• By Dartington SRU
  • Posted on Thursday 03rd November, 2011

Reducing child abuse potential

Many children’s services are required to deliver evidence-based interventions, but for those working within the child protection system this is a difficult task. Whilst many interventions have proved successful at improving outcomes for families living in a number of different contexts, very little is known about the effectiveness of these programs when delivered to those involved with the child protection system, particularly when there is evidence or suspicion of child maltreatment. However, new research suggests that one program - Parent Child Interaction Therapy (PCIT) - is successful at both reducing risk factors associated with child maltreatment as well as reducing notifications of abuse to child protection services. Australian researchers Rae Thomas and Melanie Zimmer-Gembeck of Griffith University recently reported the results of their experimental trial in the journal Child Development. The study involved 150 mothers and their children (mean age 5 years) from Queensland, Australia. Each was in contact with child protection services either because they were referred by professionals who had identified them as suspects of maltreatment, or because they requested help with their child’s behavior and high levels of family stress.Regardless of the route by which they became known to the child protection system, the mothers were confirmed to be at high risk of child maltreatment following semi-structured clinical interviews conducted by trained psychologists. Each family was randomly allocated into one of two conditions. Those allocated to the first condition received standard PCIT and those allocated to the second ‘control’ condition were placed on a three month waiting list - at the end of 12 weeks they too would receive PCIT. Three months is a shorter wait than is usual for experiments of this kind, however it was deemed essential to limit the length of the wait because of the high-risk nature of the sample. Parents on the waiting list were contacted weekly for brief conversations about family issues and other concerns.One of the main risk factors for child abuse and maltreatment is coercive parenting. Coercive patterns of interaction arise through negative reinforcement, meaning that a child has learnt that naughty behaviors such as running around and acting out attract attention from their parent, albeit in the form of a reprimand. Increasingly worse behavior is adopted and even more attention follows, thus the parent unintentionally reinforces the bad behavior. Escalating levels of coercive interactions between parent and child can eventually lead to child maltreatment. A lack of knowledge of and inappropriate use of discipline, aggressive and harsh communication styles, a lack of parental sensitivity and high levels of stress are also commonly associated with coercive family relationships and implicated in the onset of maltreatment. Thus, the goal of PCIT is to reduce all of these risk factors by coaching parents to have more positive interactions with their children. Parents are taught specific skills prior to each phase of the intervention. Those skills are then practiced in a therapy room, under the observation of the PCIT therapist who watches from behind a two-way mirror and communicates with the parent via a ‘bug-in-the-ear’ device. This allows the therapist to coach the parent, give immediate feedback and positive encouragement during real-time interactions with their children. Parents are also required to practise their new skills, unsupervised, at home. The number of sessions that the family attends depends on how quickly they attain mastery in all of the skills in which they are coached. Once they can consistently demonstrate positive interactions with their child, and also personally express a clear understanding of their own change, the intervention comes to a close. In the first phase of PCIT, known as Child Directed Interaction (CDI), the focus is on building a warm and positive relationship between child and parent. The child is allowed to take the lead in interactions and parents develop skills related to giving praise, imitating play, describing behavior, being enthusiastic, ignoring undesirable behavior and avoiding criticism of their child. In the second phase of the intervention, known as Parent Directed Instruction (PDI), parents are taught to maintain age-appropriate and realistic expectations of their child’s behavior as well as to develop fair and consistent boundaries and disciplinary strategies. Parents are coached, again from behind the mirror, on the time-out procedure and responding consistently to misbehavior. PCIT has proved to be effective in several randomized controlled trials with single and multiple-problem families, but this is the first evaluation to test the standard program with families in which there is known or suspected maltreatment. The Australian trial revealed that after completing PCIT, there were significant reductions in child abuse potential (related to the specific risk factors identified earlier), greater parent sensitivity, better behaved children and fewer notifications to child protection services in the program group when compared with the families on the waiting list. However, there was a high attrition rate. Only 42% of those families allocated to the intervention condition actually completed PCIT to the satisfaction of their coach. Whilst non-completers did receive some benefits from attending PCIT sessions, the most substantial improvements were demonstrated by those who completed the program, particularly, according to the researchers, in relation to the more entrenched risk factors.Whilst the dropout rate might be high, Thomas and Zimmer-Gembeck argue that it is no higher than is usually observed by other services working with high-risk families or those with children experiencing significant conduct problems. They argue that whilst more research is needed to identify the ‘active ingredients’ of PCIT in terms of the specific mechanisms that effect change in parent and child interactions, the program should nevertheless ‘be one treatment of choice for practitioners working with parents at high risk of child maltreatment’. Reference: Thomas R and Zimmer-Gembeck M (2011) Accumulating Evidence for Parent-Child Interaction Therapy in the Prevention of Child Maltreatment, Child Development, 82, 1, p177-192.

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