Infant / Parent Psychotherapy: Clinical Understanding &

Treatment

Natalie Roth, Ph.D.Jessica Singleton, Ph.D.

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

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

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

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”)

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

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

Meta-Analysis 101

A study of studies Usefulness Cohen’s d Effect size

interpretation:Small: .00-.32

Moderate: .33-.55Large: .56+

The Current Meta-Analysis

Models Identified: Psychodynamic Educational Infant Massage Eclectic

Types of Practitioners: Psychologists Psychiatrists Social Workers Nurses Paraprofessionals

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)

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)

Citation NTotal Effect

Armstrong 181 .283Benoit 27 1.646Cohen 60 3.661Cooper 64 .175Cramer 38 .758Glover 16 2.233Johnson 31 .209Jump 45 .117Lieberman 53 1.424Meyer 34 1.083Onozawa 25 1.338Palmer 47 .304Pardew 23 .829Rauh 53 .915Riksen-Walraven 75 .308Robert-Tissot 150 .610Schuler 171 .375Spiker 683 .190Vitucci 57 .886Wadsby 88 .478Wasik 41 .327Wendland-Carro 36 1.308Whitt 32 .640

Combined (23) 2030 .551

-2.00 -1.00 0.00 1.00 2.00

Favors Cntl Favors Int

Parent-Infant Relationship

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

Infant-Parent Psychotherapy

Attachment Perspective/Relationship based Selma Fraiberg/Alicia Lieberman “Ghosts in the Nursery” Child-parent psychotherapy

Infant-Parent PsychotherapyPractitioners

Psychologists Psychiatrists Social workers Family therapists Nurses Child development

specialists Occupational

therapists

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

Infant-Parent Psychotherapy:Assessment

Observations include:1. Parent-child interaction2. Child-examiner interaction3. Multiple settings/times4. Developmental history5. Parent report of problem6. Parent’s history7. Cultural issues

Infant-Parent Psychotherapy: Key Concepts

“Kitchen therapy” Techniques:

Behavior-based strategies

Play Verbal

interpretation Ports of Entry

Four Modalities:1. Concrete

Assistance2. Emotional

Support3. Developmental

Guidance4. Psychodynamic

Psychotherapy

Infant-Parent PsychotherapyPorts of Entry

The child’s behaviorThe parent-child interactionThe child’s representationsParental Representations

Intertwined parent-child representationsParent-therapist relationship

Infant-Parent PsychotherapyConcrete Assistance

Locating resources Providing

transportation Advocacy Completing forms

Infant-Parent PsychotherapyEmotional Support

Look, Listen, Acknowledge, and Show Empathy

Awareness of the parent’s and child’s messages

Infant-Parent PsychotherapyDevelopmental 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

Infant-Parent PsychotherapyPsychodynamic 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?

Infant-Parent PsychotherapyReview

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

Infant-Parent Psychotherapy:An Overview of Therapeutic Approaches

Parent-Child Interaction Therapy (Sheila Eyberg)

Combining play therapy and behavioral techniques

More to come…

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)

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)

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

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

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

Patterson et. al (1991): Coercion Theory

Child ProblemBehaviors(Arguing,

Aggression)

Withdrawal of Parental

Request

Increase in Problem Behaviors

Negative Reinforcement Increases Intensity

of BehaviorOver Time

Patterson et. al (1991): Coercion Theory

Negative ParentBehaviors(Yelling)

Momentary Compliancefrom Child

Increase in Negative Behaviors

Negative Reinforcement Increases Intensity

of BehaviorOver Time

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

Structure of PCIT

Child Directed Interaction (CDI)Teaching Session One Hour Session Parents alone Presentation of skills

“Rules”ReasonsExamplesModeling/demonstrationRole-play with parents

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)

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)

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

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

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

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.”

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”

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

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)

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

Structure of PCIT

Command

No Opportunity

Whoops!(Start Over)

Obey

Labeled Praise

Back to Play!

Disobey

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

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

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

Structure of PCIT

The Chair

Child stays on chair 3 min. plus 5 seconds quiet

Are you ready to(obey original

command?)

Obey Acknowledge

Structure of PCIT

Command

Obey

Praise

Back to Play!!

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

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

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”