Utilizing parent-child interaction therapy to help improve the outcome of military families
Authors: Robin Gurwitch, PhD, Shantel Fernandez, PhD, Erica Pearl, PsyD, Geoffrey Chung, PhD
The Department of Defense (2010) estimates that there are just under 2 million family members associated with 1.4 million active duty members. Approximately 1.2 million of these family members are children between birth and 18 years old, and 76 percent of these children are under the age of 12. Accounting for turnover and military duty performed by the National Guard and Reserve, it is estimated that between 1.76 to two million children have a parent who has been deployed in harm’s way since 2001 (Chartrand, Frank, White, & Shope, 2008; Cozza, 2011). Based on published research to date, we know that military youth and parent-child relationships are negatively affected by Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) deployments, and furthermore, these effects are most acute during the stage of deployment (White et. al, 2011).
With the war now extending over 10 years, most findings related to military children point to negative behavioral, emotional and academic outcomes in youth who have experienced an OEF/OIF-related deployment of a parent (Barker & Berry, 2009; Barnes, Davis & Treiber, 2007; Chandra et al., 2010; Chandra, Martin, Hawkins & Richardson, 2010; Chartrand et al., 2008; Flake, Davis, Johnson & Middleton, 2009; Huebner & Mancini, 2005; Lyle, 2006). During parental deployment, the rate of mental and behavioral health visits for children three to eight years of age shows an increase compared to the rate of visits when a service-member (SM) parent is at home (Eide, Gorman, & Hisle-Gorman, 2010). Similarly, the number of behavioral or mental health diagnoses in children of all ages is higher among children whose SM parent is deployed than the number of diagnoses among children whose SM parent is at home (Gorman et al., 2010; Mansfield, Kaufman, Engle & Gaynes, 2011). Acute stress/adjustment disorders, depressive disorders and pediatric behavior problems show the sharpest increases during periods of deployment (Mansfield et al., 2011).
About Parent-Child Interaction Therapy
Parent-Child Interaction Therapy (PCIT) is a strong evidenced-based practice developed by Dr. Sheila Eyberg for use with young children (2-7) with significant behavior problems (Brinkmeyer & Eyberg, 2003). The Kaufman Report (2004) lists PCIT as one of the three best practices for working with children with a history of maltreatment, a growing concern in military families. PCIT is now being used to improve the overall outcome in military families with young children.
PCIT, an assessment-driven intervention, is unique in parent management training and therapy programs as it involves direct coaching of the parent with her/his child. Studies have consistently found improvements in child behaviors reported by caregivers on standardized measures (Chase & Eyberg, 2008). There have been similar findings related to reductions in parenting stress (Harwood & Eyberg, 2006) and depression (Ho, 2004). These findings are important as PCIT is applied to military families, since military parents report parenting stress at a significantly higher level than the national norm (Flake et. al., 2009). PCIT has shown success in generalizing behavior improvement from the home to school settings and to untreated siblings (Brestan et al, 1997). Recent data suggests PCIT can be effective in reducing some forms of childhood anxiety (e.g., separation anxiety disorder; Choate et al. 2005). Both findings have implications to change the trajectory of findings with military children.
PCIT involves two phases of treatment that include coaching sessions with the parent and child, with parents mastering a set of skills prior to moving forward in each phase. In this way, PCIT is an extremely transparent treatment and for military families, the structure and criterion-oriented design of PCIT would seem to be a good fit. The goals of the first phase of PCIT (Child Directed Interaction or CDI) are consistent with improving the parent-child positive relationship. For example, an important goal is to increase focus on positive behaviors while decreasing negative attention for inappropriate behaviors. Also, as young children may have increased anxiety and trauma symptoms similar to their parent’s, CDI also focuses on improvements in these areas.
Once mastery in CDI is met, the family moves to the second phase, the Parent-Directed Interaction. Here, the focus is on increasing consistency, predictability and parents’ ability to follow-through with an effective positive discipline program. This phase of treatment is designed to improve parents’ abilities to give effective commands, set appropriate limits, implement contingency management, problem-solve discipline situations and decrease remaining negative child behaviors. Gradual generalization from clinic-based “minding” exercises to “real life” discipline is then implemented. Families graduate from PCIT in an average of 12-15 sessions; the short-term nature of PCIT is believed to also be appealing to military families where mobility and change are common.
Not only does PCIT seem ideally suited to military families as they cope with stressors of deployment and reunification, PCIT may also be extremely beneficial for service member families affected by Post-Traumatic Stress Disorder (PTSD) and/or Traumatic Brain Injury (TBI). With a reduction in unpredictable, loud and chaotic behaviors common in children with disruptive behaviors, triggers of PTSD may be reduced. As PCIT is extremely structured and skills and words taught to use with discipline are very predictable, PCIT has been shown to be effective in improving family relationships and reducing behavior problems with families where cognitive deficits are present. It is believed that SMs with TBI can achieve similar results in their families; furthermore, it is believed that PCIT will increase SMs skills in consistent parenting and the expression of positive feelings. These skills contribute to effective parenting and hold the promise of building a stronger marital partnership. Finally as rates of child behavioral and emotional problems are higher than normative findings when a parent has been diagnosed with a mental health disorder such as PTSD (Marmar, 2009), the predictability and consistency provided by PCIT would result in a less stressful home as well as benefit family members who have been diagnosed with PTSD, depression or another mental health disorder.
Child-Adult Relationship Enhancement
In addition to PCIT, a program was developed at Cincinnati Children’s Hospital to teach PCIT principles to those in child-serving systems. Child-Adult Relationship Enhancement (CARE) was developed for those working with children of all ages (Pearl, 2008). It is not therapy and can be provided by non-clinicians. Like PCIT, CARE utilizes positive skills to connect with children, a set of techniques for giving children effective positive commands, and selective ignoring techniques to redirect problematic behaviors. For those working with military families, CARE can be used by parents and other caregivers, child care providers, preschool, Head Start and school teachers, extracurricular activity leaders, and faith-based youth group leaders. CARE training can be completed in a few hours and is taught in groups. CARE has been adapted and can be implemented relatively quickly and easily to any systems interacting with military families and caregivers can acquire new ideas as they work to reduce distress in their families through all phases of deployment. CARE can function as a preventative set of skills to reduce the number of military families who may need therapy. When therapy is needed, CARE can serve as a perfect adjunct to PCIT when this specific treatment is being implemented.
Provider Training and PCIT Implementation
Over the course of two years, approximately 20 providers affiliated with Tripler Army Medical Center’s (TAMC) Child and Adolescent Psychiatry Services, School Behavioral Health Team, Child and Adolescent Psychology Services, and Schofield Barracks Child and Adolescent Assistance Center have received training in PCIT and CARE from Cincinnati Children’s Hospital Medical Center (CCHMC) personnel. This training has been conducted as part of a study investigating the benefits of PCIT for military families with young children. Since August 2011, TAMC personnel have provided PCIT to 24 families, with 40 percent having already completed treatment. Early findings indicate improvements in child behaviors as is seen in PCIT with traditional populations. Military personnel with young children continue to be recruited for the study. Over 20 CARE trainings to military schools, child development centers and hospital clinics have also been provided.
Therapists serving military families at Ft. Belvoir are also currently being trained to provide PCIT. Furthermore, in partnership with the U.S. Marine Corps, Family Advocacy Program, therapists from nine Marine bases, as well as Fleet and Family Services in the Navy, have participated in similar training. Along with initial training, CCHMC personnel have provided weekly phone consultation regarding ongoing treatment cases. Therapists are reporting changes consistent with PCIT changes seen in civilian populations. The Institutional Review Board (IRB) application to evaluate this training and intervention program has been submitted and is currently under review.
In summary, PCIT with civilian populations has been shown to effectively reduce behavior problems in young children, improve the parent-child relationship, reduce parenting stress and decrease parental depression. The study currently underway has adapted PCIT for military families who have experienced deployments with the anticipation of similar outcomes to civilian studies, as well as improvement in marital satisfaction and parent and child trauma symptoms. Such outcomes would be significant to addressing the mental health needs of service members and their families who continue to give so much of themselves.
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Robin Gurwitch, PhD, a licensed psychologist and APA Fellow, is a faculty member at Duke University Medical Center and Center for Child and Family Health. She is involved in research, training and direct services to families impacted by trauma; she is interested in ways to enhance resilience in those touched by crisis and trauma. Research efforts also focus on the dissemination of Evidence-Based Treatments, particularly PCIT. Dr. Gurwitch is a master trainer in PCIT, certified by PCIT International. She served as the chair of the APA Presidential Task Force on the Mental Health Needs of Military Families. She is a member of the Military Working Group of the National Child Traumatic Stress Network. With colleagues, she is adapting PCIT and CARE for military families in an effort to enhance positive relationships in this special population.
Shantel Fernandez, PhD is the curriculum specialist of the School Behavioral Health Team at Tripler Army Medical Center and the coordinator of the Tripler Early Behavioral Health Team. She is a faculty member in the Department of Child and Adolescent Psychiatry Services. She is a licensed clinical psychologist that provides direct service to military families, provider and community trainings, and consultation services. Dr. Fernandez is interested in the areas of pediatric sleep, anxiety and trauma. Her research focuses on the dissemination of evidenced based services with military families.
Erica Pearl, PsyD, is a licensed clinical psychologist and assistant professor with Cincinnati Children's Hospital Medical Center. She trains PCIT and was one of the developers of Child Adult Relationship Enhancement (CARE). Her research focuses on the dissemination of evidenced based treatments for families exposed to trauma and violence.
Geoffrey Chung, PhD, is the director of training for the Clinical Child Psychology Postdoctoral Fellowship at Tripler Army Medical Center. He is a faculty member in the Department of Psychology, Child and Adolescent Psychology Service. In addition to training students in Clinical Child Psychology, Dr. Chung provides direct service to military families, leads educational & resiliency workshops for families affected by deployment, and facilitates collaborative projects to improve quality of care to military youth. His areas of interest include delivery of culturally-sensitive care to diverse populations and transportation of evidence supported procedures to settings that care for underserved populations and military families. Chung holds board certification in Clinical Child and Adolescent Psychology from the American Board of Professional Psychology.