Los Angeles bets big on Parent-Child Interaction Therapy to reduce adverse childhood experiences

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By Christie Renick

In June 2014, the Los Angeles County Board of Supervisors began implementing the recommendations made by the Blue Ribbon Commission on Child Protection, which calls for augmented child maltreatment prevention efforts.

While implementation of the commission’s many recommendations is a long-term venture, leaders are hoping that the rollout of a maltreatment prevention initiative may improve child safety in the short-term.

First 5 LA, a taxpayer-supported initiative that provides a variety of services to families with young

children in Los Angeles County, is investing $20 million in child maltreatment prevention with a five-year therapist-training program known as Parent-Child Interaction Therapy (PCIT).

The goal is to train up to 400 PCIT practitioners through the state. First 5 LA’s PCIT grant is in partnership with the county’s Department of Mental Health, through which PCIT providers can access state-funded reimbursement for services.

PCIT emphasizes improving the quality of the parent-child relationship through one-on-one live coaching. During a PCIT session, a parent-child pair plays and interacts in a therapy room while the therapist watches through a one-way mirror and guides their interactions using a discrete earpiece worn by the parent. PCIT is typically delivered in a series of 12 to 14 sessions and is broken into two main parts, relationship enhancement and strategies to improve compliance.

In Los Angeles, PCIT is being made available to families at risk of becoming involved with the child welfare system, or who have open cases but are not currently in the process of having their parental rights terminated.

After linking a lack of prevention services with “an excessive number of referrals and investigations” and high caseloads in the county’s dependency court system, the Blue Ribbon Commission’s final report, issued in April, called on the county’s board of supervisors to direct the Department of Public Health and First 5 LA to jointly develop a comprehensive prevention plan.

By training hundreds of clinicians and therapists who will serve thousands of families in the county, this will be the largest PCIT initiative since its development in the early 1970s, a prospect that excites researchers close to the strategy.

“The prospect of prevention is very powerful because we’ve shown the parents, with PCIT…[they] can change and become positive, nurturing, sensitive parents who can set limits with their children in a safe and effective way,” said Cheryl McNeil, a professor of psychology at West Virginia University. “Prevention efforts with PCIT encourage parents to use highly positive parenting tools before they get into negative interactions with their children.”

A Strategy Emerges

PCIT was developed in the early 1970s by Dr. Sheila Eyberg and is based on the work of psychologist Diana Baumrind. Baumrind is known for her work around authoritative parenting, a concept based on the importance of parents providing young children with both limits and nurturing.

The PCIT approach often changes the parent’s perception of the child’s behavior as much as the child’s behavior itself. According to the research, this shift in perception is critical because physically abusive parents often believe they are disciplining their children appropriately, given the child’s seemingly “unmanageable” behavior.

Today PCIT is supported by over 20 years of research, including many randomized controlled trials, a method that is considered the gold standard of empirical research.

In a 2004 article in the peer-review Journal of Consulting and Clinical Psychology, a study focusing on abusive parents found that PCIT was more effective than traditional group-based parent-training approaches when it came to reducing physical abuse recidivism (49 percent vs. 19 percent recidivism).

PCIT is also recognized as an evidence-based practice by the Substance Abuse and Mental Health Services Administration. In April 2013, former commissioner of the Administration on Children, Youth & Families Bryan Samuels identified PCIT and four other strategies as “interventions found to be promising or well-supported” by his agency.

“The evidence overwhelmingly supports this model and shows that it’s very robust, much more than I thought in my early career,” said McNeil, who worked closely with Dr. Eyberg during the early development of PCIT. “It now tells us that PCIT works for child maltreatment. If we can have this kind of change with families who already have multiple reports of abuse and we can drop their recidivism rate down to 19 percent, imagine what we can do if we catch them earlier in the cycle.”

Los Angeles Times columnist Sandy Banks sat in on a PCIT session at ChildNet in Long Beach, and had this to say about it in her column this spring:

“The coaching process might seem rigid, with its scripted jargon and mandatory steps. But it’s teaching parents something more important than how to deal with misbehavior. I watched Ponsar show her son how to manage frustration, as she sat next to him fiddling with Mr. Potato Head. ‘I am having such a hard time putting this thing together,” she announced, as Rhyon looked on. “I’m going to take a deep breath and try again.’”

Equally impressed with a visit to a PCIT session was Philip Browning, director of the Los Angeles Department of Children and Families.

“I observed an actual Parent-Child Interaction Therapy session and was really impressed that a young child was able to appropriately change his behavior through interactions with his father, who was being cued by the therapist,” said Browning, in a statement to The Chronicle.

Browning continued: “As the father appropriately rewarded the child verbally, I witnessed the child’s behavior changing right in front of me. PCIT is a great resource for foster and biological parents. In most cases, payments are eligible through the Medi-Cal program, so it doesn’t cost the parent anything. PCIT intervention has allowed foster parents to keep foster children in their home.”

The Los Angeles Plan

As year one of the PCIT project comes to a close, 34 providers have been trained to deliver PCIT services to families, and First 5 LA is looking ahead to training nearly 20 more providers in the next fiscal year. The long-term goal is to partner with between 80 and 100 providers, and train four PCIT clinicians at each provider.

Each trained clinician is expected to carry six to eight cases at a time. According to the Substance Abuse and Mental Health Services Administration web site, the cost of training runs between $3,000-5,000 per person.

Altogether, the PCIT initiative is expected to train a specialized cadre of 320 to 400 therapists, clinicians and other specialists who will have the capacity to treat as many as 3,200 families at any given time in Los Angeles County. In a seminal 2004 study, Chaffin et al. estimated the cost of treating a parent-child pair at between $2,208-$3,638.

“We’re growing our workforce to serve the mental health needs of children under the age of five,” said Sam Chan, district chief of Family and Community Partnerships at the Los Angeles County Department of Mental Health (DMH). “Our youngest children are the most vulnerable in our system, and the more we build a trained workforce the more we’ll be able to meet a huge public need that we haven’t been able to meet before.”

The launch of a large-scale PCIT program puts Los Angeles in league, again, with the State of Florida. According to the PCIT International website, Florida is home to three separate PCIT research centers as well as five certified trainers, including PCIT founder Dr. Eyberg.

Los Angeles and Florida also received waivers several years ago that permitted both to redirect federal foster care money toward prevention and family preservation.

The Los Angeles initiative is made possible through a partnership between First 5 LA and DMH. The partnership, wherein DMH acts as the administrative body, allows therapists to participate in 100 hours of training, and provides Medi-Cal matching, indigent care support, and capital support to make necessary upgrades to the facilities offering PCIT services.

“First 5 covers the costs of facility upgrades through a grant with DMH – this has been a barrier to providers in the past,” said Chan. “The success of the program speaks for itself among our providers, and the program is very popular once the costs are taken care of.”

After completing the one-year training, providers can bill Medi-Cal and draw down Early Periodic Screening and Diagnostic Treatment (EPSDT) dollars from the state, through DMH.

Caseworkers can refer new families for PCIT services after conducting a mental health screening on a child. For existing cases, referrals can be made during a case plan update, an annual re-screening, or when the child exhibits a behavioral indicator that mental health services are needed.

Most often, referrals will be made by county social workers, and the services are available to biological parents, kinship caregivers and foster parents.

More information about PCIT, including a list of providers, is available on First 5 LA’s website.

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Christie Renick is the Southern California Coordinator for Fostering Media Connections, publisher of The Chronicle of Social Change, where this story first appeared.

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