Approximately half of all children entering the foster care system exhibit clinically significant behavioral or emotional problems and are in need of mental health services [10Burns BJ, Phillips SD, Wagner HR, et al. Mental health need and access to mental health services by youths involved with child welfare: a national survey. J Am Acad Child Adolesc Psychiatry 2004; 43(8): 960-70.
[http://dx.doi.org/10.1097/01.chi.0000127590.95585.65] [PMID: 15266190] ]. One of the first studies assessing the mental health of children in the foster care system was published by McIntyre and Kessler [11McIntyre A, Keesler TY. Psychological disorders among foster children. J Clin Child Psychol 1986; 15(4): 297-303.
[http://dx.doi.org/10.1207/s15374424jccp1504_2] ] who sampled 158 children in foster care between 4 and 8 years of age. Results from this study demonstrated that children in foster care exhibited a much higher rate of mental health concerns than those in the general population [11McIntyre A, Keesler TY. Psychological disorders among foster children. J Clin Child Psychol 1986; 15(4): 297-303.
[http://dx.doi.org/10.1207/s15374424jccp1504_2] ]. Similarly, Clausen, Landsverk, Ganger, Chadwick, and Litrownik [12Clausen JM, Landsverk J, Ganger W, et al. Mental health problems of children in foster care. J Child Fam Stud 1998; 7(3): 283-96.
[http://dx.doi.org/10.1023/A:1022989411119] ] found that nearly two out of five foster children scored above the clinical cut-off point on the Total Problems scale on the Child Behavior Checklist (CBCL) [13Achenbach TM. Integrative guide for the 1991 CBCL/4-18, YSR, and TRF profiles 1991.]. In this study, Clausen et al. [12Clausen JM, Landsverk J, Ganger W, et al. Mental health problems of children in foster care. J Child Fam Stud 1998; 7(3): 283-96.
[http://dx.doi.org/10.1023/A:1022989411119] ] compared the rates of mental health problems in children between the ages of 4 and 16 years in foster care across 3 counties in California. The findings from this study align with the previous findings demonstrated in Tennessee [11McIntyre A, Keesler TY. Psychological disorders among foster children. J Clin Child Psychol 1986; 15(4): 297-303.
[http://dx.doi.org/10.1207/s15374424jccp1504_2] ], wherein 43 to 50% of foster children displayed clinically significant behavior problems on CBCL narrow-band subscales (e.g., attention problems, aggressive behavior), broad-band scales (i.e., internalizing and externalizing), or Total Problems scale [12Clausen JM, Landsverk J, Ganger W, et al. Mental health problems of children in foster care. J Child Fam Stud 1998; 7(3): 283-96.
[http://dx.doi.org/10.1023/A:1022989411119] ].

Heflinger, Simpkins, and Combs-Orme [14Heflinger CA, Simpkins CG, Combs-Orme T. Using the CBCL to determine the clinical status of children in state custody. Child Youth Serv Rev 2000; 22(1): 55-73.
[http://dx.doi.org/10.1016/S0190-7409(99)00073-0] ] examined externalizing behaviors among foster children and analyzed data from 105 children (ages 2-18) in state custody through the Children’s Problem Outcome Review Team. Heflinger et al. [14Heflinger CA, Simpkins CG, Combs-Orme T. Using the CBCL to determine the clinical status of children in state custody. Child Youth Serv Rev 2000; 22(1): 55-73.
[http://dx.doi.org/10.1016/S0190-7409(99)00073-0] ] utilized the CBCL to provide information about problems at a global level (i.e., Total Problems score), as well as two broad-bands of behavior: Internalizing Problems and Externalizing Problems [13Achenbach TM. Integrative guide for the 1991 CBCL/4-18, YSR, and TRF profiles 1991.]. At the global level, 33% of children in foster care reported having significant behavior problems; moreover, 31% of foster children demonstrated externalizing problems at either borderline or clinical levels [14Heflinger CA, Simpkins CG, Combs-Orme T. Using the CBCL to determine the clinical status of children in state custody. Child Youth Serv Rev 2000; 22(1): 55-73.
[http://dx.doi.org/10.1016/S0190-7409(99)00073-0] ]. Specifically, 20% were reported to have externalizing problems within the clinical range of severity, which is similar to children already receiving treatment in clinical settings [14Heflinger CA, Simpkins CG, Combs-Orme T. Using the CBCL to determine the clinical status of children in state custody. Child Youth Serv Rev 2000; 22(1): 55-73.
[http://dx.doi.org/10.1016/S0190-7409(99)00073-0] ].

According to Clausen et al. [12Clausen JM, Landsverk J, Ganger W, et al. Mental health problems of children in foster care. J Child Fam Stud 1998; 7(3): 283-96.
[http://dx.doi.org/10.1023/A:1022989411119] ] there are two reasons children in foster care are at higher risk for mental health problems: (1) child maltreatment and (2) adjustment difficulties inherent in foster care. Maltreatment negatively impacts children across multiple domains, such as increased disruptive behavior problems, social withdrawal, and difficulty developing secure attachments [15Azar ST, Wolfe DA. Child physical abuse and neglect. Treatment of childhood disorders 1998; 501-44.-17Eckenrode J, Laird M, Doris J. School performance and disciplinary problems among abused and neglected children. Dev Psychol 1993; 29(1): 53-62.
[http://dx.doi.org/10.1037/0012-1649.29.1.53] ]. Externalizing behavior problems often present as core symptoms in maltreated children; that is, externalizing behavior (e.g., oppositionality) is highly correlated with childhood physical abuse [18Kolko DJ. Child physical abuse.2002.]. Maltreated children in foster care may benefit most from an intervention that aims to decrease externalizing behavior, provide foster caregivers with safe discipline strategies, and enhance the foster caregiver-child relationship.

Behavior problems in foster children are associated with placement instability [19Pardeck JT. Multiple placement of children in foster family care: An empirical analysis. Soc Work 1984; 29(6): 506-9.
[http://dx.doi.org/10.1093/sw/29.6.506] ]. In a study examining the placement experiences of 184 foster children, Palmer [20Palmer SE. Placement stability and inclusive practice in foster care: An empirical study. Child Youth Serv Rev 1996; 18(7): 589-601.
[http://dx.doi.org/10.1016/0190-7409(96)00025-4] ] demonstrated that children’s problem behavior was a stronger predictor of placement stability than the child’s gender, parents’ preparation of the child for separation, or social workers’ training in separation. Newton, Litrownik, and Landsverk [21Newton RR, Litrownik AJ, Landsverk JA. Children and youth in foster care: Distangling the relationship between problem behaviors and number of placements. Child Abuse Negl 2000; 24(10): 1363-74.
[http://dx.doi.org/10.1016/S0145-2134(00)00189-7] [PMID: 11075702] ] conducted a prospective study examining the relationship between change in placement and problem behavior in foster children. Results from this study were consistent with Palmer’s [20Palmer SE. Placement stability and inclusive practice in foster care: An empirical study. Child Youth Serv Rev 1996; 18(7): 589-601.
[http://dx.doi.org/10.1016/0190-7409(96)00025-4] ] earlier findings: externalizing behavior at entry into foster care was found to be the strongest predictor of placement changes [21Newton RR, Litrownik AJ, Landsverk JA. Children and youth in foster care: Distangling the relationship between problem behaviors and number of placements. Child Abuse Negl 2000; 24(10): 1363-74.
[http://dx.doi.org/10.1016/S0145-2134(00)00189-7] [PMID: 11075702] ]. This finding reinforces the notion that children entering the foster care system with high rates of externalizing behavior are less likely to have successful, stable placements.

Highlighting the need for foster children to find a permanent placement, Newton et al. [21Newton RR, Litrownik AJ, Landsverk JA. Children and youth in foster care: Distangling the relationship between problem behaviors and number of placements. Child Abuse Negl 2000; 24(10): 1363-74.
[http://dx.doi.org/10.1016/S0145-2134(00)00189-7] [PMID: 11075702] ] found that multiple placement disruptions can aggravate children’s mental health. For foster children who were initially within normal limits on the CBCL, the number of placement breakdowns predicted increased internalizing and externalizing behaviors. While Palmer [20Palmer SE. Placement stability and inclusive practice in foster care: An empirical study. Child Youth Serv Rev 1996; 18(7): 589-601.
[http://dx.doi.org/10.1016/0190-7409(96)00025-4] ] asserted that foster care workers are already making strong efforts to help children modify their behavior, foster children may benefit from caregiver-child focused interventions aimed at reducing disruptive behavior and strengthening the caregiver-child bond.

PCIT is made up of two treatment phases [40Eyberg SM, Funderburk B. Parent-child interaction therapy protocol 2011.]. In the first phase, Child-Directed Interaction (CDI), a therapist spends one session, teaching caregiver(s) foundational play therapy skills. The caregiver is taught to use “PRIDE” skills—praise, reflect, imitate, describe, enjoy—during one-on-one “special playtime” with the child during weekly therapy sessions and daily, 5-minute practice sessions in the home. Caregivers also learn to avoid questions, commands, and negative talk, also known as the “don’t” skills, during CDI. Using a microphone and earpiece, a PCIT therapist provides live coaching to caregivers from behind a two-way mirror as caregivers engage in play with their child. Coaching involves a parallel process wherein therapists employ the same behavioral principles (e.g., praising appropriate use of skills, avoiding negative talk) to improve caregivers’ skills as caregivers are expected to use with their children. CDI coaching sessions continue until caregiver skills meet mastery criteria (i.e., 10 praises, 10 reflections, 10 descriptions, and 3 or fewer “don’t skills” during a 5-minute coding period). The use of mastery criteria is intended to capitalize on the idea of overlearning skills; caregivers who demonstrate high ratios of positive to negative parenting skills are more likely to retain these habits outside of sessions [33McNeil CB, Hembree-Kigin TL. Parent-child interaction therapy 2010.
[http://dx.doi.org/10.1007/978-0-387-88639-8] ]. CDI mastery typically occurs after about six to eight sessions of PCIT.

Following CDI mastery, the therapist teaches caregiver(s) a set of disciplinary strategies focused on compliance training. This second phase of treatment, Parent-Directed Interaction (PDI), aims to hone caregiver skills in giving effective commands (i.e., commands that are singular, specific, direct, and positively stated) and delivering consistent, predictable consequences (i.e., labeled praise for compliance and time-out from positive reinforcement for noncompliance). Again, caregivers are coached in PDI skills during therapy sessions and complete daily at-home practice of both CDI and PDI skills. Mastery of the PDI phase occurs when the caregiver gives 75% or greater effective commands and 75% or greater correct subsequent follow-through, during a 5-minute coding session. Caregivers often achieve PDI mastery in six to ten sessions.

Following mastery of CDI and PDI, PCIT therapists work ideographically with families to achieve a variety of remaining goals such as decreasing sibling conflict, improving public behavior, and generalizing behavioral gains to the classroom. Throughout PCIT, caregivers also complete a weekly self-report measure of child behavior problems called the Eyberg Child Behavior Inventory (ECBI) [41Eyberg SM, Pincus D. Eyberg child behavior inventory and sutter-eyberg student behavior inventory-revised: Professional manual 1999.]. In addition to CDI and PDI skills mastery, families must report child behavior problems within normal limits on the ECBI and confidence in managing their child’s behavior in order to graduate from PCIT [33McNeil CB, Hembree-Kigin TL. Parent-child interaction therapy 2010.
[http://dx.doi.org/10.1007/978-0-387-88639-8] ]. The typical course of PCIT lasts for about twelve to twenty sessions from baseline assessment to graduation.

For more than four decades, researchers have investigated the impact of PCIT through efficacy and effectiveness trials in a variety of contexts. See Lieneman, Brabson, Highlander, Wallace, and McNeil [42Lieneman CC, Brabson LA, Highlander A, Wallace NM, McNeil CB. Parent-Child Interaction Therapy: Current perspectives. Psychol Res Behav Manag 2017; 10: 239-56.
[http://dx.doi.org/10.2147/PRBM.S91200] [PMID: 28790873] ] for a recent comprehensive literature review. Effect sizes for pre- to post-treatment decreases in child behavior problems as reported on the ECBI are routinely measured in the “very large” to “huge” range in samples from community-based treatment settings (e.g., d = 2.30 [43Danko CM, Garbacz LL, Budd KS. Outcomes of parent-child interaction therapy in an urban community clinic: A comparison of treatment completers and dropouts. Child Youth Serv Rev 2015; 60: 42-51.
[http://dx.doi.org/10.1016/j.childyouth.2015.11.007] ], d = 1.65 [44Lieneman CC, Quetsch LB, Theodorou LL, Newton KA, McNeil CB. Reconceptualizing attrition in Parent-Child Interaction Therapy: “dropouts” demonstrate impressive improvements. Psychol Res Behav Manag 2019; 12: 543-55.
[http://dx.doi.org/10.2147/PRBM.S207370] [PMID: 31413647] ]). See Cohen [45Cohen J, Ed. Statistical power analysis for the behavioral sciences 1988.] and Sawilowsky [46Sawilowsky S. New effect size rules of thumb. J Mod Appl Stat Methods 2009; 8(2): 467-74.
[http://dx.doi.org/10.22237/jmasm/1257035100] ] for more information on effect size classifications. Families report maintenance of treatment gains at one-, two-, three-, and six-year follow-up assessments subsequent to PCIT [47Boggs SR, Eyberg SM, Edwards DL. Outcomes of parent-child interaction therapy: A comparison of treatment completers and study dropouts one to three years later. Child Fam Behav Ther 2004; 26(4): 1-22.
[http://dx.doi.org/10.1300/J019v26n04_01] -49Hood KK, Eyberg SM. Outcomes of parent-child interaction therapy: Mothers’ reports of maintenance three to six years after treatment. J Clin Child Adolesc Psychol 2003; 32(3): 419-29.
[http://dx.doi.org/10.1207/S15374424JCCP3203_10] [PMID: 12881030] ]. Drawing from a meta-analysis of common effective components of behavioral parent training programs, PCIT’s large effects can be attributed in part to its core features of: (1) increasing positive interactions, (2) in-session practice, (3) emotional communication, and (4) time-out of from positive reinforcement [50Kaminski JW, Valle LA, Filene JH, Boyle CL. A meta-analytic review of components associated with parent training program effectiveness. J Abnorm Child Psychol 2008; 36(4): 567-89.
[http://dx.doi.org/10.1007/s10802-007-9201-9] [PMID: 18205039] , 51Lieneman C, Williford D, Quetsch L, Thomas B, McNeil CB. Behavioral treatments.Disruptive, impulse-control, and conduct disorders: Features, assessment, pathways, and intervention 2018; 211-37.
[http://dx.doi.org/10.1016/B978-0-12-811323-3.00009-2] ]. The positive effects of PCIT have been measured through caregiver-based outcomes as well. A 2007 meta-analysis of PCIT research demonstrated improvements across studies in positive and negative parenting practices following treatment [52Thomas R, Zimmer-Gembeck MJ. Behavioral outcomes of parent-child interaction therapy and triple p-positive parenting program: A review and meta-analysis. J Abnorm Child Psychol 2007; 35(3): 475-95.
[http://dx.doi.org/10.1007/s10802-007-9104-9] [PMID: 17333363] ]. Improvements in caregiver emotion regulation [53Lieneman C, Girard E, Quetsch L, McNeil CB. Emotion regulation and attrition in Parent-Child Interaction Therapy. J Child Fam Stud 2019.
[http://dx.doi.org/10.1007/s10826-019-01674-4] ], as well as decreases in parenting stress [54Lanier P, Kohl PL, Benz J, Swinger D, Moussette P, Drake B. Parent-child interaction therapy in a community setting: Examining outcomes, attrition, and treatment setting. Res Soc Work Pract 2011; 1(6): 689-98.
[http://dx.doi.org/10.1177/1049731511406551] [PMID: 24839378] -56Lyon AR, Budd KS. A community mental health implementation of Parent-Child Interaction Therapy (PCIT). J Child Fam Stud 2010; 19(5): 654-68.
[http://dx.doi.org/10.1007/s10826-010-9353-z] [PMID: 20877583] ] and risk for future maltreatment [39Chaffin M, Silovsky JF, Funderburk B, et al. Parent-child interaction therapy with physically abusive parents: efficacy for reducing future abuse reports. J Consult Clin Psychol 2004; 72(3): 500-10.
[http://dx.doi.org/10.1037/0022-006X.72.3.500] [PMID: 15279533] , 57Lanier P, Kohl PL, Benz J, Swinger D, Drake B. Preventing maltreatment with a community-based implementation of parent-child interaction therapy. J Child Fam Stud 2014; 23(2): 449-60.
[http://dx.doi.org/10.1007/s10826-012-9708-8] [PMID: 24443637] ] are also evident.

A growing literature base provides evidence of PCIT’s generalizability across diverse cultural groups [58Capous DE, Wallace NM, McNeil DJ, Cargo TA. Parent-child interaction therapy across diverse cultural groups.Parent-child interactions and relationships: Perceptions, practices and developmental outcomes 2016; 1-44.]. PCIT has demonstrated positive treatment effects in samples of predominately African-American [59Capage LC, Bennett GM, McNeil CB. A comparison between African American and Caucasian children referred for treatment of disruptive behavior disorders. Child Fam Behav Ther 2001; 23(1): 1-14.
[http://dx.doi.org/10.1300/J019v23n01_01] , 60Fernandez MA, Butler AM, Eyberg SM. Treatment outcome for low socioeconomic status African American families in Parent-Child Interaction Therapy: A pilot study. Child Fam Behav Ther 2011; 33(1): 32-48.
[http://dx.doi.org/10.1080/07317107.2011.545011] ], Latinx [61Borrego J Jr, Anhalt K, Terao SY, Vargas EC, Urquiza AJ. Parent-Child Interaction Therapy with a Spanish-speaking family. Cognit Behav Pract 2006; 13: 121-33.
[http://dx.doi.org/10.1016/j.cbpra.2005.09.001] -63McCabe KM, Yeh M, Garland AF, Lau AS, Chavez B. The GANA program: A tailoring approach to adapting Parent-Child Interaction Therapy for Mexican Americans. Educ Treat Child 2005; 28: 111-29.], and Native American [64Bigfoot DS, Funderburk BW. Honoring children, making relatives: the cultural translation of parent-child interaction therapy for American Indian and Alaska Native families. J Psychoactive Drugs 2011; 43(4): 309-18.
[http://dx.doi.org/10.1080/02791072.2011.628924] [PMID: 22400462] ] cultural groups. A variety of adaptations or tailoring approaches have been used to improve upon the cultural validity of PCIT; for example, some Puerto Rican families preferred the involvement of extended family members in the treatment [63McCabe KM, Yeh M, Garland AF, Lau AS, Chavez B. The GANA program: A tailoring approach to adapting Parent-Child Interaction Therapy for Mexican Americans. Educ Treat Child 2005; 28: 111-29.]. Worldwide, evidence of PCIT’s effectiveness has been reported by researchers in Australia [65Phillips J, Morgan S, Cawthorne K, Barnett B. Pilot evaluation of parent-child interaction therapy delivered in an Australian community early childhood clinic setting. Aust N Z J Psychiatry 2008; 42(8): 712-9.
[http://dx.doi.org/10.1080/00048670802206320] [PMID: 18622779] ], Norway [66Bjørseth Å, Wichstrøm L. Effectiveness of Parent-Child Interaction Therapy (PCIT) in the treatment of young children’s behavior problems. A randomized controlled study. PLoS One 2016; 11(9)e0159845
[http://dx.doi.org/10.1371/journal.pone.0159845] [PMID: 27622458] ], China [67Leung C, Tsang S, Sin TS, Choi S. The efficacy of Parent-Child Interaction Therapy with Chinese families: Randomized controlled trial. Res Soc Work Pract 2015; 25(1): 117-28. [https://doi.org/10.1177/1049731513519827].
[http://dx.doi.org/10.1177/1049731513519827] ], Germany [68Briegel W, Walter T, Schimek M, Knapp D, Bussing R. Parent-Child Interaction Therapy: In-room-coaching. Ergebnisse einer ersten deutschen Fallstudie. Kindh Entwickl 2015; 24(1): 47-54.
[http://dx.doi.org/10.1026/0942-5403/a000158] ], Iran [69Hatamzadeh A, Pouretemad H, Hassanabadi H. The effectiveness of parent-child interaction therapy for children with high functioning autism. Procedia Soc Behav Sci 2010; 5: 994-7.
[http://dx.doi.org/10.1016/j.sbspro.2010.07.224] ], Japan [70Hosogane N, Kodaira M, Kihara N, Saito K, Kamo T. Parent-Child Interaction Therapy (PCIT) for young children with Attention-Deficit Hyperactivity Disorder (ADHD) in Japan. Ann Gen Psychiatry 2018; 17(9)
[http://dx.doi.org/10.1186/s12991-018-0180-8] ], South Korea [71Park YN, Lee SY, Kim JY, Rhee ER. The effectiveness of parent-child interaction therapy for Korean families. Youngyuah Adong Jungsingungangyungu 2016; 9(1): 29-50.], Taiwan [72Chen YC, Fortson BL. Predictors of treatment attrition and treatment length in Parent-Child Interaction Therapy in Taiwanese families. Child Youth Serv Rev 2015; 56: 28-37.
[http://dx.doi.org/10.1016/j.childyouth.2015.10.009] [PMID: 26705373] ], the Netherlands [73Abrahamse ME, Junger M, Chavannes EL, Coelman FJ, Boer F, Lindauer RJ. Parent-child interaction therapy for preschool children with disruptive behaviour problems in the Netherlands. Child Adolesc Psychiatry Ment Health 2012; 6(1): 24.
[http://dx.doi.org/10.1186/1753-2000-6-24] [PMID: 22694924] ], and the United States [74Eyberg SM, Boggs SR, Algina J. Parent-child interaction therapy: A psychosocial model for the treatment of young children with conduct problem behavior and their families. Psychopharmacol Bull 1995; 31(1): 83-91.
[PMID: 7675994] ].

Despite the overwhelming evidence that PCIT is effective in improving behavioral outcomes for children with challenging behavior or histories of maltreatment, the reality is that PCIT may not be feasible in some child welfare contexts due to a number of logistical and financial restraints. PCIT may be cost-prohibitive for some child welfare agencies, with start-up costs estimated at $14,000 and treatment costs estimated at $1,000 per client [79Goldfine ME, Wagner SM, Branstetter SA, McNeil CB. Parent-Child Interaction Therapy: An examination of cost-effectiveness. J Early Intensive Behav Interv 2008; 5(1): 119-41.
[http://dx.doi.org/10.1037/h0100414] ]. PCIT also requires delivery by trained mental health providers with masters’ degrees, which for many agencies may require training of staff and restructuring of personnel [80Mersky JP, Topitzes J, Grant-Savela SD, Brondino MJ, McNeil CB. Adapting Parent-Child Interaction Therapy to foster care: Outcomes from a randomized trial. Res Soc Work Pract 2016; 26(2): 157-67.
[http://dx.doi.org/10.1177/1049731514543023] ]. High attrition rates pose another problem for child welfare agencies looking to use PCIT as a model for pre-service training. Standard PCIT has an estimated 33% dropout rate [81Werba BE, Eyberg SM, Boggs SR, Algina J. Predicting outcome in parent-child interaction therapy: success and attrition. Behav Modif 2006; 30(5): 618-46.
[http://dx.doi.org/10.1177/0145445504272977] [PMID: 16894233] ], and non-kin foster parents have higher attrition rates than kinship foster parents [82Timmer SG, Sedlar G, Urquiza AJ. Challenging children in kin versus nonkin foster care: perceived costs and benefits to caregivers. Child Maltreat 2004; 9(3): 251-62.
[http://dx.doi.org/10.1177/1077559504266998] [PMID: 15245678] ]. Mersky and colleagues [83Mersky JP, Topitzes J, Janczewski CE, McNeil CB. Enhancing foster parent training with parent-child interaction therapy: Evidence from a randomized field experiment. J Soc Social Work Res 2015; 6(4): 591-616.
[http://dx.doi.org/10.1086/684123] [PMID: 26977251] ] cited the intensity and duration of treatment as a major barrier to the implementation of PCIT in the foster care setting. Foster parents typically have multiple children in their care and may be less inclined to participate in an intensive 12- to 20-week program focused on a single child. The recognition of these barriers to the treatment has served as a catalyst for the development of PCIT adaptations for the child welfare system.

One such adaptation maintained all the components of standard PCIT but added one hour per week of in-home coaching [84Timmer SG, Zebell NM, Culver MA, Urquiza AJ. Efficacy of adjunct in-home coaching to improve outcomes in parent-child interaction therapy. Res Soc Work Pract 2010; 20(1): 36-46.
[http://dx.doi.org/10.1177/1049731509332842] ]. The rationale for the additional in-home coaching practice was to promote the generalizability of skills and allow the caregiver to practice skills with therapist support in a real-world setting, complete with siblings, other adults, and environmental distractions. Although the study did not focus on foster parents, non-kin foster parents were included in the sample, along with biological parents and kin caregivers. Participants were randomly assigned to either receive additional in-home PCIT coaching or in-home social support services. Both PCIT with and without in-home coaching yielded similar improvements in child and caregiver behavior; caregivers who received additional in-home coaching sessions did not fare better in terms of skill acquisition, quality of performance by the last session, or speed in completing treatment than those in the social support group. However, those in the in-home coaching group used significantly more positive verbalizations, had lower parental stress, and experienced child behavior as less problematic (as measured by the ECBI Problem Scale).

McNeil, Herschell, Gurwitch, and Clemens-Mower [85McNeil CB, Herschell AD, Gurwitch RH, Clemens-Mowrer L. Training foster parents in Parent-Child Interaction Therapy. Educ Treat Child 2005; 28: 182-96.] conducted an exploratory single-group study on a condensed version of PCIT with 30 foster child-foster parent dyads. Instead of the individualized, multi-week format, foster parents in this study attended a two-day group training. On the first day of training, foster parents attended a didactic session without their foster children in order to learn CDI skills and engage in discussions and role-plays to enhance skill acquisition. On the second day of training, foster parents brought their foster child with them and were trained in PDI skills. They were then given an opportunity to practice discipline skills with their children while a therapist coached from behind a one-way mirror. Other foster parents watched these parent-child interactions from the observation room, and childcare was provided any time a parent-child dyad was not being coached. The workshop ended with the development of a plan for each foster parent to roll out PCIT into the home setting.

In this study, the key components of PCIT were maintained (e.g., CDI and PDI skills, live caregiver coaching). However, a number of elements from the standard format were excluded in order to adapt PCIT to the child welfare context: at-home practice, coding of CDI and PDI skills, progress based on mastery, and the use of a back-up room in the time-out procedure (i.e., foster parents had the option of using a back-up room or another consequence such as restriction of privilege). This modified format of PCIT presented a number of advantages for the foster parent population. The two-day workshop significantly reduced the time commitment for caregivers and the cost of training for child welfare agencies, thereby increasing the feasibility of implementation. The group-based format lent itself to the discussion, observational learning, and social support among the foster parent participants.

After the 2-day workshop, 27 of the 30 participants completed a 1-month follow-up, and 8 participants completed a 5-month follow-up. Although the average pre-treatment ECBI Problem and Intensity Scale scores were measured in the clinical range, these scores fell in the average range one month after treatment. Interview data collected at the 1-month follow-up indicated that 80% of foster parents were using skills acquired during the workshop and 68% were satisfied with the time-out procedure. Scores on a treatment satisfaction survey were high immediately following the training but saw a small, yet statistically significant drop in satisfaction ratings at follow-up. Parents who completed the 5-month follow-up continued to report ECBI Intensity scores below clinical cutoffs and a decline in Problem scores, suggesting that these parents were better able to manage their children’s behavior. The findings from this single-group study were promising in that they offered preliminary support for the use of a two-day workshop format for foster parents and their children. The methodological weaknesses of this study (e.g., lack of a control group, small sample size) prompted further evaluation of this abbreviated format.

Project Connect is a PCIT adaptation that was developed as an extension of the McNeil et al. [85McNeil CB, Herschell AD, Gurwitch RH, Clemens-Mowrer L. Training foster parents in Parent-Child Interaction Therapy. Educ Treat Child 2005; 28: 182-96.] study in collaboration with two community partner agencies [86Topitzes J, Mersky JP, McNeil CB. Implementation of parent-child interaction therapy within foster care: An attempt to translate an evidence-based program within a local child welfare agency. J Public Child Welf 2015; 9(1): 22-41.
[http://dx.doi.org/10.1080/15548732.2014.983288] [PMID: 25729340] ]. The group format was retained, but biweekly phone consultations and homework were added to support the transfer of skills to the home environment. Observational data using the DPICS-III [87Eyberg SM, Nelson MM, Duke M, Boggs SR, Eds. Manual for the dyadic parent-child interaction coding system 2004.] was also added to track changes in parenting behavior from baseline to eight weeks after baseline. The authors examined two variations of the model: (1) brief PCIT, a two-day workshop followed by six phone consultations conducted over eight weeks and (2) extended PCIT, a three-day workshop followed by four phone consultations conducted over six weeks [80Mersky JP, Topitzes J, Grant-Savela SD, Brondino MJ, McNeil CB. Adapting Parent-Child Interaction Therapy to foster care: Outcomes from a randomized trial. Res Soc Work Pract 2016; 26(2): 157-67.
[http://dx.doi.org/10.1177/1049731514543023] , 86Topitzes J, Mersky JP, McNeil CB. Implementation of parent-child interaction therapy within foster care: An attempt to translate an evidence-based program within a local child welfare agency. J Public Child Welf 2015; 9(1): 22-41.
[http://dx.doi.org/10.1080/15548732.2014.983288] [PMID: 25729340] ]. Trainings were delivered by PCIT-trained therapists and took place on Saturdays for approximately eight hours with a group of six to eight families. Phone consultations were 15 to 20 minutes in length and typically occurred in the evenings. Additionally, childcare was provided for all Saturday sessions to remove barriers to participation, namely for foster parents with multiple children in their care.

The schedule of the first Saturday workshop began with didactic instruction on CDI skills, followed by role-playing to practice these skills. The therapists then coached the foster parents as they practiced CDI skills on one another. The bulk of the training was dedicated to live coaching; there were 3, 45-minute live coaching sessions, and all parents received at least 2 coaching sessions. Foster parents not actively engaged in live coaching observed another parent’s live coaching session from an observation room. The session ended with a discussion of questions and homework, and phone consultations were scheduled with each family. The second workshop followed the same format as the first but with PDI skills instead of CDI skills. For the three-day workshop, foster parents received an additional Saturday session at the eight-week mark. Phone consultations allowed providers to follow up with families on homework, answer any questions, and ensure foster parents were implementing PCIT skills in the home.

Families were randomly assigned to the two-day workshop condition, three-day workshop condition, or a waitlist control group. Rates of attrition were similar across the 3 groups (i.e., approximately 25%), a relatively low rate of attrition compared to other PCIT studies [56Lyon AR, Budd KS. A community mental health implementation of Parent-Child Interaction Therapy (PCIT). J Child Fam Stud 2010; 19(5): 654-68.
[http://dx.doi.org/10.1007/s10826-010-9353-z] [PMID: 20877583] , 81Werba BE, Eyberg SM, Boggs SR, Algina J. Predicting outcome in parent-child interaction therapy: success and attrition. Behav Modif 2006; 30(5): 618-46.
[http://dx.doi.org/10.1177/0145445504272977] [PMID: 16894233] ]. The fact that the attrition rate did not differ between the brief and extended conditions indicated that the booster session did not negatively impact foster parent engagement [86Topitzes J, Mersky JP, McNeil CB. Implementation of parent-child interaction therapy within foster care: An attempt to translate an evidence-based program within a local child welfare agency. J Public Child Welf 2015; 9(1): 22-41.
[http://dx.doi.org/10.1080/15548732.2014.983288] [PMID: 25729340] ]. Mersky and colleagues [80Mersky JP, Topitzes J, Grant-Savela SD, Brondino MJ, McNeil CB. Adapting Parent-Child Interaction Therapy to foster care: Outcomes from a randomized trial. Res Soc Work Pract 2016; 26(2): 157-67.
[http://dx.doi.org/10.1177/1049731514543023] , 83Mersky JP, Topitzes J, Janczewski CE, McNeil CB. Enhancing foster parent training with parent-child interaction therapy: Evidence from a randomized field experiment. J Soc Social Work Res 2015; 6(4): 591-616.
[http://dx.doi.org/10.1086/684123] [PMID: 26977251] ] reported more detailed findings from this investigation. Foster parents in the two treatment conditions reported significant decreases in parenting stress on the Parenting Stress Index-Short Form (PSI-SF) [88Abidin RR, Ed. Parenting Stress Index (PSI) manual 1995.] and improvements in parenting behavior [83Mersky JP, Topitzes J, Janczewski CE, McNeil CB. Enhancing foster parent training with parent-child interaction therapy: Evidence from a randomized field experiment. J Soc Social Work Res 2015; 6(4): 591-616.
[http://dx.doi.org/10.1086/684123] [PMID: 26977251] ]. Foster parents improved on measures of labeled praise, positive parenting behavior, and negative parenting behavior, but no differences between groups were found on the use of negative talk. There were no significant outcome differences between the brief PCIT and extended PCIT versions, which supports the use of the more time- and cost-effective two-day model over the three-day model [83Mersky JP, Topitzes J, Janczewski CE, McNeil CB. Enhancing foster parent training with parent-child interaction therapy: Evidence from a randomized field experiment. J Soc Social Work Res 2015; 6(4): 591-616.
[http://dx.doi.org/10.1086/684123] [PMID: 26977251] ]. Both interventions yielded significant changes in child behavioral outcomes [80Mersky JP, Topitzes J, Grant-Savela SD, Brondino MJ, McNeil CB. Adapting Parent-Child Interaction Therapy to foster care: Outcomes from a randomized trial. Res Soc Work Pract 2016; 26(2): 157-67.
[http://dx.doi.org/10.1177/1049731514543023] ]. Scores on the ECBI Intensity and Problem Scales decreased for all 3 groups, and all groups had ECBI Problem scores below the clinical cutoff at 14 weeks after the baseline assessment. However, only the two treatment groups saw scores drop below the clinical cutoff on the ECBI Intensity Scale. Similarly, scores on the CBCL Externalizing and Internalizing Scales significantly decreased for all three groups, but only the two intervention groups had scores that fell below the clinical threshold post-treatment. Upon further analysis, Mersky et al. [80Mersky JP, Topitzes J, Grant-Savela SD, Brondino MJ, McNeil CB. Adapting Parent-Child Interaction Therapy to foster care: Outcomes from a randomized trial. Res Soc Work Pract 2016; 26(2): 157-67.
[http://dx.doi.org/10.1177/1049731514543023] ] found that those in the extended condition experienced further improvement in internalizing and externalizing behavior after the 8-week mark, but this was not the case for those in the brief condition. Although these results must be bolstered by further study, they suggest that a booster session may help with the maintenance of gains seen in foster parent and foster child behavior.

An exploratory study based on the abbreviated PCIT models for foster parents utilized a 5- to 7-session, clinic-based, individualized format [89Blair K, Bennett K, Mersky J, Topitzes J, McNeil CB. 2017.Brief PCIT: An intervention designed to reach more child welfare families. PCIT International Convention Traverse City, Michigan. 2017.]. Brief PCIT maintained more of the standard format of PCIT than the group-based formats, and thus provided foster parents with more opportunities for individualized coaching. The first session was a typical intake/observation session, followed by 2 sessions dedicated to CDI teaching and coaching. An optional CDI coach session was added if needed. Foster parents then received 2 sessions of PDI teaching and coaching with the option of a third PDI session if needed. Preliminary findings from a sample of six participants demonstrated a decrease in scores on both ECBI Intensity and Problem Scales for all but one participant. Two of the participants had clinically significantly pre-treatment scores on both ECBI scales that were no longer in the clinical range post-treatment. A qualitative study on Brief PCIT in the child welfare context identified additional barriers by asking foster parents and providers about their experiences with the intervention [90Blair K, Topitzes J, Winkler EN, McNeil CB. Parent-Child Interaction Therapy: Findings from an exploratory qualitative study with practitioners and foster parents. Qual Soc Work 2020:1473325020917722.]. In this particular study, PCIT providers added elements to Brief PCIT in order to address child traumatic stress (e.g., psychoeducation for parents on trauma and traumatic stress and physiological/cognitive relaxation strategies). Overall, foster parents cited minimal challenges to participating in treatment but stated that the time commitment was difficult to manage. Foster parents deemed the therapeutic alliance with their PCIT provider to be a tremendous source of support that promoted success and retention. They also found the integration of trauma-informed treatment to be helpful in understanding their foster children’s behavior and emotions. The practitioners, on the other hand, cited two main barriers to treatment: (1) foster parents’ perceived stigma associated with participating in treatment and (2) foster parents’ tendency to overreport child behavior difficulties. To problem-solve around these issues, practitioners formed small groups or “learning collaboratives” comprised of approximately seven therapists to discuss challenges, brainstorm possible solutions, and promote fidelity to the model. The work of Blair et al. [89Blair K, Bennett K, Mersky J, Topitzes J, McNeil CB. 2017.Brief PCIT: An intervention designed to reach more child welfare families. PCIT International Convention Traverse City, Michigan. 2017., 90Blair K, Topitzes J, Winkler EN, McNeil CB. Parent-Child Interaction Therapy: Findings from an exploratory qualitative study with practitioners and foster parents. Qual Soc Work 2020:1473325020917722.] has introduced yet another abbreviated adaptation of PCIT with its own modifications for both foster parents and their providers.