By Ariel Sabar
Special To The Washington Post
— Edith, a retired Capitol Hill staffer from Washington, was at the end of her rope last year over the mayhem her 5-year-old great-grandson Wayne was causing at preschool. "I was on speed dial" at the school, says Edith, who is raising two of her great-grandchildren. "He was hitting kids, destroying the classroom, tearing the ABCs off the wall, just terrorizing the building."
The principal begged her to seek help, and Edith soon enrolled Wayne — and herself — in an emerging psychological treatment for out-of-control preschoolers called Parent-Child Interaction Therapy (PCIT). The program has been slowly making its way into clinics across the country after years of randomized trials that have won it recognition as one of the most effective treatments for young children prone to frequent and destructive meltdowns.
Unlike traditional play therapy, in which a therapist plays with the child while the parent stays in a waiting room, PCIT takes aim at both child and parent (or chief caregiver) and at the day-to-day mechanics of their relationship. Its premise is simple: that the best way to help children with titanic tempers is to coach parenting in real time.
Parents who enroll in PCIT get their own personal trainer: a social worker or psychologist who dispenses guidance through a wireless earpiece. In a typical session, the therapist retreats behind a one-way mirror and instructs parents — sometimes even feeding them lines to say — as they play with and learn to discipline their children. The live feedback catches ineffective parenting habits in their tracks and helps parents hew to PCIT's somewhat rigid script, which combines effusive praise and attention for good behavior with a clear system of warnings and timeouts for bad.
"It gave me a sense of 'someone's got my back,' " says Edith, who entered PCIT with Wayne at a mental health clinic in August 2012. (Like other parents quoted in this article, Edith asked that only her first name be used.)
Wayne is typical of children who benefit from the therapy, which researchers have found most effective for those ages 2 to 7. According to clinical studies, families who complete PCIT see lasting improvements in child behavior: less-frequent and less-intense tantrums, less crying and whining, and less hyperactivity and inattention. Parents had less stress and enjoyed parenting more, and typically developed a closer relationship with their children.
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To one degree or another, nearly every preschooler has an inner Dennis the Menace. But families who enter PCIT have typically reached a crisis. Their kids have been expelled from day care or preschool. Parents, demoralized by one too many public meltdowns, have grown isolated from friends and emotionally withdrawn from their children.
A common refrain is: I love my child, but I no longer like her.
"I have had folks come in and say, 'What I need is Supernanny,' " says Teresa Loya, a clinical social worker who is the PCIT coordinator at the Kennedy Krieger Institute's Family Center in Baltimore. "More than that, though, they often say, 'I need to get rid of this kid.' "
"At our darkest moments, we thought, 'This child can't live with us anymore; he's going to have to go to a home,' " says Jennie, a 30-year-old mother of three in Auburn, N.Y., who once locked herself and her newborn in a bathroom for safety from her raging 5-year-old son, Alex. Jennie tried everything — play therapy, medication, a gluten-free diet — before she and Alex began making a weekly six-hour drive last year to the PCIT program at the Child Mind Institute in Manhattan.
"I always thought that kids with [behavior disorders] came from abusive households or really sad, poor conditions where they witnessed violence. My son comes from a pretty cushy middle-class lifestyle. I felt very ashamed, like I'm not a good parent."
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Most families complete PCIT after 10 to 20 weekly, hour-long sessions. In the first phase of PCIT — called child-directed interaction (CDI) — the parent is taught to notice and praise even the briefest moments of good behavior ("Thank you for sharing your toys!"), while mostly ignoring defiance. In the second phase — called parent-directed interaction (PDI) — the parent is taught to issue calm and concrete commands ("Put the crayons in the box" rather than simply "Clean up your mess") and to respond to noncompliance with predictable, immediate consequences (a warning, followed by escalating timeouts).
The sequence is not accidental: The idea is that the discipline becomes effective — and, ideally, unnecessary — only once the child discovers he can get as much attention for good behavior as for bad. The therapy does not end until the parent has demonstrated — live, with the child — that he or she has mastered the CDI and PDI skills.
Parents maintain the skills at home by establishing a timeout room and having at least five minutes a day of "special time" with their child. That often means playing together with toys and using the relationship-building techniques learned in CDI. If a child misbehaves in public, parents are instructed to find a makeshift timeout area; a stairwell landing or a restroom alcove will do. "Immediate consequences are hands-down the important thing," says Steven Kurtz, a child psychologist who conducts PCIT at the Child Mind Institute.
Once parents graduate from the program, therapists schedule a follow-up phone call a few months later — and, if necessary, a "booster" session. Medicaid and most private insurance cover PCIT as family or individual therapy. Patients without insurance can expect to pay $150 to $200 per session in an area like Washington, according to one local therapist.
Edith finished the program after three months. Now, she says, Wayne is a seemingly different child, sitting still in class, advancing a level in reading, trusted by teachers to help out in class. "I feel like I can live now," Edith says.
Jennie reported similar results after graduating from PCIT. Tantrums that had drawn blood and lasted for hours are now mild and over within a couple of minutes. "Rarely do we have to use a timeout, rarely does it go beyond a warning," she says of Alex, who has mild autism. "He just seems so much more like a typical child now. People that know us ask: What did you do?"
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Young children, taking the first steps toward independence, are in many ways naughty by nature. By one estimate, the typical preschooler disobeys 25 to 50 percent of his parents' commands. Psychologists advise professional intervention only once the defiance becomes so disruptive that it upends family life.
"It's when the frequency of the behavior reaches a point where it starts influencing relationships with peers, family and teachers," says Kelly O'Brien, a clinical psychologist. "It's when it becomes multiple times per day over routine requests like getting ready for bed or turning off the computer to go to dinner."
To determine whether PCIT is appropriate, a therapist interviews the family, administers a parent questionnaire and standard child behavior assessment, and watches the parent and child play. Though some children entering PCIT may have already received a diagnosis of attention deficit hyperactivity disorder or oppositional defiant disorder, a psychiatric diagnosis isn't necessary for treatment.
The therapy isn't right for everyone. Psychologists say that children who have been sexually abused by caregivers, and parents who have low IQ, serious mental illness or substance abuse issues are better served by programs that tackle those underlying problems first. Because of PCIT's time demands, parents have to be motivated. "The parent has to be organized enough to make a weekly outpatient therapy appointment," Loya says. "That kind of sounds like a given. But for a lot of folks, that's not the case."
Psychologists say that the consequences of untreated behavior disorders in children are not just glares at the grocery store or the playground: Research has found that such children are more apt later to have drug and alcohol problems, to drop out of school, to develop other mental illnesses and to spend time in prison.
Though stimulants such as Ritalin are often prescribed for behavioral problems, medicine alone is not seen as an effective treatment for young children with disruptive behavior disorders.
PCIT may also play a role in reducing child abuse. A 2004 study in the Journal of Consulting and Clinical Psychology found that 850 days after treatment, 19 percent of physically abusive parents who had undergone PCIT had been re-reported to child welfare authorities, compared with 49 percent of physically abusive parents who received conventional services. A new line of PCIT research is also showing promising results with autistic children.
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PCIT has its roots in the early 1970s, when Sheila Eyberg, now a professor emeritus at the University of Florida in Gainesville, began developing the technique out of frustration with the two prevailing interventions: play therapy, in which a therapist gleans a child's inner dramas from the way he plays with toys in a clinic; and behavior therapy, in which parents meet with a therapist once a week to discuss their child's behavior problems and develop responses.
Parent and child were rarely with the therapist at the same time. As a result, the child associated the calming effects of play therapy with the therapist, not her own parents. Parents, meanwhile, struggled to apply the therapist's lessons at home.
Eyberg's insight was, in essence, to cast parents as play therapists to their own children. The professional therapist still had an important role but was behind the scenes, performing a kind of ventriloquism through an earpiece until parents internalized the therapist's voice.
Eyberg won federal money for a pilot study in the mid-1970s; over the next three decades, randomized clinical trials began finding large, lasting improvements in child behavior and in parents' skills, attitudes and stress. But PCIT remained largely confined to university settings where Eyberg and her former graduate students taught. The therapy met resistance from some traditional therapists, who had been trained to listen to patients, not to tell them what to do.
The intensive training and supervision required of new PCIT therapists was another impediment. That began to change in the late 1990s, with growing interest among health professionals and public health officials in evidence-based treatments, whose effectiveness had been demonstrated in controlled scientific studies.
Jennifer Wyatt Kaminski, a developmental psychologist at the Centers for Disease Control and Prevention, led a meta-analysis of 77 published studies on evidence-based treatments for early childhood behavior problems. The results, published in 2008 in the Journal of Abnormal Child Psychology, found that one of the most successful strategies was to increase the number of positive everyday interactions between parents and children.
PCIT's live coaching and laserlike focus on the parent-child relationship make it distinctive, but the therapy shares many of the same goals as other highly regarded interventions, such as the Incredible Years and the Triple P: Positive Parenting Program.
"You're relationship-building and providing children with positive attention in such a way that it reduces their need to seek out attention through" undesirable behaviors, Kaminski says.
For parents who have built emotional defenses against their children's rages, that can at first be a challenge. "I realized I had gotten to the point where I was so afraid of sparking yet another tantrum that I barely spoke to my son anymore," said Jennie, the mother from upstate New York. "As much as Alex would complain at first [about PCIT] — 'Stop complimenting me, stop talking to me' — eventually he'd say it less and less. Eventually, he said to me, 'I love my compliments.' "
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Sabar is a writer in Washington. His e-book, "Small Town Renegade," about a maverick psychology professor, will be released as an Amazon Kindle Single in January.