Barriers to Clinician Implementation of Parent-Child Interaction Therapy (PCIT) in New Zealand and Australia: What Role for Time-Out?

Abstract

Background: Parent-Child Interaction Therapy (PCIT) is an effective parent training approach for a commonly occurring and disabling condition, namely conduct problems in young children. Yet, despite ongoing efforts to train clinicians in PCIT, the intervention is not widely available in New Zealand and Australia. Methods: We undertook a cross-sectional online survey of clinicians in New Zealand and Australia who had completed at least the 40-h initial PCIT training, to understand the barriers they encountered in their implementation efforts, and the extent to which attitudes toward time-out influenced implementation. The overall response rate was 47.5% (NZ: 60%; Australia: 31.4%). Results: Responses suggested that participants generally viewed PCIT as both acceptable and effective. Australian participants reported seeing significantly more clients for PCIT per week than those in NZ (Medians 0 and 2, respectively; χ2(1) = 14.08, p < 0.001) and tended to view PCIT as more effective in treating disruptive and oppositional behaviour (95% CI: −0.70, −0.13, p = 0.005). Participants currently seeing PCIT clients described it as more enjoyable to implement than those not using PCIT (95% CI: −0.85, −0.10, p = 0.01). Thirty-eight percent of participants indicated that they adapt or tailor the standardised protocol, primarily by adding in content relating to emotion regulation, and removing content relating to time-out. Participants generally felt that they had fewer skills, less knowledge, and less confidence relating to the Parent-Directed Interaction phase of PCIT (which involves time-out), compared with the Child-Directed Interaction phase. Conclusion: While we had hypothesised that time-out represented an intra-intervention component that detracted from implementation success, results suggested that clinician concern over the use of time-out was present but not prominent. Rather, the lack of access to suitable equipment (i.e., one-way mirror and ear-piece) and difficulties associated with clients attending clinic-based sessions were barriers most commonly reported by clinicians. We suggest that future research might consider whether and how PCIT might be “re-implemented” by already-trained clinicians, moving beyond simply training more clinicians in the approach.

Protocol for a randomised pilot study of a novel Parent–Child Interaction Therapy (PCIT) ‘re-implementation’ intervention

“…Where the clinician is already seeing a full caseload of PCIT clients (our preliminary research suggests this is unlikely), they will remain eligible for inclusion as we are interested in whether the provision of additional supports might influence the nature and quality of implementation. For example, the PCIT treatment protocol recommends the use of a time-out room in the Parent-Directed Interaction phase, and clinicians have indicated that this requirement can be problematic, which at times results in this phase being omitted or adapted [ 14 ].…”

“…Existing research suggests that PCIT is viewed as an effective and acceptable intervention to both PCIT-trained clinicians in Aotearoa/New Zealand [ 14 , 15 ], to Indigenous Māori parents when delivered ‘by Māori, for Māori’ [ 13 ], and to families accessing a public mental health service in Aotearoa/New Zealand [ 16 ]. However, a 2019 survey of PCIT-trained clinicians in Aotearoa/New Zealand found that—even where the clinician was using PCIT in their work—the average number of families seen per week for PCIT, per clinician was 1.03 [ 15 ].…”

“…However, a 2019 survey of PCIT-trained clinicians in Aotearoa/New Zealand found that—even where the clinician was using PCIT in their work—the average number of families seen per week for PCIT, per clinician was 1.03 [ 15 ]. A subsequent 2021 survey of PCIT-trained clinicians found that the median (IQR) typical number of clients seen for PCIT per week was 0 (0 to 1) in Aotearoa/New Zealand, compared to 2 (2 to 3) in Australia, a statistically significant difference [ 14 ].…”

“…Rather than prioritising the training of more clinicians in PCIT (though this remains important), our intention is to better understand what it would require for already-trained clinicians to begin (or resume) implementing PCIT in their practice. We have described this as ‘re-implementation’, which we defined as ‘resuming implementation, implementing again and/or implementing differently’ [ 14 ]. Relatively little research attention has been given to reinvigorating unsuccessful programme implementation, possibly due to pragmatic considerations such as grant funding expiring after initial implementation efforts (i.e.…”

“…Our interest is in those clinicians to whom PCIT is acceptable, who may have encountered barriers which have impeded their initial desire to incorporate PCIT in their practice. Through engaging with PCIT-trained clinicians in surveys and focus groups, we have identified that these barriers include the lack of access to suitable equipment to support the delivery of PCIT (for example, audio-visual equipment) and families being unable to easily attend clinic-based sessions (traditionally held during working hours in a fixed location) [ 14 ]. Facilitators of PCIT’s use included access to a suitable room or clinic space, the ability to co-work PCIT cases with another clinician and having other PCIT-trained colleagues in the workplace [ 14 ].…”