On a Thursday in early August, psychologist Steven Kurtz is preparing one of his clients, Maria, for a therapy session. A calm, cheerful woman with long, dark hair, Maria has been in training at the Child Mind Institute in New York City with her six-year-old son, Ryan (not his real name), for months to ready him for this day. Her goal seems simple: to coax Ryan to obey a simple command. But Ryan does not take direction well.
Maria and Ryan are undertaking a brand of parent training called Parent-Child Interaction Therapy (PCIT) designed to correct oppositional behavior in children. Until now, Maria has let Ryan pick their activities. Today, for the first time, Maria will choose something to do.
One command at a time, Kurtz tells Maria. She practices: “Can you give me the blue piece?” The psychologist corrects her: “Give me the blue piece.” Commands must be direct, to avoid any implication of a choice. Praise immediately if he obeys, Kurtz advises; when he does not, say: “If you don't hand me the blue piece, you have to sit in the time-out chair.” If he gets off the chair, Mom's line is: “You got off the chair before I said you could. If you get off the chair again, you will have to go to the time-out room.”
“Like the Lord's Prayer, the words are always the same.” Kurtz explains. “Spoken with the same intonation.”
Kurtz removes the bins for storing toys now in the room; they are more likely to be used as weapons than for cleanup, he reasons. Another issue is Ryan. He is at a computer downstairs and feels like staying there. When Maria drags the thin, dark-haired boy into the room, he is scowling. “This is boring!” he shouts.
Kurtz explains the new rules to Ryan. “Until now, you've been choosing the activities.” Today, Kurtz says, “Mom is going to take turns with you.”
“Hey—I have this car. I have this car!” the boy interrupts. He is holding one of the toy cars in the room. Kurtz continues: “When Mom chooses the activity, it's very important that you follow her directions. If you don't, she is going to tell you to go in this chair. If you stay in this chair, you get to go back and play with her again. If you don't, you have to go in this room.” He gestures toward the door of a narrow enclosure in one corner of the room. “No, I will stay in here!” Ryan yells.
Kurtz exits and sets up shop in a small observation room behind a wall of one-way glass. Kurtz can watch the pair, but they cannot see him. Maria will listen to his directions through an earbud she is wearing.
Maria tells Ryan that their special time is beginning. “Would you like to pick an activity?” she asks. Ryan is throwing toys around the room. “Hold off on all instructions until later,” Kurtz advises. “What is he doing?” The therapy calls for narrating a child's actions, to show interest and help focus a child's attention on a task. “Right now he's playing with the cars,” Maria says.
Cars are flying around the room. Bang! Crash! Bang! Maria does not scold, shout or even look at Ryan. She stares straight ahead. “Look for that split second he does something you like,” Kurtz advises. “When he stops throwing ... for a second ...”
Most young children willfully disobey or throw tantrums from time to time. Yet when every routine task—fastening a seatbelt, holding hands at the corner, getting dressed—ignites a confrontation, parents often seek help. Designed for kids who are two to seven years old, PCIT changes the way parents respond to their children. It strengthens the bond between parent and child while providing consistent rules and incentives for cooperation.
Rather than treating a disorder, PCIT is aimed more broadly at disruptive behavior, which can range from talking back to severe aggression. The most common mental health concern for young children, disruptive behavior is a feature of several different diagnoses, including oppositional defiant disorder (ODD)—extreme disobedience and hostility toward authority figures—and conduct disorder, in which kids flaunt rules, fight, lie, steal and engage in other alarmingly bad behavior.
Ryan has attention-deficit hyperactivity disorder (ADHD), which often spurs conduct problems. He is not so much driven to defiance as he is inexorably drawn to whatever is most alluring at the moment—a television show, hot chocolate, a playground, even sleep. His need to pursue his current activity causes him to refuse conflicting requests or demands. Every morning Maria had forcibly pulled Ryan out of bed and dressed him. When Ryan's grandmother had taken care of him after school and turned off the TV, Ryan angrily threw all the available books and toys onto the floor.
More than 100 research articles, including eight randomized trials, have demonstrated that PCIT is highly effective in ameliorating such reactions, and the gains are lasting. The stakes go beyond family dynamics. Little kids with significant behavior problems are at high risk of serious antisocial behavior later on. “Previous research is very clear: if early child behavior problems are not corrected, they are likely to escalate to behaviors that are more destructive and intractable,” says Jennifer Wyatt Kaminski, a developmental psychologist at the Centers for Disease Control and Prevention. “Preventing risky and violent behavior in adolescents is an important public health issue.”
Because of its scientific backing, PCIT is gaining international recognition and making rapid headway into clinics in pockets of the country—principally, Delaware, California, the Carolinas, Pennsylvania, Oklahoma and Iowa—where large-scale training programs are in effect. The therapy most likely will become more widely disseminated when PCIT International, an organization established in 2009, rolls out its planned protocol for certifying therapists. Certification will make it possible for interested parents to find qualified therapists on the Internet.
Recent adaptations have retrofitted the approach to suit older children, and—taking advantage of its emphasis on parenting skills—to prevent relapse in abusive parents. PCIT offers useful tactics, too, for controlling more moderate forms of troublesome behavior in children. “It is a way to change your vocabulary and speak to your kids in a positive manner,” says Joshua Masse, a clinical psychologist at Delaware's Division of Prevention and Behavioral Health Services. Kurtz adds, “This is the manual that parents should be given.”
“Your Imagination Flies Like Your Robot”
PCIT got its start in the early 1970s, when Sheila M. Eyberg was a clinical psychology intern at the Oregon Health Sciences University. She treated behavior problems with play therapy, in which a therapist coaches a child to describe his or her emotions during playtime, as a route toward self-acceptance. Eyberg noticed that her charges “seemed to calm down, ‘self-correct,’ and try to please me,” she wrote in PCIT Pages: The Parent-Child Interaction Therapy Newsletter in 2004. But, she penned, “their parents were not reporting similar experiences at home. Nor were they reporting changes in their children's behaviors.” Instead of bonding with their parents, the kids were connecting with Eyberg.
Psychologist Constance Hanf, also then at O.H.S.U., was piloting an approach that addressed these concerns. She was training mothers to act as therapists for their children, who had developmental disabilities. A key target of Hanf's program was the parent-child bond. According to attachment theory, that bond provides a secure base from which a child can explore the world and helps that child control his or her emotions. In Hanf's therapy, parents built that connection while playing a game of the child's choosing. As one of Hanf's students, Eyberg constructed PCIT around her teacher's scaffold.
Last summer Laura (not her real name), a fun-loving young mother, gave a textbook demonstration of this element of PCIT during one of her therapy sessions. Her son, whom I will call Gabriel, a small six-year-old with light brown, curly hair, had just created a robot out of magnets.
“Oh, you choose to play with the magnets!” Laura says. “Beautiful robot. I love it.”
“Now it's a castle,” Gabriel says of his creation. Gabriel has ODD.
“It's so smart—you converted a robot into a castle,” his mother says.
Gabriel sticks out his tongue. “You're sticking out your tongue,” Laura narrates.
“People hate him so he started to transform,” Gabriel says of his robot.
“That's very smart,” his mother compliments. “Thank you for telling me the whole story.” Gabriel starts speaking in a funny, robotic voice. Laura copies him.
“Your imagination flies like your robot,” Laura says. “You can come up with different designs like this. It's amazing to me.”
Laura describes and imitates Gabriel's actions, repeats what he says—all of which let the child lead—and acts happy and relaxed. Laura's behavioral descriptions also show she is interested, demonstrate proper speech and help Gabriel stay focused on the task. Laura frequently praises the boy, telling him exactly what she likes about what he is doing. In addition, parents are told to ignore minor misbehavior, so that the child learns that only behaving appropriately earns him attention. Laura has met the criteria for mastery: in five minutes, she issues five behavioral descriptions, five reflections, 15 praises, and fewer than three commands, questions and criticisms.
The second phase of PCIT, which Maria and Ryan were just starting, is directed at limit setting and discipline. It is also based on Hanf's therapy, which included a component geared toward controlling behavior. Parents guide a child with clear instructions and consistent consequences, such as praise for compliance and time-out for disobedience. Parents graduate from this phase when three quarters of their commands are direct and the child complies with all of them.
Laura is close. Gabriel complies with some but not all of her requests. When Laura says she wants to do a puzzle, Gabriel protests: “I am tired of listening! I don't want to do this. Can we go out?” Gabriel does not work on the puzzle for long, but he does eventually agree to sit next to Laura and put the pieces away—and he never needs to sit in the time-out chair, although Laura threatens to put him there.
Gabriel and Laura have already come a long way. Earlier in the year Gabriel had been very unhappy and angry. He acted aggressively toward Laura and refused to obey her. “Get ready for bed or get ready for school ... to get him to do anything was very, very hard,” Laura recalls. Now Gabriel complies with her requests much more often. “When I ask him to turn off the iPad, he hands it to me,” Laura says. “He knows that if he doesn't, there's a consequence.”
In one landmark test of the therapy, published in 1998, Eyberg, now at the University of Florida, and her colleagues gave PCIT to 22 families of three- to six-year-old children with ODD and assigned 27 others to a waitlist. The parents who received treatment interacted with their children more positively, praising them more and criticizing them less, than those on the waitlist. The children of the parents who participated in PCIT, in turn, were more likely to do what was asked of them. These parents noted large improvements at home as well, rating their child's behavior within the normal range, on average, by the end of treatment. Many of these kids no longer qualified for a diagnosis of ODD. A 2003 study revealed that the treated children became even easier to handle in the following three to six years, perhaps because children and parents reinforce one another's good behavior over time.
In a 2007 meta-analysis (statistical review) of 13 studies of PCIT, psychologists Rae Thomas and Melanie J. Zimmer-Gembeck, both then at Griffith University in Australia, confirmed that the therapy is linked to significantly improved parenting and reduced negative behavior in kids. It boosts warmth from parents, decreases their hostility and reduces their stress. It also diminishes aggression and oppositional behavior among children.
The success of PCIT is thought to stem, in part, from its emphasis on rehearsal of a particularly relevant set of skills. In a meta-analysis of 77 investigations of parent-training programs published in 2008, Kaminski and her colleagues found that requiring parents to practice the appropriate actions with their children during the training sessions seemed to be critical to correcting parent behavior. Kaminski's team also noted that parent proficiency tended to improve whenever moms and dads were taught to talk to their kids about emotions and to effectively listen to them. In addition, the researchers identified the two essential elements to boosting children's behavior ratings: instructing parents to interact positively with their children—expressing enthusiasm and following the child's lead—and to respond consistently to a child's actions.
Sometimes the child is not the problem; the parent is. Parenting education and training has been a staple in child welfare for decades. Typically parents discuss their experiences and strategies in groups, but such conversations often fail to change the family dynamic, and parental neglect or abuse persists.
In the early 2000s Mark Chaffin, a child abuse researcher at the University of Oklahoma Health Sciences Center, wanted to test PCIT with such parents on the grounds that teaching skills might be more effective than discussing concepts. The state child welfare system sent him 110 adults who had been reported multiple times for physical abuse of their children. The parents received 12 to 14 one-hour sessions at the university's large PCIT center. In addition, Chaffin required these mothers and fathers to participate in a motivational exercise. “If your five-year-old is driving you crazy, you are fairly motivated,” Chaffin explains. “But we were concerned that people coming from child welfare would not be happy to be sent to a program.” In Chaffin's program, parents were asked to consider their parenting goals and whether their actions aligned with those goals.
The combination approach worked. More than two years later only 19 percent of the parents who had received both PCIT and the motivational interview had been reported again for abuse—compared with 49 percent of those who had been assigned to a standard parenting group, according to a 2004 study by Chaffin and his colleagues. “We got large effect sizes in reduction of child welfare recidivism,” something that is hard to budge, Chaffin says.
In a follow-up trial published in 2011, Chaffin's team extended these results to more severe cases of abuse and neglect and a more realistic therapeutic setting: a small inner-city agency under contract with the state's child welfare system. Among 192 parents who had averaged six prior referrals to child welfare, a motivational interview along with PCIT led to a recidivism rate of around 17 percent two and a half years later, compared with about 65 percent for those who received standard group therapy along with a motivational interview. “Even if you are motivated, typical group therapy doesn't give you a lot of benefit,” Chaffin concludes.
The children involved in Chaffin's studies ranged from four to 12 years old, so he and his colleagues adapted the treatment to older kids. Time-outs were replaced with logical consequences—such as taking away objects that a child is actively misusing—and loss of privileges. And praise was less demonstrative. Instead of exclaiming “What a nice tower!” to a child playing Legos, a father might challenge his 11-year-old son to a tower-building race. “Oh, you're killing me!” the dad might praise. In a 2012 case study, Eyberg and her colleagues also found that PCIT greatly improved the newly aggressive and oppositional behavior of an 11-year-old who had suffered a traumatic brain injury from a gunshot wound.
“Please Hand Me the Pink Doughnut”
PCIT holds useful lessons for more ordinary circumstances as well: ignore bad behavior, praise good; tell a child what to do rather than what not to do; phrase commands as such, not as questions or suggestions. Indeed, Eyberg and her colleagues found that two abbreviated versions of the technique significantly improved the behavior of 30 three- to six-year-olds whom their mothers had characterized as having moderate behavior problems. Both a four-session group intervention and written materials describing how to practice PCIT garnered similar benefits, suggesting that hands-on coaching may not be necessary in milder cases.
Back at the Child Mind Institute, Ryan has calmed down but balks at the suggestion that he play his mother's game. Soon he is sent to the time-out chair, but he will not sit there voluntarily and gets up repeatedly. Then, before he can be moved to the time-out room, he kicks his mother and pushes her into the room, locking her inside, and then knocks over all the big metal chairs. Kurtz intervenes.
For more than an hour, Ryan goes from the time-out room to the time-out chair and back again, crying and protesting. “I'll kill you! I'll kill you! You're nuts!” he shouts. Maria remains calm. She smiles and laughs to help ease the tension.
Finally, Ryan elects to stay in the chair, so Maria attempts a command. She tells Ryan to come sit next to her. “To do what?” he challenges. He is sent back to the chair. Yet again he stays there, whimpering. Twenty minutes later, in response to a period of relative silence, Maria says. “You're sitting quietly. Are you ready to come and sit with me?” “Yes.” He walks over to her, sobbing softly.
“Okay. Please hand me the pink doughnut.” He finds the pink doughnut from a smattering of plastic toys spread out on the table—and hands it to her.
“Thank you for doing what I told you.” She pets his face and smiles. He is still teary.
“Now please hand me the banana.” He does.
“Yay! Good listening.” She kisses him. Ryan brings his mom one more item, a plastic potato chip, before Kurtz ends the session.
That afternoon Ryan passed another milestone. When Kurtz enters the room, Maria flashes a wide smile. She gives Kurtz a thumbs-up, and the two exchange a high five. Ryan does not feel like celebrating, however. “I had a very hard day,” he sighs.