Parent-Child Interaction Therapy
A therapeutic intervention that encourages positive interactions between parents and children to reduce the risk of abuse
- Positive effect on reducing re-referrals for child physical abuse
- Positive effect on reducing the risk of child abuse
- Evidence was of a moderate strength
Overall effectiveness: 1 (maximum 2)
Strength of evidence: 2 (maximum 3)
Overall effectiveness: 1 (maximum 2)
Strength of evidence: 2 (maximum 3)
What is this?
Parent-Child Interaction Therapy was originally developed in the 1970s in the USA. It aims to help parents to respond to severe disruptive behaviours by children aged 2-7 years old, and improve the parenting relationship. More recently, Parent-Child Interaction Therapy has been adapted to meet the needs of children experiencing abuse or neglect. The information included here addresses the effectiveness of Parent-Child Interaction Therapy for preventing the recurrence of child abuse.
In 2017, NICE guidance on Child abuse and neglect recommended that Parent-Child Interaction Therapy should be used with families with children under 12 who have experienced physical abuse or neglect. A report published in 2017 by the Early Intervention Foundation and the Local Government Association noted that Parent-Child Interaction Therapy has the most consistent evidence base for improving children’s outcomes where there are concerns about physical abuse.
How is it meant to work?
Parent-Child Interaction Therapy combines play therapy and behavioural therapy to encourage positive interactions between the parent and child that promote good behaviours in children and reduce negative behaviours. Parents are directly coached by a therapist while they interact with their child. When adapted for families affected by abuse and neglect, the therapeutic focus is on addressing parenting behaviours that might contribute to abuse.
What are the evaluated outcomes?
- Re-referral for child abuse
- Risk of child abuse
How effective is it?
Re-referral for child abuse
Overall, Parent-Child Interaction Therapy tended to show a positive effect on the recurrence of child abuse, leading to reduced re-referrals. It is effective for reducing re-referrals in cases involving physical abuse but not those involving neglect.
This is based on moderate strength evidence from four research studies that collectively included 572 parent-child pairs.
Risk of child abuse
Overall, Parent-Child Interaction Therapy tended to show a positive effect on the risk of child abuse in families.
This is based on moderate strength evidence from nine studies. Six of these studies, which included 604 parent-child pairs, found that risk of child abuse was reduced in relation to parenting beliefs, expectations and external stressors.
Where has it been studied?
Eleven studies were analysed in this review. Of these, nine were carried out in the USA and two were in Australia. Therefore, the review does not provide evidence on whether these research findings are applicable to the UK.
Who does it work for?
Parent-Child Interaction Therapy was originally designed to address behavioural problems of young children aged between two and seven years. In all six studies included in the review that reported the gender of the children, the majority of child participants were male. The majority of parent participants were mothers.
The review found that this intervention was most effective for parents who felt motivated to take part. Parents who did not attend voluntarily (e.g. because they were court-mandated) may have had low motivation, which may explain the high drop-out rate across the reviewed studies. There was some evidence that coupling Parent-Child Interaction Therapy with motivational interviewing techniques improved the engagement of less motivated parents.
When, where and how does it work?
The review found that Parent-Child Interaction Therapy was effective in reducing re-referrals for cases involving physical abuse but not those involving neglect or violence between parents. The reviewers suggest that Parent-Child Interaction Therapy may be well suited to addressing avoidant attachment styles displayed by children who have experienced physical abuse, by helping to improve parents’ skills in interacting with their children. However, this intervention may be less well suited to addressing anxious attachment styles of children affected by neglect or parental violence.
When the child is in care and lives apart from their birth family, the intervention is less effective as parents will not have the opportunity to practice their skills through homework. This may lead to parents reverting to previous, negative behaviours.
What are the costs and benefits?
No economic analysis is included in the review. The reviewers note that Parent-Child Interaction Therapy is a relatively expensive method of treatment as it requires trained therapists and modified treatment rooms.
How is it implemented?
Parent-Child Interaction Therapy has been implemented and delivered in a wide variety of locations including the USA, Australia, Canada, Cyprus, Denmark, Germany, Hong Kong, Indonesia, Japan, Lebanon, the Netherlands, New Zealand, Norway, Singapore, South Korea, Switzerland and Taiwan. It is not currently delivered in the UK.
How is it delivered?
Parent-Child Interaction Therapy is delivered in two stages. Stage one is called the ‘child-directed interaction’. During this stage, the parent plays with their child in a non-directive way. The goal of this stage is to strengthen the relationship between the parent and child, increase positive interactions between the parent and child and increase the skills and confidence of the parent.
Stage two is called the ‘parent-directed interaction’. This stage supports the parent to set appropriate boundaries for their child’s behaviour, so that any negative behaviours are successfully managed. This might involve helping parents to manage their own emotional reactions and avoid harsh punishment.
During both stages, the parent receives coaching from a therapist via an ear piece. Parents are set daily homework assignments to help them practice what they have learned. This intervention has been studied in a variety of settings, including clinic-based settings and the family home.
The average length of intervention is between 12 and 14 sessions. One study with families considered at risk of abuse found that when parents were required to master stage one before initiating stage two, this extended the average number of sessions to 53. Another study indicated that prolonged delivery may impact negatively on drop-out rates. Where Parent-Child Interaction Therapy has been combined with motivational interviewing, parents’ engagement has been more successful.
Who can deliver it?
It is delivered by therapists with a range of professional backgrounds (e.g. psychologists, psychiatrists, family therapists and clinical social workers), who have been trained in the model.
In the 11 studies included in the review, therapists included psychology graduate students, master’s level and doctoral level psychologists, clinic-based therapists with a full-time clinical caseload and experienced psychologists working in a children’s hospital. Some therapists were new to delivering Parent-Child Interaction Therapy and others had a number of years of previous experience.
What are the training and supervision requirements?
PCIT International sets out training requirements on its website for becoming a certified Parent-Child Interaction therapist.
Training and supervision arrangements were not specified in 6 of the studies included in the review. Where training arrangements were described, the therapists were either trained by the staff undertaking the study or other certified trainers. Supervision arrangements were only specified in four of the studies. In three studies, therapists received weekly clinical supervision by a member of the research team. In the fourth study a co-therapy model was also employed with supervisors joining therapists (behind a one-way mirror) to observe sessions.
What supports good implementation?
Six of the 11 studies included in the review described their methods for establishing and monitoring fidelity. A range of measures were taken across these studies, including:
- Following session-by-session protocols to ensure consistency in the content delivered
- Trainer observation of the first 10 sessions delivered by a newly trained therapist
- Periodic observation of therapy sessions to monitor adherence to the session protocol
- Videotaping sessions and checking a sample against a protocol checklist
- Ongoing training to maintain therapists’ skills.
In most of the reviewed studies, modifications were made to the standard Parent-Child Interaction Therapy protocols to adapt content and delivery methods for the needs of specific client groups. Some of the studies adapted the intervention so that it could be used to support foster carers rather than birth parents.
- Parent-Child Interaction Therapy has a positive effect in reducing re-referrals for cases involving child physical abuse. However, no effects were found for child neglect
- It draws on attachment theory and social learning theory to improve relationships between parents and their children, re-shape parents’ expectations of their child and reduce parental distress
- The effectiveness of Parent-Child Interaction Therapy to reduce child abuse depends on parents being motivated to engage and complete both stages of the intervention. However, prolonged delivery over a large number of sessions may lead to high drop-out rates
- The qualifications and training requirements for therapists and set-up costs may make Parent-Child Interaction Therapy a relatively costly intervention.
This summary comes from an original systematic review called: Efficacy or Chaos? Parent-child interaction therapy in maltreating populations: A review of research. (Batzer, S., Berg,T., Godinet, M.T. & Stotzer, R.L.) Published 2018.