1. Infant / Parent Psychotherapy: Clinical Understanding & Treatment Natalie Roth, Ph.D. Jessica Singleton, Ph.D.

2. Choose Your Approach Based on Need  Emotional Support (look, listen, acknowledge, and show compassion)  Concrete Resources (food, housing, clothing, medical care)  Developmental Guidance (basic child care routines and safety needs, observation of the baby’s competencies, and anticipation of new milestones)  Advocacy (speak for those who cannot)  Infant-Parent Psychotherapy (when support and guidance are not adequate)  Weatherston, D.J. (1995). “She does love me, doesn’t she?” Zero to Three, February/March, p. 8

3. Infant-Parent Psychotherapy: An Overview of Therapeutic Approaches  Infant-Parent Psychotherapy Psychoanalytically based Both parents and infant are the “patient” “Corrective attachment experience of the therapeutic relationship” Interpretation (transference, projective identification) Increasing parents’ self-esteem, knowledge, and skills

4. Infant-Parent Psychotherapy: An Overview of Therapeutic Approaches  Focusing on Infant Behavior (Terry Brazelton and colleagues) As part of an evaluation process (pediatric examination; Neonatal Behavioral Assessment Scale, Bailey) Infant’s response to the test situation initiates discussion Examples: Overstimulated baby At-risk attachment situations

5. Infant-Parent Psychotherapy: An Overview of Therapeutic Approaches  Interaction Guidance Focus on mother’s behavior Establish therapeutic alliance (home visits, education, advice, practical help, support, and intervening with other agencies) Positive reinforcement of maternal behaviors that are good (videotaping and replay, then “in vivo” interaction) Alternate: Entire Network of Family Interactions (“the family triad”)

6. Infant-Parent Psychotherapy: An Overview of Therapeutic Approaches  Watch, Wait & Wonder (Elisabeth Muir) Parent-child interaction is port of entry Parent-child play time: parent follows child’s lead Discussion with therapist: therapist follows parent’s lead

7. Infant-Parent Psychotherapy: An Overview of Therapeutic Approaches “ Floortime”  (Stanley Greenspan) Technique and philosophy centered on developing meaningful adult/child interactions to promote cognitive and social/emotional development 5 Step technique  Observation  Approach- Open the Circle of Communication  Follow the Child’s Lead  Extend and Expand  Child Closes the Circle

8. Meta-Analysis 101  A study of studies  Usefulness  Cohen’s d  Effect size interpretation: Small:.00-.32 Moderate:.33-.55 Large:.56+

9. The Current Meta-Analysis  Models Identified: Psychodynamic Educational Infant Massage Eclectic  Types of Practitioners: Psychologists Psychiatrists Social Workers Nurses Paraprofessionals

10. Outcome Measures  Ainsworth Maternal Sensitivity Scale (Ainsworth, Blehar, Waters, & Wall, 1978)  AMBIANCE (Bronfman, Parsons, & Lyons-Ruth, 1999)  Chatoor Mother/Infant/Toddler Play Scale (Chatoor, 1986; Chatoor, Menville, Getson, & O’Donnell, 1988)  Crittenden Experimental Index of adult-infant Relations (Crittenden, 1981)  Home Observation for Measurement of the Environment (Bradley & Caldwell, 1977)  Klein-Briggs Observation of Communicative Interaction Scales (Klein & Briggs, 1987)

11. Outcome Measures  Mother-child relationship evaluation (Roth, 1961)  NCAST Feeding and Teaching Scales (Barnard, 1989)  Parent/Caregiver Involvement Scale (Farren et al., 1986)  Parental Attitudes Toward Childrearing (Goldberg & Easterbrooks, 1984)  Parenting Sense of Competence Scale (Johnston & Mash, 1991)  Parenting Stress Index(Abidin, 1990)  Quality of Parental Support and Parent- Child Interaction Observations (Erickson et al., 1985)  Relationship Survey (Simpson, Rholes, & Nelligan, 1992)

13. Moderators : Large Effect Sizes  Large ES: Mental Health Therapists Psychodynamic, Interaction Guidance, Massage, Eclectic Models Brief to moderate length Hispanic and White clients Parents with <HS education

14. Infant-Parent Psychotherapy  Attachment Perspective/Relationship based  Selma Fraiberg/Alicia Lieberman  “Ghosts in the Nursery”  Child-parent psychotherapy

15. Infant-Parent Psychotherapy Practitioners  Psychologists  Psychiatrists  Social workers  Family therapists  Nurses  Child development specialists  Occupational therapists

16. Infant-Parent Psychotherapy: Major Tenants  The attachment system is the organizer of children’s responses  Problems in infancy are addressed in the context of the attachment relationship  Transactional development

17. Infant-Parent Psychotherapy: Assessment  Observations include: 1. Parent-child interaction 2. Child-examiner interaction 3. Multiple settings/times 4. Developmental history 5. Parent report of problem 6. Parent’s history 7. Cultural issues

18. Infant-Parent Psychotherapy: Key Concepts  “Kitchen therapy”  Techniques: Behavior-based strategies Play Verbal interpretation  Ports of Entry  Four Modalities: 1. Concrete Assistance 2. Emotional Support 3. Developmental Guidance 4. Psychodynamic Psychotherapy

19. Infant-Parent Psychotherapy Ports of Entry The child’s behavior The parent-child interaction The child’s representations Parental Representations Intertwined parent-child representations Parent-therapist relationship

20. Infant-Parent Psychotherapy Concrete Assistance  Locating resources  Providing transportation  Advocacy  Completing forms

21. Infant-Parent Psychotherapy Emotional Support  Look, Listen, Acknowledge, and Show Empathy  Awareness of the parent’s and child’s messages

22. Infant-Parent Psychotherapy Developmental Guidance  Non-didactic  Speak through the child  Interpret:  “She loves it when you hold her like that.”  “I wonder what he is saying to us now.”  Encourage play  Model  Encourage: eye contact, smiling, waiting, following  Offer suggestions

23. Infant-Parent Psychotherapy Psychodynamic Psychotherapy  Understanding the parents’ reaction to their child in the context of their personal history  Include the infant  What was it like for you when he follows you around?  How was your relationship with your parent?

24. Infant-Parent Psychotherapy Review  Emotional support, warmth, and empathy  The infant is always present  Point out accomplishments  Provide parent education  Be on time for all sessions  Help them increase their feeling vocabulary  Group settings are possible  Time issues  Provide opportunities for positive experiences  Always remain open, curious, and reflective

25. Infant-Parent Psychotherapy: An Overview of Therapeutic Approaches  Parent-Child Interaction Therapy (Sheila Eyberg) Combining play therapy and behavioral techniques More to come…

26. Parent-Child Interaction Therapy (PCIT)  Developed by Sheila Eyberg, Ph.D. (University of Florida)  For children ages 2-6 with a range of behavioral, emotional, and family problems (e.g. difficult termperament, hyperactivity, faulty social information processing, genetic difficulties)

27. Parent-Child Interaction Therapy (PCIT)  Manualized (Hembree-Kigin, T. L., & McNeil, C. B. (1995). Parent-Child Interaction Therapy. New York: Plenum)  Based on attachment theory and social learning theory  Short-Term (10-16, 1 hr. sessions)  Assessment-driven  Empirically supported  Divided into two phases: Child-Directed Interaction (CDI) Parent-Directed Interaction (PDI)

28. Theorectical Foundations of PCIT  Baumrind’s Parenting Styles Authoritarian (high demandingness, low warmth) Permissive (high warmth, low demandingness) Authoritative (high warmth, high demandingness) Nurturance and firm limits are both necessary for healthy outcomes

29. Theorectical Foundations of PCIT  Attachment Theory Focus of CDI is to restructure parent- child relationship to provide a secure attachment  Asserts that sensitive and responsive parenting provides the foundation for the child’s knowledge that he/she will be responded to when necessary.  Results in more effective emotional and behavioral regulation

30. Social Learning Theory  Patterson et. al (1991) Coercion Theory  Behavior problems are inadvertently established or maintained by dysfunctional parent-child interactions  Both child and parent actively engage in the continuation of the cycle, which is maintained through negative reinforcement

31. Patterson et. al (1991): Coercion Theory Child Problem Behaviors (Arguing, Aggression) Withdrawal of Parental Request Increase in Problem Behaviors Negative Reinforcement Increases Intensity of Behavior Over Time

32. Patterson et. al (1991): Coercion Theory Negative Parent Behaviors (Yelling) Momentary Compliance from Child Increase in Negative Behaviors Negative Reinforcement Increases Intensity of Behavior Over Time

33. Patterson et. al (1991): Coercion Theory  Parent of children with externalizing behaviors have been found to be: Power-assertive (Authoritative) and Lax (Permissive) It’s this combination of intermittent reinforcement that produces such a strong reinforcement system

34. Structure of PCIT  Child Directed Interaction (CDI) Teaching Session One Hour Session Parents alone Presentation of skills “Rules” Reasons Examples Modeling/demonstration Role-play with parents

35. Structure of PCIT  CDI  “Don’t” Rules Follow the Child’s Lead  No Commands (attempt to lead; risk negative interaction)  No Questions (are often hidden commands, take lead from the child, can suggest disapproval, can suggest not listening)  No Criticism (Points out mistakes rather than correcting them, lowers self-esteem, creates unpleasant interaction)

36. Structure of PCIT  CDI  “Do” Rules  PRIDE Praise (Labeled; “Thanks you for using your indoor voice) Reflect (Allows child to lead; shows that parent is listening; shows that parent understand; improves speech) Imitate (Let’s the child lead; teaches parent how to “play”, show approval of child’s activity; teaches child how to play with others) Describe (“sportscaster”, child leads, child knows you’re paying attention, shows interest and approval, teaches vocabulary, holds child’s attention to the task) Enthusiasm! (Let’s the child know you enjoy being with them, makes the play more fun, adds quality of warmth)

37. Structure of PCIT  CDI  IGNORE (talking to the wall) annoying, obnoxious behavior; use STRATEGIC ATTENTION to increase desireable behavior  STOP THE PLAY for dangerous or desctructive behavior and use safe discipline technique

38. Structure of PCIT  CDI  Suggested Toys Creative constructional toys (blocks, Mr. Potato Head, Toy farm w/ animals, crayons and paper) Avoid  toys that encourage rough play  toys that lead to aggressive play  toys that require limit setting (scissors)  toys that discourage conversation  toys that lead parent or child to pretend they are someone else

39. Structure of PCIT  Coaching is the primary method of parent training (“bug in the ear”) allows immediate feedback prevents miscommunication provides support enables therapist to calm and reassure parent if needed provides opportunity for reframing parent attributions

40. Structure of PCIT  Common Coaching Statements Labeled Praises  “Good ignoring!” Gentle correctives  “Oops, a question.” Directives  “Can you reflect that?” Observations  “He quiets down when you talk softly like that.”

41. Structure of PCIT  Weekly Coaching Sessions  Homework “Special Time” 5-10 Minutes/day  Reduces resistance  Able to sustain quality  Hart to concentrate for longer  Reduces likelihood of problems  Doesn’t have to be rigid  Not contingent on behavior  Ending: “I’m going to pick up the toys now. You can help me if you want”

42. Structure of PCIT  Mastery of CDI DPICS (Descriptive Parent Child Interaction) coding for 5 minutes  10 labeled praises  10 behavior descriptions  10 reflections  No commands, questions, or criticisms

43. Structure of PCIT  Parent-Directed Interaction (PDI) Concentrates on:  Issuing clear commands  Providing consistent consequences for both compliance (labeled praise) and noncompliance (time-out procedure)

44. Structure of PCIT  PDI Effective Commands  Direct (telling, not asking)  Positive (what to DO, not stop doing)  Single (one at a time)  Specific (not vague)  Age-appropriate  Given in a normal tone of voice  Used only when really necessary  Explained after obeyed

45. Structure of PCIT Command No Opportunity Whoops! (Start Over) Obey Labeled Praise Back to Play! Disobey

46. Structure of PCIT “ If you don’t (original command), you’ll have to do to the time out chair” Obey Labeled Praise Back to Play! Disobey

47. Structure of PCIT The Chair Child stays on chair 3 min. plus 5 seconds quiet Are you ready to (obey original command?) Obey Praise Doesn’t Stay on Chair

48. Structure of PCIT Child Gets Off Chair “You got off the chair before I said you could. If you get off again, you’ll go to the Time Out Room” Child gets off again Child goes to time out room + 1 minute of quiet Back to Chair

49. Structure of PCIT The Chair Child stays on chair 3 min. plus 5 seconds quiet Are you ready to (obey original command?) Obey Acknowledge

50. Structure of PCIT Command Obey Praise Back to Play!!

51. Structure of PCIT  House Rules Standing Commands  No aggressive behavior  No destructive behavior Procedure  Label behavior for child  Explain rule to child  No chair warnings  It’s over when time is up

52. Structure of PCIT  Public Misbehavior Procedures (“time out can travel”)  Make plan before leaving home  Describe desired behavior  Take along ”time out chair” (towel)  Discuss back-ups

53. Structure of PCIT  Last session: Posttreatment-evaluation Discussion and Feedback  Perception of reasons for change  review measures  show pre and post video tape  Address remaining concerns  Schedule “boosters”