Parent-Child Interaction Therapy is a dyadic behavioral intervention developed by Eyberg and her colleagues for two- to seven-year-old children and their caregivers (Brinkmeyer & Eyberg,2003). Its primary focus is to decrease externalizing child behavior problems, increase child social skills and cooperation, and improve parent- child relationship and interaction patterns. To date, Parent-Child Interaction Therapy has been used primarily in the management of disruptive behavioral disorders with an established evidence base in this population (e.g., Eyberg et al.,2001; Eyberg, Nelson,
& Boggs,2008; Hood & Eyberg,2003). A typical course of Parent-Child Interaction Therapy consists of about 14 weekly, one-hour sessions. Parent-Child Interaction Therapy has two main components, Child-Directed Interaction and Parent-Directed Interaction. In the initial Child-Directed Interaction component, the focus is on devel- oping a warm and nurturing bond between parents and children through play. This is followed by the Parent-Directed Interaction component in which, through the use of play therapy and behavioral therapy, parents learn more effective ways of disciplining their children. Given the evidence for its efficacy in helping two- to seven-year-old children with behavioral difficulties, Parent-Child Interaction Therapy was adapted for use in the management of anxiety disorders in this same age group in more recent years.
In an open trial pilot study, Pincus, Santucci, Ehrenreich, and Eyberg (2008) utilized Parent-Child Interaction Therapy with ten children (M age 6.2 years;
range4–8) with separation anxiety disorder diagnosed using the Anxiety Disorders Interview Schedule (Silverman & Albano,1996). Although mean Anxiety Disorders Interview Schedule Clinician Severity Rating decreased from 5.8 pre-treatment to 4.2 post-treatment (nopvalues were reported), they did not decrease below non-clinical levels (as described in Chap. 2, a Clinician Severity Rating of 4 or greater on the Anxiety Disorders Interview Schedule indicates a clinical diagnosis). Additionally, according to Pincus and colleagues (2008), although improvements in separation symptoms were noted in practiced situations, children continued to have difficulties with separation in new situations. Given these early findings, Pincus and colleagues (2008) added a third component, they called Bravery-Directed Interaction, which is further described in Sect.4.2.1.
4.2.1 Bravery-Directed Interaction
Similar to the Child-Directed Interaction and Parent-Directed Interaction compo- nents of traditional Parent-Child Interaction Therapy, the Bravery-Directed Interac- tion component consists of one Teach session for parents followed by two or more Coach sessions. Psychoeducation about anxiety, factors that maintain anxiety, and links among thoughts, physical feelings, and behaviors is provided during this Teach session. Additionally, therapists help parents build fear and avoidance hierarchies and
reward lists, demonstrate how to complete and practice hierarchies with their children outside of sessions, and discuss the importance of using Child-Directed Interaction skills (e.g., praising brave behaviors and reflecting on emotions and behaviors) and avoiding avoidance during the Teach session. Coach sessions follow in which thera- pists ‘coach’ parents on ways to develop exposure practices during the week between therapy sessions, as well as problem solve around exposures already conducted. The Bravery-Directed Interaction component uses CBT-like principles, although it main- tains the same behavioral focus of traditional Parent-Child Interaction Therapy.
Pincus and colleagues presented preliminary data on a randomized control trial of the Bravery-Directed Interaction (Pincus et al.,2008; Puliafico, Comer, & Pincus, 2012) component of Parent-Child Interaction Therapy in which 38 four- to eight- year-old children (15 males; no additional demographic data provided) with a primary diagnosis of separation anxiety disorder were randomized to either the Bravery- Directed Interaction arm or a 9-week waitlist control arm after which time the children received the active treatment. They report that the parent-child dyads who received the modified Parent-Child Interaction Therapy had greater improvements on separation anxiety, general psychopathology, parent-child interaction, and parent stress than those in the waitlist control arm at post-treatment, with 73% of children no longer meeting diagnostic criteria for separation anxiety disorder post-treatment, and these improvements were maintained at a 12-month follow-up visit (Puliafico et al.,2012).
Further data from this randomized control trial would be necessary to fully evaluate the efficacy of Parent-Child Interaction Therapy and the modified CBT-like Bravery- Directed Interaction in the treatment of preschool anxiety disorders, but no such data have been published. Although the aforementioned preliminary data suggest that Bravery-Directed Interaction, a modification of Parent-Child Interaction Therapy, may be helpful in the treatment of separation anxiety disorder, further evaluation with larger sample sizes and more rigorous methodology is needed.
4.2.2 Coaching Approach Behavior and Leading by Modeling
Another anxiety-focused modification of Parent-Child Interaction Therapy designed to treat young children with several different anxiety disorders, including separation anxiety disorder, social anxiety disorder, generalized anxiety disorder, or specific phobia, is the Coaching Approach Behavior and Leading by Modeling (CALM) program (Comer, Puliafico, Aschenbrand, McKnight, Robin, Goldfin, & Albano, 2012). In this modification of Parent-Child Interaction Therapy, the Child-Directed Interaction component remains unchanged, the Parent-Directed Interaction compo- nent is omitted, and the CALM program, a 12-session manual-based modification, is added. In the CALM program, the foci in four initial Child-Directed Interaction sessions are the parent-child relationship, psychoeducation about anxiety, and the development of fear hierarchies. This is followed by eight exposure sessions during which parents complete exposure tasks with their children while wearing an in-ear earbud that allows them to hear and receive real-time, in-session coaching or indi-
vidualized feedback. The CALM program emphasizes parent modeling of approach behaviors for the child, setting clear expectations about the child’s behavior, using effective communication with the child in anxiety-provoking situations, and using praise following the child’s display of brave behaviors while ignoring behaviors such as avoidance and whining. The CALM program’s developers emphasize that the individualized, real-time feedback via the earbud in the parent’s ear during ses- sions distinguishes this program from other CBT-like programs that utilize exposure (Comer et al.,2012).
Nine children (Mage5.4 years;SD1.3; range4–8) with a primary anxiety disorder diagnosis (separation anxiety disorder, social anxiety disorder, or specific phobia), established by the Anxiety Disorders Interview Schedule (Silverman &
Albano,1996), participated with their parents in a pilot study of the CALM program (Comer et al.,2012). Children with a moderate degree of interference, as measured by a score of less than 55 on the Children’s Global Assessment Scale (Shaffer, Gould, Brasic, Ambrosini, Fisher, Bird, & Aluwahlia,1983), were excluded. The Children’s Global Assessment Scale is a clinician rating of overall functioning rated on a 100-point scale with higher scores reflecting higher adaptive functioning. No changes in the Anxiety Disorders Interview Schedule Clinician Severity Rating or the Children’s Global Assessment Scale were noted between two baseline assessments conducted by independent assessors one to four weeks apart. Two of the nine children dropped out of treatment early. Using an intent-to-treat analysis, six (66.7%) of the nine children no longer met criteria for any diagnosis post-treatment. A mean Anxiety Disorders Interview Schedule Clinician Severity Rating decrease of 2.8 (SD 2.0) for the primary diagnosis was noted (nop value reported). Additionally, a mean improvement in the Children’s Global Assessment Scale of 21 points (SD 11 points) was noted (no pvalue reported), with six (66.7%) of the nine children categorized as having a functional improvement of at least 10 points, or movement from one interval on the Children’s Global Assessment Scale to the next interval, which would be clinically significant (Shaffer et al.,1983).
Comer et al. (2012) hypothesized that direct modifications in parenting practices and parenting reinforcement contingencies were responsible for the improvements noted in the six children. Although this small open trial pilot study provides pre- liminary support for this modified approach to Parent-Child Interaction Therapy and suggests that reshaping parenting practices may be helpful in reducing children’s anxiety, significant study limitations must be highlighted. For example, the small sample size and the fact that children with significant impairment (i.e., those with Children’s Global Assessment Scale scores of less than 55) were excluded from participating in the study are significant limitations. In fact, the pre-treatment mean Children’s Global Assessment Scale score was 61.4, placing the children in the ‘vari- able functioning with sporadic difficulties or symptoms in several but not all areas’
category, suggesting that these children were not severely impaired (Shaffer et al., 1983), even at treatment start. Relatedly, the investigators reported that the two chil- dren who dropped out of the study were the most severely impaired of all study participants as they both had an Anxiety Disorders Interview Schedule Clinician Severity Rating of 7 out of 8 for their primary anxiety disorder diagnosis, with 0
indicating no impairment and 8 indicating significant impairment. Additionally, the two children who dropped out had a high number of comorbid anxiety and non- anxiety diagnoses and the lowest global functioning as measured by the Children’s Global Assessment Scale. Finally, as reported by the investigators, one independent evaluator who was blind to treatment related data but not to assessment time points completed all research assessments at all time points.
In summary, Parent-Child Interaction Therapy and its derivative interventions, all of which have a strong behavioral focus, show promise in the treatment of anxiety disorders in young children, but have limited empirical evidence to document their efficacy and warrant further evaluation.