Introduction
The COVID-19 pandemic has presented significant stress for young families across several domains, and in many circumstances has increased the need for therapeutic services to help families cope with a range of emotional and behavioral health concerns. For caregivers, the pandemic has led to new stressors including financial strain due to lost or reduced employment, loss of child care, disruption of professional and parenting responsibilities, and isolation from social supports. The lasting impacts of the pandemic are still unknown, but rapid-cycle data collection, as well as lessons learned from prior disasters, indicate declines in mental health and wellbeing for both young children and their caregivers, with a disproportionate impact on low-income families and people of color (Center for Translational Neuroscience, 2020 a and b; Cluver et al., 2020).
Given the increased stress for parents and young children, there may be a greater need for emotional and behavioral interventions, yet many mental health service providers have been closed or operating at reduced capacity during the pandemic to protect the health of clinicians and families. Many have transitioned to virtual services, which has posed a range of financial and logistical challenges for clinicians and families and simultaneously has yielded creative adaptations by both families and clinicians with unexpected benefits.
This article presents the perspectives of a group of seasoned infant and early childhood mental health clinicians and supervisors from three agencies on the adaptations they made in delivering two evidence-based treatments for young children’s mental health. As part of a federal grant funded by the Substance Abuse and Mental Health Services Administration, the Department of Behavioral Health trained and supported clinical teams to offer two dyadic treatments – Parent-Child Interaction Therapy (PCIT) (McNeil & Hembree-Kigin, 2010) and Child-Parent Psychotherapy (CPP) (Lieberman & Van Horn, 2011).
The project focused on increasing access to these therapeutic interventions for urban, low-income Latinx (people of Latin American origin or descent) and African American families with children under the age of six. Families sought these services with a range of presenting concerns, but most commonly to address emotional and behavioral symptoms consistent with reactions to trauma or toxic stress, including externalizing behavior (e.g., aggression, defiance), anxiety, sleep disruption, hyperactivity, withdrawal, and attachment difficulties).
The clinical teams reflected on the adaptations they made to these evidence-based treatments in a series of reflective forums convened by the external evaluators for the system of care grant. Those conversations were recorded, transcribed, and then analyzed as part of this paper. The clinical teams then reviewed the analysis and added additional clinical reflections and lessons learned.
Parent-Child Interaction Therapy
Parent-Child Interaction Therapy (PCIT) is a manualized evidence-based practice designed to treat challenging behaviors among children 2-7. PCIT targets caregivers’ attunement and limit-setting with their child to improve both their attachment relationship and child prosocial behavior. PCIT involves dyadic sessions in which the caregiver and child play together while the clinician observes and coaches from behind a one-way mirror. As treatment progresses, caregivers reach mastery criteria in two phases of therapy: Child-Directed Interaction (CDI) in which caregivers engage in dyadic play using new skills (summarized with the acronym PRIDE), and Parent-Directed Interaction (PDI) in which caregivers learn to give effective commands and follow through with a structured time-out sequence.
Across the two stages, PCIT is highly structured and data-driven, and families are asked to complete weekly homework and questionnaires (McNeil & Hembree-Kigin, 2010). In recent years, PCIT was adapted for a telehealth format (“I-PCIT”) (Comer et al., 2015), but in-person treatment was still the norm before the pandemic. Among the clinicians in this sample, there was a wide range of experience implementing PCIT prior to the pandemic: a few clinicians had experience implementing I-PCIT as a supplement to in-person therapy, whereas other clinicians were still completing their formal training in traditional PCIT.
Silver linings. The clinicians observed that PCIT, in comparison with other therapies, may be particularly conducive to a telehealth format. In PCIT’s standard format, the therapist is already separated from the family via the one-way mirror and communicating through a bug-in-the-ear device. Hence, it may be less jarring to switch to remote treatment in which they communicate through an earpiece via their respective devices. The clinicians highlighted the potential for some families (with the time and motivation) to attend sessions more frequently and therefore progress through PCIT more quickly. One clinician noted that some families’ compliance with homework (daily play sessions) increased because they were home more often. When homework completion did not improve, it created an opportunity to discuss and address barriers to clinical progress other than lack of time, such as caregiver beliefs that playtime may reward challenging behavior or caregivers’ discomfort with their own play skills.
Further, facilitating PCIT in a virtual format brings the clinician into the home and provides a more comprehensive picture of the child’s behavior. Parent coaching in real-time in the context where the child’s behavior occurs may support accelerated skill integration into everyday life. For example, the clinicians noted that they could coach caregivers through moments when siblings disrupt the play, a common issue that cannot be directly addressed in the clinic.
Further, they could individualize the time-out sequence to the spaces available in the home. One clinician described virtually coaching a parent through a child’s tantrum at home, a helpful therapeutic opportunity that was unlikely to occur in the clinic because children often exhibit different behavior depending on the context, and have different stimuli at home that can trigger and soothe their dysregulation. Through this experience, the caregiver felt more confident and supported, while also ensuring that they were seen as the clear authority figure because the child was unaware that they were being coached.
One clinician observed that technological challenges, such as disrupted video connection, required additional creativity but could be used as an opportunity. For instance, many parents feel awkward practicing the Child-Directed Interaction (CDI) skill of behavioral descriptions (i.e., narrating the child’s play). When in the clinic together, some clinicians would ask parents to “pretend I cannot see what’s happening” to help them master this skill; the lapses in the video provided spontaneous opportunities to practice describing the child’s play.
Barriers and adaptations. The availability of toys is a major concern because there is specific guidance regarding appropriate toys to use for play in PCIT, and many families did not have the resources to purchase them. In response, the agencies worked to package and distribute PCIT toys to families. One clinician introduced them to families as a way to reinvigorate dyadic play, and noted that “families have been very receptive not just to get a toy but also providing ideas for, this is how you could play with your child using these toys.” Other clinicians worked with caregivers to identify objects in the home that could be used for CDI, such as art supplies.
Of note, clinical data collection was reported to be quite challenging via telehealth. The PCIT manual specifies that the caregiver completes a behavior rating scale (the Eyberg Child Behavior Inventory) at each session. Without consistent access to computers, printers, HIPAA-compliant document-sharing platforms, and sufficient session time to complete the questionnaire verbally, the frequency with which these assessments were completed decreased significantly.
Child-Parent Psychotherapy
Child-Parent Psychotherapy (CPP) is an evidence-based intervention for young children (0-5) who experienced traumatic events. CPP is an intensive three-stage treatment in which dyads engage in play and conversation to process trauma, recognize triggers, increase safety, and build their bond. CPP has been rigorously evaluated and shown to improve attachment security and reduce trauma symptoms, behavioral concerns, and maternal distress (Lieberman & Van Horn, 2011). The three phases of CPP are:
- The Foundational Phase, which includes assessment and engagement;
- The Core Intervention; and
- Recapitulation and Termination, with a focus on sustaining gains (Lieberman & Van Horn, 2011).
The clinicians reflected that the adaptability of CPP to a telehealth format was variable depending upon the family and their stage in treatment. As one clinician put it: “I think commensurate with the model itself …it’s complicated.”
The initial phase of treatment in which the CPP clinician meets primarily with the caregiver was more easily adapted to telehealth. Nevertheless, the clinicians noted that it can be more challenging to be attuned to the caregivers’ reactions to discussing trauma via telehealth, and one clinician suggested more explicit invitations for caregivers to take breaks during emotionally intense conversations. Of concern, a clinician noted that there may be unexpected “pop up” visits from children who may overhear upsetting content. A deep, trusting caregiver-clinician bond is foundational to CPP, but relationship formation may be more challenging when treatment is initiated via telehealth.
Silver linings. Play interactions and other creative mechanisms for joining with the family can serve as an inroad for fostering a safe, collaborative, therapeutic space—even amid social distancing. This trusting relationship, in turn, lays the groundwork for rich play, exploration, and meaning-making of relational and emotional themes relevant to dyadic healing. Synchrony in play with a child provides a frame for discussing trauma; while this is more challenging via telehealth, clinicians shared strategies for facilitating a therapeutic atmosphere and responsive interactions virtually.
One clinician described attempting to play with a child who was racing toy cars; while she did not have a car, she used a staple remover and “he was so gracious in inviting my ‘automobile’ in, and I kind of matched it on the screen with where the track was and at least I got to be a part of the race.” While navigating CPP processes through a screen can be challenging, clinicians who are holding the virtual space may also bear witness to “really beautiful spontaneous gorgeous interactions.”
As families completed the Foundational Phase, some clinicians opted to fully employ the technological platform to co-create the trauma narrative with the caregiver and subsequently co-deliver it to the child. One clinician described her efforts to support a caregiver in creating a narrative using a slideshow format to cohesively explain the traumatic event that prompted treatment, including digital content such as family pictures and music to further individualize it.
Barriers and adaptations. Early in treatment, creating a clinical space where confidential information could be shared between the caregiver and clinician can be challenging, especially in small homes and apartments. The clinicians observed that there was “so much to juggle” that they felt depleted of energy after the session and wondered if “the family was picking up on my own anxiety.” Dyadic sessions were logistically difficult because the caregiver is trying to both communicate that they are paying attention to the child and also look at the screen whenever the clinician speaks.
One clinician was piloting a hybrid approach using a bug-in-the-ear device (like in PCIT) to talk to caregivers who would then be the conduit to the child. Young children’s participation was also noted to be mixed once the novelty of telehealth abated. As an adaptation, one clinician described abbreviating playtime with children because their attention spans were observed to be shorter for interactions on a screen versus in person. In terms of building a relationship with very young children, “that felt experience, it isn’t there… are you even really a person if you are just on the screen?”
In terms of appropriate CPP toys (e.g., dolls to represent family members, emergency vehicles), clinicians explored the use of paper dolls as more accessible and inexpensive while still salient enough to depict interpersonal themes. In the absence of therapeutically relevant toys on the family’s end, clinicians were able to use their own toys as visuals to help ground children’s understanding of the narrative.
CPP is a treatment for trauma and as such requires a feeling of safety; several clinicians shared about working with families to create a fort or set up a tent in which to engage in therapy. One clinician posited that this may “promote this sense of empowerment and self-efficacy for the parent to create a safe cocoon for their child and having that be a co-created process.”
Dyadic Treatment via Telehealth: Common Themes Across PCIT and CPP
Despite being very different in their theoretical orientation and specific activities, clinicians noted some common challenges to adapting PCIT and CPP for children under six to a telehealth modality. First, they highlighted the impact of being in the families’ homes as opposed to the therapy room. While the therapy room and toys have specific associations with the work of treatment, the family living room, for example, has many other uses and does not prime the child or caregiver for therapy. Similarly, the device used for video conferencing is often used for other activities such as communicating with friends and playing games, and one clinician observed “sometimes it’s so informal to be able to access [therapy] virtually that it’s not necessarily safeguarded in the same way.” Establishing a therapeutic frame can be especially challenging with young children: “I know the clinician has worked with mom on how to bring him into the session and how to prepare him for it, but still, he’s three.” Further, interruptions from other children and family members are common and can distract from the therapeutic work, such as when siblings join the session or family members enter the room and turn on the television. At the same time, blending therapeutic work into the home setting can present new opportunities – such as observing dyadic behavior in the home setting and in vivo coaching – that can promote the generalization of therapeutic skills. Some families accessed therapy more often and made more rapid progress because the barrier of transportation was removed. While relationship-building can be challenging via telehealth, when done well the increased vulnerability of being in the family’s home can also speed up rapport building in some cases.
In addition, both CPP and PCIT require specific types of toys that families may not own. The clinicians shared their efforts to purchase, package, and distribute toys, noting that a one-size-fits-all approach was not realistic given the different treatments, developmental stages, and toys already in the home. It was also challenging to ask families to keep the toys reserved for therapy rather than available throughout the week so they would serve as a cue for therapeutic work.
Logistically, the clinicians recommended a test run with each family to ensure that there were no technological concerns, describing detailed test calls in which the clinician and the family would test their audio and video capacity in different locations of their homes, from different angles, and on different devices. While connectivity issues may happen regardless, this preparation reduced some frustrations and aligned parents and clinicians in a shared effort of preparing for a new form of communication. Of note, some families were unable to continue with their treatment due to limited connectivity, devices, and/or digital literacy.
Conclusions
During the COVID-19 pandemic, families living in low-income communities of color have been particularly hard hit by the negative economic, health, and mental health impacts of the virus. Some of these families were already engaged with mental health clinicians to address emotional and behavioral concerns that they had about their young child. Others reached out to these professionals to get help as the lock-down continued. Clinicians who had been providing Child-Parent Psychotherapy (CPP) and Parent-Child Interaction Therapy (PCIT) in an east-coast city shared the benefits, challenges, and adaptations to providing these treatments via telehealth.
Overall, benefits to the telehealth format included: the generalization of skills to the child and family’s natural environment; reduced barriers of transportation to sessions; and innovative use of materials, places, and self to boost child regulation and caregiver self-efficacy. Challenges included: lack of therapeutic toys and designated space at home; disruptions and distractions; and maintaining data collection.
Of central importance across both evidence-based practices were clinician flexibility and adaptability. Their roles expanded to include technical support and toy distribution, and sessions often changed in frequency, length, participants, and content. There was marked variability in family and clinician experiences with telehealth based on myriad factors including the families’ stage in treatment before the pandemic, type of treatment, clinician training, etc.
While we were not able to say which variables were most salient in predicting a successful outcome, due to the open-ended data collection method used to synthesize the clinicians’ experiences, future research in a larger sample should document these patterns. For example, did child age predict the success of telehealth? Nature of presenting problems? The number of caregivers involved or the number of other children in the home? Whether or not the family was directly impacted by COVID-19, either economically or physically?
The key theme in clinician observations seemed to be their creative solutions and genuine commitment to dyadic treatment under unanticipated and complex circumstances. The central story that emerged for both evidence-based practices was the importance of meeting families where they are, being flexible, and building upon strengths. Even as the world recovers from the COVID-19 pandemic, these clinical silver linings may inform and expand treatment modalities for families who have trouble engaging in office-based treatment for reasons unrelated to the pandemic, such as lack of local providers, transportation challenges, or health/mobility concerns.
References
Center for Translational Neuroscience (2020a, June 24). Flattening the Other Curve: Trends for Young Children’s Mental Health Are Good for Some but Concerning For Others. Medium. https://medium.com/rapid-ec-project/flattening-the-other-curve-7be1e574b340
Center for Translational Neuroscience (2020b, June 30). Flattening the Other Curve, Part 2: Trends for Parental Well-Being Are Improving Overall, but Not for Everyone. Medium. https://medium.com/rapid-ec-project/flattening-the-other-curve-part-2-5661a2d36a82
Comer, J. S., Furr, J. M., Miguel, E. M., Cooper-Vince, C. E., Carpenter, A. L., Elkins, R. M., … & DeSerisy, M. (2017). Remotely delivering real-time parent training to the home: An initial randomized trial of Internet-delivered parent–child interaction therapy (I-PCIT). Journal of Consulting and Clinical Psychology, 85(9), 909.
Cluver, L., Lachman, J. M., Sherr, L., Wessels, I., Krug, E., Rakotomalala, S., . . . McDonald, K. (2020). Parenting in a time of COVID-19. The Lancet, 395, e64. https://doi.org/10.1016/S0140-6736(20)30736-4
Lieberman, A. F., & Van Horn, P. (2011). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York, NY: Guilford Press.
McNeil, C. B., & Hembree-Kigin, T. L. (2010). Parent-child interaction therapy. Springer Science & Business Media.
Acknowledgements
This article, and the clinical services it describes, were supported by the District of Columbia Social Emotional and Early Development Project (DC SEED), grant number 6H79SM063426 from the Substance Abuse and Mental Health Services Administration (SAMHSA). DC SEED is a 4-year SAMHSA awarded grant to the DC Department of Behavioral Health to support the expansion and strengthening of mental health services for children ages 0-6 and their families. The views and opinions expressed are those of the authors and do not necessarily reflect those of SAMHSA.
The authors would like to acknowledge the critical support and leadership of Meghan Sullivan, PsyD, in assisting with conceptualization and review of this article. In addition, we express our deepest gratitude to Gail Avent, JD, MBA, Total Family Care Coalition. Ms. Avent is a highly talented and valued Peer Specialist and leader, who played a critical role in mitigating ongoing stressors associated with COVID. Through virtual and in-person means, Ms. Avent checked in with families regularly as a touchpoint for social support and assessment of needs. In addition to offering concrete resources related to food insecurity, housing insecurity, and/or other instrumental needs, the work of Ms. Avent and her staff served as a reminder that families were not alone.
Authors
Davis, Annie E., PhD
Georgetown University Center for Child and Human Development
Saad, Georgette, LICSW
Mary’s Center for Maternal and Child Care, University of Maryland Baltimore
Williams, Dorinda, PhD, LICSW
Georgetown University Center for Child and Human Development
Wortham, Whitney, LGSW, MPH
Community Connections
Perry, Deborah F., PhD
Georgetown University Center for Child and Human Development
Aron, Emily, MD
Georgetown University, Department of Psychiatry
Neff, Audrey, LICSW
MedStar Georgetown University Hospital
Biel, Matthew G., MD, MSc
Georgetown University Medical Center, USA
