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This paper describes the initial evaluation of the Therapist-Parent Interaction Coding System (TPICS), a measure of in vivo therapist coaching for the evidence-based behavioral parent training intervention, parent-child interaction therapy (PCIT). Sixty-one video-recorded treatment sessions were coded with the TPICS to investigate (1) the variety of coaching techniques PCIT therapists use in the early stage of treatment, (2) whether parent skill-level guides a therapist's coaching style and frequency, and (3) whether coaching mediates changes in parents' skill levels from one session to the next. Results found that the TPICS captured a range of coaching techniques, and that parent skill-level prior to coaching did relate to therapists' use of in vivo feedback. Therapists' responsive coaching (e.g., praise to parents) was a partial mediator of change in parenting behavior from one session to the next for specific child-centered parenting skills; whereas directive coaching (e.g., modeling) did not relate to change. The TPICS demonstrates promise as a measure of coaching during PCIT with good reliability scores and initial evidence of construct validity.
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Assessing the Key to Effective Coaching in ParentChild
Interaction Therapy: The Therapist-Parent Interaction
Coding System
Miya L. Barnett &Larissa N. Niec &
I. David Acevedo-Polakovich
Published online: 5 November 2013
#Springer Science+Business Media New York 2013
Abstract This paper describes the initial evaluation of the
Therapist-Parent Interaction Coding System (TPICS), a mea-
sure of in vivo therapist coaching for the evidence-based
behavioral parent training intervention, parentchild interac-
tion therapy (PCIT). Sixty-one video-recorded treatment ses-
sions were coded with the TPICS to investigate (1) the variety
of coaching techniques PCIT therapists use in the early stage
of treatment, (2) whether parent skill-level guides a therapists
coaching style and frequency, and (3) whether coaching me-
diates changes in parentsskill levels from one session to the
next. Results found that the TPICS captured a range of
coaching techniques, and that parent skill-level prior to
coaching did relate to therapistsuse of in vivo feedback.
Therapistsresponsive coaching (e.g., praise to parents) was
a partial mediator of change in parenting behavior from one
session to the next for specific child-centered parenting skills;
whereas directive coaching (e.g., modeling) did not relate to
change. The TPICS demonstrates promise as a measure of
coaching during PCIT with good reliability scores and initial
evidence of construct validity.
Keywords Parentchild interaction therapy .PCIT .
Behavioral parent training .Child conduct problems .
Mediators of change .In vivo coaching .Assessment-guided
Behavioral parent training (BPT) has been identified as the
best practice for the treatment of young children with conduct
problems (Brestan and Eyberg 1998;Eybergetal.2008). BPT
teaches parents effective strategies to change childrensbe-
haviors, such as positive reinforcement, selective attention,
and consistent discipline. However, limited knowledge exists
about which mechanisms most effectively change parents
behaviors to maximize the improvement in childrensbehav-
ior (Weersing and Weisz 2002). Simply teaching parenting
skills via lecture or didactic has not proved adequate to pro-
mote behavior changes in parents (Eddy et al. 1998; Nix et al.
2009). In fact, directive teaching (e.g., teaching new skills or
confronting parents) can lead to resistance in treatment
(Patterson and Forgatch 1985). More complex strategies ap-
pear to be related to parentsbehavior change. Understanding
these mechanisms of change may be the most important
investment in research to improve clinical training and treat-
ment implementation in the future (Kazdin and Nock 2003;
Weersing and Weisz 2002).
One proposed mechanism of change in BPT is therapist
in vivo feedback to parents during parentchild interactions,
often referred to as coaching(Shanley and Niec 2010).
Coaching is specific, immediate feedback that a therapist
provides while a parent practices new skills with his/her child.
This type of feedback allows the therapist to quickly respond
to a parents behaviors while they are happening, which
reinforces positive parenting behaviors or immediately cor-
rects mistakes (Herschell et al. 2002). For example, if a parent
gives their child a specific and labeled praise for sharing, then
a coach would reinforce this parent by saying, That was a
M. L. Barnett :L. N. Niec (*):I. D. Acevedo-Polakovich
Center for Children, Families and Communities, Department of
Psychology, Central Michigan University,
Mt. Pleasant, MI 48858, USA
M. L. Barnett
I. D. Acevedo-Polakovich
J Psychopathol Behav Assess (2014) 36:211223
DOI 10.1007/s10862-013-9396-8
great labeled praise. Whereas, if a parent gave a vague,
unlabeled praise the interaction might look as follows:
Parent:Thank you.
Therapist :Thank you for…”
Parent:Thank you for sharing with me.
Therapist :Great labeled praise. Now he knows what it
is you like.
A recent meta-analysis of BPT programs revealed that
programs that include coaching have a greater effect size than
programs without it (Kaminski et al. 2008). Although
coaching can lead to important parent outcomes, limited re-
search explains what types of coaching are effective
(Herschell et al. 2008; Shanley and Niec 2010). A valid and
reliable behavioral observation measure of the therapist-parent
interactions that occur during coaching is necessary to begin
to address this goal (Snyder et al. 2006).
PCIT is a BPT with a robust evidence-base, which uses
coaching as a primary mechanism to change parent behaviors
(Herschell et al. 2002). PCIT is similar to some other effective
BPT programs in that it is based on a two-stage model of
treatment (e.g., Barkley 1987; Forehand and McMahon
1981), where the first stage, Child-Directed Interaction
(CDI), teaches parents child-centered interaction skills and
non-confrontational behavior management skills, while the
second stage, Parent-Directed Interaction (PDI), teaches par-
ents to implement effective and consistent discipline strategies
(Kaminski et al. 2008). However, PCIT includes innovative
features that distinguish it from many BPT programs: It is an
assessment-driven intervention that uses coaching to shape
parentsacquisition of skills in session (Eyberg and
Funderburk 2011;Niecetal.2011).
During the first phase of PCIT, parents are taught to in-
crease their positive interactions with their children, using
skills such as reflections, child-focused descriptions, and gen-
uine, specific praises. These skills are sometimes referred to as
the Doskills (i.e., reflections, behavior descriptions, and
labeled praises), because they are behaviors parents are en-
couraged to increase. During the CDI phase, parents are also
taught to decrease their use of questions, commands, and
criticisms in order to avoid negative interactions and to keep
their child in the lead of the play situation. These behaviors are
sometimes referred to as Dontbehaviors (Bell and Eyberg
2002;Niecetal.2011). When parents enter the second phase
of PCIT, they learn consistent discipline techniques for non-
compliance and misbehavior (Eyberg and Funderburk 2011).
Coaching during the first and second phases of PCIT
differs markedly. Because the first phase, CDI coaching,
is the focus of this study, we do not describe the PDI
phase in depth. For more extensive descriptions of the two
phases of PCIT, please see McNeil and Hembree-Kigin 2010
or Niec et al. 2011.
Both phases of PCIT have a similar structure. Parents are
initially taught the targeted parenting skills in a didactic session
during which therapists teach parents through interactive tech-
niques such as modeling and role-playing. Subsequent to the
didactic session, parents and children attend coaching sessions
together. Coaching sessions are structured to include (1) a brief
discussion with the therapist about progress and goals, (2) a
standardized, 5-min behavior observation of the parentchild
interaction, and (3) coaching, during which parents practice the
child-centered skills in a play situation with their children while
the therapist provides feedback from an observation room
through a microphone and bug-in-the-ear receiver.
During the parentchild behavior observation prior to
coaching, the therapist assesses the parentsuseoftheDo
and Dontskills (see Table 1for examples). The assessment
is meant to guide the therapists coaching, allowing more focus to
be given to a parents weaker skills (Bahl et al. 1999). After the
assessment, therapists spend the majority of the treatment session
coaching the parent. The immediate feedback and social rein-
forcement provided through coaching is meant to facilitate skill
development with general parenting skills (e.g., selective
attention) along with the specific Doskills (Borrego
and Urquiza 1998; Eyberg and Matarazzo 1980).
Therapists use a variety of different techniques during
coaching; including directive and responsive techniques
(Borrego and Urquiza 1998;seeTable2for examples).
Directive techniques explicitly tell the parent what to do or
say (e.g., Tell Johnny, Great job building that tower.’”);
whereas responsive techniques reinforce the parents use of a
skill (e.g., You just used an excellent praise). Directive
Tabl e 1 DPICS-III categories of parent behaviors (Eyberg et al. 2005)
Description Examples
A declarative sentence where a
parent states what a child is doing
or recently did.
Your building
A nonspecific verbal statement of
approval of an attribute, behavior,
or product of the child.
Thank you
Good work
A specific verbal statement of approval
of an attribute, behavior, or product
of the child.
Thank you for
cleaning up.
Reflection A statement where a parent repeats or
reflects back what the child said.
Child: Itsfast.
Parent: Itsfast.
Tal k
A statement that criticizes a childs
activity, behavior, or verbalizations.
Thats the wrong
Question A descriptive or reflective comment
expressed in the form of a question.
What does a
cow say?
A declarative sentence that requests
that a child perform a specific
activity or behavior.
Please hand me
that red block.
A sentence which requests a child do a
behavior stated in a question form.
Can you hand
me that block?
212 J Psychopathol Behav Assess (2014) 36:211223
techniques, such as modeling a skill for a parent, are consid-
ered valuable when a parent is first learning the skills and
rarely uses them spontaneously; whereas, responsive tech-
niques may be used at any time to reinforce a parentsexisting
skills. PCIT researchers and clinicians recommend that re-
sponsive techniques should be used frequently as a way to
shape behavior when parents approximate a correct skill,
because the social reinforcement (i.e., therapistspraise)will
lead to efficient behavior change (Borrego and Urquiza 1998;
McNeil and Hembree-Kigin 2010). However, these recom-
mendations are based on theory and have limited empirical
support. To date, only one study has examined the impact of
coaching style on parentsskill acquisition. Findings suggest
that parents acquire skills at a higher rate when coaching
includes more constructive advice (e.g., Be careful with
those commands)thanpositivefeedback(e.g.,Great job
praising him; Herschell et al. 2008).
Because there is a dearth of literature investigating PCIT
coaching specifically, we examined the literature on behavior
change in therapy more generally to determine which
coaching techniques might be most likelyto influence parents
skill acquisition. The findings in the broader literature remain
mixed. For example, in a study that examined counselors
acquisition of therapy skills rather than parentsskill acquisi-
tion, modeling was the only effective feedback strategy to
change behaviors when compared with criticism and praise
(Gulanick and Schmeck 1977). Alternatively, research exam-
ining how therapist behaviors impact client outcomes, sug-
gests that supportive and reinforcing therapist behaviors facil-
itate behavior change in clients, whereas directive behaviors
lead to resistance (Hill et al. 1988; Patterson and Forgatch
1985). During parent training sessions, parents were more
likely to respond with resistance after a therapist made efforts
to teach or confront them, whereas there was reduced parent
noncompliance after the therapist provided support (Patterson
and Forgatch 1985). Furthermore, clients receiving cognitive-
behavioral treatment were more likely to respond with resis-
tance after directive, teaching statements by the therapist
(Watson and McMullen 2005). Finally, it has been suggested
that a combination of modeling and social reinforcement is
necessary to shift client behaviors (Traux 1968). More exten-
sive research is needed to understand how these different
therapeutic styles impact client behaviors for efficient and
effective behavior change during PCIT.
In PCIT, it is intended that therapists (1) base their coaching
techniques on their assessment of parentsskills (e.g., Bahl
et al. 1999), (2) use behavior principles to guide their inter-
ventions (e.g., Borrego and Urquiza 1998), and (3) implement
a wide variety of techniques to change parent behaviors
(McNeil and Hembree-Kigin 2010). However, little research
has evaluated the extent to which therapists actually do these
things or the types of coaching techniques that are most
efficacious (Herschell et al. 2008; Shanley and Niec 2010).
Further, an established measure does not yet exist to evaluate
what happens between therapists and parents during coaching.
In other words, not only do we not yet know exactly what
efficacious coaching should look like, we do not have a way to
measure it.
Study Aims and Hypotheses
The present study took the first step to address the pressing
questionHow do we assess therapist-to-parent coaching in
Tabl e 2 TPICS categories
Behavioral code Description Example
Directive coaching
Model A therapist delivered statement that the
parent is intended to repeat.
Thank you for sharing.
Prompt A stem line that ends with the therapist
trailing off so the parent completes the
Thank you for…”
Command A statement that tells or suggests to the
parent what to say or do.
Tell her what you like about her
Drills An exercise that sets a specific skill goal or
time to focus on a skill.
Lets see how many praises you
can do in 1 min.
Responsive coaching
Labeled praises A specific positive statement about a
That was a great behavior
Process comments A statement that ties the childsbehaviorsto
the parentsbehaviors
She smiled when you praised
Reflective descriptions A statement that informs a parent what skill
they used.
That was a behavior description.
Corrective criticism A correction of a parentsbehavior. Whoops, that was a question.
Unlabeled praises A nonspecific praise of the parent. Great!
J Psychopathol Behav Assess (2014) 36:211223 213
PCIT? We developed a psychometric tool, the Therapist-
Parent Interaction Coding System (TPICS), which measures
both the coaching techniques used and the parent skills
targeted by PCIT therapists. The primary aim of the study
was to investigate the construct validity of the TPICS as a
measure of coaching in PCIT. To do so, we used the TPICS to
investigate coaching during familiesearly treatment ses-
sions (CDI coaching sessions 2 and 3). Our decision to
focus on coaching early in treatment was based in part on
the finding that coaching can significantly change parent
behaviors in as few as two sessions (Shanley and Niec
2010). Further, a PCIT treatment study with physically
abusive parents found that 70 % of parents demonstrated
a change trajectory in the way they reinforced their chil-
drens positive behaviors within the first three sessions of
treatment (Hakman et al. 2009). Given that coaching has
the potential to lead to such swift, significant changes in
parent behaviors, and given that families often drop out of
treatment early in the process (Fernandez and Eyberg
2009), it is valuable to examine what happens in those
early sessions to facilitate (or impede) parentsskill acqui-
sition. To address our primary aim we explored three
1. What techniques do PCITcoaches use in the early stage of
coaching? This question was intended to assess whether
the TPICS is capable of capturing the various techniques
used by PCIT therapists during coaching. We expected
that therapists would implement a wide range of tech-
niques, tapping all the TPICS codes, and that every ther-
apist statement would be coded, suggesting that all ther-
apist verbalizations could be defined by the TPICS.
Finally, this question was intended to provide previously
unknown information regarding the frequency of different
types of coaching techniques in early coaching sessions.
2. Does a parents assessed skill-level at the beginning of
session guide a therapists coaching of that skill? Based
on recommendations by PCIT researchers and clinicians
that a parents observed parenting skills should inform the
therapistscoaching(e.g.,Bahletal.1999; Borrego and
Urquiza 1998; Eyberg and Funderburk 2011), we hypoth-
esized that parenting skills assessed at the beginning of
the session would be related to therapiststype and fre-
quency of coaching; specifically, that the frequency of
parenting skills (behavior descriptions, praises, re-
flections) assessed at the beginning of session would
be negatively correlated with directive coaching,
such that lower levels of a skill would lead to more
directive coaching statements focusing on the skill.
Conversely, we predicted that the initial frequency of
parenting skills (behavior descriptions, praises, re-
flections) would be positively correlated with respon-
sive coaching, such that higher levels of a skill
would lead to more responsive coaching statements
focusing on the skill.
3. Does coaching mediate parentsskill acquisition from one
session to another? The research regarding the most
effective types of therapist feedback (e.g., direct, critical,
supportive) is mixed and remains to be clarified (Gulanick
and Schmeck 1977; Patterson and Forgatch 1985; Traux
1968). Although little empirical literature has examined
PCIT coaching, evidence from the broader parenting lit-
erature suggests that a wide range of therapist feedback
techniques may influence change in parenting behaviors.
Thus, we hypothesized that both directive and responsive
coaching of positive parenting skills (behavior descrip-
tions, reflections, labeled praises) would mediate the re-
lationship between parenting skills from one session to
the next.
ParentChild Dyads The data used in the present study
were archival, provided by a pilot randomized control trial
(RCT) evaluating the efficacy of group versus individual
PCIT in the treatment of young childrens conduct prob-
lems (Niec et al. 2013). Participants included families that
presented to a university mental health clinic for treatment
of their 2- to 7-year-old childrens disruptive behaviors. In
order to qualify for participation, the following require-
ments were met: (1) the child met DSM-IV criteria for
Oppositional Defiant Disorder or Conduct Disorder (APA
2000) and had conduct-disordered behaviors rated by a
caregiver in the clinical range of severity on a standardized
measure of child behavior (e.g., Behavior Assessment
System for Children-II Externalizing Composite cutoff
score of T>70); (2) at least one caregiver participated; (3)
the family was not involved in Child Protective Services;
and (4) children taking psychotropic medications had a
period of stabilization before they entered the study.
We evaluated parent skills and therapist coaching in the
second or third coaching session of the CDI phase of treatment
and the subsequent coaching session for 61 parentchild
dyads. These 61 dyads consisted of 47 families including 33
families with only one caregiver and 14 families (28 care-
givers total) with two caregivers. Of the caregivers included in
this study, 60.7 % were biological mothers, 16.4 % were
biological fathers, 16.4 % were other female caregivers (e.g.,
grandmothers, step-mothers), 6.5 % were other male care-
givers (e.g., grandfathers). When more than one care-
giver participated in treatment, both caregivers received
individual coaching time, and coaching sessions were
coded for both caregivers.
214 J Psychopathol Behav Assess (2014) 36:211223
Families in this study were randomly assigned to the indi-
vidual or group treatment conditions. Families from both
treatment conditions were represented, including 26 parents
who received individual PCIT and 35 parents who received
group PCIT. Treatment sessions were conducted once a week
for approximately 1 h each for families in individual PCITand
2 h for parents in group PCIT to allow time for all of the
parents in the group to receive equal amounts of coaching.
Both treatment conditions included the same number of ses-
sions, the same PCIT treatment components, the same amount
of coaching per dyad, and the same therapists. Differences
included the presence of other families during group sessions,
which allowed for group discussions before and after
coaching. However, the RCT (Niec et al. 2013)revealedno
differences across treatment conditions for primary outcome
variables. In both treatment conditions, parents were first
taught the targeted skills in a didactic session and coaching
sessions followed. The RCT used a standardized protocol that
included four CDI coaching sessions.
Therapists The therapists in this study were 13 advanced
doctoral students in clinical psychology. All the therapists
had completed core clinical work and at least a year of PCIT
training. Treatment was conducted with co-therapy teams, and
all junior therapists (less than 2 years of experience with
PCIT) were matched with advanced therapists. Therapist ex-
perience in PCIT ranged from 1 to 5 years. A licensed clinical
psychologist with over 10 years of experience with PCIT
supervision provided training and weekly supervision to all
therapists. Dr. Sheila Eyberg, the developer of PCIT, provided
case consultation when questions arose that could not be
resolved by the study team.
Dyadic ParentChild Interaction Coding System-III (DPICS-
III) The DPICS-III (Eyberg et al. 2005) is a behavioral obser-
vation coding system that was designed to measure the quality
of the interaction between parentchild dyads and parentsuse
of effective parenting skills. We assessed parentsinteractions
with their children during the 5-min Child-Led Play portion of
the measure administered during each CDI treatment session.
The DPICS categories coded in this study include Unlabeled
and Labeled Praises,Reflections ,Behavior Descriptions ,
Negative Talk,Questions ,andIndirect and Direct
Commands (see Table 1). The DPICS-III has been standard-
ized for use with children ages 3 through 6. Interrater reliabil-
ity on parent verbalizations has ranged from correlations of
0.69 (Behavioral Description)to0.99(Direct Command)for
the parent codes (Eyberg et al. 2005). DPICS accurately
discriminates between families with and without a child with
behavioral concerns (Robinson and Eyberg 1981)and
treatment sensitivity of the DPICS has been shown in PCIT
and other treatment outcome studies (e.g., Schuhmann et al.
1998; Webster-Stratton and Hammond 1990).
Therapist-Parent Interaction Coding System The TPICS is a
behavioral observational coding system developed to assess
the interactions between the therapist and the parent during
in vivo coaching. The TPICS manual was developed by a
doctoral-level graduate student in clinical psychology and a
PCIT Master Trainer, a clinical psychologist with extensive
experience in PCIT who was vetted by Dr. Sheila Eyberg to
disseminate the protocol with fidelity. As part of the manual
development, the graduate student and PCIT Master Trainer
reviewed numerous video recordings and transcripts of PCIT
coaching sessions and discussed different types of
verbalizations used by therapists. They then classified these
verbalizations into categories, with the primary goal that the
TPICS would be able to capture all verbalizations made by the
therapist with good reliability. In order to remain consistent
with existing research and theory related to PCIT, the TPICS
followed similar coding rules as the DPICS-III (Eyberg et al.
2005), and classified different coaching codes as being either
in the category of being directive or responsive as delineated
in a previous article on the subject (Borrego and Urquiza
1998). Similarly to the DPICS-III, the TPICS is intended to
code every verbalization and includes a hierarchical ranking
of codes so that each verbalization can only be coded into one
code if the verbalization could be classified as more than one
code. The manual includes a definition of each code, illustra-
tive examples, specific guidelines to aid discrimination be-
tween codes,and decision rules to help the coder when there is
uncertainty of which code is appropriate. For research pur-
poses, the TPICS is best used with video-recorded sessions so
that reliability of coding can be evaluated.
Every TPICS code includes two components (1) the spe-
cific technique used to coach the skill (e.g., Modeling,
Prompting, Constructive Correction), and (2) the skill the
therapist coaches (e.g., Labeled Praise, Reflection, Behavior
Description, Other). For example, if the therapist said, That
was an excellent reflection, then that statement would be
coded as giving a labeled praise about a reflection. The
TPICS includes codes for ten separate coaching techniques
that have been categorized as being either directive or respon-
sive (see Table 2). The directive category includes only the
coaching techniques that occur prior to aparents behavior.
These codes include modeling the correct use of a skill (e.g.,
Therapist says, I like how you are staying at the table,with
the intention of the parent repeating this statement);
prompting a skill with a stem phrase, (e.g., Thank you
for…”); giving parents clear and direct commands (e.g.,
Describe what he is doing); suggesting a parent behavior
with an indirect command (e.g., Can you think of something
to praise her for?); and using specified exercises called drills
J Psychopathol Behav Assess (2014) 36:211223 215
(e.g., Lets see how many behavior descriptions you can use
in a minute).
Responsive coaching techniques follow aparentsbehavior
and include providing labeled praise for what the parent is
doing (e.g., Nice reflection); a non-specific unlabeled
praise (e.g., Good!), constructive corrections (e.g.,
Oops, a question); reflective descriptions (e.g., You u s e d
a behavior description); and making process comments about
how a parents skills are affecting the child (e.g., Your praise
is really helping him stay calm and focused.).
In order to code the behavior the therapist is targeting, the
TPICS uses the established DPICS-III codes (e.g., labeled
praise, reflection) for any of the specific parenting skills that
are the focus in PCIT. Though PCIT therapists emphasize
coaching specific parenting skills that are measured at the
beginning of every session (e.g., behavior descriptions), they
also focus on improving the overall parentchild relationship
by coaching parenting behaviors such as demonstrating en-
joyment of the child, and other specific selective attention
strategies (e.g., ignoring). As these behaviors are important
in PCIT, though they are not measured specifically, we includ-
ed the category, Otherto refer to any time a therapist
coached a different parenting skill.
DPICS Coding For the original RCT, the 5-min behavior
observations of parentsskills during treatment sessions were
video-recorded and coded by a primary coder blind to the
study hypotheses. Prior to coding, the primary coder was
trained intensively over a year in the DPICS-III coding system
and met criteria (k>0.80 for all categories) with an expert-
rated standard training tape. To test the reliability of the
primary codes, interrater coders at an outside institution inde-
pendently coded randomly selected segments. Interrater
coders were blind to study hypotheses, participantstreatment
condition, and treatment session number. Of the 114 5-min
behavior observations of parentsskills used for the present
study (61 sessions that also had TPICs coding completed and
53 subsequent sessions) 37 (32 %) of these sessions were
coded for interrater reliability. Pearson Product Moment cor-
relations were calculated on the child-centered interaction
skills of interest for this study. Interrater reliability coefficients
for Labeled Praise (r(37)=0.73), Unlabeled Praise (r(37)=
0.79), Reflections (r(37)=0.80), Behavior Descriptions
(r(37)=0.88), and a compilation of Dontbehaviors
(r(37)=0.83) were all found to be good.
TPICS Coding After creation of the TPICS categories, we
selected and coded a segment of video-recorded CDI coding
from a clinical session to serve as a criterion tape for TPICS
trainees. The use of a criterion tape is consistent with the
training procedure often used for research conducted on ther-
apist behavior observation measures (e.g., Eames et al. 2009).
The primary coder established initial reliability for the TPICS
mastery-criteria videotape with an expert rating done by a
PCIT Master Trainer. Reliability for both the coaching tech-
nique used (k=0.90) and parent behavior targeted in coaching
(k=0.93) were high. After reliability was established, the
primary coder and Master Trainer reached a consensus on
the codes on which they had disagreed and established the
mastery criteria for the training tape.
To evaluate the reliability of the TPICS for this study, an
interrater coder was trained by the primary coder. Training
included tutorial and discussion of the TPICS codes, coding
transcripts, completing quizzes, and coding video-recorded
sessions. The interrater coder exceeded the criterion of 80 %
with the expert-rated tape for both the coaching technique (k=
0.90) and the parent behavior that was targeted (k=0.86).
Video-Recorded Session Samples All treatment sessions were
recorded. Sessions of families who completed the CDI didac-
tic and the first CDI coaching session were included if (1) the
coaching portion of the session was 13.5 min or longer, (2) the
segment was from the second or third CDI session, and (3) the
recording was audible. Of the 80 possible recorded segments,
61 met these requirements. Of the 61 video segments in the
study, 53 of the parentchild dyads attended the following
weeks session. The 5-min behavior observations of parent
behaviors from these 53 dyads were included as a measure of
behavior change between sessions. See Table 3for an expla-
nation of the coded segments.
Data Analysis
Twenty-eight caregivers included in the study had the same
child, which violated the assumption of independence. A
random-effects regression model (RRM) was used based on
Hedeker et al.s(1994) recommendations for clustered data.
This model allows for inferences at the level of the individual
parent while controlling for the degree of dependence at the
family level (Hedeker et al. 1994).
Tabl e 3 Portion of treatment session coded
Coding system
Time during session Behaviors coded N
DPICS-III 5 mins. of coding prior to
Parenting Behaviors 61
TPICS First 5 mins. of coaching Therapist Coaching 61
DPICS-III Subsequent session 5 mins.
of coding prior to coaching
Parenting Behaviors 53
DPICS-III Dyadic Parentchild Interaction Coding System-Third Edi-
tion; TPICS Therapist-Parent Interaction Coding System
216 J Psychopathol Behav Assess (2014) 36:211223
The data were analyzed for outliers using standard-
ized residuals. Based on recommendations on identifying
and removing outliers, cases with standardized residuals
greater than 2.5 were removed from the data set
(Stevens 1984). Outliers included therapists whose num-
ber of coaching statements was higher or lower than
what would be predicted given the parentsskillslevel.
Two outliers were identified for labeled praises, three
outliers were identified for reflections, and two outliers
were identified for behavior descriptions. Analyses were
run with and without outliers, and results were signifi-
cantly influenced for labeled praises and behavior de-
scriptions. Because the outliers did not appear to be
related to error, and are instead representative of actual
outliers from the population, results both with and
without the outliers are reported when there was an
influence on statistical significance (Stevens 1984).
In order to test the hypothesis that coaching mediated the
relationship between parenting skills at the beginning of one
treatment session and the subsequent session, Baron and
Kennys(1986) conceptual and statistical recommendations
for testing mediation were used. First, the parent skill
level during the subsequent session was regressed on
the skill level from the previous session to determine
if there was an effect to mediate. Then the frequency of
use of a coaching technique (e.g., responsive coaching)
was regressed on initial parent skill level. In the third
regression, the parents skill level in the subsequent
session was regressed on the coaching technique.
Interrater Reliability
One primary coder completed the TPICS coding. Of the 61
video-recorded sessions, 16 (25 %) were randomly selected
for reliability coding by a second, independent coder. Kappa
tests were run for interrater reliability on the PCIT coaching
technique used and the category of parenting skill coached.
Interrater reliability was excellent for both coaching technique
(k=0.94) and parent behavior (k= 0.90). Pearson Product
Moment correlations were used to analyze the interrater reli-
ability of specific therapist and parent codes (Table 4).
Reliability coefficients were very good to excellent (r=0.87
to 1.0), with the exception of two coaching techniques
(Reflective Description [r=0.65], Corrective Criticism [r=
0.70]) and one category of parent behavior (Other [r=0.63]),
which demonstrated adequate reliability. The TPICS demon-
strated the breadth and clarity of codes necessary to code
every therapist verbalization during coaching with adequate
to excellent reliability.
What Techniques Do Coaches Use?
As expected, coaches used a variety of techniques during the
early coaching sessions (Table 5). Modeling (M=11.72,
SD =6.33) and Labeled Praises (M=9.23, SD =4.67) were
the techniques coaches used most frequently, while the tech-
niques that were used the least were Drills (M=0.05, SD =
0.22), Corrective Criticisms (M=0.46, SD =0.81), and
Process Comments (M=0.23, SD =0.53). Test of normality
suggested that the majority of codes were used rarely and
positively skewed, with the only exceptions being Modeling
Tabl e 4 Interrater reli-
ability of the therapist-
parent interaction coding
Coaching techniques
Total directive 0.99
Model 0.99
Prompt 0.98
Indirect/direct command 0.88
Drills 1.0
Total responsive 0.99
Labeled praises 0.96
Process comments 0.99
Reflective descriptions 0.65
Corrective criticism 0.70
Unlabeled praises 1.0
Targeted parent behavior
Behavior description 0.95
Labeled praises 0.90
Reflections 0.96
Dontskills 0.87
Other 0.63
Tabl e 5 Therapist coaching techniques during 5-min TPICS
Minimum Maximum MSD
Total directive 2 33 14.11 6.35
Model 1 28 11.72 6.33
Prompt 0 4 11.07 1.25
Indirect/direct command 0 6 1.95 1.74
Drills 0 1 1.05 0.22
Total responsive 2 23 10.33 5.15
Labeled praises 2 22 9.23 4.67
Process comments 0 2 1.23 5.53
Reflective descriptions 0 4 0.87 1.16
Corrective criticism 0 4 1.46 0.81
Unlabeled praises 0 23 4.26 4.88
N=61. MMean. SD Standard Deviation
J Psychopathol Behav Assess (2014) 36:211223 217
and Labeled Praises, which were normally distributed
(Table 6). Composites of all directive and responsive coaching
techniques revealed that, on average, therapists used signifi-
cantly more directive coaching statements (M= 14.11 ,
SD =6.35) than responsive coaching statements (M=10.33,
SD =5.15, t(60)= 3.23, p<0.01). That is, coaches told parents
what to say more often than they praised them for saying it or
explained what they said.
In regards to the parenting behaviors therapists targeted
during coaching, by far the most frequently targeted behaviors
were the Doskills (i.e., parenting behaviors meant to be
increased; M=24.43, SD =7.08). Therapists also frequently
coached otherparent behaviors (M= 10.15, SD =7.67).
Otherparent behaviors included different skills that are
addressed in PCIT, but not systematically measured by the
DPICS-III, such as ignoring negative child behavior, being
enthusiastic, and following the childs lead. Of the targeted
parenting Dobehaviors, therapists targeted labeled praises
most frequently (M=8.15, SD =4.25) and behavior descrip-
tions least often (M=5.93, SD =3.91). Therapists rarely
targeted Dontbehaviors (i.e., parenting behaviors meant
to be decreased; M=1.07, SD =1.25), suggesting the possibil-
ity they used other forms of behavior modification (e.g.,
selective attention and shaping) to address these behaviors
instead (Table 7).
Does a Parents Skill-Level Guide a Therapists Coaching?
Directive Coaching We used a RRM to test the hypothesis
that parents with fewer skills would receive more directive
coaching statements (e.g., modeling, prompting, commands,
and drills). Using the full sample, directive coaching tech-
niques were significantly, negatively related to parentsuse of
behavior descriptions (β(61)= 0.39, t(59.97) = 3.35,
p=0.001). That is, when parents offered fewer behavior de-
scriptions during the assessment of their interactions with their
children, coaches were more likely to use directive techniques
to increase parentsskill acquisition. No significant relation-
ship was found between directive techniques and parentsuse
of labeled praises, (β(61)=0.16, t(53.17)=1.34, p>0.05,
or reflections, β(61)= 0.12, t(46.36)=0.93, p>0.05) with
the full sample. However, when the outliers were removed
from the analyses, directive coaching techniques were also
significantly and negatively related with a parents skill use of
labeled praises, β(59)= 0.33, t(44.88) = 2.85, p<0.01.
Significance levels were not impacted for behavior descrip-
tions, β(59)=0.38, t(57.82)= 3.53, p=0.001, or reflections,
β(58)= 0.08, t(51.31)=0.63, p>0.05, when outliers were
removed. Thus, as expected, therapists used more directive
coaching techniques when parents demonstrated deficits in
their use of the child-centered skills labeled praises and be-
havior descriptions.
Responsive Coaching A RRM was also used to test the hy-
pothesis that therapists would provide more responsive
coaching statements (e.g., praise) to parents when their use
of a skill was already frequent. In other words, if parents
spontaneously used a skill often, the therapist would have
many opportunities to reinforce the parentsdemonstrations
of that skill. As expected, when outliers were removed
from the analyses, responsive coaching techniques were
significantly, positively correlated with labeled praises,
β(59)= 0.29, t(58.00)=2.35, p<0.05. A relationship was
not found for behavior descriptions, β(59)=0.12,
t(58.99)=1.04, p> 0.05, or reflections, β(58)=0.12,
t(53.62)=0.24, p>0.05. That is, parents who already gave
their children many labeled praises received many respon-
sive statements from coaches. With outliers included, no
significant relationships existed between responsive
coaching techniques and parentsskill levels in the child-
centered skills. For a summary of the relationships be-
tween parents skills and coaching styles see Table 8.
Does Coaching Mediate ParentsSkill Acquisition?
Baron and Kennys(1986) preconditions for mediation were
tested for both directive and responsive coaching with the
Tabl e 6 Normality of therapist coaching techniques
Shapiro-Wilk Statistic
Model 0.95*
Prompt 0.52
Indirect/direct command 0.86
Drills 0.23
Labeled praises 0.96**
Process comments 0.67
Reflective descriptions 0.76
Corrective criticism 0.62
Unlabeled praises 0.79
N=61. * = p>0.01. ** p>0.05
Tabl e 7 Parent skills coached during 5-min TPICS
Minimum Maximum MSD
Tot al doskills 12 44 24.43 7.08
Labeled praises 1 23 8.15 4.25
Behavior descriptions 0 22 5.93 3.91
Reflections 0 30 6.66 4.71
Tot al dontbehaviors 0 5 1.07 1.25
Total other behaviors 0 43 10.15 7.67
N=61. MMean. SD Standard Deviation
218 J Psychopathol Behav Assess (2014) 36:211223
development of the three targeted parenting skills (i.e., behav-
ior descriptions, labeled praises, and reflections) from one
session to the next. Preconditions for mediation were met for
labeled praises with responsive coaching (Fig. 1). To test the
mediational model, parent skill level from the subsequent
session was regressed on both parent skill level during the
initial session and the coaching technique targeting this skill.
The significant relationship between the parentsinitial skill
level and next-session skill level, β(52)=0.25, t(47.72)= 1.85,
p<0.05, was no longer significant when responsive coaching
was added to the regression equation β(52)=0.20, t(49)=
1.44, p=0.08. This suggests that responsive coaching had a
partial mediation effect on a parents skill development for
labeled praises.
Directive coaching did not meet the preconditions for
mediation, as this technique was not related to a parentsskill
level in the subsequent session for any of the skills.
Understanding the therapeutic techniques that lead to success-
ful and efficient behavior changes in parents during PCIT is
important to further both the effectiveness and the dissemina-
tion of the treatment model. In order to accomplish these
goals, however, a behavioral observation measure is necessary
(Snyder et al. 2006). This study took the first step to address
that need by developing a new behavioral observation mea-
sure, the TPICS, which allows for the direct coding of thera-
pistsin vivo coaching during PCIT. We explored (1) the types
of coaching techniques therapists used, (2) whether the as-
sessment of parenting skills guided that coaching, and (3)
whether coaching, as measured by the TPICS, mediated par-
entsskill acquisition from one session to another. As predict-
ed, the TPICS was capable of capturing a variety of coaching
techniquesimplemented by therapists during the early stage of
coaching. Coaching related to the assessment of parenting
skills such as behavior descriptions and labeled praises, but
not to parentsreflections. Also as expected, responsive
coaching techniques mediated the acquisition of parenting
skills from one session to another.
Therapists Use a Range of Coaching Techniques
The TPICS tapped variations in therapist coaching styles
during the early PCIT coaching sessions. As predicted, thera-
pists implemented a range of both directive and responsive
techniques, with modeling (e.g., Therapist says, for parent to
repeat, Youre building a blue tower.)andlabeled praises to
parents (Great job describing his behavior!) being the most
frequently used techniques. Overall, therapists targeted the
Doskills (i.e., labeled praises, reflections, behavior descrip-
tions) approximately five times for every minute of coaching;
whereas they coached the Dontskills (i.e., questions, com-
mands, criticisms) once in 5 min of coaching. This is consis-
tent with recommendations that during the first phase of
treatment, PCIT coaches should selectively ignore parent
Tabl e 8 Relationships between parenting skills and therapist coaching
Coaching technique Parenting skill
Directive coaching 0.08 0.38** 0.33**
Responsive coaching 0.12 0.12 0.29*
RF DPICS-III assessment of reflections. BD DPICS-III assessment of
behavior descriptions. LP DPICS-III assessment of labeled praises. Out-
liers removed. N=58 for RF. N=59 for BD. N=59 for LP. *p<0.05; **p
Predictor Variable :
Initial use of
Labeled Praises
Outcome Variable :
Next Session use of
Labeled Praises
= .25*
Mediating Variable :
Predictor Variable :
Initial use of
Outcome Variable :
Next Session use of
Labeled Praises
= .29* = .22*
Fig. 1 Mediational model for
labeled praises and responsive
coaching. N=52. *p<0.05
J Psychopathol Behav Assess (2014) 36:211223 219
behaviors that are targeted for reduction and attend enthusias-
tically to parent behaviors that are targeted to increase (Eyberg
and Funderburk 2011).
Therapist Coaching is Guided by Parent Skills
PCIT is an assessment-driven intervention that emphasizes
actual behavior observation of parent skills to guide thera-
pistsin vivo feedback (Bahl et al. 1999). Previous to this
study, however, no empirical evidence supported this link.
Our findings support the assumption that therapists use the
behavior observations at the beginning of a session to guide
their coaching during a session. Specifically, parents who
were low in behavior descriptionsasassessedbythe
DPICS-III received more directive forms of coaching from
the therapist. When outliers were removed from analyses for
labeled praises, parent-skill level was negatively related to
directive coaching (i.e., parents with low skill levels received
a high amount of directive coaching), but positively related to
responsive coaching (i.e., parents who were strong with la-
beled praises at the beginning of session received a high level
of responsive coaching throughout session). Parentsuse of
reflections did not relate to therapist coaching. This suggests
that while therapists often use assessment-guided treatment,
they may not always do so. The finding has implications for
therapist training, as the link between parent skill and therapist
coaching is a key concept in PCIT. It is promising that the
TPICS could reveal differences in the associations, for in the
future, such a measure may be used by trainers to assess
whether therapists-in-training are using the assessments of
parentsskills effectively.
Responsive Coaching Mediates ParentsSkill Acquisition
Mediational models between parentsskill levels and
coaching techniques were evaluated to test whether respon-
sive and directive coaching techniques would mediate the
relationship between parent skills from one session to another.
The mediational model was supported, with responsive
coaching techniques mediating a parents acquisition of la-
beled praises. Directive coaching did not mediate parents
session-to-session acquisition of skills.
Although older research demonstrates the value of such
directive feedback as modeling in the context of therapists
skill acquisition (Gulanick and Schmeck 1977), research on
parent resistance offers a possible explanation for the current
finding. That is, in a non-coaching-based BPT intervention,
parents who received directive techniques were more resistant
to implementing the skills (Patterson and Forgatch 1985). This
study was potentially not able to fully capture the influence of
directive coaching because it only looked at behavior changes
from one session to another. Further, the limitations of a small
sample require that interpretations be made with caution.
Additional research is necessary to better understand the util-
ity of directive statements, and the immediate and distal out-
comes related to these coaching techniques.
Responsive coaching includes therapist statements that
occur after a parents behavior. Such coaching may be explic-
itly supportive (e.g.,. Great labeled praise!), neutral (e.g.,
That was a behavior description.), or gently corrective
(Oops, that was question.). Key to responsive coaching is
that it always follows a parentsverbalization. Our findings
provide preliminary evidence that responsive coaching ac-
counts for a significant portion of the variance in parents
acquisition of labeled praises during PCIT. The importance
of responsive coaching in this study is consistent with past
research that suggests parent compliance with therapist sug-
gestions increases whenparents feel supported by the therapist
(Patterson and Forgatch 1985). Given the numerous factors
that may influence skill development (e.g., parentspractice at
home, severity of child conduct problems), it is notable that
responsive coaching could mediate parentsskill acquisition
during a single coaching session. However, a need remains to
look beyond skill acquisition within a session to look at skill
acquisition over the length of treatment. One direction for
further research would be to evaluate how coaching styles
impact more distal outcomes in PCIT, such as the speed of a
parents skill acquisition, attrition, and adherence to treatment.
The Therapist-Parent Interaction Coding System
Although research within the realm of behavioral parent train-
ing supports the relationship between a therapists competence
and treatment outcomes for parents (Eames et al. 2009;
Forgatch et al. 2005) and despite the fact that coaching is
generally considered a critical mechanism of change in
PCIT, prior to this study, no measure of therapistsin vivo
coaching of parentchild interaction has been reported. Our
preliminary findings suggest that the TPICS has promise as a
measure of therapist-parent interaction during PCIT coaching.
The instrument provides a direct measure of therapist behav-
iors rather than general impressions of the treatment session,
which is valuable because coded behavior has been associated
with dropout in treatment, whereas general ratings have not
(Harwood and Eyberg 2004). Further, the TPICS assesses
core components of PCIT, such as how well therapists use
behavior observations of parentchild interactions to guide
their coaching (Bahl et al. 1999). Initial explorations of reli-
ability reveal that the TPICS demonstrates good interrater
reliability, with most coefficients above 0.85. Another strength
of the TPICS is that its codes are capable of measuring a
breadth of different coaching styles, while these different
codes can be collapsed into the responsive and directive
composites in order to investigate how broad styles impact
parental behavior change. Overall, the flexibility of the TPICS
to reliably capture specific or broader coaching styles
220 J Psychopathol Behav Assess (2014) 36:211223
increases its research and clinical utility. For example, when
training new PCIT therapists, it is valuable to be able to
capture commonand infrequent techniques in order to provide
accurate feedback to the trainee and shape their skills. Finally,
the use of the TPICS in this study identified a potential
mediator of change in PCITresponsive coaching. This find-
ing and the relationships between therapist coaching and
parent skills as assessed by the TPICS provide initial support
for the construct validity of the measure.
Previous research on therapist coaching in PCIT has used
analogue methodology with nonclinical samples (e.g.,
Herschell et al. 2008; Shanley and Niec 2010). This study
furthered existing literature by (1) evaluating a clinical sample
of families and (2) assessing actual therapist and parent be-
haviors during treatment sessions. Further, this study ad-
dressed issues of non-independence by using the random-
effects regression model (RRM), which controlled for the
degree of dependence on a family level, allowing for infer-
ences to be made at an individual level. The majority of
research on dyads and families ignores the violations of inde-
pendence, which can increase Type I and Type II errors and
compromise the validity of the results (Kenny et al. 2006).
Though it is a potential limitation of this study that the RRM
did not fully control for the degree of dependence between
two caregivers (e.g., mother and father)in treatment together,
it was considered to be a better alternative to leaving one of the
caregivers out of the study. Frequently, due to difficulties with
recruitment and issues of dependence in data analysis, fathers
are not included in research on child psychopathology and
treatment, which has led to a bias towards mothers in the field
(Phares 1992). This studys use of the RRM sought to address
this limitation.
In order to craft future investigations of therapist coaching
in behavioral parent training interventions, it is important to
consider the limitations of this study. Therapists in this study
were all graduate students in the same training clinic, which
may limit the ability to generalize findings to therapists in
community settings or to more experienced therapists. Future
studies on the TPICS should use a wider variety of clinicians
to improve understanding of the utility of all the different
codes, especially given that many of the codes were rarely
used in this population. Our sample of parents and children
came from a relatively homogenous population within a rural
area. Furthermore, our sample size was relatively small, and it
is possible that this limited the number of significant results.
Finally, this study investigated coaching only during the first
phase of PCIT (i.e., child-directed interaction) and only ex-
amined behavior change from one session to the next. It is
likely that different coaching styles are effective in the second
phase of treatment, and it is possible that we were not able to
capture the effectiveness of different coaching techniques on
more distal outcomes. Given the limitations, the findings
should be considered a first step in the investigations of
PCIT coaching and more research is warranted. However,
despite these cautions, the step taken here is important and
provides a direction for further study of the question: What
makes an effective PCIT coach?
The findings from this study have significant implications for
clinical practice, research, and training issues related to PCIT.
First, although evidence suggests that therapists used the
behavior observations of parentsskills to guide their
coaching, it was also apparent parentsskill did not always
guide coaching. Furthermore, while directive coaching tech-
niques (e.g., modeling) may be valuable to teach parents a
skill when they do not display it spontaneously (Gulanick and
Schmeck 1977), only responsive coaching mediated the rela-
tionship between a parents skill level from one session to the
This study added to the growing body of evidence that
in vivo feedback is related to behavior change in parents
(Kaminski et al. 2008; Shanley and Niec 2010) and that
certain feedback styles relate to more behavior change than
others (e.g., Herschell et al. 2008). The TPICS has the poten-
tial to improve the training and evaluation of PCIT therapists.
With further development, the measure may allow researchers
and clinical trainers to assess how effectively therapists use the
parentchild behavior observations to guide their coaching
and which types of coaching they favor. Research should
continue to investigate whether the TPICS can measure
coaching styles that predict short- and long-term behavior
changes in parents in order to further develop our understand-
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author from the National Institute of Mental Health (MH 070483). The
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... The individual: 1) acquires the knowledge verbally or via observation, 2) turns this into procedural knowledge by acting on what they have learned, and 3) practices the behavior repeatedly until it becomes automatic. In EBT parent-training programs, these theories of learning and skill building may take the form of techniques such as modeling (e.g., demonstrating a skill for a caregiver to emulate), coaching (e.g., directly prompting a caregiver to use a skill in a real-time situation), and feedback (e.g., praising a caregiver immediately following skill use; Barnett et al., 2014;Shanley & Niec, 2010). ...
... As noted by McNeil and Hembree-Kigin (2010), potential benefits of coaching in PCIT include the ability to observe caregiver-child interactions in real time, the opportunity to tailor recommendations to specific individuals and families based on live clinical data, rapid learning of effective parenting skills, and the ability to offer a high level of support to caregivers as they practice the skills learned in session. A growing empirical literature offers support for these benefits, including a documented association between coaching and the acquisition of the positive parenting skills taught in PCIT and treatment retention (A.D. Herschell et al., 2008;Barnett et al., 2018Barnett et al., , 2014 M. L. Barnett et al., 2017;Niec, 2018;Shanley & Niec, 2010). It is essential that PCIT therapists' unique coaching styles are tailored to address the distinct needs of each family they serve. ...
... Importantly, the use of drills is not recommended until the fourth CDI coaching session and later. Two studies examining early CDI (e.g., prior to the fourth coaching session) have found that heavily directive techniques such as drills are associated with less change in caregiver skill use and higher treatment attrition (Barnett et al., 2014; M. L. Barnett et al., 2017). Although Barnett et al. (2014), M. L. Barnett et al. (2017)) note that additional research is needed to fully understand the impact of directive coaching on caregiver skill use, research indicates that building the therapeutic alliance in early therapy sessions is important for strengthening rapport (Kazdin et al., 2005). ...
Parent-Child Interaction Therapy (PCIT), an evidence-based parent-training treatment, is unique from many other parent-training programs in that it utilizes coaching (i.e., in-vivo support) and feedback to enhance targeted parenting skills. One important skill-building technique in PCIT is a “drill” (within-session skill practice for a brief, focused time). Although the PCIT protocol states that drill exercises should be used starting in the fourth coaching session, limited guidance is present – leaving specifics and implementation to therapist discretion. This paper compiles drills used by PCIT therapists and trainers to provide practitioners with a variety of drill options and suggestions for utilization. We include a description of each drill, examples of clinical situations for which each drill may be appropriate, and recommendations for introducing a drill in session, with discussion regarding the importance of using culturally-sensitive language. Case vignettes are included to illustrate recommendations outlined within the paper and the application of specific drills.
... Given that coaching is a core component of PCIT and has been associated with larger effect sizes, research has begun to investigate the types of coaching statements that lead to improved outcomes for parents and children [23]. The therapist-parent interaction coding system (TPICS) was developed to investigate different coaching styles related to improved parental skill development in PCIT [23,24]. The TPICS measures two categories of coaching styles-directive coaching and responsive coaching. ...
... Past research using the TPICS has investigated how coach behaviors in early CDI sessions related to parent skill acquisition and engagement in treatment [23]. In the first study validating the TPICS, responsive coaching was found to mediate parental skill acquisition between one session and the next, while the use of directive coaching was not [24]. Another study, conducted with English-and Spanish-speaking families, similarly found that skill acquisition between two sessions of PCIT was impacted by responsive coaching [25]. ...
... A team of four research assistants were trained on the empirically validated, Therapist-Parent Interaction Coding System (TPICS [24]), and Dyadic Parent-Child Interaction Coding Systems (DPICS [34]). Videotapes of 5-min segments of the second CDI coaching session, in line with what was conducted in the original TPICS study [24], from 49 participants of the GANA and MY PCIT studies, were digitized and transcribed. ...
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Parent–child interaction therapy (PCIT) is a best-practice treatment for behavior problems in young children. In PCIT, therapists coach parents during in-vivo interactions to strengthen the parent–child relationship and teach parents effective ways of managing difficult child behaviors. Past research has found that different therapist coaching styles may be associated with faster skill acquisition and improved parent engagement. However, most research examining therapist behaviors has been conducted with English-speaking families, and there is limited research examining therapist behaviors when working with Spanish-speaking clients. In this study, English- and Spanish-speaking therapists’ coaching behaviors (e.g., directive versus responsive) were examined, as well as their association with client outcomes, including speed of parental skill acquisition and treatment completion. Results suggested that coaching styles varied significantly between sessions conducted in Spanish versus English. In Spanish sessions, therapists had more total verbalizations than in English sessions and demonstrated higher rates of both total directive and responsive coaching. Responsive coaching was found to predict treatment completion across groups, while directive coaching was not. Directive and responsive coaching were not found to predict the rate of parental skill acquisition. Implications regarding the training of therapists and emphasizing cultural considerations are discussed.
... It is possible that the style and type of coaching may influence not only the development of parental skills, but also the therapeutic relationship and the likelihood of attrition. In their initial evaluation of the Therapist-Parent Interaction Coding System (TPICS), which allows for direct coding of therapists' coaching in PCIT, Barnett et al. [50] found that therapists use a range of both directive and responsive coaching statements. In looking at session-to-session change, Barnett et al. [50] found that responsive coaching mediated parents' skills acquisition, with parents using more labeled praises in the following session, while directive coaching techniques were associated with fewer labeled praises and behavior description in the following session. ...
... In their initial evaluation of the Therapist-Parent Interaction Coding System (TPICS), which allows for direct coding of therapists' coaching in PCIT, Barnett et al. [50] found that therapists use a range of both directive and responsive coaching statements. In looking at session-to-session change, Barnett et al. [50] found that responsive coaching mediated parents' skills acquisition, with parents using more labeled praises in the following session, while directive coaching techniques were associated with fewer labeled praises and behavior description in the following session. In a follow up to this study, Barnett et al. [25] found that responsive coaching predicted faster completion of the CDI phase, while families who dropped out of treatment received fewer responsive coaching statements and more skill drills. ...
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Parent–child interaction therapy (PCIT) is one of the strongest evidence-based treatments for young children with behavior problems. Despite the efficacy of PCIT, many families fail to complete treatment, with attrition rates ranging from 30 to 69 percent. Preliminary research on attrition in PCIT treatment studies has linked maternal distress, negative verbal behavior (critical and sarcastic comments towards the child), lower socioeconomic status (SES), and fewer child major depressive disorder (MDD) diagnoses with premature termination from PCIT. However, more research is still needed to identify the range of reasons for treatment discontinuation. The purpose of the present study was to explore the range of reasons for premature termination from PCIT by conducting in-depth interviews with parents who discontinued PCIT using a qualitative design methodology. Results yielded eight themes, which were organized into three constructs: child-directed interaction (CDI) successes, difficulties with treatment, and the need for more clarity and orientation. Several existing treatment strategies that emerged from the data could be applied to PCIT to further enhance it and potentially reduce dropout (e.g., reconceptualizing dropout from PCIT, micro-orienting strategies used in other cognitive and behavioral therapies and dialectical behavior therapy). Understanding the reasons why parents drop out of PCIT and exploring different adaptations that can be made can further enhance this evidence-based treatment and increase its accessibility.
... Even though therapists in both interventions were instructed to counsel in a supportive way, we predicted that the therapists in the nondirective intervention would demonstrate greater emotion-and relationship-focused behavior, as they were specifically instructed to mainly support the parents in reflecting of their feelings and behaviors. Based on previous studies [16][17][18], we hypothesized that, in turn, high levels of both guiding and structuring therapist behavior and sensitive, emotionand relationship-focused behavior would lead to a reduction in blind-rated ADHD and ODD symptom severity, and parent-rated functional impairment. ...
... Previous literature reported a link between positive or responsive therapeutic behavior and improved treatment outcomes [16,18]. In accordance with these findings, our results revealed a significant mediation effect through emotion-and relationship-focused behavior. ...
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The study examined potential mediating effects of therapist behaviors in the per-protocol sample (n = 108) of a randomized controlled trial comparing a behavioral and a nondirective guided self-help intervention for parents of children with externalizing disorders (4–11 years). Additionally, from an exploratory perspective, we analyzed a sequential model with parental adherence as second mediator following therapist behavior. Outcomes were child symptom severity of attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder rated by blinded clinicians, and parent-rated child functional impairment. We found a significant indirect effect on the reduction of ADHD and functional impairment through emotion- and relationship-focused therapist behavior in the nondirective intervention. Additionally, we found limited support for an extended sequential mediation effect through therapist behavior and parental adherence in the models for these outcomes. The study proposes potential mediating mechanisms unique to the nondirective intervention and complements previous findings on mediator processes in favor of the behavioral group. Trial registration NCT01350986.
... Parent-Child Care (PC-CARE) is a brief (1 pre-treatment plus 6 weekly sessions) dyadic parenting intervention for children aged 1-10 years. We developed the protocol using research on effective strategies in parenting interventions [1,7], coaching [8], and implementation in community mental health settings [9]. We wanted to develop a brief intervention that addressed problems with engagement (i.e., client attrition/retention) reported in research on parenting interventions in community settings [2,3]. ...
... Allowing them to give voice to their attitudes and beliefs in this way is consistent with motivational interviewing styles of engagement in treatment [12]. We planned to use a coaching modality with the parent and child together, which has been found to increase the effectiveness of parenting interventions [8]. Finally, the intervention needed to be feasible for use in a community mental health setting. ...
Full-text available
Research shows that parenting interventions struggle with keeping clients in treatment. The purpose of this study was to compare attrition and rates of improvement in caregiver-child dyads participating in either Parent–Child Care (PC–CARE), a brief, 7-session parenting intervention or Parent–Child Interaction Therapy (PCIT) over a 7–week period. Participants were 204 caregiver-child dyads referred to either PC-CARE (N = 69) or PCIT (N = 135) between 2016 and 2019. Children were aged 2–7 years, referred for treatment by county Behavioral Health Services, and Medicaid funded. Findings showed that PC–CARE participants were 2.5 times more likely than PCIT participants to complete 7 sessions, all other things being equal, and showed significantly greater rates of improvement during this timeframe in reported child behavior problems and parenting stress. In conclusion, compared with PCIT, PC–CARE showed greater retention and rate of improvement in child and parent outcomes over a comparable time period.
... It is also immediate, in the sense therapist comments occur in close temporal proximity to parent behavior, which allows parents to practice or adjust their behavior shortly after the original behavior. A few studies have found in vivo feedback to affect parent behavior (Barnett et al., 2014;Barnett et al., 2017;Heymann et al., 2021), which supports its role as an active ingredient in parenting programs. ...
Full-text available
Transportation of evidence-based programs (EBPs) to a new cultural setting is often preferred over the comprehensive process of developing a new program. Intervention fidelity has been suggested as a predictor of successful transportation. The present study examined whether fidelity and parent behavior improved when implementing the U.S.-developed Attachment and Biobehavioral Catch-up (ABC) intervention in Norwegian child welfare services (CWS). 11 child welfare workers received training and supervision to become ABC parent coaches. Fidelity was assessed through video-recordings of parent coaches' in vivo feedback at each home-visit session. Parent sensitive behavior was assessed using video-recordings of parent–child interactions, recorded before each ABC session. Mixed effects modeling showed that ABC fidelity increased over the course of training and supervision. Furthermore, parent behavior improved over the course of families' exposure to the intervention. These demonstrate that an EBP transported to a novel cultural setting can obtain promising levels of fidelity and intervention outcomes.
... PC-CARE was founded on research on effective mechanisms in parenting interventions [4,13,14], as well as research on parent coaching [15] and implementation in community mental health settings [16]. Some of the most effective evidence-based behavioral parenting interventions involve teaching new skills each week in a 12-week group format (Incredible Years [17]), teaching caregivers skills then using live "bug-in-the-ear" coaching over 14-20 weeks to help caregivers develop "mastery" of those skills (Parent-Child Interaction Therapy; PCIT [18]), teaching new strategies and active skills training weekly for 10 individual or 5 group sessions (Level 4 Triple-P [19]), or using a combination of teaching and video review over 10 sessions (Attachment & Biobehavioral Catch-Up [20]). ...
Full-text available
Parent-Child Care (PC-CARE) is a brief intervention for children with externalizing behaviors designed to address issues with their access to and retention in treatment. A growing evidence base of open trials and comparison studies support PC-CARE’s benefits, but no randomized controlled trials (RCTs) of its effectiveness exist. The current study presents the first RCT of PC-CARE, a 7-session dyadic parenting intervention (trial number removed for blind review). Participants included a racially/ethnically diverse sample of 49 children (29% female) aged 2–10 years and their caregivers. Participants were randomly assigned to PC-CARE or waitlist control. Families participating in PC-CARE showed greater reductions in children’s externalizing behaviors, improvements in children’s adaptive skills, declines in parental stress, and increases in parents’ positive communication skills, compared to families on the waitlist. The results of this first RCT of PC-CARE support the effectiveness of this brief intervention in improving children’s behaviors.
... Another challenge is that fidelity measures are largely EBP-specific, limiting the ability to capture behavior change across the implementation of multiple EBPs (Perepletchikova, 2011). For a parenting program, fidelity might be measured using a behavioral observation system that measures common elements (e.g., teaching how to praise positive child behaviors) across different evidence-based parenting programs (Garland et al., 2010a), or a measure that captures processes that are unique to the intervention (Barnett et al., 2014;Eames et al., 2008). Innate to issues related to fidelity are questions related to the flexibility or adaptability of EBPs, as modifications to EBPs are recognized as being common to improve the fit for the client, provider, and organization (Aarons et al., 2012;Lau et al., 2017;Stirman et al., 2013). ...
Dissemination and implementation (D&I) research is a transdisciplinary field that emerged to facilitate the uptake and sustainment of evidence-based practices within real world settings. As opposed to traditional clinical research, which focuses on client level outcomes (e.g., symptom checklists), D&I research focuses on outcomes related to clinicians, organizations, and systems of care. This chapter provides an overview of D&I research, including implementation science frameworks, outcomes, strategies, and designs. Throughout the chapter, roles for clinical psychologists in conducting D&I research are highlighted.
Research on the delivery of behavioral assessment and treatment via telehealth has focused largely on child outcomes and parent procedural fidelity. By contrast, the behavior of the therapists coaching parents to conduct assessment and treatment has garnered little research consideration. In this study, we conducted a retrospective analysis of behavior therapists' coaching behaviors when directing parents to conduct functional analysis (FA) and functional communication training (FCT) with their young children with autism via telehealth. Coaching behaviors for five experienced behavior therapists across seven parent-child dyads were scored using a combination of standardized and novel behavior codes. Therapists displayed more social engagement behaviors than any other type of behavior throughout the study, and rates of antecedent and consequence behaviors shifted across the FA and FCT phases. Results are discussed in relation to therapists' goals during behavioral assessment and treatment and the implications for training behavioral therapists to coach parents via telehealth.
Although live coaching using behavioral principles is a powerful mechanism of change in behavioral parent training (BPT), little research has examined the coaching process. We used a cross-sectional sample of coaches with different levels of training in the evidence-based behavioral parent training model parent-child interaction therapy (PCIT) to begin to understand how training impacts coaching techniques. Forty-six coaches including PCIT lay helpers, therapists, within-agency and global/regional trainers, provided a sample of coaching in response to a standardized parent-child interaction. Level of training was significantly and positively associated with coaching verbalizations (r(44) = .80, p < .001). Training level was also associated with effective coaching strategies such that as training increased, coaches used more strategies related to positive treatment outcomes for families. Results suggest that coaches with less training may benefit from additional education around certain types of responsive coaching strategies. Findings raise important questions about how "adequate" and "optimal" coaching might be defined.
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This paper focuses attention on the therapeutic relationship in parent-child therapy by using social reinforcement with parents and children as it relates to Parent-Child Interaction Therapy (PCIT). As in other therapy contexts, it is argued that having the therapist serve as a mediator of social reinforcement facilitates client change, After discussing different aspects of PCIT, we discuss the therapeutic relationship as viewed through other theoretical frameworks. This is followed by a discussion of the role of social reinforcement in the parent-child relationship. We then discuss at methodological and applied levels, the importance of therapist accuracy and consistency in the delivery of reinforcement as a means of changing the parent-child relationship. Next, this is followed by a discussion of the therapist-to-parent-to-child sequential chain of behaviors involved in PCIT. Finally, suggestions for future empirical studies are considered.
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The impact of therapist characteristics on maternal compliance and satisfaction was examined with a parent-training program, Parent-Child Interaction Therapy (PCIT). Participants were 45 mothers with children between the ages of 24 and 83 months. Each mother was taught components of PCIT using one of three therapist communication styles: (1) positive, (2) neutral, and (3) constructive criticism. Although all groups demonstrated an increase in skill level from pre- to post-treatment, mothers in the constructive criticism therapist group used the target skills at a significantly higher rate at post-treatment than the two other groups. No difference was found on maternal satisfaction. The importance of considering therapist variables when providing parent training is discussed.
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Because the results of a regression analysis can be sensitive to outliers (either on y or in the space of the predictors), it is important to be able to detect such points. The author discusses and interrelates the following 4 diagnostics that are useful in identifying outliers: studentized residuals, the hat elements, Cook's distance, and Mahalanobis distance. Guidelines are given for interpretation of the diagnostics. Outliers will not necessarily be influential in affecting the regression coefficients. (27 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study employs a factorial design to investigate the efficacy of all possible combinations of modeling, praise, and criticism as a means of teaching empathic responding to counselor trainees. Measures of empathy were taken on 64 female introductory psychology students at the beginning of an experimental session and following each of two training segments. Results indicate a significant effect for modeling and stage of training. There was a significant interaction between modeling and stage of training such that subjects in the modeling conditions were rated higher in empathy than those in the no‐modeling condition at the mid‐ and postmeasure but not at the premeasure. Results are in agreement with one previously published study but are inconsistent with two others. Discussion focuses on the critical elements of effective feedback techniques.
A 3-year-old boy, “Christopher,” ran recklessly around the playroom overturning chairs and tables, stopping just long enough to poke a Lincoln Log in his mother’s face and yell, “Stupid bitch! I’m gonna kill you! Pottyhead.” She had come for help after awakening from a nap to find her young son hovering over her with a kitchen knife. Christopher’s mother had a history of being abused by her step-father and was now in a violent relationship with her spouse. Christopher had witnessed many confrontations between his parents including incidents in which his father choked his mother, a vase was thrown and shattered on a wall, and both of his parents shouted obscenities at each other. Christopher was exhibiting serious aggression both at home and toward other children at daycare.
This manual is designed to serve several purposes. First, it sets forth detailed instructions on conducting a highly effective, empirically validated program for the clinical training of parents in the management of behavior problem children. Second, it provides a series of parent handouts to be used during the course of the program. These handouts include various rating scales and forms to be completed by the parent, as well as instructions to the parent for use with each step of the program. The handouts are designed to be easy to read and brief. They are not meant to be used without training by a skilled child/family therapist. Finally, the manual outlines methods of assessment that the trainer may wish to employ in the initial evaluation of the child and family or in the periodic evaluation of treatment effects throughout training. The program was designed for children between 2 and 11 years of age. (PsycINFO Database Record (c) 2012 APA, all rights reserved)