PC-CARE: a promising brief parent-child intervention

In the United States, approximately two-thirds of children are exposed to a traumatic event before reaching the age of 16 (Copeland, Keeler, Angold, & Costello, 2007). Following a traumatic event, children may be referred for mental health services by family members or professionals who notice changes in the child’s behaviors or moods. Such changes can include increases in aggressive, angry and defiant behaviors–often related to hyperarousal. These behaviors are not only symptoms of traumatic stress, but they can also cause problems in the parent-child relationship. As positive parent-child relationships promote children’s adjustment after traumatic events (Scheeringa & Zeanah, 2001), it is essential that children receive treatment to repair or enhance those relationships if impaired. Unfortunately, many children do not receive mental health services due to difficulties accessing providers (SAMHSA, 2013) and lack of insurance (Bethell et al., 2011), among other barriers to mental health services.

When children can access mental health services, there are many evidence-based treatments available. However, these treatments often require significant time commitments (e.g., three to 18 months). Even three months can feel unmanageable for parents who are overwhelmed, and among those who begin treatment, attrition rates can be as high as 40-70 percent (Kazdin, 2008), especially in parenting-focused interventions. Thus, researchers have called for briefer interventions, as well as interventions that are less intensive and able to be provided in different settings (Sanders & Kirby, 2010).

In response to these concerns, we designed Parent-Child Care (PC-CARE) to be a brief dyadic intervention for children aged 1-10 years with mild to moderate externalizing problems or problems in the caregiver-child relationship. PC-CARE incorporates many aspects of effective parent behavior management therapies, such as Helping the Noncompliant Child (McMahon & Forehand, 2003), the Incredible Years (Linares, Montalto, Li, & Oza, 2006), Parent-Child Interaction Therapy (PCIT; Timmer, Urquiza, & Zebell, 2006), and Triple P – Positive Parenting Program (Sanders, Cann, & Markie-Dadds, 2003), but presents the information in a briefer, more streamlined manner. PC-CARE incorporates concepts derived from social learning theory (e.g., parental operant reinforcement, consistency, limit setting, modeling) and attachment theory (e.g., parental sensitivity and reciprocity, positive and protective interactions).

For children with trauma histories, PC-CARE can be an effective standalone intervention when the primary trauma symptoms are hyperarousal-related, an adjunct intervention when difficulties within the parent-child relationship interfere with successful progress through therapy, and a preventive intervention while children adjust to a new home (e.g., foster, adoptive, reunification). The PC-CARE manual has also been translated to Spanish and used effectively with Spanish-speaking families.

Structure of PC-CARE for Traumatized Children

While the process of PC-CARE is highly structured and consistent for all children, specific content and strategies vary based on the child’s history and needs. Treatment involves one pre-treatment and six treatment sessions, each 50 minutes long. Each session contains time to check-in with the parent and child; time to teach them the skills for that session; time for the therapist to coach parents as they play with their child; and time to talk about how effective parents think those skills will be for them at home. Unlike many parenting interventions, the child is considered to be a key player in the therapeutic process of improving the quality of the parent-child relationship.

Pre-Treatment Session

During a pre-treatment session, therapists collect behavioral measures regarding child behaviors and trauma symptoms, and observe and assess the caregiver and child during a 12-minute semi-structured play scenario. Therapists orient the dyad to treatment, explaining what will happen each week and provide psychoeducation about the likely cause of the child’s behavior problems (e.g., the effects of trauma on children). For children exposed to trauma, therapists explain how the child’s behaviors are related to traumatic experiences while modeling the importance of talking openly about trauma.

Treatment Sessions 1-5

In sessions 1-5, therapists check in with the caregiver and child about current behavior; teach that week’s skills; observe the caregiver and child in play; and coach the caregiver (and sometimes the child) to use skills effectively. At the end of the session, therapists review treatment gains and give homework to practice the skills over the coming week. Therapists explain how improving the parent-child relationship is important for creating a sense of safety for children who have experienced trauma and help parents recognize how to use skills when the child struggles with trauma-related symptoms. If children engage in trauma-related play, the therapist coaches the parent to remain calm and supportive while adding themes of safety. The skills taught each week include:

• Session 1: positive communication skills, transitions, creating a compliance-friendly environment
• Session 2: selective attention, redirecting, modeling, calming strategies
• Session 3: rules, choices, when-then/if-then statements
• Session 4: giving effective commands, removal of privileges
• Session 5: redo, hand-over-hand (if appropriate), recovery

Treatment Session 6/Post-Treatment

In session 6, therapists collect behavioral measures; review all the skills; including which worked best for the family; help parents develop plans for managing future behavior problems; conduct a 12-minute observation; and have a shorter period of coaching. Caregivers are then contacted one month following treatment completion so therapists can obtain an update on the child’s behaviors and offer an optional booster session.

Outcomes and Training

Families who have agreed to be in research at our clinic have reported good outcomes after completing PC-CARE. We have a retention rate of 93 percent in our outpatient clinic. At the end of PC-CARE, parents report significant improvements in children’s disruptive behaviors; reductions in overall trauma symptoms; and less parenting stress. Parents are also observed to use the skills more frequently, and dyads are observed to share more positive engagement.

A training model for training other clinicians to provide PC-CARE has also been developed. Thus far, PC-CARE training (i.e., weekly meetings with the trainer; live training at each session for two clients; and demonstration of treatment competencies) has been provided to licensed and unlicensed psychologists; marriage and family therapists; clinical social workers; master’s level developmental psychologists with no prior clinical training; and bachelor’s level behavioral support clinicians. Training can be provided on an agency level (training a number of therapists within the same agency) or at an individual level (training a number of private practitioners in a small cohort).

References

Bethell, C. D., Kogan, M. D., Strickland, B. B., Schor, E. L., Robertson, J., & Newacheck, P. W. (2011). A national and state profile of leading health problems and health care quality for US children: Key insurance disparities and across-state variations. Academic Pediatrics, 11, S22-S33.

Copeland, W. E., Keeler, G., Angold, A., & Costello, E. J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64(5), 577-584.

Kazdin, A. E. (2008). Evidence-based treatments and delivery of psychological services: Shifting our emphases to increase impact. Psychological Services, 5, 201–215.

Linares, L. O., Montalto, D., Li, M., & Oza, V. S. (2006). A promising parenting intervention in foster care. Journal of Consulting and Clinical Psychology, 74, 32.

McMahon, R. J., & Forehand, R. (2003). Helping the noncompliant child: Family-based treatment for oppositional behavior (2nd ed.). New York: Guilford Press.

Sanders, M. R., Cann, W., & Markie-Dadds, C. (2003). The Triple P-Positive Parenting Programme: A universal population-level approach to the prevention of child abuse. Child Abuse Review, 12, 155–171.

Sanders, M. R., & Kirby, J. N. (2010). Consumer involvement and population based parenting interventions. Administration, 58, 33-50.

Scheeringa, M., & Zeanah, C. H. (2001). A Relational Perspective on PTSD in Early Childhood. Journal of Traumatic Stress, 14, 799-815.

Substance Abuse and Mental Health Services Administration. (2013). Behavioral Health, United States, 2012. HHS Publication No. (SMA) 13-4797. Rockville, MD: Substance Abuse.
Timmer, S. G., Urquiza, A. J., & Zebell, N. (2006). Challenging foster caregiver–maltreated child relationships: The effectiveness of parent–child interaction therapy. Children and Youth Services Review, 28, 1-19.