Improving mental health outcomes through parent and teacher engagement in school-based early intervention

The primary aim of this research project is to evaluate the acceptability and efficacy of school-based Parent-Child Interaction Therapy (PCIT) early intervention that is matched to the individual needs of young children with conduct problems. A randomised controlled trial will be conducted. Children identified via a screening as eligible for participation in the early intervention program will be will be divided into two groups according to whether or not they present with callous-unemotional (CU) traits. These children and their families will then be randomised to receive one of two interventions: (1) Standard PCIT or (2) PCIT-CU, an adaptation of PCIT for children who show clinically significant levels of conduct problems and callous-unemotional (CU) traits (e.g., lack of empathy/guilt, uncaring attitudes). CU traits are known diagnostically as "with limited prosocial emotions". Standard PCIT: Standard PCIT is a clinic-based protocol, which draws on real-time, wireless technology to provide in vivo coaching of parent-child interactions by a therapist observing the parent-child dyad from behind a one-way mirror. Treatment is divided into 2 phases: (1) Child-Directed Interaction (CDI) and (2) Parent-Directed Interaction (PDI). During CDI, parents are coached in traditional play therapy skills. Parents are taught to consistently attend to and reinforce positive child behaviours via five "do" skills, including descriptive praise, descriptions of appropriate child behaviour, reflections of appropriate child speech, imitations of appropriate child behaviour, and expressions of enjoyment, while simultaneously withdrawing their attention from attention-seeking behaviours. During CDI, the overall purpose of applying these skills is to improve the quality of the parent-child relationship. During PDI, parents are coached to set limits and provide appropriate, consistent consequences for inappropriate behaviour. The overall purpose of PDI is to reduce the frequency and intensity of disruptive child behaviour, and to allow parents to effectively manage disruptive behaviour if/when it does occur. The first treatment session of each phase begins with a Teach session during which parents are taught specific skills, which are then practiced in the following Coach sessions. In standard PCIT, treatment dosage varies between families because transition between phases and to graduation from treatment depends on parents reaching a prescribed level of the phase-specific skills (‘mastery criteria’). However, prior research indicates improved outcomes and lower attrition rates using a fixed approach to dosage, whereby transition through and from treatment occurs after completing a pre-specified number of sessions, rather than a variable approach that requires reaching skill mastery. The current protocol utilises this fixed approach, with all families receiving 14 weekly, one-hour treatment sessions during the CDI and PDI phases. This treatment dose is consistent with the average number of PCIT sessions completed in prior research (i.e., 12-16 sessions). Families allocated to the standard PCIT treatment condition will receive an additional seven weekly telephone consults following the PDI phase (to control for possible differential dose effects [see below]). These calls elicit updates regarding behavioural difficulties, and involve therapists assisting parents to apply PCIT skills to manage difficulties. In total, families allocated to standard PCIT will receive a total of 21 sessions delivered weekly. The therapy will be delivered by a therapist certified in standard PCIT, delivered one-on-one in school-based research clinic. PCIT-CU: PCIT-CU builds upon standard PCIT by (a) explicitly coaching parents in CDI to increase their warm/affectionate behaviours and responsivity to the child; (b) systematically supplementing punishment-based strategies in PDI with reward-based techniques; and (c) training parents to deliver emotional skill-building instruction to the child via a 7-session adjunctive module (called "CARES"; Coaching and Rewarding Emotional Skills) that intensively targets children's insensitivity to others’ distress cues. The adapted CDI-CU phase begins with a Teach session educating parents on the importance of warm/affectionate and emotionally responsive parenting, and CDI-CU skills are taught and modelled. The fifth of five CDI “Do” skills is adapted to explicitly train and coach parents to express warm and affectionate behaviours (e.g., positive touch, increased eye contact). This skill is called "Emotional Expression". Components of standard PCIT maintained in the CDI-CU phase include increasing attention to positive child behaviours and reducing control and criticism of the child. Following the initial CDI-CU Teach session, families complete six CDI-CU coaching sessions, during which parents receive in vivo coaching by a therapist from behind a one-way mirror while practicing CDI-CU skills in play with the child. The CDI-CU phase is hypothesised to increase parental physical affection and responsivity. The adapted PDI-CU phase phase integrates an individualised token system directly into the standard PCIT discipline sequence. Standard PCIT components of effective commands, ignoring minor misbehaviours, and time-out following child noncompliance and other problem behaviours are maintained. PDI-CU begins with a Teach session educating parents on effective commands and the importance of reward-based strategies with children with co-occurring conduct problems and CU traits. The PDI-CU discipline sequence is modelled and role-played with parents and children in the first coach session before in vivo coaching begins. Children earn tokens for positive behaviours (e.g., compliance, prosocial behaviours) and for 'positive opposites' of negative behaviours (e.g., praise of manner instead of swearing). PDI-CU is hypothesised to increase parental consistency in using an individualised token system to more intensively reinforce child compliance and other positive behaviours, relative to praise alone. The novel, adjunctive CARES module targets emotional deficits in children with conduct problems and CU traits by training parents to engage in emotional skills building activities with the child. The six CARES foci are: (1) refocusing attention to facial micro-expressions (e.g., changes in the eye region) to teach better identification and interpretation of others’ feeling states, particularly distress; (2) developing emotional language; (3) teaching the importance of context and perspective taking when interpreting meaning in emotional displays; (4) using modelling, role-play, and social scripts to teach children to engage in empathic, prosocial behaviour; (5) using positive reinforcement established in earlier phases (praise, token system) to encourage prosocial behaviour and motivate compliance with learning activities; and (6) teaching developmentally appropriate cognitive-behavioural strategies to address reactive aggression stemming from frustration-based anger when reward driven behaviours of children with co-occurring conduct problems and CU traits are thwarted. A discussion on when and how to phase out the token system initiated in PDI-CU occurs during the final CARES session. CARES is hypothesised to improve CU traits and empathy by improving children's distress sensitivity. As in the standard PCIT protocol, PCIT-CU CDI/PDI will be delivered in a total of 14 weekly, one hour treatment sessions, with the PCIT-CU families receiving an additional seven weekly treatment sessions following the PDI phase, meaning that families allocated to PCIT-CU will receive a total of 21 face-to-face sessions delivered weekly. The therapy will be delivered by a therapist certified in standard PCIT and trained in the adapted protocol, delivered one-on-one in school-based research clinic. To avoid intervention cross-over that could threaten the integrity of the study, different therapists will deliver standard PCIT and PCIT-CU treatments, and within each condition there will be two therapists to avoid confounding therapist and treatment. Teacher participation in PCIT/PCIT-CU: The caregiver(s) of participating children will be asked to consent children's teaching staff receiving and providing information regarding the student's participation in PCIT. If consent is given, all teaching staff directly involved with the child receiving PCIT (e.g., classroom teacher(s), learning support staff) will be provided the opportunity to access and request support services from the child’s PCIT therapist. At the time of the baseline assessment, one teaching staff will be invited to complete several questionnaires about the student's behaviour at school. After CDI Coach 2, teaching staff will be invited to participate in an upcoming PCIT session in the PCIT clinic and classroom coaching. The in-clinic and in-class behavioural coaching support provided to the child’s teaching staff will follow the guidelines outlined in the PCIT treatment protocols, involving coaching from the child’s PCIT therapist in the application of teacher-student relationship-building skills and behaviour management strategies as the teacher-student dyad engages in play-based activities. Throughout PCIT, teaching staff are encouraged to contact the PCIT therapist to discuss the PCIT strategies, the student's progress in PCIT, and/or the student's behaviour at school via phone or in-person meeting. All preschool, Kindergarten, Year 1, and Year 2 teaching staff at participating schools will be invited to participate in a one-day-equivalent professional learning workshop face-to-face. The newly-developed workshop is focused on providing information about the development of conduct problems and practical experience in evidence-based behaviour management strategies. This workshop will take place during the first two terms of each new school year.