by Mary Romm, Licensed Professional Counselor in Gloucester, VA

The Scoop on Parent-Child Interaction Therapy

Are these some of the thoughts inside your head?

“My child is out of control.”

“I don’t enjoy spending time with my kid anymore.”

“My kid hits/bites/kicks me.” 

“Another daycare kicked my child out today.”

Are you ready for help? 

Who PCIT Can Help

As a therapist, I’ve utilized Parent-Child Interaction Therapy (PCIT) to help children ages 2-7 who have extreme behavioral challenges and seen them learn to listen and behave. I’ve used PCIT in my work with kids who had to wear a monitoring bracelet because they ran away so much, broke mirrors in a rage, and used the shards to carve up furniture, or parents were ready to commit them. Those same kids then listened to their parents, no longer engaged in extreme attention-seeking behaviors, and were able to calm down when they were upset and even talk about their feelings. I’ve seen it work with less intense cases, too, but those aren’t as fun to write about. PCIT works. 

PCIT can treat most concerns related to children’s behavior. This includes ADHD, anxiety disorder, autism spectrum disorder, oppositional defiant disorder (ODD), selective mutism, trauma-exposed children, and more.

So What Is PCIT?

Parent-Child Interaction Therapy is an evidence-based approach that has 50 years of research behind it. Research shows it keeps children out of therapy for up to seven years, when they hit adolescence and their brain begins to rewire. Lots of the skills you will learn in PCIT will always be relevant — many of them are as good with 6-year-old kids as they are with teens or even adults. PCIT is not a therapy where another adult takes your child and works with them for an hour before bringing them back to you, and you don’t know what they did in that hour. As a therapist, I love working with this age range because I know early intervention is key. (Also, angry 5-year-olds throwing chairs aren’t nearly as scary as angry 14- or 15-year-olds.)

How Does PCIT Work?

There are two phases to PCIT. The first phase is called Child-Directed Interaction, or CDI. I like to picture CDI as laying the stable foundation of a house. CDI teaches you the skills that play therapists use. It helps you begin to enjoy playing with your child again and learn how to manage their behavior with positive attention alone. In this first phase, you’ll already see a huge reduction in behavior issues due to the child receiving quality, purposeful time with the adult and the adult learning many new tactics to manage that child’s behavior without yelling or accidentally reinforcing the behavior. This is foundational work.

The second phase is called Parent-Directed Interaction, or PDI. PDI is where you get specific discipline skills to help you control your child’s behavior. Now that the relationship foundation is completely stable and your skills are memorized, we can move into learning how to consistently and effectively discipline your child.

Throughout PCIT, you’ll track the reduction in your child’s problematic behavior on a form called an Eyberg Child Behavior Inventory, or ECBI. As a parent, you get to rate your child’s behaviors and see how those behaviors change as treatment goes on.

Is PCIT Forever?

Great news! You will graduate from PCIT in as little as 3-6 months if you do the homework and work hard in sessions. PCIT is not a vague therapy where things end when it feels right; there are specific guidelines and instructions on how to graduate from therapy, all of which are parent-driven. 

How Does PCIT Compare to Other Therapies?

Ideally, because PCIT builds that strong foundation in the Child-Directed Interaction phase, it should be done before any other therapy, even before trauma therapy. Trauma therapy does include several PCIT elements; thus, it is done after PCIT. PCIT should especially be done before talk therapy, as PCIT has the research base behind it. Once kids feel safe and secure in their relationship with their parents, and once parents know how to consistently handle their child’s behaviors, then other therapies can be attempted. However, they usually are not needed at that point. 

Is PCIT Covered by Insurance?

Yes, as long as your insurance has mental health care coverage and your therapist accepts insurance or is able to be an out-of-network provider, PCIT should be covered.

 To learn more about PCIT, please visit this PCIT info page and PCIT International’s page for parents.

 If you live in Virginia and want to start online PCIT for your child, please visit check out Mary’s practice, Willow Tree Healing Center.  You can find more therapists who use PCIT by searching for therapists in your area and filtering your results by Type of Therapy > Parent-Child Interaction Therapy. 

Separation anxiety is one of the most common challenges parents face. It can make leaving a child with a caregiver or at daycare difficult and can undermine quality of life for both the parent and child. Separation anxiety is also completely normal, especially in very young children.

Children naturally long to be close to their caregivers, and separations compromise that closeness. Managing separation anxiety requires parents to balance the child’s need to be close to them with the expectation that children will become progressively more independent as they get older.

In some children, separation anxiety persists well beyond the toddler and preschool years, affecting their ability to comfortably attend school or spend time with friends. This type of severe separation anxiety affects 4% of children and 1.6% of teenagers.

Separation anxiety usually begins when a child is 6 or 7 months old, then peaks in the toddler and preschool years.

Separation Anxiety in Children: Symptoms and What’s Normal

Separation anxiety usually begins when a child is 6 or 7 months old, then peaks in the toddler and preschool years. Older children may have occasional bouts of separation anxiety, especially in new situations such as before going to sleepaway camp.

Babies and young children may have symptoms such as:

• Not wanting to sleep alone
• Crying when a caregiver leaves
• Throwing tantrums to prevent a caregiver from leaving
• Being anxious about serparations
• Clinging to a parent before serparations

Older children may have additional symptoms, including:

• Lying and other behaviors to avoid going to school
• Changes in behavior as a separation approaches
• Excessive worry about a parent or other loved one

When Separation Anxiety Is Extreme: What Is Separation Anxiety Disorder?

When separation anxiety is severe and chronic, or when it interferes with daily life, it may be considered a mental health diagnosis.

Researchers do not know what causes separation anxiety disorder. Like other mental health conditions, it is likely a combination of social, biological, and psychological factors. Children with a history of trauma or abuse may be more vulnerable. Symptoms usually appear in elementary school, between third and fifth grades. They include:

• Being terrified to sleep alone
• Excessive, chronic worry about the safety of a parent
• Refusing to go to school or crying each day before school
• Nightmares about separation
• Physical complaints such as muscle pain and stomach aches
• Not wanting to be alone
• Chronic worry about getting lost
• Unusual safety concerns
• Being clingy in a way that is not age typical, such as when a 10-year-old wants to be with their parents and not their friends
• Not wanting to do fun things or spend time with friends if it means being away from home

How to Deal with Separation Anxiety

Separation anxiety is no one’s fault. It is not a sign that a child is spoiled or manipulative. The distress children feel is very real, though as children get older, they learn that vocal expressions of distress may stop their parents from leaving. When dealing with separation anxiety, parents should not:

• Punish children.
• Lie about separations. Sneaking out of the house after promising not to leave can erode trust.
• Say things that might trigger anxiety. If a child is showing no signs of separation anxiety, don’t reassure them or tell them how brave they are to go off on their own.
• Make goodbyes last too long. It’s natural to want to comfort a crying child, but long goodbyes and long buildups to inevitable departures may actually prolong a child’s suffering.
• Panic or look distressed. Parents love their children and do not want to see them sad. But when parents express sadness or fear about separations, this can make the child think there is real danger.
• Reward children for separations. Rewards and punishments are controversial for many reasons. Even experts who support them agree that they work best for behaviors children choose—such as cleaning up a bedroom or doing homework. Separation anxiety is an emotional reaction, not a behavioral choice.

Choosing the right care provider is also critical for reducing separation anxiety. Daycare providers, nannies, and babysitters who are sensitive to the child’s needs can help. Talk to care providers about the importance of comforting and distracting the child—not ignoring them while they cry or punishing them for becoming anxious.

Some research suggests that forming a close attachment to a loving, accessible secondary care provider can ease separation anxiety. This means that daycares that provide the same carer each day, nannies, and consistent babysitters may be better options than an ever-shifting roster of childcare providers.

Some other strategies parents can adopt to ease separations include:

• Develop a comfortable (but short) ritual for separations. Some children like to have a special blanket, sing a song, or get a set number of kisses.
• Talk to children about why they are anxious. Young children may have trouble articulating their fears, but older children can often explain them. You may find that the problem is not separation, but something else, like a mean teacher or bully at school.
• Explain departures in language children can understand. For example, you might tell a toddler that you will see them after their nap, at dinner, or in “three sleeps.”
• Be honest and keep promises. Don’t say you won’t leave, that you will only leave when the child gives permission, or that you will be back in just a minute if these things aren’t true.
• Practice separations in low-stress contexts. Try dropping a child off at grandpa’s house for an hour or inviting a beloved uncle or aunt to take them on an outing. This gets the child used to separations and can help with preparing for the transition to school.
• Don’t spend lots of time talking about the separation before it happens. This can build anxiety.
• When your departure draws near, talk about the fun things your child can do while you are gone.
• Be loving and affectionate, not distracted or frustrated, during departures.
• Develop a plan with caregivers for supporting a child with separation anxiety. Each care provider should have several strategies they can try to help calm a child who is anxious or upset. Care providers should never ignore or punish a crying child.

Separation anxiety can be difficult for both parents and children. Parents may feel stress at each separation or adjust their entire lives to reduce separations when a child has intense anxiety. This can affect an entire family, and even undermine careers. A therapist can help families manage separation anxiety in a way that minimizes trauma and honors the needs of every family member. GoodTherapy can help you find a therapist.

References:

1. Bowlby, R. (2007). Babies and toddlers in non-parental daycare can avoid stress and anxiety if they develop a lasting secondary attachment bond with one carer who is consistently accessible to them. Attachment & Human Development, 9(4), 307-319. doi: 10.1080/14616730701711516
2. Ehmke, R. (n.d.). What is separation anxiety?. Retrieved from https://childmind.org/article/what-is-separation-anxiety
3. Krecklow, L. L. (2018, August 28). Separation anxiety: Dos and don’ts to help your child (and you) be brave. Retrieved from https://gozen.com/separation-anxiety-dos-and-donts-to-help-your-child-and-you-be-brave
4. Separation anxiety disorder in children. (n.d.). Stanford Children’s Health. Retrieved from https://www.stanfordchildrens.org/en/topic/default?id=separation-anxiety-disorder-90-P02582
5. Swanson, W. S. (2015, November 21). How to ease your child’s separation anxiety. Retrieved from https://www.healthychildren.org/English/ages-stages/toddler/Pages/Soothing-Your-Childs-Separation-Anxiety.aspx

Social anxiety causes feelings of panic or fear during interactions with people. It can occur only in certain situations or nearly all of the time. For adults, it often means avoiding other people, groups, or large crowds. But social anxiety can show up much earlier in life. In infants and toddlers, social anxiety will look much different that it does in adults.

Where Does Social Anxiety Come From?

It can be hard to pinpoint what causes social anxiety in infants and young children. One study found infants could learn socially anxious behavior from their mothers. A mother with social anxiety may display those behaviors to a child through interactions with strangers. The study indicated these nonverbal cues could teach the child that strangers are a source of anxiety.

Genetics also affect whether a child will have social anxiety. Genes help determine an infant’s disposition, or personality. Research shows certain genetic traits can increase risk for anxiety and situational phobias. Some of these traits may include inhibition and fear of being judged. Fear in low-threat situations could also help predict social anxiety.

Home life and environment can exacerbate risk factors. Trauma could trigger social anxiety at a young age. Addressing these issues with children early may pave the way for good mental health in the future. In addition, the severity of a child’s social anxiety can vary. Some children grow out of it as they develop, while others internalize the anxiety when they are older. [fat_widget_right]

Signs of Social Anxiety in Infants and Toddlers

Social anxiety may look similar to shyness, separation anxiety, or autism. There is no set age when symptoms start to appear. It is common to notice social anxiety in preschool or other social settings. However, parents may notice signs that could predict social anxiety in children from the time they are newborns.

Signs of social anxiety in infants may include:

• Fear of or disinterest in new things
• Difficulty calming down
• Strong reactions to small changes
• Being upset by new noises or people
• Seeming overly sensitive to mild discomfort

These behaviors can be stressful for parents. Infants cannot communicate clearly what is causing them distress. Parents may worry their child is in pain or that they have done something wrong.

As infants grow into toddlers, their social anxiety may appear in other ways. It may be easier to understand what is causing a toddler stress. But knowing how to deal with a socially anxious toddler can still be challenging.

Signs of social anxiety in toddlers may include:

• Fears and phobias
• Refusal to give up routines
• Noise or tactile sensitivity
• Dislike for getting dirty
• Lengthy rituals
• Picky eating
• Following parents constantly
• Shyness or distrust of strangers
• Sleep problems

Parents of a socially anxious toddler may worry they are raising a “difficult” child. This causes some parents to punish their child for anxious behavior. Punishing a child for signs of social anxiety can have the opposite effect of what is intended. Toddlers who are punished for anxiety-rooted behavior may “close off” from parents. One study showed that harsh parenting may cause an already fearful toddler to become even more anxious. It also led to lowered neural processing ability in preschool.

A therapist can help address behavior issues that stem from social anxiety. They can show parents how to work with the behavior constructively.

How Are Separation Anxiety and Social Anxiety Related?

Reading books or watching movies that depict confident young children can give watching toddlers a hero to mimic.

Separation anxiety can be normal in young children. They may cry or become worried when a parent drops them off or leaves the room. But separation anxiety may be soothed in the short term. Some parents use entertaining distractions to help kids settle into social situations.

But for toddlers with social anxiety, distractions may not improve the situation. Social anxiety can cause children to worry about being around others as well as separation from parents.

Social anxiety can stem from separation anxiety, or both may occur together. Toddlers with social anxiety may seem afraid to participate in group activities or play with peers. If they also have separation anxiety, it may be difficult to calm them after a parent leaves. This can make preschool or daycare a stressful event.

Tips for Parents of Socially Anxious Infants and Toddlers

If an infant shows signs of social anxiety, it can help to model calm, self-soothing behavior. Modeling healthy reactions in social settings can help teach young children these behaviors. In addition, giving toddlers a chance to practice before new situations may help them feel more confident. For example, a parent might invite them to practice show-and-tell before the big day. Reading books or watching movies that depict confident young children can give watching toddlers a hero to mimic.

Instead of feeding into fearful behaviors, it can be more helpful when parents give enthusiastic praise when toddlers try something new. Explaining a child’s anxiety to any caregivers, teachers, and other parents will help them understand their behavior. This can help inform how they act around the child. Caregivers can help by fostering positive interactions. This can reinforce the idea that others do not have to be a source of anxiety.

Medication and Socially Anxious Infants and Toddlers

It is considered best practice to not give medication to children under the age of 5, except in extreme cases. Social anxiety does not typically warrant medication at this age. Young children are sensitive to the effects of medication. Medicating too early may cause unwanted side effects. If the anxiety persists when the child is older, consult a professional about the next step for treatment.

How Therapy Can Help Infants and Toddlers with Social Anxiety

It may be too soon to tell if an infant or toddler has social anxiety. A therapist can help parents or caregivers address behaviors that indicate a child’s discomfort in social settings. Some therapists specialize in mental health issues in young children. They may give an assessment that more clearly reveals where the child is struggling.

Seeing a family therapist together can be helpful for parents. It can give them guidance for any difficulties they have in helping their child. Seeing parents talk calmly with a therapist can help children with social anxiety understand the social setting is safe for them. A therapist may also be able to identify root causes of a child’s social anxiety.

Children grow and change over time. Understanding that it is always okay to ask for help is a lesson they are likely to take with them through the rest of their life.

References:

1. A guide for community child serving agencies on psychotropic medications for children and adolescents. (2012). American Academy of Child & Adolescent Psychiatry. Retrived from https://www.aacap.org/App_Themes/AACAP/docs/press/guide_for_community_child_serving_agencies_on_psychotropic_medications_for_children_and_adolescents_2012.pdf
2. Brooker, R. J., & Buss, K. A. (2014). Harsh parenting and fearfulness in toddlerhood interact to predict amplitudes of preschool error-related negativity. Developmental Cognitive Neuroscience, 9, 148-159. doi: 10.1016/j.dcn.2014.03.001
3. Buss, K. A. (2011). Which fearful toddlers should we worry about? Context, fear regulation, and anxiety risk. Developmental Pscyhololgy, 3(47), 804-819. Doi: https://doi.org/10.1037/a0023227
4. Cuncic, A. (2018, February 16). How to cope as a parent of a preschooler with social anxiety. Retrieved from https://www.verywellmind.com/preschool-child-with-social-anxiety-3024286
5. de Rosnay, M., Cooper, P. J., Tsigaras, N., & Murray, L., (2006). Transmission of social anxiety from mother to infant: An experimental study using a social referencing paradigm. Behaviour Research and Therapy, 8(44), 1165-1175. Doi: https://doi.org/10.1016/j.brat.2005.09.003
6. Kendler, K. S., Prescott, C. A., & Meyers, J. (2003, January 9). The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Arch Gen Psychiatry, 9(60), 929-931. doi: 10.1001/archpsyc.60.9.929
7. Rogers, C. E., Sylvester, C. M., Mintz, C., Kenley, J. K., Shimony, J. S., Barch, D. M., & Smyser, C. D. (2017). Journal of the American Academy of Child & Adolescent Psychiatry, 2(56), 157-166. doi: https://doi.org/10.1016/j.jaac.2016.11.005
8. Schwartz, C. E., Wright, C. I., Shin, L. M., Kagan, J., & Rauch, S. L. (2003, June 20). Inhibited and uninhibited infants “grown up”: Adult amygdalar response to novelty. Science, 5627(300), 1952-1953. doi: https://doi.org/10.1126/science.1083703
9. Social anxiety: Risk factors. (n.d.). Retrieved from https://childmind.org/guide/social-anxiety-disorder/social-anxiety-disorder-risk-factors
10. Versfeld, P. (n.d.). The highly sensitive child and behavioral inhibition. Retrieved from https://skillsforaction.com/highly-sensitive-child