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Management of Disruptive Behavior

Management of Disruptive
Behavior53
in Young Children

Disruptive behavior tends to worsen with time, but it can be treated effectively. Parent-child interaction
therapy (PCIT), an evidence-based treatment for preschoolers with disruptive behavior and their parents,
focuses on changing ineffective parent-child interaction patterns. The first phase, focusing on child-directed
interaction, strengthens the parent-child relationship, builds the childs self-esteem, and reinforces the childs
prosocial behaviors. The second phase, focusing on parent-directed interaction, introduces parent management training. Treatment is guided by assessment and continues until parents master interaction skills and
child behavior problems fall within the normal range. Emerging evidence suggests that treatment gains are
maintained for several years posttreatment. Key words: aggressive behavior, behavior problems, child,
disruptive behavior, oppositional, parent-child interaction, preschoolers

Erin M. Neary, BS
Graduate Student
Sheila M. Eyberg, PhD, ABPP
Professor
Department of Clinical and Health Psychology
University of Florida
Gainesville, Florida

S PART OF their normal development, preschool-age children are highly active, often
moody, and aggressive. Moreover, typical
preschoolers disobey 25% to 50% of their parents
commands.1 With such frequent negative behavior
typical of young children, how can parents decide
if the bad behavior they are seeing in their preschooler signifies a significant concern or is within
normal limits? Disruptive behavior refers to a wide
range of conduct problems, such as oppositional,
stubborn, aggressive, and impulsive behaviors, that
cluster together and occur at higher rates than usual
for preschoolers of the same age. Normal children
show many of the problem behaviors seen in
children with diagnosed disruptive behavior, but
their behavior problems are fewer and occur less
frequently.2 Disruptive behavior occurs at the same
rate in chronically ill as healthy children, and
although children with developmental disabilities
have a higher rate of disruptive behavior than
others, their scores on measures of disruptive
behavior remain within normal limits on average.2
PREVALENCE AND STABILITY OF
DISRUPTIVE BEHAVIOR
Disruptive behavior in preschool-age children is
more common than previously thought.3 Richman
and Graham4 found 15% of 3- and 4-year-old
Inf Young Children 2002; 14(4): 5367
2002 Aspen Publishers, Inc.

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children had mild behavior problems, and 7% had


moderate to severe behavior problems. However,
OBriens5 more recent 1996 sample of Midwestern,
middle-class parents of toddlers revealed 23%
reported clinically significant disruptive behavior.
In another recent study with Head Start youngsters,
Webster-Stratton6 found a similarly high rate. Overall, disruptive behavior is the single most common
reason for referral to child mental health services.7
In addition to its high prevalence, disruptive behavior shows a high degree of stability. In both clinicreferred and community samples, disruptive behavior persists from the preschool to the early
elementary school years,810 from childhood to
adolescence,3,11,12 and from childhood to adulthood.1315
ORIGIN AND COURSE OF DISRUPTIVE
BEHAVIOR
Disruptive behavior originates from multiple
interacting child and family factors. Child factors
include difficult temperament,16 hyperactivity,17
neuropsychologic abnormalities affecting social
information processing,18 and genetic factors that
interact with family factors in the development and
maintenance of disruptive behavior.19 Family factors include parent antisocial personality disorder,20 maternal depression,21,22 stressful life events,23
anger,24 parent conflict about childrearing,25 social
isolation,26 single-parent status, and poverty.21 Family factors are believed to affect child behavior
through their influence on parenting behaviors.27,28
Parents interactions with their young children are
the most salient influence on childrens behavioral
development.
During the preschool years, as their verbal skills
become more proficient, children normally amass
increasingly more socially acceptable means of
communicating their wishes and needs29 and regulating their emotions. In contrast, childrens disruptive behavior tends to worsen qualitatively with
time3032 and is a stepping stone to later internalizing
of problems as well.33,34 Of course, not all children
with disruptive behavior maintain mental health

problems to adulthood, but early disruptive behavior is the single most substantial risk factor for
adolescent delinquency and adult criminal behavior.3538 Young children with disruptive behavior
also have an elevated risk of psychiatric problems
in adulthood, including a higher suicide rate.39 All
told, early disruptive behavior results in enormous
societal costs.19,40
IMPORTANCE OF EARLY INTERVENTION
A younger age of onset is associated with greater
severity of disruptive behavior throughout its
course,19 and disruptive behavior can be reliably
identified in children as young as age 3.32,41 Evidence also suggests that intervention is more
effective at the preschool age than when children
are older.4244 Effective treatment of disruptive behavior prior to school entry may prevent the
associated problems with academic performance
and peer relationships that require multiple interventions only a few years later.4547
Primary care physicians are often the only professionals to see young children before school
entry48 and are thus critical to early identification.
Studies4951 have found that at least 20% of the 2- to
5-year-olds seen in primary care settings have
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)52 disorders, yet
young children with significant psychopathology
are frequently not referred for treatment.53 Identification of child psychopathology is difficult.
Costello et al49 found that pediatricians were able to
correctly identify only 17% of children with mental
health problems. With increasing use of the Diagnostic and Statistical Manual for Primary Care
(DSM-PC),54 recognition of the problems that require referral to mental health providers is likely to
improve. Further, due to their effectiveness in
screening, behavior rating scales have been recommended for use in primary care settings.2 The use
of rating scales has been shown to improve pediatrician recognition and referral of children who
need mental health treatment.55 In the authors
experience, pediatricians are the primary referral

Management of Disruptive Behavior

source for children referred from the health center


to the clinic for parent-child interaction therapy.
PARENT-CHILD INTERACTION THERAPY
Parent-child interaction therapy (PCIT) is an
empirically supported treatment designed for families with preschool-age children with a range of
behavioral and emotional problems.56 The evidence base of PCIT has been established with
children who have disruptive behavior disorders,
and PCIT also is used clinically to treat the behavior
problems of children with an array of primary
diagnoses including neurologic impairment,57 developmental disorders,58 and chronic illnesses59 as
well as mood and anxiety disorders60 and childabusive families,61,62 where the identified patient is
usually the parent. If particularly difficult issues
arise that persist outside the parent-child interaction and hinder treatment progress, PCIT may
occur concurrently with other treatments, such as
stimulant medication for attention deficit hyperactivity disorder (ADHD), individual therapy for a
depressed parent, or group social skills training for
the child.
Conceptual foundations of PCIT
Baumrinds63,64 developmental research associating parenting practices with child outcomes has
influenced the development of PCIT. She described
the authoritative parenting style as one in which
parents are highly responsive and highly demanding, and she demonstrated that young children
whose parents who do not adequately meet their
dual needs for nurturance and limits are less likely
to have successful and healthy outcomes. Her
description of the authoritative parent has been
strongly associated with positive child behavior in
many studies (eg, those of Azar and Wolfe,65 Olson
et al,66 and Querido and Eyberg67). This research
suggests that to promote optimal child outcomes,
treatment must focus on promoting optimal
parenting styles and parent-child interactions.
PCIT draws on both attachment and social learning theories to change maladaptive parent-child

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interactions to ones that characterize authoritative


parenting (see Foote et al68). Parents are taught
specific skills to establish a nurturing and secure
relationship with their child while increasing the
childs prosocial behavior and decreasing negative
behavior. Maladaptive parent-child attachments
have been consistently linked to childrens aggressive behavior, low social competence, poor coping
skills, low self-esteem, and poor peer relationships6973 as well as increased maternal stress and
child abuse and neglect.74 Thus, in PCIT, parents
first learn a child-directed interaction (CDI), in
which their part is similar to that of a play therapist.
The parents use skills that restructure the play
interaction in ways designed to create a secure
attachment.
Once parents have mastered the CDI, they learn
the parent-directed interaction (PDI), in which they
incorporate specific behavior management techniques based on social learning theory. Social
learning theory emphasizes the contingencies that
shape the dysfunctional interactions of disruptive
children and their parents. These interactions are
characterized by mutual and escalating aversive
behaviors resulting from the attempts of both the
parent and the child to control behaviors (eg,
arguing, criticizing, whining, aggression) of the
other. This cycle of aversive behavior must be
interrupted by a change in parent behavior, which
involves clear limit-setting that is firmly and consistently enforced during the early years in the context
of an authoritative relationship.75,76 PDI specifically
addresses these processes by establishing consistent contingencies for the childs behaviors that are
implemented in the context of the positive parentchild attachment relationship established through
the CDI interactions.
Assessment in PCIT
PCIT is an assessment-driven treatment. Assessments provide information that helps to determine
treatment needs, evaluate treatment progress, and
assess treatment outcome. The intake assessment
makes use of multiple informants and methods of
measurement to enable an accurate conceptuali-

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zation of the child and environmental factors contributing to the development and maintenance of the
childs disruptive behavior. Assessment methods
include clinical interviews, parent and teacher rating
scales, behavior observations, and measures of parent functioning and satisfaction with treatment (see
Table 1 for a summary of measures developed
specifically for use with PCIT).
The intake assessment begins with a semistructured interview with the childs parents. As the
first contact between therapist and parents, the dual
goals of the interview are to establish a strong
therapeutic alliance and to gather information. The
therapist also attempts to build positive expectations
for treatment outcome. At the same time, the
therapist describes the realistic demands of treatment and helps parents consider potential barriers

to therapy and how they might be managed.


Following the interview, parents complete several rating scales to quantify the childs behavior.
Because the focus of PCIT is on the transactional
nature of the parent-child relationship as it affects
the childs behavior, parents also complete selfreport measures of their own psychological functioning, as well as their parenting style and behaviors that help in tailoring the treatment process.
Finally, standard parent-child interactions are observed in the playroom so that the specific behaviors that serve to maintain the childs disruptive
behavior can be noted and the baseline data can be
charted.
Behavioral observations of the parent-child interactions are recorded throughout treatment to
help the therapist determine parents skill acquisi-

Table 1. Assessment measures in parent-child interaction therapy


Measure

Assesses

Semistructured interview98

Childs presenting behavior problems; factors maintaining the


problems; discipline strategies; family variables that may impact
treatment; psychosocial, family, medical, and educational
history; familys goals and expectations for therapy

Eyberg Child Behavior Inventory (ECBI)2

Parental measure of disruptive behavior at home; 36-item


instrument containing two scales: the intensity scale and the
problem scale; appropriate for children aged 216

Sutter-Eyberg Student Behavior


Inventory-Revised (SESBI-R)2

Teacher measure of disruptive behavior at school; 38-item


questionnaire that provides parallel information to that of the
ECBI

Dyadic Parent-Child Interaction Coding


System-II (DPICS-II)99

Parent-child interactions in the clinic; coded during three,


5-minute standard situations that require increasing amounts of
parental control; 26 codes may be used including verbalizations, vocalizations, and physical behaviors; certain sequences
of behavior also may be coded

Revised Edition of the School Observation


Coding System (REDSOCS)100

Childs disruptive behavior in the classroom; measures the


occurrence of inappropriate, noncompliant, and off-task
behaviors in 10-second intervals; results in 10 minutes of
observed behavior per child in each session; typically observe
on three different school days

Therapy Attitude Inventory (TAI)101

Consumer satisfaction with and parent perception of treatment


program

Management of Disruptive Behavior

tion and guide the course of treatment. Parents also


complete the child behavior rating scale regularly
during treatment to track the childs changes at
home. PCIT ends when parents demonstrate mastery of the interaction skills and the childs behavior
is within normal limits. At the conclusion of treatment, many measures are readministered to evaluate outcome, including the extent of generalized
effects, and to provide a baseline for follow-up
booster sessions.
Format of PCIT
In PCIT, the child and parents are seen together
for weekly, 1-hour sessions. The principles and
skills of each phase of treatment are first explained
to parents alone in a teaching session using modeling and role-play. In subsequent coaching sessions, parents take turns practicing the skills as one
plays with the child in the playroom while his or her
partner observes with the therapist from an observation room. The therapist coaches the parent in
the playroom through a bug-in-the-ear microphone. Most coaching statements are brief, precise,
labeled praises for use of skills (eg, good behavioral description), as well as comments on the
parents style (eg, nice genuine praise), or the
effect of the skills on the child (eg, she is talking
to you more as you reflect more). Coaching
statements also include redirections, suggestions,
noncritical corrections, and interpretations of the
childs behavior. This concentrated, immediate
feedback during the parent-child interaction hastens skill and allows parents to correct mistakes in
their use of new skills before practicing them.
Parents progress through treatment is performance
based. They must meet predetermined skill criteria
before moving from one phase to the next and
before completing treatment. Treatment lasts about
13 sessions on average, but may range from 5 to 25
sessions depending on factors such as parents
regular attendance and motivation to practice.
Child-directed interaction
In the CDI phase of treatment, parents allow the
child to lead the play and learn to use differential

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social attention to apply the nondirective PRIDE


skills to the childs positive behaviors (see Fig 1).
The acronym PRIDE helps parents remember the
skills that convey positive attention: P stands for
praising the childs appropriate behavior, R
stands for reflecting or repeating acceptable talk,
I involves imitating suitable child play, D represents describing appropriate play, and E stands
for being enthusiastic. Parents also learn to avoid
attempting to control the interaction with commands, questions, or criticisms, which can lead to
resistance and negative exchanges. They learn to
ignore annoying child behavior and to distinguish
negative behaviors that are potentially dangerous
and cannot be ignored. Before they have learned
the PDI, parents are instructed to stop the play if
they are faced with behavior that could become
dangerous and deal with it as they normally would.
Parents practice the CDI skills during the weekly
PCIT sessions as well as 5 minutes each day
between sessions. The 5-minute daily home sessions (called special time) are long enough to
produce a therapeutic effect while remaining short
enough not to exhaust parents. As children begin
to enjoy the relationship with their parents created
by the CDI, they are less resistant to the limits and
rules that their parents learn to set in the second
phase of treatment.
Parent-directed interaction
In the PDI phase of treatment, parents learn to
decrease disruptive behavior that is too dangerous to
be ignored, is controlled by reinforcers other than
parents attention, or does not extinguish easily.
Parents continue to use the PRIDE skills to reinforce
their childs positive behavior during PDI, but they
learn also to direct their childs behavior when
needed. They first learn specific skills for giving
effective commands. As outlined in Table 2, commands should be direct, specific, age-appropriate,
positively stated, and respectful. Commands also
should be given one at a time and only when
necessary. The reason that it is important for the child
to obey the command should be explained either
before the command is given or after it is obeyed.

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PRIDE rules

Reason

Examples

Praise appropriate
behavior.

Causes your childs good behavior


to increase.
Lets your child know what you like.
Increases your childs self-esteem.
Makes you and your child feel
good.

Good job of putting the toys


away!
I like the way you are playing
so gently with the toys.
Great idea to make a fence for
the horses.
Thank you for sharing with me.

Reflect appropriate
talk.

Lets your child lead the conversation.


Shows your child that you are
listening.
Demonstrates that you accept and
understand your child.
Improves your childs speech.
Increases verbal communication
between both of you.

Child: I drew a tree. Parent:


Yes, you made a tree.
Child: The doggy has a black
nose. Parent: The dogs nose is
black.
Child: I like to play with blocks
Parent: These blocks are fun.

Imitate appropriate
play.

Lets your child lead.


Shows your child that you approve
of the activity.
Shows that you are involved.
Teaches your child how to play with
others and take turns.
Increases the childs imitation of the
things that you do.

Child: I put a nose on the


potato head. Parent: Im putting
a nose on Mr Potato Head, too.
Child: (drawing circles on a
piece of paper). Parent: Im
going to draw circles on my
paper just like you.

Describe appropriate
behavior.

Lets your child lead.


Shows your child that you are
interested.
Teaches your child concepts.
Models speech for your child.
Holds your childs attention on the
task.
Organizes your childs thoughts
about the activity.

You are making a tower.


You drew a square.
You are putting together Mr
Potato Head.
You put the girl inside the fire
truck.

Be Enthusiastic.

Lets your child know that you are


enjoying the time you are spending
together.
Increases the warmth of play.

Child: (carefully placing a blue


Lego on a tower)
Parent: (gently touching the
childs back) You are REALLY
being gentle with the toys.

Fig 1. PRIDE skills. Source: This is a prepublication version of material from a forthcoming work tentatively titled
Comprehensive Handbook of Psychotherapy, Volume 2, edited by T Patterson and F Kaslow to be published in Spring
2002. Copyright 2001, John Wiley & Sons, Inc. All rights reserved.

Management of Disruptive Behavior

59

Table 2. Eight rules for effective commands in parent-directed interaction


Rule

Reason

Examples

1. Commands should be
direct rather than
indirect.

Leaves no question that the child is


being told to do something.
Does not imply a choice, nor suggest
that the parent might do the task for
the child.
Is not confusing for young children.

Please hand me the block.


Put the train in the box.
Draw a circle.
Instead of
Will you hand me the block?
Lets put the train in the box.
Would you like to draw a circle?

2. Commands should be
positively stated.

Tells child what to do rather than


what not to do.
Avoids criticism of the childs behavior.
Provides a clear statement of what
the child can or should do.

Come sit beside me.


Put your hands in your pocket.
Instead of
Dont run around the room!
Stop touching the crystal.

3. Commands should be
given one at a time.

Helps child to remember the whole


command.
Helps parent to determine if child
completed entire command.

Put your shoes in the closet.


Put your shirt in the hamper.
Instead of
Put your shoes in the closet, take a
bath, and brush your teeth.
Clean your room.

4. Commands should be
specific rather than
vague.

Permits children to know exactly


what they are supposed to do.

Get down off the chair.


Talk in a quiet voice.
Instead of
Be careful.
Behave!

5. Commands should be
age appropriate.

Makes it possible for children to


understand the command and be
able to do what they are told to do.

Put the blue Lego in the box.


Draw a square.
Instead of
Change the location of the azure
plastic block from the floor to its
container.
Draw a hexagon.

6. Commands should be
given politely and
respectfully.

Increases the likelihood that the child


will listen better.
Teaches the child to obey polite and
respectful commands.
Avoids child learning to obey only if
yelled at.
Prepares child for school.

Child: (banging block on table).


Parent: (in a normal tone of voice)
Please hand me the block.
Instead of
Parent: (said loudly) Hand me that
block this instant!

7. Commands should be
explained before they
are given or after they
are obeyed.

Avoids encouraging child to ask


why after a command as a delay
tactic.
Avoids giving child attention for not
obeying.

Parent: Go wash your hands.


Child: Why?
Parent: (ignores, or uses time-out
warning if child disobeys).
Child: (obeys).
Parent: Now your hands look so
clean! It is so good to be all clean
when you go to school!

continues

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Table 2. Continued
Rule

Reason

Examples

8. Commands should be
used only when
necessary.

Decreases the childs frustration (and


the amount of time spent in the timeout chair).

Child: (running around)


Parent: Please sit in this chair. (Good
time to use command)
Instead of
Parent: Please hand me my glass from
the counter. (Not a good time to
use a direct command)

Source: This is a prepublication version of material from a forthcoming work tentatively titled Comprehensive Handbook of Psychotherapy,
Volume 2, edited by T Patterson and F Kaslow to be published in Spring 2002. Copyright 2001, John Wiley & Sons, Inc. All rights reserved.

These rules make it absolutely clear to both the child


and the parent what is expected and help assure that
the child is able and inclined to obey.
The PDI procedure follows an algorithm that
parents are taught to follow precisely (see Fig 2).
Parents are directed to pay attention only to
whether the child obeys or disobeys the command.
When the child obeys, the parent gives a labeled
praise for the childs compliance, which includes
an explanation of why the childs behavior pleases
the parent, and then returns to the PRIDE skills of
CDI until another command is needed. If the child
disobeys, a time-out is initiated that continues until
the child obeys the parents original command. This
procedure provides parents with a specific response for child compliance or noncompliance at
each step, enabling consistency to occur almost
automatically. It also provides a procedure that is
predictable and fair to the child, allowing frequent
opportunities for the child to choose to obey and
end the time-out.
The time-out procedure is initially anxiety-provoking for parents, though. Children often say
hurtful things or have major temper tantrums in
their attempts to manipulate parents into giving in.
In PCIT, parents practice the PDI the first time
during a treatment session, so that therapists are
able to offer emotional support to enable parents to
follow-through calmly during these very stressful
first experiences with consistent time-out. The PDI
coaching sessions allow therapists to coach parents

in relaxation skills and other anger-control techniques when indicated.


Parents initially practice the PDI skills at home in
5- to 10-minute daily clean-up sessions following the
5-minute CDI sessions. Gradually, parents extend
their commands to other times of the day and finally
to only those times when obedience is highly
important. After parents have learned to use the basic
PDI algorithm, they may be taught variations of the
basic procedure for specific aggressive behaviors or
misbehaviors in public situations. Throughout treatment, parents are encouraged to use problemsolving techniques to apply the PCIT principles they
have learned to specific problem situations. Once
children learn that there are predictable consequences for breaking the rules, they learn not to test
limits, which helps parents to feel more in control of
their childs behaviorand their own.
SPECIAL ISSUES IN THE APPLICATION OF
PCIT
PCIT is guided by a comprehensive treatment
manual77 that includes the specific components of
each treatment session as well as general guidelines
for tailoring treatment to the individual differences
and special needs of children and families. These
guidelines have been developed through clinical
experience and during weekly group supervision
meetings when difficult or unique situations in
treatment are discussed. PCIT therapists across the

Management of Disruptive Behavior

Example Please put the car in the toy box.

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COMMAND
Disobey

Obey

WARNING
(CHAIR)

LABELED PRAISE

Stay calm. Take the child immediately to the


chair as you say, You didnt do what I told
you to do, so you have to sit on the chair.
Stay on the chair until I tell you that you can
get off. (3 minutes + 5 seconds quiet)

Disobey

Obey

CHAIR

LABELED PRAISE

Example: Nice job of cleaning


up. I like it when you listen.

Gets off

Stays on

Take the child directly back to the chair while


saying: You got off the chair before I told you
that you could. If you get off the chair again
before I tell you to, you will go to the time-out
room. Stay on chair until I tell you that you
can get off. (This time-out room warning
occurs only once.)

WARNING
(TIME-OUT
ROOM)

RETURN TO
TASK

Go to chair and say: Are you


ready to put the car in the toy
box?

Take the child directly to time-out room while


saying, You got off the chair before I told you
that you could, so you are going to the timeout room. (1 minute + 5 seconds quiet). Then
bring the child back to the chair and say,
Stay on the chair until I tell you that you can
get off.

TIME-OUT
ROOM AND
CHAIR

ACKNOWLEDGE

Gets off

RETURN TO
TASK

Take the child to the time-out room while


saying, You got off the chair before I told you
that you could, so youre going to the timeout room. (1 minute + 5 seconds quiet). Then
bring the child back to the chair and say, Stay
on the chair until I tell you that you can get
off.

TIME-OUT
ROOM AND
CHAIR

Stays on

If no, All right. Then stay on the


chair until I tell you that you can
get off.

etc.

ACKNOWLEDGE

If yes, All right. (Back to the


table; repeat command if
necessary)

If you dont put the car in the toy box, you


will have to sit on the time-out chair.

Gets off

Example: Thank you for doing


that so quickly!
Its good to make the room tidy
before we leave.

If no: Okay, stay here until I tell


you that you can get off.
If yes: All right. (Back to table;
repeat command if necessary)

Stays on

Example: Fine
Go to the chair and say: Are
you ready to come back and
put the car in the toy box?

Fig 2. Parent-directed interaction algorithm. Source: Adapted from Handbook of Parent Training: Parents as CoTherapists for Childrens Behavior Problems (2nd ed.) by JM Briesmeister and CE Schaefer. Copyright 1998, John Wiley
& Sons, Inc. Reprinted by permission of John Wiley & Sons, Inc.

country also discuss issues that arise in treatment on


a listserv and meet annually for a 2-day conference
addressing clinical issues and new research directions in PCIT. Some relatively common guidelines
drawn from the manual are highlighted to illustrate
how individual factors may be addressed in PCIT.
Emotionally distressed parents
Most parents of disruptive children are emotionally distressed. It is difficult to live with a disruptive
child without experiencing stress. Parents also have
stressors not related to child behavior that are

important as well. In each PCIT session, therapists


address these stressors, albeit briefly, to indicate
their concern for the parents not only as agents of
child change. The therapists provide support and
help parents problem-solve if indicated. When
parents are clinically depressed or experiencing
other psychopathology, the therapist will encourage the parent to seek additional help.
Resistant/defensive parents
Parents may feel incompetent, frustrated, helpless, guilty, and embarrassed when seeking help

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with a disruptive child, and these feelings may


manifest as resistance to treatment. Repeated expressions of skepticism about treatment techniques
and failure to use or practice the skills on a regular
basis may be expressions of this resistance. The
PCIT therapist will acknowledge the feelings that
underlie parental resistance and reassure parents
that the difficult child behaviors are not their fault.
The therapist may further reassure the parents that
many children with similar problems have totally
changed these behaviors when parents begin using
the special skills that they are learning. Along with
this, the therapist may point to the changes their
child has shown during the course of a single
coaching session as evidence of the parents ability
to use the skills effectively. At the same time, the
therapist will point to the need for daily practice for
the changes to last and will convey understanding
of the difficulty of finding 5 minutes each day. The
therapist will help the parents to problem-solve
barriers to homework completion and will be
supportive of the parents efforts in the face of the
very real stressors in the parents lives.
Divorced/separated parents
Conducting therapy with divorced or separated
parents is especially challenging. If the parents still
have an adequate working relationship, both parents may be invited to participate in PCIT, especially if both continue to be involved in the childs
care. In most cases, however, divorced parents are
in conflict and unable to work together in treatment. In these cases, the child is usually seen alone
with the primary custodial parent unless the child
spends a significant amount of time with both
parents and both parents wish to be involved in the
childs treatment. When parents in conflict are both
seen, they are seen in separate sessions with the
child, much like two separate therapy cases. The
therapist will explain to the parents in advance that
although the progress of one dyad will not be
discussed with the other, their records may not be
confidential from the other parent depending on
their legal status vis--vis the child.

Intellectually limited parents


Parents in the low average range of intellectual
functioning and their children have been able to
benefit from PCIT. For the intellectually limited
parent, the PCIT therapist must simplify the vocabulary and the sentence structure of the PCIT
skills. For example, reflection is called repeating and the if-then statements are changed to
statements of choice. The parent also is given more
time and repetition in learning the skills of CDI and
PDI. During the teaching sessions, the therapist
uses Mr Bear, a large teddy bear that plays the role
of the child in role-play practice. More than one
teaching session may be conducted before beginning coaching sessions to allow repeated role-play
practice of skills that are particularly difficult for the
parent. More parent-child coaching sessions are used
as well, usually spaced at twice-weekly intervals to
aid retention between sessions. Parents are given
simplified handouts for their use before home practice sessions. Although treatment progresses more
slowly with parents who are intellectually limited,
these parents can learn to use CDI and PDI effectively
to improve their relationship with their child and
improve their childs behavior.
Abusive parents
Children with disruptive behavior are at risk for
physical abuse. The therapist addresses the question of abuse in the pretreatment assessment and
responds to ethical and legal obligations to ensure
the childs safety at any time during treatment that
abuse is suspected. Parents with a documented
physical abuse history are often referred for PCIT.
In these cases, the child may or may not have
significant behavior problems, and the primary
focus of treatment may be the parent. Frequently,
the child is not living with the parent during
treatment, limiting the parents opportunity to practice the PCIT skills outside the treatment session.
Whenever possible, the therapist tries to arrange
supervised parent-child visitation for the purpose
of PCIT practice. Typically, the CDI phase of

Management of Disruptive Behavior

treatment leads to dramatic changes in the childs


affect and behavior as well as the parents perceptions of their childs behavior. During the PDI phase
of treatment, therapists routinely incorporate relaxation training and anger-control training into their
coaching, and make a special point of commenting
on the childs responsiveness to differential social
attention as a method of discipline for the child.
OUTCOME RESEARCH
PCIT is one of several treatments for conduct
problems in young children that have been designated as an empirically supported treatment.78 The
empirically supported treatments for young children, which have demonstrated child behavior
outcomes superior to a control group in welldesigned, randomized controlled trials, include
those developed by Forehand and colleagues,79
Hamilton and MacQuiddy,80 Patterson and colleagues,81,82 Tremblay and colleagues,84,85 and
Webster-Stratton and colleagues83 as well as PCIT.84
The evidence base for PCIT includes comparisons of treated children to wait-list controls,85,86
untreated classroom controls,87 modified treatment
groups,88 treatment dropouts,89 and group parent
training.58 Each comparison has demonstrated the
superiority of treatment over various control conditions. Studies also have shown reliable changes
from outside to within normal limits on parent
ratings and observational measures of childrens
behavior problems and important changes in the
interactional style of fathers and mothers in play
situations with their child, including increased
reflective listening, prosocial verbalization, and
physical proximity and decreased criticism and
sarcasm.90 Significant changes in parents personal
distress, parenting locus of control, and psychopathology also have been found,91 and studies have
consistently shown high parent satisfaction with
treatment. Moreover, the dropout rate of 30% to
35% from PCIT compares favorably with the estimated 40% to 60% rate of attrition among all
children who enter outpatient treatment.92

63

Generalization of the changes that occur during


PCIT has been observed in both the home and
school without direct intervention in those settings.
For example, the behavior of the untreated siblings
of treated children has significantly improved,
suggesting generalization of the new parent behaviors.93 The treated children also have evidenced
classroom behavior that is indistinguishable from
their peers after PCIT,87 demonstrating generalization to school.
Long-term maintenance of the effects of PCIT has
been observed as well. Parent ratings of child
behavior problems, child activity level, and
parenting stress have shown maintenance at 2-year
follow-up, with most children remaining free of
diagnoses of disruptive behavior disorders over
that time.94 In a comparison of PCIT completers and
dropouts at 1- to 3-year follow-up, Edwards and
colleagues89 found significantly fewer symptoms of
disruptive behavior for treatment completers, and
their mothers reported significantly less parenting
stress. The treatment completers also have been
evaluated at 4- to 6-year follow-up and found to
have maintained their treatment gains over this
extended time period.95
CONCLUSION
This article described PCIT, a theoretically based,
assessment-driven, clinically grounded, and empirically supported short-term treatment for young
children with disruptive behavior and their families. As the evidence base of PCIT expands, it will
be important to extend the investigations of effectiveness to real-world clinics where treatment is
provided without the intensive scrutiny of supervisors and cameras recording the fidelity of sessions
delivered by doctoral-level psychology students.
The empirically supported treatments for children
have not yet become the standard of care in most
community clinics, where most young children
with disruptive behavior disorders are treated.
The dissemination of PCIT is only beginning to
be addressed (see Herschell et al96 for a discussion

64

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AND

YOUNG CHILDREN/APRIL 2002

of PCIT training models). A text has been written


that outlines PCIT and provides recommendations
for its implementation,97 and workshops have been
conducted at national conferences (eg, Association
for the Advancement of Behavior Therapy, American Psychological Association). Maintaining treatment integrity is a primary concern, however,
because the effectiveness of PCIT cannot be assured without adherence to its critical components

(ie, coding the parent-child interactions to guide


treatment sessions) and clinical guidelines. The
issue of dissemination is a critical direction for
research and a critical concern for all of the
empirically supported treatments for young children with disruptive behavior disorders because of
the lifelong consequences of disruptive behavior
that is not effectively treated to families and to
society.

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