MFT-6101 Case Study Option #1 Alan and Stephanie present for therapy with their 13-year-old child, Taylor, and their 4-year-old child, Abby. Taylor was assigned female at birth, but identifies as trans masculine. Abby was assigned female at birth and appears comfortable in her gender. Alan is a 41-year-old, Caucasian cisgender male. Stephanie is a 38-year old African American cisgender female. They have been married for 15 years. Both parents state that they want to support Taylor, but don’t understand why “she wants to be a boy.” They also state that they feel uncomfortable talking to Abby about Taylor’s gender identity because they think it may be confusing or upsetting for her. Alan and Stephanie report that they have strong Christian beliefs and have always believed that God doesn’t make mistakes. They say this is a message they give Taylor often. Taylor reports knowing he was male “for as long as he can remember,” but feeling like there must be something wrong with him to feel that way. He came out as trans to his parents 6 months ago. He states that he wishes he wasn’t trans and that he had just been born a boy. Taylor reports that his friends are really supportive but that he gets picked on a lot by other kids at school for being trans. He states that he has one teacher at school who is a trans woman, and he looks up to her a lot. However, he reports that most teachers misgender him (i.e., use female pronouns) and that school officials treat him like a girl by making him use the girls’ locker room and restrooms. He states that he finds this very distressing, and it makes him not want to go to school. Taylor says he loves his parents but feels like he can’t talk to them and that they don’t really understand or support him. He reports that they ask him not to dress “too boyish” in public. He also states he feels he can’t be himself at Church and wishes he could not go, but that it is really important to his parents. Alan and Stephanie report that their biggest concern is Taylor’s mood. They report that he is frequently withdrawn and “looks depressed.” They also state that they have noticed changes in Abby’s behavior over the past six months. They report that she is often clingy towards them and Taylor and will occasionally lash out at her parents in anger. When she does this, Alan and Stephanie report that Abby will scream at them, and they confess that they will often yell when they get angry. They state that they are not sure what to do at these times. Option #2 George presents for therapy with his son, Isaiah. George is a 48-year-old Black cisgender male. Isaiah is a 17-year-old Black cisgender male. George reports that Isaiah has recently become confrontational with him. He states that when Isaiah doesn’t want to do something, he will ignore George, and if George pushes him on it, he will yell. George reports that Isaiah’s mother, Lily, works away from home and stays out of town most days. She is typically with the family only one or two days a week. George states that Isaiah’s behavior is usually worse toward his mother, but that lately he has also been argumentative with George. Isaiah reports that he is bothered a lot by his parent's requests and that they ask him to do stuff when he is busy playing his games. George admits that when it is just the two of them, Isaiah is often on his own a lot after school and that he doesn’t ask much of Isaiah. He states that when Lily is home, they try to do more and ask a lot more of Isaiah. Isaiah reports that he feels like his mom doesn’t understand him and makes a lot of demands of him. George states that he is also concerned about Isaiah’s schoolwork, which he feels has been declining over the last couple of months. He says that he thinks Isaiah spends too much time playing video games and not enough time doing schoolwork. Isaiah reports that he feels frustrated with school because he has trouble keeping up and then feels like it is pointless to try. George reports that his biggest concern is that Isaiah will not finish school and that he will not have a good life. He also worries that if Isaiah is confrontational with other people, they will see him as a threat, and he could end up being killed or arrested. He states that this has never really been an issue before, but he is concerned about it becoming more problematic, especially now that Isaiah is close to being 18. Social Work in Public Health, 26:471–481, 2011 Copyright © Taylor & Francis Group, LLC ISSN: 1937-1918 print/1937-190X online DOI: 10.1080/19371918.2011.591629 Social Learning Theory and Behavioral Therapy: Considering Human Behaviors within the Social and Cultural Context of Individuals and Families ANNIE McCULLOUGH CHAVIS Department of Social Work, Fayetteville State University, Fayetteville, North Carolina, USA This article examines theoretical thoughts of social learning theory and behavioral therapy and their influences on human behavior within a social and cultural context. The article utilizes two case illustrations with applications for consumers. It points out the abundance of research studies concerning the effectiveness of social learning theory, and the paucity of research studies regarding effectiveness and evidence-based practices with diverse groups. Providing a social and cultural context in working with diverse groups with reference to social learning theory adds to the literature for more cultural considerations in adapting the theory to women, African Americans, and diverse groups. KEYWORDS Social learning theory, behavioral therapy, human behavior, social context, cultural context, environment, effectiveness, evidence-based practice, African Americans, diverse groups INTRODUCTION Social learning theory is one of the most recent approaches to addressing people in need and applying the theory to human problems within a social context. The utilization of the theory as an applicable approach to change human behaviors began in earnest in the 1950s. Its use in the social and behavioral sciences as a mental health intervention grew in popularity in the Address correspondence to Annie McCullough Chavis, Fayetteville State University, Department of Social Work, 1200 Murchison Road, Fayetteville, NC 28301. E-mail: achavis@ uncfsu.edu 471 472 A. McCullough Chavis late 1950s as interest in insight-oriented approaches waned. Social learning theory is one of the most influential theories of learning and human development and is rooted in many of the basic concepts of traditional learning. The theory focuses on learning that occurs within a social context and that people learn from one another (Ormond, 1999); however, the theory adds a social element. It proposes that people can learn new information and behaviors by observing other people. Thus, the use of observational learning, imitation, or modeling explains a wide variety of human behaviors using social learning theory and approach. Behavioral therapy has its roots and basic principles within social learning theory. Centered on principles of learned behavior that occurs within a social context, behavioral therapy focuses upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B. F. Skinner. Coady and Lehmann (2008) noted that Pavlov (1927) demonstrated that, through association in time and space, the sound of a bell could have the effect of cueing a dog to produce a biological reaction of salivation-classical conditioning/learning. B. F. Skinner (1953, 1974) documented that when behavior occurs, whatever follows it (the consequences of behavior) can either increase or decrease the frequency, duration, or intensity of the behavior (Coady & Lehmann, 2008). Albert Bandura (1977) added to the development of the therapy by exploring the role of cognition and emphasizing that people learn vicariously. Burman (1997) stated behavior therapy is an approach to psychotherapy based on learning theory that aims to treat psychopathology through techniques designed to reinforce desired and extinguish undesired behaviors. Today, with the thrust for evidencebased practice and measurable results, behavioral therapies are widely used to change general as well as dysfunctional behaviors such as depression, anorexia, chronic distress, substance abuse, anxiety, obesity, phobia, passivity, obsessive behavior, self-mutilating behavior, anger disorders, mental retardation, and alcoholism (Mehr, 2001). The explanation of these behaviors is based largely on culture. Culture is a major factor in explaining and intervening in human behaviors. Culture shapes human behavior and the social environment. The social environment of today is one of many challenges and warrants the use of evidence-based practices that focus on culture to meet the needs of consumers seeking help with problem behaviors. All individuals are social beings and carry within them their cultural experiences that affect all aspects of behavior. This article focuses on two case illustrations and discusses learned behaviors: the usability of social learning theory and behavioral therapies within the social and cultural context. The cultural context refers to the environment and cultural influences but recognizes that society, community, as well as cultural heritage, values, beliefs, thinking, and traditions affect individuals and families (McCullough-Chavis & Waites, 2004). For this article, the social and cultural context includes the culture, community, family, school, Social Learning Theory and Behavioral Therapy 473 work, and all systems within the social environment of consumers. The article concludes with a discussion of the importance of social learning theory and approaches to usability with individuals from varied cultural backgrounds such as African Americans and women. LITERATURE REVIEW Interventions and Effectiveness Social learning interventions and behavioral approaches to changing human behaviors are among the most studied and reported in the literature. According to Mehr and Kanwisher (2007), persons conduct more controlled outcome research on behavioral therapies than on any other psychotherapy due to the use of scientific methods and the ability to measure outcomes using evidence-based practice techniques and instruments. Behavioral therapy points toward the new emphasis in the social sciences on empiricism (observable evidence) in evaluating the outcomes of intervention with children, adults, couples, and families (Mehr & Kanwisher). They stated the surge in the therapy movement toward efficiency, research-supported methods, and evaluation of outcomes, is a credit to behaviorists, and there is evidence that these approaches do change behaviors. Uses of the approaches in systems or settings include public school programs for emotionally handicapped children, residential programs for people who are mentally retarded, residential and outpatient programs for children identified as mentally ill, and juvenile and adult corrections facilities (Mehr & Kanwisher). In many settings and systems, behavioral therapies are the primary approaches employed to change unacceptable learned behavior in children and adults. Therefore, the service delivery environment, with its focus on outcome indicators and evidence-based practice, owes a great debt to behaviorists who remain the most proficient group of practitioners in measuring intervention outcomes (Granvold, 1994). Behavioral therapies are efficient therapies and several research studies document effectiveness for a wide range of behaviors. Mehr and Kanwisher (2007) postulated that the effectiveness of behavioral approaches seems well documented, particularly for consumers who have behavior problems that use behavioral approaches. Weisz, Hawley, and Doss (2004) statistically examined 236 published randomized trials on treatment for youth (age 3–18 years) spanning the years 1962 through 2002. They found that across various outcome measures, 80% of treated youngsters improved after treatment more than those not treated. Behavioral treatments proved more effective than nonbehavioral treatments regardless of client age. Mehr and Kanwisher reported that a major positive feature of behavioral strategies is that a majority of their proponents are thoroughly indoctrinated in the scientific method 474 A. McCullough Chavis and extremely concerned with proving whether the techniques of behavioral therapy work. Therefore, many behavioral studies, and particularly controlled studies, support the claims of significant behavior evaluations, as well as evidence-based practices claims. Prochaska and Norcross (2007) described several meta-analyses conducted on adults, couples, and families concerning the effectiveness of behavioral therapy that produced similar results. For example, in a 1983 study conducted by Norcross and Wogan (cited in Prochaska & Norcross, 2007) behavior therapists reported seeing clients less frequently and for a shorter duration than psychotherapists of other persuasions; and only 7% of their clients, on average, had more than a year of treatment. Literature documents the use of behavior approaches to deal with persons in individual, group treatment, and family settings. Mehr (2001) discussed a 1986 study, reported by Nardone, Tryon, and O’Conner on a cognitive-behavioral group treatment for reducing impulsive–aggressive behavior in adolescent boys in a residential setting for boys. During the course of the project, the frequency of impulsive–aggressive behavior on the part of the boys declined dramatically. However, during a follow-up period, the therapist discovered that the positive gains slowly eroded and disappeared within 5 weeks. With more focus on evidence-based practices, this finding clearly emphasizes the need for maintenance reinforcement programs after behavior therapy programs. Other studies point to the use of social learning theory as a family intervention. Kilpatrick and Holland (2009) suggested that social learning theory utilization as a family intervention is particularly effective with families that have issues with internal and external environmental factors. They reported that families who experience high levels of disruptions, communication problems, and families that have children who experience difficulty with social systems within the community are a few examples of intervention utilizing social learning theory. In other studies, as cited in Kilpatrick and Holland (2006, 2009); Sayger, Horne, and Glaser; Sayger, Horne, Walker, and Passmore; and Szykula, Sayger, Morris, and Sudweeks measured the effectiveness of social learning family interventions with children with behavioral disorders and their families in a variety of settings. The results according to the authors have been remarkable, with significant decreases in negative behaviors of children in the study and subsequent increases in positive behaviors at home and in school. Sayger et al. (1988) reported the maintenance of positive behavioral changes after a 9- to 12-month followup. Behavioral approaches have proved to be effective with children and their families in child psychiatric outpatient treatment. Szykula et al. (1987) avowed in a comparison of strategic and behavioral family therapies in an outpatient child psychiatric facility, that 100% of the families participating in social learning theory family-intervention treatment demonstrated gains toward their treatment attainable goals and 67% of those in the strategic Social Learning Theory and Behavioral Therapy 475 family therapy group made gains toward treatment goals. In treatment with parents, Sayger et al. (cited in Kilpatrick and Holland (2006, 2009)) found that parents participating in social learning family interventions reported significant more positive than negative side effects of their participation in treatment. The literature review suggests social learning and behavioral interventions are effective in changing human behaviors across several environmental settings in treating children, adults, and families. The theory and approaches have a strong research and evidence-based background that demonstrate effectiveness within the social context of human behaviors. However, the literature does not provide sufficient information concerning effective interventions with all target groups, particularly diverse groups such as women, African Americans, and people of color consumers. Today, any efforts at interventions and problem resolutions must be in tune with the distinctive culture, values, and community customs of all consumers within their social and cultural context. Understanding theory and the impact of behaviors on human development are collectively a part of interventions in the social and behavioral sciences. For example, in social work, the influence of theory driving practice is evident, and all the social sciences expound evidence-based practices as sufficiently interrelated to outcomes pertaining to human behaviors within the social context. To illustrate the relationship concerning human behaviors, theory, and behavioral interventions, two case illustrations discuss the need for changes in human behaviors. The two cases demonstrate how to use social learning theory and behavioral approaches with different individuals and families in different settings and disciplines, and particularly in social work. CASE ILLUSTRATIONS The case illustration of Paula demonstrates the use of behavioral therapy in a public school setting. The second case illustration of Jamaal exemplifies the use of social learning theory in a family intervention case with an emphasis on social work.1 Paula, age 10, is one of five students in an exceptional classroom. Her disruptive behavior prevents her from being in a regular classroom. Paula’s behavior disrupts the learning environment due to her hyperactivity and impulsivity. She constantly squirms in her chair, snaps her fingers, taps her feet, talks loudly to the other students during class, and gets up and moves about the classroom without permission instead of listening and following instruction from the classroom teacher or teacher assistant. Paula is the oldest child of John and Megan Head. She has an 8-year-old brother Tim who attends the same elementary school in a regular class. The parents report no major behavioral problems with him but state that Paula 476 A. McCullough Chavis has difficulties remaining in her seat while eating, as well as when the family watches television or engages in most family activities. They use time-out techniques when these disruptions occur. They expressed concerns about Paula’s behavior and often inquire from the school about her behavioral and educational progress. In this case illustration modified and adapted from Mehr (2001), to help Paula change the undesirable classroom behaviors, the teacher, teacher assistant, school psychologist, and social worker met several times and decided to implement a behavioral treatment plan with Paula. After several discussions, they targeted two behaviors for change: talking to other students and leaving her seat without permission. The focus of intervention was observation and recording of the behaviors, verbal counseling, verbal praise, and loss of playtime because of breaking these two rules. If Paula spoke or left her seat without permission, the aide reminded her of the loss of playtime for rule breaking. If Paula behaved acceptably, she received verbal praise. The primary person responsible for the behavioral program was the teacher aide, and for a day, she observed Paula and recorded how often she disrupted the class concerning the targeted behaviors. The disrupted behaviors occurred 25 times during the one day of observation before any intervention. The next week the teacher aide informed Paula of the program and the consequences if the two disrupted behaviors occurred. At the end of each class period when Paula did not speak out or leave her seat without permission, she earned a gold star beside her name on the board. At the end of the day, she could take a gold star home to her parents if she earned stars in more than one half of the classroom sessions. At the end of the week, Paula was down to eight disruptions a day and showed much progress as recorded by the teacher’s aide. The next week, the aide added another behavior to change and explained the addition to Paula. By the end of the second week Paula was down to four disruptions a day, and after another week, Paula took home a gold star each day. Some days there were one to no disruptions, and this change continued for the remainder of the school year. More significantly, Paula’s schoolwork improved with the improvement in behavior, and the positive changes continued until Paula did not need gold stars to maintain her behavior. Using predata and data during the intervention, the case of Paula illustrates the application of principles of learned behavior. It shows that humans can learn to change undesirable behavior with behavioral therapy and evidence-based practice within a social context. Modified and adapted from Kilpatrick and Holland (2006), the second case illustration of Jamaal exemplifies the use of social learning theory in a family intervention case. This case illustrates the use of treatment goals consistent with the principles of the theory. Jamaal, a 22-year-old African American male, is gay and the only child of Joe and Mary Jones. After graduating from college, he returned home to live and work as a high school teacher. Jamaal’s parents are highly religious Social Learning Theory and Behavioral Therapy 477 and do not approve of Jamaal’s sexual orientation or his homosexual relationships. They will not converse with Jamaal about his sexual orientation or relationships. They believe in intimate heterosexual relationships and that God condemns any other relationships. Jamaal is very close to his parents and expresses concern about their denial or disapproval of his relationships. He desires the acceptance of his choice of relationships and sexual orientation by his parents. Jamaal believes in God but has concerns about being gay and being accepted within his social environment. Many in his family, church, and extended family are homophobic. Other family members suspect that Jamaal is gay but are not quite sure of his sexual orientation so he selects and guards his communication with extended family, except for his cousin, James. Although Jamaal interacts with James more than with other extended family, Jamaal has never revealed any information regarding his sexual orientation or ambivalent feelings about being gay or nonacceptance by his parents to James. However, Jamaal suspects that James is aware of his sexual orientation. His parents avoid the subject and are consistent in their disapproval. Jamaal feels lonely, ashamed, angry, and isolated. Consequently, he is having considerable difficulty managing his needs for intimacy. The negative social pressure he feels from his family and social environment are burdensome and depressing. Jamaal came to counseling seeking assistance in learning how to manage his intimacy, loneliness, shame, anger, and pain. Additionally, he needs help learning to accept his homosexuality and help with communication skills to assist in facilitating meeting other persons. There is also a need to learn new ways of conversing with his parents and family members concerning their homophobia and his sexual orientation. In this case illustration, the focus of intervention is with Jamaal and his parents as they are experiencing difficulties with an ineffective family structure and boundaries (Kilpatrick & Holland, 2006) that could inhibit problem solving (homosexuality, intimacy, communication and feelings of shame, pain, anger, and confusion). The communication within the family as dictated by the family rules is weakened by unrealistic expectation and appears complicated by these rigid family rules and family roles. There is also confusion within the family and clearly with Jamaal. This confusion limits the family’s capacity to overcome their life challenges and feelings of insecurities, dissatisfaction, and discomfort with the level of intimacy within the family and the environment (Kilpatrick & Holland, 2006). The family operates as a closed family system concerning family rules, boundaries, and communication, and dealing with Jamaal’s sexual orientation. Also Jamaal’s communication is poor regarding his feelings, and he finds it difficult to maintain intimate relationships. Utilizing social learning theory, it would be very appropriate and useful to work with Jamaal and his family concerning the following goals as stated by Kilpatrick & Holland (2006) and modified for this case. 478 A. McCullough Chavis 1. Learn to develop coping strategies to manage fear and loss (son’s sexual orientation, family, and son’s acceptance of sexual orientation) within the social and cultural context. 2. Develop skills and knowledge concerning self-control to manage, family, life, and the social environment of extended family and religious family more effectively. 3. Help in communication skills that will permit family rules, roles, and boundaries to be more open that will allow greater means and ways of expressing feelings, meeting people, and sharing with family and friends that includes the cultural context in meeting the unique style, life experiences, and worldview of the family. Social learning theory interventions are appropriate for use with Jamaal and his family. Cognitive thoughts, beliefs, and development of communication skills from a cultural perspective are major focal points of intervention with Jamaal. The case also focuses on appropriate learned behaviors by normalizing the problems of the family and focusing on strengths within the social and cultural context. Social learning theory and behavioral approaches are applicable in a variety of environments and disciplines. DISCUSSION AND IMPLICATIONS Social learning theory offers a structured and learned approach to dealing with a variety of behavioral concerns in many different disciplines and settings. Although, I only discuss two case illustrations, this article presents the importance of treating and focusing on learned behaviors using theory and strategies in an effort to change behaviors from a social and cultural context. The target population of the two cases consisted of a female consumer and an African American male consumer from diverse groups. The question of the applicability of the theory and approaches with diverse groups is a major criticism and of concern to this author and others. Kilpatrick and Holland (2009) stated that in some cultural groups, the specific approaches used in social learning theory are not valued or endorsed; rather, they appear as being White, middle class, or incompatible in other ways with many cultural groups. Although behaviorists expound empowerment and concrete changes of consumers, the research rarely addresses cultural, multicultural, or African American issues, despite important theoretical contributions made by Cheek (1976) and Kantrowitz and Ballou (1992). Cheek, a pioneer in assertive training was one of the first behaviorists to generalize behavior theory specifically to counseling with African Americans. He demonstrated the validity of behavioral concepts with African American clients and supplied a culturally relevant view to the therapy. Cheek affirmed that assertive behavior varies between African American and White cultures, Social Learning Theory and Behavioral Therapy 479 and that both groups need to understand the frame of reference of the other (Ivey, Andrea, Ivey, & Simek-Morgan, 2002). The work by Cheek had particular implications for women. Kantrowitz and Ballou (1992) suggested that the behavioral focus on individual skill training could neglect social issues and support dominant group values. They asserted that assertiveness training is an example of evidence-based treatment and will probably meet with the approval of the sexually harassed woman, and the social norm of women’s duty to protect themselves is not seriously questioned. The women’s distress is temporarily reduced, but the social status quo of the dominant society is also decisively protected. That is, necessary social change does not occur. Even though the literature cites the wide use of social learning theory and behavioral therapies, a careful examination of the literature found a paucity of information to support effective and evidence-based application with women, African Americans, and diverse groups. A wide array of behavior therapies applying the principles is applicable for use with these groups, but what is not as clear is whether substantially conducted research studies prove efficacy and effectiveness. Empirically, behavioral therapies yielded a great deal of effective therapies, and some took into account the culture and worldview of African Americans and others, but according to Cheek (1976) behaviorists should not seek to ‘‘make African Americans White’’ or to have women think like men but to recognize the perspective and worldview of different groups. His pioneering works demonstrate how to use the approaches effectively with African American clients when modified to meet the client’s unique style, life experiences, and worldview. The worldview and culture of African Americans and other diverse groups are uniquely different from the dominant group. Nobles (1973) argued that the African view of ‘‘self’’ is contingent upon the existence of others, oneness of being, and a balance and harmony with all things. McCullough-Chavis and Waites (2004) contended that the cultural context is an important aspect of individuals and families. Thus, a criticism of social learning theory and behavioral therapies from a cultural perspective is the somewhat exclusion of diverse cultures and an African view of ‘‘self.’’ If Cheek can demonstrate effectiveness with African American consumers when adjusted to meet the consumer’s unique linguistic style and life experiences (Ivey et. al., 2002), and Kantrowitz and Ballou (1992) with women, then behaviorists should consider these adjustment and adaptations when working with consumers from diverse groups. CONCLUSION This article presents two case illustrations and focuses on the importance of human behaviors within the social environment. The literature points to 480 A. McCullough Chavis evidence-based practice and the effectiveness of the theory and approaches. However, the author believes that to make an unmitigated claim of effectiveness and aggregate evidence-based practice those utilizing the theory and approaches must prove their effectiveness through more research with other groups as demonstrated with the dominant group. The social environment of today is a multicultural environment, which warrants the use of culturally focused evidence-based practices to meet the needs of consumers seeking assistance with problem behaviors in a variety of environmental settings and disciplines. In addition, the Code of Ethics for social workers states there is a responsibility to ‘‘understand culture and its function in human behavior and society, recognizing the strengths that exist in all cultures’’ (National Association of Social Workers, 1996, p. 9). Thus, it is critical and imperative that social workers, practitioners, counselors, sociologists, psychologists, educators, and behaviorists practice more from a culturally focused perspective. To be effective, professionals must acquire further knowledge and skills about the cultures, values, beliefs, practices, and worldviews of individuals and families who come from different and varied cultural backgrounds. This article and its use of two case illustrations offer a structural and practical approach to dealing with human behaviors within the social and cultural context. It helps professionals understand and intervene appropriately and effectively with consumers from various cultural backgrounds. NOTE 1. Please note that for this article, the names in the two case illustrations are pseudonym. REFERENCES Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall. Burman, S. (1997). An agenda for social work education and practice: A multitheoretical approach in intervention planning. Journal of Teaching in Social Work, 15(1/2), 81–95. Cheek, D. (1976). Assertive Black : : : : Puzzled White. San Luis Obispo, CA: Impact. Coady, N., & Lehmann, P. (Eds.). (2008). Theoretical perspectives for direct social work practice: A generalist-eclectic approach. New York, NY: Springer. Granvold, D. (Ed.). (1994). Cognitive and behavioral treatment: Methods and applications. Pacific Grove, CA: Brooks/Cole. Ivey, A., Andrea, M., Ivey, M., & Simek-Morgan, L. (2002). Theories of counseling and psychotherapy: A multicultural perspective (5th ed.). Boston, MA: Pearson. Kantrowitz, R., & Ballou, M. (1992). A feminist critique of cognitive-behavioral therapy. In L. Brown & M. Ballou (Eds.), Theories of personality and psychopathology: Feminists reappraisals (pp. 70–87). New York, NY: Guilford. Social Learning Theory and Behavioral Therapy 481 Kilpatrick, A., & Holland, T. (2006). Working with families: An integrative model by level of need (4th ed.). Boston, MA: Pearson. Kilpatrick, A., & Holland, T. (2009). Working with families: An integrative model by level of need (6th ed.). Boston, MA: Pearson. McCullough-Chavis, A., & Waites, C. (2004). Genograms with African American families: Considering cultural context. Journal of Family Social Work, 8(2), 1–19. Mehr, J. (2001). Human services: Concepts and intervention strategies (8th ed.). Boston, MA: Allyn & Bacon. Mehr, J., & Kanwisher, R. (2007). Human services: Concepts and intervention strategies (10th ed.). Boston, MA: Allyn & Bacon. National Association of Social Workers. (1996). Code of ethics. Washington, DC: NASW Press. Nobles, W. W. (1973). Psychological research and the black self-concept: A critical review. Journal of Social Issues, 29(1), 11–31. Ormond, J. E. (1999). Human learning (3rd ed.). Upper Saddle River, NJ: Prentice Hall. Pavlov, L. P. (1927). Conditioned reflexes: An investigation of the physiological activity of cerebral cortex. London, England: Oxford University Press. Prochaska, J. O., & Norcross, J. C. (2007). Systems of psychotherapy: A transtheoretical analysis (6th ed.). Belmont, CA: Thomson Brooks/Cole. Skinner, B. F. (1953). Science and human behavior. New York, NY: MacMillan. Skinner, B. F. (1974). About behaviorism. New York, NY: Random House. Weisz, J. R., Hawley, K., & Doss, A. (2004). Empirically tested psychotherapies for youth internalizing and externalizing problems and disorders. Child & Adolescent Psychiatric Clinics of North America, 13, 729–815. Copyright of Social Work in Public Health is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Journal of Family Social Work ISSN: 1052-2158 (Print) 1540-4072 (Online) Journal homepage: www.tandfonline.com/journals/wfsw20 Parent–Child Interaction Therapy: A Meta-Analysis of Child Behavior Outcomes and Parent Stress Morgan E. Cooley, Amanda Veldorale-Griffin, Raymond E. Petren & Ann K. Mullis To cite this article: Morgan E. Cooley, Amanda Veldorale-Griffin, Raymond E. Petren & Ann K. Mullis (2014) Parent–Child Interaction Therapy: A Meta-Analysis of Child Behavior Outcomes and Parent Stress, Journal of Family Social Work, 17:3, 191-208, DOI: 10.1080/10522158.2014.888696 To link to this article: https://doi.org/10.1080/10522158.2014.888696 Published online: 22 May 2014. Submit your article to this journal Article views: 5585 View related articles View Crossmark data Citing articles: 25 View citing articles Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=wfsw20 Journal of Family Social Work, 17:191–208, 2014 Copyright © Taylor & Francis Group, LLC ISSN: 1052-2158 print/1540-4072 online DOI: 10.1080/10522158.2014.888696 Parent–Child Interaction Therapy: A Meta-Analysis of Child Behavior Outcomes and Parent Stress MORGAN E. COOLEY, AMANDA VELDORALE-GRIFFIN, RAYMOND E. PETREN, and ANN K. MULLIS Department of Family & Child Sciences, Florida State University, Tallahassee, Florida Parent–Child Interaction Therapy (PCIT) is a behavioral family therapy approach that aims to establish a parent–child relationship that will enable parents to teach their preschool-age child prosocial skills, leading to a decrease in inappropriate and maladaptive behaviors. The purpose of this article is to review recent research on PCIT and conduct a meta-analysis to evaluate the effectiveness of this parenting intervention as reported in 11 studies that met criteria for involvement. In addition to child behavior, this meta-analysis focuses on parenting stress as a primary outcome of interest. The authors found an emphasis on effectiveness, dissemination, and portability to diverse populations in our review of PCIT outcome studies from 2004 to 2011. Implications for practice, policy, and research are addressed. KEYWORDS Parent–Child Interaction Therapy, PCIT, parent training, parent & child, behavioral parent training, meta-analysis Parent–Child Interaction Therapy (PCIT) is a behavioral family therapy approach that aims to establish a parent–child relationship that will enable parents to teach their preschool-age child prosocial skills, leading to a decrease in inappropriate and maladaptive behaviors (Eyberg, 1988). Drawing from operant and play therapy techniques, PCIT is an assessmentdriven model for parents and children to learn a global set of strategies and techniques that are adaptable to their lifestyle and function (Eyberg, 1988). Address correspondence to Morgan E. Cooley, Department of Family & Child Sciences, Florida State University, 242 Sandels Building, Tallahassee, FL 32306. E-mail: mec03f@my.fsu.edu 191 192 M. E. Cooley et al. Pretreatment assessment includes observational coding of child externalizing behaviors, identification of solutions attempted by parents, and observation of parent–child interaction (Eyberg, 1988). Parents attend didactic sessions before bringing the child into therapy. PCIT has two phases: Child-Directed Interaction (CDI), which resembles traditional play therapy, and ParentDirected Interaction (PDI) in which parents practice skills with their child under the direction of the observing therapist (see Eyberg, 1988, for a more detailed overview of specific phases). Post-treatment assessment includes a parent interview reviewing changes and an observation (Eyberg, 1988). Treatment continues until the child’s externalizing behaviors are brought within normal limits (e.g., ability of a caregiver to manage hyperactivity, noncompliance, aggression, or disruptive behavior), signaling success and completion of the program, or until clients dropout, which is the unilateral decision of the family and often classified as failure (Werba, Eyberg, Boggs, Algina, 2006). According to Werba et al. (2006), factors affecting family success and attrition are largely unknown, though dropout rates from child psychotherapy have been noted as high as 40% to 60% (Wierzbicki & Pekarik, 1993). Why Is Treatment Needed? Thomas and Zimmer-Gembeck’s (2007) meta-analytic review gave an overview of behavioral parent training, the theoretical formations, and the delivery formats and specific intervention strategies of PCIT and Triple PPositive Parenting Program. Triple P, like PCIT, is a behavioral parenting intervention. However, the specific format and delivery method is very different and includes media, individual, and group-level interventions (Thomas & Zimmer-Gembeck, 2007). In general, Thomas and Zimmer-Gembeck (2007) noted that behavioral interventions have shown to be effective in past research (e.g., Barlow & Stewart-Brown, 2000; Serketich & Dumas, 1996); that PCIT is built on tenets of social learning theory, differential reinforcement techniques, and attachment theory; and highlights differing formats and details of a PCIT intervention. One aspect that is not discussed in this previous review is why intervention including parents is important for preschool and early school-age children with behavior problems. For many years, disruptive behavior disorders have not only been a major public concern but also one of the most costly mental health issues in the United States (Kazdin, 1995; Scott, Knapp, Henderson, & Maughan, 2001). Children categorized with disruptive behavior disorders are more likely to have impairment in multiple domains (e.g., social, academic, etc.) and are more likely to have chronic symptoms that last beyond their childhood years (Lambert, Wahler, Andrade, & Bickman, 2001). Research has shown that disruptive behavior in childhood may last through multiple stages of development, increase susceptibility to criminal or delinquent behaviors, Parent–Child Interaction Therapy 193 and create many other problems for children as they enter social relationships and adulthood (Loeber, Green, Keenan, & Lahey, 1995; Moffitt, 1993; Patterson, 1993; Robins, 1981). Current Use of PCIT PCIT is designed to (1) increase the child’s self esteem and decrease externalizing behaviors, (2) give parents a feeling of greater self-effectiveness and competence, and (3) increase positive interaction between parent and child (Eyberg, 1988). Originally, PCIT was intended for use with preschool age children, but it is becoming more widely used with many different populations and wider age ranges of children with externalizing behavior problems (Eyberg, 1988). Populations that have been treated with PCIT interventions include oppositional preschoolers and early school-age children (Boggs et al., 2004; Lyon & Budd, 2010; Nixon, Sweeney, Erickson, & Touyz, 2004; Phillips, Morgan, Cawthorne, & Barnett, 2008; Ware, McNeil, Masse, & Stevens, 2008), foster children with kin or nonkin caregivers (McNeil, Herschell, Gurwitch, & Clemens-Mowrer, 2005; Timmer, Urquiza, & Zebell, 2006), maltreated child–parent dyads (Chaffin et al., 2004; Timmer, Sedlar, & Urquiza, 2004; Timmer, Urquiza, Zebell, & McGrath, 2005), children on the autism spectrum (Soloman, Ono, Timmer, & Goodlin-Jones, 2008), children with mental retardation (Bagner & Eyberg, 2007), children with behavior problems who were born prematurely (Bagner, Sheinkopf, Vohr, & Lester, 2010), and ethnically diverse populations and international samples (Leung, Tsang, Heung, & Yiu, 2009; McCabe & Yeh, 2009; Phillips et al., 2008). Thomas and Zimmer-Gembeck (2007) suggested a need for studies focused on the dissemination and portability of PCIT to minority and limitedresource populations in community settings, following the establishment of this intervention as an efficacious treatment among moderate and highincome families. Some studies in this review have begun to answer this call. McCabe and Yeh (2009) compared a cultural adaptation of PCIT, standard PCIT, and treatment as usual (TAU; therapy) among 58 Mexican American children above the clinical cutoff on the Eyberg Child Behavior Inventory Intensity Scale. Results showed that Guiando a Niños Activos (GANA) and PCIT were more effective in the reduction of child externalizing and total parent stress than TAU; however, results of GANA and PCIT groups did not differ significantly on any measure. The authors noted that, compared to the average number of PCIT sessions (14), in previous studies, those including the PCIT and GANA groups took four to five sessions longer. These findings indicate that PCIT may be adaptable to fit the needs of Mexican American families; however, treatment completion may take longer. In a pilot study, Lyon and Budd (2010) examined an implementation of PCIT in a community mental health setting with a sample comprised primarily of low-income, urban, and minority children (50% Black, 29% Multiracial, 194 M. E. Cooley et al. 21% Latino). Of the 14 families enrolled in the single-group study, eight dropped out and only four completed treatment successfully. Due to the small sample size in this study, conclusions could not be made regarding the effectiveness of PCIT among this sample. Importantly, however, results from this study underscored a more primary need to examine reasons for attrition, particularly among socioeconomically disadvantaged populations. Studies indicate that income and education influence treatment retention in parenting training programs (Reyno & McGrath, 2006). Importantly, barriers to treatment retention may be mediated by parents’ attributes and attitudes (Reyno & McGrath, 2006; Werba et al., 2006). Werba et al. (2006) found that, though being on a wait-list control group was the strongest predictor of dropout, other predictors of dropout included inappropriate parenting behavior and parent domain stress (i.e., this included domains that are measured utilizing the Parenting Stress Index [PSI]: parental competence, isolation, attachment to child, parental health, role restriction, depression, and relationship with spouse or other parent; Abidin, 1995). Dropout was not predicted by demographic factors, distance from the treatment facility, or child attributes (Werba et al., 2006). These findings indicate that parental attitudes, attributes, and motivation may be more important determinants than socioeconomic status in PCIT treatment retention (Lyon & Budd, 2010; Werba et al., 2006). Studies including more representative samples are still needed to assess the influence of race and ethnicity on treatment retention and compare interactions between race/ethnicity and other predictors of treatment dropout (e.g., income, education, parental styles, parental attitudes). There have been many studies supporting various levels of success of PCIT, but most have been positive in regards to child problem behaviors. At follow-up 1 and 2 years after treatment, Nixon et al. (2004) reported maintenance of decreased oppositional behaviors as reported by mothers (n = 17) for a sample of preschool-age children. In a study of children born premature and their parents (n = 28), Bagner et al. (2010) found a decrease in attention problems, aggressive behaviors, and externalizing and internalizing behaviors after 4 months of treatment. In this same sample, 80% of the children were able to maintain these behavior changes at a 4-month followup. In another study including mothers of children (n = 30) diagnosed with mental retardation (MR) and oppositional defiant disorder, fewer disruptive behaviors were reported at home following treatment with PCIT (Bagner & Eyberg, 2007). Although there was not a statistically significant reduction in the amount of problem behaviors, parents of a sample of boys age 5 through 12 with high-functioning autism spectrum disorders and clinically significant behavior problems (n = 19) rated the behaviors as less severe following treatment (Solomon et al., 2008). The most current meta-analysis of PCIT reviewed behavioral outcomes of children including literature up to the year 2003 (Thomas & ZimmerGembeck, 2007). The primary focus of this study is to evaluate the findings of Parent–Child Interaction Therapy 195 various studies based on this widely disseminated parenting intervention for children with disruptive behavior problems. This meta-analysis intends to fill in the current gap by including PCIT studies from 2004 through 2011 and will include outcomes related to parent stress as well, because this variable was not included in the previous analysis of PCIT. The secondary purpose is to examine and compare findings with previous research. Variables of interest in this synthesis are (1) child problem behaviors, (2) intensity of problem behaviors, and (3) parental stress. The authors of this study were primarily interested in looking at studies that implemented a treatment versus control group to examine whether PCIT has an impact on the previously identified variables. The included studies will be synthesized to determine whether Thomas and Zimmer-Gembeck’s (2007) recommendations regarding greater portability and utilization of PCIT in diverse contexts were met or addressed in more recent studies of PCIT (see Table 1). METHOD Inclusion and Exclusion Criteria for Meta-Analysis Studies using traditional formats of PCIT, whether in a laboratory, community, or a home-based setting, are included in this synthesis. Studies incorporating abbreviated PCIT (ABB) will be excluded because there is no predetermined PCIT (ABB) format, and it varies depending on the study and agency employing the intervention. PCIT (ABB) often incorporates instructional videotapes and telephone consultations during therapy instead of the live format typical of traditional PCIT (Nixon et al., 2003). The final (n = 11) studies included in this meta-analysis focus on (1) reporting the effectiveness of PCIT, (2) at least one measure of parent stress or child behavioral outcome, and (3) the information necessary to calculate effect sizes for this study. Studies were automatically disqualified if they did not report the statistics necessary for meta-analytic computation. Further, studies were excluded if they met at least one of the following criteria (see Figure 1): 1. The article was not printed in English. 2. PCIT was delivered in an unstandardized format, such as video, Internet, or telephone format as often utilized in PCIT (ABB). 3. Outcomes related to alleviating child externalizing behaviors were not reported in the study. 4. The study did not include parent–child or primary caregiver–child interactions. 5. The study included adjunct in-home coaching or an added motivational intervention. 196 N = 32 Puerto Rican preschool children ages 4 through 6 with attention-deficit/ hyperactivity disorder or behavior problems and their parents or primary caregivers N = 54 preschool aged children around age 6 with behavioral difficulties and their parents or primary caregivers N = 19 male children ages 5 through 12 with autism spectrum disorder and their primary caregiver N = 110 Chinese children ages 2 through 8 and their parents or primary caregivers referred from a community-based setting N = 150 Australian children ages 2 through 8 years old and their primary female caregivers N = 46 children around age 4 and their parents or primary caregivers N = 120 children (age not reported) and their parents or primary caregivers referred from a community-based setting N = 14 children ages 2 through 7 and their primary caregivers N = 37 Mexican American children ages 3 through 7 and their parents or primary caregivers T: Immediate treatment, C: Waitlist N = 30 children ages 3 through 6 with mental retardation and their primary female caregivers N = 28 children ages 1.5 through 5 born prematurely and their mothers T: Treatment Completer, C: Dropout T: Treatment Completer, C: Alternative treatment T: Treatment Completer, C: Dropout T: Treatment Completer, C: Dropout CBCL Externalizing, ECBI (Intensity & Problem), PSI short (Parental Distress, PCDI, Difficult Child) ECBI (Intensity & Problem) CBCL Externalizing, ECBI (Intensity & Problem), PSI short (Parental Distress, PCDI, Difficult Child) CBCL Externalizing, ECBI (Intensity & Problem), PSI short (Parental Distress, Difficult Child) ECBI (Intensity & Problem), PSI (Parent Domain, Child Domain) ECBI (Intensity & Problem) ECBI (Intensity & Problem) T: Immediate treatment, C: Waitlist T: Treatment Completer, C: Matched comparison (similar to waitlist) T: Immediate treatment, C: Waitlist ECBI (Intensity) CBCL Externalizing, ECBI (Intensity & Problem), PSI short (Parental Distress, PCDI, Difficult Child) CBCL Externalizing, ECBI (Intensity & Problem), PSI short (Parental Distress, PCDI, Difficult Child) ECBI (Intensity & Problem) Measure T: Immediate treatment, C: Waitlist T: Immediate treatment, C: Waitlist T: Immediate treatment, C: Waitlist Intervention Participants Note. CBCL = Child Behavior Checklist; ECBI = Eyberg Child Behavior Inventory; PSI = Parenting Stress Index; PCDI = Parent-Child Dysfunctional Interaction; T = treatment; C = control. a Studies were separated based upon intervention group. 11. McCabe & Yeh (2009) 10. Lyon & Budd (2010) 9. Lanier et al. (2011) 7. Thomas & Zimmer-Gembeck (2011) 8. Boggs et al. (2004) 4. Nixon, Sweeney, Erickson, & Touyz (2004) 5. Solomon, Ono, Timmer, & Goodlin-Jones (2008) 6. Leung, Tsang, Heung, & Yiu (2009) 3. Matos, Bauermeister, & Bernal (2009) 2. Bagner, Sheinkopf, Vohr, & Lester (2010) 1. Bagner & Eyberg (2007) Studya TABLE 1 Summary of Individual Studies Parent–Child Interaction Therapy 197 Potential Studies Identified Academic Search Complete (n = 61) PsychINFO (n = 57) Excluded studies Academic Search Complete Not conducted in U.S. (n = 10) Not in English (n = 1) PCIT (ABB) (n = 1) Reported different outcomes (n = 28) Teacher-child outcomes (n = 2) Enhanced/in-home PCIT (n = 5) Small sample/Case Study (n = 4) PsychINFO Not conducted in U.S. (n = 7) Not in English (n = 0) PCIT (ABB) (n = 1) Reported different outcomes (n = 22) Teacher-child outcomes (n = 2) Enhanced/in-home PCIT (n = 8) Small sample/Case Study (n = 7) Studies kept for further methodological coding then excluded Academic Search Complete No control/comparison group (n = 3) PsychINFO No control/comparison group (n = 4) Final studies included in research synthesis (n = 7) FIGURE 1 Flow chart of the excluded and included studies in research synthesis. Note. PCIT (ABB) = Parent–Child Interaction Therapy (Abbreviated). 6. The study included fewer than 10 participants. 7. The study did not contain a control, comparison, or alternative treatment other than PCIT. Search Strategies The studies included in this meta-analysis were found through the search engines of Academic Search Complete and PsychINFO. Studies were narrowed down to include the most current literature available from 2004 to 2012. The time frame of 2004 to 2012 was chosen to include studies not yet published at the time of Thomas and Zimmer-Gembeck’s (2007) metaanalytic review of PCIT and Triple-P parenting interventions. Keywords included parent–child interaction therapy or PCIT . The majority of the studies could be found in either database, and Academic Search Complete 198 M. E. Cooley et al. provided the highest amount of useable results. Initially, Academic Search Complete yielded 135 results and PsychINFO yielded 388 results. After eliminating studies that incorporated behavioral parenting interventions other than PCIT, Academic Search Complete yielded 61 results and PsychINFO yielded 57 results. A secondary search, by journal scanning and searching through the reference pages of each article, was conducted as well, but did not produce any additional results. The process for determining study eligibility included scanning each title in the list of results provided by Academic Search Complete and PsychINFO. If article title included Parent–Child Interaction Therapy or PCIT the entire article was scanned for the report of means and standard deviations. If these data were not available, the study was disqualified. If the title did not include Parent–Child Interaction Therapy or PCIT but included information that looked relevant to a parenting intervention, the abstract or entire article was scanned as well. The first author of this study was the judge for inclusion and exclusion of articles in this study and has academic training relevant to this field. Coding Procedures Data have been extracted using meta-analytic techniques to calculate the effect of this intervention on improving parent stress and child behaviors. Measures of interest are (1) child problem behaviors as measured by the Child Behavior Checklist (CBCL; Achenbach, 1994a, 1994b, 2001; Achenbach & Rescorla, 2000), (2) child characteristics as measured by the Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999), and (3) parent stress measured by the Parenting Stress Index (PSI; Abidin, 1995). The CBCL lists 100 problem behaviors of children and asks parents or caregivers to report on the frequency (Achenbach, 1994a, 1994b, 2001; Achenbach & Rescorla, 2000). The manual contains norms for different age groups and sex of the child. The ECBI (Eyberg & Pincus, 1999) is a 36-item parent report of child disruptive behavior based on severity of behavior and how problematic the behavior is for the parent. This synthesis will include two measures of the Parenting Stress Index (PSI). The PSI in traditional format (Abidin, 1995) is a 101-item measure that includes child domain, that gauges child problem behaviors that lead to frustration in creating a relationship with the child, and a parent domain, that measures the parents’ personal view of parental-role functioning. This analysis will include studies with documented use of the PSI Short Form (Abidin, 1995), which is a 36-item measure and includes three sections: parental distress, parent–child dysfunctional interaction (PCDI), and difficult child. The majority of studies on PCIT use the PSI, so no other measures were included in this analysis for uniformity of results. Relevant features were coded only as they pertained to child behavior and parenting stress of the treatment and control group. Some of the studies did not report Parent–Child Interaction Therapy 199 all three scales that have been selected for this synthesis; however, when at least two scales were reported that related to the domains of interest—child behavior and parenting stress—the study was still included. The first two authors of this article served as the two independent coders. Both hold graduate degrees in social work or marriage and family therapy and are knowledgeable about the therapeutic techniques and scales being examined in this article. The first author of this meta-analysis identified coding protocol and relevant measures to be extracted by independent coders. Because the coding protocol was determined prior to the coding process, inter-rater reliability was 100%. The only discrepancy occurred before the coding process and revolved around whether to include differing forms of the measures included in this study for child behaviors and parenting stress. This issue was resolved by discussing the issue, identifying the potential implications of including or eliminating multiple measures, and then doing a literature search to determine what has been done in the past. Authors determined that it would be acceptable to include one measure for child behaviors and one measure for parenting stress, because the vast majority of literature included two specific measures (i.e., the ECBI and PSI). In addition, varying measures generally captured the same information. Statistical Methods Effect sizes were calculated using standardized mean difference (d) metric and the following formula: d = Y T – Y C /SYpooled , where Y T is the mean effect size for the treatment group and Y C is the mean effect size for the control group in each study. Negative effect sizes indicate the treatment group (i.e., those that received PCIT) scored lower on measures of child behavior problems and parent stress than the control group, indicating that PCIT was an effective treatment. Conversely, positive effect sizes signify that the treatment group scored higher or no differently on measures of child behaviors than the control group, indicating that PCIT was not an effective treatment. Standardized mean difference is the most appropriate statistical analysis for comparing two groups based upon their respective mean scores when outcome variables are operationalized differently between studies (Cooper, Hedges, & Valentine, 2009). Mean effect sizes and standard errors were computed for each of the outcomes of interest. These were used to obtain z-scores and Q-values used to conduct a Q-test of homogeneity. Significant Q-values indicate high levels of heterogeneity among the effect sizes across studies for that measure. In other words, there was a high degree of variability between studies in the reported impact of PCIT on the outcomes with significant Q-values. Based on the Q-test, a mixed-effects model was used for the analysis of studies. The Q-test was significant, suggesting that the model explains some, but not all, of the between-studies variation. A random-effects model was 200 M. E. Cooley et al. used to account for the heterogeneity of effect sizes in CBCL Externalizing, ECBI Intensity, ECBI Problem, and PSI Difficult Child. A fixed-effects model was used to account for the homogeneity of effect sizes in PSI Parental Distress and PSI Parent Child DI. The random-effects model assumes that “effect sizes may differ from each other because of both sampling error and true variability in population parameters” (Cooper et al., 2009, p. 580). A fixed-effects model “assumes all effect sizes estimate a common population parameter, and that observed effect sizes differ from that parameter only by virtue of sampling error” (Cooper et al., 2009, p. 576). RESULTS Results from the meta-analysis suggest that PCIT has a generally positive impact on reducing child problem behaviors and parenting stress (see Tables 2 and 3). All reported effect sizes use Cohen’s d. Child Behaviors CBCL EXTERNALIZING Effect sizes for externalizing child behaviors ranged from –2.54 to –.19 and the mean effect size was –1.06 [–1.93, –.19]. Results from three of the four studies reporting on these behaviors were significant, indicating that PCIT was effective in reducing child externalizing behaviors (Bagner & Eyberg, 2007; Bagner et al., 2010; McCabe & Yeh, 2009). ECBI INTENSITY Intensity of child behavior ranged from –2.81 to –.28 with a mean effect size of –.1.06 [–1.51, –.61] showing that parents saw a general decrease in the intensity of their child’s behavior. However, only five of the 10 studies using TABLE 2 Mean Effect Sizes, Standard Errors, and z-Scores by Outcome Mean d CBCL Externalizing ECBI Intensity ECBI Problem PSI Parental Distress PSI PCDI PSI Difficult Child −1.06 −1.06 −.98 −.73 −.94 −.80 SE z .44 .23 .19 .12 .15 .27 −2.39 −4.58 −5.09 −5.85 −6.31 −2.95 Q df ∗ 17.46 38.22∗ 33.07∗ 4.47 4.61 15.85∗ 3 9 10 4 3 4 Note. CBCL = Child Behavior Checklist; ECBI = Eyberg Child Behavior Inventory; PSI = Parenting Stress Index; PSI PCDI = Parenting Stress Index Parent-Child Difficult Interaction. ∗ p < 0.05. 201 −1.51 [–2.46, −.56]g −2.81 [–3.92, −1.70]g −1.65 [–2.48, −.81]g — −.33 [–1.24, .58] −1.59 [–2.03, −1.15]g −.28 [–.72, .51] −1.18 [–1.81, −.56]g −.52 [–1.11, .07] −.73 [–1.96, .51] −.49 [–1.15, .16] −1.06 [–1.51, .61] −1.09 [–1.98, −.19]g −2.54 [–3.60, −1.48]g — — — — −.19 [–.63, .24] — — — −.79 [–1.46, −.12]g −1.06 [–1.93, −.19] −.67 [–1.53, .20] −1.74 [–2.67, −.82]g −2.04 [–2.92, −1.16]g −.32 [–1.00, .36] −1.59 [–2.63, −.56]g −1.52 [–1.96, −1.08]g −.56 [–.99, −.12]g −1.43 [–2.08, −.78]g −.42 [ − .97, .13] −.42 [–1.64, .79] −.36 [–1.01, .29] −.98 [–1.36, .60] dc −.02 [ − .86, .82] −.79 [–1.61, .03] — — — −.97 [–1.36, −.58]g −.65 [–1.09, −.21]g — — — −.60 [–1.26, .06] −.73 [ − .97, −.48] dd −.52 [–1.38, .33] −.37 [–1.17, .42] — — — −1.20 [–1.59, −.81]g — — — — −.85 [–1.52, −.17]g −.94 [–1.23, .65] de −.59 [–1.45, .26] −1.39 [–2.27, −.51]g — — — −1.30 [–1.69, −.91]g −.20 [ − .64, .24] — — — −.57 [–1.23, .09] −.80 [–1.05, −.56] df Note. 1. Bagner & Eyberg (2007); 2. Bagner, Sheinkopf, Vohr, & Lester (2010); 3. Matos, Bauermeister, Bernal (2009); 4. Nixon, Sweeney, Erickson, & Touyz (2004); 5. Solomon, Ono, Timmer, Goodlin-Jones (2008); 6. Leung, Tsang, Heung, & Yiu (2009); 7. Thomas & Zimmer-Gembeck (2011); 8. Boggs et al. (2004); 9. Lanier et al. (2011); 10. Lyon & Budd (2010); 11. McCabe & Yeh (2009). a Child Behavior Checklist Externalizing. b Eyberg Child Behavior Inventory Intensity. c Eyberg Child Behavior Inventory Problem. d Parenting Stress Index Parental Distress. e Parenting Stress Index Parent Child Dysfunctional Interaction. f Parenting Stress Index I Difficult Child. g Represents significance p < .05. SPSS Version 20 statistical software was used to conduct all statistical analyses. 1 2 3 4 5 6 7 8 9 10 11 Overall Mean db da TABLE 3 Summary of Effect Sizes and Confidence Intervals for Individual Studies From Time 1 to Time 2 202 M. E. Cooley et al. the ECBI Intensity measure showed significant decrease in scores between the treatment and control group (Bagner & Eyberg, 2007; Bagner et al., 2010; Boggs et al., 2004; Leung et al., 2009; Matos, Bauermeister, & Bernal, 2009). Although PCIT had a significant effect on decreasing the intensity of child behavior for only one half of the studies involved in this analysis, there was some reduction in intensity of behaviors across each study. ECBI PROBLEM The ECBI Problem measure was the most commonly used measure and the only one included across all studies. Effect sizes for ECBI Problem ranged from –2.04 to –.32 and the mean effect size was –.98 [–1.36, –.60]. Although all studies showed at least a small reduction in how much of a problem the child’s behavior was for the parent, only six out of 11 studies showed significant decreases following treatment of PCIT (Bagner et al., 2010; Boggs et al., 2004; Leung et al., 2009; Matos et al., 2009; Solomon et al., 2008; Thomas & Zimmer-Gembeck, 2011). Parenting Stress Overall, results indicate that PCIT significantly reduced parenting stress. Moderate to large effect sizes were reported for PSI Parental Distress (–.73), PSI Parent Child DI (–.94), and PSI Difficult Child (–.80). PARENTAL DISTRESS Mean differences of parent distress ranged from –.97 to –.02 with a mean effect size of –.73 [–.97, –.48]. Of the five studies reporting on parent’s perceived level of distress in regards to parenting, two were significant (Leung et al., 2009; Thomas & Zimmer-Gembeck, 2011). This suggests that there were some, but no consistent, differences between the treatment and control groups. PARENT CHILD DI Of the four studies that examined dysfunctional parent–child interactions, two reported a significant reduction in such interactions as reported by the parents (Leung et al., 2009; McCabe & Yeh, 2009). Effect sizes ranged from –1.2 to –.37 and the mean effect size was –.94 [–1.23, –.65]. DIFFICULT CHILD Two of five studies showed significant differences between treatment and control group on parent’s perception relating to the difficulty of their child’s Parent–Child Interaction Therapy 203 behaviors (Bagner et al., 2010; Leung et al., 2009). Effect sizes ranged from –1.39 to –.20 and the mean effect size was –.80 [–1.32, –.27]. DISCUSSION The purpose of this article was to review recent research on PCIT and conduct a meta-analysis to evaluate the effectiveness of this parenting intervention as reported in 11 studies. In addition to child behavior, this meta-analysis focused on parenting stress as a primary outcome of interest. This study capitalized on an advantage of meta-analytic techniques, which is the ability to pool results from underpowered studies, which may be susceptible to Type I errors (Lipsey & Wilson, 2001). Results suggest that PCIT does have a beneficial impact on parents’ and primary caregivers’ perceptions of all outcomes examined, including child externalizing behaviors (CBCL Externalizing), the child’s temperament and self-regulatory abilities (PSI Difficult Child), the frequency of child behavior problems (ECBI Intensity), parent/caregiver tolerance for child behaviors (ECBI Problem), the difficulty of parent/caregiver–child interactions (PSI Parent-Child Dysfunctional Interaction), and parent/caregiver overall distress (PSI Parent Distress). We found an emphasis on effectiveness, dissemination, and portability to diverse populations in our review of PCIT outcome studies from 2004 to 2011. This indicates a change from prior studies that focused on efficacy trials including primarily middle-class samples that often did not include children with mental and developmental disorders (Thomas & Zimmer-Gembeck, 2007). Included in this meta-analysis are children with oppositional defiant disorder and comorbid mental retardation (Bagner & Eyberg, 2007), children born prematurely (Bagner et al., 2010), low-income minority children (Lyon & Budd, 2010), and boys with autism spectrum disorders (Solomon et al., 2008). Also, some studies included children from different cultures: Puerto Rican (Matos et al., 2009), Chinese (Leung et al., 2009), Australian (Thomas & Zimmer-Gembeck, 2011), and Mexican American (McCabe & Yeh, 2009). Although the effects reported by all studies in this meta-analysis were in the expected direction and showed some beneficial impact of PCIT, the significance of the results was mixed across studies. One reason for the mixed results may be the recent proliferation of PCIT efficacy studies among diverse populations. PCIT was originally tested with a more homogenous population (Thomas & Zimmer-Gembeck, 2007), but as the intervention becomes more widely utilized it may lose some of its effectiveness when introduced to different cultural groups or more high-risk populations (Council of National Psychological Associations, 2003). Another reason for the mixed significance may be that several of the studies included in this analysis, some of which were pilot studies, used small samples (e.g., Bagner & Eyberg, 2007; Bagner 204 M. E. Cooley et al. et al., 2010; Lyon & Budd, 2010; Matos et al., 2009; McCabe & Yeh, 2009; Soloman et al., 2008). Small samples may reduce significance of results (Cohen, 1988). There are some limitations to this study. Due to the increasing use of multiple formats of PCIT, studies often include unstandardized and/or undocumented alterations to curricula with the number of “pure” PCIT studies being limited. As a result, only 11 studies met requirements for the current meta-analysis. Although the dissemination of PCIT to homogenous populations and the adaptation of PCIT to a variety of groups and cultural contexts is encouraging, variety among the included studies precluded the substantive examination of moderators related to methodological differences, sample construction, and issues of study quality. Although our results support the broad effectiveness of PCIT across a number of outcomes among a homogenous sample, more research is clearly needed to examine the effectiveness of PCIT among each of these individual populations in community settings. RECOMMENDATIONS AND CONCLUSION These results have implications for clinical intervention and practice, policy, and research. First, it appears as though new studies are showing more portability of PCIT to more diverse populations. The next step is to continue to increase PCIT studies with specific populations to determine the effectiveness of PCIT with specific populations in community settings. Clinicians and professionals offering interventions should be trained to deliver standardized formats and ensure they are able to address the needs of diverse populations as they arise, in a way that does not alter the focus or content of the intervention. In general, it appears that PCIT has a generally positive impact on child behaviors and, despite mixed results of the individual studies, an ameliorating effect on parental stress. Because of these individual differences, it may be useful to examine the effectiveness of PCIT with specific populations and specific conditions, as PCIT may be effective in ameliorating parenting stress in some populations under certain conditions. This may be explained through a moderator analysis to determine what variables influence the nature of the relationship between pre-treatment parenting stress scores and post-treatment scores. This is congruent with the recommendation in the previous paragraph to increase PCIT studies with specific populations in community settings. Examining setting or demographic factors may be the first step in determining what variables moderate PCIT treatment. In future studies, it may also be helpful to further examine the relationship between improvement in child behaviors and improvement in parenting stress to determine whether a confounding relationship is present, as improvement in one may affect improvements in the other. Longitudinal research could Parent–Child Interaction Therapy 205 examine this relationship over time and help researchers determine the impact of PCIT versus other influences. In regards to policy, parenting programs have shown general success in improving parenting skills and reducing negative child behaviors (Thomas & Zimmer-Gembeck, 2007); and researchers have noted that parenting stress can have a large impact on a child’s social, emotional, and behavioral wellbeing throughout their life span (Hotchkiss & Gordon Biddle, 2009). Policy makers need information on research-based interventions to make informed decisions, as family issues are becoming a more prevalent issue in the policy realm (Bogenschneider, 2006). These concerns raise implications for government funding and taxpayer dollars, the child welfare system, educational system, as well as judicial system. With these multiple contexts involved, it could be assumed that even some change in one of these areas may impact them all, which raises the need for more definitive information about programs such as PCIT. It seems that PCIT can be an effective treatment and that it shows promise in alleviating child behavioral concerns in an increasing variety of settings. More detailed attention needs to be paid as to the “who,” “what,” “when,” and “where” of this intervention. Who is best suited for PCIT or one of its varying formats (i.e., population); what version of PCIT provides the most consistent positive outcomes; when should families be targeted for intervention; and, where, in regard to setting, does PCIT produce the most positive outcomes? PCIT has received increasing attention in research. This analysis did not include the many formats of PCIT, which may change or enhance results. As more studies are being conducted, future research should center around making a distinction as to whether there is a significant difference in “pure” PCIT treatments and PCIT interventions that have been enhanced or abbreviated. 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Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24, 190–195. Journal of Behavioural Sciences, Vol. 26, No. 2, 2016 Are Siblings Different as ‘Day and Night’? Parents’ Perceptions of Nature vs. Nurture *Fatima Kamran, PhD Institute of Applied Psychology, University of the Punjab, Lahore, Pakistan The qualitative study explored parents perceptions and attributions of personality differences among their children. Twelve parents were interviewed using Interpretative Phenomenological Approach. The analysis revealed that the parents attributed the siblings‟ personality differences to a combination of biological vs. psychosocial factors. It revealed meaningful insights as reflected by the themes that revolved around nature vs. nurture, psychosocial influences, parental identification and role modeling, gender, birth order and role expectations. Interestingly, despite sharing the same genetics, living in similar environmental conditions, children tend to display diversity in their behaviors and overall personality. Parents sometimes describe their children as opposite as „day and night‟ which raises a question to investigate the factors that cause such extreme diversity in their personalities. There is a need to further explore parental expectations and criteria for an ideal child as well as knowing about the relative contribution of nature vs. nurture factors in determining personality differences. Keywords. Perception of parents, attributions, children‟s personality, siblings Parent child relationship has been explored involving a variety of dimensions. There is considerable research, analysing the meaning of parents‟ perceptions of child characteristics, particularly in the area of temperament. This study aimed to qualitatively explore parent‟s understandings of perceived differences in their children‟s personalities with reference to sibling comparisons. The parent-child relationship consists of a combination of behaviors, feelings, and expectations that are unique to a particular parent and a particular child (Willson, Shuey, Elder, & Wickrama, 2006). The relationship involves the full extent of a *Correspondence concerning this article should be addressed to Fatima Kamran, PhD, Assistant Professor, Institute of Applied psychology, University of the Punjab, Lahore, Pakistan. Email: fatimakamran24@yahoo.com 96 KAMRAN child's development. The quality of the parent-child relationship is influenced by a multitude of factors, including; parent's age, experience, education, self-confidence, stability of the parents' marriage, beliefs and perceptions that determine their parenting styles as well as the unique characteristics of the child compared with those of the parent (Plomin & Daniels, 2011). Therefore, it is important to understand the dynamics underlying parental perceptions of their children‟s personality, the level of understanding and insight into their interests, abilities and behavior patterns (Birditt, Miller, Fingerman, & Lefkowitz, 2009). Parents are well aware of the behavioral differences between their children. This is particularly true for dimensions of temperament. When asked about their children's temperaments, parents frequently remark about extreme personality differences in their children as they come from different families. It suggests that commonly siblings show no resemblance in their temperaments. However, behavioral genetic research consistently reveals that temperament is genetically influenced (Siegler, DeLoache, & Eisenberg, 2011). Therefore, genetically related siblings should show some similarity in temperament. Could parents be exaggerating the behavioral differences between their children? If so, do the observed relations between sibling differences in temperament and child outcome reflect parental expectations rather than actual child behavior? Qualitative studies can add rich meaningful insights to explore such dynamics. Parental perceptions of their children‟s personalities and behaviors are also a reflection of the family processes that influence children‟s psychological well-being and subsequent development, but this impact is rarely studied (Shek, 2007). Drawing on family systems theories show how between- family, within-family, and within-individual differences emerge from family interactions that ultimately influence parental perceptions of the individual differences in their children‟s personalities (Solmeyer, Feinberg, Sakuma, Hostetler, & McHale, 2010). Understanding a child's temperament and personality traits provides a framework for judging their behavior in a variety of settings over time and facilitates understanding of personality development. Parents can provide first hand information about the influence of various factors in causing personality differences among siblings. This knowledge of the extent of biological and psychosocial influences contributes towards explaining commonalities and differences found among siblings as perceived by parents (Pandey & Kumar, 2009). PARENTS‟ PERCEPTIONS 97 Emmelkamp (2006) investigated parent-child interaction by studying how the parents categorize their child‟s behavior. It was found that the behavior emanating from the child is received as a series of impressions by the parent and then perceived as relevant or meaningful according to the cognitive organization or schemas of the parent. It means that a qualitative analysis of parents‟ attributions, understandings and beliefs depending on their schemas, can provide rich information instantly, but on the other hand, schemas can contribute to stereotypes and make it difficult to retain new information that does not conform to one‟s established schemas. It may cause the parents to identify and describe their children according to their preexisting concepts or apperceptions, past experiences and backgrounds that may or may not be the actual case (Whiteman, McHale, & Soli, 2011). Some factors may influence behavior towards children. These may include; „Relationship-driven effects‟. These effects refer to the matching of parent-child characteristics. For example, perhaps the child's temperament does not match the parent's preferences or expectations (Feinberg, Solmeyer, & McHale, 2012). Another aspect may involve „Parent-driven effects‟ which means that parents might treat their children differently for reasons of their own. A parent might have a particular reason for favoring or rejecting a particular child: for example, because the child was unwanted-its conception was unplanned (Eriksen & Jensen, 2009) Sometimes a child might be treated in a particular way by a parent, not because of that child's own characteristics, but because of the characteristics of his or her sibling. If parents find the first born to be „difficult; they may have a tendency to consider their next child comparatively easy and vice versa and as a result, they would have a different attitude towards each child and consequently lead to increase preexisting differences between siblings (McHale, Updegraff, & Whiteman, 2012). Rationale/ Significance of the Study Phenomenological theories of personality focus on an individual‟s subjective experience of their world, that is, their phenomenological experience (Killoren, Thayer, & Updegraff, 2008). Particularly people‟s subjective experience, or their self-concept, is seen as the core of individuals‟ personalities. Since parents are generally the major source of influence in the early years of child development, the way parents deal with their children and provide a certain type of home environment influences their personality development (Kennedy & Kramer, 2008). 98 KAMRAN Parental influence is studied extensively, however, their attributions to these personality differences needs to be explored across different cultures. In Pakistan, the parent-child relationship involves parents in a more authority role, with prolonged parental responsibilities to cater for their children‟s needs, even when children become adults, which consequently develops reciprocal strong emotional bonding/ dependency and expectations. It is worth exploring how these expected roles of their children develop and how do most parents perceive and describe individual differences of children‟s personalities since an early stage. Objective of the Study The study aimed to focus on why and how parents tend to develop their perceptions about the personality, abilities and interests of their children to understand the Attributional styles that lead to comparisons and individual differences as perceived by the parents. Method A qualitative research approach was used for this study. The theoretical perspective most often associated with qualitative researchers has been phenomenology (Bogdan & Biklen, 2004). The phenomenological approach, was used to understand the factors attributed by the parents to individual differences in siblings personalities. Further, the context is important to the interpretation of data. This approach requires that the researcher "centers on the attempt to achieve a sense of the meaning that others give to their own situations" (Smith, 2007, p. 12). The data collected in a qualitative study includes more than words; attitudes, feelings, vocal and facial expressions, and other behaviors are also involved. The data in the present study consist of interview transcripts. Three processes are blended throughout the study: collection, coding, and analysis of data (Glaser & Strauss, 1967). This approach encourages the kind of flexibility so important to the qualitative researcher who can change a line of inquiry and move in new directions, as more information and a better understanding of what are relevant data are acquired (Brotman et al., 2005). The study involved in-depth interview transcripts obtained from twelve parents (both parents of one family) that constituted the data for Interpretative Phenomenological Approach. A detailed analysis of the reported perceptions was carried out. PARENTS‟ PERCEPTIONS 99 Sample It comprised of twelve transcripts from a small scale qualitative project undertaken by the researcher. The inclusion criteria was to recruit parents with at least two children between the ages 2-12 years, with a maximum five year of age difference, in order to get a relatively homogenous sample to increase the likelihood of making comparisons among the siblings. The aim was to discern commonalities of view point and reported experience. A convenience sampling strategy was used; parents were recruited through the researchers‟ social networks. The participants were informed about the nature of research through discussion with the researcher and information sheets were given before they agreed to take part so that their decision to participate could be deemed „informed‟. The participants agreed to provide their data for non commercial research purposes with a condition to maintain anonymity. Both parents living together as married were included in the study, thus, excluding the single parents. Table 1 Demographic Characteristics of Participants Case No. Parent Age Education Occupation 1 2 3 4 5 6 7 8 9 10 11 12 Father Mother Father Mother Father Mother Father Father Mother Father Mother Mother 39 32 37 31 40 35 40 36 29 44 42 39 Masters Graduation Masters Graduation Graduation Masters Masters Masters Graduation Graduation Masters Graduation Banking Housewife Chartered Accountant Govt. officer Businessman Education Business Business Housewife Govt. Officer Education Housewife Monthly Family Income Rs1,95,000 NA Rs.1,75,000 Rs. 65,000 Rs.1,86,000 Rs.45,000 Rs.1,00000 Rs.2,00000 NA Rs.1,00000 Rs50,000 NA No. of Children 2 2 3 3 3 3 2 2 2 3 3 2 Research Design and Procedure Data were generated through one-to-one interviews, with each participant being interviewed separately. A semi-structured but open ended interview schedule was developed on the basis of the research aims and existing relevant research literature. It began with broad questions regarding perceived differences between participant‟s children and progressed towards questions around explanations for these differences 100 KAMRAN and perceived importance of birth order. This was piloted with one person who met the inclusion criteria as no amendments to the schedule were identified as necessary; the data from this interview were used in the study. The interviews took place in the participants‟ home and lasted around 30-40 minutes, with each participant interviewed by the researcher. Each interview was digitally recorded and then transcribed. Original names and identities were removed for the purpose of confidentiality. All interviews were tape-recorded and, based on four pilot interviews already conducted. The interviews were informal and open-ended, and carried out in a conversational style. Analytic Procedure. Transcripts were analysed using Interpretative Phenomenological Analysis (IPA) (Smith, 2007; Smith & Eatough, 2012). IPA was particularly used because it provides a systematic way of analyzing qualitative data that aims to explore participants‟ experiences, cognitions and meaning making. At the same time in IPA, there is a recognition that the outcome of any qualitative analysis represents an interaction between participants‟ accounts and the researchers‟ interpretative frameworks. Hence, the analytic process used here is both phenomenological and interpretative as the focus of this study is examining factors influencing personality development which is While it is not claimed that the thoughts of an individual are transparent within verbal reports, analysis is undertaken with the assumption that meaningful interpretations can be made about that thinking (Smith, 2007). The analysis involved reading all the transcripts thoroughly and making comments on the left margin. After analyzing the comments in detail, on the basis of commonalities and concepts emerging from the narratives, these descriptions were given theme titles as reflected in the comments. Initially a number of themes emerged which were gradually merged and categorized on the basis of similarities and common issues to constitute super ordinate themes to be discussed as main attributes of perceived personality differences. The researcher‟s interpretations and subjective accounts were described in main themes. Analysis The analysis revealed three major themes that emerged from the data: (1) Common Experience Attributions; (2) Demographic Factors as Determinants; (3) Parental Influences. (See Flow Chart 1) PARENTS‟ PERCEPTIONS 101 Flow Chart 1. Reflecting Super Ordinate Themes The subordinate themes are outlined below;  Nature vs. Nurture  Birth Order & Role Expectations  Psychosocial Influences  Parental identification and Role Modeling Common Experience Attributions encompasses a combined contribution of genetics, and gender specific behaviors. The narratives reflected that the parents had some common experience attributions of their children‟s personality differences. It appeared to be a combination of biological vs. psychosocial factors. Interplay among the influences of; Genetics and demographics such as Gender, Birth order and Age stage interacting with environment was found. It can be said that in addition to predetermined factors, the children‟s personality differences were attributed to psychosocial...
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