Parent Child Interaction Therapy as a Family-Oriented Approach to Behavioral Management Following Pediatric Traumatic Brain Injury: A Case Report

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1 Parent Child Interaction Therapy as a Family-Oriented Approach to Behavioral Management Following Pediatric Traumatic Brain Injury: A Case Report Matthew L. Cohen, MS, Shelley C. Heaton, PHD, Nicole Ginn, MS, and Sheila M. Eyberg, PHD Department of Clinical and Health Psychology, University of Florida Introduction All correspondence concerning this article should be addressed to Matthew L. Cohen, MS, Department of Clinical & Health Psychology, College of Public Health and Health Professions, University of Florida, PO Box , Gainesville, FL, , USA. mlcohen@phhp.ufl.edu Received May 5, 2011; revisions received September 8, 2011; accepted September 12, 2011 Objective To present a case study illustrating the application of parent child interaction therapy (PCIT) for management of a child s externalizing behaviors related to a severe traumatic brain injury (TBI). Methods An 11-year-old boy s history and injury are described, followed by a description of PCIT and the course of therapy. Results After 9 sessions of PCIT, the child displayed fewer negative behaviors, and his mother s distress was reduced. Conclusions This case demonstrates the feasibility of using PCIT with a child older than the recommended age range to address behavior problems associated with TBI. Key words behavior problems; case study; parent child interaction therapy; pediatric traumatic brain injury; traumatic brain injury. Traumatic brain injury (TBI) occurs at a rate of 70 per 100,000 in children under 18 years of age, is a leading cause of death and disability, and accounts for more than $1 billion in hospital expenses annually (Langlois, Rutland-Brown, & Thomas, 2006; Schneier, Shields, Hostetler, Xiang, & Smith, 2006). Pediatric TBI symptom severity and duration are highly variable and can have long-term sequelae for the child that includes cognitive, academic, social, functional, and behavioral components (Fletcher, Ewing-Cobbs, Miner, Levin, & Eisenberg, 1990; Taylor et al., 2002; Yeates et al., 2004). Up to 50% of children with severe TBI experience problem behaviors that can persist well beyond the postacute recovery phase (Brown, Chadwick, Shaffer, Rutter, & Traub, 1981; Fay et al., 2009; Yeates, 2010), which poses an important treatment challenge to pediatric psychologists and neuropsychologists. Children with more severe brain injuries, with greater socioeconomic disadvantage, and with a preinjury history of behavior problems are at greatest risk for developing persistent postinjury behavior problems (see Taylor, 2010; and Yeates, 2010 for reviews). Pediatric TBI also has significant impact on the family system. In the initial year following injury, there can be significant family dysfunction coupled with caregiver stress, burden, anxiety, and depression (Wade, Taylor, Drotar, Stancin, & Yeates, 1998). The effects on the family often last for >6 years following the injury (Wade et al., 2006) and exceed the burden faced by families of children with injuries outside the central nervous system (CNS). Furthermore, there appears to be a complex but important relationship between family functioning and functioning of the child recovering from TBI, highlighting the importance of taking a systemic approach to treatment of postinjury behavior problems (Kinsella et al., 1999; Taylor et al., 2001). Behavioral and emotional changes following TBI are fairly common in pediatric TBI, although there is no specific behavioral profile uniquely attributed to TBI (Brown et al., 1981). In fact, a wide range of problems can be observed, including depressed or anxious mood, personality changes, inattention and hyperactivity, and oppositional behaviors. Externalizing problems, such as Journal of Pediatric Psychology 37(3) pp , 2012 doi: /jpepsy/jsr086 Advance Access publication October 17, 2011 Journal of Pediatric Psychology vol. 37 no. 3 ß The Author Published by Oxford University Press on behalf of the Society of Pediatric Psychology. All rights reserved. For permissions, please journals.permissions@oup.com

2 252 Cohen, Heaton, Ginn, and Eyberg disinhibition and oppositional defiance, occur more frequently in pediatric TBI than the general population (Brown et al., 1981) and can negatively affect a child s functioning both at home and school. Although it is well-established that children with pre-existing behavior problems (e.g., attention deficit/hyperactivity disorder, ADHD) are at greater risk for postinjury behavioral sequelae, it has been suggested that TBI can exacerbate preinjury behavior problems in some children and increase the risk for additional, novel behavior problems (Max et al., 1998). Furthermore, even children with no history of behavioral or emotional problems are at risk for developing post-tbi behavior problems, particularly those more severely injured (Brown et al., 1981; Bloom et al., 2001; Fletcher et al., 1996). Research has also supported the notion that family factors such as socioeconomic disadvantage, and family burden, distress, and dysfunction are risk factors for poor postinjury functioning of the child, and better family functioning may moderate some of the effects of brain injury (Anderson, Catroppa, Morse, Haritou, & Rosenfeld, 2005; Taylor et al., 1995, 2001). Thus, there is an acute need not only to treat behavior problems arising after pediatric TBI through interventions directed at the child, but also to target important outcome moderating factors, such as family burden and stress. Existing treatment approaches targeting behavior problems after severe pediatric TBI include structuring the child s environment to provide positive behavioral supports (Ylvisaker, Jacobs, & Feeney, 2003), implementing cognitive behavioral approaches with the injured child (Selznick & Savage, 2000; Suzman, Morris, Morris, & Milan, 1997; Ylvisaker, 2006), and training parents to be stronger advocates for their injured child s needs in the school setting (Glang, McLaughlin, & Schroeder, 2007). However, despite strong evidence for family factors affecting pediatric TBI outcome, only a few evidence-informed, family-centered interventions have been developed and successfully applied to pediatric TBI (see Wade, 2010 for review), and interventions directly targeting parent child interactions have been limited to work with very young children. Over the past decade, Wade and colleagues have been developing and refining a family problem-solving approach that seeks to improve functioning for not on the injured child, but their family members as well (Wade, 2010). Although their treatment program targeted the whole family and evidence suggested a reduction in behavior problems of school-age children, parent child interactions were not a specific intervention target. Recently, the group extended some of their early work with families of school-age children and adolescents with TBI to provide a web-based parenting skills program for families of very young (ages 3 8 years) children (Wade, Oberjohn, Burkhardt, & Greenberg, 2009). The program consisted of 10 web-based sessions that included self-guided didactic information, video modeling skills, and exercises, with related in vivo coaching of target skills by a trained therapist. Preliminary data from nine participating families indicated significant improvement in targeted parenting behaviors, which were maintained at follow-up, but only five families completed treatment. Among this small group of treatment completers, there was a noted trend for reductions in child behavior problems, providing tantalizing evidence that interventions targeting parent child interactions may have positive effects on child behaviors after severe TBI. Positive interpersonal interactions within the home are important for creating a supportive family environment. In turn, a supportive family environment protects the family against additional stress and burden and improves the child s adaptation to the injury (Wade, 2006). Although the research being conducted by Wade and colleagues suggests that intervention programs targeting parent child interactions may be a viable treatment approach for pediatric TBI, it is unclear whether these methods would work well with older children. Furthermore, it is unclear whether already existing, manualized parent child interaction treatments (e.g., Parent Child Interaction Therapy; PCIT) can be applied to this population. In this case study, we present PCIT outcomes for behavior problems and family functioning of a severely brain-injured adolescent 19 months postinjury. PCIT is an empirically supported intervention designed for families with young children with disruptive behavior disorders. After completing PCIT, children s disruptive behavior is reduced to within normal limits both in the home (Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998) and classroom (McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991), and these changes are maintained in both settings over time (Funderburk et al., 1998; Hood & Eyberg, 2003). PCIT has also been applied successfully to the treatment of children experiencing a broad range of behavioral, emotional, and family problems (Zisser & Eyberg, 2010) as well as externalizing behavior problems in the context of medical conditions (e.g., Bagner, Fernandez, & Eyberg, 2004). Although PCIT was designed for the treatment of young children (i.e., ages 2 7 years), it has been implemented for treatment of physically abusive parenting with dyads in which children ranged up to 12 years of age (Chaffin et al., 2004). To our knowledge, however, child outcomes have not been reported for children at this age.

3 PCIT Following Pediatric TBI 253 PCIT sessions incorporate parent child interactions that are coached from an observation room (via wireless bug in the ear) to aid the parent in building positive interaction patterns with the child. The direct and concrete interaction patterns coached during PCIT may be particularly beneficial for children with TBI who have deficits in working memory (Levin et al., 2002) and executive control (Ornstein et al., 2009). For example, rather than saying clean up your toys when you re done, a parent would be coached to use the more concrete, direct command please put the blue truck in the toy box, and the child would be praised following compliance to each simple command. Alternatively, one might argue that frontal lobe injury (which is common in severe TBI) would impair a child s ability to learn from consequences and adapt their behavior based on parental response, such that behavioral interventions relying on operant conditioning through discipline would be ill-suited to this population (Ylvisaker, Turkstra, & Coelho, 2005). This issue may be particularly relevant in the second phase of PCIT in which the child s compliant behaviors are reinforced through positive attention and praise, and noncompliant behaviors discouraged by contingent application of a time-out procedure. Although prior research has shown that child behavior change occurs in both phases of treatment (Eisenstadt, Eyberg, McNeil, Newcomb, & Funderburk, 1993), it is unknown whether frontal lobe pathology would specifically interfere with the effectiveness of the second phase of PCIT. This case study provides a preliminary opportunity to explore these issues because the child had extensive frontal lobe damage. In PCIT, parents are taught skills to establish a nurturing and secure relationship with their child, while also increasing their child s prosocial skills and reducing disruptive behaviors. Treatment focuses on establishing Baumrind s (1976) authoritative parenting style in which parents are taught to be empathic and supportive while using clear communication and setting firm limits. PCIT consists of two phases: the child-directed interaction (CDI), which focuses on increasing parental warmth and strengthening the parent child relationship, and the parent-directed interaction (PDI), which teaches parents a structured and consistent approach to discipline. In CDI, parents learn to follow their child s lead in a play situation and use differential social attention to give positive attention to prosocial behaviors and ignore negative behaviors. Parents also model appropriate play behaviors (such as sharing) for their children. At the completion of PCIT, parents typically show decreases in negative, critical talk, and increases in prosocial talk and physical warmth toward their child (Eisenstadt et al., 1993). In the PDI phase of PCIT, parents learn to give specific, age-appropriate, direct commands to their children and to follow each command with a clear, consistent contingency plan for compliance and noncompliance. Parents are taught to provide positive reinforcement for compliance and to begin a time-out sequence following noncompliance (Eyberg & Bussing, 2010). Several randomized controlled trials have shown that children participating in PCIT increase their compliance to parental commands and decrease their disruptive behaviors in comparison to wait-list controls (Bagner & Eyberg 2007; Schuhmann et al., 1998). Consistent pairing of child compliance with parental reinforcement is presumed to underlie the behavioral changes that occur during the PDI phase of treatment. It is possible that cognitive impairments post-tbi could dampen the effects of this type of operant conditioning. However, the immediate, direct, and concrete interaction style of PCIT may be particularly beneficial for children with TBI who have cognitive deficits (Levin, 2002; Ornstein et al., 2009). In this case report, we aim to show that PCIT may be an effective treatment for managing the behavior problems that can result from pediatric TBI and improving the quality of the child s relationship with his or her parents, thus relieving stress on the family system. We applied this intervention with an 11-year-old boy with a preinjury diagnosis of ADHD-combined type from a socioeconomically disadvantaged family who was the unfortunate victim of a severe traumatic brain injury. These characteristics (severe TBI, preinjury behavior problems, low socioeconomic level) are all negative predictors of long-term behavior problems following pediatric TBI (Schwartz et al., 2003). If the intervention is successful for a high-risk family with multiple negative predictors of postinjury behavior problems and for whom PCIT is not traditionally targeted, the effectiveness of PCIT may also be indicated for children with lesser TBI severity and for whom PCIT is a more traditional fit (e.g., younger children). Thus, the purpose of this case study was to demonstrate (a) the feasibility of treating the family of a child with TBI and negative prognostic indicators using PCIT, (b) a quantitative reduction in the number of problem behaviors after PCIT, and (c) a qualitative and quantitative reduction in parental distress after PCIT. Patient Presentation D.W. is an 11-year-old, right-handed Caucasian male of low socioeconomic status and a rural upbringing. He was

4 254 Cohen, Heaton, Ginn, and Eyberg first seen by our clinic for neuropsychological evaluation. That assessment resulted in a referral for psychotherapy. We describe here his psychosocial history before injury, the results of his neuropsychological examination, and his course of treatment for behavior problems. Preinjury History, Family Environment, and Testing D.W. was born full term weighing 7 pounds 2 ounces and achieved developmental milestones at or before the developmentally expected timepoints. D.W. s immediate family lives together and consists of his biological mother, stepfather, and younger sister (aged 4 years). D.W. s biological father has not been in contact with the family since D.W. was 12 months old. D.W. also has several aunts, uncles, and cousins living within close driving distance, and his family is close with their church community. Both of his parents completed High School, his stepfather is a farmer, and his mother stays at home with both children and is the primary disciplinarian. At the request of his parents, D.W. was evaluated at age 5 years by a school psychologist and subsequently diagnosed with ADHD Combined Type, which was treated with atomoxetine for the 6 years preceding his accident. D.W. s historical diagnosis of ADHD was confirmed in the context of his post-tbi neuropsychological evaluation. Following his school evaluation, formal school accommodations were implemented to address D.W. s ADHD-related learning needs, including extra time on tests and perimission to take examinations in a separate room. Prior to his TBI, he obtained As and Bs in school, had always been on the honor roll, and had several close friends. His mother completed the Behavior Assessment System for Children Second Edition (BASC-2; Reynolds & Kamphaus, 2004) and the Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, & Kenworthy, 2000) as part of his neuropsychological evaluation in order to (retrospectively) assess his behavior before the injury. On these measures, D.W. was rated as having normal levels of behavior on all scales (Table I). His history is not significant for any major illnesses or injuries. Description of Injury, Postinjury Presentation, and Testing At the age of 10 years, 3 months D.W. was the victim of an accidental gunshot wound to the head from a handgun that he and another child found in the home. Neuroimaging showed that the bullet entered the right frontal brain region and exited in the right parietal region, causing parenchymal laceration and hemorrhage Table I. Parent-Reported Behaviors and Cognitive Test Performance Measure Scale/Index/Subtest Preinjury Postinjury T-Score a Parent-Reported BASC-2 Externalizing b Behaviors Internalizing Additional Clinical b Scales Adaptive Skills b BRIEF Behavioral Regulation b Metacognition b Standard Score c Cognitive Test WISC-IV VCI N/A 98 Performance PRI N/A 63 d WMI N/A 74 PSI N/A 62 d CMS Visual Immediate N/A 72 Visual Delayed N/A 91 Verbal Immediate N/A 100 Verbal Delayed N/A 91 TEA-Ch e Selective Attention N/A 55 d Sustained Attention N/A 75 Attentional Control N/A 65 d Note: BASC-2¼ Behavior Assessment System for Children, Second Edition; BRIEF¼ Behavior Rating Inventory of Executive Functioning Parent Form; WISC- IV ¼ Wechsler Intelligence Scale for Children, Fourth Edition; CMS ¼ Children s Memory Scale; TEA-Ch ¼ Test of Everyday Attention for Children a (mean ¼ 50, std dev ¼ 10) b clinically significant behavior problems (according to each test s manual) c (mean ¼ 100, std dev ¼ 15) d Impairment (2 std dev below normative mean) e Selective Attention ¼ Sky Search subtests (attention score); Sustained Attention ¼ Score! Subtest; Attentional Control ¼ Creature Counting subtest (timing score). along the bullet tract, as well as skull fractures along the right frontal and parietal bones. D.W. was intubated in the ambulance and upon admission to the emergency department was reported to have a Glasgow Coma Scale (Jennett & Bond, 1975) of 8 (in the context of intubation), which according to common severity classifications (e.g., Fletcher et al., 1990) indicated a severe TBI. Imaging further revealed subarachnoid and thin subdural hemorrhages and multiple bullet fragments in the right frontal region. He underwent a right decompressive craniectomy, right frontal lobectomy, and evacuations of intraparenchymal and epidural hematomas. After 5 weeks of inpatient acute hospital care, he was transferred to a rehabilitation hospital where he remained for 2 weeks before being discharged home into his family s care and outpatient rehabilitation services. D.W. was first seen through our clinic 8 months postinjury for neuropsychological testing (with author S.H.) to evaluate his cognitive and behavioral functioning and to offer recommendations for faster school reintegration

5 PCIT Following Pediatric TBI 255 and continued functional recovery. At that time, his family noted that he had difficulties with attention, memory, and impulsivity in excess of what he experienced before the injury. He had left-sided hemiparesis and walked with an ankle/calf brace, but was otherwise able to ambulate without assistance. No difficulties were observed in his speech or language, and his mother did not report any observed deficits in these domains. Formal post-tbi neuropsychological testing revealed significant impairment in perceptual reasoning, processing speed, working memory, visual immediate memory, broad math and written language skills, visuospatial skills, fine motor dexterity, executive functioning, and attention (abbreviated results are presented in Table I). Behaviorally, D.W. s family reported that since his injury he had become verbally and physically aggressive, emotionally volatile, impulsive, oppositional, defiant, and inattentive (Table I). D.W. s teacher, who completed the same measures, reported behavior problems consistent with parent ratings. It should be noted that D.W. did not resume taking atomoxetine for his ADHD symptoms after the injury at the recommendation of his neurosurgeons, and there is some uncertainty regarding how much of his behavior change is attributable to the TBI/lobectomy and how much is due to the cessation of atomoxetine. However, this potential confound is representative of the pediatric TBI population, in that children with ADHD are more likely to sustain a TBI (Bloom et al., 2001) than children without ADHD. Course of Psychotherapy D.W. s mother reported a constellation of symptoms that included both internalizing and externalizing components, such as frequent mood changes, crying, anger, aggressive behavior, opposition, and defiance. Therapy initially focused on helping D.W. develop strategies to relax, problem-solve, and identify and verbalize his emotions (five sessions). As therapy continued, more was learned about the time course of D.W. s symptoms. Often, his emotional difficulties followed the repercussions he experienced for his impulsive, attention seeking, oppositional, or defiant behaviors. For example, feelings of anger, sadness, or anxiety often followed negative feedback from parents, teachers, and peers. In an effort to curtail this sequence, we established a token economy to reward good behaviors and punish bad behaviors with poker chips that could accumulate to a tangible reward. This was monitored over seven additional sessions in which he continued to practice relaxation and problem-solving strategies. However, the token economy was only mildly successful, and we speculated that its ineffectiveness was partially due to the failure of an abstract reinforcement (poker chips) to overcome his executive functioning deficits (e.g., stopping and switching). Furthermore, the system of reward and punishment was complicated by patterns of negative interaction within the family system, which became more apparent as therapy progressed. The behaviors that were created and/or exacerbated by D.W. s TBI caused significant strain on his family system. His mother reported significant caregiver burden, anxiety (including panic attacks), and feelings of guilt following the accident. Although we would have liked to see her for individual psychotherapy, this was not financially viable for the family. As therapy progressed it also became evident that D.W. and his mother could benefit from learning skills to facilitate communication and improve their relationship. Unlike the token economy, which provided abstract and delayed feedback, D.W. required a system that involved immediate, direct, and concrete feedback on his behavior. To meet this goal and also to foster a more positive home environment with positive, effective communication, we applied PCIT, which has been successful in meeting both of these goals (Eisenstadt et al., 1993). Although we are not aware of any studies specifically applying this treatment approach to older children with pediatric TBI, we hypothesized that PCIT would be a viable approach. Methods Procedure PCIT D.W. and his mother participated in weekly PCIT sessions that each lasted 1 h and were conducted by two advanced graduate students who were trained in the PCIT protocol. D.W. and his mother were coached through the PCIT phases (CDI, PDI) in a therapy playroom while the therapists observed through a one-way mirror, listened via microphone in the playroom, and communicated with D.W. s mother through a bug in the ear device. The therapists followed the official PCIT treatment protocol for each session (Eyberg & Funderburk, 2011; training information available at In the first phase of treatment, the CDI phase, D.W. s mother learned the CDI skills, such as labeled praise, reflection, and behavioral description of D.W. s play in order to increase the positivity and warmth in their interactions. She was also taught to avoid criticism, commands, and questions, which are referred to as CDI Don t skills and all function to take the lead away from the child. After mastering CDI skills to criterion D.W. and his mother were transitioned to the PDI phase of treatment, which focuses on teaching parents effective discipline procedures for dealing with child

6 256 Cohen, Heaton, Ginn, and Eyberg noncompliance and other disruptive behaviors. D.W. s mother learned to use simple, direct commands followed by labeled praise for child compliance and a time-out sequence for noncompliance. In the PDI protocol, younger and smaller children are typically carried to a time-out chair if they do not voluntarily go when instructed. Because D.W. was too big to be carried, we planned to use the swoop and go procedure (Eyberg & Funderburk, 2010), which involves having the parent quickly gather the toys in a basket and leave the playroom, with them holding the door closed. This procedure effectively turns the playroom into a time-out room and could be used in the event that D.W. refused to go voluntarily to the time-out chair. Data Collection Progress in PCIT is assessed weekly using a parent-report instrument measuring behaviors at home [Eyberg Child Behavior Inventory (ECBI); Eyberg & Pincus (1999)] and an observational coding system measuring the quality of the parent child interaction during treatment sessions [the Dyadic Parent Child Interaction Coding System Third Edition (DPICS); Eyberg, Nelson, Duke, & Boggs (2004)]. The ECBI is a 36-item questionnaire that contains two scales: a 7-point intensity scale that measures the frequency of child disruptive behaviors from never (1) to always (7) and a yes no problem scale that measures the extent to which parents experience their child s behavior as difficult to manage. Quantifying parental distress in this way, using the problem scale, isolates the distress that stems directly from the child s problem behaviors and not from other sources. The intensity and problem scales of the ECBI yield inter-rater (mother father) reliability coefficients of.69 and.61 (Eisenstadt, McElreath, Eyberg, & McNeil, 1994) and test retest reliability coefficients of.80 and.85 across 12 weeks and.75 and.75 across 10 months, respectively (Funderburk, Eyberg, Rich, and Behar, 2003). The intensity scale of the ECBI takes 5 min to complete and was administered to D.W. s mother at the start of each session. The DPICS (Eyberg et al., 2004) is a behavioral coding system that includes categories of parent verbalization and child responses to parent commands. A brief, 5-min sample of the relevant parent child interaction is coded each week to provide guidance to the therapist for coaching the parent and to monitor weekly changes in positive and negative parent and child behaviors targeted for change. DPICS scores also indicate when parents are ready to move from the CDI to PDI phase of treatment and are one set of criteria for treatment completion. PCIT completion criteria also include an ECBI intensity scale score within 1/2 standard deviation of the normative mean, and parent report of confidence in managing their child s behavior on their own. Results Feasibility of using PCIT to Treat the Family of a Child with TBI D.W. and his mother successfully completed PCIT in 9 sessions (3 CDI and 6 PDI) over the course of 13 weeks. This was a shorter course of treatment than is typically reported in PCIT outcome studies, where treatment is often complete within sessions (Bagner 2007; Schuhmann et al., 1998). In her initial CDI Coach session, D.W. s mother demonstrated an immediate proficiency in the CDI skills (labeled praises, reflections, and behavior descriptions). She reported practicing the skills daily and noticed an immediate improvement in D.W. s disruptive and attention-seeking behaviors. During the second CDI coaching session, she displayed 13 labeled praises, 11 reflections, and 3 behavior descriptions in a 5-min observation period, and she displayed no commands, questions, or criticisms during the 5-min observation. The mastery criteria for CDI are 10 of each positive following skill (behavior description, reflection, and labeled praise) and fewer than 3 of the leading behaviors (commands, questions, and criticisms) combined. Her scores indicated extremely rapid CDI mastery with the exception of behavior descriptions, to which D.W. responded very negatively. Her skills remained strong at the third CDI coaching session, other than the frequency of her behavior descriptions, to which D.W. now reacted even more negatively. Moving to PDI before parents reach all CDI mastery criteria is generally not recommended, but in considering D.W. s atypical and strong negative reaction to behavior descriptions, combined with the mother s facility in using reflection and praise to provide positive attention, it was determined that moving on to PDI after the third CDI coaching session would be best. The PDI skills, including the swoop and go time out procedure, were taught to D.W. s mother. In the family s first PDI coaching session, D.W. s mother continued to use the CDI skills proficiently, and she quickly learned the PDI skills with coaching. D.W. responded well to the use of PDI skills, and the time out procedure did not have to be employed in any of the sessions. D.W. s mother reported that D.W. also responded well to the skills at home and had rarely required timeout at home. Additionally, she reported never having to use the swoop and go procedure at home

7 PCIT Following Pediatric TBI 257 because D.W. went to and stayed on the time-out chair immediately when told to do so. Siblings are often included in later PDI sessions if parents have identified specific sibling behavior concerns. D.W. s mother had been informally practicing the CDI and PDI skills at home with D.W. s 4-year-old sister. We invited her to bring in her daughter for one formal PDI session with both children. In this session, D.W. s mother was coached to shift her positive attention effectively between the two children, praise them for playing nicely together, and apply the PDI skills to behavior problems that arose in sibling play (i.e., failure to listen when told to share). D.W. s mother reported an improvement not only in the relationship between the siblings, but also in her daughter s oppositional and disruptive behaviors. The family completed PCIT successfully after D.W. s mother consistently met PDI criteria as well as CDI criteria (in two of the three positive attention categories). These findings support our first aim, suggesting the feasibility of using PCIT to treat the family of a child with TBI. D.W. s mother was able to learn and use the PCIT skills effectively, as determined by DPICS coding, in a relatively short period of time, especially when considering the many pre-existing stressors that the family faced (e.g., low SES). Treatment was successfully implemented for this family with only minor modification (i.e., omission of the DB criterion) to the standard PCIT protocol. Reduction of Problem Behaviors To assess our second aim of reducing of problem behaviors with PCIT, we examined D.W. s weekly ECBI intensity scores. During the initial PCIT session, the CDI Teach session, D.W. s mother continued to report high levels of impulsive and oppositional behavior and rated his behaviors at 133 on the ECBI intensity scale. By the end of treatment, D.W. s ECBI score was 60 in PDI Coach 5 (Figure 1), which is well within the normative range of behaviors for children his age and represents a significant decrease: reliable change index (RCI) ¼ 6.01, which exceeds the cutoff of 1.96 (p <.05) (Jacobson & Traux, 1991). After completing PCIT, D.W. and his mother attended three additional sessions (over 4 weeks) to facilitate problem solving and coping related to temporary stressors the family was experiencing. D.W. s low ECBI scores were maintained over these sessions (Figure 1). Reduction of Parental Distress To address our third aim, we examined the qualitative and quantitative changes in the distress experienced by Figure 1. Reduction in problem behaviors as measured by the ECBI intensity scale. Clinically significant behavior problems >114. Figure 2. Reduction in parental distress as measured by the ECBI problem scale. D.W. s mother posttreatment. At the completion of PCIT, she reported feeling that her bond with D.W. had improved. Although his compliance was high throughout PDI sessions, as measured by DPICS, D.W. s mother noted a tremendous decrease in his oppositional and attention-seeking behaviors at home during PDI. especially at bedtime. She also reported that her stress related to managing the children s behaviors had decreased steadily throughout treatment. Her scores on the ECBI problem scale further reflected these changes, decreasing from 21 to 12 following treatment, which represents a clinically significant decrease (RCI ¼ 3.28, p <.05) in parental distress associated with D.W. s disruptive behaviors (Figure 2). This finding is encouraging because parental distress is a major concern following pediatric TBI (Wade et al., 1998, 2006).

8 258 Cohen, Heaton, Ginn, and Eyberg Discussion Children who have sustained TBI often demonstrate behavior problems after their injury. Evidence-based treatments for child disruptive behavior disorders hold promise for application to the post-tbi behavior problems shown by these children. This case study examined the outcome of PCIT with an 11-year-old child with premorbid ADHD whose behavior problems were reported to have worsened after his injury and were found to improve with treatment. Our results suggest that further study of PCIT as one component of pediatric TBI rehabilitation is warranted. A reduction in parenting distress was also reported by the child s mother after treatment, likely resulted from a combination of factors, foremost being the steady changes the mother observed in their her behavior. The lessened conflict in the home that accompanies decreases in child behavior problems, the high degree of parental investment, and perhaps also the support that the mother received when dealing with these behaviors in treatment, likely played a significant role as well. Reductions in parenting stress are characteristically found following PCIT (Schuhmann et al., 1998) and suggest that the mother in this case study will be better equipped to manage her child s continuing special needs in the future. Further research is needed to replicate and elaborate the findings in this case to discover how they might generalize to children with diverse patterns of cognitive and behavioral functioning. Cognitively, the child described here demonstrated relatively unimpaired verbal comprehension and verbal memory. Despite significant injury to his frontal lobes, he was able to benefit from PCIT. It is not known whether children sustaining greater injury would be as able to benefit from this form of behavioral intervention. Indeed, future research is needed to clarify the underlying mechanism(s) of therapeutic change. For example, it may be that only the first phase of PCIT (i.e., CDI) is required. This is the phase in which parents learn to use differential social attention alone to shape child behavior. Indeed, in this case study, his mother s ratings of D.W. s behavior problems declined dramatically after only a few sessions of CDI and well before PDI was introduced. In addition to limitations inherent in case study designs, there are additional limitations that are important to consider. First, our case study used only parentcompleted questionnaire data and therapist observations to document D.W. s primary behavior problems (i.e., noncompliance). Inclusion of multiple informants and multiple methods of measurement would add confidence to our results and further validate the reported treatment effects. It would also be useful for future studies of this nature to include outcome measures of additional constructs, such as family cohesion, also speculated to change with treatment. Including D.W. s sister in treatment likely added to his improved behavior in the home, although this component of PCIT was not evaluated separately from the total treatment protocol. It would be useful to study the impact of including siblings in treatment systematically in future research. Also, the involvement of both parents is an important avenue of future investigation in a TBI population. It would also be important for future research to assess treatment maintenance over a longer period of time. Traumatic brain injury is a leading cause of disability in children under 18 years of age and often results in changes in behavior that cause significant family stress. However, there are few treatment options for children and families experiencing behavior problems. PCIT is an empirically supported treatment for young children with disruptive behavior problems (Eyberg, Nelson, Boggs, 2008) that has also been found effective in the context of medical conditions (Bagner, Sheinkopf, Vohr, & Lester, 2010). In the current case study, we showed that PCIT employed with an 11-year-old boy with a severe TBI was feasible and successful in reducing the number of behavior problems and level of parental distress related to these behaviors. This appears to be a promising therapy method for pediatric TBI and future research is needed to replicate and extend our findings. Acknowledgments We would like to thank D.W. and his family for their hard work and for their willingness to share their experiences with the psychological and medical. Conflicts of interest: Author S.E. receives royalties from use of the ECBI. References Anderson, V. A., Catroppa, C., Morse, S., Haritou, F., & Rosenfeld, J. (2005). Identifying factors contributing to child and family outcome at 30 months following traumatic brain injury in children. Journal of Neurology, Neurosurgery, and Psychiatry, 76, Bagner, D. M., & Eyberg, S. M. (2007). Parent child interaction therapy for disruptive behavior in children with mental retardation: A randomized controlled trial. Journal of Clinical Child and Adolescent Psychology, 36,

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