Parent-Child Interaction Therapy (PCIT) for Youth Anxiety: A Meta-Analysis Review

Introduction to Parent-Child Interaction Therapy (PCIT) for Youth Anxiety

A review of Parent-Child Interaction Therapy (PCIT) for youth anxiety, authored by Sharon Phillips and Matthew Mychailyszyn.
Addresses the applications of PCIT for youth anxiety.
Affiliations:
- Towson University, Towson, MD, USA
- Mount Washington Pediatric Hospital, Baltimore, MD, USA
Keywords: Parent-child interaction therapy, Anxiety, Parent training, Childhood (birth – 12 years), Parent-child relations
Anxiety disorders are prevalent in youth and can have negative impacts if untreated.
PCIT is effective for treating externalizing problems.
PCIT may be uniquely advantageous for treating anxiety due to its accessibility for younger children, for whom traditional cognitive behavioral therapy (CBT) may not be suitable.
Parent training in PCIT effectively supports parents in coping with their child’s anxiety symptoms.
Meta-analysis to determine the efficacy of PCIT and its adaptations in reducing anxiety symptoms in youth.
Databases searched: PsycINFO and PubMed.
15 articles met the inclusion criteria.
Finding: PCIT was significantly more effective at reducing anxiety symptoms compared to control groups.
Participants with comorbid diagnoses experienced comparable anxiety reduction to those without comorbidities.
Participants with subclinical anxiety levels also showed significant symptom reductions.
PCIT may be a promising early intervention for halting the progression toward disorder-threshold anxiety.
Conclusion: PCIT is an effective intervention for ameliorating anxiety symptoms in youth.

Prevalence and Manifestation of Anxiety Disorders in Youth

Anxiety disorders have a prevalence rate of $7.1\%$ in children and adolescents aged 3–17 years old (CDC, 2019).
Characterized by excessive fear, varying by specific disorder, with associated physiological and behavioral responses.
Manifests somatically with autonomic arousal (e.g., increased heart rate) and/or gastrointestinal distress.
Common behavioral responses: crying, clinginess, freezing, or tantrums.
The fear response is persistent and leads to avoidance of feared situations (Higa-McMillan et al., 2013).
Untreated anxiety disorders negatively impact youths’ quality of life and long-term functioning.
Can lead to impairments in learning and school attendance, potentially resulting in lower-paying jobs and reduced quality of life in the long term (Gonzalvez ´ et al., 2018; Higa-McMillan et al., 2013; Sanchez et al., 2019; Wood, 2006).
Can also influence children’s self-esteem and social functioning (Rappo, Alesi, & Pepi, 2017; Sanchez et al., 2019).
There is a clear need for treatments for youth with anxiety disorders.

Evidence-Based Interventions for Youth Anxiety

Cognitive-behavioral therapy (CBT) is the gold standard treatment for youth anxiety disorders and symptoms (Rith-Najaran et al., 2019; Whiteside et al., 2019).
CBT protocols include:
- Psychoeducation on anxiety disorders and coping strategies
- Cognitive restructuring
- Exposure to feared stimuli (Higa-McMillan, Kotte, Jackson, & Daleiden, 2017).
Brief, intensive CBT has also been found to have high effectiveness (Ost ¨ and Ollendick, 2017).
Barriers to CBT for early youth:
- Traditional CBT techniques are less developmentally suited for younger children due to cognitive immaturity (Minde et al., 2010).
- Young children may struggle to access, reflect on, and discuss their internal feelings or cognitions, hindering CBT implementation.
Families play a considerable role in maintaining symptoms, suggesting benefits to treatment approaches targeting family members and relationship functioning.

Parent-Child Interaction Therapy (PCIT) for Youth

PCIT focuses on modifying parent-child interactions to change child behaviors (Eyberg & Funderburk, 2011).
Two core components: Child-Directed Interaction (CDI) and Parent-Directed Interaction (PDI).
CDI: Trains parents to follow their child’s lead during play, fostering the understanding that positive attention is received for appropriate play (Zisser-Nathenson, Herschell, & Eyberg, 2017).
- Therapist coaches caregiver in what types of statements to say while playing with their child until the caregiver can show sufficient independent competency of the key skills, also referred to as PRIDE skills (praise, reflect, imitate, describe, and enjoy).
- Strengthens the parent–child bond and helps the parent learn how to use their attention to change child behaviors (Eyberg & Funderburk, 2011).
- Caregivers are also told during this stage to avoid commands, questions, and negative talk, and to use planned ignoring when their child is exhibiting disruptive behavior.
PDI: Caregivers give directions during playtime and learn to follow through with appropriate responses when a child is noncompliant (Zisser-Nathenson et al., 2017).
- Therapists teach caregivers how to effectively give commands and a time-out routine to follow when their child does not comply with commands (Eyberg & Funderburk, 2011).
PCIT is typically used to treat disruptive behaviors in young children, but some researchers have started to examine the use of PCIT with anxiety including:
- Separation Anxiety Disorder (SAD; Chase & Eyberg, 2008; Choate et al., 2005; Pincus, Santucci, Ehrenreich, & Eyberg, 2008)
- Selective Mutism (SM; Catchpole et al., 2019; Roslin, 2013)
- Behavioral Inhibition (BI; Barstead et al., 2018)
- Social Phobia/Social Anxiety Disorder (Comer et al., 2021; Gold, 2016)
- A variety of anxiety disorders (Bandi, 2019; Comer et al., 2012; Gross-Kaminetsky, 2019; Mazza, 2019)
- Subclinical anxiety symptoms (Abrahamse, Junger, van Wouwe, Boer, & Lindauer, 2016; Agazzi, Tan, Ogg, Armstrong, & Kirby, 2017; Phillips, Morgan, Cawthorne, & Barnett, 2008; Timmer et al., 2010).
Rationale for adapting PCIT for anxiety: understanding the interactional role of parent and child in the manifestation of youth anxiety.
Baumrind’s (1966) developmental theory: effective communication, nurturance, and consistency of behavioral expectations reflect an optimal parenting style.
Parent training in PCIT teaches parents how to effectively manage their child’s anxiety and decrease accommodation of symptoms (Comer et al., 2012).
PCIT and its adaptations uses techniques grounded in social learning theory (Bandura, 1986; Patterson, Reid, & Dishion, 1992) to change parent–child interactions that may reinforce child avoidance of anxiety provoking stimuli (Catchpole et al., 2019).
Drawing from tenets of attachment theory (Bowlby, 1980; Ainsworth, 1974) parents also learn to exhibit warmth and demonstrate responsiveness by providing reinforcement through labeled praise and attention to the child behaving bravely, which could lead to those behaviors occurring more frequently in the future (Pincus et al., 2008).
PCIT provides parents with training to become more consistent in their parenting, which can reduce anxious symptomology (Chase & Eyberg, 2008).
PCIT can also target treating anxiety disorders in children under seven years old where CBT might not be as effective (Comer et al., 2012; Pincus et al., 2008).
Researchers have explored PCIT adaptations to treat anxiety disorders and symptoms as some evidence-based treatments may not include formalized parent training.
Adaptations of PCIT include:
- The Turtle Program (Barstead et al., 2018)
- PCIT for Selective Mutism (PCIT-SM; Catchpole et al., 2019; Roslin, 2013)
- Coaching, Approach behavior, Leading by Modeling (CALM; Comer et al., 2012, 2021; Gross-Kaminetsky, 2019; Bandi, 2019)
- Group PCIT (Gold, 2016)
- BRAVE Start (Mazza, 2019)
- PCIT for SAD (Pincus et al., 2008).
The Turtle Program: Includes parent and child groups and implements treatment in the child’s school environment, focusing on intrusive parenting (Barstead et al., 2018).
PCIT-SM: Adds a Verbal Directed Interaction component, teaching parents to increase opportunities for the child to speak (Catchpole et al., 2019; Roslin, 2013).
CALM: Replaces the PDI component of PCIT with an exposure-based component (Comer et al., 2012).
Group PCIT: Includes the same components of PCIT proper, but treatment is delivered in a group format with parents taking turns on being coached (Gold, 2016).
BRAVE Start: Teaches parents BRAVE MIND (Behavior descriptions, Reflections, Affection, Validation, Effective Praise, Modeling, Incentivizing, Negotiating, and Deliberate ignoring) skills to use while leading their child through exposures instead of PRIDE skills (Mazza, 2019).
PCIT for SAD: Adds a component termed Bravery-Directed Interaction, where the parent and child practice separating (Pincus et al., 2008).
The efficacy of these adaptations for treating anxiety disorders in youth remains unclear, as clinical research is still in its early stages.
Previous meta-analyses on PCIT focused on:
- Externalizing behavior problems
- Attention Deficit/Hyperactivity Disorder (ADHD; Thomas & Zimmer-Gembek, 2007; Thomas, Abell, Webb, Avdagic, & Zimmer-Gembek, 2017; Ward, Theule, & Cheung, 2016)
- Autism Spectrum Disorder (ASD; Vetter, 2018)
- Families with a history of physical abuse (Foley, 2010; Kennedy, Kim, Tripodi, Brown, & Gowdy, 2016).
Meta-analyses on externalizing behavior problems: PCIT can significantly reduce child disruptive behaviors with medium to large effect sizes (Thomas & Zimmer-Gembek, 2007; Thomas et al., 2017; Ward et al., 2016).
Vetter (2018) meta-analysis: PCIT can effectively treat symptoms associated with ADHD or ASD.
Meta-analyses on families with a history of child abuse or neglect: PCIT is effective in reducing abuse potential (Foley, 2010; Kennedy et al., 2016).
No meta-analyses were found that looked at using PCIT for anxiety, or any internalizing problems.

Current Study

The current meta-analysis aims to review the current research on different adaptations of PCIT for treating anxiety disorders in youth.
Goals:
1. Determine the overall efficacy of using PCIT as an intervention for anxiety symptomology in youth.
2. Determine which adaptations of PCIT are most effective.
3. Characterize the current literature investigating the implementation of PCIT for youth anxiety to identify potential gaps and make suggestions for future research.

Method

Studies were identified through online database searches of PsycINFO and PubMed.
Initial search: June 2020 using search terms ((“parent-child interaction therapy” OR PCIT) AND (anxiety)).
Start date for database searches: 1988 (PCIT developed in the 1970s).
Yielded studies were stored and managed using DistillerSR.
Initial search yielded 55 results.
An additional article was found through communication with an expert in the field.
Reference lists of included studies were also searched – this yielded 13 additional studies to be screened for inclusion.
After duplicates were removed, 56 total studies remained.
A final search was conducted mid-September 2020 and yielded 8 additional results to be screened.

Inclusion and Exclusion Criteria

Inclusion criteria:
1. Studies had to be written in English.
2. Studies had to implement PCIT or an adaptation of PCIT.
3. Participants had to be children between the ages of 2 and 10 years old.
4. The study had to report measurement of anxiety symptoms at pre- and post-intervention; studies where internalizing symptoms were reported as a broad construct were included in addition to anxiety symptoms in order to increase the scope of the study.
5. Studies had to have more than one participant.
Exclusion criteria:
1. Case studies were excluded.
2. Studies were excluded if the sample of participants overlapped with another study that met inclusion criteria to meet assumptions of independence.
3. Eligible studies were able to be unpublished work such as doctoral dissertations.

Article Screening and Coding

The first author conducted abstract screening and full text screening based on the inclusion criteria.
Study characteristics of interest were detailed in an Excel file by the first author in order to be analyzed.
Characteristics of interest included:
- Participant characteristics (ages, diagnoses)
- Intervention characteristics (type of adaptations used, program length, location the program was delivered in, and information on who delivered the program)
- Experimental characteristics (control group information, person that reported the symptoms, measures used).
Quantitative data on anxiety symptoms was transposed by the first author into an Excel file that contained equations to calculate effect sizes.
If studies met all inclusion criteria but did not include the information needed to calculate effect size (mean, standard deviation, and sample size at pre and post), the authors attempted to contact the researchers to obtain that information. If that information was not available, the study was excluded from this meta-analysis.

Statistical Analyses

Studies that did not employ control groups were eligible for inclusion
Traditional effect size computations compare intervention groups to control groups at a given timepoint (typically post-intervention).
The standardized mean gain (SMG; Lipsey & Wilson, 2001) was calculated as the measure of effect size.
SMG allowed for the summary effect size of all intervention groups to be compared to the summary effect size of all control groups to determine if the magnitude of change is significantly different.
The correlation between pre- and post-test scores was needed to calculate the standardized mean gain, but since most studies do not report this value, the recommended estimate of $r = 0.7$ was used (Rosenthal, 1993).
Hedge’s g was calculated and interpreted according to the same standards as Cohen’s d (Borenstein, Hedges, Higgins, & Rothstein, 2009; Lipsey & Wilson, 2001).
- $0.2$ reflects a small effect
- $0.5$ a medium effect
- $0.8$ and beyond characterizing a large effect.
The Q-statistic was calculated.
A Fail-Safe N (Lipsey & Wilson, 2001) was computed.

Results

Study Characteristics

15 studies were identified.
370 children were involved, ranging in age from 2 years to 9.75 years.
Participants from six of the studies did not have an anxiety disorder diagnosis, participants from four studies focused on participants that had a particular anxiety diagnosis, and the remaining five studies utilized youth participants with a variety of anxiety disorder diagnoses.
Of the nine studies that included a comparison group, four utilized a within group waitlist control, three used an active control, and two used a waitlist control group
Two of the studies had comparison groups where the participants of that group actually did receive PCIT, however they were separated from the primary experimental group in those investigations because participants did not have an anxiety diagnosis (Chase & Eyberg, 2008) or did not have exposure to interpersonal violence (IPV; Timmer et al., 2010).
The assessment of symptomology relied upon a variety of instruments that measured general anxiety symptoms, disorder-specific symptoms, disorder-related impairment, and clinical improvement.
Measures used:
- Spence Children’s Anxiety Scale-Parent Version (SCAS-P; Nauta et al., 2004)
  - a parent report measure comprised of 38, 4-point Likert-type items that assess for the frequency with which a broad range of common youth anxiety symptoms
- Screen for Child Anxiety Related Emotional Disorders (SCARED;
  - Birmaher, Khetarpal, Brent, & Cully, 1997) is a 41-item measure of a child’s anxiety designed for use in children ages 8 and older
- Child Behavior Checklist (CBCL Achenbach, 1991; Achenbach & Edelbrock, 1991)
  - Completed by parents, the CBCL has 118 items that are scored from 0 to 2 depending on the degree to which the particular item characterizes the child
- Pre-School Anxiety Scale (PAS; Spence, Rapee, McDonald, & Ingram, 2001)
  - is a parent report measure for parents of children aged 3 to 5 years old.
  - The PAS consists of 34 items that are scored from 0 to 5 based on how true the item is for the child.
- Child Anxiety Impact Scale (CAIS; Langley, Bergman, McCracken, & Piacentini, 2004)
  - is a parent-report measure that assesses impairment related to child anxiety.
  - The measure consists of 27 items and is rated on a scale from 0 to 3 based on how much the child’s anxiety has impacted each activity listed in the items.
- Selective Mutism Questionnaire (SMQ; Bergman, Keller, Pia´ centini, & Bergman, 2008)
  - is a parent-report measure consisting of 17 items.
  - This measure assesses the selective mutism symptoms in the home, school, and community.
- Clinical Global Impression-Severity Scale (CGI-S; Guy & Bonato, 1970)
  - is a clinician-report measure that assesses illness severity.
  - This measure consists of one item that is rated on a 7-point scale assessing the severity of a person’s illness.
- Child Behavior Scale (CBS; Ladd & Profilet, 1996)
  - is a teacher-report measure consisting of 59 items that are scored from 1 to 3 depending how much the item applies to the child.
All but two studies (Barstead et al., 2018; Comer et al., 2012) had parents report on anxiety symptoms.

Quantitative Data Synthesis: Standardized Mean Gain (SMG)

All studies were included in the calculation of the summary effect size for the PCIT intervention group and all studies that included a comparison group were included in the calculation of the summary effect size for the comparison groups.
For the 15 studies that investigated the use of PCIT for youth anxiety, the summary pre-post (i.e., SMG) effect size estimate was significant at $g = 0.96$ (95% CI: 0.70, 1.22, p < .001) for reducing anxiety symptomology.
For the 8 studies that also included a control group, the summary pre-post effect size estimate for the control groups was also significant, at $g = 0.40$ (95% CI: − 0.07, 0.87, p < .001) for reducing anxious symptomology.
When directly comparing the summary effect sizes for both groups, there was a significant difference ( $Z = 2.05$ , $p = 0.041$ ), with the intervention groups demonstrating significantly greater change from pre- to post-intervention in terms of reductions in anxiety than the control groups.
PCIT interventions were found to have a large effect size at $g = 0.96$ while the control groups were found to have a small to moderate effect size at $g = 0.40$ .
Two studies (Chase & Eyberg, 2008; Timmer et al., 2010) utilized comparison groups that also received PCIT, and as such were conceptually different from the control groups employed in other studies.
The summary pre-post effect size for the control groups became non-significant and was reduced to 0.05.
The PCIT intervention group still demonstrated significantly greater reductions in anxiety than the control groups ( $Z = 6.32$ , p < .001).
For the calculation of Fail-Safe N, a criterion effect size of 0.2 was selected as the criterion value reflecting the point at which results might no longer be clinically meaningful as that is the value that is representative of a small effect size.
Using this criterion effect size, the Fail-Safe N was calculated to be 56.

Secondary Analyses

PCIT Adaptations

For the nine studies that used an adaptation of PCIT, the summary pre-post effect size was 1.04 (95% CI: 0.61, 1.47, p < .001).
For the six studies that used PCIT as usual, the summary pre-post effect size was 1.07 (95% CI: 0.67, 1.46, p < .001).
When directly comparing the two groups, there is not a significant difference ( $Z = -0.13$ , $p = .896$ ).

Comorbid Diagnoses and Symptoms

Comorbid disorders and symptoms that were present in the included studies were disruptive behavior problems, Autism Spectrum Disorder, Attention Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder.
For the 8 studies that had participants with comorbid disorders or symptoms, the pre-post summary effect size was significant at 0.66 (95% CI: 0.37, 0.95, p < .001).
For the seven studies that had participants that did not have comorbidity, the pre-post summary effect size was significant at 0.90 (95% CI: 0.54, 1.26, p < .001).
When directly comparing the two groups, there was not a significant difference in summary effect sizes ( $Z = -1.01$ , $p = .314$ ).

Anxiety Diagnosis Versus Symptoms

For the ten studies where the participants had at least one anxiety diagnosis, the pre-post summary effect size is significant at 1.18 (95% CI: 0.92, 1.45, p < .001).
For the five studies where the participants did not have an anxiety disorder diagnosis, the pre-post summary effect size was significant at 0.75 (95% CI: 0.60, 0.91, p < .001).
When directly comparing the two groups, there was a significant difference between the summary effect sizes ( $Z = 2.71$ , $p = .007$ ).

Discussion

Summary of Findings and Implications

There was found an overall large effect size for the intervention groups.
PCIT was also found to be effective regardless of whether the intervention used was an adaptation to standard delivery or PCIT proper.
PCIT significantly reduced anxiety symptomology even when children did not have clinical levels of anxiety.
PCIT may have ancillary benefits insofar as it may decrease levels of anxiety even when this is not the primary reason for referral.
The current findings suggest that PCIT may have transdiagnostic effects beyond the externalizing problems that it was initially developed for.
Thomas et al. (2017) also found that PCIT was effective in treating disruptive behavior disorders regardless of whether or not comorbidity existed, and the current-meta-analysis yielded similar results.
Current analyses found that PCIT was effective in treating anxiety symptoms regardless of whether there were comorbid externalizing problems or not.
PCIT’s effectiveness in treating both externalizing and internalizing problems even with other comorbid problems is a notable strength of the protocol.
PCIT may be specifically beneficial for SAD because the treatment may target the parent–child relationship before starting separation practices as exposures (Chase & Eyberg, 2008).
PCIT may be beneficial specifically for SM because it can help parents learn to reinforce talking and avoid reinforcing nontalking (Catchpole et al., 2019).
PCIT may be suited for treating Behavioral Inhibition because of its accessibility for younger children and because it will target maladaptive parent–child interactions early in childhood.
It is unclear based on the research at this time whether PCIT is better at treating certain anxiety disorders over others.
PCIT may be able to reduce some of the barriers seen with the current gold standard treatment (CBT) because PCIT is able to be used with younger children and parents are heavily included in this treatment (Comer et al., 2012; Minde, Roy, Bezonsky, & Hashemi, 2010).
The use of PCIT for youth anxiety disorders also allows for the therapist to provide in vivo coaching of the parents during exposures, which may help with treatment progress (Comer et al., 2012).
As receiving training and learning treatment protocols can cost large amounts of money and take extensive amounts of time, there may be a need for evidence-based treatment packages that can work for a variety of psychological problems.

Limitations and Future Directions

One of the limitations of this meta-analysis is the number of participants in the included studies.
Studies differed in the level of training of the therapist that was implementing the intervention, with some therapists not yet being certified as PCIT therapists.
This meta-analysis also included studies that examined anxiety disorders or subclinical anxiety symptoms.
The grouping together of studies that include youth with diagnosed anxiety disorders and youth with subclinical anxiety for the primary analysis and two of the secondary analyses may have led to different results than if the studies had been separated.
Further studies are needed to investigate the use of different adaptations of PCIT.
Future studies can also focus on comparing PCIT to other evidence-based interventions for treating anxiety to determine whether they have similar effect sizes.

Conclusion

PCIT and adaptations of PCIT are effective for treating youth anxiety regardless of whether children had a clinical diagnosis of anxiety or whether they had any comorbid symptomology.
PCIT may provide new benefits to children with anxiety due to the unique aspect of parent training and because it can be used with younger children.