Disruptive behaviour is one of the most frequent reasons that young children are referred to child and adolescent mental health care services worldwide (1). Statistics show that of the population in the US, 7–9% of children have a diagnosed behavioural problem (2), and in the Western culture, there is an increase in prevalence of behavioural problems and disorders (3). Disruptive behaviour disorders (DBD) include oppositional defiant disorder (ODD) and conduct disorder (CD). Children with DBDs show patterns of defiant and uncooperative behaviour and their behaviour can often be characterised as stubborn, disobedient, irritable or even (physically) aggressive (4). Displaying such behaviour has an effect on the child, as well as on his or her surroundings and society at large (5, 6). Long-term effects of untreated externalising, disruptive behaviour include school dropouts, peer rejection, developing antisocial personality disorders, higher public costs for health care and education, and both non-violent and violent delinquency and criminality in adulthood (7–11). However, protective factors include enhancing prosocial skills for children and fostering the mental wellbeing of the parents (12). Additionally, according to a longitudinal study, when parental supervision and involvement is high in the early years, it reduces risk of developing delinquency during adolescence (13). Moreover, addressing problem behaviour at a young age diminishes the risk of the problems getting worse and interfering with child’s social and emotional development (14). Offering early intervention for children who exhibit behavioural problems, is beneficial for multiple reasons. Firstly, the problem behaviour has not yet been fully manifested, and children are still somewhat malleable at a young age. Secondly, the child’s cognitive skills are still in development, meaning that they have fewer resources to challenge or question interventions. Thirdly, parents are still the factor with the most influence on a young child, as peers and society still have limited impact on a pre-schooler (14). Therefore, to prevent child disruptive behaviour or intervene at an early stage, children need evidence-based programs that focus on ameliorating parental skills and diminishing child disruptive behaviour. Research concludes that treatments for child disruptive behaviour where parents are the primary agents of change have the most substantive evidence for effectiveness (15).
There are currently a few parent management training (PMT) programs, that focus on improving a parent-child interaction, that are being implemented worldwide (16). Within these PMT programs, research shows that the programs based on the social learning theory are most effective (15), of which the Parent-Child Interaction Therapy (PCIT) is one (17). PCIT is an evidence-based treatment that focuses on diminishing externalising child behaviour disorders by strengthening parenting skills (18). The therapy focuses on increasing positive parenting skills, whilst reducing child disruptive behaviour (19).
PCIT has been well-researched pan culturally, where effect sizes vary between 49% and 59% (20). Specifically in the Netherlands, PCIT has also shown to be effective with higher effect sizes in an RCT comparing PCIT to another Dutch treatment (M = 45.4, SD = 3.6 for PCIT, versus M = 34.0, SD = 4.93, t(23) = 6.25, p < .001) (21). Although these effect sizes indicate that PCIT is an effective treatment, the current study aims to focus on the gains that can still be achieved by letting more families benefit from PCIT by increasing the effect sizes, the accessibility, and the impact of the treatment by focusing on strengthening positive parenting skills.
Worldwide, drop-out rates vary between 12–67% (22), and specifically in the Netherlands, studies indicate that there is a high attrition and that parents have a hard time to grasp the different parenting skills. In that study, fifty-two percent of parents who received PCIT dropped out (21). Attrition rates worldwide seem to be attributed to parenting stress levels and treatment barriers (22). This indicates that treatment should focus on making parents feel more confident in their parenting, thus potentially diminishing parenting stress and – with that – dropout rates. Additionally, positive parenting skills appear to be crucial for bettering the parent-child relationship (8). A meta-analysis on PCIT shows that when skill mastery is required for completion of the treatment, child externalising behaviour was significantly lower than when this was not a requirement (20). If the parenting skills have been mastered, PCIT has shown to make impactful long-term improvements on parental warmth, responsiveness and effectiveness (19). Additionally, studies show that performance and motivation of a skill can be improved when deliberately practicing that skill (23). Moreover, parenting programs that incorporate the opportunity to practice new skills with their child, are considered more effective interventions than those where this is not the case (24). This suggests that it could be beneficial for parents to be able to practice the skills they learn in the therapy more intensely, hence potentially reducing the dropouts and magnifying the scope of the treatment. In addition, research indicate that a current obstacle in PCIT is that parents may have a hard time to grasp parenting skills, which leads them to drop-out due to the inability to fully understand and translate the parenting skills to their home-setting (21). Therefore, to bridge the gap between practicing the skills in the therapy, and applying the skills in a home-setting, the current study will implement a Virtual Reality (VR) element. Over the past years VR has become increasingly popular within the mental health care sector, as it creates opportunities that would otherwise not be possible (25).
VR offers multiple advantages in the field of psychological research. Firstly, a stimuli can be presented in three dimensions (25). Secondly, a virtual environment can be manipulated and controlled to create scenarios for participants, whereas in a real-world environment, there are always variables present that cannot be controlled (26). Thirdly, VR technology is designed for immersion, meaning that the created virtual world becomes the real world for a moment (27). Clearly, VR is an experience generator that opens up possibilities to create experiences that would otherwise not be possible (27). Thus far in psychology and psychiatry, VR has been an effective tool in the treatment of anxiety disorders, PTSD, schizophrenia, eating disorders, and substance abuse disorders (28). It is most commonly used in exposure-based therapy and for behavioural skills training (29). Considering the current study, we will focus on the use of VR for the behavioural skills training of parents. The goal of a behavioural skills training is to teach certain skills in order to apply them to multiple environments (30). When using VR for behavioural skills training, the goal is to create an environment where skills that are currently found difficult to master, are practiced in VR. A study regarding developing mindfulness skills for borderline personality disorder has shown that practicing mindfulness within the virtual environment creates the opportunity to generalise the skills to the natural context outside of therapy (31). Additionally, it has also been shown that practicing and training skills for dangerous situations, such as fire hazards in a virtual environment was also effective (30). These studies are precedents of how it is possible to apply VR to practice and train skills in a virtual environment. Thus, this study aims to implement VR as a low-threshold opportunity for parents to practice the skills they are taught in the therapy, on their own time, within the context of their own home.
To date, no study has previously implemented VR to improve positive parenting skills in PCIT or other PMT programs. However, considering that studies indicate that a current attrition obstacle in PCIT is that parents may have a hard time to grasp the parenting skills, the addition of VR as a tool to practice skills, which can henceforth be generalised to a person’s natural context, seems to be a good addition to the therapy. Nonetheless, research suggests that VR should and could in no way replace the clinician, but rather it be integrated in the therapy in order to enhance the intervention (32). Therefore, the implementation of VR within PCIT creates an accessible platform for parents to further grasp the positive parenting skills, thus increasing the potential for PCIT to have an impactful and lasting effect. The research group involved in this project, have previously tested this VR-concept for PCIT with a test 360-degrees video showing the PCIT-skills (33). This was consequently evaluated by PCIT-therapists and the researchers. All therapists and researchers were enthusiastic about the prospect of adding this VR-element to the therapy, creating the additional opportunity for parents to practice (33). For example, if parents are divorced and do not always have their child with them, they can practice the parenting skills nonetheless through VR. Therefore, the purpose of implementing PCIT-VR is to magnify the scope and give parents an easy opportunity to solidify the positive parenting skills in the comfort of their own home.
Aims
The primary goal of this research project is to evaluate the implementation of VR to PCIT. We expect to find that PCIT-VR will ameliorate positive parenting skills, leading to faster skill mastery. We believe that if the positive parenting skills are trained more frequently by implementing the VR-element, additional effects will also take place, such as achieving Child-Directed Interaction (CDI)-skill mastery sooner than when not using VR and increasing treatment completion rate. We expect that by implementing a VR-element, it will innovatively magnify the scope of families (for example for split families with separated parents) who can benefit from PCIT. In addition, parental stress, child disruptive behaviour and analytics of VR will be secondarily measured.
As a whole, PCIT-VR is developed as an enhanced version of PCIT, where focus lies on ensuring that parents practice and learn positive parenting skills intensely. This is done by incorporating practicing with VR as an integral part of the therapy. The threshold to practice skills at home using VR is low, as parents are simply able to use their mobile phones. PCIT-VR create the opportunity for parents to practice and become familiar with the skills they have been taught in the therapy sessions, in the comfort of their own home. The implementation of VR functions as an additional ‘skill training’. Providing families with PCIT-VR at an early age and early stage, can potentially prevent them from needing more intensive help at a later stage and can possibly minimise the impact of child disruptive behaviour – not only on the long run, but also during the therapy itself.
Secondary objectives are effects that we expect as a result of the overall amelioration of positive parenting skills that cause both parental stress and child disruptive behaviour to diminish. Therefore, we secondarily expect that the total amount of PCIT sessions will diminish, and we believe that the overall completion of treatment will increase. Secondary objectives also include positive VR-experiences and general therapy satisfaction. Furthermore, we expect that PCIT-VR will secondarily lead to a better quality of parent-child relationship. We expect that the effects of PCIT-VR are further maintained and engrained on the long-term due to the additional skills training provided by the VR scenarios.