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Contents lists available at SciVerse ScienceDirect

Child Abuse & Neglect

Parent–child interaction therapy: A manualized intervention

for the therapeutic child welfare sector
Rae Thomas a,∗ , Amy D. Herschell b
a
Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast,
Queensland 4229, Australia
b
Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Children who have experienced maltreatment can often display behavioral difficulties;
Received 2 January 2013 their parents may lack disciplinary knowledge, be less sensitive to their children, and engage
Received in revised form 16 January 2013
in coercive parenting practices. Parent–child interaction therapy (PCIT) is a well-known,
Accepted 14 February 2013
evidence-based treatment (EBT) for child behavior problems and within the last decade has
Available online xxx
garnered significant evidence to suggest its utility for parents engaged in child maltreat-
ment. This article uses a case example to describe PCIT treatment phases and PCIT research
Keywords:
Parent–child interaction therapy within the child maltreatment sector is synthesized with particular focus on treatment
Evidence-based treatment modifications. Successful augmentations and modifications include a motivation compo-
Child maltreatment nent, keeping therapeutic time shorter rather than longer, and whether to incorporate
individual counseling and in-home PCIT are also considered. Practical strategies from both
a therapeutic and research experience are discussed.
© 2013 Elsevier Ltd. All rights reserved.

Introduction

Sarah is a single mother of 3 boys aged 3, 5, and 6 years. She was referred from child welfare after an investigation of
inappropriate physical discipline. She was cautioned and referred to a tertiary intervention service for parenting support.
At referral, Sarah disclosed previous domestic violence from the boys’ father, financial difficulties, feelings of inadequacy as
a parent, limited discipline strategies, and frustration with parenting her youngest child (John) in particular.
Sarah reported John had severe temper tantrums of unknown cause, that he was aggressive and mean to his older
siblings, and that he would hit and swear at both her and his siblings when in trouble or if unable to have his way. John
was also reported to be aggressive at daycare. Sarah reported she did not know how to handle John’s aggressive outbursts
and she would spank him and drag him to his room. Sometimes this worked; sometimes it did not. Sarah reported feeling
disempowered in her role as a parent and identified John’s externalizing behavior as a treatment priority.

Parent–child interaction therapy (PCIT)

PCIT was originally developed for families with children aged 3–7 years with clinical levels of child externalizing behavior
problems (Eyberg, 1988; McNeil & Hembree-Kigin, 2011). Founded on social learning theory (Bandura, 1977; Patterson, 1982)
and developmental psychology research (e.g., attachment theory; Bowlby, 1969; optimal parenting styles; Baumrind, 1966),
PCIT draws on Constance Hanf’s (1969) 2-stage model to offer strategies to support positive parent–child relationships and
to manage disruptive behaviors. PCIT has been implemented with a broad spectrum of caregivers including biological, foster,

∗ Corresponding author.

0145-2134/$ – see front matter © 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.chiabu.2013.02.003

Please cite this article in press as: Thomas, R., & Herschell, A.D. Parent–child interaction therapy: A manualized interven-
tion for the therapeutic child welfare sector. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.02.003
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and adoptive parents as well as grandparents. For simplicity, we will refer to all caregivers as “parents.” Traditionally, a PCIT
therapist observes parent–child dyads through a 1-way mirror and by using a bug-in-the-ear device, coaches the parent
to attend to the child’s appropriate behaviors consistently and predicably. The behavior management techniques coached
in PCIT are designed to aid children’s emotion regulation by providing parents with developmentally appropriate language
and skills (McNeil & Hembree-Kigin, 2011).
PCIT has two sequential phases known as Child Directed Interaction (CDI) and Parent Directed Interaction (PDI). Each
phase teaches parents communication skills that foster positive parent–child relationships and strategies of differential
reinforcement. Similar to other parenting interventions, each phase includes a didactic session designed to teach the parent
specific skills related to each phase of the therapy. However, a unique aspect of PCIT is the direct coaching sessions that are
the focus of the remaining treatment. Coaching sessions provide the parent with immediate feedback and remediation of skill
implementation. Length of treatment is variable because progression in PCIT is based on weekly assessments and transition
from CDI to PDI occurs when pre-prescribed skills (Mastery Criteria) for the first phase have been achieved. However, average
treatment length is usually 12–16 weeks (McNeil & Hembree-Kigin, 2011).
Weekly assessments are standardized measures completed at each session to monitor child behavior (Eyberg Child
Behavior Inventory; Eyberg & Pincus, 1999) and parenting skills (DPICS-III; Eyberg et al., 2004). Monitoring and coding of
parental skills occurs in both the structured observation assessment sessions conducted pre- and post-treatment as well as
weekly during the first 5 min of each coaching session. Treatment is completed when the parent successfully and consistently
meets Mastery Criteria of both treatment phases (CDI and PDI), when the child’s behavior is within normal limits, and when
the parent expresses a clear understanding of their own change and role in the family system (Eyberg & Funderburk, 2011).

Why PCIT might be considered an evidence-based treatment (EBT) for Sarah and John?

Risk factors for child maltreatment are well-known and include negative and coercive patterns of parent–child inter-
actions (Cicchetti & Valentino, 2006) and parents’ lack of knowledge or inappropriate use of discipline (Kolko, 2002). Also,
maltreating parents are less likely to be sensitive in interactions with their children (Lindhiem, Bernard, & Dozier, 2011), have
fewer positive interactions (Milner & Chilamkurti, 1991), are often more stressed (Sprang, Clark, & Bass, 2005), and have
more aggressive communication styles than non-maltreating parents (Bousha & Twentyman, 1984). Further, maltreated
children are more likely to have externalizing behavior (Kolko, 2002) than those children not maltreated. For families with
histories of using aggressive strategies to manage child behavior, PCIT treatment outcome studies (both community and lab-
based) have regularly produced statistically and clinically important improvements in observations of positive parent–child
interactions, reductions in child externalizing behavior and parent stress, and increases in maternal sensitivity (e.g., Chaffin,
Funderburk, Bard, Valle, & Gurwich, 2011; Chaffin et al., 2004; Timmer, Zebell, Culver, & Urquiza, 2010; Thomas & Zimmer-
Gembeck, 2011, 2012). Therefore, PCIT has been identified as an EBT for families with young children who have experienced
physical abuse (e.g., The California Evidence-Based Clearinghouse for Child Welfare, 2012).
Some manualized interventions, including PCIT, have been adapted in attempts to better meet the needs of families
accessing services in diverse settings and with diverse needs (e.g., primary care, Berkovits, O’Brien, Carter, & Eyberg, 2010;
anxiety, Pincus, Eyberg, & Choate, 2005). PCIT researchers working with maltreated children and their families have also
augmented or modified PCIT for this population by adding a motivation component, in-home coaching, or varied treat-
ment length. Choosing whether to modify the original PCIT design requires careful consideration and collection of data to
understand if the augmented version of PCIT will yield comparable results to what would be expected using the standard
protocol.
The PCIT research team in Sacramento, for example, have augmented clinic-based PCIT with in-home coaching (Timmer
et al., 2010). They compared PCIT and in-home coaching to PCIT and in-home social support. In-home PCIT coaching was
similar to clinic-based coaching but the PCIT coach sat behind and to the side of the parent while coaching. In the social support
component the therapist commented on the child’s progress and provided advice and strategies for parent nominated
challenges. Due to the extra practice of PCIT skills, it was expected that in-home coaching would enable faster and greater
remediation of inappropriate parent–child interaction, produce greater reductions in child externalizing behavior and parent
stress, and greater increases in positive parent–child communications. Outcomes, however, indicated that although the in-
home coaching group had less stress and fewer problems with their child’s behavior at mid-assessment, no differences
between in-home coaching or social support groups were found for the rate of skill acquisition or quality of parent–child
interactions at treatment completion and, as is often the case in high-risk populations, both groups had significant attrition.
Therefore, augmenting PCIT with either in-home coaching or social support did not alter treatment outcomes at completion.
Many families referred from child welfare services to parenting interventions are required to attend by the courts or as
conditions for case management and therefore may be less motivated to participate in interventions than those families
who self-refer. With this in mind, Chaffin and colleagues conducted 2 randomized controlled trials (RCT) augmenting PCIT
with a 6-session motivation component (Chaffin et al., 2004, 2011). The motivation sessions were based on motivational
interviewing principles and included testimonials from previous families, discussing the positive and negatives of forceful
discipline, an opportunity for parents to reflect on their own experiences of being “supervised,” and for parents to develop
individualized goals. In 2 separate trials (1 lab-based, 2004; and 1 field-based, 2011) In both trials, Chaffin and colleagues
demonstrated reductions in child welfare notifications with this PCIT variation and in the PCIT + motivation group (Chaffin
et al., 2004) significantly reduced attrition from therapy compared to the other 2 interventions. Interestingly, Chaffin et al.

Please cite this article in press as: Thomas, R., & Herschell, A.D. Parent–child interaction therapy: A manualized interven-
tion for the therapeutic child welfare sector. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.02.003
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(2004) also compared PCIT + motivation with “enhanced PCIT” where families completed PCIT + motivation but were also able
to access individualized therapeutic services as needed. However, enhanced PCIT did not fare better than PCIT + motivation in
reducing future child welfare reports. Therefore, augmenting PCIT with a motivation component may increase the likelihood
of families completing therapy but providing individual therapy in conjunction with PCIT may not produce added benefits.
Finally, another PCIT research group compared a time-variable version of PCIT (long PCIT) to a standard 12-week PCIT
(short PCIT; Thomas & Zimmer-Gembeck, 2012). In the long PCIT format participants concluded PCIT when they had attained
skills to Mastery Criteria and could demonstrate effective behavior management strategies. The length of time to PCIT com-
pletion ranged from 12 to 52 weeks. In contrast, participants in short PCIT concluded treatment after 14 weeks (included
coaching and didactic sessions) regardless of whether the parents met Mastery Criteria. It was expected maltreating families
would require lengthier treatment times to garner full benefits of the PCIT intervention. This was not the case. When com-
pared at 12-weeks, maltreating families in short PCIT had greater improvements in child behavior and positive parent–child
interactions than participants in long PCIT. Also, when short PCIT outcomes were compared to long PCIT outcomes at
completion of treatment (remember this ranged between 12 and 52 weeks for long PCIT participants), short PCIT was
as effective as long PCIT for all measures and more effective for observed positive parent–child interactions. Not only were
short PCIT participants significantly more likely to complete PCIT than long PCIT participants (Thomas & Zimmer-Gembeck,
2012), PCIT participants who completed treatment were less likely to have future reports for child maltreatment (Thomas
& Zimmer-Gembeck, 2011).
Taken together, these data suggest that the 12- to 14- week protocol of PCIT is effective in reducing child behavior
problems, parent stress and increasing positive parent–child interactions in families with a history of child maltreatment.
However, attrition may remain a problem. Perhaps when working with maltreating families, a motivation component paired
with traditional length PCIT with no adjunct services would increase retention and consequently the likelihood of positive
therapeutic outcomes.

Tailoring treatment for Sarah and John

As with all manualized interventions, it is important to individualize treatment for each family’s needs (N’zi & Eyberg,
2013). PCIT seeks to maximize the positive qualities within the dyadic relationship and teach the parent skills to enhance
their parenting. Tailoring coaching to the individual needs of a parent and child is an essential element to PCIT. Two parts
of the assessment process are critical to tailoring treatment. First, parent–child dyads are observed in a 25-minute play
scenario that allows the therapist to identify strengths and weaknesses within the dyad. Observations are made of both
the parent’s skills and how the child responds to the parent overtures. These observations form part of the therapist’s
case conceptualization and are discussed with the parent. Second, parents are invited to construct specific goals for both
themselves and their child. The needs identified through therapist observations and parent goals form the basis of tailoring
coaching techniques for each family and are revisited throughout PCIT.
Observation assessment. Sarah reported that as a parent she found John’s externalizing behavior problems challenging
and she felt unable to respond to him in a sensitive manner. During the pre-assessment observation task, Sarah and John
played together in a room with toys for approximately 25 min. For the first 10 min, Sarah was instructed to play with John
and follow his lead in the play (Child Led Play). During this 10 min, 5 min serves as a “warm-up” period, and the remaining
5 min is coded. In contrast to her self-report, Sarah was observed to have warm and sensitive interactions with her son. She
followed his lead in the play and they readily laughed together. However, after several minutes Sarah appeared distracted,
looked around the room, and disengaged from play. She asked John over 20 questions within a 5 min period (e.g., “What are
you building?” “How high will you make it?”) and offered no praises during this time.
After 10 min, Sarah was instructed to change the activity and have John play along with her according to her rules (Parent
Led Play). Similar to the first scenario, the first 5 min of this 10 min interval serves as a “warm-up” period, and the remaining
5 min is coded. To comply with the instruction, Sarah made an initial, tentative suggestion about changing the toys. Her
voice was soft, and her tone hesitant. John indicated he did not want to change toys. Sarah then used distraction to gain
compliance. This was successful and John’s focus was shifted.
After the Parent Led Play scenario, Sarah was instructed to let John know that Special Playtime had finished and he was
to pack away the toys (Clean Up). Sarah commenced packing away the toys and John followed.
Case conceptualization. By asking many questions, John’s play was restricted and the interaction became a series of ques-
tions and answers. Sarah’s lack of praises for John’s efforts and behavior suggested that she payed less attention to John’s
positive behavior than his noncompliant behavior therefore reinforcing noncompliance. Sarah appeared to genuinely enjoy
spending time with John by sharing laughter and smiles; however, she was unable to sustain play for more than a few
minutes. John clearly enjoyed her company. When asked to provide John with an instruction, Sarah became tentative and
demonstrated both a lack of parenting strategies to gain compliance (she opted for distraction) and her feelings of disem-
powerment in parenting (her soft and hesitant tone). After domestic violence experiences, some mothers become fearful
of aggression in their children as it revivifies their trauma. Because of this, they may use parenting strategies that avoid
potential conflict such as direct instructions. Sarah demonstrated one of these strategies (distraction rather than instruc-
tion). She may have been fearful of John’s expected response to instruction and concerned she would have to manage his
noncompliant and aggressive behavior.

Please cite this article in press as: Thomas, R., & Herschell, A.D. Parent–child interaction therapy: A manualized interven-
tion for the therapeutic child welfare sector. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.02.003
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Goal setting. Sarah’s identified goals were to learn strategies to manage John’s behavior, to feel more empowered in her
role as parent, and to learn strategies to cope when feeling frustrated. While there was warmth in the play, Sarah indicated
she often felt frustrated and resentful towards John, and did not enjoy the time she spent with him. For John, Sarah identified
she would like him to play “nicely” with others, be less angry when things did not go his way, and comply more frequently.

PCIT Phase 1: CDI

CDI coaching focuses on teaching the parent behavior management skills and communication techniques (known as the
PRIDE skills) to strengthen the parent–child relationship. Specifically, parents are taught to effectively Praise their child’s
positive behavior, thus reinforcing prosocial and desired child behaviors, Reflect the child’s statements to facilitate reflective
listening skills, Imitate and Describe the child’s play to enhance the child’s self-esteem and self-worth, and to Enjoy the
play to create a positive context for the interaction. In addition, parents are taught to avoid using questions, commands and
criticisms.
Children appropriate for PCIT are noncompliant and often aggressive. Parents are taught to consistently implement
the strategy of deliberately not engaging with the child while the child is engaged in minor undesirable behavior that
would usually “bait” the parent and produce a reaction (e.g., speaking somewhat rudely, snatching), and to limit the use of
controlling the play by questioning, instructing, or criticizing the child whilst playing. The aim of these strategies is to build
a positive and warm relationship between the child and parent, give the parent practice in effective behavior management
techniques, teach the parent that some behaviors will disappear if you do not react, and allow the child to take the lead
in interactions. These behavior management techniques focus on positive rather than negative child behaviors whereby
children are rewarded for desirable behavior with praise and attention and receive little attention for misbehavior.

Tailoring CDI for Sarah and John

There were several goals for Sarah and John in CDI. First, it was important to specifically focus on increasing the positive
moments of play between Sarah and John. Because Sarah had limited strategies to gain compliance and did not praise John in
the observation assessment, one goal was to increase her PRIDE skills and decrease her controlling questions and instructions
to create an environment of respect, and to demonstrate that praise increased a child’s compliant behavior. For example,
“You have a great imagination” and “Playing with you is fun” produced smiles from John and he continued to create new
designs with the lego. “Thank you for sharing with me,” increased the likelihood of John sharing with her in the immediate
future. By reflecting his statements and imitating his play, Sarah demonstrated to John that she was listening, interested in
his comments, and thought his ideas were worthy of imitation. When Sarah increased her reflections and descriptions, John
initiated more verbal interactions with his mother.
Because of his noncompliance and young age, it was only a matter of time (CDI session 2) before John tested his mother by
banging toys on the table. He did this with a small smile on his face and looked directly at his mother to see her reaction. To
actively assist Sarah in sitting with the discomfort and stress of John misbehaving, she was coached to do exactly as instructed
and to deliberately ignore his misbehavior. As soon as John began to play gently with the toys, Sarah was coached to reengage,
praise John for playing gently, and resume play with him. During the next two CDI sessions, John continued to test his mother
and the period of his difficult behavior lengthened. Sarah was coached in exactly the same way. Importantly, she was also
coached to remain calm and to breathe deeply if stressed. The therapist acknowledged that John’s difficult behavior (e.g.,
sassing, playing rough with the toys) was challenging for her to manage and “pushed her buttons.” This validated Sarah’s
parenting experiences while assisted her to overcome her concerns about not being able to manage John’s behavior. By
remaining firm in her resolve to ignore John’s misbehavior, and have calm and reassuring coaching from her therapist, Sarah
was provided with opportunities to experience successful behavior management strategies while managing her stress and
frustration and increasing her sense of empowerment. By CDI session 6, Sarah had consistently reached Mastery Criteria in
the PRIDE skills and effectively withdrawn attention for all misbehavior. She was encouraged by the changes she noticed
in John’s behavior. By completion of CDI, he improved his behavior, preferring to play with Sarah than misbehave. Sarah
reported enjoying John’s company more and life at home was a little more relaxed; however, there were still some problems
with him complying to her requests. She felt empowered with the positive behavior management strategies but stated these
did not work for some of John’s more challenging behaviors.

PCIT Phase 2: PDI

Building on the success of positive behavior management strategies and the coaching techniques used in CDI, more direct
behavior management strategies are taught during PDI. The goals of PDI are for parents to acquire and demonstrate the ability
to set limits, become consistent and fair in implementing discipline strategies, and to reduce child noncompliance (McNeil
& Hembree-Kigin, 2011). To achieve this, parents are (a) taught to give effective instructions, (b) coached in the use of the
time-out procedure, (c) helped to establish house rules and public behavior guidelines, and (d) assisted to maintain clear
and consistent responses to child misbehavior.
Prior to the first PDI session, the child, parent, and therapist participate in a joint session where the child learns the
new rules. This session is often referred to as “Mr Bear,” as PCIT therapists working with younger children use a toy (often

Please cite this article in press as: Thomas, R., & Herschell, A.D. Parent–child interaction therapy: A manualized interven-
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a teddy bear) to illustrate what happens when “Mr Bear” complies or does not comply with instructions. The session is
therapist lead and allows the parent to become familiar with the delivery of instructions as modeled by the therapist. The
instructions are short, direct, and polite (e.g., “Please pass me the blue lego block”). Forming instructions in this manner
grounds parents in effective communication techniques and facilitates predictability for the child. In addition, the time-out
procedure is modeled by the therapist and “Mr Bear” demonstrates the consequences of compliance and noncompliance.
Parents are taught to issue an instruction and wait for compliance (a silent count to five), if compliance is not forthcoming,
give a two-choice warning (compliance or time-out), followed by a silent count to five. The child is then instructed to sit on
the time-out chair. If the child does not comply, the parent is taught to use a back-up to the time-out (e.g., time-out space,
swoop and go). Should the child comply at any point in the time-out sequence, the sequence is stopped and the child is
praised for compliance. Praise is graduated with effuse praise reserved for immediate compliance (e.g., “Great job of doing
what I asked straight away. Now you do not have to go to the time-out chair.”) to a medium praise for compliance after
two-choices (e.g., “Thank you for doing what I asked.”). Whereas an acknowledgement is given for compliance after the
time-out procedure is complete (e.g., “Fine”). Importantly, after the time-out sequence is complete the child is still required
to comply with the parental instruction (see McNeil & Hembree-Kigin, 2011 or Eyberg & Funderburk, 2011 for full details).
The time-out sequence is rote learnt and is mastered by completion of PCIT providing predictability for the child and an
effective and controlled behavior management strategy for the parent.

Tailoring PDI for Sarah and John

Sarah was eager, yet apprehensive, at the commencement of PDI due to her concerns over John’s potential reaction to
instruction. However, she had experienced success in the CDI phase and was determined to proceed with enhancing her
parenting skills. John was curious in the “Mr Bear” session and indicated an understanding of the consequences by attempting
to help “Mr Bear” comply with instruction to avert the consequence of time-out. Early in the PDI phase, John had to go to
the time-out chair multiple times within one session. However, as the sessions progressed and he learned that his mother
would consistently apply the consequence, the frequency of time-outs decreased until eventually he did not need to go to
the time-out chair.
Sarah’s biggest challenge was to overcome her anticipation of John’s volatility. As the therapist was aware of this, coaching
in PDI often involved monitoring Sarah’s emotional reactions to John’s behavior. The therapist would often reflect Sarah’s
apparent distress and offer support (e.g., “Your face looks a little worried at the moment. Could you wiggle your fingers at
me if you need a break?”). Before each session, the therapist would check with Sarah how things had been the previous
week and how she was doing emotionally and tailor the session (duration and level of instruction) to ensure Sarah and
John experienced opportunities to succeed. Throughout PCIT Sarah became increasingly able to regulate her emotions, be
able to experience and consequently manage her discomfort, and respond to John’s misbehavior in a positive and consistent
manner.
After seven sessions in PDI, Sarah was able to maintain PRIDE skill mastery and implement the time-out procedure
without coaching. At completion Sarah reported John rarely went to time-out as once she initiated the time-out sequence
John would groan, say “alright” and comply. The predictability of the time-out sequence and consistent outcomes allowed
John to anticipate the consequences for his action and choose how to respond to Sarah’s instructions. John’s day care center
also reported positive improvements in John’s behavior. Sarah had discussed with them the time-out procedure and they
were using a modified version with all the children with success. Sarah also reported using these strategies with success for
her two older children.

PCIT in other populations

Evidence of the effectiveness of PCIT has been demonstrated to varying degrees in diverse populations. For example,
positive child behavior change has been documented in studies conducted with depressed mothers (Timmer et al., 2011),
for children with language disorders (Allen & Marshall, 2011), autism (Solomon, Ono, Timmer, & Goodlin-Jones, 2008),
intellectual impairment (Bagner & Eyberg, 2007), and adapted for depressed (Lenze, Pautsch, & Luby, 2011) and anxious
(Pincus et al., 2005) children. In addition, positive outcomes for children and their parents have also been reported for
culturally diverse families (e.g., BigFoot & Funderburk, 2011; Leung, Tsang, Heung, & Yiu 2009).

Training in PCIT

Given the recent broader implementation of PCIT in community settings an active area of investigation has been around
training/implementation models. Recent research has found that reading and workshop training without extended consul-
tation is not enough for clinicians to develop sufficient skills in PCIT (Herschell et al., 2009). Instead, extensive consultation,
advanced training, clinical oversight, and organizational supports seem to be necessary for high quality implementation with
good fidelity (Herschell, Kolko, Baumann, & Davis, 2010). Some have begun to examine technologies to enable PCIT trainers
to provide moment-by-moment feedback (Funderburk, Ware, Altshuler, & Chaffin, 2008) and efficient review of session
videos (Wilsie & Brestan-Knight, 2012) to help clinicians learning PCIT by providing regular clinical oversight. However, the
amount of advanced clinical consultation and supervision necessary for high quality implementation of PCIT is unclear. A

Please cite this article in press as: Thomas, R., & Herschell, A.D. Parent–child interaction therapy: A manualized interven-
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Statewide trial is currently underway to investigate training outcomes associated with different training models (train-the
trainer, learning collaborative approach, and on-line training; NIMH R01 MH095750 PI: Herschell).
In response to training diversity, PCIT International (www.pcit.org) has created guidelines (PCIT Training Guidelines,
2009) to support high quality training in PCIT. In order to receive PCIT training, clinicians must: (1) hold a masters degree or
higher in the mental health field; (2) be actively working with children and families; and (3) be licensed in his or her field or
receive supervision from a licensed person trained in PCIT. An agency must: (1) provide appropriate space (e.g., playroom,
observation room, time-out space) and equipment (e.g., assessment measures, bug-in-the-ear device) for PCIT; (2) serve a
population of clients who are appropriate for PCIT (e.g., 2.5–7 years with disruptive behavior); and (3) allow clinicians to
participate in training and consultation without penalties for loss of billable hours.
Currently, the PCIT training guidelines (2009), require a commitment of 1-year. Training comprises 2 dydactic training
components (1 for a week, the second over 2 days) and close supervision from the PCIT trainer. Clinicians must also meet
pre-specified competencies, and complete at least 2 PCIT cases. For information on PCIT training including the training
guidelines please refer to the PCIT website: http://www.pcit.org/or http://www.pcittraining.tv/

Future research to aid practitioners

Decades of treatment outcomes studies of PCIT have demonstrated that there are significant benefits obtained by par-
ents and children when treatment is completed; however, supporting treatment completion remains a challenge. Several
PCIT studies have demonstrated a reduction in child maltreatment recidivism for families who complete PCIT compared
to those who do not (Chaffin, Silovsky et al., 2004; Chaffin, Funderburk et al., 2011; Thomas & Zimmer-Gembeck, 2011).
As the implementation of PCIT has broadened from university/medical centers to community-based settings, important
lessons have been learned and areas in need of additional study have been identified. For example, attrition rates in uni-
versity/medical center efficacy trials have been reported to range from 18 to 35% (Thomas & Zimmer-Gembeck, 2007). In
contrast, some attrition rates for PCIT community-based studies have been as high as 67–69% (Lanier et al., 2011; Pearl et al.,
2012). Initial studies about attrition have suggested that there are important treatment and family characteristics that are
associated with higher levels of attrition including income, maternal depression (Timmer et al., 2011), transportation (Lanier
et al., 2011), and whether the family was mandated to attend treatment (Galanter et al., 2012). Additional information is
needed to better understand this important issue, and to develop strategies to buffer against attrition.
One strategy often attempted to decrease attrition is to offer the intervention in the home environment. In theory, one
would expect in-home PCIT to have significantly less attrition than clinic-based PCIT; however this is not the case. Published
in-home PCIT studies appear to have similar attrition rates to the clinic-based studies cited above (e.g., 35%, Galanter et al.,
2012; 40%, Ware, McNeil, Masse, & Stevens, 2008). Further, in a direct comparison of in-home vs clinic-based PCIT, Lanier
et al. (2011) had an attrition rate of 69% but attrition did not differ between groups. We know that there seems to be no
added benefit to augmenting standard clinic-based PCIT with home-based sessions (Timmer et al., 2010) and clinic-based
PCIT has been found to demonstrate gains at a faster rate compared to in-home PCIT (Lanier et al., 2011). Therefore, given
the high cost of implementing in-home PCIT (e.g., travel time and reimbursement costs) with possibly no added benefit,
further studies comparing in-home and clinic-based PCIT are essential.
As mentioned, Chaffin et al. have developed another strategy (e.g., motivational interviewing) to combat attrition. For
families referred from child welfare, with low or moderate motivation, a 6-session, group-based motivation component prior
to PCIT improved treatment retention (Chaffin et al., 2009). Also, Thomas and colleagues are currently trialing a 3-session
individual motivation component (using the same treatment manual as Chaffin et al., 2009) in conjunction with 12-week
PCIT. Families have greater gains from interventions when they complete the required intervention dose. How to maximize
the effectiveness of an intervention by decreasing attrition is one of the next important research agendas.

Conclusion (and a quick word about data)

There is a large quantity of evidence to support the utility of PCIT for children with behavioral difficulties within the child
welfare sector. As with any therapy, individualizing PCIT for each family remains essential. However, adaptations of PCIT
(in-home coaching, motivation components, additional individual counseling and length) vary in outcomes. All clinicians
care about providing timely, appropriate and effective services for their clients. We all owe it to families to check we are
doing this. Should any adaptations to the PCIT protocol be conducted, it is a missed opportunity for researchers, clinicians
and ultimately families, if outcome assessments are not collected.

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Please cite this article in press as: Thomas, R., & Herschell, A.D. Parent–child interaction therapy: A manualized interven-
tion for the therapeutic child welfare sector. Child Abuse & Neglect (2013), http://dx.doi.org/10.1016/j.chiabu.2013.02.003