Parent–Child Interaction Therapy-Callous Unemotional Adaptation for a Preschool Boy With Conduct Problems

1 Theoretical and Research Basis for Treatment

Conduct problems (CP) are one of the most common reasons for child referrals to residential and outpatient mental health services (Silverthorn et al., 2001). Children with CP are chronically non-compliant, defiant toward authority figures, and aggressive, being captured by diagnostic categories of oppositional defiant disorder (ODD) and conduct disorder (CD). Youth diagnosed with ODD exhibit a pattern of angry and irritable mood with argumentativeness and defiant or vindictive behavior. ODD strongly predicts later onset of CD, which presents as a repetitive and persistent pattern of behaviors in which the basic rights of others or major age-appropriate norms are violated (American Psychiatric Association, 2013); however, approximately 40% of children with ODD never progress to more severe CPs (Lahey & Loeber, 1997). There is significant variability in the biological, cognitive, emotional, and social characteristics of children with CP, and it is widely accepted that CP develops via multiple pathways with relatively unique causal processes (Frick et al., 2014a). Distinguishing more homogeneous subtypes of children with CPs has proven critical to classifying differentiations in developmental course, prognosis, and etiology and has clinical utility in regard to identifying effective treatment options (Frick, 2012; Kimonis et al., 2019).

The presence of callous unemotional (CU) traits identifies a distinct subgroup of youth with more severe, stable, and aggressive CPs that are often instrumental in nature relative to children with CP-only (Frick et al., 2014b). Decades of research on childhood CU traits informed the introduction of a “With Limited Prosocial Emotions” (LPE) specifier to the diagnosis of CD in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013). A child diagnosed with CD will meet the LPE specifier diagnostic criteria if he or she pervasively exhibits two of the following four traits (a) lack of remorse or guilt, (b) callousness-lack of empathy, (c) lack of concern regarding performance in important activities (e.g., school, work, other structured activities), and (d) shallow or deficient affect (American Psychiatric Association, 2013). Relative to children with CP-only, the externalizing behaviors of children with CP+CU are thought to be underpinned by distinct neurodevelopmental factors (Frick et al., 2014a).

First, children with CP+CU display a fearless temperament with atypicalities in processing reward cues and punishment, such that they have a heightened reward sensitivity while simultaneously displaying punishment insensitivity (Byrd et al., 2014). For example, caregivers of children with CP+CU consistently report discipline strategies taught in parent management treatments, such as “time-out,” as less effective than for children with CP-only but rate reward strategies as effective (Haas et al., 2011). These temperamental differences are implicated in the weak conscience development of children with CP+CU as described in greater detail below (Frick & Morris, 2004).

Second, children with CP+CU show multilevel emotional processing deficits, including reduced arousal to others’ distress cues (Frick et al., 2014a), deficits in emotional attention (Kimonis et al., 2006), and neurocognitive deficits in empathic processing relative to CP-only children (Viding et al., 2012). In early childhood, their insensitivity to the distress they cause in others and to their caregivers’ attempts at punishment inhibits them from experiencing unpleasant internal states such as anxiety, guilt, or emotional discomfort. These emotional states are necessary for the development of moral socialization and the prevention of future transgressions (Blair, 1995). Some have argued that deficits in these emotional states are the most critical intervention target for CP+CU children (Kimonis et al., 2019).

Finally, the development of CP for children with CU traits is associated with a parenting style characterized by low warmth and low responsivity (Kroneman et al., 2011; Pasalich et al., 2011). Attachment security research suggests that parental warmth and responsivity to child emotions are both critical to a secure caregiver–child relationship. This secure relationship serves as the foundation from which the child develops internal working models of the self and the world (Kochanska & Kim, 2013). Indeed, children with fearless temperaments who were exposed to attachment-secure parenting practices (e.g., warmth, responsivity, clear boundaries) showed improved conscience development relative to children exposed to insecure attachment practices (Fowles & Kochanska, 2000). Kochanska and Thompson (1997) suggest that optimal socialization strategies for youth with CP+CU should focus on fostering mutual responsivity between the caregiver and child through increasing rewards for appropriate behavior, rather than relying on punishment-oriented strategies due to punishment insensitivity and reward dominance observed in children with CP+CU. Accordingly, improving caregivers’ mutual responsivity and warmth has been identified as a key intervention target for improving conscience development in children with CP+CU (Kimonis et al., 2019). When left untreated, the parent–child relationship is at risk of disengagement from parent and child interactions and lowered levels of parental warmth and involvement (Hawes et al., 2011).

The most efficacious treatment for young children with CPs is parent management training (PMT); however, children with CP+CU show a poorer response to family-based interventions compared with those with CP-alone (Hawes et al., 2014). Hawes et al. (2014) reviewed 33 clinical intervention studies examining CU traits and found that children high on CU traits had an increased likelihood of continuing to meet diagnostic criteria for a disruptive behavior disorder at post-treatment and were at increased risk for clinically significant levels of CP when compared with children with CP-only. Kimonis et al. (2014) also found that when compared with children with CP-only, children with CP+CU showed more severe CP after receiving individual PMT. This lower rate of response to treatment for children with CP+CU is attributed to the unique cognitive, emotional, biological, and familial factors underlying their development of CP (Frick, 2012).

The failure of traditional interventions to improve outcomes equally across levels of CU traits has led to an increased focus on integrating knowledge about the causes of CPs with the development of innovative intervention approaches aimed at improving outcomes for those with elevated CU traits. For example, augmenting PMT with parent–child emotion recognition training to target the pervasive emotional deficits associated with CU traits produced improvements in empathy and reductions in CPs that were superior to PMT alone for children with CP+CU (Dadds et al., 2012). Kimonis and colleagues (2019) also systematically adapted an intensive PMT program called Parent–Child Interaction Therapy (PCIT) for children with CP+CU, building on its focus on increasing parental responsivity (Kimonis & Armstrong, 2012).

PCIT is an empirically supported behavioral intervention focused on improving emotional warmth and attachment in parent–child dyads and reducing disruptive behaviors in young children aged 2.5 to 7 years (Eyberg, 1988). The main goals of PCIT include enhancing the quality of the parent–child relationship, decreasing challenging behaviors, increasing children’s prosocial behaviors, strengthening parenting skills, and reducing parent stress (Eyberg, 1988). PCIT consists of two phases, each emphasizing a different skill set. The first phase, child-directed interaction (CDI), aims to develop a warm and responsive parent–child relationship. During the second phase, parent-directed interaction (PDI), parents learn how to deliver commands and use effective discipline strategies targeted at increasing compliance and reducing levels of child challenging behaviors (Eyberg, 1988).

PCIT is a compelling treatment platform for meeting the unique needs of children with CP+CU. PCIT emphasizes the use of positive parenting strategies to strengthen the parent–child relationship, which aligns with research suggesting an inverse relationship between parental warmth and CP+CU traits. In addition, PCIT has been found to be effective when adapted for various populations and has been shown to improve emotional outcomes in children (Luby et al., 2012).

The adaptation of PCIT for children with CP+CU, called PCIT-CU, differs from standard PCIT by: (a) systematically and explicitly coaching parents to use warm and emotionally responsive parenting practices, (b) shifting emphasis from punishment-oriented to reward-oriented behavior management strategies, and (c) addressing the core emotional deficits of children with CP+CU with an adjunctive module (Coaching and Rewarding Emotional Skills [CARES]), thus targeting the three specific risk factors unique to CU traits outlined above (Kimonis et al., 2019). Preliminary tests of the PCIT-CU adaptation show promising evidence toward developing an intervention that addresses the distinct needs of children with CP+CU (Fleming et al., 2017; Kimonis & Armstrong, 2012; Kimonis et al., 2019). The results of an open trial pilot study of PCIT-CU found significant decreases in both child CP (ds = 1.67–2.00) and CU traits (ds = 1.00–1.11), as well as increases in empathy (ds = 0.47–0.72) among young children selected for CP+CU using well-validated tools (Kimonis et al., 2019). Participants maintained treatment gains at 3 months’ postintervention. In addition, parents reported high levels of satisfaction with the program and levels of treatment dropout were low (26%) relative to rates reported in studies of standard PCIT in university-based clinics (30%–50%; Stokes et al., 2018). However, this open trial study cannot conclude whether PCIT-CU is superior to standard PCIT in improving CPs of this population, which is currently being tested in a randomized control trial that is underway (Kimonis et al., 2018). The current case study builds on the prior preliminary empirical support for an adapted version of PCIT to treat a young child presenting with CP+CU.

2 Case Introduction

Luca was 4½ years old when he presented for a diagnostic interview at a local pediatric psychiatry clinic. Luca had a long history of sleep problems, CP, aggression, and symptoms of hyperactivity and inattention (e.g., constant motion, impulsive responding, and limited attention) per parent and teacher report. Luca resided with his biological mother, father, and his older brother. He also had two older half siblings who lived in the home one weekday and every other weekend. When Luca was 3 years, 11 months his parents first brought their concerns to his pediatrician who suggested that Luca was “too” young for a diagnosis of attention-deficit/hyperactivity disorder (ADHD) and associated medication treatment. This pediatrician prescribed clonidine (0.2 mg day total; ½ pill in a.m. and ½ in p.m.) to address Luca’s aggressive behaviors and then referred him to a psychologist. While his parents reported that the clonidine seemed to reduce the frequency and severity of Luca’s disruptive behaviors, the behaviors persisted and interfered with his adaptive functioning across settings.

A comprehensive assessment for diagnostic clarification was indicated after a complete diagnostic interview given the range of symptoms and a pediatric psychologist administered the following assessment battery: Kaufman Assessment Battery for Children–Second Edition (KABC-II; Chadwick Center on Children and Families, 2004), Child Behavior Checklist (CBCL; parent and teacher forms; Achenbach, 2001), Adaptive Behavior Assessment System–Third Edition (ABAS-3; parent and teacher forms; Harrison & Oakland, 2015), Inventory of Callous Unemotional Traits (ICU-Parent Preschool version; Frick, 2004), and Behavior Rating Inventory of Executive Function-Preschool (BRIEF-P; parent and teacher forms; Gioia et al., 2000).

Luca’s Fluid Crystallized Index (FCI) on the KABC-II was 85 and he demonstrated average abilities for short-term memory and long-term memory/retrieval. He scored in the below average range on comprehension/knowledge and visual processing. His mother’s ratings on the CBCL were in the clinical range for the Internalizing Problems (T-score = 71), Externalizing Problems (T-score = 92), and Total Problems (T-score = 79) Composites. His mother endorsed many clinical concerns on the DSM subscales including: Affective Problems (T-score = 70), Anxiety (T-score = 73), Oppositional Defiant Problems (T-score = 80), and Attention Deficit/Hyperactivity Problems (T-score = 71). Teacher ratings on the CBCL were in the borderline range for Internalizing Problems (T-score = 62) and in the clinical range for the Externalizing Problems (T-score = 77) and Total Problems (T-score = 70) Composites. Luca’s teacher endorsed clinical concerns on two DSM scales: Oppositional Defiant problems (T-score = 70) and Attention Deficit/Hyperactivity Problems (T-score = 79). The BRIEF-P Index scores were in the clinical range as follows for parent and teacher, respectively: Inhibitory Self-Control (T-score = 92 and 83), Flexibility Index (T-score = 72 and 72), Emergent Metacognition Index (T-score = 85 and 66), and Global Executive Composite score (T-score = 87 and 76). The BRIEF-P results supported CBCL findings related to deficits in inhibiting behaviors, controlling emotions, carrying out tasks, and aggressive behaviors. The ICU was completed by mother and teacher and total scores were 32 and 37, respectively. These scores indicated that Luca displayed CU traits around 1 SD above the mean for preschool age boys according to mother’s ratings (M = 23.11, SD = 10.61) and about 1.5 SD above the mean according to teacher’s ratings (Ezpeleta et al., 2013). Finally, both mother and teacher rated impairments on the ABAS-3 General Adaptive Composite score (Standard Score = 75 and 78, respectively). In summary, a multimethod, multirater evaluation documented impairments across settings in Luca’s executive functions and adaptive behaviors, as well as the presence of internalizing and externalizing psychopathology (e.g., aggression, lack of impulse control, hyperactivity, and defiance). Results provided sufficient evidence to support DSM-5 diagnoses of attention-deficit/hyperactivity disorder–combined presentation (ADHD-C), and ODD, with clinically significant levels of CU traits present.

3 Presenting Complaints

In both home and school settings, parents reported Luca presented with severe aggression which included hitting his mother and peers, and throwing objects/furniture at teachers and peers. In fact, Luca’s classroom aggression was so severe that the preschool and parents agreed that his behavior would always be video recorded so that parents could review incidents with school staff. Furthermore, his parents and teacher reported concerns related to Luca’s hyperactivity/impulsivity, non-compliance with adult directions, stubbornness, lack of empathy and remorse after physical transgressions, and blaming others when things did not go his way. Luca’s mother, Lorena, was worried that Luca would hurt someone and reported that he had already hurt classroom peers by placing his hands on their necks, hitting them, and throwing objects at them. Luca’s parents reported he had few friends and had trouble maintaining healthy social interactions with same-age peers due to his physical aggression. Pertaining to family relationships, Luca’s parents anecdotally reported that Luca was more defiant and aggressive toward his mother leading to an especially strained relationship relative to his father. Luca also showed signs of behavioral sleep concerns in that he would only sleep through the night if he co-slept with his parents or older brother, and this had been an ongoing concern since Luca graduated from his crib.

4 History

Luca was born full-term and the pregnancy and birth were unremarkable. Parents reported that Luca met all developmental milestones either on time or early. He had no history of chronic physical health conditions. He lived with his family since birth. At the time of this evaluation and throughout treatment, Luca was taking medication (e.g., clonidine) for aggression since age 3 years, 11 months. Luca’s parents described family life as stable, with full-time employment (both parents) and adequate finances and social supports. Luca was enrolled in a private preschool and the school staff were actively working with his family to keep him enrolled in the program, despite the severity of his behaviors. Caregivers reported Luca’s father had hyperactivity as a child (never treated with medication or therapy) and experienced harsh parenting (e.g., scolding, spanking). Luca’s mother reported a diagnosis of anxiety that coincided with Luca’s behavioral problems at age 2 years. The family had briefly (~8 weeks) tried applied behavioral analysis therapy with a board-certified behavior analyst (BCBA) to treat Luca’s disruptive behaviors at age 3, but they reported that they “did not stick with it,” as they perceived the strategies taught to be ineffective (e.g., redirection, planned ignoring, punishments). Although family life was described as stable, many stressors were identified at intake including Luca’s disruptive behaviors, sleep problems, and caregiver stress associated with Luca’s behavior.

5 Assessment

6 Case Conceptualization

Given the presenting CPs and associated CU traits, Parent–Child Interaction Therapy for Callous Unemotional Traits (PCIT-CU) was used, a recent adaptation of standard PCIT (Kimonis et al., 2019). As in standard PCIT, in PCIT-CU parents are coached to use the PRIDE skills (praise, reflect, imitate, describe, emotion expression & identification). The “E-Enjoy” PRIDE skill (i.e., the parent shows they are happy and enjoying time with their child) is slightly modified in PCIT-CU to emphasize “Emotional Expression.” This involves coaching parents to show warmth, affection, to use eye contact, and to label emotional states that the child and parent experience during play. For example, caregivers are encouraged to use affectionate physical touch and to engage their child’s eye contact when providing labeled praise. As in standard PCIT, in PCIT-CU parents must avoid using questions, commands, and criticisms during CDI (e.g., “Don’t” skills), as this takes the lead of play away from the child and can make the play less fun.

PCIT-CU integrates an individualized token economy within the PDI sequence that requires parents to deliver a token to the child each time he or she complies with a parent’s command. Children also receive a token if they comply with the parent’s original command after the parent issues a warning that the child will go to time-out if he or she does not comply. If a child refuses to comply with the original command after one warning, parents follow the standard PDI process involving placing the child in a time-out chair for 3 min and 5 quiet seconds, after which the child is asked if they are ready to comply with the original directive. The child does not earn a token for compliance if they must go to time-out chair. If the child leaves the time-out chair, they are returned to the chair and given one warning ever that if they leave the time-out chair without permission, they will go to the time-out room, consistent with standard PCIT. The child can earn many tokens over the course of a PDI session in PCIT-CU, as well as at home during Special Play and for compliance throughout the day. The child and parent develop a rewards bank wherein the child can exchange earned tokens for a preferred reward from a list of previously established reward options. The therapist assists the family with identifying and regularly refreshing suitable small and big rewards to ensure the child has access to both immediate and long-term reinforcers contingent upon their speedy compliance with parent issued commands. This addition of a token economy integrated into the PDI sequence in PCIT-CU is aimed at addressing the reward dominant style of children with CP+CU. In PCIT-CU, parents must meet the same mastery criteria regarding CDI and PDI skills as in standard PCIT, but in PDI-CU parents must combine the labeled praise for compliance with a token. Luca participated in PCIT-CU treatment with both his mother and father. Both parents completed weekly ratings of Luca’s behaviors, which were monitored over the course of treatment. After completing PCIT-CU, Luca’s family opted not to complete the adjunctive CARES module (e.g., emotion training) due to personal reasons (e.g., scheduling, taking off work) and satisfaction with treatment outcomes.

7 Course of Treatment and Assessment of Progress

The PCIT-certified therapist followed the PCIT-CU manual as described above, engaging the child and both parents throughout treatment. One parent was in the room with Luca at a time and the other parent remained with the therapists observing the session.

DPICS

Lorena mastered the CDI skills according to DPICS coding criteria by CDI-CU Session 5 and Jose by CDI-CU Session 6. Lorena began treatment with few behavior descriptions and reflections, but many labeled praises (10 in CDI-CU 1, see Figure 1). She had very few “Don’t” skills from the start of treatment through to graduation. In CDI-CU Session 1 (see Figure 2), Jose made no behavior descriptions but many reflections (11) and several labeled praises (6). He also had 10 questions, three commands, and one criticism and continued to have greater than three “Don’t” skills (questions, commands, and criticisms combined) until CDI-CU 5, where he reduced to zero and remained below three “Don’t” skills for the remainder of treatment.

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Figure 1.

Mother’s CDI skills.

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Figure 2.

Father’s CDI skills.

Lorena mastered the PDI skills by PDI-CU Session 3, the first time her PDI skills were coded. She provided 10 direct commands, to which Luca complied 100% of the time and she successfully delivered a labeled praise and a token following his compliant behavior 100% of the time. Jose met mastery criteria by PDI-CU Session 4. He provided six direct commands and one indirect command (86% effective direct commands). Luca complied with all direct commands (100% compliance) and Jose followed through with a labeled praise and a token 100% of the time. PDI skills are not typically coded in PDI-CU Session 4, but in PDI-CU Session 5, however, Jose indicated that he would not be able to attend PDI-CU Session 5 for work-related reasons, so the therapists and caregivers agreed to code him a week in advance. Of note, Luca was motivated by the token economy and was easily engaged in identifying a reward hierarchy and noticeably enthusiastic about collecting and counting his tokens during PDI-CU sessions. At the end of PDI-CU sessions, Luca made comments about his tokens and rewards and for what he thought he would exchange them. Furthermore, the times in which Luca had to be sent to time out, he did not appear very distressed, as is often the case among children with CU traits (Kimonis et al., 2014).

ECBI

Parent report of Luca’s behaviors on the ECBI improved over the course of treatment. At the CDI-CU teach session, both parents rated Luca’s behavior in the clinically significant range on the ECBI with identical ratings, Intensity and Problem T-scores of 71 and 69, respectively. As illustrated in Figures 3 and 4, both parent’s ratings of Luca’s disruptive behaviors progressively decreased over the course of treatment, and by graduation mother’s ratings were T-scores of 56 and 41 on Intensity and Problem scales (see Figure 3), respectively, and father’s ratings were 49 and 41 (see Figure 4), respectively. These scores were well within normal limits for children aged 2 to 16 years. Jose was absent for CDI-CU 3 and PDI-CU 5 sessions and thus did not have scores for these sessions.

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Figure 3.

Mother’s ECBI ratings.

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Figure 4.

Jose’s ECBI ratings.

8 Complicating Factors

During PCIT-CU sessions, both parents were easily coached, responded well to therapist feedback, and were enthusiastic in their play with Luca. Thus, there were few complicating factors. One particularly notable complicating factor, however, was that Luca was difficult to engage in play with his mother during CDI-CU Sessions 1 to 3. For the first CDI-CU coaching session, Luca had difficulty transitioning from the waiting room, where he was playing on a tablet to the therapy room. The first 10 min of this session Luca screamed, “Stupid! Stupid!” repeatedly at his mother and thus CDI coding was not completed with mother and she was instead coached to ignore his misbehavior and attend to any positive behaviors (e.g., sitting still, touching a toy). Lorena appeared distressed and tearful during this coaching session. Luca eventually started to play with his mother and she was then coded and coached in CDI before transitioning to coding and coaching his father. When debriefing this session, the therapist and parents discussed ways to reduce the difficult transition from the waiting room to the therapy room and parents decided not to bring the tablet to future sessions. For the second CDI-CU coaching session, the therapist and parents decided to have Jose in the playroom first and the session started off smoothly. Once mother entered the room, Luca quickly became verbally and physically aggressive hitting his mother during the first 2 min of coding. It was hypothesized that Luca was upset by transitioning to play with his mother because he was having fun with his father. Consistent with standard PCIT, this session was stopped due to aggression and Lorena expressed disappointment and concern that PCIT-CU was not going to be effective for her family. At the start of the third CDI-CU coaching session, three simple room rules were introduced for Luca (not a part of standard PCIT or PCIT-CU) and were repeated at the beginning of each following session: (a) Keep your hands to yourself, (b) Talk in a calm voice, and (c) Play gently with the toys. A visual support with these rules was posted in the treatment room at Luca’s eye level. During the third CDI-CU coaching session, Luca often whined and wandered into the time-out room to escape the play interaction with Lorena but participated more actively in play with Jose. Despite these behaviors, both parents were coded and coached in CDI-CU skills, as well as planned ignoring and differential reinforcement for positive opposite behaviors (e.g., staying in the treatment room, sitting and playing with mother). In CDI-CU coach Session 4 and future sessions, Luca engaged in more prosocial behaviors with his mother in play (e.g., playing from the start, talking to both parents in a calm voice, allowing parents to play with toys) and the therapist was able to dedicate more time to coaching CDI-CU skills than in previous sessions.

9 Access and Barriers to Care

There were no apparent access issues or barriers to care. The family had health insurance coverage that was accepted by the university psychiatry clinic where treatment was delivered and were able to afford their co-payments. Furthermore, the family had adequate transportation to and from appointments and was able to arrange childcare for their other children for the duration of PCIT-CU treatment. Both parents worked full-time and their employers were supportive of them taking leave on a weekly basis to attend their afternoon appointment. However, parents did decline participation in the adjunctive treatment CARES, citing the need to be at work full-time and to fulfill after-school family duties as reasons for non-participation. Finally, Luca’s preschool teachers worked closely with the family to implement behavioral supports at school for Luca so that he could remain in his private, preschool placement.

10 Follow-Up Visit

The family returned for a follow-up session 4 months after completing treatment. Lorena and Jose both completed the ECBI and continued to report low scores on both the Intensity (53, 49, respectively) and Problem (41, 41, respectively) scales. Furthermore, both parents were coded in their use of CDI skills and continued to demonstrate mastery level “Do” skills (e.g., 10 or greater of each skill) while keeping the “Don’t” skills to a minimum (e.g., below 3). Parents reported continued satisfaction with Luca’s progress and that he had transitioned well into the first month of Kindergarten in a new school. Parents reported that they had phased out the token economy consistent with PCIT-CU guidelines as Luca was following directions well with praise alone. Parents reported continued concern around his ADHD symptoms (e.g., inattention, fidgeting, fiddling with objects in his desk) during classroom instruction and the therapist suggested the parents talk to the school about accommodations through a Section 504 Plan.

11 Treatment Implications of the Case

This case study documented the use of a treatment adaptation for children with CU traits (PCIT-CU) to reduce non-compliance and disruptive behaviors in a 4-year-old boy with ODD, ADHD, and CU traits, as well as to improve parenting skills and warmth in dyadic interactions. During PCIT-CU, Luca received ongoing medication management from his pediatrician, who prescribed 0.2 mg Clonidine per day for aggression over the course of treatment. There is evidence to support the use of clonidine for treating ADHD and disruptive behavior disorders, wherein clonidine showed a significant effect on parent-rated conduct symptoms (Connor et al., 2000).

This case study furthers the literature in support of PCIT-CU, along with medication management, as a viable treatment for improving CP and CU traits in preschool age children. Although Luca’s aggression toward Lorena during early sessions made her skeptical of PCIT-CU, by treatment completion both caregivers described the intervention as valuable for improving their relationship with their son and teaching them effective strategies to manage his non-compliance and aggression. Over the course of the intervention, both caregivers rated Luca as showing significant improvements in the intensity of his behaviors and how problematic they were, which dropped from the clinical range to within normal limits by the end of treatment. These gains were maintained at 4-month follow-up. Similarly, parent ratings of CU traits improved from by the end of treatment, while teacher’s ratings remained the same; but the ICU was not collected at follow-up. In summary, this case study demonstrates clinically meaningful improvements in child antisocial and disruptive behaviors.

These findings should be interpreted within the context of some limitations. First, Luca received ongoing medication management for symptoms of aggression. Therefore, it is difficult to know if the medication, the PCIT-CU program, or a combination of the two was most responsible for reducing Luca’s symptoms. However, the dosage and type of medication remained consistent throughout PCIT-CU treatment. Second, Luca’s diagnosis of ADHD makes it difficult to disentangle the unique contribution of CU traits versus ADHD symptoms to Luca’s aggression, limited prosocial behaviors, and disinhibition. It is possible that ADHD and the associated impulsivity directly lead to more severe disruptive behaviors. Third, the primary therapist and DPICS rater were not masked to details of the case or to time point. Of note, a secondary coder was present and coded all sessions with high interrater reliability (e.g., greater than 90%). Future studies should include masked ratings of DPICS observations and long-term follow-up to assess whether any intervention benefits are maintained over time. Finally, in this case, the family was unable to complete the adjunctive CARES module that is a core component of the PCIT-CU intervention as it is designed to target the emotional deficits of children with CU traits that are thought to contribute to their severe antisocial behaviors (Datyner et al., 2016; Kimonis et al., 2019). The family cited time as a barrier and reported satisfaction with the improvements their child had made in the course of PCIT-CU treatment. It is possible that caregiver desire to end treatment after PCIT-CU affected their ratings on the ICU at the end of treatment. Administering an ICU at 4-month follow-up would have provided further clarification on the presence of CU symptoms. It is possible that further improvements in CP and CU traits would have been achieved with the implementation of this module. The CARES intervention teaches children emotional literacy skills and teaches caregivers to promote emotional awareness and empathic responding that are critical to moral development (Armstrong & Kimonis, 2013; Datyner et al., 2016).

12 Recommendations to Clinicians and Students

While the evidence behind PCIT-CU is in its infancy, clinicians with experience in standard PCIT who treat young children with ODD and CU traits will likely find this intervention easy to implement. The adapted manual has a similar layout and flow to standard PCIT. While PCIT-CU requires some additional materials, namely tokens for the token economy, therapists will find these items are usually easily obtained. An emerging body of research supports PCIT-CU as an effective treatment for improving child behavior in children with CU traits through increasing warmth in parent–child interactions, using a token economy system to motivate the child to follow parent directions, and delivering an adjunctive module to enhance emotional literacy skills (Kimonis et al., 2014; Kimonis et al., 2019). While this child did not complete the third component of PCIT-CU, an open trial of the full PCIT-CU program with 23 children found promising results for improving CP, CU traits, and empathy levels (Kimonis et al., 2019). More rigorous tests of PCIT-CU are underway in an ongoing randomized controlled trial, which can speak to whether PCIT-CU confers additional benefits beyond standard PCIT for children with CP and CU traits who show a particularly severe pattern of antisocial behavior that responds poorly to traditional interventions.