Infant / Parent Psychotherapy: Clinical Understanding & Treatment Natalie Roth, Ph.D. Jessica...
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Transcript of Infant / Parent Psychotherapy: Clinical Understanding & Treatment Natalie Roth, Ph.D. Jessica...
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 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
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)
Infant’s 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 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)
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
child’s lead Discussion with therapist: therapist
follows parent’s 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 Child’s Lead Extend and Expand Child Closes the Circle
Meta-Analysis 101
A study of studies Usefulness Cohen’s d Effect size
interpretation:Small: .00-.32
Moderate: .33-.55Large: .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, & O’Donnell, 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 .283Benoit 27 1.646Cohen 60 3.661Cooper 64 .175Cramer 38 .758Glover 16 2.233Johnson 31 .209Jump 45 .117Lieberman 53 1.424Meyer 34 1.083Onozawa 25 1.338Palmer 47 .304Pardew 23 .829Rauh 53 .915Riksen-Walraven 75 .308Robert-Tissot 150 .610Schuler 171 .375Spiker 683 .190Vitucci 57 .886Wadsby 88 .478Wasik 41 .327Wendland-Carro 36 1.308Whitt 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 PsychotherapyPractitioners
Psychologists Psychiatrists Social workers Family therapists Nurses Child development
specialists Occupational
therapists
Infant-Parent Psychotherapy: Major Tenants
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
Observations include:1. Parent-child interaction2. Child-examiner interaction3. Multiple settings/times4. Developmental history5. Parent report of problem6. Parent’s history7. Cultural issues
Infant-Parent Psychotherapy: Key Concepts
“Kitchen therapy” Techniques:
Behavior-based strategies
Play Verbal
interpretation Ports of Entry
Four Modalities:1. Concrete
Assistance2. Emotional
Support3. Developmental
Guidance4. Psychodynamic
Psychotherapy
Infant-Parent PsychotherapyPorts of Entry
The child’s behaviorThe parent-child interactionThe child’s representationsParental Representations
Intertwined parent-child representationsParent-therapist relationship
Infant-Parent PsychotherapyConcrete Assistance
Locating resources Providing
transportation Advocacy Completing forms
Infant-Parent PsychotherapyEmotional Support
Look, Listen, Acknowledge, and Show Empathy
Awareness of the parent’s and child’s messages
Infant-Parent PsychotherapyDevelopmental 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 PsychotherapyPsychodynamic 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 PsychotherapyReview
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
Baumrind’s 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 child’s 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 ProblemBehaviors(Arguing,
Aggression)
Withdrawal of Parental
Request
Increase in Problem Behaviors
Negative Reinforcement Increases Intensity
of BehaviorOver Time
Patterson et. al (1991): Coercion Theory
Negative ParentBehaviors(Yelling)
Momentary Compliancefrom Child
Increase in Negative Behaviors
Negative Reinforcement Increases Intensity
of BehaviorOver Time
Patterson et. al (1991): Coercion Theory
Parent of children with externalizing behaviors have been found to be: Power-assertive (Authoritative) and Lax (Permissive)
It’s 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”ReasonsExamplesModeling/demonstrationRole-play with parents
Structure of PCIT
CDI “Don’t” Rules
Follow the Child’s 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 (Let’s the child lead; teaches parent how to “play”,
show approval of child’s activity; teaches child how to play with others)
Describe (“sportscaster”, child leads, child knows you’re paying attention, shows interest and approval, teaches vocabulary, holds child’s attention to the task)
Enthusiasm! (Let’s 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 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
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 don’t (original command), you’ll 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
Doesn’t 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, 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
House Rules Standing Commands
No aggressive behavior No destructive behavior
Procedure Label behavior for child Explain rule to child No chair warnings It’s 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”