Autism Spectrum Disorders (ASD) are neurodevelopmental disorders characterized by fundamental deficits in social interaction and communication. ASD occurs in 0.8% to 2.0% of school-aged children, some with co-morbid disruptive behaviors.1 Parent-child interaction therapy2 (PCIT) is an evidence-based treatment for disruptive behavioral disorders in children aged 2 to 7 years and provides support to caregivers. Numerous clinical studies on the use of PCIT for children with ASD and their caregivers have reported positive effects.3 PCIT aims to strengthen the relationship between caregiver and child and improve child compliance. In-clinic PCIT reduces problematic children’s behaviors through live coaching of caregiver-child interactions using a one-way mirror with microphone and headphones. In Western countries, PCIT is offered in a variety of settings, including at home and in hospital (in clinic), but also online, depending on patient needs. While in-clinic PCIT began in Japan about 10 years ago, Internet-Provided PCIT (I-PCIT) was implemented in 2020 due to contact limitations created by the COVID-19 pandemic. To date, there has only been one case report (one case of abuse) on the effectiveness of I-PCIT in Japan,4 therefore, an accumulation of data from further studies is needed. This study compared the efficacy of three clinical PCIT cases and one I-PCIT case in children with ASD.
This study was approved by the ethics committee of the International University of Health and Welfare. Three parent-child dyads were classified as clinical PCIT and one dyad as I-PCIT. The four male children in the International University of Health and Welfare (Nasushiobara, Tochigi, Japan) study were between 3 and 5 years old (mean 3.6 years, median 3, 0 years) and were diagnosed with ASD, based on the DSM. -5 criteria. While the clinic-based PCIT provides live coaching to parents in a clinic, I-PCIT uses a webcam to broadcast parent-child interactions in real time from their homes. PCIT is assessment-based treatment. Assessments were carried out before and after treatment using observations and standardized questionnaires, mainly the Eyberg Child Behavior Inventory (ECBI). The ECBI was used to assess problematic behaviors in children. The scale consists of 36 items and includes an intensity scale and a problem scale. The Intensity Scale measures the frequency of various behaviors on a 7-point scale and the Problem Scale ranks the behavior as problematic or not (yes or no). The Japanese version of the ECBI has been standardized by Kamo and the cut-off scores are 124 for the intensity scale and 13 for the problem scale in Japan.5 Parents completed the ECBI at each session. Initially, the intensity of the ECBI before and after treatment and the problem scores were compared using a t-test to verify the effect of the entire PCIT treatment session, which included two phases: child-directed interaction (CDI) and parent-directed interaction (PDI) for the four cases (Fig. 1a) . Second, we compared the rate of improvement in ECBI intensity scores before and after each intervention for clinical PCIT and I-PCIT (Fig. 1b).
Figure 1a shows the pre- and post-intervention scores. The mean ECBI intensity scores before treatment was 130.5 and after treatment was 66.0. The mean ECBI problem scores before treatment was 16.0 and after treatment was 1.7. There were significant differences before and after full PCIT treatment for in-clinic and I-PCIT treatments (m = 4, ECBI intensity scores: P = 0.0002, effect size (r) = 0.97; ECBI problem scores: P = 0.018, effect size (r) = 0.90; 1a). Although the number of subjects is limited, Figure 1b shows that clinical PCIT and I-PCIT demonstrated robust efficacy in statistical validation. All dyads showed improvement in ECBI intensity and problem scores that ranged from 36.8 to 54.8% (mean 45.6, SD 7.3) to 78.5 to 91.3 % (mean 84.8, SD 5.2), respectively, for clinical PCIT (m = 3) and were 62.6% and 100% respectively for I-PCIT (m = 1; 1b).
The PCIT has been effective in improving behavior problems in all cases, regardless of the type of PCIT. By effectively using either type of PCIT, transparent PCIT processing is achievable in the COVID-19 era. Like our previous study,4 the current PCIT study may improve the ecological validity of treatment by encouraging adoption of PCIT at home where therapists can observe the most problematic behaviors. In clinical PCIT, children are sometimes calm and obedient to when they are at home, making it difficult for the therapist to intervene. However, for I-PCIT, advanced preparation such as Wi-Fi and Home Video settings is required.
The authors declare no conflict of interest.
MM and YM wrote the initial manuscript and approved the final manuscript. MK conceptualized the study and KK and TK supported the implementation of PCIT therapy. All authors have read and approved the final manuscript.