Clinicians Don’t Deviate from Protocol By Providing Supplemental Services

I want to respond to the recent Chronicle of Social Change article about Parent-Child Interaction Therapy (PCIT).

I think the article misses an important point, which is that the Training, Intervention, Education and Services for Families (TIES) clinicians, while making small adjustments in the way they provide PCIT to fit the needs of their different adoptive families, are not “adapting” the PCIT model.

They are still providing PCIT within the parameters of the protocol. Yes, they often provide their TIES intervention before they begin PCIT. Yes, during PCIT, they often call parents mid-week to talk about how things are going. But these do not interfere with the core components of the intervention defining it as PCIT.

Therapists make small adjustments with all the parents and children we see to meet their specific clinical needs (especially children in the child welfare system). The unique contribution of the TIES clinicians lies in the special information they provide adoptive parents about the challenges of adoption.

Through their Ties Transition Model (TTM), they have formalized a largely psycho-educational component to help adoptive parents understand the effects of their adoptive children’s early adverse experiences on their current behavior. They can (and should) continue to use these insights as they coach parents to mastery of play therapy and behavior management skills in PCIT. The understanding TIES clinicians have about adoption helps engage parents in the treatment process and believe in the promise of change.

One of the things I’ve learned in dealing with maltreated children is that it is the accumulation of parent-child interactions that eventually develop and guide who we are. While specific acts of abuse can cause bruises and scars, as a mental health provider I am more concerned with children’s daily exposure to yelling, demeaning, overly harsh punishment, and cruelty that comes with those bruises and scars.

These early negative experiences are what lies in the heart of so many of our social ills – substance abuse, school drop-outs, entry to gangs, domestic violence, and the intergenerational perpetuation of maltreatment.

What do we try to accomplish with a child removed from the care of an abusive parent and placed in the homes of adoptive parents? Abused children do not shed their early memories like an old coat. No, they bring with them remnants of those past relationships. Every time an adoptive parent raises their voice – it returns the adopted child to mental imagery of a past relationship filled with fear and anger. We now know, from two decades of trauma research, that this imagery leads to problems with emotional regulation, impulsivity, and becomes a pathway to aggression.

Even worse, many maltreated children carry these same coercive relationship strategies into their adoptive homes, leading them to re-create those destructive but familiar relationship patterns.

To successfully address the problem of difficult adoptions, we need to establish highly predictable patterns of parent-child interaction to replace those older destructive patterns. These changes in parent-child relationship patterns, from hostile and coercive to positive and loving, is what PCIT does. We provide parents with the information to understand how to effectively parent– even the very difficult children who have only recently come into their homes.

Whether the child is a biological offspring, a grandchild, a foster child, or an adopted child, the basic elements of a positive parent-child relationship are the same. Because we know that maltreated children carry ‘bits and pieces’ of their past coercive relationships into their adoptive homes, we provide both parents and children the opportunity to practice and master a new way to live their life through PCIT.

As I have often said, the elements of PCIT are not new. We have known what makes a healthy relationship between a parent and a child for many decades. What is unique is that we practice these newfound skills until both the parent and child master them, overcome the child’s prior distorted perception of a relationship with a parent, and to set them on a different trajectory.

Through three decades of research, PCIT has been demonstrated to be an effective mental health treatment, and model for intervening when children are difficult to parent. In the world of treatment outcome research, the effect size (the index that measures the magnitude of the treatment effect) is higher than nearly all other mental health interventions – a testament to the potency of this intervention. Does PCIT work with children who are defiant and non-compliant? Yes. Does it work with abusive parents? Yes. Does it work with different types of parent care providers (e.g., biological parents, foster parents, kin caregivers, adoptive parents)? Yes. So, I can say very assertively – PCIT works!

So the issue for us is more focused on ‘How do we get this highly effective intervention, which can make such a tremendously positive impact on so many type of families, accessible to these families?’ and ‘How do we educate therapists about the special needs of traumatized children?’ rather than how we create an evidence base for each clinical decision therapists make for adoptive families in their care.

The aforementioned article cited Debbie Riley in suggesting we need more funding for research in determining what’s effective for adoptive families. I am always in favor of more research funding. But, in this area, we need more funding for implementation.

This is why I have been so impressed with First 5 LA and their effort to change the landscape of Los Angeles County mental health. While I understand that nearly everything in Los Angeles takes on a scale larger than everything else – for First 5 LA to make such an investment to the children and families in Los Angeles reflects their investment in their future.

It would be interesting to know what kinds of effects TIES’ TTM has on adoptive families. However I would argue that a more pressing need is to understand how we can make interventions more accessible to communities in need.

Anthony Urquiza, Ph.D., specializes in the medical evaluation, psychological assessment and treatment of abused and neglected children, and is director of the CAARE Center at UC Davis. He is also director of the PCIT Training Center.

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