Parent-Directed Interaction

Cheryl B. McNeil, Ph.D.

West Virginia University

Credits

McNeil, C. B., & Hembree-Kigin, T. L. (2010). Parent-Child Interaction Therapy (2^nd ed.). Springer.

Eyberg, S. M., & Funderburk, B. W. (2011). Parent-Child Interaction Therapy Protocol. PCIT International.

Let’s �Check In

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• ECBI
• CDI Daily Practice

Let’s Talk About Values

There are hundreds of studies showing that PCIT works for families.��However, most of these studies were conducted by White, American researchers with White, American families. Most of the caregivers in these studies were mothers identifying as heterosexual and female. ��Although there is strong evidence that PCIT works for families from diverse backgrounds, it’s important to me that I learn about the ways in which this does or doesn’t fit with your:�

• Family’s values and beliefs
• Parenting history (i.e., the �way you were raised, �previous parenting �practices you’ve tried)
• Community and culture

�Whenever you see this symbol, feel �free to share your thoughts and �feelings about what’s on the slide.

Children Need Structure

Say what you mean, and mean what you say

Delivering the same discipline skills when you have a headache as you would if you found a $20 bill

Delivering consequences in the same, exact way with a neutral expression and a pre-determined script

Using discipline skills without bending the rules or consequences

During PDI…

So Where Do We Begin?

• Typical PCIT cases misbehave over 100 times per day
• It is impossible to be 100% consistent, predictable, and following through with 100 misbehaviors per day
• The central issue with misbehavior is basic disrespect for authority

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We address this with �COMPLIANCE TRAINING!

Starting Off Small

• First step is to increase compliance with caregiver commands (i.e., getting your child to DO what you tell them to do)
• We will address STOPPING behaviors (getting your child to stop hitting, kicking, biting, etc. ) once your child is highly compliant
• Must change your child’s bad habit of saying “No!” whenever they are told to do something����

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• One way to increase compliance is by learning to give effective commands

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Giving Effective Commands

The 8 Rules of�Effective Commands

• Make it clear they are being told, not asked�� “Will you sit down?”� � “Please sit down.”�
• Make it clear that the child, not caregiver, is the one to do the task �� “Let’s put that puzzle away.” �� “Put that puzzle away.”

Let’s Practice!

• Tell the child what to do instead of what not to do (positive opposite)

“Stop running around.”

“Please sit beside me.”�

• Children are more likely to comply with positively stated instructions
• Improves child’s self-esteem as they get to do the “right” thing

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Let’s Practice!

• Multi-part commands can be overwhelming and difficult for children to remember

“Go to your room, put these cars away, and bring me your

sippy cup.”�

“Put the cars in the box.”

• Inclusive commands are unclear as individual tasks are not specified

“Clean up the playroom.”�

“Put the cars in the box.”

• Helps you determine if your child completed the entire command

• Vague commands can be misinterpreted
• Specific commands tell the child exactly what to do and leave little room for misunderstanding

“Behave” or “Settle down”

“Hand me the marker” or “Use your quiet voice”

• Avoid calling your child’s name and expecting them to read your mind

• A child must be physically and cognitively capable of doing the command.

“Put those miniature figurines in the container.”

“Put the dolls back in the box.”

� (to a 3-year-old)

“Write your name.”

“Write a ‘J’ on this line.”

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• Use a calm, neutral tone of voice when giving commands
• Raising your voice can make interactions unpleasant
• Using an angry tone of voice can signal to a child that they can get away with ignoring instructions given in a neutral tone
• It is possible to be firm and polite:

Tip: Start with “Please”

“I said give me the crayons now!”

“Please give me the crayons.”

• Explanations may be used before a command or after the child has obeyed, but not in between command and compliance
• Reasoning in between command and compliance will increase � noncompliance

You: “Please put the cars away.” � Child: “Why?” � You: “Because it’s almost time to leave

You: “It’s almost time to leave. Please put the cars away.”�

• Explanation before command 🡪 increases compliance

Oops, you dropped a Lego. Please pick it up.

• Explanation after compliance 🡪 adds genuineness to the praise

Thanks for picking up the Lego! Now we won’t accidentally step on it.

• Too many commands will frustrate your child
• Too many commands make it difficult for you to be consistent
• Indirect commands can be used when you want to make a suggestion (e.g., “How about you build something with your Magna-Tiles?”)
• Ask yourself:

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“Is it essential that I give a command to correct this behavior?”

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Why Play Commands?

• We start with easy tasks to set your child up for success in learning the PDI routine (e.g., “Please hand me the red block.”)
• Goal is not to teach your child to hand you blocks but to obey you when you give a direct command

What do you think your child will do when given a direct command?

Your child will either…

In PDI, you will learn to respond consistently and predictably to compliance and to noncompliance.

Praise Compliance

• If the child obeys right away, give a � labeled praise!
• Be enthusiastic!
• Praise compliance, rather than the � task itself.

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Determining Noncompliance

• Sometimes it is unclear whether a child’s response is a comply or noncomply.
• Let’s review these subtleties together.

What do you do when your child…

…dawdles?

Example:�You: Please hand me the red block.

Child: (whines) Do I have to?�Child continues to play with blocks.

Use the 5-Second Rule

• Count silently, “one-thousand-one, one-thousand-two, one-thousand-three…”
• If child has not made attempt to comply by 5, treat as NONCOMPLY

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What do you do when your child…

…does a variation of �your request?

Example:�You: Please hand me the red block.

Child: (Hands you the white block)

If the command was developmentally appropriate and you pointed so that there was no confusion, treat as NONCOMPLY.

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What do you do when your child…

…ignores you?

Example:�You: Please hand me the red block.

Child: (Continues playing as if they did not hear you)

If certain that your child heard the instruction, �treat as NONCOMPLY.

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What do you do when your child…

…partially complies?

Example:�You: Please hand me the red block.

Child: (Shoves the block toward you)

If your child does not comply even after a visual cue (e.g., pointing to your hand), treat as NONCOMPLY.

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What do you do when your child…

…complies with a �negative attitude?

Example:�You: Please hand me the red block.

Child: Here’s your stupid block! (Puts block in your hand)

Treat as COMPLY, but be more specific in the second command (e.g., “Now, please put the green block in my hand gently.”)

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What do you do when your child…

…undoes the command?

Example:�You: Please hand me the red block.

Child: (Puts block in your hand but immediately takes it back)

Treat as COMPLY, but next time specify command (e.g., “Please put the red block in my hand and leave it there.”)

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What if your child does not comply?

Time-Out in a Chair

When Done Correctly, �Time-Out is Highly Effective

• Keeps child from stimulating activities
• Few consequences are more aversive than complete boredom
• Can be done immediately after inappropriate behavior
• Can be safely administered �many times a day

…Time-Out? Really?

• Most PCIT parents are skeptical of using time-out in a chair
• Their child will not go to time-out
• Their child will not stay in time-out
• Our time-out procedure is different
• We teach children to go to time-out
• We teach children to stay in time-out
• We use a scientifically proven time-out procedure

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A Diagram of the �PCIT Time-Out Procedure

Time-Out Warning:�A Promise, Not a Threat

• After child disobeys a command, give warning statement
• Use warning statement verbatim
• 5-Second Rule to allow compliance
• Do not repeat the command
• Gesturing is allowed
• Comply 🡪 Labeled Praise
• Noncomply 🡪 Time-Out

“If you don’t [put the

car in the box], you’ll have to

sit on the time-out chair.”

Time-Out Chair

• Sturdy, adult-sized chair
• In a safe space
• Away from entertainment
• Visible to caregiver

Carrying Child to Time-Out

• Quickly stand up and move toward child
• Calmly state the consequence with neutral �tone of voice and no extra words
• Safely lift child from behind (either under �the arms or around the chest) and take them �to time-out chair
• Ignore all aggression on the way to� time-out

“You didn’t do what I �told you to do so you �have to sit on the �time-out chair.”

Placing Child in Time-Out Chair

• Step back from child and say:

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• Ignore all verbal behavior
• Wait for 3 minutes + 5 seconds of silence

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“Stay on the chair until I say you can get off.”

Why 3 minutes + 5 seconds?

• 3 minutes = the shortest time-out period that is effective for children ages 2-7 years
• 5 seconds of silence: for child to learn that time-out ends when child is quiet, NOT because of what child does/says
• Restart 5-second countdown if child talks, cries, �screams, pounds on chair, etc.

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What if your child…

• Use the “barrel carry” and move quickly
• Ignore all aggression on the way to time-out chair

…resists going to the �time-out chair?

What if your child…

Continue with the time-out sequence

…complies on the �way to time-out?

What if your child…

Quickly remove toy from child’s hand without speaking

…takes a toy to time-out?

What if your child…

Continue with the time-out sequence

…puts themselves �in time-out?

What if your child…

• Take child to bathroom before PDI session
• Continue with time-out sequence if you are comfortable to do so
• Bring extra set of clothes to session

…says they have to go �to the bathroom?

After the 3-Minute Time-Out

Wait for 5 seconds of silence and say:

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If child indicates NO, say:

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and restart timer for 3 minutes + 5

seconds of silence

“You are sitting quietly on the chair. Are you ready to [put the car in the box]?”

“Stay on the chair �until I say you can get off.”

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Time-out does NOT end until the original command is obeyed!

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Obeying the Original Command

• If child indicates YES (verbal response not required), lead child back to task and point to task.
• If child does NOT obey, take child back to time-out chair and repeat time-out sequence.
• If child obeys, acknowledge:

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TO

“Thank you.”� “Okay.”

or �“Alright.”

Use of a Second Command

• Immediately issue a second command
• Comply 🡪 Enthusiastic labeled praise 🡪 Return to CDI
• Noncomply 🡪 Warning statement
• Comply after warning 🡪 Labeled praise
• Noncomply after warning 🡪 Repeat time-out sequence

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What if your child gets off the time-out chair?

Time-Out Room

• Child-proofed room
• Well-lit
• Typically the child’s bedroom
• More details on time-out room will be � provided next week

Rationale for the �Time-Out Room

• Time-out chair is not effective if child can get off chair
• Time-out room is used as a � back-up procedure
• Teaches child to stay on time-out � chair
• When used consistently, � children learn quickly �to stay on the chair

When to Use the �Time-Out Room

• Child escapes from chair*
• Child scoots chair
• Child rocks chair
• Child stands on chair

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*Use the “50% of Body Weight” Rule to determine if child has escaped from chair

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Time-Out Room Procedure

• Issue once-in-a-lifetime warning the first time your child escapes, scoots, rocks, or stands on the chair as you place them back on chair
• Issue this warning once for each of the 4 misbehaviors�����
• If child leaves chair again, they go to the time-out room for � 1 minute + 5 seconds of silence
• After 1 minute + 5 seconds of silence, � return child to time-out chair and say:

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“You got off the chair before I said you could. If you get off the chair again, you’ll go to the time-out room. Stay on the chair until I say you can get off.”

ONCE-IN-A- LIFETIME

“Stay on the chair �until I say you can get off.”

Child Complies with Command or Warning

Time-Out for Children who Stay on the Chair

Chair

You didn’t do what I told you to do, so you have to sit on the timeout chair.”

You are sitting quietly on the chair. Are you ready to put the red block in the box?

Chair

Acknowledge

Second Command

Labeled Praise

Yes

Okay

Good job of following directions!

Child Obeys

NO!

Stay on the chair until I say you can get off.

Wait 3 minutes + 5 seconds of silence

Back away from the chair and say:

Stay on the chair until I say you can get off.

Child Obeys

Now, please hand me the blue block.

Wait 3 minutes + 5 seconds of silence

Disobeys Warning

You got off the chair before I said you could. If you get off the chair again, you will go to the time-out room. (This warning occurs only once in child’s life)

Stay on the chair until I say you can get off.

Take child back to chair

Child Gets Off

Time-Out Room

You got off the chair before I said you could, so you have to go to the time-out room.

Stay on the chair until I say you can get off.

Escape from Time-Out

Take child to time-out room while saying:

Back away from the chair and say:

Wait 1 minute + 5 seconds of silence

Then return child to chair and say:

Time-Out Chair

If the child gets off again, repeat steps until they stay on the chair.

Wait 3 minutes + 5 seconds of silence

Role Plays

Refrain from Using PDI Until Coached

• You must practice PDI with the therapist before doing � it at home (PDI with sibling occurs later in treatment)
• Review the Time-Out Sequence diagram
• You will be coached through the Time-Out Sequence � next week
• Schedule extra time for the session
• Be committed to following through
• PDI procedure will be covered at the beginning of the next session

PDI PLEDGE

“I promise not to use PDI at home until I have practiced it in session with the therapist and we agree to start using it at home.”

Handouts

• Review handouts
• “Eight Rules of Effective Commands” Handout
• “Time-Out Diagram” Handout
• “Using a Time-Out Room in Your Home” handout
• CDI Daily Practice Handout
• Remember: Daily Special Time is the best preparation for PDI!

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Any Questions?