EDUCATION AND TREATMENT OF CHILDREN Vol. 28, No.

2, IVIAY 2005

Adapting Parent-Child Interaction Therapy

for Young Children with Separation
Anxiety Disorder
Donna B. Pincus
Department of Psychology,
Boston University, Boston, MA
Sheila M. Eyberg
Department of Clinical and Health Psychology,
University of Florida, Gainesville, FL
Molly L. Choate
Department of Psychology,
Boston University, Boston, MA

Abstract

Separation Anxiety Disorder (SAD) is currently the most prevalent, yet most under-researched
anxiety disorder in childhood. To date, there have been few studies investigating the effi-
cacy of interventions for young children with SAD. The primary purpose of this paper is to
describe the process of tailoring Parent Child Interaction Therapy (PCIT) for young children
aged 4-8 with SAD. The paper provides a theoretical rationale for using PCIT to treat young
children with SAD. The first randomized clinical trial for young children with SAD is then
described. The paper focuses on the process of adapting PCIT to make it most relevant for
children with SAD. The specific challenges and rewards of conducting PCIT with anxious
children and their parents are presented.

Over the past decade, there has been burgeoning interest in the study of
the etiology, maintenance and effective treatment of anxiety disorders in
childhood. Of the anxiety disorders experienced by children, separation
anxiety disorder (SAD) has been shown to be the most prevalent, account-
ing for approximately one-half of the children seen for mental health treat-
ment of anxiety disorders (Bell-Dolan, 1995). Despite the growing evi-

Corresponding Author: Donna B. Pincus, Ph.D., Director, Child and Adolescent Fear
and Anxiety Treatment Program, Center for Anxiety and Related Disorders at Boston
University, 648 Beacon Street, 6'*^ Floor, Boston, MA 02215, (617) 353-9610,
dpincus@bu.edu.

Pages 163-181
164 PINCUS etal.

dence that SAD is so prevalent in early childhood and may be linked to

later psychopathology (Lease & Strauss, 1993), there has been a paucity of
empirical studies investigating the efficacy of interventions for SAD in
young children. Although treatment studies have typically included chil-
dren aged seven and above, thus far, treatment research of children under
aged seven with anxiety disorders has been limited to case reports with
expected methodological limitations (Ollendick, Hagopian, & Huntzinger,
1991). Existing treatment studies and case studies that have been con-
ducted with children with SAD have not typically included children in the
preschool and early childhood years (aged 4-7), despite the frequent early
onset of SAD (Eisen, Engler, & Geyer, 1998; Eisen & Kearney, 1995). This
may be due to the fact that it is more difficult to assess young children
using standard self report questionnaires, or due to the fact that many of
the intervention strategies currently being evaluated with older children
contain large cognitive components, which would likely be developmen-
tally inappropriate and beyond the capabilities of a very young preschooler
with SAD. Eurthermore, the young preschooler may not yet have devel-
oped the cognitive and communicative abilities to verbalize their fears or
to engage in self control procedures that would be commonly taught to
older children (Eisen & Kearney, 1995). To date, there are no known inter-
ventions that have been designed or tested specifically to treat SAD in the
preschool and early childhood years. The development of such an inter-
vention seems critical to promoting young children's healthy functioning
and positive developmental trajectories.

Phenomenology of Separation Anxiety Disorder in Early Childhood

Children with SAD experience developmentally inappropriate distress

and unrealistic fear when confronted with separation from a caregiver,
and experience significant interference in daily functioning (American Psy-
chiatric Association, 2000). Children often display excessive and persis-
tent worry about separation, behavioral and somatic distress when faced
with separation situations, and persistent avoidance or attempts to escape
from such situations (Albano, Chorpita, & Barlow, 1996; Bell-Dolan, 1995).
Separation worries commonly reported by children include worries about
harm befalling either an attachment figure or themselves, worry that a
parent may never return, or worries that they themselves will be lost, kid-
napped, or killed. Particularly for young children, nightmares with themes
of separation are quite common (Erancis, Last, & Strauss, 1987). Young
children with SAD often display disruptive, oppositional behaviors as well
as avoidance behaviors that cause significant interference in child and fam-
ily functioning. Children may have tantrums, may cling to parents, may
shadow parents from room to room, or may refuse to play without a par-
ent present. Some children may become quite desperate in their attempts
to contact parents, even feigning illness, devising excuses to escape or avoid
separation situations, refusing to sleep alone, or pleading to have parents
ADAPTING PCIT FOR YOUNG CHILDREN WITH SAD 165

sleep with them (Tonge, 1994). Although some separation anxiety is cer-
tainly part of normal early development, once the symptoms of separation
anxiety begin to exacerbate and interfere with daily functioning, signifi-
cant social, familial, and academic dysfunction may occur (Strauss, Frame,
& Forehand, 1987; Turner et al., 1987). Children with SAD may be at risk
for school avoidance and for impaired social interactions with other chil-
dren (Beidel & Turner, 1998). Children with SAD are also more likely to
report somatic complaints (e.g., headache, stomachache) than children di-
agnosed with phobic disorders (Last, 1991). In a review of 95 children
admitted to a psychiatry inpatient unit, children with SAD reported a sig-
nificantly greater number of medically unexplained physical symptoms
than those with other diagnoses (Livingstone, Taylor, & Crawford, 1988),
with reports of abdominal pain and heart palpitations significantly more
likely in children with SAD compared to children with other disorders.
These physical symptoms can lead to the child eliciting immediate care
and attention from the parent, which can result in positive reinforcement
and secondary gain that may further perpetuate the problem.

Early Childhood Separation Anxiety Disorder: Risks for Later Psychopathology

Childhood anxiety disorders such as separation anxiety disorder ap-

pear to have a chronic course if left untreated (Keller et al., 1992). In fact,
child anxiety disorders appear to be linked to anxiety disorders in adult-
hood. Retrospective studies suggest that childhood anxiety disorders fre-
quently precede adult anxiety disorders (Aronson & Logue, 1987; Deli to,
Perugi, & Maremmani, 1986). Adult patients with panic disorder have been
shown to report high rates of separation anxiety disorder in childhood
(Klein, 1981; Silove, Parker, Hadzi-Pavlovic, Manicavasagar, &
Blaszczynkski, 1991). A prospective study of subjects diagnosed with sepa-
ration anxiety in childhood has supported modest associations with panic
disorder with agoraphobia as well as with major depression (Klein, 1995).
Another study found that childhood separation anxiety disorder conferred
a risk for comorbidity of anxiety disorders in adulthood (Lizpsitz et al.,
1994; Lipsitz, Mannuzza, Liebowitz, Klein, & Fyer, 1997). In one longitu-
dinal study of young children with clinical, sub-clinical and non-clinical
levels of separation anxiety (Kearney, Sims, Pursell, & Tillotson, 2003), sepa-
ration anxious children were assessed at age three years and 3.5 years later.
Results indicated that children with clinical SAD, compared to those with
sub-clinical SAD or no symptoms of SAD, had a disproportionately higher
number of comorbid diagnoses and experienced significantly greater so-
matic concerns, anxiety and general internalizing behavior 3.5 years later.
In addition, their parents experienced greater depression, obsessive-com-
pulsive behavior, phobic anxiety, and general distress. Thus, while most
children with non-clinical SAD symptoms experience a natural dissipa-
tion of SAD symptoms in childhood, children with clinical levels of SAD
may continue to experience stable, significant distress. Without proper
 166 PINCUS etal.

treatment, these young children may go on to experience further emotional

difficulties. Given that the developmental period of early childhood is
seen as such a sensitive period of development, and given that SAD is
associated with psychopathology later in life, it seems critical to begin to
establish effective treatment procedures for SAD at its earliest stages.

Parenting Style and Early Childhood Anxiety

Numerous studies across several different child anxiety research cen-

ters have suggested that parents of anxious children may inadvertently
facilitate anxious responses in children through modeling fear or avoid-
ance (Muris, Steerneman, Merckelback, & Meesters, 1996), attempting to
control the child's behavior in a way that limits psychological autonomy
(Hock, 1992; Hudson & Rapee, 1997; Siqueland, Kendall, & Steinberg, 1996),
overprotecting the child (Hirshfeld, Biederman, Brody, Faraone, &
Rosenbaum, 1997b; Stubbe, Zahner, Goldstein, & Leckman, 1993), or fa-
cilitating avoidant coping responses (Barrett, Rapee, Dadds, & Ryan, 196;
Chorpita, Albano, & Barlow, 1996; Dadds, Barrett, Rapee, & Ryan, 1996).
Other studies have indicated that parents may affect children's develop-
ment of healthy emotion focused coping strategies by trying to manage
their child's anxiety or reinforcing anxious responding in their children
(Spence, 1994). Even though parents may have the best of intentions, nega-
tive and aversive parent and child interactions may develop when parents
become critical of children's inability to separate, resulting in children cry-
ing or displaying other signs of behavioral or emotional distress. Any
attention to this distress could easily reinforce children's behavior, thus
reinforcing the cycle of anxiety and continuing the aversive parent child
interactions. Eisen, Engler, and Geyer (1998) suggest that parents of chil-
dren with SAD, in particular, can fall prey to three "traps" that can inad-
vertently facilitate childhood anxiety: (a) overprotection, (b) excessive re-
assurance, and (c) aversive parent child interactions. Each of these traps
could encourage child anxiety because the parent provides attention dur-
ing a child's fearful displays. In addition, numerous other research stud-
ies on parenting styles of parents of anxious children have found some
evidence that parents of anxious children may tend to grant less psycho-
logical autonomy, evidence less warmth and acceptance, and are more criti-
cal of their children compared to parents of children without a psychiatric
diagnosis (Hudson & Rapee, 2000; Siqueland et al., 1996).

Parent Training Treatment Approaches for Child Anxiety: Targeting Maladap-

tive Parenting Styles and Aversive Parent Child Interactions

Findings from existing treatment studies suggest that interventions

aimed at modifying maladaptive parenting styles, improving family mem-
ber functioning and increasing positive parent child interaction could be
helpful in preventing or ameliorating SAD in young children. In fact, in
ADAPTING PCIT FOR YOUNG CHILDREN WITH SAD 167

one of the most recent controlled trials of child anxiety treatment, Barrett,
Dadds, and Rapee (1996) compared CBT to a condition that included CBT
plus a parent-training component and to a waitlist control condition. In
the parent-training component, parents were taught how to reward cou-
rageous behavior using verbal praise, they were taught to ignore non-brave
behaviors, and they were taught how to extinguish excessive anxiety in
their child. At post-treatment, results showed that CBT plus a parent-train-
ing component was better than CBT alone. CBT plus parent training was
found to be superior even at one year post-treatment for reducing children's
anxious behaviors. Although this study did not include children younger
than age 7, it is likely that such a parent training component might be
especially beneficial to parents of even younger children. In an effort to
develop effective parent training programs for very young children with
anxiety, researchers have begun to draw upon empirically validated
parenting treatments that have been shown to be effective for childhood
behavior disorders. The following skills have been viewed by child anxi-
ety researchers as important components to include in a parent training
program to reduce child anxiety: (a) enhancing parent attention (teaching
parents to be more effective monitors of children's behaviors), (b) com-
mand training (teaching parents to deliver clear, direct commands), (c)
differential reinforcement (teaching parents to ignore or minimize atten-
tion for fearful displays), and (d) shaping (positively rewarding children
for brave behaviors) (Eisen, Engler, & Geyer, 1998; Ginsburg, Silverman,
& Kurtines, 1995). For the period of early childhood, it has been suggested
that a successful parent treatment component should involve rearranging
dyadic caregiving interactions or family interactions to promote secure,
healthy attachment between parents and children (e.g., Barkley, 1987;
Schuhmann et al., 1998). Thus, there is growing evidence such a parent
training approach may be especially useful for young children with SAD.

Parent Child Interaction Therapy

Brief Overview of Standard PCIT Treatment

Parent Child Interaction Therapy (PCIT; Brinkmeyer & Eyberg, 2003) is

an empirically supported treatment designed to treat children with dis-
ruptive behavior disorders and their families. The treatment is designed
to help parents build a warm and responsive relationship with their child
and to manage their child's behavior more effectively. PCIT is based on
the assumption that improving the parent-child interaction will result in
improvement in both child and family functioning (Foote et al., 1998). PCIT
draws on both attachment and social learning theories in training parents
to interact in attentive, responsive and warm ways with their child (Hood
& Eyberg, 2003). The standard PCIT protocol has two phases, labeled Child-
Directed Interaction (CDI) and Parent Directed Interaction (PDI). The CDI
portion focuses on changing the quahty of the parent-child relationship;
 168 PINCUS etal.

parents are taught nondirective interaction skills and are taught to increase
warmth, responsiveness, attention and praise during playtimes with their
child. Differential reinforcement of child behavior through praise for ap-
propriate behavior and consistent ignoring of undesirable behavior helps
provide a positive form of behavioral management throughout CDI. Par-
ents are coached to utilize these skills as they play with their child. In the
PDI portion of treatment, parents are taught methods of incorporating
clearly communicated and age appropriate instructions to the child. Us-
ing techniques based directly on operant principles of behavior change,
parents are taught to provide consistent positive and negative consequences
following the child's obedience and disobedience. The therapist also as-
sists the parent to learn how children's behavior is shaped and maintained
by the child's social environment. In PCIT, the treatment is performance
based and does not end until the parents have demonstrated mastery of
the skills; the average number of weekly 1 hour sessions ranges from 9 to
16, with an average of 13 sessions (Schuhmann, Foote, Eyberg, Boggs, &
Algina, 1998).

PCIT Outcome Studies

There have been numerous studies demonstrating statistically and clini-

cally significant improvements in children's behavior at the end of treat-
ment, and at long term follow up (e.g., Eyberg & Robinson, 1982; Foote,
Eyberg & Schuhmann, 1998; Hood & Eyberg, 2003; McNeil, Capage, Bahl,
& Blanc, 1999; Schuhmann et al., 1988). PCIT outcome studies have docu-
mented change in the interactional style of parents with their child, sig-
nificant improvements in child compliance and disruptive behaviors, im-
provements in parents' level of distress, and improved family function-
ing. In addition, parent behaviors have been shown to generalize to inter-
actions with other children in the family as reflected by improved behav-
ior of siblings (Brestan, Eyberg, Boggs & Algina, 1997; Eyberg & Robinson,
1982). Because the specific goals of PCIT are to teach parents to build a
more positive relationship with their child, to teach their child desirable,
appropriate behaviors, and to decrease their child's inappropriate behav-
iors, the treatment can be readily applied to a patient's unique problems.
PCIT treatment programs have already been adapted for use with chil-
dren with Attention Deficit Hyperactivity Disorder (Nixon, 2001), language
delays (Eyberg & Boggs, 1998), chronic illness (Bagner, Fernandez, &
Eyberg, 2004), for neglected children (Mcrae, 2003), for physically abusive
famihes (Urquiza, 1996), for children at risk for physical abuse (Singer,
2000), and for use by teachers (Collett, 2002; Mclntosh, 2000). However,
PCIT has yet to be applied to families with separation anxious children.

Parent Child Interaction Therapy for Young Children with SAD

Given that PCIT is a well-established parent training program that has

ADAPTING PCIT FOR YOUNG CHILDREN WITH SAD 169

been specifically developed for use v^ith preschool age children, and given
that PCIT aims to promote warmth, acceptance, and positive interactions
between parents and children, it is likely that PCIT will improve the se-
cure attachment between parents and young children. The improved at-
tachment and warmth following PCIT may help strengthen the child's feel-
ing of security and thus help the child to separate from the parent with less
distress. Furthermore, PCIT incorporates each of the specific skills child
anxiety researchers have indicated as essential to teach parents in treat-
ment to reduce child anxiety, such as enhancing parent attention, teaching
parents differential reinforcement, teaching parents to shape children's
behavior, and teaching parents to deliver clear commands to children, and
thus, could be expected to be effective in reducing children's separation
fearful behaviors. The PCIT treatment protocol appears to directly alter
the parenting styles found to be associated with parents of anxious chil-
dren. Thus, it seems that PCIT could be a potentially useful treatment if
adapted for children with SAD.

Application of PCIT for Young Children with SAD: A Randomized Clinical Trial

Clinical Trial Applying PCIT to children with SAD: Overview of Design

The first randomized controlled clinical trial is currently being imple-

mented at Boston University to investigate the efficacy of applying PCIT
to the treatment of young children ages 4-8 with separation anxiety disor-
der. The specific goals of this project are: (a) to evaluate the efficacy of
PCIT for reducing separation anxious behaviors in young children; (b) to
assess long term maintenance of change at 3, 6, and 12 months following
treatment; and (c) to investigate potential mechanisms of action in treat-
ment. This research project is the first controlled clinical trial for child-
hood anxiety that has included children younger than age 7, and thus, has
the potential to fill in a significant gap in our knowledge of this at-risk
population. Through this project, 58 children with a principal diagnosis of
SAD are being randomly assigned to one of two conditions following a
pre-treatment assessment. In the first condition, participants receive an
immediate full course of PCIT over approximately 9 weekly sessions (PCIT
condition). The second condition consists of a waitlist (WL) (attentional
control) condition in which participants are required to wait 9 weeks prior
to receiving treatment, at which point they receive a post-waitlist assess-
ment. After the post-waitlist assessment, waitlist participants then receive
a full course of PCIT. Randomization occurs within gender so that the
ratio of males to females is equal across conditions. All participants are
undergoing a post-treatment assessment, as well as three follow-up as-
sessments (conducted 3 months, 6 months and 12 months following comple-
tion of treatment).
 170 PINCUS etal.

Recruitment of Participants

Participants are currently being recruited through the normal patient

flow into the Child and Adolescent Fear and Anxiety Treatment Program
at the Center for Anxiety and Related Disorders at Boston University. The
study includes both males and females from all ethnic backgrounds. The
age range of 4-8 was selected due to the prevalence of SAD in early child-
hood, and due to the lack of existing anxiety treatment investigations in-
cluding young children. All patients must receive a principal diagnosis of
SAD assigned at pre-treatment, based on DSM-IV criteria, and at least one
parent or caregiver must be available to accompany the child to all treat-
ment sessions.

Measures

The study includes a multimodal assessment of anxiety, including di-

agnostic interviews with the parent and child, parent self report instru-
ments, child self report instruments, and behavioral observation and cod-
ing measures of parent child interaction. Specifically, the Anxiety Disor-
ders Interview Schedule (Child and Parent Version) (ADIS-IV-C/P:
Silverman & Albano, 1997) is being utilized as the diagnostic interview
measure. Although reliability data does not exist for children younger
than age 7, the ADIS-IV C/P has been utilized with younger children; how-
ever, the Parent Interview has typically been relied upon more heavily for
diagnostic purposes. While the full ADIS-IV-CP is being used during the
initial diagnostic assessment, a shorter version of the ADIS is being uti-
lized for all post-treatment and follow up assessments to track the mainte-
nance of children's improvement.
Child self-report measures were included in the present study to allow
for the assessment of the young child's perspective of his or her own feel-
ings of anxiety. In reviewing potential measures for this project, it was
determined that very few child anxiety self-report measures have been
validated for use with children younger than age 7. Measures were in-
cluded that had specific separation anxiety subscales, such as the Multidi-
mensional Anxiety Scale for Children (MASC; March et al., 1997). Other
measures, such as the Fear and Avoidance Hierarchy, was included based
on our and our colleagues' previous experience successfully utilizing the
FAH with children younger than age 7. Several developmental adapta-
tions were implemented in the administration of these measures, such as
providing reading assistance to children and using visual aids when nec-
essary, such as the "fear thermometer", which shows a visual analog scale
of "degrees" of fear. Parent self report measures being utilized include
the Child Behavior Checklist (CBCL: Achenbach & Fdelbrock, 1983), the
Eyberg Child Behavior Inventory (ECBI; Fyberg & Pincus, 1999), the
Parenting Stress Index (PSI: Abidin, 1997), the Parental Locus of Control
Scale (PLOC; Campis, Lyman, & Prentice-Dunn, 1986), the Weekly Record
ADAPTING PCIT FOR YOUNG CHILDREN WITH SAD 171

of Anxiety at Separation (WRAS; Choate & Pincus, 2001), and the Therapy
Attitude Inventory (TAI; Eyberg, 1993). In addition to self report mea-
sures, the Dyadic Parent-Child Interaction Coding System II (DPICS-II;
Eyberg, Bessmer, Newcomb, Edwards, & Robinson, 1994) is being utilized
as an observational measure of parent and child behaviors in the labora-
tory during four 5-minute standard situations that vary in the degrees of
parental control expected. The DPICS has been modified to include a sepa-
ration situation in which the parent is called out of the room for five min-
utes. All situations in the DPICS are being videotaped and coded.

Process of Adapting PCIT for Families with a Child with SAD

Utilizing Parent Feedback and Clinical Observations to Modify PCIT Treatment

for Anxious Children and Families

In the course of treating the first ten children who entered the study, we
gathered useful information and feedback from parents about the most
and least useful parts of treatment, areas of concern that were not addressed
through PCIT treatment, and any difficulties or concerns parents had in
implementing PCIT treatment with their anxious child. All parents from
this initial group of families reported increased feelings of warmth and
closeness with their child, and reported that they were quite surprised by
the child's overwhelmingly positive reaction to the new five minute "spe-
cial playtime." In addition, although the majority of parents reported that
their anxious children were, on the whole, very compliant, they stated that
the PDI skills came in handy when dealing with other siblings in the house,
or when managing the occasional misbehavior of their anxious child. Nine
out of ten parents reported that the PDI skills increased their confidence in
their parenting abilities.
Although this initial group of families reported many positive effects of
PCIT, we noticed that children were not naturally being encouraged by
parents to enter new, more challenging separation situations. When asked,
parents reported that they did not always encourage their child to enter
new situations if the situation could cause the child excessive anxiety or
undue distress. Several parents noted that in an effort to not feel like a
"bad parent," they often found themselves being overly reassuring to chil-
dren when approaching a new situation. We observed several parents
asking children questions perhaps more to reassure themselves than to
reassure the child (e.g., "Are you sure you're going to be ok if I leave for
five minutes? I'll be right in the waiting room, no need to worry.. .you can
come find me if you need me"). Thus, although parents came to treatment
because they wanted their child to become more independent and have an
easier time with separation, we observed that many parents seemed intol-
erant of having their child experience distress due to their own concerns
that anxiety might be harmful to their child. Parents questioned whether
 172 PINCUS etal.

they "gave" anxiety to their child, and asked PCIT therapists for ways to
encourage children appropriately to enter new situations without being
forceful and without engaging in a power struggle with their child. Fur-
thermore, parents asked how to begin to help their child enter new situa-
tions, and whether they should just let the child cry or whether they should
be comforting. All of these clinical observations and parent questions led
us to determine that although the CDI and PDI components seemed to be
helping parents, an anxiety education component seemed necessary to in-
clude in a treatment of early childhood SAD. In addition, we determined
that parents needed guidance to know how to help children to begin prac-
ticing entering new developmentally appropriate situations while endur-
ing parental separation. Thus, we determined that to make PCIT most
relevant to families with children with separation anxiety, we needed to
add something to the existing protocol that would formally and system-
atically address common concerns of parents with anxious children, and
that would help children to make progress toward being less distressed
during everyday separation situations. We considered many issues with
regard to designing this "anxiety specific" phase of treatment, including
session length, number of sessions, the positioning of this treatment phase,
and the ways to maximize the clinical effectiveness of treatment so that it
would be most germane to families of differing backgrounds. We deter-
mined that the most efficient and seamless way to integrate these skills
into PCIT would be adding these skills in a new phase of treatment that
could complement the existing CDI and PDI components.

Integrating Anxiety Education for Parents into PCIT: Designing the "Bravery
Directed Interaction" (BDI) Phase

The Bravery Directed Interaction Teach Session (BDI TEACH). The BDI
Teach Session was designed to provide parents with education about the
nature of anxiety, the cycle of anxiety, the importance of teaching children
not to avoid situations, and instruction in the ways to set up an effective
exposure practice for children so that separation situations can begin to be
practiced. An important first goal of the BDI TEACH session is to educate
parents about the cycle of anxiety and about the factors that maintain anxi-
ety in children. A second goal is to teach parents the importance of apply-
ing PCIT-CDI skills in separation situations. A third goal is to explain to
parents the importance of not avoiding situations that may involve sepa-
ration, and appropriate ways to conduct "separation practices" with their
young children. The session begins with an explanation of the nature of
anxiety, and parents are taught that anxiety is a natural human emotion
that is not harmful to children. They are also provided education about
the etiology of anxiety. Parents are taught that they do not "give" children
an anxiety disorder but rather that anxiety disorders likely arise from the
synergistic effects of several factors. The relationship between a child's
thoughts, feelings and behaviors are explained to parents, and parents are
ADAPTING PCIT FOR YOUNG CHILDREN WITH SAD 173

assisted in completing a blank "cycle of separation anxiety" handout in

which parents insert a child's thoughts/worries about separation, their
child's common physical symptoms/complaints, and their child's behav-
ioral reactions. Parents are also taught about ways that certain parenting
behaviors may inadvertently reinforce separation anxious behaviors in
children, and are taught how modifying these behaviors can affect the
overall cycle of separation anxiety. Finally, parents are taught the concept
of exposure, and the rationale for helping children to begin to practice
small steps toward the larger goal of becoming more tolerant of separation
from a parent or caregiver. Parents are given a handout, "The Do's and
Don'ts of Helping Your Child with Separation Practices," which summa-
rizes the information from the session, similar to handouts from CDI and
PDI. The Fear and Avoidance Hierarchy is discussed with parents to de-
termine which situations parents feel are most important to focus on in
treatment. Parents are instructed to continue CDI practices during the
week, and to bring their child in for the first BDI Coach Session the follow-
ing week.
BDI Coach #1. The BDI Coach session was designed to help parents
and children begin the process of exposure practice. An important first
goal of the SAD COACH #1 session is to explain the purpose of the "Brav-
ery Ladder" to the child and to encourage the child to engage in choosing
the first step to practice over the week. The second goal is to encourage
parents to apply CDI skills to encourage children's approaching of new
situations. A third goal is to have children and parents brainstorm at least
five rewards that have to do with spending special time with mom and/or
dad that could be earned by practicing situations on the bravery ladder.
The fourth goal of the session is for therapists, parent(s) and child to agree
upon a clearly stated homework assignment (exposure practice) for the
week, and for parents to use CDI and BDI skills to praise the child for their
efforts in taking a step on the bravery ladder. One aspect of the BDI Coach
Session that was purposefully implemented was to have children choose
the first exposure practice rather than having parents choose the first ex-
posure practice. As research has shown that children with anxiety disor-
ders often are given less psychological autonomy and control, we thought
it would be important to allow the child some choice in which situation
would be worked on first. Further, allowing the child to choose is compa-
rable to the child's experience through CDI; whereas children were able to
choose the game or toy in CDI, they now get to choose the exposure prac-
tice in BDI.
BDI Coach #2. The purpose of the BDI Coach session is to follow up
with parents and children about their progress and success in beginning
exposures. An important first goal of the SAD Coach Session #2 is to re-
view the child's and parents' homework from the previous week, and to
discuss whether child was successful in entering the first activity on the
Bravery Ladder. The second goal is to discuss with parents the ways that
parents reacted if child had separation incidents this week, and to coach
 174 PINCUS etal.

parents ir\ applying CDI and BDI skills to encourage children's approach-
ing of nev^^ situations. Parents are reminded that separation anxiety is not
to be punished; rather, brave behavior should be reinforced. A third goal
of the BDI Coach Session #2 is to apply stickers to the Bravery Ladder next
to any achieved situations. The fourth goal of the session is for therapists,
parent(s) and child to agree upon a clearly stated homework assignment
(nevvf step on the Bravery Ladder) for the next week, and for parents to use
CDI skills to praise the child for their efforts in taking another step on the
bravery ladder. Parents are informed that the next treatment session will
be the PDI Teach Session, and that this is a parents- only session. How-
ever, parents are instructed to continue BDI practices each week. This
session is designed to help children to begin to gain some momentum in
working their way up bravery ladder; they are reminded that they may
choose a reward from their reward list (e.g., special time with mom and/
or dad) for each new situation achieved.

Modifying the Treatment Structure: Treatment Format and Length

We decided that the Bravery Directed Interaction phase of treatment

would be best positioned after CDI and before PDI. By starting with CDI
skills, parents are able to gain concrete skills for improving tiie warmth
and positive interaction with their youngster. These skills are practiced
throughout the remainder of treatment, consistent with the original PCIT
treatment protocol. We noted that most parents were able to reach crite-
rion for CDI within 3-4 sessions. By the end of CDI, parents reported that
they felt successful and were "ready" to help their child to become more
brave during separation. Further, children had developed a relationship
with study therapists and seemed motivated to make gains that would
impress both parents and the PCIT therapists. Thus, the Bravery Directed
Interaction phase naturally seemed to fit after CDI. Parents were taught
about the nature and cycle of anxiety, and ways to facilitate their child in
entering new situations. They were also taught to apply CDI skills such as
labeled praise to separation practice situations. Consistent with the for-
mat of the rest of PCIT, the BDI Coach Sessions #1 and #2 followed natu-
rally after the BDI Teach Session, and children were given control of where
to start with practicing steps on the Bravery Ladder. Just like CDI prac-
tices that continue throughout the rest of treatment, BDI practices also con-
tinue throughout the remainder of treatment, giving children ample time
to make progress on their Bravery Ladders. Finally, after children have
had time to make some gains in their BDI practices, parents are then brought
in for the PDI teach session, followed by the coach sessions. With this new
modification, treatment appeared to flow well from one phase of treat-
ment to the next phase of treatment, with parents learning specific skills
during each phase that would help modify the aversive parent child inter-
actions that had been occurring during separation situations. Children
were being reinforced for their gains on the Bravery Ladder with more
ADAPTING PCIT FOR YOUNG CHILDREN WITH SAD 175

special time with mom and dad, thus increasing natural positive reinforc-
ers in the child's environment. Furthermore, placing BDI prior to PDI al-
lowed for continued check up with children on their progress throughout
treatment.
One challenge to conducting PDI after BDI is to be sure to help distin-
guish the difference between misbehavior and refusal to engage in a situ-
ation due to anxiety. We have had to modify PDI slightly so that we clearly
communicate to parents that we are not instructing them to utilize time
out procedures when children refuse to separate; rather, they are to only
use time out procedures during situations where children refuse to com-
ply with commands unrelated to separation. During situations where chil-
dren refuse to separate, parents are taught to utilize CDI skills of praising
even small steps toward compliance, breaking down the situation into sev-
eral smaller steps, ignoring tantrums, and shifting positive attention to
brave behaviors. Further, since CDI practice continues throughout the treat-
ment, we have found that this helps children who perhaps are not truly
"anxious" about separating, but receive the most attention from parents
during their separation refusal and anxious displays. Thus, this structured
positive time, combined with parents' new CDI skills, perhaps work in
tandem to contribute toward shifting the attention from separation situa-
tions to more positive playtime, thus increasing children's desire to com-
ply with parents' requests and to "show off their new brave skills that
will be reinforced rather than crying or whining, which they learn will be
ignored.
In terms of treatment length, it appears that PCIT for children with SAD
is still comparable in length to standard PCIT, but the sessions are distrib-
uted differently. For example, we noted that all sixteen parents in our
sample thus far have been able to reach criterion levels on their CDI skills
in approximately 3-4 sessions. The BDI component, as we have designed
it, now comprises three sessions (one teach session and two coach sessions
including the child). The PDI component has lasted 3-4 sessions, depend-
ing on whether the child has an additional diagnosis of ODD. Unlike
treating children where the primary problem is ODD, we have found that
children with SAD are generally quite compliant when parents ask them
to do something. It is likely that the nature of the interaction is different
between parents and children with behavior problems and parents and
children with anxiety difficulties, and thus, fewer PDI sessions may be
sufficient for parents with children with SAD. Overall, total average length
of this modified PCIT treatment with children with SAD has been 10 ses-
sions.

Modifying the DPICS to Measure Separation Distress.

The Dyadic Parent Child Interaction Coding System-II (DPICS-II; Eyberg,

Bessmer, Newcomb, Edwards, & Robinson, 1994) is an integral compo-
nent of PCIT. We made one modification to the standard DPICS situations
176 PINCUS etal.

to attempt to better assess for changes in children's ability to tolerate brief

separations from parents. We have now included observation of a "sepa-
ration situation" in which parents are called out of the room for 5 minutes,
and a female graduate student confederate enters the room to play with
the child. Parents and children's reactions are captured on videotape as
parents are asked to initiate the separation situation. Children's and
parent's behaviors are then coded using an expanded DPICS coding scheme
that includes coding of anxious behaviors displayed by the child (e.g., cry-
ing, clinging, nailbiting, refusing to separate, etc.), behaviors displayed by
the parent (e.g., reassuring child, questioning child, ignoring inappropri-
ate behavior, etc.), as well as parent and child verbalizations (e.g., com-
mand, praise, critical statement), vocalizations (e.g., laugh, yell), and physi-
cal behaviors (e.g., destructive behavior, positive touch) Thus, the modi-
fied DPICS now includes four 5-minute standard situations: the first stan-
dard situation requires the child to lead the play for 5 minutes, the second
standard situation requires the parent to lead the play for 5 minutes, the
third standard situation requires the parent to leave the room for 5 min-
utes, and the fourth standard situation requires the parent to instruct the
child to clean up the toys. Thus, the total time for the modified DPICS is
now 20 minutes.

Treatment Acceptability: Utilizing Parent Peedback to Improve Treatment

We are gathering parents' feedback about treatment acceptability

through a structured exit interview, through a self report questionnaire
(Therapy Attitude Inventory), and through our treatment session log sheets,
where we record any notable comments parents or children make during
PCIT sessions regarding the nature or format of treatment. Thus, we are
gathering information about parents' views of the most effective compo-
nents of PCIT for SAD for reducing their child's separation distress, their
views of the least helpful parts of treatment, and their views or sugges-
tions for ways the treatment format could be even more beneficial to them.
We also are assessing concomitant changes parents' report that may occur
as a result of treatment, such as child's improved academic functioning,
improved sibling behavior, decreased parenting stress, etc. with the aim
of designing a treatment that is acceptable to parents and young children.

Challenges to Conducting PCIT with Children with SAD and their Parents

Although we have found working with parents of anxious children to

be very rewarding, we have encountered several specific challenges when
attempting to coach parents using traditional PCIT coaching procedures.
Although the standard coaching procedures are in fact utihzed with coach-
ing parents of children with SAD, we have observed that the emphasis
and focus of coaching may need to be slightly different with parents of
anxious children. Based on research showing that parents of anxious chil-
ADAPTING PCIT FOR YOUNG CHILDREN WITH SAD 177

dren tend to grant less psychological autonomy, evidence less warmth and
acceptance, and tend to be more rigid in their parenting, and based on our
clinical observations during sessions, we have tailored our coaching in CDI
to encourage parents to allow children to lead the play. Many parents
have been observed "taking over" the play situation, putting play pieces
together for the child, and solving any "problems" that came up in the
play instead of allowing children to solve problems on their own (e.g.,
telling child how to put something together correctly, or how a toy should
be used). In order to help parents with this, therapists have been taught to
focus on praising parents for letting children choose the toy and lead the
play activity. Further, therapists are taught to praise parents for utilizing
"play talk" with their child, as it promotes a warm and fun interaction, but
requires the parent to "let go" and be playful with their children. Parents
are also coached and praised for not asking questions, and for rephrasing
questions as statements as to not inadvertently lead the play. Parents of
anxious children, who may be anxious themselves, have also been observed
being verbally critical of themselves for accidentally asking the child a
question during CDI. PCIT therapists have been taught to handle this by
teaching parents to remember that the focus of the playtime is to create a
warm interaction, and that their success in CDI is guaranteed if the playtime
is mutually enjoyable, warm, and fun. Thus, parents are taught to be "easy"
on themselves if they accidentally ask a question, and are given lots of
praise by therapists for focusing on making the interaction positive and
enjoyable for themselves and their child, and for not being critical of them-
selves. In this way, parents are, in a sense, being coached and praised for
exhibiting behaviors that are incompatible with anxious parenting styles.
In addition, when coaching parents of anxious children, we emphasize the
importance of reflecting the child's emotions as well as the child's behav-
iors, in order to help the child develop more appropriate emotion identifi-
cation skills and a "feelings" vocabulary to use to express themselves more
effectively to parents when they are in distress. Finally, parents who ini-
tially have been observed to be somewhat uptight and reserved with their
child are encouraged to "let go" and have fun during the CDI playtime.
Thus, though the majority of coaching techniques utilized are identical to
those utilized in the standard PCIT protocol, we have found that coaching
anxious families are often largely focused on these specific skills: Parents
are coached for utilizing labeled praise for appropriate child behaviors,
for not asking questions, for allowing the child to lead the play, and are
encouraged to let go, relax, and enjoy the playtime with their child.

Rewards of Conducing PCIT with Children with SAD and their Parents

Though data collection from the randomized clinical trial will continue
for three more years, we have already discovered numerous rewards of
conducting PCIT with separation anxious children and their families. First,
parents who seek treatment for their child's SAD are often ready for some
178 PINCUS etal.

concrete skills that they can utilize with children when they are anxious.
Parents have already reported that the skills learned in all three phases,
CDI, BDI and PDI, have all been helpful and useful at different times for
helping their anxious child as well as the other children in their home.
Before seeking help at our Center, a number of families reported that they
either had never sought help before for their child's separation anxiety, or
that they had sought the wrong kind of therapy (e.g., one parent had her 8
year old child in more traditional talk therapy for several years prior to
seeking help at our Center, and was frustrated with her child's lack of
progress). Two families had been advised to put their young children on
medication and sought alternative treatment because they were hesitant
to do so. As separation anxiety is disruptive for the parent and family as
well as for the child's functioning, one benefit of utilizing a tailored ver-
sion of PCIT with this population is the ability to help change the nature of
the parent-child interactions to make them more positive, and to help
quickly return the child to normal everyday activities. Another benefit
and reward of utilizing PCIT with families of anxious children is that we
have found parents in this population to be very compliant, perhaps due
to their own anxiety, and perhaps due to other factors. In any case, par-
ents' compliance with all homework and high degree of involvement in
session may be two additional factors that could be contributing to
children's observed success. Parents report that they are pleased to not
have to put child on medication for anxiety, are appreciative of having
skills for improving attachment and warmth, and have reported that the
benefits of their new parenting skills are being reaped by all members of
the family. One mother and father even noted that they noticed them-
selves utilizing the CDI skills with each other in their marriage, and that
these skills have been extremely helpful in promoting warmth in their re-
lationship. Overall, through ongoing data collection in our randomized
clinical trial, we will be better able to determine the efficacy of this modi-
fied version of PCIT for treating clinically significant separation anxiety
disorder in young children.

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