Parent-child interaction therapy for children diagnosed with reactive attachment disorder

Parent-child interaction therapy for children diagnosed with reactive attachment disorder

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Parent-child interaction therapy for children diagnosed with reactive attachment disorder
Soulounias-Arriaga, Demetria
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[Tampa, Fla]
University of South Florida
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Subjects / Keywords:
Positive interaction styles
Play therapy
Behavior problems
Dissertations, Academic -- Child and Family Studies -- Masters -- USF ( lcsh )
non-fiction ( marcgt )


ABSTRACT: Parent-Child Interaction Therapy is a probably efficacious, evidenced-based treatment, which has been proven to decrease problem behaviors of children, as well as improve parent-child interactions. The first phase is the Child-Directed Interaction (CDI), which allows the child to lead the play session, while parents are taught to interact without giving demands, asking questions, or providing criticism. According to the DSM-IV-TR, Reactive Attachment Disorder is a rare diagnosis. Many attachment therapists indicate that traditional approaches to treatment have not been demonstrated as being effective with these children. This study will examine the CDI phase of Parent-Child Interaction Therapy as a potential treatment option for children diagnosed with Reactive Attachment Disorder.
Thesis (M.A.)--University of South Florida, 2009.
Includes bibliographical references.
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by Demetria Soulounias-Arriaga.

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Soulounias-Arriaga, Demetria.
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Parent-child interaction therapy for children diagnosed with reactive attachment disorder
h [electronic resource] /
by Demetria Soulounias-Arriaga.
[Tampa, Fla] :
b University of South Florida,
Title from PDF of title page.
Document formatted into pages; contains X pages.
Thesis (M.A.)--University of South Florida, 2009.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
Mode of access: World Wide Web.
System requirements: World Wide Web browser and PDF reader.
3 520
ABSTRACT: Parent-Child Interaction Therapy is a probably efficacious, evidenced-based treatment, which has been proven to decrease problem behaviors of children, as well as improve parent-child interactions. The first phase is the Child-Directed Interaction (CDI), which allows the child to lead the play session, while parents are taught to interact without giving demands, asking questions, or providing criticism. According to the DSM-IV-TR, Reactive Attachment Disorder is a rare diagnosis. Many attachment therapists indicate that traditional approaches to treatment have not been demonstrated as being effective with these children. This study will examine the CDI phase of Parent-Child Interaction Therapy as a potential treatment option for children diagnosed with Reactive Attachment Disorder.
Advisor: Debra Mowery, Ph.D.
Positive interaction styles
Play therapy
Behavior problems
Dissertations, Academic
x Child and Family Studies
t USF Electronic Theses and Dissertations.
4 856


Parent-Child Inter action Therapy for Children Diagnosed With Reactive Attachment Disorder by Demetria Soulounias-Arriaga A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Child and Family Studies College of Behavioral and Community Sciences University of South Florida Major Professor: Debra Mowery, Ph.D. Trevor Stokes, Ph.D. Mary Fuller, Ph.D. Date of Approval: November 20, 2007 Keywords: adoption, positive interaction styl es, play therapy, behavior problems, bonding Copyright 2009, Demetria Soulounias-Arriaga


Dedication This thesis would have been nearly impossible without mention of the many people who supported me throughout this process. I would like to thank my mother and father for instilling in me the value of e ducation and a lifetime of encouragement and support. I must also thank my husband a nd children for allowing me the opportunity to pursue my goals and for their love, laughter and energy that make life a gift everyday. You are all the great lo ves of my life. I couldnÂ’t have completed this without th e best thesis committee ever organized. First, I would like to thank my initial major professor, Dr. Trevor Stokes, to whom I owe my eternal gratitude for his patience, guidan ce and wisdom. I feel honored to have had the opportunity to work with you. I will never forget our Thur sday meeting chats. I am also honored to consider you my friend. Dr Mowery, thank you for agreeing to become my major professor at the end of my journey. Dr. Stokes coul dnÂ’t have left me in better hands. You were patient and kind and I will never forget your positive inspiration. Dr. Fuller, thank you for all of your time and great wisdom. I was extremely fortunate to have you on my committee. Completing my MasterÂ’s Degree was a wonde rful journey and I will be indebted forever to the University of South Florida Beha vior Analysis Program.


Acknowledgements I would like to extend my a ppreciation to the faculty of the Applied Behavior Analysis Program. I would also like to th ank my colleagues and friends who gave me constant encouragement and guidance through my first research experience. I would like to thank the participant families who invite d me into their homes and lives and for attempting to break the cycle of abuse and negl ect. To the participant mothers, you are truly inspiring women. I woul d also like to thank the two children who participated in my research. You are both: intelligent, energe tic, and wonderful children. May the rest of your lives be filled with a family, stability and love.


i Table of Contents List of Tables iii List of Figures iv Abstract v Chapter One Introduction 1 Literature Review 1 Reactive Attachment Disorder 2 Forms of Attachment Therapy 3 Available Research on Attachment Therapies 7 Parent-Child Interaction Therapy 11 Child Directed Interaction (CDI) 11 Parent-Directed Interaction (PDI) 12 Available Literature on Sequence Effect 12 Available Literature on the Ma intenance Effects of PCIT 13 PCIT for Foster Parent s and Biological Parents 15 The Present Study 18 Chapter Two Method 20 Participants 20 Instrumentation 23 Indirect Measures Using Rating Scales 23 Eyberg Child Behavior Inventory (ECBI) 23 Social Validity Questionnaire 24 The Kinship Center At tachment Questionnaire 24 Experimental Design 25 Variables Defined 26 Independent Variable 26 Dependent Variables 27 Procedures 29 Baseline Sessions 29 Treatment Sessions 30 Interobserver Reliability 34 Chapter Three Results 35 CDI Skills 35 Parent Behavior to Increase 35 Parent behavior to Decrease 41 Eyberg Child Behavior Inventory (ECBI) 43


ii Social Validity 44 Kinship Center Attach ment Questionnaire 46 Chapter Four Discussion 47 Limitations Recommendations for Future Research 53 Conclusions 56 References 57 Appendices 63 Appendix A. Direct Observation Form: Parent CDI Skills 64 Appendix B. Behavi oral Definitions 65 Appendix C. Social Validity Questionnaire 66 Appendix D. Kinship Center Attachment Qu estionnaire 67


iii List of Tables Table 1. Parental ratings on social vali dity questionnaire 45


iv List of Figures Figure 1. Multiple baseline across participants for CDI increase skills 37 Figure 2. Multiple baseline across participants for labeled praises 38 Figure 3. Multiple baseline across participants for refl ective statements 39 Figure 4. Multiple baseline across participants fo r behavioral descriptions 40 Figure 5. Multiple baseline data for parent CDI skills to decrease 42 Figure 6. ECBI total intensity scores for Jimmy and Trevor 43 Figure 7. ECBI total problem scores fo r Jimmy and Trevor 44


v Parent-Child Interaction Therapy for Children Diagnosed With Reactive Attachment Disorder Demetria Soulounias-Arriaga ABSTRACT Parent-Child Interaction Therapy is a probably efficacious, evidenced-based treatment, which has been proven to decrease problem behaviors of children, as well as improve parent-child interactions. The first pha se is the Child-Directed Interaction (CDI), which allows the child to lead the play session, while parents ar e taught to interact without giving demands, asking questions, or providing criticism. According to the DSM-IV-TR, Reactive Attachment Disorder is a rare diagnosis. Many attachment therapists indicate that traditional approaches to treatment have not been demonstrated as being effective with these children. This study will examine the CDI phase of ParentChild Interaction Therapy as a potential tr eatment option for children diagnosed with Reactive Attachment Disorder.


1 Chapter 1 Introduction Literature Review Parent-Child Interaction Th erapy (PCIT) is an evidence-based treatment for families of young children with behavior pr oblems. Treatment begins with a childdirected interaction (CDI) phase in which parent s learn to follow their child’s lead in play situations, using skills similar to traditio nal play therapy techniques to enhance the parent-child relationship. Th e purpose of the CDI phase is to “restructure the parentchild relationship and provide th e child with a secure attach ment to his or her parent” (Storch, 2005, p. 106). The parent-directed in teraction (PDI) phase of treatment is introduced after CDI skills are mastered. In the PDI phase, parents learn ways to provide consistent consequences for child appropriate behaviors as well as a systematic time-out procedure for child non-compliance (Brinkmeyer & Eyberg, 2003). Both phases of PCIT teach parents basic behavioral principles fo r managing child behavior; parents learn to ignore or punish maladaptive child behaviors and to reward appropr iate child behaviors with positive attention. As cited in Timmer, Urquiza, Zebell, a nd McGrath (2005, p. 828) “PCIT has been effective in reducing behavior problems in children (Eisenstadt, T. H., Eyberg, S., McNeil, C., Newcomb, K., & Funderburk, B ., 1993; Eyberg, 1988; Eyberg & Robinson, 1982), and maintaining these positive effects up to 6 y ears post treatment (Hood & Eyberg, 2003). Treatment effects also have b een shown to generalize to school settings


2 (Funderburk, B., Eyberg, S., Newcomb, K., Mc Neil, C., Hembree-Kigin, T., & Capage, 1998; McNeil, Eyberg, Eisenstadt, Newcom b, & Funderburk, 1991), and to untreated siblings (Brestan, Eyberg, Boggs, & Algi na, 1997; Eyberg & Robinson, 1982). In addition, PCIT also has been shown to be as effective for foster parents as biological parents. According to parent reports, ch ild behavior problems go from above normal limits at pre-treatment to within normal limits at post-treatment. In addition, parents report less personal distress as their child’s disruptive behavior decreases” (Schuhmann, Foote, Eyberg, Boggs & Algina, 1998). Although empirically established for th e treatment of disruptive behavior, researchers have also proposed PCIT for treat ing the internalizing be havior disorders of young children, including Genera lized Anxiety Disorder ( GAD) and Separation Anxiety Disorder (SAD) (Choate, Pincus, Eyberg & Barlow, 2005; Eyberg, 1979; Lyman & Hembree-Kigin, 1994). PCIT provides opportunitie s for parents to model and reinforce many positive coping skills. PCIT also helps reduce harsh discipline (Eisenstadt et al., 1993), which is significantly linked to both internalizing and exte rnalizing behavior disorders in young children. A study of PCIT wi th children with a primary diagnosis of SAD demonstrated significant reductions in anxiety, along with lower rates of disruptive behavior (Choate, Pincus, E yberg, & Barlow, 2005). Based on these studies, PCIT seems to be a promising treatment for internalizing disorders. Reactive attachment disorder The diagnosis of Reactive Attachment Disorder (RAD) of Infancy or Early Childhood from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR, American Psychiatric Association [APA], 2000), is


3 characterized by disturbed and developmentally “inappropriate social relatedness in most contexts, that begins before age 5 and is asso ciated with grossly pa thological care” (APA, 2000, p. 127). Two different types are desc ribed. The Inhibited Type includes: “persistent failure to initiate or respond in a developmentally appropr iate fashion to most social interactions, as manifest by excessi vely inhibited, hyper vigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resist ance to comforting, or may exhibit frozen watchfulness” (APA, 2000, p. 130). The Disinhi bited Type is described by “diffuse attachments as manifest by indiscriminate so ciability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with re lative strangers or lack of selectivity in choice of attachme nt figures)” (APA, 2000, p. 130). Also, to be diagnosed with RAD, the child must not ha ve a developmental delay as in Mental Retardation and does not meet criteria for a Pervasive Developmental Disorder (APA, 2000). The DSM-IV-TR criteria also states th at the child’s histor y should also include “pathogenic care”, as evidenced by at least one of the following: “persistent disregard of the child’s basic emotional needs for comfor t, stimulation, and aff ection; persistent disregard of the child’s basic physical needs, repeated changes of pr imary caregiver that prevent formation of stable attachments (e .g., frequent changes in foster care)” (APA, 2000, p. 130). According to the DSM-IV-TR, “… Reactive Attachment Disorder appears to be very uncommon” (APA, 2000, p. 129). Forms of attachment therapy Werner-Wilson and Davenport (2003, p. 182) discuss how “It would seem logical that a form of family therapy would be the treatment choice” for children with RAD based on the description in the DSM IV TR; however,


4 “most of the current clinical writing takes an individualized approach in which the child is the primary target of intervention.” In ma ny instances, a diagnosis of RAD is made off of a questionnaire called th e Randolph Attachment Disorder Questionnaire (RADQ) (Randolph, 2001). The RADQ is one of the better known checklists and is used by attachment therapists and others, but cri tics consider it lacks specificity and is unvalidated. The checklist includes 93 behaviors. Many of these behaviors either overlap with other disorders, like Conduct Disorder and Oppositional Defiant Disorder, or are not related to attachment difficulties. Randolph is often cited by ot her Attachment Therapists around the country as being the foremost rese archer in Attachment Therapy. Her RADQ, though invalidated by independently published research, is widely used in the Attachment Therapy (AT) community to diagnose and evaluate the conditi on called "attachment disorder", which is not found in the DSM-IV-T R. None of Randolph's research has been published in peer-reviewed psycholo gy journals (Mercer, 2002). AT has also been referred to as hol ding therapy, rage-reduc tion therapy, and Zprocess therapy, among other terms (Mal oney, 2003). Jean Mercer, a psychology professor at Richard Stockton College in New Jersey is an outspoken critic of holding therapy and other aspects of attachment ther apy. AT is a broad term with no generally agreed-upon meaning. AT as applied in attachment disorders has involved one or more of the following techniques: Therapeutic Parenting, Holding Therapy and Rebirthing (Mercer, 2002). Therapeutic Parenting could be viewed as the least physically intrusive of all of the techniques. For example, these “therapeut ic parenting” techniques may be used either by parents in the child’s own home or by sp ecially trained foster parents who care for


5 children while they are receiving other form s of AT. Thomas (2000) explains how parents are to achieve the position of “stronger and/or wiser” person by “commanding and demanding respect and by using eye contact to assure the child of the presence, love, and attentiveness” (p.85). One main com ponent of this technique enforces child compliance with such practices as “strong sitting,” or “power sitting”. “Power sitting” is a tool used by some attachment therapists to teach children “self control”. Parents are told to choose a “think spot”, which should be a spot on the floor with a small washable, rubber-backed rug for children over four year s of age. Correct body position includes legs and hands folded, back straight, head st raight, no other body parts moving as well as no talking is permitted. Parents are recomm ended to face the children toward a blank wall. Power sitting is recommended to be 5 consecutive minutes in length with an additional 1 minute per age year of the child (Thomas, 2000). The child is to be given positive attention only when doing this properly and no privileges are to be allowed until the sitting is completed; this is to be done th ree times a day. The child is given the choice between the prescribed period of power sitting or 2 hours of “wimpy sitting,” for lack of compliance with the “power sitting rules” (Thomas, 2000, p.73). Other forms of parental control are seen as necessary for the child’s es tablishment of “self-control”. For example, children may not be allowed to speak until spoken to in the car. If they speak, they must be required to hold their hand over their mout hs for 5 to 15 minutes. Withholding of food and completing heavy chores are other aspe cts of this technique. Mercer (2001) describes that of all the aspects of AT, therap eutic parenting seems to come closest to any accepted practice. She states that some as pects of therapeutic parenting seem to “resemble applied behavior analysis” (p. 8). However, she mentions that in AT, the main


6 objective is to strengthen th e “authority of the therapeutic parent which makes many of the possible reinforcers non-contingent on th e child’s behavior” (p. 8). Also, Mercer points out that any written mate rials describing the practice of therapeutic parenting fails to clarify how procedures such as power si tting are actually induced. There are many distinct differences between “therapeutic pare nting” and applied behavior analysis (ABA). One distinction of ABA is that child behavi or is observed and analyzed to determine a function, in which a treatment is designed ba sed on that function. In ABA, the least restrictive procedure is always recommended and considered and procedures that have not been evaluated for effectiveness are not used in case they could cause potential psychological or physical harm. The practice of holding therapy involves “res traint that is intended to stimulate the release of old anger and to ready the child for the fo rmation of good relationships” (Mercer, 2001, p. 2). Although holding ther apy is an important feature of AT, practitioners vary greatly in their opinions a bout details of the treatment. Delaney and Kunstal (1993) regard holding as a treatme nt of last resort and have cautioned practitioners to check on legal and insurance guidelines and never to threaten a child with abandonment or use of excessi ve provocation (Mercer, 2002). The AT controversy has mostly cente red on “rage reduction therapy”, more currently known as “holding therapy”. A mild form of holding therapy may just include a child being held by his/her parent while enfo rcing eye contact in an effort to improve the attachment. However, in some instances this therapy may include verbal abuse, restraining, or procedures such as deep tissue massage, aversive tickling, “compression holding therapy”, and punishme nts related to food and wate r intake and enforced eye


7 contact. One or more adults sit on the floor or on a sofa restraining the child being treated. Practitioners base its use on the assumption that rage resulting from early mistreatment must be provoked and released in order for the child to form an emotional attachment (Mercer, 2001). Mercer (2001) describes the most distur bing technique used by some attachment therapists called “rebirthing” from Crowder’s (2000) article. Crow der (2000) states the procedure involves wrapping a child tightly in blankets, covering them with pillows, and holding them down by several adults who pus h on the pillows in imitation of uterine contractions (Mercer, 2001). The child is to work to escape from the restraint and to be “reborn”. The claim is that this process will allow for a readiness to enter new positive relationships because the negative relationships from the past have been deleted. Mercer (2001) discusses how attachment therapists have been implicated in th e deaths of at least four children (Crowder, 2000; Horn, 1997; Smith, 1996). The most publicized case occurred in April 2000. A child undergoing th e rebirthing therapy at the Attachment Center at Evergreen was held tightly inside a blanket for more than 70 minutes as five adults pushed on her and encouraged her to be “reborn,” and told her to “go ahead and die”. She vomited and was asphyxiated (Crowder, 2000). Available research on attachment therapies Mercer (2001) explains that the available evidence regarding the efficacy of AT is weak because there are not any reported studies of the effect of AT on ch ildren using random assi gnment to groups. Much of the referenced evidence involves th ree quasi-experimental studies, a dissertation, and one journal article based on th is dissertation (Mercer, 2002).


8 In a study conducted by Lester (1997), 12 fa milies with adopted children received AT. The children experienced different levels of treatment, many with 3-hour sessions, daily for weeks. The parents completed two rating scales on four occasions (before the childÂ’s initial assessment, at the time of th e initial assessment, after the assessment but before therapy began, and at least 4 weeks after therapy be gan). Average scores were presented, but there were no statistical analyses Lester reported that all scores improved over time, but that the greatest improvement occurred before therapy had begun. She noted that the parents might simply have felt better after ta lking to someone about their difficulties. A study conducted by Becker-Weidman (2006), attempted to use the RADQ and a behavior checklist pre-post for 34 childre n. Becker-Weidman re ported statistically significant improvements and attributed them to the treatment. In the absence of a comparison group, it is not possible to state that the treatment was effective. The one published study conducted by My eroff, Mertlich, and Gross (1999) conducted a two group, pre-post-design of conve nience. Twenty-three families who had contacted the Attachment Center at Evergreen (ACE) for thei r adopted children were the participants in the study. The parents completed the Child Behavior Checklist (CBCL, Achenback & Rescorla, 2001; Achenback & Re scorla, 2000) before and after treatment. This instrument lists approximately 100 problem behaviors that chil dren might display. These measures ask parents or caregivers to report on the frequency of specific problem behaviors displayed by their children on a th ree-point scale (0=nev er to 2=often). Normative data were derived from a larg e diverse population of both non-referred and clinic-referred children and their parents. The use of the CBCLÂ’s two scales of


9 Internalizing and Externalizing behaviors are scored as a measure of the severity of children’s symptoms. The treatment group was composed of 12 children and the untreated comparison group was composed of 11 children whose parent s made contact with, but were unable to bring them to ACE. Therefore, this was not a controlled study, as there was not a random assignment of participants. The dependent variables were the sc ores on the CBCL on the dimensions of aggression and delinquenc y, and the independent variable was the implementation of a two week intensive treatment package which included: therapeutic holding, cognitive restructuring, psycho-dramatic reenactment, and inner child metaphor therapy. Both groups of parents completed th e CBCL after their init ial contact and again after a 4-week interval. Fo r the treatment group, the two week “intensive therapy” occurred midway between the two reports. The referred child, parents, and treatment team consisting of one therapist and the treatm ent foster mother, were all present for 30 hours of therapy. Specifically, the 30 hours of therapy was broken down into three hours per day for 10 consecutive days. Each family entering treatment at Evergreen was assigned to a therapeutic parent who houses the child for the two weeks of treatment. This means that the interactions the parent and child have together are the three hours during the actual treatment time, weekends, and certain times during the two weeks when the parent and child have interactions for limited amounts of time. All therapists and therapeutic parents were trained systema tically at the Attachment Center. In this study, the therapeutic holding tec hnique is described as being “designed to imitate the infant nurturing position on a couch. The child lies across the therapist’s lap with their head resting on a pillow. This allows for close proximity, eye contact, and


10 physical restriction” (Myero ff et al., 1999, p. 307). Psychodram atic reenactment involved the treatment team using role-plays of importa nt people in the child’s past allowing for a gradual progression into the even ts of the past, and the abil ity to confront and express what is needed leading the child to an interp ersonal sense of mastery. This also allows for “revisions of old self perceptions and fant asies about self and past significant figures” (Myeroff et al., 1999, p. 308). Inner child metaphor is also utilized during these sessions as the child is asked to visualize himself/hers elf in the past, and while being held, is asked a series of questions about th at early time and how those experiences and feelings relate to his/her present relationships. In addition to these techniques, mother-child exercises are repeated many times including holding, c overing with blankets, and feeding with a bottle. Sessions also include e xploration of any birth father issues that may be present. The adoptive father now holds the child, as ps ycho-dramatic reenactment is utilized to provoke and resolve these father issues. The pr ocess of grief and mourning is explored in relation to the many losses experienced by th ese children. This process allows for cognitive restructuring thr ough dialogue with the role–played birth parents. Myeroff et al. (1999) repo rted significant differences between the two groups, with the treatment group showing signifi cant improvements on both the aggression and delinquency subscales. Some thr eats to internal validity incl ude that the parents of the children paid thousands of dollars for th eir children to receive treatment and the children’s problem behaviors and delinquency we re measured only by parental reports. None of the reported studies involved a randomized experimental design. All of the studies on AT reported positive treatment results based on pre-post ratings, or quasi


11 experiments. Attachment was never defined in these studies, and there were no direct measures of problem behaviors. Parent-Child interaction therapy Parent-Child Interaction Therapy (PCIT) is a manualized treatment developed for children between the ages of 2 and 7 y ears with behavior problems (Hembree-Kigin & McNeil, 1995). PCIT is based on the 2-stag e operant model devel oped by Hanf (1969). Eyberg (1988) modified the Hanf model by incorporating aspects of traditional play therapy. PCIT incorporates both traditional play therapy and behavioral techniques. Throughout the intervention, the th erapist observes parent-child interactions from behind a one-way mirror. The parent often wears a bug-in-the-ear device, a small earphone that allows the therapist to coach and provide feedback on skills throughout the session. In the absence of this technology, the coachi ng may be provided in the home environment or clinic, with a therapist shadowing the parent and providing f eedback discretely. Child directed interaction (CDI ). PCIT begins with a relationship enhancement phase, or Child Directed Inter action (CDI) phase. This phase of the treatment is based on attachment theory and designed to create more positive interactions between the parent and child and to teach parents to build better relationships with their children. This is accomplished in a variety of ways. First, the parent learns to implement new skills in the context of play. The parent is instructed to follow the childÂ’s lead during play. Parents are taught to avoid questions, criticisms, and co mmands, in an effort to allow their child to lead during play time. Allowing the child to lead the play incr eases the likelihood that the childÂ’s behavior will be appropriate, gi ving parents many opportunities to praise good behavior. During this phase, parents also are instructed in th e use of differential


12 reinforcement. Parents provide enthusiastic a ttention using behavioral play therapy skills. These skills come together to create th e acronym PRIDE (praise, reflection, imitation, description, enthusiasm). If the child beco mes disruptive (e.g., pl aying roughly with the toys), parents are inst ructed to ignore the behavior. While ignoring, the parent physically turns away from the child such that there is no eye contact, physical contact, or verbal contact. Once the child returns to appropriate play, the parent is instructed to turn his or her attention back to the child enthusiastica lly. This phase lasts approximately 4-7 weeks or until the parent has reached the “maste ry criteria” for the parenting skills (e.g., 10 labeled praises in 5 minutes). Parent-directed interaction (PDI ). Parent-Directed Interact ion (PDI) is the next phase, during which parents are taught a safe and effective discipline procedure. During this phase, child compliance is targeted. Parents are taught three skills to manage problem behaviors: (1) how to give an effec tive instruction, (2) how to praise compliance to instructions, and (3) how to punish non-co mpliant behavior, using a systematic timeout procedure. Parents are coached to be consistent and remain calm during these interactions. Available literature on sequence effect Eisenstadt, et al. (1993) ev aluated the effectiveness of Parent-Child Interaction Therapy (PCIT) for 24 mother-child dyads. Families received 14 weekly sessions of PCIT, with half receiving Child-Directed Inte raction training first (CDI-First group) and half receiving Parent-Direct ed Interaction training fi rst (PDI-First group). At midtreatment, the PDI training stage was more effective than the CDI stage for reducing non-compliance and disruptiveness. The groups we re also compared at post-treatment to


13 examine the impact of stage sequence. The PDI-First group was more improved on parent report of conduct problems, a nd mothers were more satisfied with therapy. The two groups were combined to examine overall treatment outcome. Families moved from outside normal limits to within normal li mits on compliance, conduct problems, activity level, and maternal stress, and showed impr ovement in internalizing problems and child self-esteem. Gains were maintained at 6-week follow-up. Available literature on the ma intenance effects of PCIT Eyberg et al. (2001) examined 1a nd 2-year long-term outcomes of PCIT treatment. Twenty families completed the tr eatment program and 13 were available for a follow-up evaluation. Along with other rating scales, the Dyadic Parent-Child Interaction Coding System (DPICS) (Eyberg, Nelson, Duke, & Boggs, 2005) was used in this study The DPICS was designed to assess the quality of parent-child soci al interactions. It provided an observational measure of parent and child behaviors during three 5-minute standard situations that varied in the de gree of parental contro l required. Adequate reliability, discriminative validity, and treatment sensitivity have been established in several studies (Eyberg & Robi nson, 1982). Coders were two graduate students unaware of the studyÂ’s purpose or hypotheses that a ttained 80% agreement with a criterion training tape prior to coding the participants in the study. Child categories were clustered into summary variables labeled child verbal positive and child de viant behavior. Child verbal positive behavior consisted of a child Â’s laugh or self-praise, and child deviant behavior consisted of yell, whine, cry, smar t talk, or destructive behavior. Additional child categories were examined separate ly, including alpha compliance (ratio of compliance to total commands that provide an opportunity for compliance) and


14 inappropriate physical behavior. Parent categor ies were clustered into summary variables labeled parent follow, parent lead, parent a ffection, and parent nega tive behavior. Parent follow consisted of descriptive and reflectiv e statements. Parent lead consisted of questions or commands. Parent affection consisted of praise or positive touch. Parent negative behavior consisted of critic ism or physical negative behavior. An analysis of pretreatment demographi c characteristics of those who participated in the follow-up assessment and those who di d not participate revealed no significant differences. Both frequency of maladaptive be havior and related pare ntal concerns were significantly lower than the pretreatment sc ore at both the 1a nd 2-year follow-up. Hood and Eyberg (2003) examined the main tenance of PCIT results three to six years after treatment. Twenty-three of fifty parent-child dyads who had completed PCIT treatment and an initial asse ssment participated in the follow-up evaluation. An analysis of pretreatment demographic characteristics and Eyberg Ch ild Behavior Inventory (ECBI) (Eyberg & Robinson, 1983) scores of those who participated in the follow-up assessment and those who did not participate revealed no significant differences. The ECBI is a 36item scale that measures specific behavior problems exhibited by children ages 2-16. Compared to the CBCL, the ECBI lists more commonly observed child behavior problems, including arguing and fighting with siblings. Caregivers indicate the frequency of certain behavior s along a seven-point scale (1=n ever to 7=all the time) and whether they are considered to be problems (1=yes, 0=no). Scores are summed to obtain an Intensity score and a Problem score (E yberg & Pincus, 1999; Eyberg & Robinson, 1983; Eyberg & Ross, 1978). ECBI scores at follow-up showed sta tistically significant differences when compared to pretreatment scores, although to a slightly lesser degree


15 than immediately following treatment. The au thors concluded that “t he children not only maintained their gains but also showed c ontinuing behavioral gains with time. The mothers’confidence in their ability to “control their child’s behavior was also maintained” (p. 426). An important study by Boggs, Eyberg, Edwards, Rayfield, Jacobs, Bagner, and Hood (2004) compared completers of PCIT tr eatment versus study dropouts 1to 3-years post-treatment. The authors concluded: “Resul ts indicated consisten tly better long-term outcomes for those who completed treatment than for study dropouts” (p. 2). The study emphasized, “…without completing treatment, parent s see little change in the very severe behavior problems . .” (p. 18). Th is study exemplifies how PCIT treatment is successful because it is carried out to a speci fic criterion level. There is a performance based evaluation of treatment progress. PCIT for foster parents and biological parents McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk (1991) evaluated genera lization of treatment effects from home to school setting in ten 2 to 7-year-old children who were referred for treatment of severe conduct problem behaviors occurring both at home and in the classroom. Families received 14 weeks of PCIT. No direct cla ssroom interventions were conducted. The treatment group displayed significantly greate r improvements than two control groups on all measures of conduct problem behavior in the classroom. Resu lts in the areas of hyperactivity/distractibility and social behavior were less supportive of generalization. Positive school generalization results contradict previous findings that children's behavior in the classroom either shows minimal improveme nt or worsens following parent training.


16 Timmer et al. (2005) conducted a study to ex amine the effectiven ess of PCIT with maltreating parent-child dyads. This st udy used a pre-post, group design with 136 biological parent-child dyads in which 66.9% or 91 of the children had been maltreated. Of the 91 maltreated children, 64.8%, (59) of the parents had maltr eated their children, and were considered to be at high risk of repeating the abus e. Children were between the ages of 2-8 years and had behavior problem s. Parents were required to complete a number of rating scales prior to treatment and again during their last treatment session. Parents completed a Child Abuse Pote ntial Inventory (CAPI) (Milner, 1986), which is an inventory that includes an abuse potential scale and severa l validity scales. These scales are normed and validated by a multitude of studies. The CBCL and the ECBI were also used. The Parenting Stress Inventory (PSI) (Abidi n, 1995) was also used to identify parent-child dyads that are experien cing stress and are at risk for developing dysfunctional parenting and child behavior pr oblems. The PSI contains 120 items rated on a five-point scale (1=Strongly Di sagree to 5=Strongly Agree). The Symptom Checklist 90-R ( Derogatis, 1977) is a 90-item self-report symptom inventory designed to assess cu rrent presence of psychological symptom patterns. Each item is a brief description of a psychological symptom and is rated on a five-point scale (0=no discomfort to 4=extreme discomfort). The SCL-90-R has nine symptom subscales; somatization, obsessive compulsive, inte rpersonal sensitivit y, depression, anxiety, hostility, phobic anxiety, paranoi d ideation, and psychoticism. T-scores were calculated using the norms for adult non-patients. Maltreatment history was obtained from therapistsÂ’ reports, social workerÂ’s reports, and by research staffÂ’ s review of any available court records. Children were


17 classified as either having a suspected or documented history of maltreatment, or having no history of maltreatment. For the purposes of the study, children with suspected and documented histories of maltreatment were both classified as having a history of maltreatments. Results indicated that there wa s a decrease in child behavior problems, a decrease in parental stress, and a decrease in abuse risk fr om pre-to post-treatment for dyads with and without a history of maltreatme nt. The conclusions from the results may add to the body of research supporting PCIT as a promising intervention and as a means to aid both children and parents in hi gh-risk families for maltreatment. Timmer et al. (2005) discuss several limitati ons to their study. First, there was no random assignment of abusive parent-child dyads to a PCIT condition. There was no follow-up data to demonstrate the maintenance of treatment effects over time, but relied on preversus post-treatment comparisons as indicators of treatment effectiveness. Timmer et al. (2005) discuss how “recent rese arch of PCIT has documented maintenance of reductions in child behavior problems afte r participation in PCIT for up to 6 years post-treatment” (Hood & Eyberg, 2003, p. 838). The PCIT paradigm is founded on the belief that by coaching parents to praise thei r children’s positive be haviors, ignoring their inappropriate behaviors, and teaching those skills, the children will behave well and parents will be happy with them. In other wo rds, parents’ reports of improvements in children’s behavior are more a reflection of a shift in their own attitudes towards their children than a change in children’s behavior Perhaps by shifting the parents’ behavior to focus on positive aspects of their children, there is a shift in attitudes about and perceptions of their ch ildren, and their own functioning c ould be an extension of their


18 own desire to present themselves in a favorab le light in order to retain custody of their children or to feel more co mpetent as parents. There are a number of methodological lim itations of the studies reviewed that should be considered when inte rpreting the findings. First, al l of the dependent measures were based on parental reports. The possibility for bias always exists when relying solely on parental report. Parents in the treatment group, for example, may have been biased to report positive behavioral improvements beca use of expectancy effects (i.e., “placebo” effects) or a desire to please the therapists. Only subjective rating scales were used as methods to obtain baseline data of children’ s behavior problems. Specific targeted behaviors were never defined. The parents involved in the study had invested time into the study and expressed that they felt it was an important study from the onset. This could be a potential threat to internal valid ity because the parents had invested time and energy into attending the session s and could have become a vari able that influenced their rating scores for post-tests. Additional behavioral observation data is needed to objectively measure the quantity and severity of behavior problems at both assessment periods. The Present Study Applying PCIT in a typical behavior analytic, multiple baseline design could be an effective design to show potenti al robust treatment effects and to rule out extraneous variables causing behavior to change. Futu re studies could include baseline data collection using direct measurement of behavi or as well as includi ng parental stress or other means of obtaining social validity measures.


19 It seems to be good practice to include measur es such as the stress inventory, but not to solely use subjective questionnai res and rating scales as the only means of collecting data. The purpose of this study will be to conduc t a systematic replication of the CDI phase of PCIT, extending the re search to the population of children diagnosed with RAD, in an attempt to increase positive interactions between children and parents and possibly decrease behavior problems.


20 Chapter 2 Method Participants Prior to the initiation of this research project, approval fr om the Institutional Review Board (IRB) for the Prot ection of Human Participants at the University of South Florida was obtained, as well as an additiona l approval from the Department of Children and Families, Office of Family Safety. The following criteria were used to select participants: A flyer was sent out to various agencies which work with foster children and provide trainings to foster parents. Two foster parent s independently contacted the principal investigator and the ch ildren involved met all of the cr iteria to participate in the study. During the consent process, the parent s reviewed a consent form which explained the type of assessment and treatment which was part of the study, the time required for their participation, and conditions in place that ensured confidentiality. The parents were informed that all identifying information will remain confidential and that their responses will be used for research purposes only. Parent s were also informed that they have the right to withdraw at any point Parents were asked to sign a consent form for the childÂ’s participation. In the presence of a parent or guardian, the pr incipal investigator explained participation in the study to the child using words that were age appropriate and allowed the child to ask questions and receive answ ers. Only participants receiving parent permission were included in the study.


21 The participants involved in the study we re two parent-child dyads. Both dyads included the foster mother and child (Natal ie and Trevor; Carla and Jimmy). In both cases, the foster parents were in the fina l stages of permanently adopting the child participant and had the legal authority to si gn the consent form. Trevor and Jimmy were aged 6.9 years, and 5 years, respectively. Both children displayed multiple behavior problems including, verbal and physical a ggression, non-compliance, hyperactivity, and impulsivity. Information was taken from prev ious reports and from parent report. Trevor had a history of neglect. Trevo rÂ’s history was reporte d to be significant with the diagnosis of Reactive Attachment Disorder (RAD), Inhibited Type, Attention Deficit/Hyperactivity Disord er (ADHD), Oppositional Defian t Disorder (ODD), Post Traumatic Stress Disorder (PTSD), and Ma jor Depressive Disorder. Trevor was diagnosed by a licensed Psychiatrist. Tre vor takes Ritalin and Focalin, medications which attempt to help with symptoms or behaviors associated with ADHD. (He was given the same medication and dosage during the baseline and treatment sessions.) Trevor was removed from his biological motherÂ’s care at 18 months of age. The biological mother would reportedly leave him al one in a playpen, placed in a closet for extended periods of time, while she would leav e the home to work. Trevor was placed in the care of his aunt and uncl e until the age of 5. Due to beha vioral difficulties, his aunt and uncle were unable to care for him further. Trevor was then placed in therapeutic foster care for two years. Natalie, who is the participant parent in the study, worked closely with the therapeutic foster mother in an effort to become the legally adoptive mother. During the course of the study, Nata lie was in the final st ages of permanently adopting Trevor. It was decided that the PCIT therapy would be the most beneficial for


22 the potential adoptive mother. Natalie is marri ed and a mother of 3 biological daughters. She homeschooled all of her daughters and wi shed to do the same for Trevor. She expressed her frustration with Trevor’s be havior at times, but acknowledged that his behavior was much more intense and frequent in the school setting. Trevor has had a history of significant behavior problems at hi s school setting, where he was placed in a special classroom for Emotional Disturbed ch ildren. Trevor’s problem behaviors include: verbal and physical aggression toward others, property destruction, self-induced vomiting, self-injurious behavior, exce ssive tantrums, which include screaming, crying, and selfinjury. These behavior problems had resulted in Trevor requiring time-out and physical restraint procedures. Jimmy has a diagnosis of RAD, Inhib ited Type, Oppositional Defiant Disorder, and Obsessive Compulsive Disorder. He has a formal diagnosis by a licensed therapist. He has never been prescribed medications fo r any of his behavioral problems. Jimmy also had a history of abuse and neglect. He was removed from his mother’s care at the age of 2. His biological mother was repor tedly abusing “crack” cocaine and taking psychotropic medications during her pregnancy with Jimmy. Jimmy has been placed in numerous foster care placements as his probl em behaviors were so intense and frequent, that individuals attempting to care for Jimmy were unable to properl y help him. Jimmy was placed in the care of his adoptive mother three years ago. During the course of the present study, Jimmy was permanently placed in th e care of Carla, the participant parent. Carla also legally adopted Jimmy’s younger br other and has three other foster children living in the home. Jimmy has a history of being verbally and physically aggressive


23 toward others, having intense temper tant rums, destroying property, and having night terrors. Treatment sessions were conducted in each participant familyÂ’s homes. The living room was used for the sessions. Instrumentation All aspects of the implementation of PCIT were consistent with the PCIT Treatment Manual (Eyberg and Members of the Child Study Laboratory, 1999) unless otherwise specified. The PCIT Treatment Ma nual outlines specifically what goals should be achieved during each session. Each pare nt-child dyad participated in a 60 to 90 minute session, at least once per week. Treat ment sessions lasted between 6 and 16 videotaped sessions (3 to 8 meetings). In itially, a Motorola Ultra light headset/walkie talkie was attempted to be used by both th e coach and parent in order to communicate during training and experimental sessions. However, during the first treatment session with Carla and Jimmy, Jimmy became increas ingly distracted by the headset/walkie; therefore, it was discontinued for the remainde r of sessions and was never initiated with the other parent-child dyad. During treatment sessions, a partial interval recording was used to measure the dependent variables. This investigation used direct observation of operationally defined behaviors as the primary source of data collection. Indirect Measures Using Rating Scales Data from parent report measures were ut ilized to assess the behavior problems exhibited by the children. Eyberg child behavior inventory (ECBI) The Eyberg Child Behavior Inventory (ECBI) was administered once per week. The ECBI (Eyberg & Pincus, 1999) is a


24 36-item parent rating scale of externalizing behavior in ch ildren between the ages of 2 and 16. The Intensity Scale measures the fr equency of child problem behaviors on a 7point scale from (1) never to (7) always. The Problem Scale measures the degree to which the childÂ’s behaviors are problematic for the parent on a yes-no scale. Social validity questionnaire The Social Validity Questionnaire was administered post treatment. The mothers completed the questionnaire to determine the social significance of the goals, appropriatene ss of treatment, and the social relevance of the outcome. This measure was used to assure the relevance of this research for the participants. The parents completed a questi onnaire consisting of 7 items using a 5-point Likert rating-scale. The kinship center attachment questionnaire (KCAQ ). The Kinship Center Attachment Questionnaire or KCAQ was administered post treatment The KCAQ is a newly developed attachment measure for chil dren younger than 6 years of age. It is designed to be completed by the caregiver. Kappenberg & Halpern (2006), report that it is different from other attachment measures The KCAQ was designe d to meet the need of foster and newly adopted children. Other attachment measures available assume that an attachment is already present. Those m easures are used to describe the type of attachment (e.g., secure attachment, anxious-a voidant). The authors of the KCAQ claim that it is different because it is time efficient behaviora lly based, standardized, normed, psychometrically sound and can track child be havior changes over time. Kappenberg & Halpern (2006) note that nonclin ical sample have scores have a mean of 22 and a standard deviation of 11.4, whereas the clinical sample have scores with a mean of 31.8 and a standard deviation of 14.0. However, only about 17% of that standardization


25 sample were children diagnosed with RAD and there appears to be a range of disorders, diagnosed and not, represented by the children in th e “attachment” sample. This appears to be a limitation in the standardization sampling. Experimental Design This study employed a multiple baseline desi gn across participants. After stability was established in baseline, the intervention using the procedures of CDI were introduced sequentially across participants. The single-case experimental design evaluated the treatment effects of the ChildDirected Interaction Phase of PCIT (indepe ndent variable) on parental behavior and attachment. The general requirements of a single-case experimental designs are: (a) repeated observations of performance over ti me; (b) behavior observations beginning for several sessions prior to the implementati on of the intervention; (c) stability of performance (absence of a decrease or incr ease in behavior over time) prior to the implementation of the intervention; and (d) exam ination of changes in the stability level, or trend in a series of da ta points following the introducti on of the intervention (Kazdin, 1982). This single-case experiment was desi gned to rule out factors other than the treatment variable as possible causes of changes in the dependent variable. The following techniques were used to achieve hi gh internal validity in the single-case designs. First, steps were taken to assure re liable observations. For example, observers were trained, behaviors to be observed we re operationally defined in the treatment manual, and periodic observer reliability checks were impl emented (Borg & Gall, 1989). Single-case designs also require repeated and standardized measure meant to control for internal validity. The use of repeated measurements provided a more reliable description


26 of how the participantsÂ’ beha vior changed as a result of the treatment condition. The third threat to validity that was consider ed was the description of experimental conditions. The description of each experi mental condition was precise, to promote replication within the experime nt and for other researchers to replicate in the future. Thus, the descriptions of the baseline and trea tment conditions were specified precisely to control for internal and external threats to validity. Finally, the ba seline and treatment phases in this single-case design we re stable in order to assess the effect of the treatment variable (Borg & Gall, 1989). For example, th e baseline phase continues until the rate of the response appeared to be stable or until th e responses did not increase or decrease over time. Variables Defined Independent variable The independent variable in cluded the Child Directed Interaction (CDI) phase of PC IT. This phase of the treatment is based on attachment theory and designed to create more positive interactions between the parent and child and to teach parents to build better relationships with their children. First, the parent is instructed to follow the childÂ’s lead during pl ay. Parents were taught to avoid questions, criticisms, and commands, in an effort to a llow their child to lead during play time. Allowing the child to lead play increases the likelihood that the childÂ’s behavior will be appropriate, giving parents ma ny opportunities to praise good behavior. During this phase, parents also are instructed in the use of differential reinforcement. Parents provide enthusiastic attention using beha vioral play therapy skills. Th ese skills come together to create the acronym, PRIDE (pra ise, reflection, imitation, descri ption, enthusiasm). If the child becomes disruptive (e.g., pl aying roughly with the toys), parents are instructed to


27 ignore the behavior. While i gnoring, the parent physically turns away from the child such that there is no eye contact, physical c ontact, or verbal contact. Once the child returns to appropriate play, the pa rent is instructed to turn his or her attention back to the child enthusiastically. The therapeutic goa l of CDI was for parents to reach mastery criteria of 10 or more labeled praises, behavi oral descriptions and reflective statements, while having less than 3 questions, cr iticisms and commands during a 5 minute observation. Dependent variables The dependent variables incl uded parent behaviors to increase, such as labeled praises, reflections, and behavioral descrip tions and behaviors to decrease, including: questions, criticisms and commands. These behaviors are defined as outlined in the DPICS code (Eyberg et al., 2005). The DPICS was designed to assess the quality of parent-child social interactions. It provided an observational measure of parent and child behaviors during three 5-minute standard situations that vari ed in the degree of parental control required. Adequate reliabi lity, discriminative validity, and treatment sensitivity have been established in several studies (Eyberg & Robinson, 1982). In the present study, the parental behaviors ta rgeted to increase and decrease include: Labeled praise any specific verbalization that expresses a favorable judgment on an activity, product, or attribute of th e child (That is a terrific house you made; You have a beautiful smile); Behavior Descriptions a declarative sentence or phr ase that gives an account of the objects or people in the situati on or the activity occurring during the interaction (for example, You are build ing a pickup truck; You are sitting quietly);


28 Reflections a declarative phrase or statement that immediately repeats the child’s verbalization. The reflection may be exactly the same words the child said, may contain synonymous words, or may contain some elaboration on the child’s statement, but the basic content mu st be the same as the child’s message (for example, CHILD: “I made a big square”. PARENT: “You made a big square inside this circle”) Questions -a descriptive or reflective comme nt expressed in question form. Some questions are differentiated from st atements by voice inflection; (That’s the baby?). Critical Statements/Criticisms : a verbalization that finds fault with the activities, products, or attributes of th e child (You are being naughty; That is a sloppy picture) Commands: A direction to the child Indirect command: An order, demand, or direction for a behavioral response that is implied, nonspecific, or stated in question form (e.g., Put it here, OK?; Johnny!; Lets take out the red blocks). Direct command: A clearly stated order, dema nd, or direction in declarative form. The statement must be sufficiently specific as to indicate the behavior that is expected from the child (e.g., Put your hands in your lap; Please put that block here) Baseline data will establish behavior frequency and continued data collection will assess effectiveness of the treatment condition.


29 Procedures The principal investigator served as the therapist and was a graduate student in Applied Behavior Analysis and a Certified assistant Behavior Analyst, who was also experienced in outpatient work with children and families. The principal investigator was supervised by a licensed clinical psychol ogist and University of South Florida (USF) professor. The USF professor had extens ive knowledge and training in implementing PCIT procedures. The CDI skills were ta ught to the principal investigator by the professor and assistance was given by pract icing the skills and providing feedback. Videotaped practice sessions we re conducted with the principl e investigator and a 4 year old child. The principle investigator reached mastery criteria of the CDI skills prior to the beginning of the study. The initial sessions with the participant dyads lasted approximately 60-90 minutes, while treatment sessions lasted between 90-120 minutes. Baseline lasted about nine to 11 sessions. CDI was initially taught to parents during one session. The overall effectivene ss of the CDI therapy was evaluated by repeated measure behavior observations, comparing Eyberg Ch ild Behavior Inventor y Scores, and social validity scores. Baseline sessions Prior to collecting baseline da ta, a pre-treatment assessment was conducted. The participants were introduced to the principal i nvestigator, research procedures were explained, and consent was obtained. Following the informed consent process, the principal investigator conduc ted an interview with the parent and administered the ECBI. During baseline, the intervention was not implemented. Parents were asked to bring Legos, Lincoln Logs, or Cr ayons and Paper to the sessions in 3 separate bins. The


30 therapist asked the parents to play with th eir child as they usually would. No other instructions were given. Th ese were 5 minute videotaped sessions. No feedback was provided following the 5 minut e session. After one 5 minute observation of the parentchild dyad, the ECBI was administered, and then the parent and child were asked to play for another 5 minute session. Two observa tions were videotaped per meeting. The baseline phase lasted 8-10 se ssions. It is recommended that a stable baseline must be present so that any behavior change noted during the introduction of the intervention can be attributed to the indepe ndent variable (Kazdin, 1982). Treatment session Following a stable baseline, the introduction of PCIT was given to the parents during one teaching sess ion. Procedures were implemented in the manner specified by the PCIT manual (Eyberg et al., 1999). The manual (see Appendix F) specifies procedures as follows: The goal of the CDI sessions is to teach parents the kinds of skills that play therapists use w ith children to build a good relationship with them and help them feel safe and calm. It also teaches parents how to communicate with preschoolers with limited attention spans. It teaches ways to teach your child without placing too many demands on the child, and re sults in a secure, warm relationship between parents and child, which often gets strained with oppositional children. The basic rule of CDI is to follow the childÂ’s l ead. Parents are asked to find 5 minutes of uninterrupted time every day in which CD I sessions can take place as a special therapeutic time. Parents are taught that there are numerous other times throughout the day when it is necessary to dir ect the childÂ’s activities; theref ore, this 5 minute play time should be a special time for bot h the parent and child. All to ys will be removed from the specified playroom or play area except for three specific toys which will be used during


31 treatment. Some suggested toys for the CDI sessions include: building blocks, legos, Lincoln logs, crayons and paper, etc. Some toys to avoid during CDI include ones that encourage rough play, such as bats, balls, boxin g gloves, punching bags; toys that lead to aggressive play, such as toy guns, toy sw ords, toy cowboys and Indians, super-hero figures; ones that could get out of hand and require limit setting, like paints, markers, bubbles, scissors, play dough, hammers; toys that have pre-set rules, such as board games, card games; toys that discourage conversati on, like books and video games; and ones that lead to parent or child imagining that th ey are someone else, like puppets or costumes. The first rule to learn during the CD I session is to avoid commands. Commands try to direct the play by suggesting what the child should do. Th ere are two kinds of commands: direct commands (“Sit down.”) a nd indirect commands (“Would you like to sit down?”). Commands take over the lead of the play. If the child does not obey, the play could stop being fun. CDI is a time when the child is supposed to learn that it is fun to get along and play together nicely. The s econd rule parents learn is to avoid questions. A question asks for an answer from the chil d. There are different kinds of questions: some questions ask for information (who, what, where, when, how); some are unintentional questions (voice goe s up at the end of a senten ce); question tags; questions that are really hidden commands (“Would you like to clean up?”); questions that take over the conversation; questions that someti mes suggest disapproval; and questions that often suggest that you are not rea lly listening to your child. The third rule of CDI is to avoid criticism. Criticism is a negative or contradictory statement about the child or his/her actions, such as “You are not nice” or “T hat does not go that way.” Criticism tells


32 the child what NOT to do (“Stop that, “Don’t do that!”) Criticism creates a negative interaction. Instead, parents are taught the skills which form the acronym “PRIDE” (Praise, Reflect, Imitate, Describe, and Enthusiasm). Parents first learn to praise their child’s appropriate behavior. There ar e two kinds of praise. Labele d praise is specific praise, such as “You choose such pretty colors!” a nd “You are being so caref ul with that pen!” Labeled praise is more effective because it lets children know exactly what you like. Praise increases the behavior that it follows and it makes the interaction more pleasant for both the child and parent. Next, parent s are taught to reflect appropriate talk. Reflection is repeating or paraphrasing what your child says: “Yes, that is a blue crayon.” Reflection allows the child to lead the convers ation. It shows the child that you are really listening, and it actually helps pa rents learn to listen. It s hows children that their parents accept and/or understand what they are sayi ng. Reflection also improves and increases child’s speech and language. Parents are then taught imitation. Imitation means doing the same thing that the child is doing, such as drawing a tree if the child is drawing a tree. This skill helps parents keep their attention focused on what the child is doing. Imitation helps parents to play at the child’s developmenta l level. This allows the child to lead the play, making it fun for the child and showing pa rental approval of the child’s activity. Describing appropriate behavior is taught by teaching parents to state exactly what the child is doing. For example, “You are drawing a sun”. De scriptions seem as though the parent is a sports announcer or providing a running commentary of the child’s activities. This shows the child that you ar e interested and paying atten tion to him or her and shows them that the parent approves of their beha vior. Descriptions m odel speech and teach


33 vocabulary and concepts. They also hold the child’s attention to the specific task and teach him/her how to hold their attention to a task. Parents are also taught to be enthusiastic! Using enthusiasm shows the child that the parent is enjoying the time that they are spending with their child and increases the positiv e interaction. Parents are taught to let their voice show excitement about the child’s appropriate behavior, such as. “You are being SO nice to share with me!” If children engage in inappropriate be havior during a CDI session, parents are taught to ignore. Ignoring inappropriate behavi or is the correct appr oach if the behaviors (yelling, whining, crying) are attention-seeking behaviors. Parents are taught that any attention, either positive or negative can in crease attention-seeking behaviors. Avoiding any verbal or nonverbal reacti ons to inappropriate behavior s must be continued until the behavior stops. Parents are taught to ignore the inappropriate behavior until the child is doing something appropriate. The child s hould be praised immediat ely for appropriate behavior, which teaches the child the diffe rence between respons es to good and bad behavior. Parents are informed of the process of extinction and the extinction burst, in which ignored behavior may get worse before it gets better and consistent ignoring eventually decreases many behaviors when combined with attention for appropriate behaviors. Parents are also taught that if a child engages in aggressive or destructive behaviors, these behaviors can not be ignored. CDI session s should be discontinued. Stopping the play teaches the child that good beha vior is required during special time and shows the child that limits are being set. Th e child will be told, “S pecial time is stopping


34 because you hit me. Maybe next time you w ill be able to play nicely during special time.” If possible, CDI can be attempted again later in the day. The principal investigator coached the pare nts in the CDI skills while they played with their child. Parents continue in the CDI phase of treatment until they achieve pre-set skill levels indicating mastery of the CDI. During the 5-minute coding interval at the beginning of the session, parents must give 10 behavioral descri ptions, 10 reflective statements, and 10 labeled praises, as we ll as less than 3 questions, commands, or criticisms. Parents must also ignore non-harmful inappropriate behavior. Interobserver Reliability Inter-observer agreement of the observation procedures were collected for at least 33% of the sessions distributed across experi mental conditions. A video camera was set up in a corner of the room during all tr aining and treatment sessions. The principal investigator served as the therapist and data collector during the se ssions, in order to provide immediate feedback to the particip ants. Video tapes were reviewed by the principal investigator and an independent observer scoring the experimental sessions. Inter-observer agreement was calculated by dividing the number of agreement on behaviors by intervals, by the number of agreements on behaviors by intervals plus disagreement intervals, and multiplying by 100. If there was a discrepancy in the data from the direct observation and the video tapes, data displayed on the final graphs reflect information from the video tapes.


35 Chapter 3 Results Efficacy of PCITÂ’s Child Directed Intera ction Phase was evaluated in this study. Baseline periods consisted of 8-10 videotaped sessions prior to implementation of the treatment phase, which lasted 8-15 videot aped sessions. Two 5-minute videotaped observations were conducted once per week. Data gathered from direct observation in the home and parental ratings of their child ren on standardized m easures are presented below. The two parent-child dyads who part icipated in the study reached the mastery criteria. CDI Skills Parent Behavior to Increase Figure 1 represents a multiple baseline design of participants across baselin e and treatment conditions Figures 2, 3 and 4 represent a multiple baseline for each individual behavior (labeled praises, reflective statements and behavioral descriptions). Carla demonstrated a stable baseline c ondition. She did not us e labeled praises, behavioral descriptions or re flective statements regularly during play with Jimmy. She did use each of the behaviors on one occasi on out of the 8 baseline sessions. Following the CDI teaching session, Carla did not show an immediate increase in labeled praises or behavioral descriptions; how ever, she did increase the reflective statements. Carla reached criteria of having 10 or more la beled praises within the third treatment observation. Mastery of reflective statements and behavioral descriptions was reached by


36 the 6th and 7th and treatment observations (Session s 14 and 15), however, all three CDI increase skills did not remain at the mast ery level at the same time until session 24. Natalie demonstrated a stable baseline condition and did not have knowledge of the CDI skills or use them all regularly dur ing play with Trevor. She did use labeled praises on occasion (up to 4 per session), 0 behavioral descriptions, and one reflective statement in a session. Following the first treatment teaching session, NatalieÂ’s data reflect an immediate increasing upward tre nd to well over mastery criteria in labeled praises and behavioral descri ptions. Within the second tr eatment session, Natalie reached beyond mastery criteria of re flective statements.


37 Figure 1. Multiple baseline across participants for CDI increase skills.


38 Figure 2 Multiple baseline across participants for labeled praises.


39 Figure 3 Multiple baseline across participants for reflective statements.


40 Figure 4. Multiple baseline across participants for behavioral descriptions.


41 Parent Behavior to Decrease Figure 5 represents a multiple baseline design across behaviors to decrease (questions, critic isms and commands). CarlaÂ’s baseline data indicate a high frequency of questions, ra nging from 16-28 per 5-minute observation, a moderate frequency of commands, ranging from 2-19, and a low frequency of criticisms. Following the first treatment session, Carla de monstrated a reduction in all behaviors targeted to decrease. Questions remained above criterion level for three sessions, but remained at a level trend of mastery leve l by the third teaching session (session 14), and throughout the remainder of the sessions. NatalieÂ’s baseline data reflected a hi gh frequency of questions, ranging from 1834 in a 5 minute observation, a moderate ra nge of commands, ranging from 2-15, and a 0 to low frequency of criticisms. During base line, the data reflect a slightly decreasing trend in questions. Treatment was not impl emented until stability was established in sessions 8, 9, and 10. Following the implement ation of the first CDI teaching session, Natalie immediately reached mastery criteria for questions, criticisms and commands. Session 13 reflects a slight increase in ques tions, however, Natalie displayed a reduction in all behaviors targeted to decrease throughout the rema inder of the sessions.


42 Figure 5 Multiple baseline data for parent CDI skills to decrease.


43 Eyberg Child Behavior Inventory (ECBI) Figure 6 displays the ECBI Intens ity Graph for both Jimmy and Trevor Both parents rated the childrenÂ’s behavior as be ing in the clinical range (132 or above) pretreatment, and there does not seem to be a si gnificant change in the total intensity scores following treatment. Figure 7 displays th e ECBI Problem Graph for both Jimmy and Trevor. There is not a significant change in trend for TrevorÂ’s problem score. However, JimmyÂ’s problem score totals represent a decr easing trend and were not in the clinical range post treatment. Figure 6. ECBI total intensity scores for Jimmy and Trevor.


44 Figure 7. ECBI total problem scor es for Jimmy and Trevor. Social Validity Table 1 displays the results of the post treatment parental ratings for their overall satisfaction with the treatment goals and outco mes. The social validation data showed that the parents were satisfied with the goals procedures and outcomes of the treatment program.


45 Table 1 Parental Ratings of Overall Satisfacti on with Treatment Goals, Procedures and Outcomes Outcomes Participants Questions Natalie Carla To what extent are you satisfied with the improvement of your child’s behavior? 4 5 To what extent are you satisfied with the improvement of your parenting skills? 4 5 How satisfied are you with the changes in your parent-child relationship following PCIT? 4 5 To what extent to you agree you and child have a stronger “attachment” as a result of PCIT? 4 5 Overall, how has the quality of your child’s interactions changed a result of PCIT? 4 4 Overall, how has the quality of your interaction skills changed a result of PCIT? 4 5 To what extent do you believe the study was important and meaningful? 5 5 Note. Ratings were obtained us ing a 5-point Likert type rating scale ranging from “strongly disagree = 1” to “strongly agree = 5”.


46 Kinship Center Attachment Questionnaire (KCAQ) The Kinship Center Attachment Ques tionnaire (KCAQ) was administered post treatment. Jimmy and TrevorÂ’s total scores on the KCAQ were 57 and 50. The nonclinical sample have scores with a mean of 22 and a standard deviation of 11.4, whereas the clinical sample ha ve scores with a mean of 31.8 and a standard deviation of 14.0. Both participants scored more than one deviation above the mean for assessments of a sample of children identified in their c linical sample. Both Ji mmy and Trevor scored in the range of having attachment difficulties according to the KCAQ.


47 Chapter 4 Discussion The purpose of this study was to incr ease our knowledge about the effective treatments for children diagnosed with Reactiv e Attachment Disorder. Thus, the research examined the CDI portion of Parent Child Interaction Therapy in an effort to teach parents appropriate skills to improve attachment with these children. A multiple-baseline design across participan ts was used to demonstrate the effects and of the treatment in an experimentally c ontrolled manner. The controlled effects were determined by systematically introducing the intervention at different points of time to different participants, and showing the cha nges in behavior demonstrated after the intervention and not at prior times. During the early treatment sessions, bot h parents commented that they found it difficult to say anything because they were fo cusing so much on what they should not say. The therapist explained that this is when they should practice the be havioral descriptions. Carla seemed to have problems with the reflec tive statements and beha vioral descriptions. Carla tended to interpret what Jimmy was doing while she gave behavi oral descriptions. For example, if Jimmy was drawing a circle, Carla would state, “Jimmy, you are drawing a sun”. Jimmy would become upset and st ate, “No I am not drawing a sun”. The therapist suggested that Carla refrain from interpreting anything, and to simply state the behavior. For example, “Jimmy, you are dr awing a circle,” or “You are using a red crayon”. For Natalie, some of the interp retation during the behavioral descriptions


48 allowed more conversation from Trevor. Du ring some sessions, Trevor would remain very quiet, so Natalie found it difficult to have any comments to reflect. The data of Carla’s reflective statements a nd behavioral descriptions in dicate that these were more difficult skills for her to master and the fr equency varied from session to session. Both skills increased over time Some individual differences between the mother participants exemplified some issues in teaching the CDI skills. Both parent s had a high rate of questions and commands in baseline. Natalie’s initial treatment da ta reflect an extremely high frequency of behavioral descriptions. This excessively high level of behavioral de scriptions seemed to make her interactions “feel” much less genuine. She seemed to forget to actually “play” with Trevor and solely focused on the skill. Natalie later stated th at she thought that she was supposed to comment about every behavior in which the child engaged. The researcher provided feedback to Natalie to decrease the number of behavioral descriptions and to still “have fun” with Trevor. Natalie was immediately receptive to the feedback and reduced the number of beha vioral descriptions, which resulted in a much more genuine interaction style. There were a couple of instances in between taping sessions when Jimmy would engage in whining, screaming, non-compliance, and low intensity physical aggression. These behaviors typically occurred after bei ng denied access to a preferred food item or activity. During the actual videotaped se ssions, problem behaviors did not occur. Carla’s behavior was a bit more resist ant to change. She was receptive to the teaching sessions and obtaining feedback; however, on many occasions, she seemed to have difficulty focusing on specific skills as suggested by the therapist. For example,


49 when the therapist would suggest “Just practi ce giving as many behavioral descriptions as possible, within the next 5 minutes”, Carla w ould not necessarily prac tice the skill for the entirety of the session. Another issue which seemed to affect Ca rla reaching mastery criteria involved the homework requirement and the number of sessi ons per week. At the initial teach session, parents were told to practice their CDI skil ls (homework) with the child, 5 minutes per day. The homework was not always submitte d or discussed the following session, as suggested in the treatment manual. It is believed that consisten tly practicing the CDI skills on a daily basis would have allowed the participants to reach criteria in fewer sessions. During session 21, Carla was reminded to complete her homework for the upcoming week. An additional session with Carla was held (session 22). This was the only time during treatment in which Carla had two sessions within a week. This is the week when she reached her mastery criteria. This data suggest that the more consistent the homework is completed and the more frequent the treatment sessions occur, the faster the criteria will be met. Both parents’ data suggest that there wa s quite a bit of variability in learning the CDI skills. Being able to meet criteria fo r all skills at the same time seemed to be difficult for both parents. The variability in the data suggests th at the parents would focus on learning one skill at a time or would onl y be able to increase one skill at a time. An informal observation occurred with both parents. On occasion, following an incident or anecdote of the child’s inappropr iate behavior, both parents would seem to blame the behavior on the child ’s diagnosis of RAD, when in fact other explanations were possible. For example, Natalie referen ced that when picking up Trevor from school,


50 he would engage in constant “chatter”. Sh e referred to this as a problem and as a symptom of his RAD. Her response to this constant “chatter” was a request for him to decrease his questions, talking, etc. during th e car ride home. It is hypothesized that parents of children who are diagnosed with RAD often attribute many behaviors, even age appropriate or typical beha viors on the diagnosis of RAD. It is possible that Trevor felt the need to interact or en joys interaction with Natalie. It seems detrimental to punish attempts for interactions, based on the assumpti on that there is a nega tive intention. Some treatment options available for this popul ation seem to overgeneralize behaviors exhibited by the child diagnosed with RAD as being manipulative or having ill intentions. This path only seems to further punish any attempts exhibited by the child for social interaction. If the assumption of reasonable clinical sa mple in the standardization of KCAQ is accepted for the research, the tw o participants scored more than one deviation above the mean for assessments of a samp le of children identified in their clinical sample. This means that the CDI intervention has not shown an effect on the KCAQ measure of attachment. If the present research had comp leted a pre-test assessment, there may have been an improvement on this attachment m easure with this intervention. It is also possible that the intervention was too brief to show an effect or that other therapeutic interventions are needed in addition to have a cumulative effect, such as the PDI component of PCIT. These are releva nt issues for future research. A notable change in the children’s behavior toward the researcher became apparent over the course of th e research sessions. Initially, both children did not initiate interaction with the research er and would only interact minimally when prompted by the


51 parent, with little to no eye contact provide d. The researcher di d not initiate many interactions with the childr en during baseline. However, during the treatment sessions, the researcher increased the in itiation of interactions with the children. Positive praise was provided to the children a nytime appropriate behavior wa s displayed (outside of the 5 minute videotaped sessions) during the remai nder of the sessions. During the course of the treatment sessions, both children began to independently initiate interaction with the researcher. For example, Jimmy sat next to the researcher on the couch on a couple of instances and asked her to r ead a book. Trevor would indepe ndently attempt to help the researcher with her video camera, and attemp t to provide food items. Another interesting observation occurred during the interactions with Jimmy. During a break in a session, Jimmy and the researcher colored together. When Jimmy grabbed the crayon out of the researcher’s hand, the researcher prompted him to ask appropriately when he wanted something. He was prompted to ask nicel y, and he immediately complied. It is noteworthy that Jimmy would fo llow a command of the resear cher after a short time of interaction. At the conclu sion of the study, for the first time, Jimmy provided the researcher with a warm, genuine hug. It is hypothesized that this informal observation may provide some meaningful information on how individuals must attempt to interact with children diagnosed with RAD as well as potential treatment imp lications. In this particular scenario, the researcher slowly began to interact with the children. In following with the criteria of CDI, no commands questions or criticisms were provided during the initial sessi ons. It seemed as though enough time was given for the children to “trust” the researcher or to be able to predic t that they were a safe person to be around. In addition, positive interactions provided a m eans for additional interactions. By the


52 conclusion of the study, the children and the rese archer were “friends”. The researcher was also able to provide Jimmy with a direct command and compliance was given. As mentioned above, during the treatmen t sessions, the researcher increased the initiation of interactions w ith the children. The research er also began to model or demonstrate an appropriate interaction style with the parents by using positive praise to the children anytime appropriate behavior was displayed (outside of the 5 minute videotaped sessions). For example, when Trevor would offer assistance with the researcher’s video camera, the researcher w ould provide a big labeled praise for “being so helpful”. Trevor’s helpful behavior seem ed to increase immediately. The researcher pointed out these examples to Natalie and re -iterated the power of praising and attending to behavior that she wanted to see increase in the future. This seemed to be an effective training component. The social validation data showed that th e parents were satisfied with the goals, procedures, and outcomes of the treatmen t program. Although Natalie was the most receptive in learning the new skills, she scored he r treatment satisfaction lower than Carla. It is believed that this is because Natalie s eemed to have a higher expectation for Trevor’s behavior. Even though she was satisfied with the treatment procedures, Trevor still displayed some problem behaviors. It is po ssible that although she expressed appreciation for the treatment and felt it was beneficial, Trevor’s behaviors of concern did not reduce to a level that was acceptable to Natalie. Both parents seemed to be accepting of their child’s behaviors differently The results of the parent behaviors indi cate that there was experimental control. The intervention was presented once baseline was stable for each of the participants.


53 Limitations and Recommendations for Future Research A number of limitations became eviden t over the course of this study. Some limitations were a function of the number of sessions that occurred each week, the duration of the sessions, and whether or not the homework assignment was completed daily. Sessions only occurred onc e per week. Having more frequent sessions would allow the participants to have more training sessi ons, thus may have had a larger or quicker effect on the targeted behaviors of interest. Future research should focus on increasing the number of treatment sessions per week a nd reinforcing the importance of the parent homework assignment. It is believed that co nsistently practicing the CDI skills on a daily basis would have allowed the participants to reach criteria in fewer sessions. Since the bug in the ear device was not us ed, the researcher provided feedback to the parents in the presence of the children as they played. There was no privacy in communications between the therapist and the parents during the sessions. This may be considered a limitation because the feedback fr om the researcher could have altered the childrenÂ’s behavior. The researcher served as the PCIT therap ist. Although the researcher did meet the mastery criteria and was assisted by an e xperienced clinical ps ychologist and PCIT therapist, the researcher was not formally tr ained in PCIT. The results indicated however, that the researcher was able to coach the par ticipants to criterion level in the standard length of time. This may have been true be cause the researcher was a Certified assistant Behavior Analyst and has had over 6 years of experience worki ng with children and families. The researcher conducted the trea tment and coaching sessions and scored the videotapes. It would have been beneficial to have an assi stant present du ring all baseline


54 and treatment sessions in order to help vide otape and/or take data Future replication studies should assess whether the researcher has adequate experience to serve as a coach or therapist for PCIT if form al training is not an option. Another limitation includes sampling issues The present sample was a sample in which the participants were not randomly selected but were identified as individuals who “fit” the research and who contacted the rese archer independently. The participants in the research were those with high levels of parent involveme nt and who were interested in the study and believed from the onset that it was going to be beneficial to them and their child. They were actively seeking out additional help for the children. This study was conducted with two child participants who were both diagnosed with Reactive Attachment Disorder-Inhibi ted Type. Additional studies with both Inhibited Type and Disinhibited Type, Reactiv e Attachment Disorder would be beneficial to see if there is a difference. Replication of these results with other families would be beneficial. Further research should consider implementing treatmen t in more than one setting and with other individuals to increase the ge neralizability of the results. For example, both of the children included in the study also displa yed problem behaviors within the school environment. Implementing treatment with their teachers, with whom they had problematic interactions, woul d be beneficial at improving the teacher-child relationship. It would also be beneficial to see whether both phases of PCIT (CDI and ParentDirected Interaction (PDI)) would be effectiv e at improving parent-child interactions as well as reducing problem behaviors in chil dren diagnosed with Reactive Attachment Disorder. However, based on the results of th is study and the informal observations noted,


55 the PDI portion of PCIT may not be a suitable treatment option for children diagnosed with RAD. Since PDI utilizes a time-out procedure, there is po tential for parents to have to use physical guidance procedures to fo llow through on the recommended procedures. These procedures may not be appropriate for children who have experienced abuse and/or neglect. More research in this area would be valuable. Further research may also investigat e whether these treatment effects are maintained over time. Follow up or “booster” sessions one, three, and six months post treatment would be beneficial to examine th e long-term effects of the trainings on the parent behavior. Future research should also look at tr eating problem behaviors in a typical behavior analytic fashion, su ch as conducting a behavioral assessment to determine the functions of the problem behaviors and design and implement interventions accordingly. Informal observations by the research er may have provided some meaningful treatment implications. For example, it is possible that punitive techniques including physical restraint procedures should not be us ed with this populati on. Parental reports indicated that these techniques did not improve Trevor’s behavior either in the school or home setting. On the contrary, when Trevor was no longer attending school, his behavior improved. A consideration could be made th at if children diagnosed with Reactive Attachment Disorder have experienced abuse an d/or neglect in their histories, which is true in most cases, treatments for their behavior problems should not involve punitive measures such as physical restraint procedur es. It is possible that these types of procedures may further traumatize the child and make them less likely to interact appropriately with individuals who utilize t hose procedures. The informal observation


56 exemplified that the researcher was able to build a rapport with the children by simply allowing them time to feel comfortable a nd safe without initia lly placing demands on them. This observation further exemplifies that treatment options targeted for this population should always emphasize having safe, healthy relationships at its core. Conclusions The application of PCIT effectively increased appr opriate interactions among parents and their children. Following treatment, both Jimmy and Trevor scored in the range of having attachment difficulties accordin g to the KCAQ. It is also possible that the intervention was too brief to show a long lasting effect or th at other therapeutic interventions are needed in a ddition to have a cumulative eff ect, such as basic behavioral techniques or functional assessment CDI seems to be an effective initial treatment component for any problem associated with “attachment”. Consid ering the potentially dangerous treatments that are available for families of children diagnosed with RAD, promising findings in this study could indicate that PCIT could be part of a treatment package designed for these children. PCIT is a safe, empirically based intervention that may be an effective treatment compon ent in helping children with RAD.


57 References Abidin, R. R. (1995). Parenting Stress inde x: Professional manual Odessa, FL: Psychological Assessment Resources. Achenbach, T.M. & Rescorla, L.A. (2001). Manual for ASEBA School-Age Forms & Profiles Burlington, VT: University of Vermont, Research Cent er for Children, Youth, and Families. Achenbach, T. M., & Rescorla, L. A. (2000). Manual for ASEBA Preschool Forms & Profiles Burlington, VT: University of Vermont Research Center for Children, Youth, & Families. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Becker-Weidman, A. (2006). Dyadic Developmental Psychotherapy; An Attachment Based Therapy. Child and Adoles cent Social Work Boggs, S., Eyberg, S., Edwards, D., Rayfie ld, A., Jacobs, J., Bagner, D., & Hood, K. (2004). Outcomes of Parent-Child In teraction Therapy: A comparison of treatment completers and study dr opouts one to three years later. Child & Family BehaviorTherapy, 26, 1-21. Borg, W.R. & Gall, M.D. (1989). Educational research: An introduction. White Plains, NY: Longman.


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59 Eyberg, S., Funderburk, B., Hembree-kigi n, T., McNeil, C., Querido, J., & Hood, K. (2001). Parent-Child Interaction Therapy with behavior problem children: One and two year maintenance of treatment effects in the family. Child & Family Behavior Therapy 23, 1-20. Eyberg, S. M., & Members of the Child Study Laboratory. (1999). Parent-Child Interaction Therapy Integrity Checklists and Session Materials. Retrieved September 20, 2007 from University of Florida, PCIT Laboratory Web site: Eyberg, S. M., Nelson, M., M., Duke, M., & Boggs, S.R. (2005) Manual for the Dyadic Parent-Child Interact ion Coding System (3rd edition). Retrieved November 17, 2009 from Eyberg, S. M., & Pincus, D. (1999). Eyberg Child Behavior Inventory and Sutter-Eyberg Student Behavior Invent ory: Professional Manual Odessa, FL: Psychological Assessment Resources. Eyberg, S. M., & Robinson, E. A. (1982). Pare nt-child interaction training: Effects on family functioning. Journal of Clinical Child Psychology, 11 (2), 130-137. Eyberg, S. M. & Robinson, E. A. (1983). Conduc t problem behavior: Standardization of a behavioral rating scale with adolescents. Journal of Clinical Child Psychology, 12, 347-357. Eyberg, S. M., & Ross, A. W. (1978). A ssessment of child behavior problems: The validation of a new inventory. Journal of Clinical Child Psychology, 7 113-116. Funderburk, B., Eyberg, S., Newcomb, K., Mc Neil, C., Hembree-Kigin, T., & Capage, L. (1998). Parent-Child Interaction Ther apy with behavior problem children:


60 Maintenance of treatment eff ects in the school setting. Child & Family Behavior Therapy, 20 17-38. Hanf, C.A. (1969). A two-stage program for modifyi ng maternal controlling during mother-child (M-C) interaction. Paper presented at th e meeting of the Western Psychological Association, Vancouver. Hembree-Kigin, T.L., & McNeil, C.B. (1995). Parent-Child Interaction Therapy. New York: Plenum Press. Hood, K. K., & Eyberg, S. M. (2003). Outcomes of parent-child in teraction therapy: Mothers' reports of maintenance th ree to six years after treatment. Journal of Clinical Child and Adolescent Psychology, 32 (3), 419-429. Horn, M. (1997). A dead child, a troubling defense, US News Online Retrieved August 23, 2009, from Kappenburg, E. S. & Halpern, D. F. (2006). Kinship center attachment questionnaire: Development of a caregiver completed at tachment measure for children younger than 6 years. Educational and Psychologi cal Measurement, 66 (5), 852-873. Kazdin, A.E. (1982). Single-case research designs: Methods for clinical and applied settings. New York, NY: Oxford University Press. Lester, V. S. (1997). Behavior change as reported by caregivers of children receiving holding therapy. Retrieved June 25, 2009, from Lyman, R. D., & Hembree-Kigin, T.L. (1994). Mental health interventions with preschool children. New York: Plenum. Maloney, S.B. (2003). Be Wa ry of Attachment Therapy. Quackwatch Retrieved September 15, 2009 from


61 McNeil, C. B., Eyberg, S., Eisenstadt, T., Newcomb, K., & Funderburk, B. (1991). Parent-child interaction ther apy with behavior problem children: Generalization of treatment effects to the school setting. Journal of Clinical Child Psychology, 20 (2), 140-151. Mercer, J. (2001). Attachment therapy using de liberate restraint: An object lesson on the identification of invalidated treatments. Journal of Child and Adolescent Psychatric Nursing, 14(2 ), 105-114. Mercer, J. (2002). Attachment Therapy: A treatment without empirical support. The Scientific Review of Mental Health Practice, 1 (2). Mercer, J. (2003). Violent Therapies: The Rationale behind a Potentially Harmful Child Psychotherapy. The Scientific Review of Mental Health Practice, 2 (1). Milner, J. S. (1986). The Child Abuse Potential Inventory: Manual (2nd ed.). Webster, NC: Psytec. Myeroff, R.L., Mertlich, G., & Gross, G. ( 1999). Comparative effectiveness of holding therapy with aggressive children. Child Psychiatry and Human Development 29(4), 303-313. Randolph, E. (2001). Manual for the Randolph Attachment Disorder Questionnaire Evergreen, CO: Attachment Center Press. Reactive attachment disorder. (2007, November 15). In Wikipedia, The Free Encyclopedia Retrieved October 24, 2009, from ?title=Reactive_attachment_disorder &oldid=1


62 Schuhmann, E. M., Foote, R. C., Eyberg, S. M., Boggs, S. R., & Algina, J. (1998). Efficacy of parent-child inte raction therapy: Interim repor t of a randomized trial with short-term maintenance. Journal of Clinical Child Psychology, 27 (1), 34-45. Smith, L. (1996). Full of woe. Los Angeles Times E1 Storch, E.A., & Floyd, E. M. (2005). Intr oduction: Innovative appr oaches to ParentChild Interaction Therapy. Education and Treatment of Children, 28(2), 106-110. Thomas, N. L. (2000). Parenting children with attachment disorders. In T. Levy (Ed.), Handbook of attachment interventions (pp. 67-111). San Diego: Academic Press. Timmer, S.G., Urquiza, A.J., Zebell, N. M., McGrath, J.M. (2005). Parent-child interaction therapy: Application to maltreating parent-child dyads. Child Abuse & Neglect, 29, 825-842 Werner-Wilson, R. J. & Davenport, B. R. (2003). Distinguishing between conceptualizations of attachment: Clinic al implications in marriage and family therapy. Contemporary Family Therapy, 25(2 ), 179-193.


63 Appendices


64 Appendix A: Direct Observation Form: Parent CDI Skills Parent CDI Data Sheet Date:_____________________ Individual observed: ____________________ (parentÂ’s name) Observer:__________________________ 30 Second Intervals Skills 30sec 1min 1.302.002.303.003.304.00 4.30 5.00Total Behavior Descriptio ns Reflection Labeled Praise Unlabeled Praise Positive Physical Touch Mistakes Questions Direct Command Indirect Command Criticism Negative Physical Touch


65 Appendix B: Behavioral Definitions Behavior Descriptions a declarative sentence or phr ase that gives an account of the objects or people in the situati on or the activity occurring during the interaction (for example, You are building a pickup truck; You are sitting quietly) Reflections a declarative phrase or statement that immediately repeats the child’s verbalization. The reflection may be exactly the same words the child said, may contain synonymous words, or may contain some elaboration on the child’s statement, but the basic content mu st be the same as the child’s message (for example, CHILD: “I made a big square”. PARENT: “You made a big square inside this circle”) Labeled praise any specific verbalization that expresses a favorable judgment on an activity, product, or attribute of th e child (That is a terrific house you made; You have a beautiful smile) Unlabeled praisea nonspecific verbalization that expresses a favorable judgment on an activity, product or attrib ute of the child (Great; Nice; Good work; Perfect!) Positive physical touchanytime the parent puts their arm around the child, gives a hug or kiss, puts hand on child’s leg, has teddy bear kiss child’s cheek or otherwise touches the child in a manner that is not a negative physical touch Questions -a descriptive or reflective comme nt expressed in question form. Some questions are differentiated fr om statements by voice inflection; Direct Command -declarative statements that contain an order or direction for a vocal or motor behavior to be performed and indicate that the child is to perform this behavior Indirect commandan order, demand, or direction for a behavioral response that is implied, nonspecific, or stated in qu estion form (put it here, OK:; Johnny!). Critical Statement : a verbalization that finds fau lt with the activities, products, or attributes of the child (You are be ing naughty; That is a sloppy picture) Negative physical touch -any physical touch which is intended to be directive, antagonistic, aversive, hurtful, or restrictive of th e child’s activity


66 Appendix C: Social Validity Questionnaire SOCIAL VALIDITY QUESTIONNAIRE To what extent are you satisfied with th e improvement of your child’s behavior? 1 2 3 4 5 Very dissatisfied Somewhat dissatisfied Neutral Somewhat satisfied Very satisfied To what extent are you satisfied with the improvement of your parenting skills? 1 2 3 4 5 Very dissatisfied Somewhat dissatisfied Neutral Somewhat satisfied Very satisfied How satisfied are you with the changes in your parent-child relationship following PCIT? 1 2 3 4 5 Very dissatisfied Somewhat dissatisfied Neutral Somewhat satisfied Very satisfied To what extent to you agree you and child ha ve a stronger “attachment” as a result of PCIT? 1 2 3 4 5 Completely Somewhat agree Neutral Somewhat agree Completely Disagree Agree Overall, how has the quality of your child’s interactions change d a result of PCIT? 1 2 3 4 5 Much worse Somewhat worse No change Somewhat improved Much improved Overall, how has the quality of your inte raction skills change d a result of PCIT? 1 2 3 4 5 Much worse Somewhat worse No change Somewhat improved Much improved To what extent do you believe the study was important and meaningful? 1 Not important 2 Somewhat importa nt 3 Neutral 2 Somewhat important 1 Very important


67 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 0 1 2 3 4 5 6 Adoptive Mother Adoptive Father Foster Mother Foster Father Other (please specify) Appendix: D Kinship Center Attachment Questionnaire Child’s name: __________________ Relationship to child: Date: _________________________ Directions: Please read each item below and circle the number that you think BEST describes how often your child behave s as described in the item. Please answer all questions and circle only on e number for each item. If you make a mistake, please put an “X” through the mi stake and circle the right number. Please rate your child based on his/her current behavior 0 1 2 4 5 6 never/rarely once in a while occasionally sometimes often usually 1. My child is very clingy 2. If things don’t go his/her way, my child gets very upset 3. When my child gets hurt, he /she refuses to let anyone comfort him/her 4. My child understands what is said to him/her 5. My child learns from his/her mistakes and stops a behavior when that behavi or results in a negative consequence 6. When my child is in pain, he/she doesn’t show it 7. My child is kind and gentle with animals 8. My child does not like bei ng separated from me except on his/her terms 9. My child is very whiny 10. My child talks as well as othe r children of the same age


68 Appendix D (Continued) 11. When my child is upset, he/she does not allow familiar adults to comfort him/her, but will go to strangers for comfort 12. My child teases, hurts, or is cruel to other children. 13. My child hoards food or has other unusual eating habits (e.g., eats paper, raw flour, packaged mixes, feces, etc.) 14. My child destroys or brea ks his/her own things 15. My child destroys or breaks th ings that belong to others 16. My child has an easy time ma king and keeping friends 17. My child steals things and doesnÂ’t seem to feel bad about his/her behavior 18. My child seems overly interest ed in fire, gore, and blood 19. My child has told others that I abuse him/her even though I never have 20. My child plays well with other children


69 Scoring the Kinship Attachme nt Center Questionnaire: All positively phrased items need to be reverse scored so that a low score (e.g., a caregiver re sponds “1-Never/Rarely” to the item “My child understands what is said to him/her”) reflected more attachment difficulty. The following items need to be reversed: (0 = 6); (1 = 5); (2 = 4) (3 = 3) (old value = new value for reverse scoring. 4. My child understands what is said to him/her. 5. My child learns from his/her mistakes and stops a behavior when that behavior results in a negative consequence 7. My child is kind and gentle with animals 10. My child talks as well as other children of the same age 16. My child has an easy time making and keeping friends 20. My child plays well with other children After reversing these items, add totals for total score.


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Phasellus ornare in augue eu imperdiet. Donec malesuada sapien ante, at vehicula orci tempor molestie. Proin vitae urna elit. Pellentesque vitae nisi et diam euismod malesuada aliquet non erat.


Nunc fringilla dolor ut dictum placerat. Proin ac neque rutrum, consectetur ligula id, laoreet ligula. Nulla lorem massa, consectetur vitae consequat in, lobortis at dolor. Nunc sed leo odio.