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 babys 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, doesnt 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)
Infants 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 mothers 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
childs lead
Discussion with therapist: therapist
follows parents 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 Childs Lead
Extend and Expand
Child Closes the Circle


Meta-Analysis 101
A study of studies
Usefulness
Cohens d
Effect size
interpretation:
Small: .00-.32
Moderate: .33-.55
Large: .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, & ODonnell,
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 .283
Benoit 27 1.646
Cohen 60 3.661
Cooper 64 .175
Cramer 38 .758
Glover 16 2.233
Johnson 31 .209
Jump 45 .117
Lieberman 53 1.424
Meyer 34 1.083
Onozawa 25 1.338
Palmer 47 .304
Pardew 23 .829
Rauh 53 .915
Riksen-Walraven 75 .308
Robert-Tissot 150 .610
Schuler 171 .375
Spiker 683 .190
Vitucci 57 .886
Wadsby 88 .478
Wasik 41 .327
Wendland-Carro 36 1.308
Whitt 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 Psychotherapy
Practitioners
Psychologists
Psychiatrists
Social workers
Family therapists
Nurses
Child development
specialists
Occupational
therapists
Infant-Parent Psychotherapy:
Major Tenants
The attachment system is the
organizer of childrens responses

Problems in infancy are addressed
in the context of the attachment
relationship

Transactional development



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. Parents history
7. Cultural issues
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

Infant-Parent Psychotherapy
Ports of Entry
The childs behavior
The parent-child interaction
The childs representations
Parental Representations
Intertwined parent-child representations
Parent-therapist relationship
Infant-Parent Psychotherapy
Concrete Assistance
Locating resources
Providing
transportation
Advocacy
Completing forms


Infant-Parent Psychotherapy
Emotional Support
Look, Listen,
Acknowledge, and
Show Empathy

Awareness of the
parents and
childs messages


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


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?


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


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
Baumrinds 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
childs 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 Problem
Behaviors
(Arguing,
Aggression)
Withdrawal
of Parental
Request
Increase in
Problem
Behaviors
Negative Reinforcement
Increases Intensity
of Behavior
Over Time
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
Patterson et. al (1991): Coercion
Theory
Parent of children with externalizing
behaviors have been found to be:
Power-assertive (Authoritative) and
Lax (Permissive)

Its 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
Reasons
Examples
Modeling/demonstration
Role-play with parents
Structure of PCIT
CDI
Dont Rules
Follow the Childs 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 (Lets the child lead; teaches parent how to play,
show approval of childs activity; teaches child how to play with
others)
Describe (sportscaster, child leads, child knows youre paying
attention, shows interest and approval, teaches vocabulary, holds
childs attention to the task)
Enthusiasm! (Lets 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
Doesnt have to be rigid
Not contingent on behavior
Ending: Im 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 dont (original command), youll 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
Doesnt 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, youll 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
Its 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