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

What Is PCIT Therapy?

Parent child interaction therapy uses a structured approach, achieved through two phases: Enhancing the relationship between caregiver(s) and child(ren), and strengthening the parenting skills for giving effective commands and managing challenging behavior. Therapists act as parent coaches, 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.

PCIT Age Range

PCIT is intended for children between the ages of two and seven, and their parents or caregivers. The intervention focuses on helping parents to better manage disruptive or aggressive behavior in young children in this age range. This is accomplished through positive, relationship-building play and interactions between the parent and child, as well as parent coaching provided by the therapist.²

The Origins 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.

What Can PCIT Therapy Help With?

While not considered a gold standard treatment for any one specific disorder, PCIT 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 or follow-through, and attachment issues.

Children who exhibit these challenges often also struggle with their relationship and/or attachment to their primary caregiver(s). PCIT focuses on strengthening these relationships first, through skills designed to increase mindful attention and enjoyment. The focus of PCIT 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 PCIT, caregivers are expected to engage with their child daily to practice the use of the skills being learned.

Phase 1: 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 child-directed interactions:

• 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, stop), criticisms, directing the play, or asking questions.

Phase 2: 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.³

What Are Parent Child Interaction Therapy Sessions Like?

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. 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 PCIT.

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.⁴

Benefits of PCIT

PCIT is a well-researched intervention with a strong evidence base. Studies have shown that the benefits of PCIT include:^2,5

• Reduces externalizing problems in children with disruptive behavior disorders
• Decreases negative parenting behaviors
• Reduces parent reports of child behavior problems
• Increases positive parent-child interactions
• Equips parents with positive parenting strategies
• Decreases likelihood of physical and verbal abuse in the home
• Increases communication skills in the family
• Increases child’s frustration tolerance
• Builds child’s social skills
• Improves child’s attention
• Leads to better academic outcomes for children
• Reduces parental stress

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 compliance, pro-social skills, positive parenting skills, attention, school behavior, and reductions in negative behaviors, parenting stress, and child maltreatment recurrence.⁶

Outcome studies have also determined PCIT to be effective in that they are:³

• Adaptable for children with a history of trauma
• Adaptable across genders and several ethnic groups
• Able to improve caregiver attitudes and parenting skills
• Effective for foster parents and non-biological caregivers
• Effective long-term
• Successful 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 when utilizing PCIT, 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 PCIT 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. Consistency with attendance and homework compliance leads to the most successful outcomes.

PCIT Criticism

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.⁸

How to Find a PCIT Therapist

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 PCIT using an online therapist directory and filtering by PCIT. 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.).

Cost & Insurance

Many insurance companies will cover parent child interaction therapy as either family therapy 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 PCIT reach out to their insurance provider and ask if it is a covered therapy and if there are any specific requirements for the service to be covered (e.g., a certification from the provider).

What to Expect at Your First PCIT 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 PCIT 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 needs to change. 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.

How Long Does Treatment Typically Last?

PCIT treatment generally lasts between 12 and 20 sessions, most often held on a weekly basis. This varies depending on the family’s individual needs and progress. After 12 to 20 weeks of PCIT treatment, many families go on to seek continuing care from a therapist for behavioral and emotional support outside of the scope of PCIT.⁹

Treatment progress is largely dependent upon the family’s attendance, engagement, and commitment to the process. The child’s presentation also impacts the length of treatment, including the severity of their behavioral concerns, and comorbid emotional or developmental challenges.

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.

PCIT differs from the most common alternatives in the following ways:

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

Parent management training 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 PPP 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.¹⁰

PCIT Vs. Play Therapy

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 PCIT, 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.¹¹