Teaching “special playtime” in the community

The following article was published in the March 2012 issue of the British journal “Counselling Children and Young People” under the title “PCIT at large”. Many thanks to the editor Eleanor Patrick.

Narelle Smith describes her dilemma around introducing Parent-Child Interaction Therapy (PCIT) to a group of parents in a somewhat raw ‘no frills’ fashion, instead of within a clinical one-to-one setting.

While studying my Masters degree, I became familiar with Parent-Child Interaction Therapy. The concept of using child-led play to build the relationship between parent and child lit a fire within me. Fast forward approximately six years, and I was cruising around the internet and decided to Google Parent-Child Interaction Therapy (PCIT). By chance, there was a five-day course soon to be run in the city I live in, facilitated by Dr Cheryl McNeil from the USA. Excitedly, I sent the application and fee.

I was professionally ready for a change. I’d done therapeutic casework and loved it, but my work with out-of-home care and abuse-in-care cases had taken their toll. I moved into community work, but something was missing. Clinical work with PCIT might just fit the bill.

What is PCIT?

PCIT is a short-term family clinical intervention of 10 to 14 weeks for children aged two to seven years who are displaying disruptive behaviours1. It was developed by Sheila Eyberg at the University of Florida and integrates concepts from traditional play therapy, social learning theory and attachment theory, with the aim of enhancing the relationship between parent and child, increasing the child’s positive behaviours, and improving the parents’ skills in behaviour management.

There are two phases to PCIT. The first is Child Directed Interaction (CDI), when the therapist supports the parent to develop child-centred interaction skills in a play session between the parent and the child. In effect, this is child-directed or child-led play. The emphasis is on enhancing the parent’s positive and nurturing interactions with their child. The therapist coaches the parent and role-models the techniques, providing positive reinforcement for the parent, so that s/he may do the same for the child. The therapist can be either in the room or in an observation room and linked to the parent through an earphone. Live coaching and immediate feedback to the parent make PCIT unique.

PRIDE

The skills the parent uses during the sessions are encapsulated in the acronym PRIDE, and they are called ‘PRIDE skills’:

P – Praise

The parent provides the child with descriptive praise for the child’s positive play behaviours.

R – Reflection

The parent reflects what the child says in the same tone and affect.

I- Imitation

The parent imitates the child’s positive play behaviours.

D – Description

The parent describes what the child is doing.

E – Enjoy

The more the parent enjoys this interaction with the child the more effective it will be.

During the session, the parent is required to relinquish control of the play to the child. This is key to the development of trust and safety between parent and child. So the parent does not make any commands, ask any questions, use any criticism or sarcasm, or use the words ‘don’t’, ‘stop’, ‘no’, or ‘quit’ during the play. If the child displays negative play behaviours, such as breaking the toys or getting too rough, the parent withdraws his/her attention from the child’s play and attends to their own play with increased vocalisations about what they’re doing. The moment the child returns to positive behaviours, the parent attends to the child and immediately provides descriptive praise for what the child is doing well. If the child’s disruptive behaviour is extreme, such as hitting or prolonged screaming at the parent or destruction of the toys, there are various techniques for managing this, which may involve a warning, removing the parent for a short period, or ceasing the play, depending on the nature and severity of the behaviour.

As part of the treatment, the parent is expected to spend five minutes per day doing ‘special playtime’ with their child using the PRIDE skills. This is the ‘homework’ of PCIT and is an essential element to progress in developing the relationship and connection between parent and child. Parents are asked to do only five minutes per day. If the parent sets themselves an expectation to do longer than the five minutes, there will be days when the task is too onerous and special playtime will be skipped, whereas it is vital that special playtime happens every day. Parents are asked to do 10 praises, 10 reflections, and 10 descriptions during the five minutes of special playtime. With such intensity and practice, the PRIDE skills start to generalise to interactions outside the special playtime.

When the parent and child have achieved mastery in CDI, they move to the second phase of PCIT, which is Parent-Directed Interaction (PDI). PDI tests the strength of the relationship between the parent and child developed during CDI, by allowing the parent to make some commands during the play session. If the child does not comply with the parent’s command (for example: ‘please pass me the red block’) there is a series of steps which the parent is guided through to manage the noncompliance of the child. These range from a warning to a time-out. At no stage is the child uncertain as to his/her options. Prior to entering the PDI phase, the parent, child and therapist engage in role plays to demonstrate how PDI is structured. PDI is scripted and the parent is supported to respond with the same words and actions every time. PDI is designed to support the parent in behaviour management through clear and simple commands, communicating expectations, being predictable and consistent and non-emotive, and following through.

Taking PCIT to a wider audience

During the PCIT training, to my dismay, I kept thinking about how PCIT could be applied to a group. I have done groupwork for approximately 15 years, but I was supposed to be learning how to apply PCIT in a clinical setting. I found the words tumbling out of my mouth: ‘How does PCIT translate to a group setting?’ Dr McNeil dashed my hopes. PCIT was found to be less cost-effective in a group situation and didn’t have the effect sizes they had hoped for. But I still wondered.

The organisation I work for wanted to support my need to do clinical work, although it wasn’t part of my job specifications and funding. We have a very small early intervention programme for Indigenous families. I had several meetings with management and caseworkers about how PCIT might be applied to working with Indigenous families and how it could be organised. This was exciting, as, to our knowledge, PCIT had not been used with Australian Aboriginal families. Cheryl McNeil had conducted studies with Native American and Maori families and these were helpful in reflecting how PCIT might need to be adapted, but it was new territory. Unfortunately, all of the families thought suitable for PCIT became child protection cases over the ensuing months, and I did not get the chance to start with them.

At around the same time, a coordinator of another community organisation asked me to facilitate a play workshop for the parents they were working with. There is a huge emphasis on partnerships across the community, health, and welfare sectors in this part of the world. So I wrote the play workshop, drawing on my experience of my early childhood studies and working directly with children. And at the end I tacked on the ‘special playtime’ skills taught to parents undergoing PCIT. Mission accomplished – teaching groups of parents how to build the relationship with their child through child-led play.

The play workshop was a resounding success. I was booked for more workshops. The feedback from families was heartening. Mothers who did five minutes of special playtime daily with their children (individually) were reporting better relationships with their children, fewer behavioural challenges, and better sibling relationships. After repeated exposure to the PRIDE skills in special playtime, siblings were starting to use them with each other. Mothers said it was weird to hear their young children giving each other descriptive praise.

Meanwhile, one of our transition-to-school programmes was identifying children with behavioural challenges that would make integration into the school environment thorny. It was from this programme that I received my first referral for a clinical PCIT family – and also realised that working in an ongoing way with individual families in therapy wasn’t where I wanted to be. I found it far more interesting and exciting to teach the play skills in a group environment. It didn’t help that this case was intriguing, as the mother refused to relinquish control of the play to her child. A childhood history of having the adults in control, making devastating decisions on her behalf, meant that ‘control’ was going to be a big issue for her. She was not learning the PRIDE skills to any great effect. My PCIT clinical supervisor and colleagues could only suggest that I discharge her. I work in a community development organisation, and we  don’t discharge anyone! We walk alongside them, no matter how fast or slow, until they tell us they no longer need us. The mother told me how she had seen so many professionals and been to so many services during her life, and how she loved this ‘play therapy’ because it was so different and it was good for her and her child. So, a 10 to 14 week intervention has been extended to six months, and the mother tells me she wants to continue through all of this year. I don’t mind. This is a parent who has a history of not engaging with and not trusting services, and now it seems she is engaging and trusting just a little bit.

Learning to adapt the content

Working in the community ensures that one learns how to adapt everything to a small budget with few resources. Whilst my PCIT colleagues worry about the latest ‘bug in the ear’ device and where the light switches are placed in the play room, I do PCIT in just about any setting (the minimum requirement is privacy) with toys that I’ve managed to lug in from my home, in just the one room, with a flip video camera in one hand and balancing the observation records with the other – no observation room, no one-way mirror, no bug in the ear, no video set-up. It’s PCIT at the thick edge of the wedge.

I started to offer to teach the components of CDI to parents who rang me in desperation, not knowing what to do with their aggressive and non-compliant children. These parents are all middle class, educated people who have found it difficult to relate to their children as children, and who are also unable to set limits. Some have been referred from Community Health. All I offered was a 1:1 session with parents to teach them the PRIDE skills and one other session with the child one week later to ensure their skills are on track. In the first session, I teach the parent the PRIDE skills and we do role plays to practise, with the parent enacting the part of the child so they get to feel how it is to be the child, and then with the parent playing the parent (with me as the child) to practise the skills. I give them as much explanation as they need as to how and why these techniques work. We problem solve. This first session can take up to two hours. I ask the parent to practise the skills for five minutes every day in ‘special playtime’ and we book the second session for the next week. In the second session, I observe the parent-child interaction for five minutes, noting how many times the parent uses each PRIDE skill and how the child is responding to the parent. I have a quick discussion with the parent about how s/he is using the PRIDE skills, and then I do live coaching of the parent-child interaction for 20 to 30 minutes. Sometimes I need to tailor the play skills a little to the individual child.

Special playtime can be such an intense way of relating that some children (not accustomed to a parent’s positive attention) become activated by the experience. I warn parents in the first session about the possibility of this happening and talk to them about using the PRIDE skills to also calm the child and maintain the play, rather than becoming frustrated with the child and feeling that they need to place limits on their child during special playtime. This may mean the parent needs to pick up the signals that the child is getting overexcited or overactive and respond to the child by verbalising less, quietening his/her voice, using descriptive praise for the child’s quietening activity or moments of self-control (no matter how fleeting), or bringing attention to their own quieter play.

A mother who had come to one of my Triple P (positive parenting programme) parenting courses told me that she had problems relating to her children, particularly the youngest. She said that he was defiant and rude. The daycare centre he went to two days per week had difficulties managing his behaviour. She responded to him with anger most of the time, which she wanted to change, and Triple P helped in this regard. However, she was still concerned about spiralling into depression again. I asked if she wanted to learn some play skills to try and help build the relationship and connection with her child. She was prepared to try anything. The child came along to the session with her and played quietly on his own while I explained everything to his mother. The mother learnt the play skills extremely well.

As soon as we started on role plays, the child wanted to play too, so we went straight from theory to practice and live coaching. Her child became overanimated with her total attention to him during play, and towards the end of the play session, the mother asked her child to count the cars that he had excitedly lined up. The mother had not issued any other commands in the whole session, and I could see where she was headed with this one command to count the cars at the end. She knew her child best and she knew what calmed him. Lots of other parents have learnt the skills in one session, too, either individually or in a group setting, and the feedback is excellent. Some parents need to learn more intensive positive behaviour management and limit-setting techniques because they are inconsistent and coercive. One mother said to me: ‘I am making poor lifestyle choices [smoking, drinking] because I can’t stand my two-year-old. I’ve got to the stage where I just let him hit me.’ I refer these parents to Triple P and have found that special playtime and Triple P are a nice fit.

Some thoughts and reflections

Over the past six months, I have taught approximately 50 parents how to do special playtime. I don’t know how many are actively practising it in its purest form. Even if some of them only understand the bit about giving your child five minutes per day of your undivided attention, then that may be a good start. However, making the skills accessible has presented some dilemmas that I do not yet have the answers to.

Workers who have sat in on the workshops have asked if they can teach the skills to the parents  they work with. On the one hand, they can purchase Dr McNeil’s book (1) from an online bookstore and do with it as they please. On the other hand, the people being trained in PCIT are required to have a Masters degree as a minimum. The five-day practitioner training is detailed and intense, and a one-hour skills-based session in a play workshop does not adequately prepare anyone for all of the situations that present themselves.

The evidence base for PCIT itself is extremely sound: 40 years (2) of worldwide research provides some comfort. But PCIT is all about programme integrity, and I have taken it apart and disseminated it with very little quality control. In this form it is no longer PCIT, and, as such, is no longer evidence based. And it requires trust that I am communicating the skills in a way that parents can understand so they may take it home to their children and be able to keep it wholesome and healthy. I have to ask myself: Will the special playtime learnt in this DIY approach translate to overall positive parent-child interactions, or will it all come undone because of the overriding negativity present in the home? Will special playtime then become another thing tried and discarded, and something to become cynical about?

I move forward, fairly confident that I am where I need to be and that I am being somewhat useful. Special playtime is one of many tools a family worker or therapist can use to teach parents new skills. I do enjoy seeing the glint in a parent’s eye when she grasps how her interactions with her child can be different. This year, I will expand the play workshop to two two-hour sessions. The first session will be about the mechanics of play for children, and the second session will be devoted to teaching special playtime. I will continue to offer the two individual sessions to parents who request it. And I will offer the clinical programme to parents who are in need of clinical support and are motivated to attend on a weekly basis for 10 to 14 weeks (more or less) and do their homework. Working in this way enables me to offer support for various levels of need. I am also able to reach more parents. It’s the old debate of quantity versus quality and only time will tell.

References

1 McNeil CB, Hembree-Kiggin TL. Parent-child interaction therapy. 2nd edition. New York: Springer; 2010. See also www.pcit.org

2 Eyberg SM. The PCIT story. PCIT Pages: The Parent-Child Interaction Therapy Newsletter. 2004; 1:1-2. http://pcit.phhp.ufl.edu/story.htm

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About Narelle Smith

Child & Family Worker

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