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Have a challenging child? Evidence-based therapy may help you cope

Amy Herschell and Kristen Schaffner,  experts at taming particularly difficult children, described the kind of kid who gets referred to the treatment model they espouse, one that harnesses the power of parental attention:

He's 5 and in danger of being thrown out of day care.  He's mean to other kids in his class and his siblings.  He refuses to do what adults tell him to do.  He throws things or spits or bites or swears.  He has tantrums.  His problems are so consuming, his  parents' jobs are at risk.  No one wants to be his babysitter. No one wants to be his friend.

It's the kind of behavior that puts a kid on a bad path that some never get off.

Herschell and Schaffner say a program that coaches parents to reward good behavior and ignore bad, to discipline consistently and effectively, can quickly transform even that hypothetical child into one whose behavior is better than average.

The duo, who both work at the University of Pittsburgh and West Virginia University, along with Sarah Taber-Thomas, clinical assistant professor at the University of Buffalo, spent three days in Philadelphia this month teaching therapists and managers at Community Behavioral Health about Parent-Child Interaction Therapy (PCIT). Though the program was developed in the 1970s, it has only recently begun spreading from universities to community treatment centers.   The approach has been shown to improve children's behavior both at home and at school and to reduce parental depression and stress. Studies found that the results persisted for years.

CBH offered the training to seven agencies that provide services to its Medicaid clients (there were also a few trainees from Chester County) as part of its effort to expand access to treatments that are proven to work, said Ronnie Rubin, director of CBH's Evidence-Based Practices and Innovation Center.  While translational medicine — the effort to move cutting-edge science more quickly from bench to bedside — has been trendy in the medical world for several years, Rubin said it has been slower to take off in mental health care.

Herschell said there has been widespread interest in PCIT in Pennsylvania. About 100 agencies have some workers who have  had training. Philadelphia, she said, has given an unusual amount of support at the county level.

PCIT consists of two parts delivered over 10 to 20 sessions  that last an hour or so.  In the first, a therapist helps a parent create a stronger, warmer bond with the child.

They focus on discipline in the second.  Most of the work is between the parent and child. They play — the child decides how — while a therapist watches behind a one-way mirror, coaching the parent, who wears a "bug" in the ear.

The goal is to praise the child for behaving well.  Maybe he sat still for a while or drew something creative.  If he has a tantrum, Mom can focus on drawing her own picture until he's ready to interact nicely again.  The coach may suggest what to say and do with the child but also praises the parent. "Great labeled praise," the coach might say, or "I like the way you're following his lead."  The coach, Schaffner said, is "working on shaping the parent behavior just like they're trying to shape the child behavior."

That voice in the ear is a key difference between PCIT and other efforts to help parents manage difficult children.

"Coaching is where the magic happens," Schaffner said. "It's amazing how powerful it is."

Herschell said that children in PCIT programs typically start out doing what their parents ask only about 30 percent of the time.  Average kids have compliance rates of 60 to 70 percent.  By the time the program ends, PCIT graduates are doing what they're asked 80 to 90 percent of the time, she said.

Some of this sounds like advice you'd get in any parenting program,  but the experts said children who need PCIT really are more challenging than other kids.

Rubin said that in PCIT, parents are taught the sorts of things therapists learn in advanced classes. "It's like good parenting on steroids," she said.

Some children truly are harder to parent, and a mismatch between parenting style and the child's temperament can bring out the worst in both of them.

"Negative behaviors pull for negative attention," Taber-Thomas said.  "Over time, that spirals."

Parents sometimes have trouble seeing the good in a child who misbehaves a lot, Rubin said. The program helps parents reconnect with all the good things their child is doing and to appreciate them.  That helps the child relax and feel closer to the parent.

"We're making the parent's attention more powerful and more strategic," Herschell said.

The beauty of PCIT, the trainers said, is that it "empowers" parents to change their children's lives and, as a consequence, their own.

"The difference is those therapeutic skills are being given to the parents as an agent of change," Rubin said.

The PCIT trainers will be back early next year to teach workers about the discipline phase, but Rubin hopes agencies will begin offering the program immediately to 2.5- to 7-year-olds and their parents.  People who are interested in participating in the program or referring patients to it can call 888-545-2600.   A brochure on PCIT can be found here.  And a link to a map of Philadelphia PCIT providers and their contact information is here.