Parent Child Interaction Therapy (PCIT): How It Works, Cost, & What to Expect

Core Concepts of Parent Child Interaction Therapy

The structured approach of Parent Child Interaction Therapy is achieved through two phases: first, enhancing the relationship between caregiver(s) and child(ren) and second, strengthening the parenting skills for giving effective commands and managing challenging behavior. Therapists act as coaches for caregivers, teaching strategies for engagement and compliance, while observing caregivers’ use of these skills through video or a one-way mirror and providing audio feedback in real-time.

What Can PCIT Help With?

While not considered a gold standard treatment for any one specific disorder, Parent Child Interaction Therapy can be incredibly useful in supporting parents and caregivers of young children with a variety of presenting concerns, such as non-compliance or oppositional behavior, trouble with focus and/or follow-through, difficult issues like Santa, and attachment issues. Children who exhibit these challenges often also struggle with their relationship and/or attachment to their primary caregiver(s).

Parent Child Interaction Therapy functions by strengthening these relationships first, through skills designed to increase mindful attention and enjoyment. The focus of Parent Child Interaction Therapy then shifts to using specific language and consequences to increase compliant behavior.

Phases of Parent Child Interaction Therapy

Parent Child Interaction Therapy is conducted in two distinct phases: Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI). During the first phase, the focus is on building the relationship between the child and their caregiver, leading to a stronger bond between them. As a result, the child is more attached and motivated to engage with the caregiver, including following directives. In the second phase, attention is placed on supporting caregivers’ use of effective language and behavior management techniques. Throughout the entirety of Parent Child Interaction Therapy, caregivers are expected to engage with their child daily to practice the use of the skills being learned.

Child-Directed Interaction (CDI)

During this phase, the therapist coaches the caregiver through a specific style of positive reinforcement with the child, who is able to select the toy or activity and lead the play.

The acronym “PRIDE” outlines the five positive reinforcement skills learned and practiced during CDI:

• Praise – descriptive verbal praise for preferred behaviors to encourage their continued use and build self-esteem;
• Reflection – repeating and enhancing verbalizations made by the child to reflect caregiver attention and communication;
• Imitation – mimicking sounds and actions made by the child to support social play and denote approval;
• Descriptions – literal descriptions of the child’s activity to show interest, build focus, and increase vocabulary;
• Enjoyment/Enthusiasm – expressions of genuine excitement about what the child chooses to do throughout their play.

Caregivers are also encouraged to refrain from using certain types of language while practicing PRIDE skills, such as negative-focused words (e.g., don’t, no/not, stop), criticisms, directing the play, or asking questions.

Parent-Directed Interaction (PDI)

This second phase shifts to creating a consistent and successful approach towards discipline and compliance. The lead also transitions from the child to the caregiver, beginning with small, simple commands that the caregiver reinforces either positively (e.g., praise) or with consequences (e.g., time out) depending on the child’s response. The skills in this phase focus on use of specific language, warnings, and offering the child opportunities to make a choice that will be followed with more favorable outcomes for themselves.²

Example of Parent Child Interaction Therapy

Consider the following example, which outlines how a therapist might coach a caregiver through both the CDI and PDI phases to increase attachment with their child, the focus and attention on their behavior, and their compliance with directions. In this example, the therapist has already engaged in the “teaching” portion of each phase and is now in the “coaching” portion, meaning the caregiver has learned and practiced each of the skills they are now working towards mastering.

Child-Directed Interaction (CDI)

The therapist observes the child and their caregiver through a one-way mirror. The caregiver has an earbud in to be able to hear the therapist through a headset/mic. The child is given a limited number of options for play which are manipulatable such as Legos, dolls, or blocks, and is informed that this is their “special play time” and that it will last a certain amount of time, about 20 minutes. Games and activities with pre-existing rules are inappropriate for the purposes of learning Parent Child Interaction Therapy.

The child begins their play while the caregiver focuses on practicing PRIDE skills:

• They pick up a blue block. The caregiver says, “ooh, I like that you chose the blue one!” (P, D, E) They stack the blue block on other blocks. Caregiver: I see you’re stacking them, that’s so creative! (P, D, E)
• The child uses a character to knock over a tall tower while exclaiming “boom!” The caregiver asks “why did you do that?” The therapist reminds the caregiver that they’ve asked a question, so they can remember to refrain from doing so. The caregiver quickly says instead, “boom! You knocked it down!” (P, I, D, E)
• The child plays with a horse figure and gives their caregiver a cow to use. Acting as the horse, they say “hi, want to be friends?” The caregiver responds as the cow that they would like that. The horse suggests they go find something to eat. When the caregiver doesn’t say anything, the therapist notes the opportunity to praise or reflect something about the activity. The caregiver then says “I love that idea, let’s go find some food.” (P, R)

When there are 10 minutes, 5 minutes, 2 minutes and 1 minute left the therapist prompts the parent to remind the child that their special play time will be over soon, but they will play again at home.

Throughout their play time, the therapist tallies the number of times the caregiver uses each skill, asks questions, and makes commands or criticisms to determine when they have reached the “mastery” threshold. The therapist will also likely model the use of PRIDE skills with the parent, noting and praising their use of each of the skills.

Parent-Directed Interaction (PDI)

The therapist again observes the child and their caregiver through a one-way mirror using a mic and earbud. The caregiver and child are engaged in their special play time as described above; however, the caregiver is now working on giving effective commands.

During play between the child and their caregiver, the caregiver continues to use PRIDE skills, which the therapist continues to observe and praise as well

• The therapist prompts the caregiver to make a single positively-stated command. The caregiver tells the child “hand me the little tree please.” The child hands the tree to them, and is praised with “thank you for handing that to me so quickly!” immediately. The therapist then notes “great use of specific language and labeled praise” to the caregiver.
• Shortly thereafter, the caregiver commands the child, “please hand me the long green Lego piece,” to which they reply, “no! I need all of the green ones!” The caregiver then states, “if you don’t hand me one of the long green ones, then you will have to sit in the time-out chair.” The child looks sad but hands over a green piece. The caregiver states, “I see that made you sad, but I’m very proud of you for listening.” (P, R)

The therapist continues to track the caregiver’s use of PRIDE skills and effective commands while gently prompting for any modifications to their approach. When the child again refuses to comply with a command even after the warning, the caregiver initiates the use of a time-out procedure with the therapist’s support until the child follows through with the original command and receives specific labeled praise for having done so. The family is ready for “graduation” from the program when they have met mastery of both CDI and PDI skills and are effectively using them in their home.³

Who Can Practice Parent Child Interaction Therapy?

A certification program was created in 2009 for Parent Child Interaction Therapy providers. Not all therapists who provide successful Parent Child Interaction Therapy are certified, but there are certainly benefits to finding a therapist with the certification. It’s important to consider a clinician’s training and experience as well as the reimbursement requirements of any managed care/insurance companies. Gathering information from a Parent Child Interaction Therapy provider you may be considering is instrumental in obtaining the best care and fit for your family.

Parent Child Interaction Therapy International created their certification program in an effort to establish a set of competency standards and effectively disseminate Parent Child Interaction Therapy both nationally and internationally. They note a number of benefits of receiving the certification as a Parent Child Interaction Therapy provider, which include but are not limited to access to call-in support, certification documentation for third-party payers, and inclusion in a directory database of Parent Child Interaction Therapy therapists.⁵

To meet criteria for certification, a clinician must be Master’s level or higher, complete basic training that consists of a minimum of 40 hours face-to-face training, consultation calls twice monthly, and four session reviews, either live or through video recording.⁴

Cost & Insurance

Many insurance companies will cover Parent Child Interaction Therapy as either family or individual therapy, though every policy is different. Out of pocket cost for the service also varies by location and provider, with higher amounts likely for certified therapists in metro areas like New York City, where one provider’s starting cost was quoted at $325/hour. It’s strongly recommended that anyone looking for Parent Child Interaction Therapy to reach out to their insurance provider and ask if Parent Child Interaction Therapy is a covered therapy and if there are any specific requirements for the service to be covered (e.g., a certification from the provider).

Where to Find a PCIT Provider

When looking for a clinician who can provide Parent Child Interaction Therapy, there are several options, such as going through insurance or searching the Parent Child Interaction Therapy International directory. It’s also possible to find a local therapist who specializes in Parent Child Interaction Therapy using an online directory and inputting key search terms. Once connected with a potential therapist, it’s helpful to ask about their training and/or certification, amount of experience, fidelity to the manual, and if they have the appropriate accommodations for it to be most effective (e.g., one-way mirror, mic and earbud system, separate “time out” space, etc.).

What to Expect at Your First Appointment

Once you’ve found a therapist to work with your family using Parent Child Interaction Therapy, an intake session may be somewhat different than what’s expected from a typical therapy intake appointment. Like most therapy intakes, there will likely be standard forms to complete (e.g., informed consent, privacy practices notice, etc.). However, it’s also likely that there will be several specific assessments that ask about the child’s behavior in various settings.

Many Parent Child Interaction Therapy intake sessions also include an observational component where the therapist observes the child and their caregiver to get a better sense of the child’s behavior that Parent Child Interaction Therapy would directly target. The observation period is typically divided into small segments with the therapist prompting for the use of different skills (such as those from CDI and PDI) to obtain a baseline assessment of their use and effectiveness.

Often, the therapist will provide some immediate verbal feedback from the observation, noting if Parent Child Interaction Therapy is an appropriate therapeutic approach for the child. However, they may wish to obtain a full history for the child and combine it with results of any completed assessments and their observation prior to determining if Parent Child Interaction Therapy is the best course of action.

Is Parent Child Interaction Therapy Effective?

There are hundreds of published scientific articles and book chapters focused on Parent Child Interaction Therapy available at Parent Child Interaction Therapy International. Outcomes have largely reflected improvements in a variety of areas, including but not limited to: Compliance, pro-social skills, positive parenting skills, attention, school behavior, and reductions in negative behaviors, parenting stress, and child maltreatment recurrence.⁵

Outcome studies have also determined the following benefits:²

• Adaptability for history of trauma
• Adaptability across genders and several ethnic groups
• Improvements in caregiver attitudes and parenting skills
• Effectiveness for foster parents and non-biological caregivers
• Sustained / long-term effectiveness
• Success with treating other clinical concerns, such as anxiety, depression, self-injurious behavior, ADHD, and adjustment to parental divorce

Risks of Parent Child Interaction Therapy

There are a few risks to consider with taking a Parent Child Interaction Therapy approach, the first of which is the level of time and commitment involved. Results are not often seen for several months and some caregivers can get frustrated by having to spend the first portion of their therapy on play rather than immediately delving into disciplinary strategies.

They are also considered the agents of change in the Parent Child Interaction Therapy process, so caregivers may struggle with how many new skills they are expected to learn and put into practice regularly until they become routine. There can be discomfort that comes with shifting a parenting paradigm to that degree as well as being directly taught and coached closely by the therapist. There is also a significant homework component and consistency with attendance and homework compliance leads to the most successful outcomes.

Despite these potential risks, there are a number of important benefits, the most significant of which is the effectiveness in treating disruptive behaviors and noncompliance in children. These improvements have been shown to generalize across various settings and situations and result in lower stress for caregivers, teachers, siblings, and peers as well as an increase in children’s self-esteem and social skills.⁶

Criticism of Parent Child Interaction Therapy

There have been several criticisms of the Parent Child Interaction Therapy treatment modality by experts in the field of applied behavior analysis. Critics assert that the highly structured manualized approach does not allow for individualization to each child, assess or address the functionality of the child’s disruptive behavior, or provide alternative appropriate behavior to replace those that are non-preferred.

Proponents of the approach argue that although highly structured, there is continual assessment and modification to the process as needed and that the challenging behavior is assessed and addressed in accordance with applied behavior analysis concepts, albeit less traditionally.⁷

How Is PCIT Different from Other Therapy Techniques?

Parent Child Interaction Therapy is one approach to treating challenging behavior in young children; however, there are several others. Parent Child Interaction Therapy differs from the most common alternatives in the following ways:

Parent Child Interaction Therapy vs. Parent Management Training (PMT)

This is offered for parents of children up to age 13 and often does not include the children in the process outside of check-ins. Parents are directly taught various skills and strategies which are then role-played during sessions with the clinician and transitioned to the home setting between appointments. This process is often shorter than that of Parent Child Interaction Therapy (10-12 sessions) and may be indicated when the child is older, if their attachment with their caregiver seems secure, or the family is looking for more immediate change.

Parent Child Interaction Therapy vs Positive Parenting Program (PPP)

The focus of this approach is on strengthening the caregiver’s self-efficacy and confidence in their ability to effectuate positive change in their child’s behavior. The core components of Triple P focus on creating a safe and engaging positive learning environment, using assertive disciplinary strategies, maintaining reasonable expectations for both the child and caregiver, and ensuring that the caregiver is able to care for themselves as well. This style works with caregivers of both young children and adolescents and is highly customizable for the family’s needs.⁸

Some caregivers may wonder if traditional play therapy alone would be more effective for their child than Parent Child Interaction Therapy. Although the play therapy format is a component of the more structured Parent Child Interaction Therapy,  as a standalone therapeutic intervention it can target social and emotional development more directly. When children are struggling to process, problem-solve, or manage challenging feelings or experiences, the use of play therapy may be more helpful in working through those challenges. If the child’s behavior difficulties do not appear accompanied by social or emotional concerns, Parent Child Interaction Therapy would likely be more useful.⁹

History of Parent Child Interaction Therapy

Sheila Eyberg developed the foundation of Parent Child Interaction Therapy in the 1970s in an effort to combine play therapy and child behavior therapy. The important elements of play therapy include the acceptance of the child through emotional and behavioral imitation, providing space for emotional expressiveness through fantastical play, and engaging with the child in their play to develop alternative solutions to challenges encountered during it.

Child behavior therapy, by comparison, targets behavior change techniques that caregivers could transfer into their home environment. Specific challenging behaviors are identified and tracked, so that the effectiveness of the strategies can be monitored and modified as needed.

The merging of these two techniques grew from the work of Diana Baumrind on parenting styles and Constance Hanf on improving compliance in children with developmental disabilities. Baumrind determined that out of several styles of parenting (authoritarian/disciplinarian, authoritative/democratic, and permissive/indulgent), the authoritative style was most effective for children’s development of healthy self-esteem, social skills, academic performance, and reflected the strongest bond between caregiver and child.¹⁰

The two-stage style of parent training emerged during Hanf’s program and utilized the authoritative style and bug-in-ear method of communication with caregivers during sessions. Caregivers were taught methods for attending to positive behavior, actively ignoring negative behavior, and providing effective direct commands with consequences for non-compliance.

Various assessment measures were developed and standardized during the early stages of Parent Child Interaction Therapy, one of which is most commonly used to assess progress today – the Eyberg Child Behavior Inventory (ECBI). Over the next several decades, efficacy and generalization studies were completed to ensure the effectiveness of the therapy and to adapt it for application to more diverse populations and cultures.¹¹