The practical side of working with parent–child interaction therapy with preschool children with language impairments

Abstract

A common early intervention approach for preschool children with language problems is parent–child interaction therapy (PCIT). PCIT has positive effects for children with expressive language problems. It appears that speech and language therapists (SLTs) conduct this therapy in many different ways. This might be because of the variety of approaches available, the diverse set of families SLTs work with or the different organizational structures. Understanding the critical components of PCIT would enable SLTs to map the variations that are implemented and researchers to evaluate the effects of such variation. This study aimed to identify the potentially critical components of PCIT based on the practical experience of SLTs and to identify SLTs’ rationales for the way they structure PCIT. Both parameters are important for the long term goal, that is, to develop a framework that can be used to support practice. Semi-structured interviews were conducted with 10 SLTs who had at least one year experience in delivering PCIT with preschool children with language impairment. The interviews were transcribed and analysed, using thematic analysis. Analysis of the SLT interview data identified four potentially critical components that underpin the teaching of strategies to parents: parents’ engagement, parents’ understanding, parents’ reflection and therapists’ skills. SLTs suggested that all four components are needed for the successful delivery of PCIT. The reasons that SLTs give for the way in which they structure PCIT are mainly based on organizational constraints, family needs and practicalities. SLTs consider PCIT to be valuable but challenging to implement. A framework that makes explicit these components may be beneficial to support practice.

Keywords

engagement language impairment parent–child interaction therapy preschool children therapy

I Introduction

Children with language impairments (LI) are at risk of behavioural problems, of emotional and psychosocial difficulties, and poorer employment prospects (Bercow, 2008). Bercow (2008) concluded that early identification and intervention were crucial to increase the chance of tackling these problems. A common early intervention approach for preschool children with LI is parent–child interaction therapy (PCIT). Indeed, in the United Kingdom, children with language impairments are often offered PCIT as the first intervention of choice (Falkus et al., 2016; Roulstone, 2015).

This study focuses on interventions for children with LI, in the absence of other developmental or congenital impairments. The term PCIT is used in this article for all interventions delivered by speech and language therapists (SLTs) aimed at teaching parents to modify their interaction styles and enhance their language input. PCIT is a triadic intervention model (Roberts and Kaiser, 2011): (1) the SLT teaches the parent to use specific language strategies, (2) the parent uses the strategies when communicating with the child, and (3) the strategies are used in order to improve the child’s language level. According to systematic reviews, PCIT has positive effects for children with expressive language problems, although there is insufficient evidence regarding the effects for children with receptive language problems (Law et al., 2003; Roberts and Kaiser, 2011). For example, Law et al. (2003) concluded that studies which had contrasted the outcomes of intervention delivered by clinicians with that delivered by trained parents and found no differences, although they concluded that the level of variation found in studies with parent-administered interventions suggested that some parents are more suited to parent-implemented treatments than others. Roberts and Kaiser (2011) concluded that evidence supported parent-implemented interventions that involved younger children and parents from middle class backgrounds. A recent clinical evaluation suggests that PCIT can be effectively delivered in practice (Falkus et al., 2016).

However, there are a number of challenges for SLTs in deciding on how specifically to deliver PCIT in their own clinical practice, not least the number of different approaches that are reported in the literature. For example, Roberts and Kaiser (2011) reviewed 18 articles concerning a total of nine different PCIT approaches. These interventions differ in various dimensions; for instance, group versus one-to-one therapy, home versus clinical sessions, and therapy frequency. As an example, It takes two to talk (ITTTT; Manolson, 1992) uses a group approach of eight clinical sessions combined with three individual home sessions and uses video feedback. Heidelberg parent-based language intervention (Buschmann et al., 2009) contains eight clinical group sessions in total and uses picture books and no video feedback. Gibbard’s approach (1994, now known as ‘Little talkers’) focused on the setting of objectives with parents themselves generating methods of achieving the objectives. The PCIT approach examined by Falkus et al. (2016) consists of four individual clinical sessions and uses video feedback so that parents can examine their interactions with their child. In their conclusions, Roberts and Kaiser (2011) suggest that there are two critical components of parent implemented therapies: the methods of parent training that are used and how far parents take up the strategies that have been taught. However, they also note that studies contain little information about these two components and thus they were unable to comment further on the particular contribution they make to children’s outcomes. So, as Roberts and Kaiser (2011) conclude, it is therefore not possible as yet to conclude which components of PCIT interventions are critical to maximum effectiveness.

A further challenge is that the majority of studies to date have included mainly middle class western children who spoke English as their first language (Falkus et al., 2016; Law et al., 2003; Roberts and Kaiser, 2011). These authors all acknowledge that focusing on such a specific group prevents straightforward generalization of the results to other cultural and social backgrounds and to children who learn English as an additional language (EAL) (Falkus et al., 2016; Law et al., 2003; Roberts and Kaiser, 2011). Falkus et al. (2016) mentioned that more than half of the children referred to the SLT service during their research had EAL, and they were excluded from their study. Thus a gap between research and practice is present.

In such a clinical context, guided by the principles of evidence based practice (EBP), SLTs are expected to identify the best available evidence and then apply it ‘judiciously’ (Sackett et al., 1996). Not only are they expected to appropriately apply interventions that have some proven efficacy, they are also expected to take the needs of the patient and the local policies into account (Rycroft-Malone et al., 2004). This would include the culture and social background of the family (van Kleeck, 1994) as well as the impairment of the child (Law et al., 2003).

In conclusion, SLTs have a number of approaches to choose from and have to make adaptations in order to suit different families and organizations. It is therefore not surprising that there is a variation in the way in which SLTs conduct their therapy (Roulstone, 2012). Adaptations of interventions and variation in current practice between SLTs are a logical consequence. However, research that has investigated applications of PCIT in clinical or community contexts has not so far established its unequivocal effectiveness. So, for example, Falkus et al. (2016) excluded children with EAL. A study of a shortened adaptation of the Hanen approach used within a community sample found no benefit (Wake et al., 2011). Thus it is not clear whether adaptations made for children from more diverse backgrounds, or for other individual needs and local policies reduces the effectiveness of PCIT approaches.

In order to manage these adaptations and to understand the effectiveness of PCIT, it would be helpful to identify the components of PCIT. Then variations that are made by SLTs to suit the local context of child and family can be made explicit and evaluated. In this way, it may be possible to identify whether there are components that are critical to success for all children, specific to particular groups or individuals, or optional components that can be varied to reflect the preferences of families. Anderson and van der Gaag (2005) suggested that a common framework should integrate both theory and practice. The practical view is important in order to narrow the gap between theory and practice.

This study focuses on the practical side of a framework for PCIT by collecting qualitative data from SLTs working with PCIT. Information was gathered from SLTs about their views and experience in working with PCIT, which components they see as being critical and how they deal with the issues related to individualization and local policies. This study aims to identify the potentially critical components in PCIT and to explore the rationales SLTs give for the way they structure PCIT. The research questions posed were:

What factors contribute to the successful or unsuccessful delivery of PCIT according to speech and language therapists?

What rationales do therapists give for the way they structure PCIT?

II Method

1 Overall design

This study adopted a qualitative design based on individual interviews with SLTs. One of the purposes of qualitative research is to describe and understand what is going on in the field (Boeije, 2010). In this study a qualitative design is chosen since this study aims to describe how SLTs deliver PCIT and to describe and understand the reasons SLTs give for the way they structure PCIT. Individual interviews were used in order to explore SLTs’ personal experiences, ideas and opinions; these were semi-structured in order to maintain a focus on the therapy approach in question and yet allow for participants’ experiences and opinions to shape the progress of the interview.

2 Participants

The study was opened to SLTs working with PCIT with children with LI in the south of England, both independent SLTs and those working for the National Health Services (NHS). Invitations to participate were placed in social media, including professional networks and the Facebook and Twitter feeds of the research unit undertaking the study. Additionally two SLT NHS teams who had participated in an earlier research programme (Roulstone, 2015) were approached via their manager. SLTs were eligible if they had at least one year of working experience in delivering PCIT in preschool children with LI. SLTs who expressed an interest were selected for participation via purposive sampling to obtain a range in the following characteristics: work experience, work location, PCIT approach, and the training received in PCIT (Table 1). Diversity in participant characteristics aims to tap into all the possible views and to find the widest range of responses. For this study, the aim was to establish a sample size of eight to 12 SLTs, based on considerations regarding feasibility and information saturation. During the selection process three SLTs were excluded. One was excluded since she worked primarily with children with autism spectrum disorder, and two were excluded in order to keep variety in the interventions delivered by the participating SLTs. In total, 10 SLTs were interviewed. Of these, one worked independently, eight were employed by NHS Trusts and one worked both independently and for an NHS trust. No new themes were identified during interviews nine and 10 and thus no further interviews were deemed to be required.

Table 1.

Characteristics of the participants.

Pseudonym	Age (years)	Experience in PCIT (years)	Followed PCIT training	Delivered intervention	Work setting	Group/individual
Doris	36–40	11–15	Hanen ITTTT	Own developed PCI	Community clinic	Group
Elisabeth	21–25	1–5	VPCI Camden and Islington	VPCI Camden and Islington	Health Centre	Individual
Emma	36–40	6–10	VPCI Camden and Islington	Buddies	Health Centre	Group
Isabelle	31–35	1–5	Hanen ITTTT	VPCI Camden and Islington	Health Centre	Individual
Jane	41–45	16–20	VERVE	VERVE	Community clinic	Individual
Kelly	41–45	6–10	VPCI Camden and Islington	VPCI Camden and Islington	Community clinic and independent clinic	Individual
Mary	46–50	11–15	Hanen ITTTT VPCI Camden and Islington	VPCI Camden and Islington	Community clinic	Individual
Norah	50–55	16–20	Hanen ITTTT	Own developed PCI	Independent clinic	Individual
Rosy	36–40	6–10	–	‘Little talkers’	Health Centre	Group
Sophie	31–35	6–10	Hanen ITTTT	Own developed PCIT	Children Centre	Group and/or individual

Notes. ITTTT = It takes two to talk (Manolson, 1992); ‘Little talkers’: see Gibbard, 1994; PCIT = parent–child interaction therapy; VERVE = video endorse respect vitalize eye contact; VPCI = video parent–child interaction.

To preserve participants’ anonymity, pseudonyms are used and participants’ age and experience are provided within ranges. Seven SLTs were older than 35 years; nine had received PCIT training and five were trained to use Hanen’s ITTTT (Manolson, 1992). The SLTs were delivering seven different PCIT approaches. None of them were delivering the original ITTTT.

3 Procedure

A topic guide (Appendix 1) was developed from familiarization with PCIT approaches as described in manuals of PCIT interventions, such as the manual of ITTTT (Manolson, 1992) and Heidelberg parent-based language intervention (Buschmann et al., 2009). This provided a series of open ended questions and prompts allowing an exploration of the various elements of PCIT interventions. Additionally two questions asked participants to reflect on a particular incident (either positive or challenging) in the delivery of PCIT; these questions, based on critical incident technique, are particularly helpful in exploring what, in the participants’ opinion, makes the difference between success and failure (Flanagan, 1954). The interview was pilot tested with two therapists experienced in PCIT. Based on their feedback small changes were made in the order of questions. The interviews were conducted by the first author in community settings and lasted between 49 and 74 minutes (mean: 64 minutes). Participants were asked to describe the intervention they deliver and to explain each step they usually take. The interviews were transcribed and analysed qualitatively in order to identify the potentially critical components.

The study was approved by the host university Research Ethics Committee and by the NHS Research and Development (R&D) of the host site for the research. All participants gave written informed consent.

4 Analysis

The analysis of the interview data followed an iterative approach, in that data were reviewed and fed back into successive interviews. All interviews were audio recorded and field notes were taken. The recordings were transcribed verbatim and analysed thematically by the first author, first through familiarization with the data, the identification of codes and themes (Braun and Clarke, 2006).

NVivo qualitative data analysis software (QSR International Pty Ltd, 2010) was used for data management. At each step, the analysis was reviewed by the second author; any disagreements about the codes and themes were discussed and fed into the next stage of the analysis. Mind-maps based on the data were created to support the analytic process, as suggested by Braun and Clarke (2006).

III Results

The findings are presented in respect of the two research questions. For the first question, five themes were identified, and three themes were identified for the second question.

1 Themes identified concerning the critical components

The five themes identified from the interview data are: strategies used in PCIT, parents’ engagement, parents’ reflection, parents’ understanding and therapists’ skills. Teaching parents strategies to use with their child is seen as the core focus of this therapy. In order to teach parents these strategies successfully, data suggests that the other four themes are also necessary. From now, these four themes are called the potentially critical components. Appendix 2 provides mind-maps for each theme showing the codes that have contributed to the four potentially critical components.

a Strategies

There was general consensus between the SLTs about strategies used in practice. Table 2 provides descriptions of the strategies mentioned by SLTS. The process by which SLTs identified which strategies to work on with parents varied; some SLTs worked to a pre-specified agenda and others determined appropriate strategies from a video-based assessment and discussion with the parent(s). Some SLTs delivered PCIT individually and others offered groups; locations and the use of resources varied, including the use of video and the frequency and number of sessions. The factors governing these variations are described in the final section of the results (reasons for the structure of therapy).

Table 2.

Strategies used in parent–child interaction therapy (PCIT).

Strategy	Explanation of strategy
Getting down to the child’s level (physically) Face-to-face Making eye-contact	‘The parent has to be in the child’s communication space. So there is a certain area of communication where the child will actually feel the parent there. Whereas if they are a bit too far away they won’t feel them there, giving them their full undivided attention. So they have to be within their communication space, not over the other side of the room. The second one is that they have to be opposite, directly opposite of their child’s body. So that when the child looks up, the person right in front of them is their parent. So it has to be directly opposite. And the third thing is they have to be at their eye-level, or lower than their eye-level. So again, when the child looks up, it is easy for the child to bring their eyes to meet their parent’s eyes. So those three things I think are crucial, not just one, not just eye-level, not just in your space, and not just opposite. It has to be all three and then the positioning is right, it works really well.’ (Jane)
Following the child’s play Joining him or her with his or her play	‘I think joining them with their play, so having, you know, even when it is 2 minutes. Just think, forget about everything else, just sit down and join in, and just follow what they are doing. And I think for some parents that is a massive change, a big step.’ (Kelly)
Waiting for the child to talk Observe, wait, listen Allowing pauses Observing	‘I would say: ‘Right we are gonna sit down and you are gonna observe how your child is communicating.’ (Sophie)
Commenting Responding	‘I do remember talking to a mom about how much time she spent looking in the box. While her child was playing with the truck. And I said there: “Can you see that you were looking in the box, but he was playing with this and you were missing opportunities to say train, truck, push it”.’ (Mary)
Expanding Repetition Modelling	‘We talk about expanding, so I talk to parents about expanding in two different ways really. Modelling, different types of words. Because parents often just get quite stuck on modelling nouns. So we talk a little bit about nouns, verbs, adjectives, and why children need different vocabulary. And then spend a little bit of time talking about expanding by repeating back and just adding just one extra word onto what they are saying.’ (Emma)
Not asking test questions	‘I mean in terms of particular strategies I think the one that often makes the most difference is talking with the parents about the kind of questions they are using and reducing the number of test questions. And I think that parents often report at the end, that rather than asking them what things are they are now telling them.’ (Emma)
Giving the child choices	‘We always model choices during snack time.’ (Sophie)
Turn taking	‘And every child gets a turn then when each transition has changed to post the little card into a box, they loved that, so that is building in the turn taking and they will have to wait for their turn.’ (Sophie)

b Potentially critical components

Delivering the strategies sounds like a straightforward process. However, SLTs reported that, regardless of the specific approach used, delivering PCIT was challenging particularly in terms of attendance and engagement of parents.

I think we have to work really hard sometimes to get parents to engage with us as therapists. (Doris)

It is kind of the fact that, quite often, and I would say 50 percent of the time, it doesn’t work as well. (Elisabeth)

You can have groups where you the one week you might get eight people, the next week you might get three people. (Emma)

Therapists indicated that parents’ engagement, parents’ reflection, parents’ understanding and therapists’ skills are crucial for the successfulness of PCIT.

We have had parents who have understood what we do, we have got good relationships with them, understood why they were doing what they do, but lack the reflection. They almost trust their own knowledge and confidence, and that has been a major downfall, that meant that we had to work on the same things over and over again to embed it. So I don’t really know why, but sort of anecdotally you can see that they are crucial elements. (Sophie)

c Parents’ engagement

SLTs talked about parents’ engagement in terms of taking on board information from therapy and being willing to participate in therapy. Factors such as parents’ background, understanding of the therapy, reflection skills, feelings, therapists’ skills, parents’ expectations, parents’ influence in therapy and their child’s level of engagement in therapy were all seen as impacting upon the level of parents’ engagement. Parents’ background includes their culture, their home situation, their or their children’s health problems, and their language level in English.

I suppose there is not engaging at all, the ones that just don’t come. Then there are some who come, because they feel they should, because they want their child to talk. But don’t really want to do the therapy. And then some come: ‘I want to do the therapy.’ So I would say there might three levels of engagement. (Isabelle)

The geographical area that I work in has a really diverse set of families and different expectations, different cultural expectations. I think that is always a bit of a challenge using PCIT, because sometimes culturally, you know their interaction styles can be very different. And even like getting down on the floor for some families is just so different for them. They are very directive in their questioning and that is part of their culture. (Kelly)

They might have learning disabilities themselves, things like that really kind of impact obviously on the kind of engagement that you are going to get from a parent. (Rosy)

d Parents’ reflection

SLTs underlined the importance of parents’ reflection in PCIT. If parents can reflect on their own skills and can recognize that they are doing something different to what the strategy tells them to do, SLTs felt that there is a greater chance that they will change their interaction style.

When they are told it rather than recognizing it themselves then it is not so much of a strong learning. (Sophie)

SLTs regarded the level of parent reflection as being affected by the parents’ reflection skills, their feelings, the therapists’ skills, resources used, and their understanding of the strategies. All therapists highlighted the added value of using a video to promote reflection.

I think you have to have the theory, you have to know what you are working on and then you have to be able to unpick it yourself, don’t you. (Doris)

e Parents’ understanding

SLTs indicated that parents need to understand both the aim of the therapy and how the strategies contribute. SLTs suggested a link between parents’ understanding and parents’ engagement.

I think if we give them targets that they don’t really understand, or activities that they don’t really understand then they are not going to see the worth in it and they probably won’t do them. (Sophie)

The level of understanding is influenced by parents’ intelligence, by their language level in English, by therapists’ skills, by their engagement and by their reflection skills.

I think that it is quite hard for parents to take a strategy away and use it. In my experience there are parents who do use it and they come back and they say: ‘I have used it and it is been really effective’. But I think those parents are quite few and far between. I think it is more usual for parents to say: ‘I do it’. But actually not really fully understand whether they are using the strategy. (Doris)

f Therapists’ skills

SLTs viewed the therapists’ skills, particularly questioning skills, as crucial in PCIT to promote parents’ engagement, parents’ reflection and parents’ understanding. SLTs need to ask the right questions in order to get the valuable background information of parents and to promote reflection.

So I think those kind of questions fit quite nicely into being sort of coming across as a therapist that is supportive, trying to get the parents to realize that the things they are doing that is making the difference. (Emma)

Furthermore, SLTs suggested that they must have the skills to provide a safe, supportive and positive environment, and deal with parents’ feelings in a positive way. Also, they must have explanation skills in order to help parents understand the aim of the therapy and to understand the strategies. Not least important was SLTs’ ability to synthesize information into relevant and realistic goals. According to SLTs, unrealistic expectations negatively affect parents’ engagement.

Background information sometimes is useful for what they have already tried before, what has worked, what hasn’t worked. And also, if the child has got more sort of global difficulties, again it gives an insight into perhaps the steps of progress that you might expect. (Kelly)

2 Reasons given for the structure of therapy

For the second research question, three themes were identified in the interview data: organizational constraints, family needs and practicalities. SLTs reported making choices about the location, frequency, resources, (number of) strategies, assessments of children and/or their parents, introduction and review appointments and the setting of the therapy (group vs. individual). Data suggest that participating SLTs who were trained in Hanen’s ITTTT were enthusiastic about Hanen. However, they were not able to deliver the original intervention anymore due to organizational constraints and practicalities.

I have never run a full It Takes Two To Talk course for parents, because we don’t offer that here. We haven’t got the capacity. (Isabelle)

a Organizational constraints

Virtually all SLTs explained that the biggest factor affecting how they structure therapy is the care pathway prescribed by their organization.

Our core service is that we see children for four PCIT sessions. (Elisabeth)

This pathway often prescribes the location, the frequency and the setting, which can constrain SLTs as they choose their resources, the number of strategies, the time they have to assess the children and their parents, and the time to check parents’ fidelity to the approach. SLTs also described the time constraints they experience due to waiting lists.

We have pressure from NHS, just to be effective with our time and just to see patients quickly and to get through the caseloads. (Rosy)

b Families

Some SLTs work independently and are unconstrained by prescribed care pathways; they have the flexibility to individualize therapy, based on children’s language impairment and families’ background, preferences and practicalities.

It could be two sessions, it could be a year. It often depends on what is going on with the mom. (Norah)

We would love to use video with parents, because I know that Hanen likes to use video. But one, we haven’t really had the equipment to be able to do it, and two, we had a lot of resistance of families in terms of being videoed. (Sophie)

c Practicalities

The availability of resources or suitable accommodation is another reason affecting how SLTs structure therapy.

We had to change accommodation, so we didn’t have a separate room. So unfortunately we had to drop the individual videoing part of it. (Emma)

Summing up, SLTs suggested that delivering PCIT is not that straightforward due to organizational constraints, the variety of families and the available resources per organization.

IV Discussion

This study took a qualitative approach using interviews with SLTs in order to explore critical components in PCIT and to investigate reasons therapists give for the way they structure PCIT. It appears that SLTs experience working with PCIT as challenging. The need to engage parents in PCIT is highly valued by the participating SLTs and is reported as one of the most challenging aspects of delivering the intervention. Parents’ reflection, parents’ understanding and therapists’ skills are also identified as interacting and potentially critical components. Data from the SLTs indicate that there are strong links between the four components in PCIT: parents’ engagement, parents’ reflection, parents’ understanding and therapists’ skills; if one component is not present, there is a higher risk of failure suggesting that the four are potentially critical to success (Figure 1).

Figure 1.

Potentially critical components.

SLTs in this study often see families with diverse cultural and socio-economic backgrounds, as well as families who are not that engaged prior to or during therapy; information about families’ background and parents’ feelings were regarded as important influences on the four critical components as indicated by the SLTs. Gaining the case history information in order to adapt the intervention to different types of families is also suggested in the literature (Falkus et al., 2016; Roberts et al., 2014). Other cultures may indeed have different beliefs regarding parent–child interactions (van Kleeck, 1994). However, Fey et al. (1993) caution about the danger of making assumptions about which parents will be able to cope with this kind of intervention. According to Hibbard and Gilburt (2014), the level of activation of a patient, that is, the way in which a patient engages in health care, is influenced by the knowledge, skills and confidence a person has in managing their own health and health care. A person with a low level of activation is less good at following a doctor’s advice and at managing their health when they are no longer being treated. Also, people with low levels of activation are more likely to feel overwhelmed with the task of managing their health or might misunderstand their role in the care process. Hibbard and Gilburt (2014) argue that in health-care not all patients in a particular demographic group respond in the same way when it comes to engaging in health information or participating in health-promoting activities. It is therefore important to be aware that levels of parents’ engagement differs, even within groups with the same socio-economic status (Hibbard and Gilburt, 2014). Nonetheless, based on case history information and interactions with the family SLTs must set achievable goals and adapt their approach, taking the feelings and beliefs of the family into account.

The four components identified in this study seem to correspond with the two critical components mentioned in the review of Roberts and Kaiser (2011): parent training and parents’ use of the strategies. Interventions are predicated on the notion that parents need training to understand and reflect on their use of the strategies. The quality of this training depends on the skills of the therapist. Further, according to the SLTs, parents’ level of engagement influences parents’ use of the strategies. Roberts et al. (2014) highlight the need for an appropriate training model in order to teach parents the strategies. They base their model on Particular Adult Learning Strategy (PALS) (Dunst, 2009). The PALS model displays reflection as one of the steps in adult learning. Parents’ understanding and parents’ reflection could be merged into the PALS parent training component. However, parents’ reflection is highlighted by SLTs and it may be that retaining them as separate components highlights the critical importance of parents’ reflection to the success of PCIT.

The reasons SLTs give for structuring their therapy are based on organizational constraints, the family characteristics and practicalities. In particular, the pathways and waiting lists in organizations play a considerable role in how therapy is structured; individualizing therapy to the needs of families is being experienced as luxury. This was noted by the Bercow Report (Bercow, 2008) that concluded that services for children with speech, language and communication needs (SLCN) are not commonly designed around the needs of families, but are often designed around the needs of local authorities. It seems that this constraint on delivering individualized care continues to impact on services.

Five of the SLTs had followed the Hanen training It takes two to talk (Manolson, 1992), and the ITTTT programme was praised by virtually all participants. Given these positive views it was surprising that none of them deliver the Hanen interventions due to practicalities and pathways of local authorities, although participants explained that they still use Hanen principles. Baxendale and Hesketh (2003) confirm the high costs of Hanen’s ITTTT and give suggestions for adapting this programme, for instance, using the Hanen principles in individual sessions. However, it is questionable if ITTTT is still effective after being adapted (Wake et al., 2011). For programmes where efficacy has been demonstrated, it is therefore important that adaptations made in local contexts are made explicit and evaluated. This is necessary whether the adaptations are made in response to organizational constraints, family characteristics or practicalities.

1 Strengths and Limitations

The sample of 10 participants was sufficient to reach theoretical saturation. However, this might limit the wider applicability of the study to other contexts. Further exploration of the relevance of the identified components to other clients groups and clinical contexts is needed. A selection bias might be present since it is likely that participating SLTs were those who felt they had something to say about this topic.

2 Clinical implications and further research

There seems to be no controversy between SLTs in terms of the strategies taught to parents, although in the literature, the contribution of any one strategy to the overall effectiveness of PCIT has not evaluated. However, it is the delivery of PCIT that is perceived to be challenging by SLTs in this study. The critical components identified in this study are rarely described and evaluated in the speech and language therapy literature. However, they have been explored more generally elsewhere. For example, the impact of patient engagement on take-up of interventions is a well-researched phenomenon. Referred to as the ‘blockbuster drug of the century’, the overwhelming finding of research confirms what our SLT participants know, that the more patients are engaged in the intervention, the better their outcomes (Dentzer, 2013); furthermore, evidence suggests that building patients’ skills and confidence is key to increasing engagement (Hibbard and Gilburt, 2014).

Reviews have concluded that whilst evidence supports the impact of PCIT on children’s expressive language, the evidence to support an impact on receptive language is less clear. It may therefore be that the importance of the four components will vary for children and families with different profile. However, it is possible that the four underlying components underpin SLT intervention in many contexts. SLT training might therefore benefit from explicit reference to studies which have identified ways to increase patient understanding, engagement and reflection.

Finally, SLTs felt constrained by the pathways prescribed by their employing organizations. Whilst pressures on case-loads continue to rise, there is a need to ensure that interventions are individualized to the needs of a child and family. This requires flexibility in the implementation of PCIT focusing not just on the strategies which are being taught to parents but also on the four, potentially critical, components.

V Conclusions

SLTs experience PCIT as a valuable but challenging intervention due to organizational constraints, the variety in families and lack in availability of resources. SLTs perceived the successfulness of PCIT to be related to parents’ engagement, parents’ understanding, parents’ reflection and the therapists’ skills. Further research is needed to examine the critical components and, furthermore, the effectiveness of each strategy. Future intervention studies should take the critical components and the restrictions SLTs experience into account, and should describe their intervention clearly in order to narrow the gap between research and practice. Including these critical components in any PCIT framework could help to emphasize the critical role that they play in delivering PCIT effectively.

Footnotes

Appendix 1

Topic guide

Appendix 2 Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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