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PCIT: Test 3 Notes.docx

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York University
PSYC 4030
Diane Lawless

Steps: (1) Pre-treatment assessment of child and family functioning (1-2 sessions) (2) Teaching CDI (child-directed interaction) skills (1 session) (3) Coaching CDI skills (3-4 sessions) (4) Teaching PDI (parent-child interaction) skills (1 session) (5) Coaching PDI skills (4-6 sessions) (6) Post-treatment assessment of child and family functioning (1-2 sessions) (7) Booster sessions (as needed) Overview of PCIT - DIRECT coaching – advantages o (1) Parental errors can be fixed promptly o (2) Every child presents own challenges so can make quick modifications o (3) Many parents lack confidence to use new skills without initial encouragement o (4) Therapist can shape parenting skills by successive approximations – direct = fast learning o (5) Parents not always accurate in reports, so allows for accuracy - DATA gathered at each session o Coded at beginning of each session to determine a family‟s progress toward mastery criteria o PCIT is NOT time-limited – number of sessions vary - SENSITIVITY to developmental concerns o Behaviour problems peak around 3 and decline during preschool years o PCIT must have keen sense of each child‟s developmental capabilities - INTERVENE early o (1) Problem behaviours in preschoolers tend to be less well-ingrained than older ones o (2) Much more potent because they don‟t have competing external influences like older ones o (3) Young child have fewer cognitive resources for questioning and challenging behavioural interventions o (4) Can exhibit affection towards their parents as well as cooperative behaviours which can be shaped to occur more frequently - RANGE of behaviours can be targeted o (1) Externalizing problems (non-compliance, defiance, verbal and physical aggression) o (2) Pre-conduct disordered behaviours such as cruelty to animals, stealing, lying, fire-setting o (3) Inattention and over-activity o (4) Internalizing problems (sad affect, low self-esteem, perfectionism o (4) Parent-child relationship problems in context of divorce and adoption - SPECIAL space and equipment o Observation room through one-way mirror using hearing aid device, while family in adjoining playroom o Should not include furniture that can tip over, working sinks, plants, computers, inappropriate toys o Ideal playroom = sparsely furnished, including 1 table and chairs, has covered light switches, crdstructional/creative toys o 3 room = time-out room, adjoining first 2 (small, has 2 small unbreakable windows in each door so can see them, lighted/ventilated, no furniture or objects, no electrical outlets) - TARGETS broad patterns of interaction o Rather than discrete behaviours o (1) Children engage in many of these behaviours to access attention and stimulation (GAIN ATTENTION) o (2) To escape parental demands (ESCAPE DEMANDS) o CDI  learn to use contingent attention – give attention to pro-social behaviour to increase it, ignore inappropriate behaviour to decrease o PDI  provide consistent consequences for non-compliance (so can‟t escape demands) o Targets negative attention-seeking and non-compliance - POSITIVE non-judgmental philosophy o Use labelled praise with parent, just as they do with child o Don‟t judge or blame parents o Avoid referring to therapy as parent training – teach what TO DO to become expert behaviour therapists, instead of what NOT TO do Intake Assessment and Orientation Session - Objectives: o (1) Tailored to meet special needs of each family o (2) Discuss factors that might interfere with treatment progress o (3) Results of testing serves as baseline measure – to see progress during course of treatment o (4) Accountability concerning treatment effectiveness Core Assessment Procedures - (1) Semi-structure intake interview - 45 min o Discuss limits of confidentiality o Equal involvement by both parents o Discuss information more specific to PCIT outcomes (such as previous time-out attempts) o Develop rapport and motivate parents o (1) Hear out the parents through reflecting and listening (HEARD) o (2) Validate they are not over-exaggerating or overreacting to minor problems (VALIDATED) o (3) Support them using supportive statements (SUPPORTED)  (1) They enhance rapport making the client want to come back  (2) Build parental self-esteem  (3) Model the positive tonne we want parents to use with their children  (4) Nurture parents, giving them internal resources to nurture their children in return  (5) Decrease defensiveness as parents realize this is safe place to talk without being judged/blamed o (4) Tell them positive things about their children (POSITIVE THINGS)  Other people become focused on negative and provide parents with steady diet of child criticism  We listen carefully for times when children use polite manners – great opportunity to give parents credit for good parenting o (5) Educate parents (EDUCATED)  Provide opportunities for parents to ask questions o (6) Feel encouraged and hopeful (ENCOURAGED AND HOPEFUL)  We have knowledge and expertise that will help their child  Provide encouraging statements forecasting that the family‟s problems can be effectively treated - (2) ECBI (Eyberg child behaviour inventory) – 5-10 min o Brief parent-report measure of child behaviour problems (2-6) o Intensity Score = estimate how frequently displays the 36 problem behaviours (clinical cut-off = 131+) o Problem Score = how much of a problem for child (clinical cut-off = 15+) o Administer ECBI every pre and post-treatment, also at start of every session as way of measuring treatment progression - (3) SECBI (Sutter-Eyberg child behaviour inventory) – 5-10 min if child in school o For classroom – completed by daycare/prescool/elementary school teacher o Intensity = 151+, Problem = 19+ to be in clinical range - (4) DPICS III (Dyadic parent-child interaction coding system) – 15 minutes for each parent o Direct observation of parent-child interactions o Informal observation – note how the dyad interacts in waiting area, while parents complete assessment procedures  Look for child‟s ability to play independently  Strategies child uses to gain parents attention  Parental responsiveness to child  Parental limit-setting  Warmth of interaction  Evidence of clinginess and separation anxiety o DPICS III = formal observation done in clinic playroom using:  Small table  2 chairs  Time-out chair (placed in corner of room)  Large toy box  5 sets of toys – 2 of which are placed on table, others distributed across remaining 3 corners of room (taken out of containers to allow for enough to be cleaned up) o Recommend the pre-treatment observation be videotaped whenever possible to be reviewed multiple times o III instructions for parents in DPICS III:  (1) Child-led play (5min)  child leads to play what choose, follow lead  (2) Parent-led play (5min)  parents‟ turn to choose, child plays according to parent rules  (3) Clean-up (5min)  child told to put toys away o Keep track of child and parent behaviours and verbalizations using tally marks on a coding sheet (9 categories of parent behaviour, whether child complies/does not comply/or has no opportunity to comply with parental commands)  (1) Labeled praise (specific statement expressing a favourable judgment) – “good job setting the table”  (2) Reflection (repeat child‟s talk) - child “I made a big square,” parent “You made a big blue square”  (3) Behavioural description (describe child‟s current activity) – “You‟re drawing the sun”  (4) Neutral talk (describes information other than child‟s current activity or provides acknowledgment – “That‟s a rainbow”  (5) Unlabeled praise (non-specific statement expressing a favourable judgment) – “Good job”  (6) Direct command (clearly stated order) – “Please put away your shoes”  (7) Indirect command (implied direction, often asked in question form) – “Could you put away your shoes?”  (8) Question (comment expressed as a question) – “What are you making?”  (9) Negative talk (expression of disapproval, could be sarcasm) – “Don‟t stand on the table” o After observation, ask parents to describe how typical that behaviour was in each of the 3 situations o Praise parents for any positive parenting observed during formal coding o We share test results with parents – at end of initial evaluation session, provide feedback to parents (usually have enough information from interview, behavioural observations, ECBI to determine whether they can provide a helpful service to the family) o Explain specialized parenting  only they have the power to successfully resolve child‟s problems (motivation to work hard in PCIT) – teach highly specialized skills that enable parents to manage children who do not respond well to typical parenting TEACHING CDI - Arrange for child care for this session - Have parents complete ECBI - (1) Review homework from last session (from the pre-treatment assessment and therapy orientation session) o Praise if brought homework sheet and completed most of the daily practice sessions o If brought but did minimal homework, praise for bringing but remind of importance of daily practice, and problem-solve about possible solutions o For parents who forget to bring their homework sheets, bring out new form and get it completed before continuing with the session - (2) Provide description of goals of this session, emphasizing how CDI may help resolve specific problems identified in intake evaluation o Discuss must be strong foundation (warm relationship that develops during CDI phase of treatment) o CDI takes time o Find that CDI improves children‟s self-esteem, parent-child relationship, helps children attend longer to play activities, improves frustration tolerance and perfectionism o Sell CDI to sceptical parents:  (1) CDI is therapy, not play – special playtime is therapeutic intervention – with consistency, small changes can produce large cumulative effects  (2) Have parents reflect on their own childhood experiences (help parents see they have an opportunity not to repeat the same mistakes and to parent their children differently)  (3) Overlearn skills to help generalize o Explain important rule of letting the child lead  Want to give child lots of high-quality attention while they are behaving well, also there are few naturally occurring opportunities for young children to be in the lead - (3) Discuss 5 min of daily home practice o 5 minutes offers several advantages: o (1) Removes resistance to home practice that comes with longer practice periods o (2) Parents can sustain a high degree of quality during their special playtime o (3) 5 minutes is perceived as a long time by novice play therapists who are concentrating hard on using their skills correctly o (4) Set up a situation in which the child is most likely to display pro-social behaviours o (5) 5 minutes to a young child seems like a long time to have parents‟ undivided attention o Encourage parents to handle clean up in 1 of 2 ways:  To say “I am going to pick up the toys now. You can help if you want” OR  To allow the child to continue playing by saying “Special playtime is over now. You can continue playing with the toys if you want. But, I have to do some other things right now” o Remind them that clean-up strategies will be covered in the discipline part of program - (4) Presents and models “Avoid” skills  (1) Commands – take the lead away from child, sets stage for unpleasantness if child disobeys  Direct – obvious demands  Indirect – less obvious, often phrased as a question  (2) Questions – direct conversation, instead of following and take lead away from child  Can lead child to believe parent is not really paying attention or disagrees with what child is doing  Statements can be turned into questions by inflection in parent‟s voice  During 5-min of special playtime, ask parents to give children a break from all questions  (3) Criticism and Sarcasm  (1) Criticism is not effective for decreasing problem behaviours, may even increase some undesirable behaviours – all children strive for attention (even negative)  (2) It causes unpleasantness during interaction, and want special playtime to be enjoyable for both child and parent  (3) May result in self-esteem problems  Sarcasm = neutral or even positive statements can be made critical through a parent‟s tone of voice (“Nice going”) – young children pick up on this - (5) Presents and models “Do” skills  (1) Praise  One praise every 30 seconds  Labeled = tell child exactly what it is the parent likes – included in mastery criteria because so important, can tell child what can be done in the future to earn praise  Teach that labeled praise can also be used to prevent and reduce problematic behaviour (labeled praise for incompatible behaviour)  Labeled praise helps to increase self-esteem  (2) Reflect  Parent should repeat the basic message of what child said, a form of verbal imitation  A message can be extended, elaborated on, or subtly corrected through reflection  Reflection communicates acceptance and understanding and tells the child the parent is actually listening  Reflective statements also keeps child in lead during the conversation, encouraging the child to elaborate  We ask parents to reflect nearly all appropriate verbalizations the child makes during special playtime  (3) Imitate  By imitating the child, the parent demonstrates that he or she is paying attention to the child‟s activity and thinks it is interesting enough to do also  Being imitated by parent is self esteem boost to young children  Enhances the child‟s imitation of the parent also – forming important social skills – turn- taking  By imitation, parent should play with the same or similar toy and attempt to manipulate the toy in a way that approximates what the child is doing (parallel play)  Allows to play at the proper developmental level  (4) Describe  Parents are encouraged to watch their child‟s activity closely and to comment on the child‟s appropriate play  Behavioural description = running commentary of child‟s ongoing activities  Comment has to directly refer to the child‟s behaviour (usually including the word “you”)  Neutral talk = comments that introduce information but do not refer directly to child‟s ongoing or immediately completed activity – doesn‟t use you  Want parents to use lots of behavioural descriptions, commenting on child‟s current behaviour – allow parents to join in, and show interest without leading the play  (1) Child kept in lead  (2) Child has parents‟ undivided attention – can be self-esteem building (parent thinks child‟s choice of activity is interesting)  (3) Descriptions can be used as a teaching tool for pre-academic or early elementary school concepts – can comment on sizes/shapes/sorting activities  (4) Help organize young children‟s thoughts about play, increasing the length of time they are able to attend to the task-at-hand (during special playtime, young children make fewer switches between toys, more likely to persist and problem-solve in face of challenge)  (5) Enthusiasm  Talking with animated voice with varied inflection  Communicates interest and makes playtime more enjoyable for both parent and child  Model for them how it sounds to conduct CDI skills with and without inflection - Each skill described with its rationale, examples given, and skill briefly demonstrated by therapist - (6) Present concept of strategic attention for shaping behaviour o Using “do” skills to carefully reward the behaviours or qualities we want to see them display more often o (1) Identify desirable and pro-social behaviours o (2) Be on the lookout for these behaviours to occur o Immediately when they occur, use “do” skills o Encourage parents to use strategic attention whenever possible, through the day and not just the 5 minutes of CDI practice - (7) Present concept of selective ignoring for shaping behaviour o Withdrawing attention strategically o (1) Identify undesirable behaviours they want to diminish o (2) Realize that ignoring only works for attention-seeking behaviours (when function of misbehaviour is to elicit a reaction from the parent) o (3) Causes behaviour to get worse before it gets better – in deciding whether a problem can be diminished through ignoring, the parent must make a judgment about whether he or she can tolerate having the behaviour get worse before it gets better o (4) Must be continued until the child exhibits some positive behaviour o (5) Exaggerate ignoring and attention, move away and ignore/distract which gives the opportunity for strategic attention for appropriate behaviour, model the opposite behaviour (show what TO DO)  When behaving appropriately, therapist leans toward child, makes good eye contact, uses PRIDE skills  When behaving inappropriately, turn in chair to face away from child, no eye contact, no words exchanged, facial expression blank, pretends child isn‟t there  Watch for first possible moment when attention can be returned to child – when child pauses or ceases disruptive behaviour – swings back around in chair, makes eye contact and says “Thank you for playing gently with the toy. It is so much more fun to play with you when you treat the toys nicely”  Sometimes child‟s behaviour prolonged and difficult to find momentary pause to return attention – so encourage ignore and distract – moving away, playing with different toy, enthusiastically describing their own play but as though talking to oneself  often, the child will quickly cease the disruptive behaviour to join the parent in the new and attractive activity (parent then has opportunity to provide strategic attention for appropriate behaviour)  At home  severe disruptive behaviour that cannot be ignored – discontinue playtime and discipline  In clinic  severe disruptive behaviour that cannot be ignored – walk into playroom, ask parent to leave, then clearly and firmly restate the safety rules of playroom – serious voice of therapist generally gets children‟s attention and interrupts the escalating behaviour, after 1-2min, parent is brought back into room and coaching resumes - (8) Therapist models use of skills in combination o Demonstrate combined skills o Modeling is most useful when parent perceives model to be similar to him or herself - (9) Parents role-play with therapist o After getting over their initial anxiety, many parents find this the most enjoyable part of the teaching session o Recommend doing 2 brief role-plays of about 2 minutes each o (1) Child should behave perfectly and present no behaviour management challenge o (2) Child should show intermittent minor disruptive behaviour but behave appropriately most of the time o The therapist-coach should encourage parents to begin with describing, and gradually add in the other “do” skills o Purpose of role-plays is to introduce parents to how it feels to do the skills and what it is like to have someone providing them with frequent, largely positive feedback on their performance - (10) Discuss logistics of play therapy at home o Parents should have set of 3-5 toys always available for child to play with during special playtime o Give parents a handout summarizing the types of toys that are good for CDI and those that are to be avoided o Constructional toys without pre-set rules are best (Legos, building blocks, Mr. potato head, crayons and paper)  encourage creativity and provide developmentally appropriate opportunities for problem-solving in the context of play o Caution to avoid toys conducive to rough play – balls, bats, punching bags, also toys that can be messy (scissors, play-doh), avoid board games/card games with pre-set rules – child may be loser, have trouble taking turns, or cheat causing unpleasantness during a time when we want to encourage parent-child bonding – discourage reading (interferes with spontaneous parent-child conversation), avoid toys that encourage participants to pretend they are other people, speaking through their pretend characters (dolls, costumes, puppets) - (11) Assign new homework o Given a recording sheet on which to mark whether they got in their practice and types of toys/activities involved in playtime o Homework sheet also helps to make parents feel accountable – reviewed with therapist at beginning of next session - At end of session, parents given handout summarizing the behavioural play therapy skills and their rationales - Given homework sheet to record daily practice and any problems that come up - Advantages to record e the teaching session o (1) If there is a reluctant spouse at home who may be convinced to listen o (2) May be other caregivers who were unable to attend the session but would like to learn the material o (3) Many learn best through repetition o (4) Sometimes work with parents with reading difficulties who are able to make better use of a tape than a written handout Coaching CDI - Give attention to parents‟ positive behaviours by describing and praising - When correcting parent, use constructive feedback telling them what “to do” not what “not to” - Steps for CDI: o Upon arrival, parents complete the ECBI Intensity Scale in waiting area o Therapist tallies the score and records it on the PCIT Progress Sheet, provides feedback to parent about changes over time, often using a graph to visually display the changes in ECBI scores o (1) Session begins with review of homework (10 min), provide a developmentally appropriate explanation of the coaching process for the child  4 common functions of homework non-compliance:  (1) Parent does not “buy in” to CDI  court-ordered, school-referred, less educated families – address resistance directly, emphasize 5 points, introduce CDI as an experiment  1) Parent must have a strong relationship with the child for program to work  2) Daily practice leads to faster mastery of CDI so can progress to discipline program quicker  3) CDI is therapy not just play  4) Having a short daily connecting with child adds up and leads to child wanting to please parent  5) By practicing each day, parent over-learns important behaviour management skills that become habits  (2) Parent is too stressed and disorganized to make homework a priority  Lack routine, responding to crises, feel overwhelmed by addition of one more task  1) Give them a folder at beginning of treatment – put handouts and homework in folder, choose place to keep folder at home, emphasize need to bring this to every session  2) Night-before reminder call  3) Visual reminder to practice special playtime at home  4) Mid-week reminder call  5) Incentive  6) Help them develop a routine for CDI  (3) Therapist has not sent a consistent message that homework should be a priority  1) Avoid inadvertently reinforcing non-compliance with supportive statements  2) Consistently pick up homework sheet with ECBI, making homework sheet a ticket to the session  3) Give labeled praise for remembering homework sheet  4) Give labeled praise for completing most of homework (4 out of 7 days)  5) Require parents to recreate the homework sheet if it is forgotten  6) Repeatedly educate parents about importance of homework and attribute child changes to home practice  (4) Parent practice is being sabotaged by others in the home  1) Attempt to engage the significant others in therapy  2) Problem-solve ways for parent to practice with privacy  3) Empower the parent to be assertive with others  4) Educate parent that others who have been criticized for CDO practice have found ways to complete homework  5) Forecast that significant others will stop sabotaging when they see the treatment work o (2) Code CDI skills – 5 min play therapy session with child without direct coaching (record on DPICS III recording sheet) and later transferred to PCIT Progress Sheet  Helps to monitor the effectiveness of our previous coaching, provides us with objective information that can be charted and shared with interested parents, and supplies with information about what skills should receive particular focus during next sessions  Immediately after 5min coding, find it helpful to provide parent with constructive feedback sandwich – labeled praise, suggestion regarding what the parent could do even better, finish with labeled praise  Gold standard for mastery of CDI skills:  10 labeled praises  10 reflections  10 behavioural descriptions  3 or fewer commands, questions and negative talk (sarcasm and criticism)  Ignore all negative attention-seeking behaviours  Imitate child‟s play  Be enthusiastic o (3) Directly coached on CDI skills by therapist practicing the PRIDE skills with child - 35 min– parent not coached, observes and is often taught to code from behind mirror (15 min each parent coached)  Based on concept of over-learning (to maintain the child‟s positive behaviour over time, even if some backsliding occurs), also enhances generalization outside of playtime  General principles important for effective skills coaching:  (1) Make coaching brief, fast, precise  Immediately after parent‟s verbalization  Precise, rather than general language  May take form of labeled praise, gentle corrections, directives, and observations  (2) Coach after nearly every parent verbalization  The more input the parent receives, the faster and better the skills will be learned  Parent learns to pause and wait for therapist input  Coaching proceeds more smoothly when therapist and parent develop this type of pacing  (3) Give more praise than correction  If parents aren‟t using descriptions, reflections, and praises on their own, the therapist should use directives to get the parent to make particular statements, following by labeled praises after the statements are made, and observations concerning the child‟s responses  Not wise to correct every mistake parent makes  At least 5 supportive statements for every correction  Alternative is selective ignoring for incorrect skill use, followed by strategic attention when skill is used properly  (4) Coach easier skills before harder ones  Parents more likely to feel immediate success if more focus placed on easier skills initially  Describing typically the easiest of CDI skills, followed by imitating, reflecting, avoiding criticism, and avoiding commands  Harder ones are avoiding questions and giving praise  (5) Use special exercises for difficult skills  When one skill lagging well behind, may interrupt CDI to conduct special exercises in which parent encouraged to concentrate on the particular skill  (6) Use observations to highlight effects  Many times, it isn‟t until the parent actually sees it demonstrated during a coaching session that they are able to recognize and strategically alter their communication patterns to elicit desirable child responses  The therapist should comment on the ways in which the child is responding to the parent  Because observations are wordy and may interrupt the flow of the interaction, they should be used strategically  Frequently comment on the child‟s appearance, manners, intelligence, creativity, curiosity, sense of humour, problem-solving ability, building skills, speed, artistic attire  Observations can help parents feel proud of their children and take responsibility for their children‟s behavioural improvements  (7) Make use of humour  More enjoyable for all involved if find humour  (8) Progress from more directive to less directive coaching  Empower parents to use skills autonomously – gradually reduce use of directives and corrections as parents display increased mastery of play therapy skills  (9) Coaching strategic attention and selective ignoring  Look for child behaviours that are pro-social, occur with low frequency, and are appropriate targets to increase through strategic attention  Often these behaviours are naturally incompatible with identified problematic behaviours  When an appropriate target for selective ignoring is presented during the coaching session, the therapist-coach first identifies the problematic behaviour, coaches the parent in selective ignoring until the child ceases the problematic behaviour, coaches the parent to return attention to the child for positive or neutral behaviours, and coaches the parent to keep an eye out for pro-social behaviours (which are incompatible with the problem behaviour) that can be responded to with strategic praise  Parents often try to coax children to re-engage in CDI during selective ignoring, but this breaks two of the CDI rules o (1) Provides attention for disruptive behaviour o (2) An indirect command, making it hard for them to lead the play  (10) Coaching qualitative aspects of the parent-child interaction  Qualitative aspects are also important - including physical closeness and touching, eye contact, vocal qualities, facial expressions, turn-taking, sharing, polite manners, developmentally sensitive teaching, task persistence, and frustration tolerance  (11) Physical closeness and touching  Securely attached parent-child dyads, preschoolers will frequently move from very close physical proximity with their parents to wider and wider exploration of the environment with frequent returns to the security of “home base”  Most securely attached children will play for extended periods of time within 2 or 3 feet of their parents, and parents will intermittently touch their children in an affectionate way  May coach parents to: o (1) Praise their children for more independent behaviours incompatible with clinging o (2) Combine verbal praise with physical praise such as stroking the child‟s hair o (3) Refrain from restraining gestures such as grabbing the child‟s hand to prevent a response o (4) Move closer to the child who has distanced him or herself from the parent, praising the child for allowing the parent to join in the game  (12) Eye contact, facial expressions, and vocal qualities  Modeling good eye contact is helpful but sometimes insufficient for encouraging young children to improve their own eye contact patterns  For young children who only occasionally make eye contact, parents are coached to praise their children strategically and enthusiastically for good eye contact  When eye contact is low, we coach parents to shape eye contact by lifting a toy that has captured the child‟s attention to the parent‟s eye level when they are speaking, and then strategically praising the child for good eye contact when the parent‟s and child‟s eyes meet  Exaggerate animation, then coach parents to play in more animated fashion, increasing enthusiasm in their voices, adding clapping to praises for young preschoolers, and exaggerating facial expressions – when play therapy is monotonous and boring  (13) Turn-taking, sharing, and polite manners  Over time, young children begin spontaneously praising their parents, reflecting parental verbalizations, and describing their own and their parents‟ play  The “do” skill of imitation presents a natural opportunity to coach turn-taking  Can be shaped into sharing and using polite manners  For young children who do not spontaneously share or use polite manners, we coach parents to periodically model these early social skills, clearly labeling their own behaviour so that the likelihood of imitation by the child is enhanced  (14) Developmentally sensitive teaching  Parents can overestimate or underestimate developmental level  Have seen parents:  (1) Command the child to perform a task that he or she is incapable of  (2) Impatiently interfere in the child‟s problem-solving by taking over and completing a task for the child  (3) Fail to recognize and praise the child for small increments of developmental advancement  (4) Model inappropriately advanced levels of play  These may cause the child to feel bad or lose interest  Parents told to adhere to overriding rule that the child is to remain in the lead  Coach parents to: o (1) Accurately perceive their child‟s developmental capabilities o (2) Introduce new vocabulary when reflecting and describing o (3) Reinforce developmentally appropriate learning by naming colours, counting objects, and identifying shapes  (15) Task persistence and frustration tolerance  Many children easily frustrated during play as well as during early academic tasks at school  Parents can be coached to provide strategic praise for task persistence, attempting difficult tasks, and staying calm when experiencing frustration  (16) Helping parents handle aggressive and destructive child behaviour  Must have a strategy for handling disruptive behaviour if it occurs during coaching sessions and during play sessions at home  For more serious behaviours such as physical aggression during home play sessions, we encourage parents to immediately end the special playtime  If it occurs during a clinic coaching session, coach parent to give warning they will leave if the child does this again – once exits, the therapist enters the room and may choose to: o (1) Watch the child out of the corner of the eye while ignoring o (2) Review the rules regarding dangerous or destructive behaviour o (3) Distract escalating behaviour with CDI skills and/or o (4) Put the room back together and remove any toys that were being misused, thrown or broken o Once child ceases the dangerous or destructive behaviour, the parent enters the room and CDI coaching resumes  (17) Coaching sessions with siblings  Most can extend the CDI skills to the targeted child‟s young siblings with little difficulty  However, when children are at different developmental levels, generalization of skills can be enhanced by having one session in which the parent is coached with the referred child and with each of his or her siblings in return o (4) Feedback on progress and homework assignment (10 min)  Many parents are motivated by viewing the PCIT Progress Sheet  Feedback should begin by noting for parents areas of progress in the “do” and “avoid” skills, child responsiveness to these skills, and improvements in qualitative aspects of the parent-child interaction - Parent and child meet with therapist in childproof playroom with a table, chairs, 3-5 toys appropriate for special playtime - Parents play on floor during CDI - Avoid limit setting so playroom should contain no items that may inspire child to misbehave and require parental intervention Teaching PDI - Reasons why young children benefit from parental control over their behaviour: o (1) Important part of early socialization is learning how to follow rules – begin to internalize rules for conduct and to demonstrate rule-governed behaviour that will facilitate their classroom adjustment o (2) The ability to obey and follow rules is important for the development of early social skills (rules in games, turn taking) – if don‟t develop these, at risk for peer rejection o (3) Parents of young children with behaviour problems often find it easier to do self-help tasks for their children rather than “do battle” over simple chores o (4) Although many parents do not recognize this to be true, young children really do want their parents in control o (5) Basic safety concerns dictate that young children learn to follow parental rules and respond rapidly to directions from parents o (6) Young children with disruptive behaviour and those with developmental problems are at enhanced risk for abuse, particularly when other familial risk factors are present - Approximately 2 hours required to cover the discipline skills in depth - Should collect the ECBI and CDI homework sheet, then discuss the PCIT progress sheet with parents - Importance of consistency, predictability, and follow-through o Explain the need for structure – consistency, predictability and follow-through o Consistency – consistent with skills when having a bad day o Predictability – robot response (in a routine/boring fashion) o Follow-through – if a child with behaviour problems perceives that a parent is flexible, the limits will be tested – told to establish a few rules but enforce them like a „brick wall‟ not a rubber band - First rule of PDI is children must comply when told to do something – teach consequences for compliance and noncompliance o Once a command is given, should stop everything and first determine whether the child has complied – if they have, it is followed by enthusiastic social reinforcement. Noncompliance is followed by a robotic, consistent, and aversive sequence of discipline steps - Parent need to memorize exact words in the discipline diagrams - Steps for teaching PDI: - (1) Explain use of compliance exercises (5 min) o Taught to view all misbehaviour as falling into 2 categories: noncompliance and disruptiveness o Noncompliance = refusing TO DO what one is told o Disruptiveness = doing things that one is told NOT TO DO o Disruptiveness cannot be addressed until the child first develops a basic respect for the parent as an authority figure o Parents teach children to follow directions by establishing small compliance goals along the way  First, learn to follow directions by practicing with play commands – over practice compliance through the use of simple, non-threatening tasks such as putting eyes on Mr. Potato Head  By receiving enthusiastic praise for these small accomplishments, they child begins to view compliance in a more positive light o Provided with more challenging tasks – instructing to do things they don‟t want to (performing boring task for example) o Once compliance has been improved within an exercise format, parents are coached in more „real-life‟ situations such as getting their children to take their hands for walks and getting them to come into the room from outside - (2) Discuss how to give effective instructions (25 min) o (1) Make commands direct, not indirect – so child doesn‟t test the limits o (2) Make commands single rather than compound – one instruction at a time (cannot keep a series of instructions in memory, so respond with either noncompliance or partial compliance) – breaking it down gives more opportunity for positive consequences of obeying o (3) State commands positively – what “to do” rather than what not to do – saves the child the step of having to think of an acceptable activity to do instead o (4) Be specific, not vague – child can easily misinterpret behaviour that is expected o (5) Give commands in a neutral tone of voice – need children to respond to directions issued in a normal conversational tone – firm, matter-of-fact approach that contains no trace of yelling or pleading o (6) Be polite and respectful – serves as a discriminative signal to children that an important instruction is going to follow and they should listen carefully, helps to stop indirect commands that begin with please – can be firm, yet polite at the same time o (7) Developmentally appropriate commands – both the parent and therapist agree that the child is physically and cognitively capable of following the instruction, children may be guided in more developmentally challenging activities by breaking the complex task down into smaller, simpler units o (8) Use gestures – enhances comprehension, when the child does not comply immediately the parent points so as to clarify the objects or places involved (gestures more effective than repeated commands because they involve much less negative attention and preserve the positive tone of the interaction) o (9) Use direct commands only when really necessary – reserved for times when it is important that the child obey o (10) Incorporate choices when appropriate – comply more when given choices, but only effective when choices are very simple and issued at a developmentally appropriate level – limit to 2 equally acceptable behaviours o (11) Provide a carefully timed explanation – sometimes (not always) it is appropriate for children to be given explanations for why they should do a requested behaviour, need a carefully timed – reason should either precede the instruction or be provided after the child has complied  when given between the instruction and compliance, it is a setup for an argument o Learn to evaluate whether a command is needed in a particular situation or whether a CDI skill could be used instead - (3) Discuss how to determine if child has obeyed (5 min) o Following “tough calls” should be discussed: o (1) Doing something slightly different from parent‟s request – must be assumed that the child knows which block the parent is referring to for 2 reasons: 1) only developmentally appropriate instructions are included in compliance exercises, 2) the parent pointed to the block to eliminate ambiguity in the instruction – so considered noncompliance o (2) Dawdling – slow to obey (handled with a 5 second rule) – if haven‟t complied by then, considered noncompliance o (3) Playing deaf – repeating commands and prompting eye contact provides negative attention and teaches the child that consequences can be delayed or avoided through the use of stalling tactics – form of noncompliance o (4) Partial compliance – angrily does it to test the limits, if accept it as compliance, sees the parent‟s rules as being elastic so will push the limits further next time – best response is having parent silently point to the block and point his or her hand to clarify the instruction – if child does not respond to the visual cue by placing the block in the parent‟s hand, considered noncompliance o (5) Complying with a bad attitude – must consider this compliance, ignore the bad attitude o (6) Undoing – initially obeys and then behaves in a way that negates the obedience, considered compliance – if undoing continues, the parent can be coached to follow immediately with a second instruction that is more clearly stated such as “please put the block in my hand and leave it there” – overdoing also counts as compliance (if hands all the red blocks when asked to hand a red block) - (4) Discuss consequences for obeying (5 min) o Role play what might happen if child complies o Labeled praises like “Good following instructions” o When enthusiastic labeled praises are given for listening, children begin to see compliance in a more positive light o Parent should also mention they are happy the child didn‟t have to go to time-out – sends message that parent is on child‟s team and happy when child is successful o Once child understands relationship between noncompliance and time-out, the labeled praise for not needing a time-out may be discontinued o Parents taught to return to CDI after child has been praised for compliance o Work with parents to generate a list of different labeled praises for compliance so not to sound robotic - (5) Discuss consequences for disobeying (40 min) o Only now does the mention of a time-out chair happen, otherwise risk losing parents if mention too early that the discipline program is based on time-out o Need to have established rapport and credibility first o Be prepared for major resistance when suggesting that time-out can be an effective technique o Some of reasons for choosing time-out over other types of consequences can be discussed with the parents  (1) Acting-out children are motivated to avoid time-out because it keeps them from stimulating activities, including getting attention from others  (2) Few consequences are more aversive to a young child than complete boredom  (3) Unlike some other consequences, time-out can occur within seconds of the inappropriate behaviour  (4) Unlike spanking, short time-outs can be safely administered numerous times per day, thereby allowing the parent to be more consistent in following through with consequences  (5) Unlike spanking, time-out does not cause some children to become more aggressive because the parent does not serve as a model for hitting  (6) Time-out is a commonly used discipline strategy in classrooms – use at home will promote greater cross-setting consistency and enhance the child‟s behavioural adjustment at school as well as at home o The time-out warning:  Parent must NOT repeat command, simply give the warning in a neutral tone of voice “If you don‟t put Mr. Potato Head back in the box, you are going to have to sit on the chair”  If a child complies after only the first or second word of the warning, the parent should continue saying the entire warning  Find that children will comply after the first word or two in an attempt to terminate the warning, as it is boring and aversive  But parent should follow through consistently, finishing the warning verbatim and then praising the child for compliance  Need consistent follow-through  it is a promise, not a threat  After consistent follow-through 100%, few children continue to doubt the parent‟s resolve  After warning is given, parents are taught to watch closely to determine whether the child has or has not complied  If complies, an enthusiastic labeled praise should be given - (6) Present back-ups for time-out escape (30 min) o Logical issues associated with time-out:  Avoid time-out in a corner – when an active, defiant child is placed within kicking distance of a wall, it is a safe bet that his or her feet will end up on the wall, if placed within reach of magazines, cupboards, wallpaper etc. it is very likely that the child‟s hands will be on everything within grasp  Place time-out chair in the middle of nothing (reach in all directions)  Minimize extraneous entertainment during time-out  Choose location the child can be easily observed while the parent goes about their business  Time-out chair should be a solid, wooden chair (sturdy to withstand destructive behaviour), an adult-size chair is usually more effective for several reasons:  It is harder to throw  More difficult to fall out of  Less likely to tip over  Discourages impulsive young children from hopping out because their feet do not touch the floor o Getting the child to time-out:  To help parents follow the sequence of events, the therapist can repeat earlier lessons by returning to the original role-play  Go over potential perceived problems – find that role-play is the best method for teaching parents how to get their children to time-out  Escort a co-operative child to time-out – therapist demonstrates the best way to escort a co-operative child to time-out (parent should stand up, gently take him by the hand, and walk him to time-out while explaining they need to stay on the chair until they tell him to get off, parent then walks away quickly) – child less likely to resist going to time-out if parent moves quickly and confidentially  Use barrel carry with resistive children – safest way is barrel carry in which the parent wraps his or her arms around the child (under the child‟s arms and across the chest) as if holding onto a barrel, the child‟s back should be against the parent‟s chest, parent can hold onto his/her wrist with the other hand)  To reduce the likelihood of the child physically attacking the parent, the time-out chair is positioned nearby, also parent is instructed to move quickly and confidently when taking the child to time-out  Parent must ignore all strikes and to continue moving the child to time-out as quickly as possible, if hitting is completely ignored, it rarely continues past the first one or two time-out episodes (limit negative attention) o If the child agrees to comply on the way to time-out  When children learn they can wait until their parent stands up before compliance is required, they seldom will follow instructions when their parent is seated or at a distance  The problem can be avoided if the parent takes the child to time-out the first several times this limit testing occurs  Thus, the parent would stand up and take the child by the hand  The child would try to comply even though the time has expired  The parent continues to take the child to time-out while using a slight modification of the original words, “you didn‟t do it quickly enough” o What if a child takes a toy to time-out  Not permitted, quickly take away o What if a child puts himself in time out  Doesn‟t mean child likes time-out  Ignore the fact that the child has placed himself in time-out and to follow through with the time-out warning and verbal script without interruption or alteration  Time-out immediately becomes less fun for the child once the parent takes control over the time-out process  When the child learns that placing himself in time-out will not derail the procedure, this behaviour will extinguish o Length of time-out  3 minutes  1 minute for every year of age is good for children who do not have severe behaviour problems, however, for an extremely active and disorganized 5-year old, 5 minutes would likely be too long and thereby set the child up to fail  5 seconds of silence rule  3 minutes plus 5 seconds of silence – if the child talks, cries, screams, or pounds on the chair during that period, the parent will begin the silent count to 5 again  The 3 minutes does NOT begin again just because the child is making noise, only the 5 seconds starts over  Once the child is quiet for 5 seconds, the parent should hurry over to the chair, stand out of reach of the child, and say “you are sitting quietly in the chair. Are you ready to come back and put Mr. Potato Head in the box now?” o Common misbehaviours in time-out that should be ignored  Parent instructed to ignore ALL verbalizations  Role-playing is often helpful to demonstrate proper ignoring  No direct eye-contact, but watch child, should not show disgust, amusement, or irritation (neutral and expressionless face)  Child says they have to go to the bathroom – most children can hold it for 3 minutes and their pleas are usually an attempt to get out, told to ignore requests, parents asked to allow them to go to the bathroom in the future before clinical sessions o Time-out does not end until the original instruction is obeyed  Following through with the original instruction after the time-out is critical to the success of this program and is a common flaw in the disciplinary approaches being used in many daycares and homes  Learning to comply does not occur during time-out or because of time-out  It occurs when the child has an opportunity to “replay” the original situation with a different ending  Child is able to experience the rewards associated with being cooperative, so parent asks “are you ready to come back and put Mr. Potato Head in the box?”  Child says “no” to the “are you ready” prompt – parent should count silently to 3, if the child has not made an effort to take the parent‟s hand, the child is considered to be “not ready” to follow instructions. If the child shouts “no” and refuses to take the parent‟s hand, not ready to get out of time-out  Should then say in neutral voice, “okay, stay on the chair until I tell you that you can get off” and walk away  Sometimes a child‟s verbal and physical responses to the “are you ready?” question do not match up – in this case behaviour supersedes the verbal response  Child says “yes” to “are you ready” prompt – considered ready to comply, even if doesn‟t say word “yes” o Use of several instructions to over-teach compliance  Suppose child returns to table and complies with original command, best to AVOID praising the child at this point  Instead, the parent can simply acknowledge the child‟s compliance using words such as “alright” “thank you”  Immediately after the child is given a second command very similar to the one that resulted in time- out, when child complies with the second instruction, enthusiastic labeled praises should be provided o Use of play therapy to decrease the child‟s anger level  Major goal of PCIT is to develop some give-and-take in the parent-child relationship  Parent allows the child to lead the play and is respectful of child‟s desires  When an instruction is given, it is the parent‟s time to lead the play and the child learns to reciprocate by showing respect for the parent‟s desires  Through this process, the child comes to view following directions as
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