7/28/2019 Pre-Questionnaire

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Pre-Questionnaire |

University of Miami
CONSENT TO PARTICIPATE IN A RESEARCH STUDY

Extending the reach of Parent-Child Interaction Therapy: A continuum of care of PCIT (CC-PCIT) to
meet the needs of the community

The following information describes the research study in which you are (your child is) being asked to
participate. Please read the information carefully. At the end, you will be asked to sign if you agree to
participate (and to allow your child to participate).

PURPOSE OF STUDY:

You are being asked to participate in a research study. The purpose of this study is to test the possibility of
providing di erent levels of Parent-Child Interaction Therapy (PCIT) services to families.

You and your child are being asked to be in the study because the program is designed for children who are 2
- 12 years old and their families to provide parenting education and therapy to families.

PROCEDURES:

As part of this study, you will participate in weekly sessions of Parent-Child Interaction Therapy (PCIT) or an
online version of PCIT. Based on the information that you provide your therapist about your family and child,
your family will be assigned to receive one of four forms of PCIT: Pocket PCIT Online (4 weeks of access to an
online parenting education resource), Selective Prevention PCIT (10 family sessions), Standard PCIT (an
average of 18-19 weekly sessions with a minimum 12 sessions), or i-PCIT (an average of 18-19 weekly
sessions with a minimum 12 sessions). The severity of your child’s reported behaviors, any identi ed
developmental concerns, and/or your family’s access to wi- services at home and preference for treatment
location will determine which level of PCIT services your family receives.

As a part of PCIT, PCIT Therapists video record therapy sessions including interactions between you and your
child. Sessions are video recorded so that PCIT Therapists can determine the number of speci c parenting
behaviors you demonstrate while you are interacting with your child.

All families will also complete a series of full assessments three times: before the start of the therapy, when
you complete the therapy, and three months after that. The assessments will ask about your child’s
behaviors, your feelings, your thoughts about parenting your child, and your satisfaction with treatment. In
addition, therapists will code interactions between your child and you while you are playing with toys. We will
also ask you on a weekly basis about your child’s behaviors.

The length of time you and your child are expected to participate in the study is a minimum of three to a
maximum of twelve months, with follow-up sessions at three and six months later. This means you and your
child could be enrolled in this study for a period of up to 12 months.

For families assigned to Pocket PCIT Online, your family will receive access to four weeks of online
educational resources related to the skills taught during PCIT. For families assigned to Selective Prevention
PCIT, your family will receive 10 sessions of PCIT. For families receiving standard PCIT or i-PCIT, some families
may master skills and complete the study in fewer sessions than other families. The duration of participation
is dependent upon you demonstrating the use of a certain number of parenting skills during a ve minute
interaction between you and your child and your child’s behavior being rated as similar to most other
children his or her age.

Because the UM PCIT Clinic is a training clinic, graduate students in psychology or a related eld may serve as
co-therapists with doctoral-level clinicians. All therapists receive weekly supervision from licensed
psychologists.

RISKS AND/OR DISCOMFORTS:

We anticipate you (your child) may experience some personal risk or discomfort from taking part in this study.
If behavioral or developmental concerns and/or issues arise, these concerns will be brought to your attention
within scheduled therapy sessions.

We anticipate that you may experience some personal discomfort from implementing new parenting
strategies; however, this may improve as treatment progresses. You may choose to skip any question you do
not wish to answer during the interview or questionnaires. If your family has an active case with the
Department of Children and Families (DCF) and you decide not to participate or you decide to withdraw from
the research study and you do not choose another program which is approved by your DCF case worker, you
can face risks and consequences for not meeting your case-plan requirement for completing a parenting
program.

BENEFITS:

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It is possible that you (your child) will bene t from this study by receiving parental education about positive
Child Directed and Parent Directed activities and development. It is possible that you will also bene t from
this study by receiving Parent-Child Interaction Therapy as well as coaching and consults.

CONFIDENTIALITY:

Your (your child’s) study le will be stored in a secured, locked ling cabinet in a secured, locked room.
Videotapes will be stored in a separate folder without your name (you will be assigned a number in place of
your name) in a secured, locked ling cabinet. The investigators and their assistants will consider your
records con dential to the extent permitted by law. For families receiving i-PCIT, communications will take
place over a secure video conferencing program in order to protect your privacy.

Only those associated with the research program such as PCIT therapists, research associates, your attorney,
and your caseworker are allowed to review the records. As part of training and supervision, your therapist(s)
will discuss your (your child’s) case with the licensed psychologist who supervises your (your child’s) case to
ensure the highest quality treatment possible.

The Children’s Trust, as they are the sponsor of this PCIT program, will receive reports about your
demographics, attendance, and performance in the program. The Children’s Trust only examines data in
combined form to determine the populations being served and to determine that funded programs are
e ective. The U.S Department of Health and Human Services (DHHS) may request to review and obtain
copies of your records. Your records may also be reviewed for audit purposes by authorized University or
other agents who will also be required to treat your records as con dential.

As a mandated reporter in the state of Florida, your therapist is legally obligated to report suspicion of abuse
or neglect of children or vulnerable adults. Also, your therapist is legally obligated to release your (your
child’s) records if subpoenaed by the courts.

COMPENSATION:

Children will be provided with a toy at the beginning of the program.

RIGHT TO DECLINE OR WITHDRAW:

Your (your child’s) participation in this study is voluntary. You (your child is) are free to refuse to participate in
the study or withdraw your (his/her) consent at any time during the study. In addition, you (your child) may
choose to not be video recorded during sessions. The investigator reserves the right to remove you (your
child) without your (your child’s) consent at such time that they feel it is in the best interest for you (your child).

CONTACT INFORMATION:

Dr. Jason Jent, the principal investigator for this study, will gladly answer any questions you may have
concerning the purpose, procedures, and outcomes of this project. You may contact him at (305) 243-6857 or
via e-mail at jjent@med.miami.edu. If you have questions about your rights as a research participant you
may contact the Human Subjects Research O ce at the University of Miami, at (305) 243-3195.

PARTICIPANT AGREEMENT:

I have read the information in this consent form and agree (to allow my child) to participate in this study.

I have had the chance to ask any questions I have about this study, and they have been answered for me. I
am entitled to a copy of this form after it has been read and signed.

Name of Child
* must provide value

Signature of Participant/Parent
* must provide value

Add signature

Date
* must provide value

   Today M-D-Y

Name of Participant/Parent
* must provide value

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We are asking you some information about your family so that we can better understand how Pocket
PCIT Online works

Age of child (in years) you plan to use Pocket PCIT the most for:
* must provide value

Child Gender
* must provide value

Male
Female
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Child Race
* must provide value

American Indian or Alaska Native

Asian
Black or African American
Native Hawaiian or Other Paci c Islander
White
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Child Ethnicity
* must provide value

Hispanic or Latino
Not Hispanic or Latino
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Parent (your) age

* must provide value

18-24
25-44
45-64
65+
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Parent Education Level

* must provide value

High school graduate or GED

Some college, no degree
Associate's degree
Bachelor's degree
Master's degree or higher
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Please list the number of people who live within your home
* must provide value

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Household Income Range

* must provide value

Less than $20,000

$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
Over $100,000
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This form lists 9 sentences that describe children's behavior. For each sentence:
a) Please select the choice that shows how often your child behaves that way.

After answering the 9 questions, please select the total number of behaviors you want to change

How often does your child...

Almost Almost
Never Never Rarely Sometimes Often Always Always
Do things right away when asked?
* must provide value

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Behave well at meal times?
* must provide value

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Obey, or act compliant?
* must provide value

reset
Act calm, or gentle?
* must provide value

reset
Tell you when upset and can calm
down on own?
* must provide value

reset
Play nicely with toys and carefully
with others' things
* must provide value

reset
Keep hands to self and play nicely with
others?
* must provide value

reset
Wait turn to talk?
* must provide value

reset
Concentrate or easily sit still and
focus?
* must provide value

reset

How many of the behaviors listed above do you want to change?

* must provide value

The following statements describe feelings and perceptions about the experience of being a parent. Think of
each of the items in terms of how your relationship with your child or children typically is. Please indicate the
degree to which you agree or disagree with the following items by placing the appropriate number in the space
provided.

Strongly
Disagree Disagree Not Sure Agree Strongly Agree
I nd myself giving up more of my life
to meet my children's needs than I
ever expected
* must provide value

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I feel trapped by my responsibilities
as a parent.
* must provide value

reset

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Since having this child, I have been

unable to do new and di erent things
* must provide value

reset
Since having a child, I feel that I am
almost never able to do things that I
like to
* must provide value

reset
I am unhappy with the last purchase
of clothing I made for myself
* must provide value

reset
There are quite a few things that
bother me about my life
* must provide value

reset

Strongly
Disagree Disagree Not Sure Agree Strongly Agree
Having a child has caused more
problems that I expected in my
relationship with my
spouse/parenting partner
* must provide value

reset
I feel alone and without friends
* must provide value

reset
When I go to a party, I usually expect
not to enjoy myself
* must provide value

reset
I am not as interested in people s I
used to be
* must provide value

reset
I don't enjoy things as I used to
* must provide value

reset
My child rarely does things for me
that make me feel good
* must provide value

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For these next questions, please think about your current family (the people you live with now). These
statements refer to the way your family has been in the past month. Tell us how much you agree or disagree.

Strongly Neither agree

disagree Disagree nor disagree Agree Strongly agree
We fought a lot in our family.
* must provide value

reset
Family members sometimes got so
angry they threw things.
* must provide value

reset
Family members hardly ever lost
their tempers.
* must provide value

reset
Family members sometimes hit each
other.
* must provide value

reset
Family members rarely criticized
each other.
* must provide value

reset

Strongly Neither agree

disagree Disagree nor disagree Agree Strongly agree
Family members really helped and
supported one another.
* must provide value

reset
There was a feeling of togetherness
in our family.
* must provide value

reset

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Our family didn't do things together.

* must provide value

reset
We really got along well with each
other.
* must provide value

reset
Family members seemed to avoid
contact with each other when at
home.
* must provide value

reset

Please list the email address you plan to use for registering for Pocket PCIT. This email will not be
used by our team for anything other than verifying your responses against the registration request.
In addition, we will email you four times over the next month to complete brief surveys about Pocket
PCIT Online and your family.
* must provide value

Submit

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