Parent-Child Interaction Therapy (PCIT)

Parent-child interaction therapy , PCIT

Parent-Child Interaction Therapy is an evidence-based therapy program that focuses on improving the family dynamic by creating more positive interactions and parenting strategies. PCIT is behavior focused and has shown effectiveness with children who have been abused or neglected as well as with at-risk families. 

Background and development of PCIT

PCIT has been developed over the past 50 years by Dr. Sheila Eyberg, who began researching the topic and developing the program during her postdoctoral residency. Dr. Eyberg utilized aspects of social learning, attachment theory, and eventually, work done by Diana Baumrind on authoritative parenting in order to form a unified theory and approach to working with at-risk children and families.  

Eyberg presented her method, identified as Parent-Child Interaction Therapy in 1974, and it has been validated in many empirical studies as a highly effective therapy since then. 

Parent-Child Interaction Therapy setting

Due to the nature of this style of therapy, there are some specialized setting recommendations while providing treatment. The best method of observing and interacting with the family during the initial phase of therapy is through a one-way glass with an earbud to allow for communication from the therapist to the parents or through real-time video monitoring and communication. This requires the room to be set up for proper monitoring and communication without too much interference from the therapist’s presence. 

Additionally, a barrier or time-out room is preferred. This room should be approximately 4x6 feet or so - no smaller than 4X4 and no larger than a small office with good lighting. The best practice is to have a "dutch door" cut off approximately 5 feet high or a safety glass window into the timeout room. The purpose is to monitor the child with visual contact and minimize interactions. If a time-out room can not be incorporated, then you need to have a “swoop and go” ability where the caregiver leaves the treatment room with the toys, and the child remains. Again, in this instance, it is recommended that a 5-foot dutch door is incorporated to allow visual contact with the child. 

PCIT also recommends an omnidirectional microphone and video recording device to record sessions as needed. However, ensure recordings are HIPPA compliant, and permission is secured from clients. 

The PCIT organization has a page of information with suggestions and diagrams like the one below to help anyone trying to set up a therapy room for PCIT. 



Techniques and stages of PCIT therapy

There are two distinct stages of PCIT. The first stage is known as the relationship enhancement phase, which centers around the child and allows them to direct play. The child would choose which toys and games to play with and how to play while the parents would join in and play using skills taught to them by the therapist.

These skills are easy to remember as they form the acronym PRIDE. 
  • Praise: Reinforcing positive behavior with words of encouragement.

  • Reflection: Repeating back what the child says and expanding on it in some instances.

  • Imitation: Parents mimic what their child is doing. This shows approval and support for behavior.

  • Description: Parents talk about what the child is doing to show they are paying attention to the child and help improve vocabulary. 

  • Enjoyment: Parents show enthusiasm for what the child is doing, which also indicates support.

Parents are trained to ignore any negative behavior that is minor or unsafe, limit negative comments like don’t or no, and reframe and focus on the positive. Once the parents master these skills, they move forward to the next phase of treatment. 

The second phase is the discipline and compliance phase. In this phase, parents learn to take control of the situation and make direct requests of children. When children comply, parents give immediate praise, and if the child doesn’t comply, then warnings for timeout are appropriate. This is continued with follow-through, placing in time out if compliance doesn’t occur. 



Parent-Child Interaction Therapy effectiveness

Does parent/child interaction therapy work?

There is a significant amount of research on the effectiveness of PCIT, and the results have shown it is effective on various symptoms and disorders. 

Research has demonstrated significant improvements in the following symptoms:

  • Frequent temper tantrums
  • Defiance 
  • Attachment struggles
  • Aggression
  • Destruction of property
  • Hyperactivity and attention difficulties
  • Authority problems, including talking back or interrupting

Additionally, research focused on disorder-based treatment has been conducted and found PCIT to be effective in treating several common mental health disorders.

These include: 
  • Oppositional Defiant Disorder
  • Attention Disorders
  • Conduct Disorder
  • Bipolar Disorder (Childhood onset)
  • Disruptive Mood Dysregulation Disorder
  • Trauma
  • Anxiety Disorders 
  • Caregiver concerns about attachment related to a child with an Autism Spectrum Disorder

Potential downsides of PCIT

Parent-Child Interaction Therapy is a highly effective therapy, however, it is primarily geared toward young children, so parents of older children are not served well with this therapy. This can create difficulties if parents manage problems with children of multiple ages. 

Additionally, PCIT is quite time-consuming. The parent and therapist need to meet weekly for up to two hours per session, and homework is required between sessions to solidify skills. This can create a barrier to care for some families as time is quite limited in many homes, and this can cause stressors when trying to work together. 

PCIT can also be costly. Some insurance companies will cover this therapy, but not all do. Therapists can bill individually or for family sessions, but they may only be compensated for some of the services that PCIT provides. This may leave the family with extra fees. 

Who is PCIT for? 

Parent-Child Interaction Therapy is designed for families of young children, typically ages 2-7, with externalizing behavior problems. These may be children who act out aggressively, which is why the emphasis on creating a safe and controlled space for therapy is emphasized so strongly in this therapy program.  In instances where the goal is to improve the parent’s skills strictly, the upper age range of the child's age can be adjusted to 12 instead of 7, but that is when the child’s behavior isn’t the primary focus. 

Modifications and limitations

PCIT may require modifications in certain circumstances. For example, parents with limited or no ongoing contact with their child will not be able to complete homework assignments and the necessary interactions with their child at home to solidify their skills, so modifications or a different treatment may be required. 

Parents with significant mental health problems, such as auditory or visual hallucinations or delusions or active substance use disorders, would need treatment focused on these conditions prior to undertaking any therapy for the parent-child relationship.

Parents who are hearing impaired and have trouble using the earpiece would need some form of modification to make this therapy effective, specialized equipment, and additional time in sessions to work through potential communication issues. Additionally, parents with other receptive or expressive language disorders may not be good candidates for PCIT because of the language aspect required in treatment. 

Sexually abusive parents or parents engaging in intentionally harmful physical abuse are not good candidates for PCIT. These parents need to focus on other concerns before working on potential parenting issues, including PCIT. Involving children with these parents the way PCIT requires would be traumatizing for the children. 


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Training for therapists

To practice PCIT, therapists must go through a specific training protocol and be certified as a PCIT therapist.

There are five steps in Parent-Child Interaction Therapy (PCIT) Certification. 

1. The first step is the completion of an initial 40-hour PCIT training. There are options for live training, videoconferencing training, and home training at your own pace. 

2. The second step is participation in PCIT consultation calls. Individuals will discuss and practice coding and protocol questions, client challenges, and case-specific consultation during these calls. 

3. The third step is the PCIT case video review. Therapists submit sessions to a Certified PCIT global trainer, and the sessions are reviewed and discussed to ensure that sessions are being completed to fidelity.

4. The fourth step requires the completion of 2 PCIT cases and going through all of the steps and sessions required for successful completion.

5. Then in step five, submit your PCIT certification application and practice as a certified therapist. 

Therapists can choose to further their training by becoming trainers themselves, either for their agency or a specific site, or choose to pursue training all the way up to global trainer status. 

Billing for Parent-Child Interaction therapy

Billing for PCIT can be complex. Some insurance companies cover the costs, and some do not. As a therapist, you must always ensure you know the rules from the insurance companies you are paneled with

Additionally, while the sessions are done with the family much of the time, the focus is more individualized. Much of the time, the therapist is working specifically with the parent, including during times that the children are in the room. The therapist is in communication with the parent through an earbud during these times and primarily focuses on the parent’s actions. Due to this, many therapists feel that billing for PCIT as an Individual therapy session and using coding 90837/34/32 is the best practice. This also allows for add-on complexity codes as needed in the case of much longer sessions or other additions. 

Of course, the therapist should always thoroughly document the use of PCIT, which phase, and which techniques are being used in order to maintain proper documentation and to keep track of progress. PCIT offers many resources for documenting and coding sessions to help therapists monitor clients’ behaviors and progress. 

Resources 

PCIT.com is the primary source of information about Parent-Child Interaction Therapy.

For information about training and how to sign up for training sessions and the certification process, click here. There are several upcoming trainings available.

To find a PCIT therapist in the United States or Internationally, check the links here.

If you would like to dive deeper into the research behind PCIT, the organization offers a wealth of information on completed evidence-based research

Therapists of any kind should try Theraplatform. This Web-based EMR portal offers documentation, practice management, and billing in a user-friendly and straightforward interface. TheraPlatform also offers a 30-day trial with no credit card required and you can cancel at any time.

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