Abstract

1. The Impact of Parent-Child Interaction Therapy on Maternal SensitivityRae Thomas and Melanie J. Zimmer-GembeckSchool of Psychology, Gold CoastAustralia Abstract The aim of the current randomised controlled trial was to increase maternal sensitivity and decrease child abuse potential in a sample of families at risk of or engaged in child maltreatment. The families were referred to Parent-Child Interaction Therapy (PCIT), a parenting program that is designed to improve parent-child relationships and assist with using appropriate methods for managing child behaviour problems. Outcomes of treatment were compared to an attention only control group. PCIT is a manualised treatment program founded in social learning theory and attachment theory. PCIT was designed to increase positive interactions and play between parents and children, reduce coercive parent-child interactions, improve parenting skills, and decrease child behaviour problems in families with young children (age 3 to 7). Maternal sensitivity levels were assessed using an observational technique (Emotional Availability Scales, Biringen, Robinson & Emde, 1998) and child abuse potential was assessed using a self-report measure, the Child Abuse Potential Inventory (Milner 1986). In the current study, families at risk of or engaged in child maltreatment were referred to PCIT and randomly assigned at a ratio of 2:1 to a Treatment PCIT group or an Attention Only Waitlist group. No change in maternal sensitivity was found from the pre- to the 12-week assessments in either the PCIT treatment group (N=36) or the Attention Only Waitlist group (N=22). Yet, among the PCIT treatment group and when compared to the pre-treatment assessment, maternal sensitivity had improved by completion of the program (approximately 30 weeks) and this pattern of improvement was also found when mothers reports of child abuse potential were examined. Maternal sensitivity and mother-report of child abuse potential were positively correlated, r = -.20, p < .05 suggesting both measures assessed distinct behaviours and cognitions. The importance of including observational measures in data collection is highlighted. Child Maltreatment, Attachment and Maternal Sensitivity Child maltreatment constitutes a serious disruption to a stable and nurturing caregiving environment. Consequences of child maltreatment and exposure to violence have considerable impact on child development extending to diagnosable disorders and impacting on developmental pathways (Cicchetti & Rizley, 1981; Margolin & Gordis, 2000; Rogosch, Cicchetti, Shields, & Toth, 1995). Maladaptive emotional and behavioural outcomes can include cognitive distortions (Milner, 2001), externalising behaviour (Kolko 1002), maladaptive peer relationships (Bolger & Patterson, 2001; Dodge, Pettit, & Bates, 1997), impaired academic functioning (Margolin & Gordis, 2000), increased risk of psychopathology (Higgins & McCabe, 2000) and insecure attachment relationships (Cicchetti & Toth, 1995; Crittenden & Ainsworth, 1989). The effect of maltreatment on parent-child attachment relationships is well documented (Cicchetti & Toth, 1995, Crittenden, 1988). Several studies have reported that approximately 90% of maltreated children are classified as insecure in their attachment pattern (i.e., either insecure-avoidant, insecure-ambivalent or disorganised/disoriented; Cicchetti & Toth, 1995). Indeed Egeland, Sroufe and Erickson (1983) reported that 100% of the children of psychologically unavailable mothers were classified as insecurely attached at 18 months of age. Bowlby (1951) emphasised that psychological unavailability of parents had a more pervasive and detrimental effect on attachment of an infant to a caregiver than social, financial or medical difficulties. Psychological availability of the caregiver has been postulated to distinguish the attachment of a child and maltreating caregiver from the attachment of a child and more nurturing, nonmaltreating caregiver (Cicchetti & Toth, 1995; Egeland & Erickson, 1987; Margolin & Gordis, 2000). Related to psychological unavailability, but perhaps a more subtle aspect of parenting, is the concept of maternal sensitivity. Maternal sensitivity has been identified as a key aspect of parenting style with young children and a predictor of attachment status (Ainsworth Blehar, Waters, & Wall, 1978). Ainsworth et al. (1978) described maternal sensitivity as a mother’s appropriate responding to the infant’s needs and the negotiation and flexibility of her attention and behaviour. Isabella, Belsky, and von Eye (1989) expanded the construct of maternal sensitivity to an interactive experience between the infant and the mother. In a meta-analysis of attachment studies, maternal sensitivity and attachment security had a modest, but robust correlation (r=.24, De Wolff and van IJzendoorn, 1997) and recently maternal sensitivity was identified as the strongest predictor of attachment security (Bakermans-Kranenburg, van IJzendoorn & Kroonenberg, 2004). Therapeutic interventions for families engaging in maltreatment, underpinned with attachment theory concepts, such as maternal sensitivity, may succeed where behaviourally based, psychoeducational models have been less effective (Pearce & Pezzot-Pearce, 1994). The Family Interaction Program at Griffith University built a focus on maternal sensitivity into the implementation of PCIT to families at risk of, or engaged in, child maltreatment in attempts to increase maternal sensitivity, decrease child behaviour problems and ultimately decrease child abuse potential. Parent-Child Interaction Therapy PCIT is a behavioural family skills program for families with children aged between three and seven years experiencing challenging, externalising behaviours. There are two phases of PCIT, Relationship Enhancement and Additional Skills (also known as Child Directed Interaction and Parent-Directed Interaction). Progression from one phase to the next is predominantly dependent on attaining prescribed levels of specific skills known as ‘Mastery Criteria’ (Hembree-Kigin & McNeil, 1995). Direct coaching sessions are conducted with the parent and child in a play therapy room with the psychologist in another room behind a one-way mirror. The psychologist and the parent communicate through a “bug-in-the-ear” device. This device permits the therapist to provide direct coaching of parental communication and behavior management skills, immediate feedback and social reinforcement of the parent. Parents are expected to practice the skills at home. Through PCIT parents are taught strategies to increase positive interactionsand reduce the potential for child maltreatment. • Results • Maternal Sensitivity • From the pre- to the 12-week assessment, there were no significant differences and no significant changes in maternal sensitivity among the PCIT treatment group and the waitlist comparison group. • From pre-treatment to treatment completion, significant improvement in maternal sensitivity was found among the treatment group, d=.39. • Correlation between Maternal Sensitivity and Child Abuse Potential • At pre-treatment (N = 112, maternal sensitivity was negatively correlated with child abuse potential scores, r = -.20, p < .05. This indicates that mothers who were less sensitivity were also relatively higher in child abuse potential. • Child Abuse Potential • As was found with maternal sensitivity, from the pre- to the 12-week assessment, there were no significant differences and no significant changes in child abuse potential among the PCIT treatment group and the waitlist comparison group. • From pre-treatment to treatment completion, significant improvement in child abuse potential was found among the treatment group, d=.36. • Method • Participants were clinic-referred families at risk of, or with a history of, child maltreatment. Referral sources included the Queensland, Australia Department of Child Safety, Queensland Health, Education Queensland and non-government organisations. • 121 families participating in an ongoing PCIT intervention were included in this analysis. • Families were randomly allocated to either the PCIT treatment group or the attention only waitlist comparison group at a ratio of 2:1. • N = 87 treatment participants • N = 33 attention only waitlist participants • An attrition rate of 52% occurred between pre-treatment and 12-week assessment resulting in a final sample size for pre-treatment to 12-week assessment of • N = 36 treatment participants • N = 22 attention only waitlist comparison group participants. • 70% of the children were males with a mean age of 4 years, 11 months. • 94% of parents identified themselves as White Australians while 3.5% identified themselves as either Aboriginal or Torres Strait Islander. • Weeks to treatment completion ranged from 15 to 56 (M = 30.4, SD =9.5). • Maternal sensitivity was measured using the Emotional Availability Scales Middle Childhood Version 3rd Edition (Biringen, Robinson & Emde, 1998) • Maternal sensitivity was assessed through video-taped observations of mother-child dyads during a 10-minute free play. • Maternal sensitivity was rated by independent coders blind to the treatment status of the dyads. Intraclass correlation was 0.83 for maternal sensitivity. • Child abuse potential was measured using a parent self-report measure, the Child Abuse Potential Inventory (Milner, 1986). • Clinical Implications and Future Directions • Observational measures may complement more traditional data collection assessments such as self-report measures. The inclusion of a maternal sensitivity observational measure contributed to an understanding of the effectiveness of PCIT for maltreating families. The data suggests that observational measures add important findings for interventions. • Therapeutic services for families engaged in or at risk of child maltreatment may require longer interventions to produce significant effects on entrenched cognitions and behaviours. • Alternatively, families who continued in PCIT until treatment conclusion, may differ to those families who dropped out (such as more commitment to treatment, less stress, less child behaviour problems etc). • Interventions to improve parent-child interactions among families at risk of child maltreatment often focus on improving parent-child interactions as a way to reduce parenting stress, coercive parenting behaviours, and improve child behaviour problems. Studies have shown that many parenting interventions do have these effects (Thomas & Zimmer-Gembeck, under review). Just as likely, these programs may be improving other parenting behaviours that may indicate the potential for improvement of parent-child attachment relationships, such as maternal sensitivity. Yet, few intervention studies have examined this as a potential positive program outcome.