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ISSUE BRIEF

January 2013

Use your smartphone to 

access this issue brief online.

Parent-Child 

Interaction Therapy 

With At-Risk Families

What’s Inside:

• What makes PCIT unique?

• Key components

• Effectiveness of PCIT

• Implementation in a child 

welfare setting

• Resources for further 

information

Parent-child interaction therapy (PCIT) is a family-centered 

treatment approach proven effective for abused and at-risk 

children ages 2 to 8 and their caregivers—birth parents, 

adoptive parents, or foster or kin caregivers. During PCIT, 

therapists coach parents while they interact with their 

children, teaching caregivers strategies that will promote 

positive behaviors in children who have disruptive or 

externalizing behavior problems. Research has shown that, 

as a result of PCIT, parents learn more effective parenting 

techniques, the behavior problems of children decrease, 

and the quality of the parent-child relationship improves.
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This issue brief is intended to build a better 

understanding of the characteristics and 

benefits of PCIT. It was written primarily to 

help child welfare caseworkers and other 

professionals who work with at-risk families 

make more informed decisions about when to 

refer parents and caregivers, along with their 

children, to PCIT programs. This information 

may also help parents, foster parents, and 

other caregivers understand what they and 

their children can gain from PCIT and what 

to expect during treatment. This brief also 

may be useful to others with an interest in 

implementing or participating in effective 

parent-training strategies.

What Makes PCIT Unique?

Introduced in the 1970s as a way to treat 

young children with serious behavioral 

problems, PCIT has since been adapted 

successfully for use with populations who 

have experienced trauma due to child 

abuse or neglect. The distinctiveness of this 

approach lies in the use of live coaching 

and the treatment of both parent and child 

together. PCIT is the only evidence-based 

practice in which the parent and child are 

treated together throughout the course of 

all treatment sessions. As a result, it is a 

more intensive parenting intervention and 

most applicable for children with serious 

behavioral problems, parents with significant 

limitations (e.g., substance abuse, limited 

intellectual ability, mental health problems), 

and/or parents at risk for child maltreatment. 

In randomized testing, including families 

identified by the child welfare system, PCIT 

has consistently demonstrated success in 

improving parent-child interactions. Benefits 

of the model, which have been experienced 

by families along the child welfare continuum, 

such as at-risk families and those with 

confirmed reports of maltreatment or neglect, 

are described below.

“Parent-child interaction therapy is one 

of the most effective evidence-based 

practices in the field today. Using an in 

vivo training technique, parents acquire 

more effective parenting skills, children’s 

behavioral problems improve, and 

together they develop a more positive 

and affectionate relationship. The positive 

affiliative nature developed as a result 

of participation in PCIT strengthens 

attachment and builds resilience in at-risk 

families.”

Anthony Urquiza, Ph.D., Director of Mental Health 

Services and Clinical Research at the University of 

California at Davis CAARE Center

Reduces Behavior Problems in 

Young Children by Improving 

Parent-Child Interaction

PCIT was originally designed to treat children 

ages 2 to 8 with disruptive or externalizing 

behavior problems, including conduct 

and oppositional defiant disorders. These 

children are often described as negative, 

argumentative, disobedient, and aggressive.

PCIT addresses the negative parent-child 

interaction patterns that contribute to the 

disruptive behavior of young children (Bell & 

Eyberg, 2002). Through PCIT, parents learn 

to bond with their children and develop more 

effective parenting styles that better meet 

their children’s needs. For example, parents 

learn to model and reinforce constructive 
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ways for dealing with emotions, such as 

frustration. Children, in turn, respond to these 

healthier relationships and interactions. As a 

result, children treated using PCIT typically 

show significant reductions in behavior 

problems at home and at school (Brinkmeyer 

& Eyberg, 2003; Gallagher, 2003; McNeil, 

Eyberg, Eisenstatdt, Newcomb, & Funderburk, 

1991; McNeil & Hembree-Kigin, 2010; 

Nixon, Sweeney, Erickson, & Touyz, 2003; 

Schuhmann, Foote, Eyberg, Boggs, & Algina, 

1998).

Treats the Parent and Child Together 

While many treatment approaches target 

either parents or children, PCIT focuses on 

changing the behaviors of both the parent and 

child together. Parents learn to model positive 

behaviors that children can learn from and are 

trained to act as “agents of change” for their 

children’s behavioral or emotional difficulties 

(Herschell & McNeil, 2005). Sitting behind 

a one-way mirror and coaching the parent 

through an “ear bug” audio device, therapists 

guide parents through strategies that reinforce 

their children’s positive behavior. In addition, 

PCIT therapists are able to tailor treatment 

based on observations of parent-child 

interactions. As such, PCIT can help address 

specific needs of each parent and child.

Decreases the Risk for Child Physical 

Abuse and Breaks the Coercive Cycle 

PCIT has been found effective for physically 

abusive parents with children ages 2 to 12 

(Borrego, Urquiza, Rasmussen, & Zebell, 

1999; Chaffin et al., 2004; Chaffin et al., 2009; 

Hakman, Chaffin, Funderburk, & Silovsky, 

2009; Chaffin, Funderburk, Bard, Valle, & 

Gurwitch, 2011). PCIT is appropriate where 

physical abuse occurs within the context of 

child discipline, as most physical abuse does. 

While child behavior problems and child 

physical abuse often co-occur, PCIT may help 

change the parental response to challenging 

child behaviors, regardless of the type of 

behavior problem. 

Foundational research has shown that many 

complex factors contribute to abusive 

behaviors, including a coercive relationship 

between the parent and child (Fisher & Kane, 

1998; Urquiza & McNeil, 1996). Abusive 

and at-risk parents often interact in negative 

ways with their children, use ineffective and 

inconsistent discipline strategies, and rely too 

much on punishment. These same parents 

rarely interact in positive ways with their 

children (e.g., rewarding good behavior). At 

the same time, some physically abused and 

at-risk children learn to be aggressive, defiant, 

noncompliant, and resistant to parental 

direction (Kandel, 1992; Larzelere, 1986). The 

reciprocal negative behaviors of the parent 

and child create a harmful cycle that often 

escalates to the point of severe corporal 

punishment and physical abuse. The negative 

behaviors of the parent—screaming and 

threatening—reinforce the negative behaviors 

of the child—such as unresponsiveness and 

disobedience, which further aggravates the 

parent’s behavior and may result in violence. 

PCIT helps break this cycle by encouraging 

positive interaction between parent and child 

and training parents in how to implement 

consistent and nonviolent discipline 

techniques when children act out.

Parents and caretakers completing PCIT 

typically:

• Show more positive parenting attitudes and 

demonstrate improvements in the ways that 

they listen to, talk to, and interact with their 

children (McNeil & Hembree-Kigin, 2010)
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• Report less stress (Timmer, Urquiza, Zebell, 

& McGrath, 2005)

• Use less corporal punishment and physically 

coercive means to control their children 

(Chaffin et al., 2011)

In addition, parent satisfaction with PCIT is 

typically high (Chaffin et al., 2004).

Offers Support for Caregivers 

Including Foster Parents

PCIT is now recognized as a way to help 

support foster parents caring for children 

with behavioral problems by enhancing the 

relationship between foster parents and 

foster children and by teaching foster parents 

behavior management skills. In addition 

to reporting decreases in child behavior 

problems, foster parents frequently report 

less parental stress following PCIT and high 

levels of satisfaction with the program (McNeil, 

Herschell, Gurwitch, & Clemens-Mowrer, 

2005; Timmer, Urquiza, & Zebell, 2005). One 

benefit of providing foster parents with PCIT 

skills is that they can use these same effective 

parenting skills with future generations of 

foster children.

Uses Live Coaching

PCIT is a behavioral parent-training model. 

What makes PCIT different from other parent 

training programs is the way skills are taught, 

using live coaching of parents and children 

together. Live coaching provides immediate 

prompts to parents while they interact with 

their children. During the course of this 

hands-on treatment, parents are guided to 

demonstrate specific relationship-building and 

discipline skills.

The benefits of live coaching are significant:

• Parents are provided with opportunities to 

practice newly taught skills.

• Therapists can correct errors and 

misunderstandings on the spot.

• Parents receive immediate feedback.

• Parents are offered support, guidance, and 

encouragement as they learn.

• Treatment gains (e.g., increases in child 

compliance) are recognized by the parent 

“in the moment”–which supports continued 

use of effective parenting skills.

Research is currently underway to determine 

if PCIT training can be administered via the 

Internet with Remote Real-Time (RRT) training. 

The University of Oklahoma is piloting 

these studies (see http://www.oumedicine.

com/pediatrics/department-sections/

developmental-behavioral-pediatrics/childstudy-center/programs-and-clinical-services/

parent-child-interaction-therapy/informationfor-professionals/pcit-research-at-ouhsc). 

Adaptations for Various Populations

While PCIT was originally applied to Caucasian 

families, it has been adapted for use with 

various populations and cultures, including:

• Families in which child abuse has occurred 

(Chaffin et al., 2011; Timmer, Urquiza, 

Zebell, & McGrath 2005)

• Trauma victims/survivors (The National 

Child Traumatic Stress Network, n.d.; 

Urquiza, 2010)

• Children with prenatal exposure to alcohol 

(e.g., Bertrand, 2009)

• Children aged 18–60 months with 

externalizing behaviors who were 

premature births (Bagner, Sheinkopf, Vohr, 

& Lester, 2010)
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• Children with developmental delays and/or 

mental retardation (Bagner & Eyberg, 2007)

• Older children (McNeil & Hembree-Kigin, 

2010)

• Foster parents and maltreated children 

(Timmer, Urquiza, & Zebell, 2005)

• African-American families (Fernandez, 

Butler, & Eyberg, 2011)

• Latino and Spanish-speaking families 

(Borrego, Anhalt, Terao, Vargas, & Urquiza, 

2006; McCabe & Yeh, 2009)

• Native American families (Bigfoot & 

Funderburk, 2011)

Limitations of PCIT

While PCIT is very effective in addressing 

certain types of problems, there are clear 

limitations to its use. For the following 

populations, PCIT may not be appropriate, 

or specific modifications to treatment may be 

needed:

• Parents who have limited or no ongoing 

contact with their child

• Parents with serious mental health problems 

that may include auditory or visual 

hallucinations or delusions

• Parents who are hearing impaired and 

would have trouble using the ear bug 

device, or parents who have significant 

expressive or receptive language deficits

• Sexually abusive parents, or parents 

engaging in sadistic physical abuse, or 

parents with substance abuse issues

Key Components

PCIT is typically provided in 10 to 20 sessions, 

with an average of 12 to 14 sessions, each 

lasting about 1 to 1.5 hours. Occasionally, 

additional treatment sessions are added as 

needed.

The PCIT curriculum uses a two-phase 

approach addressing:

1. Relationship enhancement

2. Discipline and compliance

Initially, the therapist discusses the key 

principles and skills of each phase with the 

parents. Then, the parents interact with their 

children and try to implement the particular 

skills. The therapist typically observes from 

behind a one-way mirror while communicating 

with the parent, who wears a small wireless 

earphone. Although not optimal, clinicians 

who do not have access to a one-way mirror 

and ear bug may provide services using 

in-room coaching. Specific behaviors are 

tracked on a graph over time to provide 

parents with feedback about the achievement 

of new skills and their progress in positive 

interactions with their child.

Phase 1: Relationship Enhancement 

(Child-Directed Interaction)

The first phase of treatment focuses on 

improving the quality of the relationship 

between the parent and the child. This phase 

emphasizes building a nurturing relationship 

and secure bond between parent and child. 

Phase I sessions are structured so that the 

child selects a toy or activity, and the parent 

plays along while being coached by the 
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therapist. Because parents are taught to follow 

the child’s lead, this phase also is referred to 

as child-directed interaction (CDI).

During Phase I sessions, parents are instructed 

to use positive reinforcement. In particular, 

parents are encouraged to use skills 

represented in the acronym “PRIDE”:

• Praise. Parents provide praise for a child’s 

appropriate behavior—for example, 

telling them, “good job cleaning up your 

crayons”—to help encourage the behavior 

and make the child feel good about his or 

her relationship with the parent.

• Reflection. Parents repeat and build upon 

what the child says to show that they are 

listening and to encourage improved 

communication. 

• Imitation. Parents do the same thing that 

the child is doing, which shows approval 

and helps teach the child how to play with 

others.

• Behavioral Description. Parents describe 

the child’s activity (e.g., “You’re building a 

tower with blocks”) to demonstrate interest 

and build vocabulary.

• Enjoyment. Parents are enthusiastic and 

show excitement about what the child is 

doing.

Parents are guided to praise wanted 

behaviors, like sharing, and to ignore 

unwanted or annoying behaviors, such as 

whining (unless the behaviors are destructive 

or dangerous). In addition, parents are taught 

to avoid criticisms or negative words—such 

as “No,” “Don’t,” “Stop,” “Quit,” or “Not”—

and instead concentrate on positive directions.

In addition to the coached sessions, parents 

are given homework sessions of 5 minutes 

each day to practice newly acquired skills with 

their child. Once the parent’s skill level meets 

the program’s identified criteria, the second 

phase of treatment is initiated.

Phase II: Discipline and Compliance 

(Parent-Directed Interaction)

The second phase of PCIT concentrates 

on establishing a structured and consistent 

approach to discipline. During this phase, also 

known as parent-directed interaction (PDI), 

the parent takes the lead. Parents are taught 

to give clear, direct commands to the child 

and to provide consistent consequences for 

both compliance and noncompliance. When 

a child obeys the command, parents are 

instructed to provide labeled or specific praise 

(e.g., “Thank you for sitting quietly”). When a 

child disobeys, however, the parents initiate 

a timeout procedure. The timeout procedure 

typically begins with the parent issuing the 

child a warning and a clear choice of action 

(e.g., “Put your toys away or go to timeout”) 

and may advance to sending the child to a 

timeout chair.

Parents are coached in the use of these skills 

during a play situation where they must 

issue commands to their child and follow 

through with the appropriate consequence 

for compliance/noncompliance. In addition, 

parents are provided with strategies for 

managing challenging situations outside of 

therapy (for example, when a child throws a 

tantrum in the grocery store or hits another 

child). Parents also are given homework in this 

phase to aid in skill acquisition.

Assessments

In addition to clinical interviews, PCIT 

uses a combination of observational and 
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standardized assessment measures to assess 

interactions between parent and child, child 

behaviors, and parental perception of stress 

related to being a parent, as well as parents’ 

own perceptions of the difficulty of their child’s 

behaviors and their interactions with their 

child. Assessments are conducted before, 

during, and after treatment.

Effectiveness of PCIT

The effectiveness of PCIT is supported by a 

growing body of research and increasingly 

identified on inventories of model and 

promising treatment programs.

Demonstrated Effectiveness 

in Outcome Studies

At least 30 randomized clinical outcome 

studies and more than 10 true randomized 

trials have found PCIT to be useful in treating 

at-risk families and children with behavioral 

problems. Research findings include the 

following:

• Trauma adaptation. PCIT is now commonly 

referred to in the cluster of traumainformed strategies. Trauma adaption to 

the model was examined in a study of PCIT 

in meeting the needs of mother-child dyads 

exposed to Interpersonal Violence (IPV) by 

reducing children’s behavior problems and 

decreasing mothers’ distress (Timmer, Ware, 

Urquiza, & Zebell, 2010).

• Reductions in the risk of child abuse. In 

a study of 110 physically abusive parents, 

only one-fifth (19 percent) of the parents 

participating in PCIT had re-reports of 

physically abusing their children after 850 

days, compared to half (49 percent) of the 

parents attending a typical community 

parenting group (Chaffin et al., 2004). 

Reductions in the risk of abuse following 

treatment have been confirmed in other 

studies among parents who had abused 

their children (e.g., Hakman et al., 2009; 

Chaffin et al., 2011).

• Improvements in parenting skills and 

attitudes. Research reveals that parents 

and caretakers completing PCIT typically 

demonstrate improvements in reflective 

listening skills, use more prosocial 

verbalization, direct fewer sarcastic 

comments and critical statements at their 

children, improve physical closeness to their 

children, and show more positive parenting 

attitudes (McNeil & Hembree-Kigin, 2010).

• Improvements in child behavior. A review 

of 17 studies that included 628 preschoolaged children identified as exhibiting a 

disruptive behavior disorder concluded that 

involvement in PCIT resulted in significant 

improvements in child behavior functioning. 

Commonly reported behavioral outcomes 

of PCIT included both less frequent and 

less intense behavior problems as reported 

by parents and teachers, increases in 

clinic-observed compliance, reductions in 

inattention and hyperactivity, decreases 

in observed negative behaviors such as 

whining or crying, and reductions in the 

percentage of children who qualified for a 

diagnosis of disruptive behavior disorder 

(Gallagher, 2003).

• Benefits for parents and other caregivers.

Examining PCIT effectiveness among 

foster parents participating with their foster 

children and biological parents referred 

for treatment because of their children’s 

behavioral problems, researchers found 
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decreases in child behavior problems and 

caregiver distress for both groups (Timmer, 

Urquiza, & Zebell, 2005).

• Lasting effectiveness. Follow-up studies 

report that treatment gains are maintained 

over time (Eyberg et al., 2001; Hood & 

Eyberg, 2003).

• Usefulness in treating multiple issues.

Adapted versions of PCIT also have 

been shown to be effective in treating 

other issues such as separation anxiety, 

depression, self-injurious behavior, 

attention deficit hyperactivity disorder 

(ADHD), and adjustment following divorce 

(Johnson, Franklin, Hall, & Preito, 2000; 

Pincus, Choate, Eyberg, & Barlow, 2005).

• Adaptability for a variety of populations.

Studies support the benefits of PCIT across 

genders and across a variety of ethnic 

groups (Capage, Bennett, & McNeil, 2001; 

Chadwick Center on Children and Families, 

2004; McCabe, 2005).

Recognition as an EvidenceBased Practice

Based on systematic reviews of available 

research and evaluation studies, a number 

of expert groups have highlighted PCIT as 

a model program or promising treatment 

practice, including: 

• The California Evidence-Based 

Clearinghouse for Child Welfare 

(http://www.cebc4cw.org/program/

parent-child-interaction-therapy) 

• The National Child Traumatic Stress 

Network (http://www.nctsn.org/sites/

default/files/assets/pdfs/pcit_general.pdf)

• National Crime Victims Research and 

Treatment Center and The Center for 

Sexual Assault and Traumatic Stress; Office 

for Victims of Crime, U.S. Department 

of Justice (http://academicdepartments.

musc.edu/ncvc/resources_prof/OVC_

guidelines04-26-04.pdf)

Implementation of PCIT in a 

Child Welfare Setting

When introducing PCIT as a referral option 

that child welfare workers may consider 

for children and families in their caseload, 

administrators will want to ensure that workers 

have a clear understanding of how PCIT works, 

the values that drive it, and its effectiveness. 

Training for child welfare staff on the basics 

of PCIT, how to screen at-risk children 

with behavior problems, and how to make 

appropriate referrals can expedite families’ 

access to effective treatment options. 

A free online training on the fundamentals 

of PCIT, the “PCIT for Traumatized Children 

Web Course” can be accessed from the UC 

Davis PCIT Training Center website (http://

pcit.ucdavis.edu/). This is a 10-hour web 

course with eight separate modules that 

discuss and show the basics of PCIT treatment 

and three supplemental modules on cultural 

considerations of treatment, parent factors 

affecting PCIT provision, and strategies for 

engaging parents in treatment. Module 2, 

“Overview of PCIT,” was designed to educate 

professionals who work with children in the 

child welfare system. This training may help a 

child welfare professional decide whether to 

refer a family to a qualified therapist for PCIT.
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Finding a Therapist

Caseworkers should become knowledgeable 

about commonly used treatments before 

recommending a treatment provider to 

families. Caregivers should receive as much 

information as possible on the treatment 

options available to them. If PCIT is an 

appropriate treatment model for a family, 

seek a provider who has received adequate 

training, supervision, and consultation in the 

PCIT model. If feasible, both the caseworker 

and family should have an opportunity to 

interview potential PCIT therapists before 

beginning treatment.

PCIT Training

Mental health professionals with at least a 

master’s degree in psychology, social work, or 

a related field are eligible for training in PCIT. 

Training involves 40 hours of direct training, 

with ongoing supervision and consultation for 

approximately 4 to 6 months, working with 

at least two PCIT cases through completion. 

Fidelity to the model is assessed throughout 

the supervision and consultation period. 

Questions to Ask 

Treatment Providers

In addition to the appropriate training, it is 

important to select a treatment provider who 

is sensitive to the individual and cultural needs 

of the child, caregiver, and family. Caseworkers 

recommending a PCIT therapist should ask 

the treatment provider to explain the course 

of treatment, the role of each family member, 

and how the family’s cultural background 

will be addressed. Family members should 

be involved in this discussion to the extent 

possible. The child, caregiver, and family 

should feel comfortable with, and have 

confidence in, the therapist with whom they 

will work.

Some specific questions to ask a potential 

therapist regarding PCIT include:

• How will the parent be involved in this 

process?

• What is the nature of your PCIT training? 

When were you trained? By whom? How 

long was the training? Do you have access 

to follow-up consultation? What resource 

materials on PCIT are you familiar with? 

Are you clinically supervised by (or do you 

participate in a peer supervision group with) 

others who are PCIT trained?

• Why do you feel that PCIT is the 

appropriate treatment model for this 

child? Would the child benefit from other 

treatment methods after they complete 

PCIT (i.e., group or individual therapy)?

• What techniques will you use to help the 

child manage his or her emotions and 

related behaviors?

• Do you use a standard assessment process 

to gather baseline information on the 

functioning of the child and family and to 

monitor their progress in treatment over 

time?

• Do you have access to the appropriate 

equipment for PCIT (one-way mirror, ear 

bug, video equipment)? If not, how do you 

plan to structure the sessions to ensure that 

the PCIT techniques are used according to 

the model?

• Is there any potential for harm associated 

with treatment?
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Conclusion

PCIT is a parent-training strategy with 

benefits for many families with child welfare 

involvement. PCIT’s live coaching approach 

guides parents while they develop needed 

skills to manage their children’s behavior. As 

parents learn to reinforce positive behaviors, 

while also setting limits and implementing 

appropriate discipline techniques, children’s 

behavioral problems decrease. Notably, the 

risk for re-abuse in these families also declines. 

PCIT holds much promise to continue helping 

parents and caregivers build nurturing 

relationships that strengthen families and 

provide healthy environments for children to 

thrive.

Resources 

The California Evidence-Based 

Clearinghouse for Child Welfare

http://www.cachildwelfareclearinghouse.org/

Chadwick Center on Children and Families

http://www.chadwickcenter.org

Child Welfare Information Gateway

https://www.childwelfare.gov/

National Child Traumatic Stress Network

http://www.nctsn.org

Parent Child Interaction Therapy 

International

http://www.pcit.org/

Parent Child Interaction Therapy Training 

Center PCIT for Traumatized Children Web 

Course

http://pcit.ucdavis.edu/pcit-web-course/

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Acknowledgment: The original (2007) and 

current versions of this issue brief were 

developed by Child Welfare Information 

Gateway, in partnership with the Chadwick 

Center for Children and Families at Rady 

Children’s Hospital San Diego. Contributing 

Chadwick authors include Daniel M. Bagner, 

Ph.D., A.B.P.P., Charles Wilson, M.S.S.W., 

and Blake Zimmet, L.C.S.W. The conclusions 

discussed here are solely the responsibility of 

the authors and do not represent the official 

views or policies of the funding agency. The 

Children’s Bureau does not endorse any 

specific treatment or therapy.

Suggested citation: 

Child Welfare Information Gateway. (2013). 

Parent-child interaction therapy with at-risk 

families. Washington, DC: U.S. Department of 

Health and Human Services, Children’s Bureau. 

U.S. Department of Health and Human Services

Administration for Children and Families

Administration on Children, Youth and Families

Children’s Bureau