Low Treatment Fidelity as an Indication to Switch Interventions: Pivoting From Child-Parent Psychotherapy to Parent-Child Interaction Therapy for Early Childhood Trauma

Abstract

Young children who experience trauma and adverse experiences are at an increased risk of developing an insecure attachment style as well as negative physical and mental health problems. These can include internalizing and externalizing behavioral problems, developmental delay, emotional dysregulation, and aggression. Several evidence-based interventions exist to treat young children with symptoms related to trauma, each with different foundational theories. This article presents the case of a 4-year-old boy with posttraumatic stress disorder who was in the middle of a legal fight between caregivers and transitioning between caregivers’ homes. Initially, therapy began with Child-Parent Psychotherapy to address caregivers’ first concerns. Later, the therapeutical approach was switched to Parent-Child Interaction Therapy due to difficulty with treatment fidelity related to caregivers’ symptoms and conflict. This case demonstrates great improvement in treatment fidelity and subsequently problem behaviors after switching to an intervention that allowed to address behavior management shortcomings in a family with ongoing conflict.

Keywords

Parent-Child Interaction Therapy Child-Parent Psychotherapy trauma behavioral intervention parent training

1 Theoretical and Research Basis for Treatment

Traumatic stress during childhood is considered a silent epidemic (D'Andrea et al., 2012). Childhood trauma includes events that pose a threat to harm or cause physical and/or emotional harm and lead to feelings of fear, terror, and helplessness (Dye, 2018). Early childhood trauma (i.e., prior to age 6) is often in the form of maltreatment (e.g., neglect and physical and sexual abuse) or associated with accidental injuries like fires, burns, or near-drownings (Child Welfare Information Gateway, 2018). Children who live in poverty, especially children of color, have a higher risk for trauma exposures in addition to life stressors like dense neighborhoods, single-parent status, and high parental stress (Roy & Raver, 2014). In fact, before age 6, children who live in poverty may have already experienced three or more traumatic events, including abuse, physical or emotional neglect, and witnessing substance abuse or domestic violence (Neitzel, 2020). Child emotional health and development is interrupted when a traumatic event occurs, placing the child at risk for future mental and physical health problems (Toof et al., 2020).

In the first 3 years of life, young children are especially susceptible to the negative impacts of toxic stress on the developing brain (Neitzel, 2020; Shonkoff et al., 2012). During this sensitive period of brain development, frequent or prolonged exposure to adverse events is associated with high cortisol levels in the brain which can lead to lasting negative effects on structures such as the amygdala, hippocampus, and prefrontal cortex (Gee, 2021; Popovic et al., 2020). Elevated cortisol levels in children who have experienced maltreatment has been associated with both internalizing problems as well as externalizing problems (Cicchetti & Rogosch, 2001), and it may additionally mediate the relationship between early childhood adversity and chronic disease in adulthood (Demakakos & Steptoe, 2022). In fact, early toxic stress among children as young as 3 months old can result in delays in communication, social-emotional, and cognitive skills as well as attachment problems (Neitzel, 2020; Shonkoff et al., 2012). Further, young children exposed to trauma are at increased risk for early learning difficulties and internalizing and externalizing behavior problems, which greatly impair adaptive functioning (Coates & Gaensbauer, 2009; McLaughlin et al., 2020). Common internalizing symptoms include withdrawal, feelings of worthlessness, and decreased self-esteem while common externalizing symptoms include aggression, crying, swings in emotions, and difficulty controlling emotional impulses (Hutchison et al., 2020).

Over the long term, children exposed to chronic early life stress are at a serious disadvantage compared to peers who have not had such experiences, particularly as it relates to learning and memory, later academic success, and future mental health problems (De Young et al., 2011; Lansford et al., 2002). These disadvantages increase the likelihood of school dropout, risky behavior, incarceration, and poor job placement (Pechtel & Pizzagalli, 2011; Saleh et al., 2017). Additionally, childhood trauma may increase risk for poorer physical health outcomes in adulthood including obesity, hypertension, stroke, and cancer (Felitti et al., 1998). Taken together, these long-lasting effects of trauma pose a serious public health problem worthy of cross-sector advocacy, interventions, and policy change (Coates & Gaensbauer, 2009; McLaughlin et al., 2020).

Attachment theory emphasizes the role of primary caregivers in protecting children in the face of perceived danger in addition to providing nourishment to children (Ainsworth, 1978). When caregivers offer comfort and protection in the face of perceived threats, children learn to regulate their emotions and manage stressful circumstances. The caregiver creates a secure base from which the young child can explore the world and develop a sense of security. Safe and healthy attachments are meaningful in increasing social adaptation and developing adequate mental health (Ainsworth, 1979; Tracy & Ainsworth, 1981). When caregivers do not fulfill this role, children will most likely feel their safety threatened and develop feelings of mistrust toward the caregiver, leading to a disrupted attachment (Owen, 2020). Adverse childhood experiences are at the root of disrupted attachment styles and emotional dysregulation (Galbally et al., 2020; Reinbergs & Fefer, 2018; Zdankiewicz-Ścigała & Ścigała, 2020).

When treating early childhood traumatic experiences, interventions founded in attachment, child development, and cognitive behavioral theories have proven successful. Among these interventions, core components of treatment involve (1) teaching caregivers to respond to child behavior in a supportive, warm manner while setting healthy limits and expectations; (2) teaching caregivers to model good social-communication skills and help their children regulate and express strong emotions; and (3) teaching caregivers to understand the impact of trauma on the developing child. Placing emphasis on caregiver skills is common to these interventions and critical to restoring the relationship between caregiver and child and promoting a healthy attachment, as well as reducing challenging child behavior (De Young et al., 2011). The most common treatments available for early childhood (i.e., ages 2+) include Attachment and Biobehavioral Catch-up (ABC; Dozier et al., 2006), Child-Parent Psychotherapy (CPP; Ghosh Ippen et al., 2011; Lieberman et al., 2005), and Parent-Child Interaction Therapy (PCIT; Eyberg et al., 2001) and for children 4 and older, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT; Cohen & Mannarino, 1996). While all these interventions have their merits, they are not universally available for a myriad of reasons (see discussion in Cambric & Agazzi, 2019). The purpose of this case study is to describe the clinical application of two of these interventions, CPP and PCIT, with a child with early life trauma exposures. The authors aim to share their rationale for treatment selection for a child with early life trauma exposures, including the order of interventions. As such, the remainder of the introduction focuses on aspects of these interventions as applied to early childhood trauma.

Child-Parent Psychotherapy is an evidence-based intervention developed at the University of California San Francisco specifically for young children aged birth to 5 years with a history of maltreatment and exposure to violence. CPP is founded in attachment theory but also integrates several other theories including psychodynamic, developmental, trauma, cognitive behavioral, and social learning theories. CPP involves three phases of treatment: (1) Foundational Phase: Assessment and Engagement, (2) Core Intervention Phase, and (3) Recapitulation and Termination: Promoting Sustainability of Gains. Through weekly dyadic play sessions, therapists and families work on strengthening and enhancing family relationships, fostering the child’s sense of safety, improving emotional regulation, and helping caregivers understand the meaning of the child’s behavior (Lakatos et al., 2019; Lieberman et al., 2015). Central to CPP is the use of the caregiver–child relationship as a vehicle to restore and protect the child’s mental health. During this time, caregivers and children work on creating a joint trauma narrative and with the therapist’s help, correcting any maladaptive representations of each other and addressing trauma triggers (Bernstein et al., 2019). In multiple randomized controlled trials (RCTs), CPP has effectively reduced symptoms associated with posttraumatic stress disorder (PTSD), reduced PTSD-related avoidance, and increased secure attachment in children and mothers (Lieberman et al., 2006; Toth et al., 2006). CPP has a Scientific Rating of 2 (e.g., Supported by Research Evidence) with High Child Welfare Relevance on the California Evidence-Based Clearinghouse for Child Welfare (2022).

Parent-Child Interaction Therapy was originally developed to treat behavioral and emotional problems in children ages 2–7 years old. PCIT fosters positive parenting skills in two phases. The first phase, Child-Directed Interaction (CDI), aims to enhance the caregiver–child relationship through a special playtime. The child gets to direct the interaction, and caregivers use positive parenting skills (i.e., labeled praise, reflection, and behavioral description) while avoiding questions, commands, and negative talk (Eyberg, 1988). During the second phase, Parent-Directed Interaction (PDI), the parent is coached to set appropriate limits and consistently follow through with consequences for disruptive behaviors. Throughout the intervention, the therapist observes the session through a two-way mirror and communicates with the caregiver through a bug-in-the-ear device. Parents must meet mastery criteria to graduate from each phase. In multiple randomized controlled trials, PCIT consistently led to large decreases in child externalizing behaviors and caregiver stress and increases in child compliance with caregiver requests and caregiver confidence in managing child behavior (Thomas et al., 2017).

Parent-Child Interaction Therapy has been widely used in cases of child maltreatment (Thomas & Zimmer-Gembeck, 2012). Most literature on this topic has shown that training in parenting skills contributes to decreasing children’s behavior problems. PCIT directly alters inconsistent and harsh parenting practices that are the source of maltreatment, replacing them with increased positive interactions. These studies have been conducted in several settings including hospitals, community mental health services, foster homes, and child welfare clinics. Primary findings include significant reduction in child behavior problems, increases in positive parenting skills and decreases in negative parental demands and parental stress, higher levels of positive attention, and decreases in children externalizing problems (Thomas & Zimmer-Gembeck, 2012). These treatment gains have reported to last up to 16 months and transcend any specific disorders and abuse exposures.

2 Case Introduction

Max was 4 years old when he presented for a diagnostic interview at a local pediatric psychiatry clinic. Max’s guardians (paternal grandmother, grandfather, paternal uncle, and his wife) noted that he had problems with aggression since they took temporary custody of him, which was after being removed from his biological parents’ care at age 14 months due to physical abuse and neglect. Max had not been previously evaluated, diagnosed, or treated for any behavioral concern.

3 Presenting Complaints

In multiple caregiver home settings, caregivers reported Max presented with severe aggression which included hitting, scratching, or biting caregivers and peers, throwing objects/furniture at caregivers, and hitting himself. Further, his caregivers reported concerns related to Max’s difficulty with transitioning between caregivers, anxious behaviors, increased frequency of negative emotionality, irritability, hyperactivity/impulsivity, non-compliance with adult directions, difficulty staying in bed at night, nightmares when sleeping, and socially withdrawn behaviors. The presence and severity of symptoms were reported to be worsening as Max aged.

4 History

The pregnancy with Max was complicated by intra-uterine drug exposure (opiates and tobacco) and little prenatal care. Max was born full-term with an unremarkable delivery. He was admitted to the Newborn Intensive Care Unit (NICU) for neonatal abstinence syndrome and discharged after 1 month. He lived with his biological parents for the first 14 months of his life. Max and his birth parents experienced homelessness, and Max experienced neglect, exposure to adult sexual behavior, and witnessed intimate partner violence. He was removed from his biological parents’ care at 14 months and placed with his paternal grandparents. At that time, Max’s paternal uncle and his wife were living in the home with Max and his grandparents. Max’s grandparents noted developmental delays and brought him to Early Steps for evaluation. He received early intervention services until age 3 for communication and social-emotional skills (records were provided for review). Grandmother reported that early intervention services were helpful for remediating speech skills as well as social-emotional skills and early intervention was discontinued when Max turned 3 years old. Max had attended a daycare from the time he entered his paternal grandparents care until the onset of COVID-19. Per grandmother’s report, the daycare was concerned with developmental delays initially but was satisfied with Max’s progression with early intervention services. The daycare shared caregiver concerns about aggression and hyperactivity but was not concerned about compliance.

Max’s biological parents occasionally visited Max under the grandparents’ supervision, but they did not adhere to their case plans and eventually had their rights terminated. As part of the permanency plan, grandparents agreed to shift temporary custody to Alex and Lauren (paternal uncle and his wife) when Max was 3 ½ years old, as the couple intended to adopt Max through the state child welfare agency. Shortly after the custody transition, Alex and Lauren separated and entered a contentious divorce and disagreed about who should have primary custody of Max at adoption. Max presented to our clinic about 6 months after the prospective parents had separated, and thus, he was moving between the homes of aunt, uncle, and grandparents daily. In this period, Max’s biological father died of drug overdose. Max’s paternal grandmother was requesting therapy services for Max and his caregivers to address disruptive and aggressive behaviors.

5 Assessment

Given the variety of concerns and severity of behaviors, a comprehensive assessment for diagnostic clarification was indicated. A pediatric psychologist administered the following assessment battery: Battelle Developmental Inventory – Second Edition (BDI-2; Newborg, 2005), Child Behavior Checklist (CBCL caregiver forms; Achenbach & Rescorla (2001)), Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus (1999)) Traumatic Events Screening Inventory Parent Report Revised (TESI-PRR; Ford, 2002). The BDI-2 provided an estimate of Max’s general developmental functioning. Max scored below average in the Adaptive (SS = 80, ninth percentile), Motor (SS = 80, ninth percentile), and Personal (SS = 82, 12th percentile) domains. He scored low average in the Cognitive Domain (SS = 87, 19th percentile) and average in the Communication Domain (SS = 104, 61st percentile). These scores suggested Max had personal and normative weaknesses but did not meet criteria for a global developmental delay. The CBCL and the ECBI provided estimates of behavior problems as rated by three caregivers: paternal grandmother (Lily), paternal uncle (Alex), and his aunt by marriage (Lauren). On the CBCL, Max’s grandmother and uncle rated him in the clinical range across Internalizing Problems (T-score = 72 both raters), Externalizing Problems (T-score = 80 both raters), and Total Problems (T-score = 74 and 77, respectively) Composites. In addition, both raters reported clinical concerns across the DSM subscales except for the Attention Deficit/Hyperactivity Problems (ADHD) scale, wherein uncle did not report ADHD problems. Max’s aunt rated borderline scores for Internalizing Problems (T-score = 63) and clinical scores for both Externalizing Problems (T-score = 68) and Total Problems (T-score = 67) Composites. Max’s aunt endorsed clinical concerns on two DSM scales: Pervasive Development Problems (T-score = 72) and ADHD (T-score = 71). On the ECBI, grandmother and uncle rated clinical scores on the Intensity scale, but his aunt rated an average score (T-scores = 68, 64, and 58, respectively). The Problem scale was in the clinical range per grandmother’s report, but not per uncle or aunt (T-scores 71, 47, and 52, respectively). The TESI-PRR assesses a child’s experience with a variety of potential traumatic events. On this administration of the TESI-PRR, Max’s grandmother reported he had multiple chronic traumatic stress exposures during the first 14 months of life including (1) separation from primary caregivers, (2) observing physical aggression between caregivers and other adults, (3) homelessness/unstable housing, (4) neglect and under stimulation, (5) malnutrition, and (6) exposure to caregiver sexual behaviors (e.g., including prostitution). More recently, Max had experienced the marital separation of his prospective adoptive parents (paternal uncle and his wife) and the stress of moving between multiple caregivers and homes. Thus, results from the evaluation provided sufficient evidence for a diagnosis of posttraumatic stress disorder for children 6 and under. While marked symptoms of ADHD were present, the psychologist recommended Max be re-evaluated once he enrolled in a full-time school program and after having completed therapy to address PTSD. Max’s difficulties with self-regulation, aggression, sleeping, compliance, and anxiety were thought to be secondary to PTSD.

6 Case Conceptualization

Given the presenting concerns and the history of adverse experiences, our clinical team in conjunction with Max’s caregivers and child welfare case manager decided that CPP was the most appropriate intervention. Max’s early childhood adverse experiences, the stress associated with moving between caregivers’ homes, the loss of his father (this event was particularly difficult for grandmother who was grieving the death of her son), and now the marital separation of his prospective adoptive parents were causing significant distress for Max and his family and interfering with his development, emotional regulation, sleep, and social relations. We hypothesized that CPP would target Max’s symptoms of trauma and support him (and his family) to return to normal development and adaptive coping, improve his capacity to respond to threats, maintain affective arousal, restore his relationships, and place the trauma responses Max experienced in perspective for his caregivers.

7 Course of Treatment and Assessment of Progress

Over four CPP Phase 1 sessions, we observed caregiver–child interactions while each caregiver played with Max, assessed caregiver mental health functioning and past trauma exposures via questionnaires and interviews, reviewed caregiver and child assessment data with caregivers (being sure not to share any individual caregiver’s data with another caregiver), and worked with caregivers on creating the Triangle of Explanations (Lieberman et al., 2015). The Triangle of Explanations is the concluding task of the Foundational Phase, wherein caregivers and the therapist work collaboratively to develop a child-focused explanation for why the child is coming to treatment. It is a critical component of intervention, and caregiver involvement is imperative as caregivers must be motivated and committed to talking openly with their child about the traumatic event(s). The child’s experiences, behavior/feelings, and reason for treatment are presented. Max’s Triangle of Explanations was “You have three homes now; this might make you feel angry, confused, or scared; this is a place where we can talk about those feelings.” This statement only described the current stressors Max was experiencing, but all the caregivers acknowledged that therapy would be a safe place to discuss Max’s other adverse experiences including the loss of relationships with biological parents and his father’s death. Developmentally appropriate discussions of these topics were encouraged and supported during CPP. For example, a common narrative that came up in therapy as Max would play with houses and act out transitioning between caregivers’ homes was “you went to live with grandma and grandpa because mom and dad were not able to take care of you, now you are also living with aunt and uncle. It’s hard to move around between houses.”

Despite our best efforts, CPP was complicated by the contentious separation and impending divorce of Max’s paternal uncle and his wife. The former couple requested to have separate CPP sessions as they did not want to see each other in the clinic and so we began to rotate caregivers in treatment with Max. One week Max would come with paternal grandmother and her son (paternal uncle), and the next week Max would attend with paternal grandfather and his aunt by marriage. While this did not affect the length of each individual session, it did affect the amount of time spent in each phase of treatment. Max and his caregivers completed 11 sessions of the Core Intervention Phase. During these sessions, caregivers struggled with regulating adult emotions associated with the growing discontent between Max’s grandparents and uncle versus his aunt by marriage over their disagreement about permanency. The former did not believe Max’s aunt should have legal custody of Max, given she was not his blood relative. The child welfare agency and Max’s aunt disagreed, and aunt maintained she wanted equal custody of Max. While therapy was supposed to be a place for Max and caregivers to communicate about his lived experiences in a therapeutic way, sessions were often derailed by caregivers criticizing the actions of one another and disagreeing about how to manage Max’s activities of daily living. We found it difficult to advance in CPP due to threats to intervention fidelity which the therapist was monitoring closely in session and in reflective supervision with colleagues. For example, regarding emotional process fidelity, caregivers were often triggered and avoidant and Max would shut down and hide under the table. Regarding dyadic-relational fidelity, the therapist struggled to hold/support so many competing child and caregiver perspectives so as to intervene in ways that strengthened the dyadic relationship. Sessions were often caregiver focused which interfered with promoting a more secure and growth-oriented relationship between caregivers and child. Procedural fidelity was challenging with caregivers rotating in and out of therapy sessions, even though sessions proceeded on a weekly basis. Further, therapy sessions were complicated by caregiver conflict (between four caregivers) about personal living choices and parenting practices, and caregivers repeatedly brought this talk up during session with Max present. Due to the high conflict, we recommended that caregivers consider family therapy as a space to improve communication. Max’s paternal caregivers followed the recommendation and made contact with a family therapist, but Max’s aunt did not participate.

The CPP Fidelity for Core Intervention Phase worksheet was completed after 11 sessions per recommended guidelines and the therapist requested a family meeting with the caregivers via telehealth to discuss the factors complicating to treatment fidelity. During the meeting, it was clear that the caregivers’ contention regarding Max’s permanency was a significant barrier to progression in CPP. Around this same time, the caregivers were participating in multiple court hearings with child welfare and undergoing court-ordered bonding assessments to ascertain which caregiver home was the best for Max’s permanency. As we waited for the results of the bonding assessment, the clinical team shared past observations with caregivers regarding their struggle to manage Max’s aggressive and non-compliant behavior within and outside of the clinical setting. Upon suggestion from our team, caregivers agreed to transition to a structured parent management training to address Max’s disruptive behavior while awaiting permanency results. Thus, we transitioned the family into PCIT and advised the family that the caregiver who was awarded permanency could return to CPP with Max in the future as indicated. All caregivers attended CDI Teach through CDI 3 of PCIT; however, from CDI 4 forward, only grandparents attended as they were awarded permanent custody and other caregivers opted not to continue treatment.

We followed the PCIT manualized protocol, engaging the child and caregivers throughout treatment. The primary therapist is a certified PCIT within agency trainer and the secondary therapists included a psychiatry fellow and a doctoral school psychology trainee working toward PCIT certification. One caregiver was in the room with Max at a time and the other caregiver remained outside the room, but not in the observation room with therapists due to COVID-19 social distancing requirements. Max was not explicitly advised of the change in intervention types, but per PCIT protocol, Max was told that he and his caregivers were coming to treatment to learn better ways to get along while they played together, as well as learn to follow directions.

Child Outcome Measure

Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus (1999)): Paternal grandparents completed the ECBI weekly to monitor Max’s behavior change over the course of therapy. The ECBI is a 36-item parent-report questionnaire that assesses conduct problems across two scales: Intensity (e.g., frequency) and Problem (e.g., impairing daily life). An average T-score on the ECBI is a 50 with a standard deviation of 10, and the clinical cutoff score for both intensity and problem subscales is a T-score of 60 or greater. The ECBI has demonstrated excellent psychometric properties (Eyberg & Pincus (1999)).

Caregiver Outcome Measures

Dyadic Parent-Child Interaction Coding System (DPICS; Eyberg et al., 2014): The DPICS-IV observational coding system was used to assess parenting skills and child compliance. The primary therapist is an experienced rater and coded all sessions and thus was not masked to the treatment session. Two secondary therapists, trained by the primary therapist, also coded all sessions and inter-rater reliability was above 85% across the sessions. Parent–child behaviors were coded per the protocol during a standard 5-minute play observation (i.e., low demand child led play) each week during the CDI phase of treatment (5 sessions) and again in sessions 2 and 3 of the PDI phase of treatment (family graduated at PDI 6). The CDI skills include P raise (e.g., Great job sitting!), R eflect (i.e., repeating the child’s talk), I mitate (i.e., play like the child), D escribe (e.g., You’re stacking blocks.), and E njoy (i.e., show positive emotion), otherwise known as the “Do” skills. At the same time, caregivers are instructed to avoid the “Don’t” skills: Questions, Commands, Criticisms. Caregivers must use 10 behavior descriptions, 10 reflections, and 10 labeled praises within a 5-minute coding to meet criteria. The CDI skills encourage child led play as the caregiver focuses on the child’s behavior and comments on child play using appropriate verbalizations, all the while promoting positive parent–child interactions. During PDI, child compliance with caregiver commands was coded in sessions 3 and 5 and computed as an averaged score across parent-led play and clean-up scenarios (total number of times complying divided by total number of commands; Eisenstadt et al., 1993). Caregivers must use direct commands with labeled praise for compliance and follow through for non-compliance on 75% of occasions to meet competency. The DPICS has good inter-coder reliability coefficients across coding categories (Shanley & Niec, 2010).

Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001): The PHQ-9 is a 9-item brief measure of depressive symptoms. It assesses how frequently respondents were bothered by each symptom (e.g., depressed mood, sleep difficulty, and anhedonia) during the last 2 weeks. Individuals report on a scale from 0 (Not at all) to 3 (Nearly every day). Summed scores greater than 9 indicate a need for additional evaluation. The PHQ-9 has demonstrated high internal consistency (α = .89) and has adequate convergent validity and sensitivity to change (Kroenke et al., 2001).

Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF; Abidin, 2013): The PSI-4-SF is a brief, 36-item measure which yields a Total Parenting Stress Score and four subscales. The four subscales are Defensive Responding, Parental Distress, Parent-Child Dysfunctional Interaction, and Difficult Child. Scores are interpreted in terms of percentile rankings, and a rank between the 15^th and 85^th percentile is considered normal. The instrument’s psychometric properties range from good to strong and it is commonly used in parenting interventions as a measure of caregiver stress (Reitman et al., 2002).

Therapy Attitude Inventory (TAI; Brestan et al., 1999): The TAI measured caregiver satisfaction with the process and outcome of therapy. Caregivers rated 10 items on a scale from 1 (dissatisfaction/problems) to 5 (maximum satisfaction/improvement of problems). The TAI total score demonstrated excellent psychometric properties (Brestan et al., 1999).

Attendance and homework compliance: Treatment acceptability was also assessed using indicators of treatment adherence and engagement, including session attendance and compliance with weekly homework activities. Attendance was measured by recording the number of missed or cancelled sessions. Homework compliance was measured using weekly homework sheets completed by caregivers during all treatment phases, which were reviewed and collected at the beginning of each treatment session. Homework compliance was calculated for CDI/PDI phases as the percentage of the total number of days of homework completion by the total number of days since the previous session, and this was averaged across sessions separately for each parent.

Child Results

ECBI: Caregiver report of Max’s behaviors on the ECBI improved over the course of treatment. At the CDI teach session, both caregivers rated Max’s behavior with the same score in the clinically significant range on the ECBI Intensity scale (T-score = 62) and in the normal range on the Problem scale (T-score = 46). Of note, the Intensity scale was just over the clinical cutoff (i.e., T-score ≥ 60) and the score was not congruent with caregiver reported distress with Max’s challenging behaviors. As illustrated in Figure 1 and Figure 2, caregivers’ ECBI ratings quickly decreased to below the cutoff score, and by graduation, caregivers’ scores were below the discharge range (T-score ≤ 55). The ECBI was mistakenly not administered during PDI 1, so that score is missing.

Caregiver Results

DPICS: Grandparents mastered the CDI skills according to DPICS coding criteria by CDI session 4. Grandmother began treatment with many labeled praises (7 in CDI 1, see Figure 3) but fewer behavior descriptions (1) and reflections (4). She made 8 statements that were coded as “Don’t skills” in CDI 1 but reduced such statements to 3 or less by CDI 2, thus meeting mastery criteria for “Don’t skills.” Grandfather started CDI with strong reflections (9 in CDI 1, see Figure 4) and fewer behavior descriptions (3) and labeled praises (2). He also had 11 statements coded as “Don’t skills” but reduced them to 3 or less by CDI 3 and maintained low use of these skills thus meeting mastery criteria for “Don’t skills.” Both caregivers met CDI criteria by CDI 4; notably, Max had 5 verbalizations during CDI 4 while playing with grandfather. Grandfather reflected all of Max’s verbalizations which gave him 100% reflections for opportunities provided and is an alternate criterion for meeting the Reflections mastery criterion when children do not make frequent statements.

Grandmother mastered the PDI skills by PDI 5, the second time her PDI skills were coded. She provided 7 direct commands, to which Max complied 100% of the time and she successfully delivered a labeled praise following his compliant behavior 100% of the time. Similarly, grandfather met mastery in PDI 5. He provided 12 direct commands and two indirect commands (86% effective direct commands). Max complied with 11 of 12 direct commands (92% compliance) and grandfather followed through with a labeled praise 75% of the time. Max went to the time-out chair during PDI 1–3 and during PDI 3 Max went to the chair one time with grandmother and 11 times with his grandfather due to repeatedly getting off the chair and having to go to time out room. After PDI 3, Max no longer had to go time out.

PHQ-9 and PSI-4-SF: Only Lily completed the PHQ-9 and the PSI-4-SF prior to and after intervention. Her pre-intervention score of 4 equated to minimal depression or in the “normal range” and she remained in this range at post-intervention with a score of 1. On the PSI-4-SF, greater improvements were noted, as Lily self-reported the following scores from pre- to post-intervention, respectively: Parental Distress = 20th percentile to 22nd percentile; Parent-Child Dysfunctional Interaction = 86th percentile to 48th percentile; Difficult Child = 92nd percentile to 58th percentile; and Total Stress = 74th percentile to 40th percentile. Thus, the Parental Distress and Total Stress scales remained within normal limits over treatment, but the Parent-Child Dysfunctional Interactions and Difficult Child scales reduced from high levels of stress to within normal limits.

Therapy Attitude Inventory: At the end of treatment, both Lily and Richard reported a high level of satisfaction with treatment based on an average of 5 out of 5 across all 10 items.

Attendance and homework compliance: Lily and Richard’s homework adherence was 56% and 37%, respectively, during PCIT. Both caregivers attended 100% of all sessions.

8 Complicating Factors

As previously discussed, treatment was complicated by the presence of multiple caregivers who had different beliefs and goals for Max’s permanency, along with Max’s involvement in child welfare. The decision to discontinue CPP and implement PCIT was not made lightly, and the primary therapist discussed this case repeatedly in reflective supervision with a seasoned CPP therapist and CPP therapists in training. Since fidelity to the CPP model was not possible, PCIT seemed a logical transition and means to support the family while they awaited permanency status due to its increased structure and focus on disruptive behavior. During PCIT, treatment fidelity was improved, but there were still some challenges with homework completion. The complexity of this case caused some strong emotions for the primary therapists (psychologist) and secondary therapists (2 trainees), and we used weekly group supervision as a space to process and reflect on feelings and thoughts, legal and ethical concerns, and the impact of trauma on child development and used this awareness to better serve our client. Group trauma-informed supervision provided trainees with a safe space to establish trust and collaboration, to reflect on our therapeutic successes, to problem-solve aspects of therapy that were not going well and reinforce our purpose, and to discuss well-being and self-care.

9 Access and Barriers to Care

There were no barriers to accessing care. The family members all had adequate resources, transportation, and health insurance to support Max’s care. This intervention occurred during a global pandemic, but there was no disruption to care due to COVID-19. We maintained social distancing, wore protective gear (therapists and clients), and sterilized therapy rooms and toys after each session.

10 Follow-Up

At 9-months post-intervention, Max and caregivers had a virtual follow-up and Lily completed the ECBI as well as provided clinical updates. Max’s scores on the ECBI Intensity and Problem scales were 48 and 41, respectively. These scores are well within normal limits and were lower than any previous scores. Lily reported that Max had settled into his new living routine of permanency with his paternal grandparents. She also reported that he is enrolled in preschool and thriving, as well as making many friends in the neighborhood and participating in some extracurricular sports. They did not resume treatment with CPP. Max’s grandparents stated that he had been enrolled in individual therapy to work on expressing emotions, and they thought that this would be sufficient for his current symptoms and level of functioning.

11 Treatment Implications of the Case

This case study documented the partial use of CPP and complete use of PCIT to reduce disruptive behaviors in a young boy with PTSD, as well as improve caregiver skills and reduce caregiver stress. While we intended to treat trauma symptoms when therapy initiated, we ultimately focused on treatment of the disruptive behaviors. The course of treatment provided valuable lessons in working with children in child welfare with trauma who have multiple caregivers. First, even if caregivers arrive at treatment and agree to treatment goals and plans, they may change beliefs and goals, and this can greatly impact the course of treatment. Therapists should monitor fidelity to treatment models and engage clients (or their caregivers) in open discussions about treatment progress. In our case, the need to pivot interventions from CPP to PCIT was real, and this was in the best interest of our child client and his mental well-being. It can be difficult for therapists to hold the interests of a child and multiple caregivers when conducting therapy, especially when caregivers are in conflict, disparage one another, and do not agree on what is in the best interest of the child.

Therapists can feel stuck as they try to hold the child-client central and remain neutral to caregiver disagreements. Along this vein, a second lesson was that therapists working with clients with complex histories and trauma need to be connected to a peer consultation group and ideally a reflective supervision group. The benefit of sharing cases with colleagues and getting peer to peer feedback has been well documented in the CPP literature (Many et al., 2016; Paré, 2016; Tomlin et al., 2014). Reflective group supervision/consultation supports therapists to make decisions that are best for the client. Reflective supervision provides a space to process strong emotions and thoughts and thereby may lessen therapist burden, stress, and burnout associated with serving complex cases (Paré, 2016).

Limitations: This report is not without limitations. As a case report, there is no comparison or control group to account for confounding variables such as time. It is possible that treatment fidelity and problem behaviors would have improved over time without changing interventions. Similarly, it is possible that the child’s behavior improved because of more consistent parenting from caregivers, including when permanent custody was awarded during PCIT, rather than due to intervention or a change in intervention. In the future, directly comparing CPP and PCIT in families with low conflict and high conflict would further address these limitations. In addition, only Lily completed caregiver pre- and post-assessments limiting findings to this one caregiver.

12 Recommendations to Clinicians and Students

Clinicians who treat young children with trauma and comorbid disruptive behaviors will find that PCIT is an effective treatment for improving parenting practices and reducing child challenging behaviors (Thomas & Zimmer-Gembeck, 2012). Working with children in child welfare adds a layer of complexity for therapists as multiple caregivers, case managers, lawyers, and judges may be involved. Therapists are encouraged to find a reflective consultation group to support their work and especially when delivering a trauma-focused intervention like CPP wherein talk of traumatic experiences is central to recovery. While our case was not successful with CPP, it is one case with complicating factors that prohibited fidelity to the CPP model. Because of low treatment fidelity to the CPP model and the child’s prominent disruptive behavior, the intervention was changed to PCIT to provide additional structure and focus more directly on disruptive behavior. In making this switch, it was particularly helpful to schedule a family meeting to review the limited progress and the hurdles which were encountered during CPP. Maintaining an objective, non-judgmental approach, reviewing the data from rating scales that had been collected, and focusing on the shared goal of helping the child allowed for a productive meeting and facilitated the joint decision to switch to PCIT, an intervention that was ultimately beneficial. This experience cannot be generalized to other cases of children in child welfare with multiple caregivers. Indeed, we encourage clinicians to consider CPP as a first line intervention for young children with PTSD and trauma exposures given its strong evidence with this population (Lieberman et al., 2006).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Heather Agazzi

Author Biographies

Dr. Agazzi is a Professor in Pediatrics and Psychiatry and a licensed psychologist at the University of South Florida. Dr. Agazzi’s research and clinical work focuses on behavioral parent training programs for children with developmental disabilities, disruptive behavior disorders, and social-emotional problems associated with adverse experiences.

Sandra is a graduate student in the School Psychology program in the College of Education at the University of South Florida. Sandra’s research interests focus on behavior-changing interventions for children with socio-emotional and health-related problems.

Dr. Hernandez is a child and adolescent psychiatry fellow at the University of South Florida. Dr. Hernandez’s research interests include irritability and neurodevelopmental disorders.

References

Abidin

R. R.

(2013). Manual for the parenting stress index, fourth edition (PSI-4). Psychological Assessment Resources.

Achenbach

T. M.,

Rescorla

L. A

. (2001). Manual for the ASEBA School-Age Forms & Profiles. University of Vermont, Research Center for Children, Youth & Families.

Ainsworth

M. S.

(1978). The Bowlby-Ainsworth attachment theory. Behavioral and Brain Sciences, 1(3), 436–438. https://doi.org/10.1017/S0140525X00075828

Ainsworth

M. S.

(1979). Infant–mother attachment. American Psychologist, 34(10), 932–937, https://doi.org/10.1037/0003-066x.34.10.932

Bernstein

R. E.

Timmons

A. C.

Lieberman

A. F.

(2019). Interpersonal violence, maternal perception of infant emotion, and child-parent psychotherapy. Journal of Family Violence, 34(4), 309–320. https://doi.org/10.1007/s10896-019-00041-7

Brestan

E. V.

Jacobs

J. R.

Rayfield

A. D.

Eyberg

S. M.

(1999). A consumer satisfaction measure for parent-child treatments and its relation to measures of child behavior change. Behavior Therapy, 30(1), 17–30. https://doi.org/10.1016/S0005-7894(99)80043-4

California Evidence-Based Clearinghouse for Child Welfare (2022). Child-parent Psychotherapy. https://www.cebc4cw.org/program/child-parent-psychotherapy/

Cambric

M.,

Agazzi

(2019). A case study of Parent–Child Interaction Therapy for the treatment of high-functioning autism spectrum disorder. Clinical Case Studies, 18(4), 270–281. https://doi.org/10.1177/1534650119843591

Cicchetti

D.,

Rogosch

F. A.

(2001). The impact of child maltreatment and psychopathology on neuroendocrine functioning. Development and Psychopathology, 13(4), 783–804, https://doi.org/10.1017/s0954579401004035

10.

Coates

S.,

Gaensbauer

T. J.

(2009). Event trauma in early childhood: Symptoms, assessment, intervention. Child and Adolescent Psychiatric Clinics of North America, 18(3), 611–626. https://doi.org/10.1016/j.chc.2009.06.001

11.

Cohen

J. A.,

Mannarino

A. P.

(1996). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child & Adolescent Psychiatry, 35(1), 42–50. https://doi.org/10.1097/00004583-199601000-00011

12.

D'Andrea

Ford

Stolbach

Spinazzola

Van der Kolk

B. A.

(2012). Understanding interpersonal trauma in children: Why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry, 82(2), 187–200, https://doi.org/10.1111/j.1939-0025.2012.01154.x

13.

Demakakos

P.,

Steptoe

(2022). Adverse childhood experiences and diurnal cortisol patterns in older people in England. Psychoneuroendocrinology, 142, 105798. https://doi.org/10.1016/j.psyneuen.2022.105798

14.

De Young

A. C.

Kenardy

J. A.

Cobham

V. E.

(2011). Trauma in early childhood: A neglected population. Clinical Child and Family Psychology Review, 14(3), 231–250, https://doi.org/10.1007/s10567-011-0094-3

15.

Dozier

Peloso

Lindhiem

Gordon

M. K.

Manni

Sepulveda

Ackerman

Bernier

Levine

(2006). Developing evidence-based interventions for foster children: An example of a randomized clinical trial with infants and toddlers. Journal of Social Issues, 62(4), 767–785. https://doi.org/10.1111/j.1540-4560.2006.00486.x

16.

Dye

(2018). The impact and long-term effects of childhood trauma. Journal of Human Behavior in the Social Environment, 28(3), 381–392. https://doi.org/10.1080/10911359.2018.1435328

17.

Eisenstadt

T. H.

Eyberg

McNeil

C. B.

Newcomb

Funderburk

(1993). Parent-Child Interaction Therapy with behavior problem children: Relative effectiveness of 2 stages and overall treatment outcome. Journal of Clinical Child Psychology, 22(1), 42–51. https://doi.org/10.1207/s15374424jccp2201_4

18.

Eyberg

(1988). Parent-child interaction therapy: Integration of traditional and behavioral concerns. Child & Family Behavior Therapy, 10(1), 33–46. https://doi.org/10.1300/J019v10n01_04

19.

Eyberg

S.,

Pincus

(1999). Eyberg Child Behavior Inventory & Sutter-Eyberg Student Behavior Inventory-Revised: Professional manual. PAR.

20.

Eyberg

S. M.

Funderburk

B. W.

Hembree-Kigin

T. L.

McNeil

C. B.

Querido

J. G.

Hood

K. K.

(2001). Parent-Child Interaction Therapy with behavior problem children: One and two year maintenance of treatment effects in the family. Child & Family Behavior Therapy, 23(4), 1–20. https://doi.org/10.1300/J019v23n04_01

21.

Eyberg

S. M.

Nelson

M. M

Ginn

N. C.

Bhuiyan

Boggs

S. R.

(2014). Dyadic parent-child interaction coding system: Comprehensive manual for research and training (4th ed.). PCIT International, Inc.

22.

Felitti

V. J.

Anda

R. F.

Nordenberg

Williamson

D. F.

Spitz

A. M.

Edwards

Marks

J. S.

(1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258. https://doi.org/10.1016/S0749-3797(98)00017-8

23.

Ford

J. D.

(2002). Traumatic events screening inventory-parent report revised (TESI). University of Connecticut.

24.

Galbally

Stein

Hoegfeldt

C. A.

van IJzendoorn

(2020). From attachment to mental health and back. The Lancet Psychiatry, 7(10), 832–834. https://doi.org/10.1016/S2215-0366(20)30337-0

25.

Gee

D. G.

(2021). Early-life trauma and resilience: Insights from developmental neuroscience for policy. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 6(2), 141–143. https://doi.org/10.1016/j.bpsc.2020.07.005

26.

Hutchison

Russell

B. S.

Wink

M. N.

(2020). Social‐emotional competence trajectories from a school‐based child trauma symptom intervention in a disadvantaged community. Psychology in the Schools, 57(8). 1257–1272, https://doi.org/10.1002/pits.22388

27.

Ippen

C. G.

Harris

W. W.

Van Horn

Lieberman

A. F.

(2011). Traumatic and stressful events in early childhood: Can treatment help those at highest risk? Child Abuse & Neglect, 35(7), 504–513. https://doi.org/10.1016/j.chiabu.2011.03.009

28.

Kroenke

Spitzer

R. L.

Williams

J. B.

(2001). The PHQ-9. Journal of General Internal Medicine, 16(9), 606–613, https://doi.org/10.1046/j.1525-1497.2001.016009606.x

29.

Lakatos

P. P.

Matic

Carson

Williams

M. E.

(2019). Child–Parent Psychotherapy with infants hospitalized in the neonatal intensive care unit. Journal of Clinical Psychology in Medical Settings, 26(4), 584–596. https://doi.org/10.1007/s10880-019-09614-6

30.

Lansford

J. E.

Dodge

K. A.

Pettit

G. S.

Bates

J. E.

Crozier

Kaplow

(2002). A 12-year prospective study of the long-term effects of early child physical maltreatment on psychological, behavioral, and academic problems in adolescence. Archives of Pediatrics & Adolescent Medicine, 156(8), 824–830. https://doi.org/10.1001/archpedi.156.8.824

31.

Lieberman

A. F.

Ippen

C. G.

Van Horn

(2006). Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 45(8), 913–918. https://doi.org/10.1097/01.chi.0000222784.03735.92

32.

Lieberman

A. F.

Ippen

C. G.

Van Horn

(2015). Don’t hit my mommy! A manual for Child-Parent Psychotherapy with young witnesses of family violence (2nd ed.). Zero to Three Press.

33.

Lieberman

A. F.

Van Horn

Ippen

C. G.

(2005). Toward evidence-based treatment: Child-Parent Psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child & Adolescent Psychiatry, 44(12), 1241–1248. https://doi.org/10.1097/01.chi.0000181047.59702.58

34.

Many

M. M.

Kronenberg

M. E.

Dickson

A. B.

(2016). Creating a “nest” of emotional safety: Reflective supervision in a Child-Parent Psychotherapy case. Infant Mental Health Journal, 37(6), 717–727. https://doi.org/10.1002/imhj.21603

35.

McLaughlin

K. A.

Colich

N. L.

Rodman

A. M.

Weissman

D. G.

(2020). Mechanisms linking childhood trauma exposure and psychopathology: A transdiagnostic model of risk and resilience. BMC Medicine, 18(1), 1–11. https://doi.org/10.1186/s12916-020-01561-6

36.

Neitzel

(2020). Addressing trauma in early childhood classrooms: Strategies and practices for success. Young Exceptional Children, 23(3), 157–168. https://doi.org/10.1177/1096250619850137

37.

Newborg

(2005). Battelle developmental inventory - second edition. Riverside.

38.

Owen

(2020). Obscure dichotomy of early childhood trauma in PTSD versus attachment disorders. Trauma, Violence, & Abuse, 21(1), 83–96. https://doi.org/10.1177/1524838017742386

39.

Paré

(2016). Creating a space for acknowledgment and generativity in reflective group supervision. Family Process, 55(2), 270–286. https://doi.org/10.1111/famp.12214

40.

Pechtel

Pizzagalli

D. A.

(2011). Effects of early life stress on cognitive and affective function: An integrated review of human literature. Psychopharmacology, 214(1), 55–70. https://doi.org/10.1007/s00213-010-2009-2

41.

Popovic

Ruef

Dwyer

D. B.

Antonucci

L. A.

Eder

Sanfelici

Kambeitz-Ilankovic

Oztuerk

O. F.

Dong

M. S.

Paul

Paolini

Hedderich

Haidl

Kambeitz

Ruhrmann

Chisholm

Schultze-Lutter

Falkai

Pergola

Bertolino

(2020). Traces of trauma: A multivariate pattern analysis of childhood trauma, brain structure, and clinical phenotypes. Biological Psychiatry, 88(11), 829–842. https://doi.org/10.1016/j.biopsych.2020.05.020

42.

Reinbergs

E. J.

Fefer

S. A.

(2018). Addressing trauma in schools: Multitiered service delivery options for practitioners. Psychology in the Schools, 55(3), 250–263. https://doi.org/10.1002/pits.22105

43.

Reitman

Currier

R. O.

Stickle

T. R.

(2002). A critical evaluation of the parenting stress index-short form (PSI-SF) in a head start population. Journal of Clinical Child & Adolescent Psychology, 31(3), 384–392. https://doi.org/10.1207/s15374424jccp3103_10

44.

Roy

A. L.

Raver

C. C.

(2014). Are all risks equal? Early experiences of poverty-related risk and children’s functioning. Journal of Family Psychology, 28(3), 391–400, https://doi.org/10.1037/a0036683

45.

Saleh

Potter

G. G.

McQuoid

D. R.

Boyd

Turner

MacFall

J. R.

Taylor

W. D.

(2017). Effects of early life stress on depression, cognitive performance and brain morphology. Psychological Medicine, 47(1), 171–181. https://doi.org/10.1017/S0033291716002403

46.

Shanley

J. R.

Niec

L. N.

(2010). Coaching parents to change: The impact of in vivo feedback on parents' acquisition of skills. Journal of Clinical Child and Adolescent Psychology, 39(2), 282–287. https://doi.org/10.1080/15374410903532627

47.

Shonkoff

J. P.

Garner

A. S.

Siegel

B. S.

Dobbins

M. I.

Earls

M. F.

McGuinn

Pascoe

Wood

D. L.

(2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663

48.

Thomas

Abell

Webb

H. J.

Avdagic

Zimmer-Gembeck

M. J.

(2017). Parent-child interaction therapy: A meta-analysis. Pediatrics, 140(3), Article e20170352. https://doi.org/10.1542/peds.2017-0352

49.

Thomas

Zimmer-Gembeck

M. J.

(2012). Parent-child interaction therapy: An evidence-based treatment for child maltreatment. Child Maltreatment, 17(3), 253–266. https://doi.org/10.1177/1077559512459555

50.

Tomlin

A. M.

Weatherston

D. J.

Pavkov

(2014). Critical components of reflective supervision: Responses from expert supervisors in the field. Infant Mental Health Journal, 35(1), 70–80. https://doi.org/10.1002/imhj.21420

51.

Toof

Wong

Devlin

J. M.

(2020). Childhood trauma and attachment. The Family Journal, 28(2), 194–198. https://doi.org/10.1177/1066480720902106

52.

Toth

S. L.

Rogosch

F. A.

Manly

J. T.

Cicchetti

(2006). The efficacy of toddler-parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder: A randomized preventive trial. Journal of Consulting and Clinical Psychology, 74(6), 1006–1016. https://doi.org/10.1037/0022-006X.74.6.1006

53.

Tracy

R. L.

Ainsworth

M. S.

(1981). Maternal affectionate behavior and infant-mother attachment patterns. Child Development, 52(4), 1341–1343. https://doi.org/10.2307/1129529

54.

Zdankiewicz-Ścigała

Ścigała

D. K.

(2020). Attachment style, early childhood trauma, alexithymia, and dissociation among persons addicted to alcohol: Structural equation model of dependencies. Frontiers in Psychology, 10, 2957. https://doi.org/10.3389/fpsyg.2019.02957