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Assessing the Key to Effective Coaching in Parent–Child
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, parent–child 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 therapist’s
coaching style and frequency, and (3) whether coaching me-
diates 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.
Keywords Parent–child interaction therapy .PCIT .
Behavioral parent training .Child conduct problems .
Mediators of change .In vivo coaching .Assessment-guided
treatment
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 children’sbe-
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 children’sbehav-
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 parents’behavior 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 parent–child 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 parent’s 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
e-mail: niec1L@cmich.edu
M. L. Barnett
e-mail: barne2ml@cmich.edu
I. D. Acevedo-Polakovich
e-mail: david.acevedo@cmich.edu
J Psychopathol Behav Assess (2014) 36:211–223
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
parents’acquisition 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 “Do”skills (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 “Don’t”behaviors (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 parent–child
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 parent–child behavior observation prior to
coaching, the therapist assesses the parent’suseofthe“Do”
and “Don’t”skills (see Table 1for examples). The assessment
is meant to guide the therapist’s coaching, allowing more focus to
be given to a parent’s 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 “Do”skills (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 parent’s 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)
Behavioral
code
Description Examples
Behavior
Descriptions
A declarative sentence where a
parent states what a child is doing
or recently did.
“Your building
atower.”
Unlabeled
Praises
A nonspecific verbal statement of
approval of an attribute, behavior,
or product of the child.
“Thank you”
“Good work”
Labeled
Praises
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: “It’sfast.”
Parent: “It’sfast.”
Negative
Tal k
A statement that criticizes a child’s
activity, behavior, or verbalizations.
“That’s the wrong
way.”
Question A descriptive or reflective comment
expressed in the form of a question.
“What does a
cow say?”
Direct
Commands
A declarative sentence that requests
that a child perform a specific
activity or behavior.
“Please hand me
that red block.”
Indirect
Commands
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) 36:211–223
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 parent’sexisting
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., therapist’spraise)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 parents’skill 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 parents’skill 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 parents’skills (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
question—How 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
skill.
“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
behavior.”
Drills An exercise that sets a specific skill goal or
time to focus on a skill.
“Let’s see how many praises you
can do in 1 min.”
Responsive coaching
Labeled praises A specific positive statement about a
parent’sbehavior.
“That was a great behavior
description!”
Process comments A statement that ties the child’sbehaviorsto
the parent’sbehaviors
“She smiled when you praised
her!”
Reflective descriptions A statement that informs a parent what skill
they used.
“That was a behavior description.”
Corrective criticism A correction of a parent’sbehavior. “Whoops, that was a question.”
Unlabeled praises A nonspecific praise of the parent. “Great!”
J Psychopathol Behav Assess (2014) 36:211–223 213
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 families’early 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-
dren’s 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) parents’skill acqui-
sition. To address our primary aim we explored three
questions.
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 parent’s assessed skill-level at the beginning of
session guide a therapist’s coaching of that skill? Based
on recommendations by PCIT researchers and clinicians
that a parent’s observed parenting skills should inform the
therapist’scoaching(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 therapists’type 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 parents’skill 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.
Methods
Participants
Parent–Child 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 children’s 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 children’s 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 parent–child
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) 36:211–223
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.
Measures
Dyadic Parent–Child 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 parent–child dyads and parents’use
of effective parenting skills. We assessed parents’interactions
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 aparent’s 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) 36:211–223 215
(e.g., “Let’s see how many behavior descriptions you can use
in a minute”).
Responsive coaching techniques follow aparent’sbehavior
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 parent’s 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 parent–child 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, “Other”to refer to any time a therapist
coached a different parenting skill.
Procedure
DPICS Coding For the original RCT, the 5-min behavior
observations of parents’skills 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, participants’treatment
condition, and treatment session number. Of the 114 5-min
behavior observations of parents’skills 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 “Don’t”behaviors
(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 parent–child dyads attended the following
week’s 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
used
Time during session Behaviors coded N
DPICS-III 5 mins. of coding prior to
coaching
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 Parent–child Interaction Coding System-Third Edi-
tion; TPICS Therapist-Parent Interaction Coding System
216 J Psychopathol Behav Assess (2014) 36:211–223
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 parent’sskillslevel.
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
Kenny’s(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 parent’s skill level in the subsequent
session was regressed on the coaching technique.
Results
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
system
n=16
Coaching techniques
r
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
Don’tskills 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) 36:211–223 217
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 “Do”skills (i.e., parenting behaviors meant to be
increased; M=24.43, SD =7.08). Therapists also frequently
coached “other”parent behaviors (M= 10.15, SD =7.67).
“Other”parent 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 child’s lead. Of the targeted
parenting “Do”behaviors, 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 “Don’t”behaviors (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 Parent’s Skill-Level Guide a Therapist’s 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 parents’use 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 parents’skill acquisition. No significant relation-
ship was found between directive techniques and parents’use
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 parent’s 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 parents’demonstrations
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 parents’skill levels in the child-
centered skills. For a summary of the relationships be-
tween parent’s skills and coaching styles see Table 8.
Does Coaching Mediate Parents’Skill Acquisition?
Baron and Kenny’s(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 “do”skills 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 “don’t”behaviors 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) 36:211–223
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 parents’initial 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 parent’s skill development for
labeled praises.
Directive coaching did not meet the preconditions for
mediation, as this technique was not related to a parent’sskill
level in the subsequent session for any of the skills.
Discussion
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-
pists’in 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-
ents’skill 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 parents’reflections. 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, “You’re building a blue tower.”)andlabeled praises to
parents (“Great job describing his behavior!”) being the most
frequently used techniques. Overall, therapists targeted the
“Do”skills (i.e., labeled praises, reflections, behavior descrip-
tions) approximately five times for every minute of coaching;
whereas they coached the “Don’t”skills (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
RF BD LP
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
<0.01
a
b
Predictor Variable :
Initial use of
Labeled Praises
Outcome Variable :
Next Session use of
Labeled Praises
= .25*
Mediating Variable :
Responsive
Coaching
Predictor Variable :
Initial use of
Outcome Variable :
Next Session use of
Labeled Praises
=.20
= .29* = .22*
Fig. 1 Mediational model for
labeled praises and responsive
coaching. N=52. *p<0.05
J Psychopathol Behav Assess (2014) 36:211–223 219
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-
pists’in 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). Parents’use 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
parents’skills effectively.
Responsive Coaching Mediates Parents’Skill Acquisition
Mediational models between parents’skill 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 parent’s 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 parent’s 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 parents’verbalization. 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., parents’practice at
home, severity of child conduct problems), it is notable that
responsive coaching could mediate parents’skill 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
parent’s 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 therapist’s 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 therapists’in vivo
coaching of parent–child 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 parent–child 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) 36:211–223
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 PCIT—responsive 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 study’s 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?
Conclusions
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 parents’skills to guide their
coaching, it was also apparent parents’skill 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 parent’s skill level from one session to the
next.
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
parent–child 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-
ingofjustwhatitisthatmakesatherapist’scoaching
competent.
Acknowledgments This study was supported by a grant to the second
author from the National Institute of Mental Health (MH 070483). The
authors acknowledge the research and clinical staff of the Center for
Children, Families and Communities and Allyn E. Richards.
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