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Cognitive and Behavioral Practice 18 (2011) 502–514

Delivering Parent-Child Interaction Therapy in an Urban Community Clinic

Karen S. Budd, DePaul UniversityBryce Hella and Hyo Bae, Illinois Institute of Technology

David A. Meyerson and Sarah C. Watkin, DePaul University

1077© 2Publ

Keywmen

Extensive evidence supports the efficacy of Parent-Child Interaction Therapy (PCIT) for reducing behavior problems in young children;however, little is known about the use of PCIT in a community mental health center (CMHC). This paper provides four clinical caseexamples of families who were referred to and successfully completed PCIT in an urban CMHC. The families were ethnically andsocioeconomically diverse and presented with a wide range of treatment concerns and needs (e.g., autism, severe maternalpsychopathology, involvement in child protective services, and complex family configurations) in addition to disruptive behavior. Ourdata and clinical observations suggest that PCIT decreased behavior problems, improved parent-child interactions, and, in some cases,reduced parental stress, with differing levels of change across families. Overall, the cases demonstrate that PCIT can be transported intoa CMHC, and they illustrate supplemental services or minor accommodations to the established treatment protocol used to addressindividual family needs. Issues regarding the balance between fidelity and flexibility in transporting PCIT to a community setting arediscussed, and future research topics are recommended.

S EVERAL empirically supported treatments (ESTs) havedemonstrated success at reducing children's exter-

nalizing behavior and are receiving widespread attention(Eyberg, Nelson, & Boggs, 2008; Weisz & Kazdin, 2010).Transporting ESTs from research settings to communityservice settings, however, is slow and challenging becauseit involves bridging differing client populations, organi-zational philosophies, and intervention goals and prac-tices (Hoagwood & Johnson, 2003; Weisz, Doss, & Hawley,2005). For example, whereas ESTs were designed for andtested with individuals meeting criteria for specificdiagnoses, community mental health centers (CMHCs)serve clients without reference to a specific DSM diagnosisbut nevertheless presenting with problems substantialenough to result in clinical referral (Snowden, Storey, &Clancey, 1989).

Slow integration of scientific evidence into practice hasserious implications for public sector mental healthsystems, which serve many of the most vulnerableindividuals and families (Aarons, Wells, Zagursky, Fettes,& Palinkas, 2009). Relative to participants in researchsettings, community clients often are of lower socio-economic status (SES), more ethnically diverse, and more

-7229/11/502–514$1.00/0011 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.

ords: behavior problems; parent2child relations; communitytal health; preschool children

likely to present with conditions that would exclude themfrom controlled research studies (e.g., comorbidities,involvement in the child welfare system, and limitedreading or cognitive functioning; Hawley & Weisz, 2002;McKay & Bannon, 2004). Further, ESTs present chal-lenges for community service settings due to theirstandardized approach. In contrast to the manualizedtreatment protocols used in ESTs, CMHCs often combineand adapt services (e.g., case management, psychoeduca-tion, assessment, and therapy) to address multipletreatment goals. The average length of care in communitymental health settings has been reported to be as low asfour visits, with less than 10% of clients remaining intreatment after 3 months (McKay & Bannon). This shortduration of treatment would rarely be enough tocomplete an EST.

One EST that has received support for use with youngchildren is Parent-Child Interaction Therapy (PCIT). PCITis a manualized intervention for children ages 2 to 7 withdisruptive behavior problems (Eyberg & Robinson, 1982;McNeil & Hembree-Kigin, 2010). Numerous PCIT efficacystudies have demonstrated substantial positive changes inparent and child behavior following treatment (e.g.,Bagner & Eyberg, 2007; Eisenstadt, Eyberg, McNeil,Newcomb, & Funderburk, 1993; Nixon, Sweeney, Erickson,& Touyz, 2004; Schuhmann, Foote, Eyberg, Boggs, &Algina, 1998; Thomas & Zimmer-Gembeck, 2007), withresearch supporting treatment efficacy 3 and 6 yearsposttreatment (Hood & Eyberg, 2003). Studies examining

503PCIT in an Urban Community Clinic

PCIT with African American (Capage, Bennett, & McNeil,2001; Fernandez, Butler, & Eyberg, 2011) and Latinofamilies (McCabe & Yeh, 2009) provide preliminaryindications that PCIT is effective across ethnic minoritygroups, although Fernandez and colleagues reported thatdropout in their sample was higher than in other PCITefficacy studies (56% compared to 32-41%). Data fromcommunity-based applications of PCIT are mixed, withsome reporting relatively low attrition levels (Chaffin et al.,2009; Phillips, Morgan, Cawthorne, & Barnett, 2008) andothers reporting considerably higher rates than efficacytrials (Lyon & Budd, 2010; McNeil, 2007; Timmer, Urquiza,Zebell, & McGrath, 2005).

This paper describes case examples of PCIT in an urbanCMHC. Our program represents a useful transition pointbetween the controlled research settings typical of mostPCIT research and real-world service settings. Our programsatisfies Weisz et al.'s (2005) criteria for clinical represen-tativeness with regard to participant enrollment andtreatment setting because it provides intervention totreatment-seeking youth in a clinical service setting.However, unlike typical clinical treatment providers, whousually consist of practicing clinicians (or even paraprofes-sionals), our therapists consisted of an LCSW and graduatestudents in a clinical psychology doctoral program whowere supervised by a doctoral-level PCIT clinician andresearcher. The latter characteristics are more commonlyfound in research settings. We provide an overview of thePCIT treatment model and case descriptions of fourfamilies involved in treatment, challenges we encountered,and lessons learned that have informed our communityintervention program.

Treatment Overview

PCIT draws conceptually on Baumrind's developmentalresearch on authoritative parenting style, social learningtheory, and attachment theory to promote positive,consistent parenting practices (Zisser & Eyberg, 2010).Treatment entails two phases: Child-Directed Interaction(CDI) and Parent-Directed Interaction (PDI). Both phasesbegin with a Teach session to introduce skills throughinstruction, demonstration, and role-play. The Teachsession is followed by Coach sessions, during which thetherapist observes from behind a one-way mirror andprovides immediate feedback and support on the parent'suse of the skills through a "bug in the ear" device while theparent and child play. Session outlines and treatmentdetails are outlined in a comprehensive PCIT treatmentmanual (Eyberg & Child Study Lab, 1999). Componentsidentified as core elements of PCIT are inclusion of bothCDI and PDI phases of treatment, individualized coachingsessions in live interactions during most sessions, coding ofparent-child interactions in coaching sessions, assignmentof homework between sessions, and use of standardized

assessment instruments to guide treatment (TrainingGuidelines for PCIT, 2009).

Thegoal ofCDI is to increase positive parentingpracticesand thereby build the child's self-esteem and improve socialand communicative skills. DuringCDI, parents are taught tolet the child lead the play and to use the PRIDE skills:Praising the child, especially by labeling specifically whatthey like about the child's behavior, Reflecting the child'sstatements or verbalizations, Imitating the child's play,Describing the child's behavior, and showing Enthusiasmduring the play. Parents are also taught to avoid usingquestions, commands, and criticisms, or negative talk. Inessence, parents learn to become play therapists. Parentslearn to change the child's behavior by linking the PRIDEskills with appropriate behavior and concurrently ignoringinappropriate behavior. Mastery criteria for the CDI phaseare met when the parent uses 10 behavior descriptions, 10reflections, 10 labeled praises, and no more than 3 totalquestions, commands, and negative talk during a 5-minuteplay period.

The objective of PDI is for parents tomanage their child'sbehavior by using direct commands and following throughwith a specific ladder of consequences (i.e., labeledpraise forcompliance and a warning, chair time-out, and a back-uptime-out room if needed for noncompliance). In the PDIphase, parents are also instructed to use the skills masteredin CDI (i.e., PRIDE skills and ignoring) between commands.As PDI progresses, parents create and introduce the child tohouse rules for managing problematic behaviors in thehome. Mastery criteria for PDI are reached when parentsgive at least four commands, 75% of which are direct, andfollow through correctly on at least 75% of the totalcommands in 5 minutes. After mastery in CDI and PDI isreached, the therapist(s) guides theparents in applying theirnewly acquired skills to the child's behavior at home andother settings. Treatment ends when, in addition to skillsmastery, parents' ratings of the intensity of child behaviorproblems drop to within one-half standard deviation of thenormative mean and parents express confidence inmanaging the child's behavior.

Method

Participants

Wedescribe the course of therapy with four families whoparticipated in PCIT to address their child(ren)'s disruptiveand oppositional behavior, provided research consent, andcompleted treatment. (Names of all clients have beenchanged to protect families' privacy.) We selected clientswith differing background characteristics and clinicalpresentations in order to illustrate varied issues encoun-tered in delivering PCIT in a community setting: comorbidchild diagnoses, mental health issues for the parents,involvement in the child protection system, and more thanone identified child in a family. Lyon and Budd (2010)

504 Budd et al.

described results from the first 12 families seen in this PCITclinic; one of the current families was included in theirstudy, and the others engaged in therapy after completionof that study.

Setting, Therapists, and Procedures

The CMHC for this study has offered a range ofpreventive and mental health services for high-risk youthand their families for over 30 years. It is funded by the stateDepartment of Human Services to serve primarily familieswith limited means (i.e., on public aid, noninsured, orunderinsured). In fiscal year 2009, 88% of the CMHC'sclientele were non-White, 86% were on public assistance,4% were on a sliding fee, and 10% had private insurance.The center's PCIT programbegan in 2005; approximately 4to 6 families are enrolled in PCIT at any one time.

Unlike most CMHCs, which are free-standing servicecenters, this CMHC is unique in the fact that it is located ona university campus and serves as a practicum training clinicfor doctoral clinical psychology students. PCIT therapists(four female, one male) included three doctoral clinicalpsychology students, an LCSW, and a faculty supervisor.Four therapists were Caucasian and one was Asian-American. All therapists received specialized training inPCIT. For the student therapists, training consisted of a 24-hour workshop prior to working with families as well asweekly group supervision and individual supervision todiscuss clinical concerns and adherence to the PCITtreatment protocol. Initial and ongoing training was ledby the Ph.D.-level clinical psychologist and LCSW, both ofwhom had extensive experience with PCIT.

PCIT sessions were held in two CMHC therapy roomsequipped with living room furniture, a table, and chairs.The therapy rooms were connected by an observationroom with one-way mirrors for monitoring sessions. Oneroom served as the primary therapy room for meetingswith families and observations of parent-child interac-tions. Following the beginning of PDI, the second roomserved as the time-out room, with slight modifications toremove potentially dangerous or easily damaged items(e.g., lamps, low-hanging pictures, easily movable chairs).

Following intake, families identified as potential candi-dates for PCIT attended two initial assessment sessionsconsisting of a clinical interview, parent-child observation,and administration of the child and parent functioningmeasures. In addition, the therapists provided an overviewof PCIT and our ongoing research evaluation and reviewedthe informed consent form. Two cotherapists conductedtreatment sessions, which typically were scheduled weeklyfor 90 minutes. Posttreatment assessment (observation andthe parent and child functioning measures) typicallyoccurred 1 to 2 weeks following the session in whichfamilies met mastery criteria.

Measures

Various measures were used to assess child and parentfunctioning during the pre- and post-treatment assess-ment sessions. The measures pertinent to this study aredescribed below.

Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999)The ECBI is a 36-item measure of disruptive behavior

developed for children between the ages of 2 and 16 years.Parents rate the frequency of behaviors on a 7-point scale(Intensity Scale) and endorse whether they perceive thebehaviors to be problematic (Problem Scale). Intensityscores greater than or equal to 132 and problem scores of 15or above are considered clinically significant (Eyberg &Pincus). One requirement for PCIT graduation is anIntensity score within one-half standard deviation of thenormativemean (raw score less than or equal to 114). Stronginter-item correlations have been reported for both theIntensity Scale (.92 to .95) and the Problem Scale (.90 to .94)in low- to middle-income African American and Latinoparents (Gross et al., 2007). In addition to pre- andposttreatment assessments, parents completed the ECBIIntensity scale at each session to gauge change in functioningand guide treatment.

Parenting Stress Index–Short Form (PSI-SF; Abidin, 1995)The PSI-SF is a 36-item measure that assesses stress

associatedwithparenting and theparent-child relationship.The measure provides a Total Stress score and the threefactor analytically derived subscales of Parental Distress,Difficult Child, andParent-ChildDysfunctional Interaction.PSI-SF scores above the 90th percentile are considered tobe in the clinical range. The PSI-SF has demonstrated goodreliability and is highly correlated with the original, longerPSI (Abidin, 1983). Higher scores on the PSI have beenshown to be related to higher levels of disruptive behavior(Ross, Blanc, McNeil, Eyberg, & Hembree-Kigin, 1998).Reitman and colleagues demonstrated good inter-itemconsistency and construct validity for the PSI-SF in a sampleof low-SES, African American parents (Reitman, Currier, &Stickle, 2002).

Dyadic Parent-Child Interaction Coding System–Third Edition(DPICS-III; Eyberg, Nelson, Duke, & Boggs, 2004)

The content and quality of parent-child interactionswere assessed using the DPICS-III, a behavioral codingsystem. Extensive psychometric data are reported in theDPICS-III manual (Eyberg et al., 2004); however, there is alack of psychometric research on the use of the DPICS withethnic minority families (Butler & Eyberg, 2006). TheDPICS coding system includes specific definitions forparent verbalizations and child responses to commands.Categories of parent verbalizations include behavior de-scriptions, reflections, labeled andunlabeledpraise, neutraltalk, questions, direct commands, indirect commands, and

505PCIT in an Urban Community Clinic

negative talk. Child behavior following a parent commandthat provides an opportunity to comply is coded ascompliance or noncompliance.

A 25-minute observation, including three 5-minutestandardized situations of child-led play, parent-led play,and cleanup, was conducted during both the initial andposttreatment assessment sessions. Observations werevideotaped, and graduate and undergraduate studentsindependently coded tapes after comprehensive trainingand regular practice to prevent observer drift, as describedin Lyon and Budd (2010). Kappa reliabilities on individualbehaviors across 29 five-minute observation segments forthe current cases ranged from .57 for negative talk to .89 forunlabeled praise. According to Landis and Koch (1977),Kappa values between .41 and .60 are consideredmoderate,between .61 and .80 substantial, and above .81 “almostperfect.” For the purpose of this study, parental Do Skills(behavior descriptions, reflections, and labeled praises)were summed across the three standardized situations atinitial and posttreatment assessment to create a totalnumber of Do Skills. Don't Skills (questions, negative talk,and, during child-led play, direct and indirect commands)also were summed across the three situations.

Treatment length was calculated as the total number ofweeks the family was enrolled in PCIT, from the initialassessment session to graduation, including missed orcanceled sessions and holiday breaks. Attendance andnumber of treatment sessions provide measures of engage-ment. Failure to attend scheduled sessions was categorizedas either cancelations (by the parent) or no-shows.

Case Descriptions and Results

Alex and His Mother

Referral Concerns and Family ContextAlex, a 5-year-old bilingualMexican-Americanmale, and

his mother sought treatment after learning about it fromanother family at his school that had previously engaged inPCIT. Presenting concerns included aggressive behavior(e.g., hitting, scratching, and pushing adults and children)at home and school, temper tantrums, noncompliance, andlow frustration tolerance. Alex resided with his biologicalmother, father, and 10-year-old sister. InPCIT, bothparentsare encouraged to participate whenever possible; however,due to the father's work schedule, Alex's father attendedonly the CDI and PDI Teach sessions. The family paid asliding scale fee and fell in the middle-income range.

Alex had a history ofmotor, speech, and language delaysand was diagnosedwith an autism spectrumdisorder (ASD)when he was 4 years old. Previous evaluations indicated thathe fell within the high-functioning range. Alex attended ahalf-day kindergartenprogramandparticipated in physical,speech and language, and occupational therapies at school.Following the initial PCIT assessment, Alex was diagnosed

with disruptive behavior disorder–not otherwise specified(DBD-NOS) in addition to ASD. There is a relatively smallbody of literature on the implementation of PCIT withchildren with ASD; however, PCIT recently has been usedwith ASD children in clinical and research settings(Solomon,Ono,Timmer,&Goodlin-Jones, 2008). Althoughour clinic generally does not provide services for childrenwith primary diagnoses of ASD, PCIT was initiated after theassessment provided evidence of significant disruptivebehaviors thatmet criteria forDBD-NOS. Alex had sufficientcognitive and language functioning to engage in PCIT, andhe responded well to social reinforcement. Whereas manyresearch-based PCIT programs require children to have aformal clinical diagnosis of an externalizing disorder and/oran ECBI Intensity score above the clinical level (i.e., ≥132)to be eligible for PCIT, ourCMHCaccepts childrenbasedonparental report and clinical interview confirming behaviorproblems, and thus Alex was accepted despite his mother'sinitial ECBI Intensity scale score of 131 (see Table 1).

Course of TreatmentAlex's mother was highly motivated and engaged in

treatment, completing PCIT in a total of 13 treatmentsessions (see Table 2). Because of Alex's ASD diagnosis,PCIT was tailored to fit the specific needs of this family, assuggested by McDiarmid and Bagner (2005) and Masse,McNeil, Wagner, and Chorney (2008). For example,coaching addressedparticular concerns related to repetitiveand stereotypedbehaviors by teaching themother to refrainfrom reflecting repetitive speech and describing stereo-typed behaviors. Alex presented with sensory sensitivitiesand difficulty with mealtime (e.g., temper tantrums andaggressive behavior). Relevant food toys were used duringlive coaching to reinforce appropriate food-related behav-iors and ignore negative behaviors while Alex and hismother engaged in pretend cooking and eating. For Alex,hugs were found to be particularly reinforcing.

During initial assessment, Alex'smother had a high rateof instructions and questions across all three situations.Numerous positive changes were demonstrated followingtreatment, including reductions in parent-reported prob-lems and observed increases inmaternal use ofDo Skills (asshown in Table 1 and Fig. 1, respectively). Alex's motherbecame more comfortable allowing him to lead the play,as evidenced by a substantial decrease in number of Don'tSkills (see Fig. 2), and Alex displayed increased positiveengagement with his mother and the play activities. Alex'smother also demonstrated mastery of direct commandsand consistent use of time-outs in PDI. Her ECBI scoresdeclined steadily throughout treatment, and Alex did notmeet criteria for DBD-NOS at the end of PCIT. Addition-ally, the mother's PSI-SF scores indicated a decrease inparental stress related to parent-child interactions andhaving a difficult child. A serious health issue of Alex's

Table 1Scores on Parent-Report Measures at Pre- and Posttreatment Across Cases

Alex Justin William Aaron Timmy

Eyberg Child Behavior Inventory (Raw Scores)Intensity Scale

Pre 131 226* 139* 182* 148*Post 84 104 68 51 45

Problem ScalePre 15* 30* 3 36* 13Post 7 18* 0 13 0

Parenting Stress Index-Short Form (Percentile)Parental Distress Scale

Pre 90* 95-99* 55 65 5-10Post 90-95* 20 50 75 5-10

Dysfunctional Interaction ScalePre 80 95-99* 85 95-99* 35Post 50 40 80 90-95* 5

Difficult Child ScalePre 95* N99* 85 95-99* 95-99*Post 75 75 30 80 5

Total Stress ScalePre 95-99* N99* 80-85 95-99* 60-65Post 85 45 55-60 85-90 1-5

* Indicates scores above the clinically significant cut-off: ECBI Intensity Scale≥132, ECBI Problem Scale≥15, PSI-SF (all scales)≥90th percentile.Note: Parent for Aaron is Father 1; Parent for Timmy is Father 2.

506 Budd et al.

grandparent at the end of treatment was reported as asignificant stressor for the family; however, they were ableto complete PCIT successfully.

Justin and His Parents

Referral Concerns and Family ContextJustin was a 4-year-old, Puerto Rican, African-American,

and Caucasian male who attended a public schoolMontessori program. The family was self-referred due toaggressive behaviors such as biting, hitting, and spitting thathad led to expulsion from a previous school placement andmultiple suspensions from his current school. Additionally,Justin was frequently noncompliant at home, and in-structions needed to be repeated in order for him to followthrough on simple tasks. PCIT began with Justin and hismother, as his father had recently left the home due tosubstance abuse issues. Twomonths into treatment, Justin'sfather reentered the home and beganparticipating in PCITsessions. Although both parents were involved in themajority of treatment, pretreatment measures were collect-ed only from Justin's mother; thus, we primarily addressinformation gathered from her. The family was lowerincome, both parents worked in the service industry, andthey paid a nominal fee ($5) for sessions.

Justin was diagnosed with attention-deficit/hyperactivitydisorder (ADHD)–combined type and oppositional-defiantdisorder (ODD) based on reports from multiple adultcaretakers, school and clinical observations, and a full

developmental and educational evaluation. During intake,information gathered about his mother's mental healthindicated that she was displaying high levels of psychopa-thology. She reported a history of depression and anxiety,for which she had received treatment in previous years.Moreover, she appeared somewhatdisheveled and lethargicin early sessions, was often late, and reported missing twolate-morning sessions because she overslept.

Course of TreatmentJustin and his family successfully completed PCIT over

the course of 41 weeks, attending a total of 29 treatmentsessions (8 CDI sessions, 18 PDI sessions, and 3 “other”sessions to review treatment progress and Justin's schoolbehavior), as shown in Table 2. Justin's mother solelyattended 8 of the sessions, his father solely attended 3sessions, and they jointly attended 18 sessions.

At initial assessment, Justin'smother reportedhigh levelsof behavioral concerns and parental stress (Table 1), andshe displayed little positive attention to Justin in parent-child interactions (Fig. 1). Over the first four observations,Justin's mother had a low rate of verbalizations in CDI playsessions, and 17% of her total verbalizations were Do Skills,based on PCIT therapists’ coding. As sessions progressed,however, the mother's proportion ofDo Skills verbalizationsto total verbalizations (i.e., labeled and unlabeled praise,behavioral descriptions, reflections, questions, commands,negative talk, and neutral talk) during the 5-minute playobservations steadily increased (see Fig. 3). Specifically,

Table 2Treatment Length and Attendance Across Cases

Alex Justin William Aaron & Timmy

Length of TreatmentWeeks 19 41 49 23

AttendanceCDI Sessions 7 8 7 6PDI Sessions 6 18 12 10Other Sessions 0 3 1 0Cancellations 1 4 19 2No Shows 1 2 3 0% Sessions Attended 87 83 45 89

Note. CDI=Child Directed Interaction; PDI=Parent Directed Interaction.

507PCIT in an Urban Community Clinic

over the course of the next 12 sessions, 64% of her totalverbalizations were Do Skills. This pattern indicated that,although the mother had low verbal fluency, she becameincreasingly proficient in Do Skills.

Due to complicating factors that arose in Justin's case,minor accommodations were made and supplementaltreatment options were arranged for the family duringPCIT. First, the PCIT therapists referred Justin's motherfor individual therapy sessions with a separate CMHCtherapist in order to address her depressive and anxietysymptoms. Second, the therapists consulted with Justin'steachers in order to teach PCIT skills for use with Justin inthe classroom. Third, CDI mastery criteria were relaxedfor Justin's mother. After five CDI Coach sessions, themother displayed 14 behavioral descriptions, 8 reflections,and 6 labeled praises in a 5-minute observation period, yetthe therapists decided to move on to the PDI phase beforeshe reached the standard mastery criteria of 10 PRIDEskills in each category. These decisions were made basedon the fact that the mother was highly distressed aboutJustin's home, school, and in-session behavior (e.g., he wasopenly defiant and difficult to redirect). She also appearedto have serious mental health issues that impeded herability to reach mastery criteria, and she was at imminentrisk of dropping out of therapy. Moreover, Justin's fatherbegan treatment and displayed a high rate of PRIDE skillusage within two CDI coaching sessions. Moving to PDIbefore mastery criteria for CDI have been reached is nottypically recommended in PCIT, and in this case, thedecision was made only after careful review and consul-tation with the doctoral supervisor.

After the 6th PDI Coach session, Justin was suspendedfrom school again. His mother was highly distressed andreported that Justin required individual therapy. Based onthe clinical conditions, a decision was made to convene ajoint therapy session involving Justin'smother, her individualtherapist, and the PCIT therapists. The goals of the meetingwere to address the recent setback in Justin's behavior whilecontinuing to focus on the progress that had been made inPCIT thus far, explain that individual therapy sessions forJustin were not recommended by the therapists at that time,and allow Justin's mother the option of terminating PCITand obtaining a referral for another agency that mightprovide the therapy modality that she requested. Thismeeting appeared to be a turning point for Justin's mother,as she learned that all of the therapists were united inrecommending PCIT for her family. This meeting also mayhave put Justin's recent school incident into perspective andhelped her to recognize that PCIT was addressing theirneeds. The family eventually completed PCIT successfully,with both parentsmeeting standardmastery criteria for PDI.

By the end of treatment, Justin's ECBI Intensity scorehad decreased by 122 points, and the mother reportedsubstantial decreases in parental distress (Table 1). Her

level of Do Skills, while still below the rate expected for CDImastery, was well above her baseline levels (Fig. 3). In theposttreatmentDPICS observation, however, Justin'smotherused minimal PRIDE skills (Fig. 1). Her demeanor wasdepressed and irritated, suggesting that she was still subjectto periods of distress that affected her interactions. Atposttreatment, Justin's teachers indicated that his aggressiveand destructive behavior in the classroom had decreased;however, inattentive symptoms persisted. His parents andteachers reported that they felt confident in managing hisbehavior, and his mother stated that her anxiety anddepressive symptoms were being addressed in individualtherapy.

After completing PCIT, Justin and his family continuedin services at the CMHC. Justin received individual therapyand family therapy, and one of the PCIT therapistscontinued to consult in the school. In addition, Justin'smother becamean advocate for PCITandprovided referralswithin the community.

William, His Biological Mother, and Foster Mother

Referral Concerns and Family ContextWilliam, a 3-year-old African-American male, his biolog-

ical mother, and his adult biological sister were mandatedby child protective services to attend the PCIT program.William was born cocaine exposed and lived with hismother in a substance abuse treatment facility for his firstyear. At age 2, a relapse led to his removal from his mother,and he was placed with his adult sister (designated as hisfoster mother). Other adult relatives lived in the familyhome but were not engaged in PCIT. The child protectivecaseworker hoped to eventually return William to hisbiological mother's custody, and successful completion ofPCIT was one of the benchmarks used to assess maternalprogress toward that goal. Initial assessment at the CMHCindicated that the child met criteria for DBD-NOS due tooppositional behavior, argumentativeness, and frequenttemper tantrums. William's mother was undergoing day

-

Figure 1. Frequency of Do Skills for each child's parent duringDPICS situations at pre- and post-assessment.

508 Budd et al.

treatment and outpatient therapy for drug and alcoholaddiction through various nonaffiliated mental healthagencies, and she lived in a halfway house for women withsubstance abuse problems. She was allowed to havesupervised visits with William on the weekends and onenight per week, and the amount of contact allowedincreased across treatment.

Course of TreatmentWilliam and his family were enrolled in PCIT over the

course of 49 weeks. They attended 19 PCIT sessions (7 CDI,12 PDI) and 1 “other” session called to discuss the family'sinconsistent attendance. William's mother attended all ofthe held sessions, and his fostermother attended 13 (68%).A major factor affecting the family's progression throughPCITwas thehigh rate of canceled appointments (Table 2).Their reported reasons for missing sessions includedattending to ill family members, scheduling other appoint-ments during regular session time, and occasionallyoversleeping, even though appointments were scheduledin the late afternoon. In addition, they had transportationand logistical issues, likely related to the fact that the familyresided over 10 miles away from the treatment facility andrelied on public transit. A further complicating factor was

Figure 2. Frequency of Don't Skills for each child's parent duringDPICS situations at pre- and post-assessment.

that William's mother was not allowed unsupervisedvisitation until late in treatment. If his foster mother orthe family's social worker could not attend sessions, Williamand his mother were unable to attend. The PCIT therapistshad regular contact with William's child protectioncaseworker in the first several months of treatment inorder to coordinate care and search for possible solutionsto the ongoing attendance issues (e.g., by having thecaseworker bring the family to sessions). After a newcaseworker was assigned, efforts to her coordinate carewere no longer successful, although the PCIT therapistsprovided summary reports of the family's treatmentprogress and attendance pattern when requested by thecaseworker or the court.

At the beginning of treatment, William's foster motherin particular struggled with his defiant behavior, whichappeared to be maintained by her attention. Throughtreatment, she was able to learn how to attend to prosocialbehavior and ignore aggravating behavior (e.g., hummingloudly in a high pitched voice), which decreased whenWilliam no longer received as much attention formisbehaving as he had in the past. As a result, his fostermother appeared to relax and enjoy playing with him assessions progressed. His foster mother unfortunatelydropped out of PCIT prior to reaching mastery criteria,although her use of the skills improved notably. Thefoster mother did not provide reasons for dropping out oftherapy. It is possible that the change in caseworker andthe difficulty maintaining communication between thePCIT therapists and caseworker made it easier for thefoster mother to disengage from treatment. Informally, itappeared that the new caseworker did not hold the fostermother accountable for missing sessions, and the newcaseworker eventually said that the foster mother did notneed to attend in order for the family to completetherapy. Moreover, there was some indication that thefoster mother was receiving messages from the nonparti-cipating adults with whom she lived that problems are notto be shared with anyone outside the family, let alone“professionals.”

Coincident with the foster mother's decision to stopattending sessions, William's biological mother was grantedunsupervised visitation. Thus, she was able to bring Williamto PCIT sessions on her own. Although the pattern ofinconsistent attendance continued, William's mother even-tually displayed mastery with CDI and PDI skills. She wasable to set limits (something that she reported was difficultfor her due to guilt about not living with him) and manageWilliam's behavior.

Because William's mother was considered the primaryparent for PCIT, her data are reported inTable 1 andFigs. 1and 2. At posttreatment assessment, William's motherreported markedly reduced levels of behavior problemsand lower levels of parenting stress related to the child's

Figure 3. Percentage of Do Skills relative to total verbalizations across sessions by Justin's mother. Note: Coding of the mother did not takeplace in all sessions, sometimes due to time constraints, because the session focused on the father, or because the PCIT protocol did not callfor coding in the session.

509PCIT in an Urban Community Clinic

behavior (Table 1). Moreover, William no longer metcriteria for DBD-NOS. Parent-child interactions at post-treatment assessment showed desired changes in both Doand Don't Skills (Figs. 1 and 2). During the graduationsession, the mother requested booster sessions, stating thatshe knew she would need them. Regrettably, within 2 weeksafter completing PCIT, the mother was found to haverelapsed on drugs, and shemoved awaywithWilliam beforebeing caught and losing custody of him yet again. Thistragic ending led us to surmise that some of the missedsessions may have been related to the mother's return tousing substances.

Timmy and Aaron and Their Parents

Referral Concerns and Family ContextThe parents of Timmy and Aaron, 5-year-old, African

American male twins, sought treatment for their sons'oppositional, defiant, and destructive behavior at homeand school. According to their parents, the twinsdamaged thousands of dollars worth of property athome, and their school teacher said they were the“worst kids she has seen” in her long career. Timmy andAaron were brought to the CMHC by their adoptive father(Father 1) of European American descent and hisromantic partner (Father 2) of Latino descent. (AlthoughFather 1 was the legal guardian, the family and clinicians

referred to Father 2 as father as well.) The twins wereadopted at the age of 2 from the state's child welfareservices after a history of neglect. At the time the case wasopened, the fathers had been dating for approximately1 year. The fathers were professionally employed, wereconsidered middle-to-upper income, and paid the fullsliding scale rate, which is atypical in our clinic.

Aaron was diagnosed with ODD and ADHD-combinedtype.He had been prescribed psychostimulantmedicationto address inattention and hyperactivity symptoms by hispsychiatrist before coming to our clinic and was takingmedication during PCIT. Timmy was diagnosed withODD. Parents’ self-reports of stress and symptomssuggested that Father 1 may have underreported his ownstress. Contrastingly, Father 2 reported experiencing highlevels of personal stress and depressive and anxietysymptoms. He informed the PCIT clinicians that he hadreceived treatment for depression in the past.

Course of TreatmentThe standard PCIT protocol is conducted with one

identified child client. Siblings may be included in laterPDI sessions if parents have identified specific siblingconcerns. This plan and the logic underlying it werediscussed with the parents at intake; the fathers explainedthat both children presented serious concerns, and theyrequested that both children be included in PCIT. This

510 Budd et al.

option has been suggested as an alternative when thereare two identified children and two participating parents(Gurwitch & Funderburk, 2008). At the outset, theclinicians decided that each parent would complete pre-,during-, and posttreatment measures for only one child.The reason for this decision was twofold: (a) continuity ofreporter for each child was important for maintainingaccurate evaluation, and (b) the clinicians did not want tooverburden the fathers with paperwork. To determinewhich parent would assess which child, clinicians askedfathers if they had a preference. The fathers, on their ownaccord, decided to choose the child they felt was “mostchallenging” to them: Father 1 chose Timmy; Father 2chose Aaron.

Although the fathers completed assessment measureson only one child, they were coached interacting with bothchildren individually and switched every other session. Forexample, duringCDICoach 1, Father 1 playedwith Timmy,and Father 2 played with Aaron. During CDI Coach 2,Father 1 played with Aaron, and Father 2 played withTimmy. After both parents met mastery criteria in CDI andPDI, one parent at a time was coached with both boyssimultaneously in order to address sibling interactionproblems, which were of particular concern to this family.For homework, fathers were assigned to work with bothchildren daily, so as not to have the children feel favored byone father over the other.

At pre-assessment, both children had clinically elevatedECBIs (see Table 1). After four treatment sessions, theclinicians observed that Father 2's ECBI Intensity scores forAaron were still very high, whereas Father 1's scores forTimmy showed steady declines and were below the clinicalcutoff. The clinicians were concerned that the children's

Figure 4. Aaron and Timmy's ECBI scores across sessions as reportedcompleting ECBIs for both children every week.

behavior might not be the only factor influencing ECBIscores: Perhaps the individual parents' stress and symptomswere biasing their reports. Additionally, the cliniciansconsidered that the fathers’ distinct family histories andcultural perspectives on parenting and child behaviormight have influenced their reports. Consequently, theclinicians decided to have both fathers complete ECBIs forboth sons every week.

After several weeks of further treatment, Father 1reported large reductions in both children's EBCI Intensityscores, and Father 2 reported little to no improvement ineither child (Fig. 4). What was surprising was that bothparents were verbally reporting improvements in bothchildren's behavior at home, at school, and in public. AtWeek 14 (PDI 7), clinicians decided to address directly thediscrepancy in ECBI scores between fathers as well as thediscrepancy between ECBI scores and verbal accounts ofthe children's behavior. The clinicians broached the subjectby showing the ECBI graphs to the fathers and reviewingspecific items on the ECBI. With minimal probing from theclinicians, the fathers communicated about how theyperceived their children's behaviors. They recognized thatthey, in fact, defined certain behaviors differently, andFather 2 noticed that hewas allowinghis pretreatment viewsof the children to impact his weekly ECBI reports. Father 2stated that he found it difficult to “compartmentalize” thechildren's behaviors. The next session, Father 2's scoresdeclined below the clinical cutoff for both children, and thefollowing session, scores further decreased, and the familygraduated.

After a total of 16 treatment sessions, the family com-pleted the PCIT program. At the end of treatment, ECBIscores for both boys were substantially reduced, Timmy no

by each father. Discontinuity in the lines is related to fathers not

511PCIT in an Urban Community Clinic

longer met criteria for ODD, and Aaron no longer metcriteria forODDandADHD. Further, bothparents displayeddramatic changes in Do and Don't Skills during parent-childinteractions (Figs. 1 and 2). At posttreatment, Father 1showed decreased stress levels, but Father 2 continued toreport elevated stress levels (Table 1). Notwithstandingchallenges faced during treatment, the family demonstratedsignificant gains in therapy and reached graduation.

Discussion

This study sheds light on an important, understudiedtopic by describing the course of PCIT for four familiestreated in an urban CMHC and highlighting treatmentissues that arose in this setting. All families successfullycompleted treatment, yet each case likely would havebeen excluded in EST research studies due to variousreasons. For example, Alex's primary diagnosis was ASD,Justin's mother presented with serious mental healthproblems, William was a ward of child protective servicesand was not living with his mother, and Timmy and Aaronwere twins who were both identified clients and whose twofathers participated in treatment. All of the children wereof ethnic minority backgrounds, and two of the familieswere very low income—conditions less likely to beencountered in research settings than among communitymental health clientele. Transporting ESTs to servicesettings entails a balance between fidelity and adaptationin order to fit contextual and client issues of the setting(McHugh, Murray, & Barlow, 2009). Below, we summa-rize and reflect on the changes we made in response toindividual issues that arose in delivering PCIT in acommunity setting.

Accommodations to the Treatment Protocol

Because our CMHC operates within a system that offersmore flexibility than a controlled research setting, we hadthe opportunity to structure sessions, enroll families, andaccommodate services to individual families. Typically, wescheduled 90 minutes rather than the traditional 50 or 60minutes for PCIT sessions in order provide time for casemanagement issues, rapport building, and periodic reviewof the treatment plan. Our entry criteria for PCIT did notrequire children tohaveECBI scores above the clinical level,as long as parent report and clinical interview confirmed thepresence of disruptive and oppositional behavior. Thisallowed us to treat clients such as Alex, whose pretreatmentECBI score was one point below the clinical cutoff but whopresented with substantial behavior problems.

We also allowed flexibility in terms of which familymembers attended treatment and how often they attended.In three of our four cases, one of the two identified parentsdid not attend all PCIT sessions. For Alex, his father's workschedule permitted him to attend only CDI and PDI Teachsessions, Justin's fatherbegan to attendPCIT severalmonths

into treatment due to the fact that he was not living in thehome at the time treatment began, and William's fostermother dropped out before she successfully completedtreatment. In the current cases, the children's behaviorimproved in spite of the lack of full treatment participationby both caregivers, although they likely would havebenefited further by both caregivers' involvement through-out treatment. The PCIT protocol allows for variations inthe focus or delivery of essential ingredients based on theunique features of the individual case (Eyberg, 2005;McNeil & Hembree-Kigin, 2010). Flexibility in parentparticipation when dictated by changing family conditionsrepresents one such characteristic. Families seen in CMHCsdeal with circumstances (such as limited discretion in theiremployment conditions, transportation barriers, or familyinstability) that make regular session attendance by bothparents difficult, so flexibility in which family membersattend treatment may often be needed.

We also tailored the PCIT protocol to address clinicalissues of the individual cases. Due to Alex's primarydiagnosis of autism, his mother was coached not to imitatestereotyped behavior or reflect repetitive speech. Sensoryissues involving food also were identified, and the therapistschose meal-related toys during PDI for the purpose ofreducing those behaviors. In the case of the twins, Timmyand Aaron, the presence of two parents in treatmentprovided an opportunity to focus on both children asidentified clients during PCIT. The therapists decided thatboth childrenwould take turns interacting with one of theirparents each week by alternating the parent-child dyadcoached across sessions. Additionally, both parents com-pleted daily homework with both of the children separately.These changes appear to fit within the tailoring built intothe PCIT treatment protocol. This family was highlymotivated to engage in treatment, whereas such recom-mendations might overburden families in which this is notthe case.

The most substantive accommodations to the treatmentprotocol occurred in the cases of Justin and William.Specifically, we decided to move Justin's family to PDIbefore his mother met standard mastery criteria in CDI.This decision may have compromised the ultimate effec-tiveness of PCIT for Justin, in that it shifted the emphasisfrom building a positive parent-child relationship to alsointroducing behavior management techniques to deal withdiscipline concerns. Some applications of PCIT (i.e., in agroup training format) have employed time-limited treat-ment for practical reasons (Niec,Hemme, Yopp, &Brestan,2005); however, there are sound theoretical and clinicalreasons for continuing CDI until mastery criteria arereached, and efficacy trials demonstrate desired outcomesof PCIT when applied with fidelity. The decision tomove toPDI in this case involved several discussions between thePCIT therapists and the supervisor, and it was ultimately

512 Budd et al.

made based on the severity of the child's behavior, themother's psychopathology, the need for effective disciplineby the family and the school, and the high risk of dropout.The PCIT protocol calls for therapists to continue to focuson CDI skills throughout PDI. Even so, it is possible thatmoving the family to PDI before the mother reachedtraditional mastery criteria for CDI lengthened treatment;the family required 18 PDI treatment sessions to achievePDI mastery.

In the case of William and his family, we decided tomaintain the family in PCIT despite highly irregularattendance. The family was initially referred for parenttraining services both due to the biological mother'sinvolvement in the child protection system and William'sbehavior problems. Her primary issue was cocaine depen-dence, which had led her tomake poor parenting decisions.William's foster mother was inconsistently engaged andultimately dropped out before she completed treatment.Additionally, the family canceled as many appointments asthey attended. Although efforts were made to coordinatewith the child protection caseworker, these efforts were notsufficient to resolve the attendance issues. The familyappeared to benefit from PCIT by strengthening themother-child relationship and providing consistency andstructure to the family system; however, William's motherrelapsed after completion of PCIT. Thus, it remains anempirical question whether it is advisable to enroll andcontinue to engage a family with the aforementionedpresenting problems and treatment concerns. At the least, itis recommended to have a structured plan for regularcaseworker-therapist contact when providing PCIT tofamilies involved in child protection services.

In spite of all four families successfully completing PCIT,the total length of time each family was involved intreatment varied widely, ranging from 19 weeks for Alex'sfamily to 49 weeks forWilliam's family. In these four cases, itappeared that the caregivers with more severe levels ofcurrent psychopathology (i.e., Justin andWilliam's families)completed treatment at a much slower rate than the otherfamilies. Of the two families with high levels of parentalpsychopathology, variability in the type of mental illnessand in the parents' ability to copewith their illnessmay haveimpacted the families’ outcomes. For example, William'smother had a long history of substance dependence thatled to poor judgment, and her substance abuse wassubstantial enough that her son was removed from hercare. Although information on the mother's substance useduring the course of PCIT is unknown, it is possible that shebegan using substances again before it became known thatshe had relapsed, and this may have contributed to herinconsistent attendance.

Justin'smother also displayed significant psychopathologyin the form of depression and anxiety, but she continued tocarry out her role as a parent. Justin's mother appeared to

function somewhat better whenher husband came back intothe home and began attending PCIT sessions; furthermore,she seemed to become more engaged in PCIT after shebegan individual therapy for her own mental health issues.Thus, it is possible that the type of psychopathology and thepresence of supportive resources affected post-PCIT out-comes for these families: Justin'smother becamean advocatefor PCIT in the community, whereas William's motherrelapsed. Although PCIT has been shown to reduce distressrelated to parenting, addressing other aspects of parentalpsychopathology goes beyond the intended scope of PCIT.In some cases, parallel services (e.g., individual or grouptherapy) may be helpful for parents presenting withsignificant psychopathology, as appeared to be the case forJustin's mother. However, adjunctive services require acommitment of time, energy, and resources thatmay actuallydetract fromparents' focus on PCIT (cf. Chaffin et al., 2004),so therapists should be cautious in generalizing from thiscase.

In two of the four families, Timmy/Aaron and Justin, thetherapists held discussions with the parents to addressobstacles in the treatment progress, and these discussionsappeared to be turning points in the families’ commitmentto and progress toward successful PCIT completion. In thecase of Timmy andAaron, the discussionwas initiatedby thePCIT therapists due to concerns about Father 2's unchang-ing ECBI ratings of Aaron's behavior. The unchangingratings were in contrast to both fathers’ verbal reports ofAaron's (and Timmy's) improved behavior and bothfathers’ mastery of CDI and PDI skills. This inconsistencybetween quantitative and qualitative reports signaled to theclinicians that a conversation with the fathers about thisdiscrepancy may be necessary for treatment to progress.

For Justin, the discussion was preceded by his mothercalling the CMHCdirector to request individual therapy forher son after his school suspension for aggressive behavior.In addition to the immediately identifiable stressor, she hadpreviously reported doubts about whether PCIT couldmeether family's needs. PCIT therapists also had noticed a trendin missed sessions, which led them to believe that Justin'smother was struggling to “buy in” to the treatment. ThePCIT therapists, in conjunction with themother's individualtherapist, were able to discuss examples of how themother'sdepression and anxietymight have been contributing to herreaction to the recent event. Moreover, the overall tone ofthis session was to support his mother in making her owndecision about whether to continue with PCIT, and thisultimately may have led to a stronger commitment toremain in therapy after she made that decision.

In addition to the therapy process factors that promptedthe therapists to adapt treatment or meet with the familyabout progress in these cases, several other challenges mayarise that potentially can derail treatment. Some ofthese issues (e.g., difficulties with homework completion,

513PCIT in an Urban Community Clinic

resistance to using time-out consistently and in therecommended format) are likely to be encountered in anyclinical setting, and others (e.g., acceptability of usingpositive attention rather than negative attention to controlchild behavior, lack of experience being played with as achild and awkwardness in that role)may bemore commonlyassociated with cultural or ecological characteristics ofclientele served in community-based settings. The PCITprotocol provides guidance for dealing with many therapyprocess issues, often by using behavioral instances duringcoaching as teaching opportunities to reinforce theprinciples underlying PCIT skills. Time is allotted at thebeginning and end of PCIT sessions to review issues andproblem-solve with parents about issues to facilitate engage-ment. As PCIT is applied more broadly in communitysettings, it will be important to learn if and how therapistshave identified effective strategies for addressing these issuesin PCIT treatment.

Limitations and Future Directions

There are several limitations of this study, including itscase design nature that precluded experimental controland the lack of follow-up data. Another limitation of thisstudy is that our CMHC differs from many othercommunity service settings, and thus the results may berestricted in generalizability. Our center's placement in auniversity context provides resources to support treatmentfidelity, such as access to a therapy room with a one-waymirror, audio-visual equipment, undergraduate researchcoders, and a research-oriented supervisor. The center'strainingmission supports our use of a cotherapymodel andclose supervision of trainees. The focus on treatment-seeking youth and families with limited means is similar toother community-based clinics, yet this center's philosophyof engagement allows formore flexibility than is available insome other community settings (e.g., a bendable atten-dance policy and access to supplemental therapy serviceswhen needed). It is unclear whether such flexibility wouldbe possible or advisable in other settings.

On the other hand, because of the uniqueness of thisCMHC and diversity of its clients, the case descriptionsprovide valuable information about the effectiveness andlimitations of PCIT under circumstances unlikely to beencountered in controlled research settings. Each of thecurrent families completed PCIT, without compromisingthe core elements of PCIT as defined by its founder andother PCIT experts (Training Guidelines for PCIT, 2009).The findings suggest areas for further research todeterminewhether the accommodations made in these cases might beeffective with other families with similar circumstances.

Research has already demonstrated that PCIT is effectivefor diverse families, including children with moderatemental retardation (Bagner & Eyberg, 2007) and families

with a history of physical abuse (Chaffin et al., 2004), andpilot work suggests its applicability for children with autism(Solomon et al., 2008). Questions to address in futureresearch may include: To what extent is generalizationfacilitated by having a second caregiver participate in PCIT,even for a limited number of sessions, compared to havingonly one parent participate? How are PCIT outcomesaffected by relaxing CDImastery guidelines in the presenceof clinical issues such as a parent's serious mental healthcondition? What is the relative effectiveness of treating asingle identified child in PCIT as compared to includingbehaviorally disruptive siblings in treatment together,particularly when two parents participate? Do the costs ofretaining families in treatment despite irregular attendanceoutweigh the benefits?

These and other questions, fueled by clinical researchin community settings, offer new directions for PCITresearchers. In light of widespread national efforts todisseminate state-of-the-art empirical treatment approachesinto clinical practice, there is a need for research into issuesthat arise in transporting ESTs into clinical settings. It isimportant to determine the conditions necessary forsuccessful implementation of PCIT outside of controlledresearch settings, and how much versatility can be exercisedby service providers without compromising the effectivenessof PCIT. This knowledge will add to the existing literaturedocumenting the robust nature of PCIT treatment forfamilies of youngchildrenwithdisruptive behavior disorders.

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The authors would like to thank the participating families and staff ofDePaul University's Family and Community Services for their support.We sincerely acknowledge the efforts of the DePaul PCIT researchassistants, whose conscientiousness, dedication, and teamwork madethis project possible. In particular, we thank graduate supervisorsChristina Danko and Silvia Henriquez, undergraduate coordinatorsDanielle Galladora and Catherine Ranieri, and each of thetranscribers and coders for their contributions.

Address correspondence to Karen S. Budd, Ph.D., Department ofPsychology, DePaul University, 2219 N. Kenmore Ave., Chicago,IL 60614. E-mail: kbudd@depaul.edu.

Received: August 8, 2010Accepted: December 1, 2010Available online 22 April 2011