Transcript Infant / Parent Psychotherapy: Clinical Understanding

Infant / Parent Psychotherapy:
Clinical Understanding &
Treatment
Natalie Roth, Ph.D.
Jessica Singleton, Ph.D.
Choose Your Approach Based on
Need
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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
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Infant-Parent Psychotherapy
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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
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Focusing on Infant Behavior
(Terry Brazelton and colleagues)
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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
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Interaction Guidance
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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)
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Alternate: Entire Network of Family Interactions
(“the family triad”)
Infant-Parent Psychotherapy:
An Overview of Therapeutic
Approaches
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Watch, Wait & Wonder
(Elisabeth Muir)
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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”
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Technique and philosophy centered on developing meaningful
adult/child interactions to promote cognitive and
social/emotional development
5 Step technique
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Observation
Approach- Open the Circle of Communication
Follow the Child’s Lead
Extend and Expand
Child Closes the Circle
Meta-Analysis 101
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A study of studies
Usefulness
Cohen’s d
Effect size
interpretation:
Small: .00-.32
Moderate: .33-.55
Large: .56+
The Current Meta-Analysis
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Models Identified:
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Psychodynamic
Educational
Infant Massage
Eclectic
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Types of
Practitioners:
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Psychologists
Psychiatrists
Social Workers
Nurses
Paraprofessionals
Outcome Measures
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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)
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Crittenden
Experimental Index of
adult-infant Relations
(Crittenden, 1981)
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Home Observation for
Measurement of the
Environment (Bradley
& Caldwell, 1977)
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Klein-Briggs
Observation of
Communicative
Interaction Scales
(Klein & Briggs, 1987)
Outcome Measures
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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)
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Parenting Sense of
Competence Scale
(Johnston & Mash, 1991)
Parenting Stress
Index(Abidin, 1990)
Quality of Parental
Support and ParentChild Interaction
Observations (Erickson
et al., 1985)
Relationship Survey
(Simpson, Rholes, &
Nelligan, 1992)
Parent-Infant Relationship
Citation
NTotal Effect
Armstrong
Benoit
Cohen
Cooper
Cramer
Glover
Johnson
Jump
Lieberman
Meyer
Onozawa
Palmer
Pardew
Rauh
Riksen-Walraven
Robert-Tissot
Schuler
Spiker
Vitucci
Wadsby
Wasik
Wendland-Carro
Whitt
181
27
60
64
38
16
31
45
53
34
25
47
23
53
75
150
171
683
57
88
41
36
32
.283
1.646
3.661
.175
.758
2.233
.209
.117
1.424
1.083
1.338
.304
.829
.915
.308
.610
.375
.190
.886
.478
.327
1.308
.640
Combined (23)
2030
.551
-2.00
-1.00
0.00
Favors Cntl
1.00
Favors Int
2.00
Moderators : Large Effect Sizes
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Large ES:
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Mental Health Therapists
Psychodynamic, Interaction
Guidance, Massage, Eclectic
Models
Brief to moderate length
Hispanic and White clients
Parents with <HS education
Infant-Parent Psychotherapy
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Attachment Perspective/Relationship
based
Selma Fraiberg/Alicia Lieberman
“Ghosts in the Nursery”
Child-parent psychotherapy
Infant-Parent Psychotherapy
Practitioners
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Psychologists
Psychiatrists
Social workers
Family therapists
Nurses
Child development
specialists
Occupational
therapists
Infant-Parent Psychotherapy:
Major Tenants
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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
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Observations include:
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Parent-child interaction
Child-examiner interaction
Multiple settings/times
Developmental history
Parent report of problem
Parent’s history
Cultural issues
Infant-Parent Psychotherapy:
Key Concepts
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“Kitchen therapy”
Techniques:
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Behavior-based
strategies
Play
Verbal
interpretation
Ports of Entry
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1.
2.
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Four Modalities:
Concrete
Assistance
Emotional
Support
Developmental
Guidance
Psychodynamic
Psychotherapy
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
Infant-Parent Psychotherapy
Concrete Assistance
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Locating resources
Providing
transportation
Advocacy
Completing forms
Infant-Parent Psychotherapy
Emotional Support
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Look, Listen,
Acknowledge, and
Show Empathy
Awareness of the
parent’s and
child’s messages
Infant-Parent Psychotherapy
Developmental Guidance
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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
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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
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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
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Parent-Child Interaction Therapy
(Sheila Eyberg)
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Combining play therapy and behavioral
techniques
More to come…
Parent-Child Interaction Therapy
(PCIT)
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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)
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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:
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Child-Directed Interaction (CDI)
Parent-Directed Interaction (PDI)
Theorectical Foundations of PCIT
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Baumrind’s Parenting Styles
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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
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Attachment Theory
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Focus of CDI is to restructure parentchild 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
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Social Learning Theory
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Patterson et. al (1991)
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Coercion Theory
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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
Negative Reinforcement
Increases Intensity
of Behavior
Over Time
Increase in
Problem
Behaviors
Withdrawal
of Parental
Request
Child Problem
Behaviors
(Arguing,
Aggression)
Patterson et. al (1991): Coercion
Theory
Negative Reinforcement
Increases Intensity
of Behavior
Over Time
Increase in
Negative
Behaviors
Momentary
Compliance
from Child
Negative Parent
Behaviors
(Yelling)
Patterson et. al (1991): Coercion
Theory
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Parent of children with externalizing
behaviors have been found to be:
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Power-assertive (Authoritative) and
Lax (Permissive)
It’s this combination of intermittent
reinforcement that produces such a
strong reinforcement system
Structure of PCIT
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Child Directed Interaction (CDI)
Teaching Session
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One Hour Session
Parents alone
Presentation of skills
“Rules”
Reasons
Examples
Modeling/demonstration
Role-play with parents
Structure of PCIT
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CDI
“Don’t” Rules
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Follow the Child’s Lead
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No Commands (attempt to lead; risk negative
interaction)
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No Questions (are often hidden commands, take
lead from the child, can suggest disapproval, can
suggest not listening)
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No Criticism (Points out mistakes rather than
correcting them, lowers self-esteem, creates unpleasant
interaction)
Structure of PCIT
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CDI
“Do” Rules
PRIDE
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Praise (Labeled; “Thanks you for using your indoor voice)
Reflect (Allows child to lead; shows that parent is listening;
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Imitate
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Describe
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Enthusiasm!
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shows that parent understand; improves speech)
(Let’s the child lead; teaches parent how to “play”,
show approval of child’s activity; teaches child how to play with
others)
(“sportscaster”, child leads, child knows you’re paying
attention, shows interest and approval, teaches vocabulary, holds
child’s attention to the task)
(Let’s the child know you enjoy being with them,
makes the play more fun, adds quality of warmth)
Structure of PCIT
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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
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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
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Coaching is the primary method of
parent training (“bug in the ear”)
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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
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Common Coaching Statements
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Labeled Praises
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Gentle correctives
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“Oops, a question.”
Directives
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“Good ignoring!”
“Can you reflect that?”
Observations
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“He quiets down when you talk softly like
that.”
Structure of PCIT
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Weekly Coaching Sessions
Homework
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“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
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Mastery of CDI
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DPICS (Descriptive Parent Child
Interaction) coding for 5 minutes
10 labeled praises
 10 behavior descriptions
 10 reflections
 No commands, questions, or criticisms
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Structure of PCIT
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Parent-Directed Interaction (PDI)
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Concentrates on:
Issuing clear commands
 Providing consistent consequences for
both compliance (labeled praise) and
noncompliance (time-out procedure)
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Structure of PCIT
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PDI
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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
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Structure of PCIT
Command
No Opportunity
Obey
Disobey
Labeled Praise
Whoops!
(Start Over)
Back to Play!
Structure of PCIT
“If you don’t (original command), you’ll have to do
to the time out chair”
Obey
Disobey
Labeled Praise
Back to Play!
Structure of PCIT
The Chair
Child stays on chair 3 min. plus 5 seconds quiet
Are you ready to
(obey original
command?)
Doesn’t Stay on Chair
Obey
Praise
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
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House Rules
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Standing Commands
No aggressive behavior
 No destructive behavior
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Procedure
Label behavior for child
 Explain rule to child
 No chair warnings
 It’s over when time is up
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Structure of PCIT
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Public Misbehavior
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Procedures (“time out can travel”)
Make plan before leaving home
 Describe desired behavior
 Take along ”time out chair” (towel)
 Discuss back-ups
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Structure of PCIT
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Last session:
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Posttreatment-evaluation
Discussion and Feedback
Perception of reasons for change
 review measures
 show pre and post video tape
 Address remaining concerns
 Schedule “boosters”
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