the overarching planning challenge is funding. In particular, programs need to balance the cost of implementing the program against training benefits and potential reimbursement by third-party payers. Equipment start-up costs must be considered as well as PCIT training for faculty and salary if new faculty is needed. Training in evidence-based interventions for young children should be considered as a way to improve parent–child relationships, reduce externalizing behaviors, and possibly prevent more significant long-term emotional/behavioral disorders. Also, this is a feasible step that is in line with practice guidelines and responsible treatment for young children.