A Case Study of Parent-Child Interaction Therapy for a Young Child with Autism Spectrum Disorder: Behavioral and Developmental Considerations

Externalizing behaviors and impairments in communication and adaptive functioning are the core defining features of the autism spectrum disorder (ASD). They are also the primary focus of interventions for children with ASD, as these conditions impact both the child’s adaptive behavior and parental mental health. This study examined the effectiveness of Parent-Child Interaction Therapy (PCIT) utilizing a case study of a 4-year-old boy diagnosed with ASD and comorbid disruptive behavior disorder. Behavioral observation data and psychometric tools with ecological validity were used across all assessments to evaluate intervention outcomes as assessed by the caregiver and the teacher. Results of both caregiver and teacher reports and observations indicated that 1) PCIT was effective in decreasing disruptive behaviors and improving parenting skills while reducing parental stress, and that 2) intervention gains had been maintained at the 3-month follow-up. Although the nature of this single case experimental study is a limitation, this article replicates and advances previous research examining PCIT success with children with autism and their parents while providing clinical implications for improving children’s adaptive behavior in a short time. a case to


Introduction
Autism spectrum disorder (ASD) is a lifelong developmental disability characte-rized by pervasive deficits in social understanding and communication, poor adaptive functioning, and the presence of stereotypical behaviors and interests (American Psychiatric Association, 2013). Although behavioral abnormalities in children with ASD are diagnosed in early childhood; certain dysfunctional behaviors may become more apparent as children mature and external expectations increase beyond their coping resources and parental or educational support. The frequency of ASD diagnoses continues to rise, with some studies suggesting that 1% of the global population has ASD (Centers for Disease Control and Prevention, 2014). The estimated prevalence of ASD in the United States is 1 in every 59 children aged eight years, with four times as many boys affected as girls (Baio et al., 2018). Additionally, ASD prevalence in Europe appears to be close to the prevalent estimates recorded in the United States and Asia (Duchan & Patel, 2012). As the prevalence of ASD has been rapidly increasing during the few last decades, it has become a critical public health concern. Problems associated with ASD include lifelong care and education costs related to high rates comorbidity and stress throughout development (Wood & Gadow, 2010).
Studies suggest that 50% -80% of children and adolescents with ASD-including higher-functioning individuals-present with comorbid disruptive behavior (Bauminger, Solomon, & Rogers, 2010;Kanne & Mazurek, 2011) beyond the core symptoms associated with ASD. Furthermore, approximately one in four diagnosed children meet full diagnostic criteria for disruptive behavior disorder (Masse, McNeil, Wagner, & Quetsch, 2016;Kaat & Lecavallier, 2013), which represents one of the most common reasons for referral to mental health clinics. Studies indicate that the prevalence of comorbid behavior difficulties is significantly higher in individuals with ASD than in the general population (Mannion & Leader, 2013). However, the exact prevalence of clinically significant behavior problems in children with ASD cannot be successfully estimated, as such studies typically include clinically referred samples (Brereton, Tonge, & Einfeld, 2006), and diverging conceptualizations of "problematic behavior".
As is common in ASD research, the nature and severity of behavior problems vary considerably among individuals, depending on age, cognitive development, and social capabilities (Wijnhoven, Creemers, Vermulst, & Granic, 2018). Specifically, toddlers and young children with ASD show a variety of co-occurring externalizing behavior, ranging from hyperactivity to physical aggression and defiance; older children and adolescents, however, demonstrate comorbid clinical concerns such as obsessive-compulsive disorder, depression, oppositional defiant disorder, conduct disorder, tic disorders, and sleep problems (Hartley, Sikora, & McCoy, 2008). If left untreated behavior problems in childhood become established and can cause barriers to learning and socialization, impeding intervention progress (Lindor, Sivarathan, May, Stefanac, Howells, & Rinehart, 2019 ASD intervention literature indicates that early identification and developmentally appropriate treatments remain urgent clinical and educational priorities; this is particularly true for children younger than age three, as their increased brain plasticity allows for quicker and greater behavior changes (Dawson, 2008). Despite the many behavioral and educational treatments that have been developed for ASD (Papadopoulos, 2018), the American Psychological Association (APA) only recognizes a few interventions as efficacious or potentially efficacious (McLeod, Wood, & Klebanoff, 2015). Applied behavior analysis and early intensive behavioral intervention have been implemented as evidence-based treatments for children with ASD. These aim to increase functional behavior, teach new skills, and reduce symptom severity (Butter, Mulick, & Metz, 2006;Van Steensel, Bogels, & Perrin, 2011). However, such behavioral interventions have been criticized for their generalization of teaching skills, lack of developmental perspective, and high treatment costs (Tews, 2007).
Hence, in moving toward more effective interventions, behavioral treatments have become more flexible and more natural (e.g., skills building in a natural setting), integrating developmental orientations involving caregivers in skills training and including child-led play and developmental learning experiences (Schreibman et al., 2015).
The elements of Parent-Child Interaction Therapy (PCIT) in ASD treatments focus on the importance of parent and family involvement as "best practices that should be incorporated into any services offered to children with ASD" (Smith & Iadarola, 2015). As a growing number of clinicians seek rapid and efficacious interventions to treat disruptive behaviors of children with ASD, PCIT has shown substantial positive effects on parent and child behavior (Bagner & Eyberg, 2007). Promising preliminary research indicates that PCIT successfully reduces externalizing behavior and increases the socio-emotional reciprocity of children with ASD that display differing levels of intellectual and social functioning (Scudder, Wong, Ober, Hoffman, Toscolani, & Handen, 2019;Ginn, Clionsky, Eyeberg, Warner-Metzger, & Abner, 2017). However, more research is needed to determine whether PCIT is an effective treatment for children on the autism spectrum with co-occurring behavioral difficulties and their families.

Parent-Child Interaction Therapy (PCIT)
PCIT is an empirically supported intervention designed to treat behavioral, emotional, and developmental disorders in children aged 2 to 7 years old; this intervention integrates perspectives from play therapy and attachment theory (Lienaman, Brabson, Highlander, Wallance, & McNeil, 2017). Research has documented PCIT efficacy for 3 to 6 years post-treatment (Budd, Hella, Bae, Mayerson, & Watkin, 2011). PCIT strengthens the parent-child relationship by fostering positive parenting skills, which, in turn, results in positive child out-D. Papadopoulos ria at the age of 40 months by a pediatric mental health multidisciplinary team. Further, during the identification procedure an IQ assessment using the Wechsler Preschool and Primary Scale of Intelligence-Third Edition was conducted in order to ensure that the child's overall level of intellectual abilities fell within the average range.
According to the initial PCIT assessment, Aris was identified as having a disruptive behavior disorder (not otherwise specified) in addition to ASD. Presenting concerns included physical aggression and defiance toward parents, teacher, and classmates, noncompliance with social rules, and an inability to successfully engage in social interactions; these issues manifested in various social contexts.
Aris and his family received several treatments before they brought him to the clinic, including speech and occupational therapies, parent consultations, and special education.
Aris' parents described him as a difficult child with strange and oppositional behaviors; these include difficulty in making transitions, in self-managing unexpected changes in his daily routine, and in coping when his parents tell him "no." In such cases, he would hit his parents, scream, and kick his legs; these behaviors were very difficult for his parents to control and manage effectively. In the kindergarten classroom, he had difficulty engaging in conversation with peers and had major issues in effectively attending the general curriculum and meeting academic goals; he frequently ran away from the class.

Developmental and Psychosocial History
Aris was a full-term healthy boy who was delivered with no complications and cried after birth. There were no medical or sensory concerns aside from seasonal allergies and sleep issues. As he grew older, Aris began waking during the night to join his parents in their bed, which resulted in fewer sleeping hours than recommended for a child of his age. His pediatrician prescribed melatonin to improve his sleep, but his parents decided not to administer it. Aris reached the normal fine motor development milestones on time, but his planning and sequencing abilities were slightly delayed. Additionally, his acquisition of communicative and language milestones was severely impaired, which is consistent with the development of children with ASD, as reported in previous studies (Leasack, Bearss, Celano, & Sharp, 2014).
Aris was assessed for early intervention at the age of 36 months; speech and occupational therapy were provided for 90 minutes each week, with limited results. During this time, Aris began exhibiting certain non-functional habits and severe disruptive and repetitive behaviors, particularly when being told to stop a preferred activity and follow a teacher's directions or when staying with a group of children during school activities.
Regarding social development, Aris demonstrated severe impairment in the theory of mind abilities (e.g. difficulty of understanding others' beliefs, desires and emotions) required for socialization. Parents reported that his play tended Psychology to be focused only on his interests (e.g., cars or dinosaurs), although he did, at times, play appropriately with peers. The parents utilized several behavioral practices, including discipline methods, positive reinforcement, and visual supports. However, these were only effective in managing his behavior for short periods and were not useful in managing his behavior or helping him cope with his emotional dysregulation.

Procedure, Setting and Therapist
After the initial assessment provided evidence of significant behavioral difficulties, the Institutional Board of the Greek Association of Mental Health for Children and Adults approved the implementation of PCIT for this single case experimental study . Informed written consent was obtained from the parent of the child for the publication of this case study. Treatment commenced after the parents completed baseline assessments that included information on child and parent functioning. Post-treatment data were gathered one week after the graduation session in which the caregiver met mastery criteria. Follow-up data were collected at 12 weeks posttreatment.
Sessions took place late on Friday afternoons, allowing Aris to attend weekly PCIT sessions without missing any school days. However, his father's work obligations hindered his PCIT participation. PCIT sessions were held in a playtherapy room connected to an observation room with a one-way mirror for coaching sessions; two video cameras were in the corner of the playroom. Toys used in this study were selected based on PCIT recommendations. During PDI, the observation room was used as a time-out room after removing any dangerous items. The cost of the sessions was covered by the family's health insurance plan and the clinic was close to Aris home, which was an important accommodating factor. PCIT treatment was provided by the author, a doctoral-level researcher in child development and certified cognitive-behavior therapist with experience in PCIT. Co-therapists included two master students in psychology. Therapists were under the supervision of a certified PCIT therapist as needed. Weekly supervision meetings retained fidelity to this treatment. All treatment sessions were videotaped, chosen randomly for observing, and then coded by the therapists to ensure interrater reliability.

Eyberg Child Behavior Inventory (ECBI; Eyberg & Pincus, 1999)
The ECBI is a 36-item comprehensive scale that uses parents' ratings of a child's behavior and includes two separate scores for "Intensity" and "Problem" scales.
The reliability and validity of the scale for assessing the severity of problematic behaviors in children ages 2 -16 have been established. The ECBI intensity scale measures the frequency of behavior problems using a 7-point Likert-type scale (1 = never to 7 = always), while the problem scale measures how problematic the behavior is by using "yes" or "no" responses from the parent. Both scales have been found to be stable over time and sensitive to the intervention effects. In the current study, ECBI scores were combined using resolved T-scores, with a Tscore > 60 considered as clinically significant.

Sutter-Eyberg Student Behavior Inventory-Revised (SESBI-R; Eyberg & Pincus, 1999)
The SESBI-R is a 38-item scale using teacher ratings to measure the intensity of various behaviors in children aged 2 -16 years. SESBI-R is based on a 7-point Likert-type "Intensity" scale that assesses common behavioral problems, and a "Problem" scale on which the teacher indicates whether different behaviors are currently a problem using "yes" or "no" responses (0-1). A forward-backward translation process was used to translate the ECBI and the SESBI-R into Greek (Beaton, Bombardier, Guillemin, & Ferraz, 2000).

2002; Greek Version: Achenbach & Rescorla, 2009)
The CBCL1 1 2 -5/C-TRF1 1 2 -5 are parent/teacher rating scales measuring the severity of internalizing and externalizing behavior and emotional states in everyday situations across home and school in children aged 18 months to 5 years.
Both forms require respondents to rate 100 items on a Likert-type scale (0 = not true, 1 = somewhat or sometimes true, 2 = very true or often). The scores are summarized into total behavioral problems, internalizing and externalizing problems, and syndrome scales, as well as into DSM-oriented scales with T-scores higher than 65 considered within the clinically significant range for all ages. Both CBCL1 1 2 -5/C-TRF1 1 2 -5 have well-documented psychometric properties.

Parenting Stress Index-Short Form (PSI-SF; Abidin, 1995)
The PSI-SF is a self-report measure of stress in the parent-child dyad designed for parents of children under 12 years. It comprises 36 items in three subscales: 1) parental distress (PSI-SD), 2) parent-child dysfunctional interaction (PSI-PCD-I), and 3) difficult child (PSI-DC). PSI-SF statements are rated on a 5-point Likert-type scale ranging from "strongly agree" to "strongly disagree"; a total stress score above 90 is clinically significant. The test-retest reliability coefficients for the total stress score ranged from .65 to .96. The PSI-SF total raw score was used at baseline and at post-treatment to assess the effects of PCIT on overall parenting stress. The PSI-SF was translated from English into Greek us-ing the forward-backward translation method (Beaton et al., 2000).

Behavioral Observations Dyadic Parent-Child Interaction Coding System (DPICS; Eyberg, Nelson, Duke, & Boggs, 2005)
The DPICS is a behavioral observation coding system created for use with PCIT in research and clinical settings;extensive psychometric data are included in the DPICS manual (Eyberg et al., 2005). DPICS assesses the quality of parent-child interactions during three 5-minute standardized play situations at the outset of each session using a video coding system. In this study, DPICS was used across all assessments and on both phases of PCIT (CDI and PDI) to measure changes in parent skill acquisition. Similar to previous PCIT studies (Agazzi et al., 2013;Budd et al., 2011), composites of "Do" skills (labeled praise, reflection, and behavior description), and "Don't" skills (questions, commands, and negative talk) were developed to teach desired parental behavior and behavior to be avoided during child-led play throughout PCIT. The DPICS was translated from English into Greek using the forward-backward process (Beaton et al., 2000).

Treatment
In keeping with the PCIT protocol (Eyberg & Funderburk, 1999), treatment involved of the two separate phases: CDI and PDI. Aris and his mother attended 19 weekly 1-hour sessions over approximately five months, which is close to the average length of treatment in studies examining PCIT for children with ASD and behavior disorders (Lienaman et al., 2017). Three of these sessions included initial behavioral observations, and CDI and PDI didactic sessions were held with the mother alone.
During the CDI teaching session, the parent learned how to allow Aris to lead during his special play time and to respond to his positive behavior by implementing positive parenting (Do) skills (labeled praise, description, and reflection). The parent was also taught to ignore minor inappropriate behaviors (e.g., crying or whining); for severe disruptive behaviors, the parent was instructed to immediately stop playing and do the same activity the next day.
The parent further learned how to avoid giving orders, asking questions, or using negative comments. The therapist coached the parent via Bluetooth technology through a one-way mirror, while listening to the dialogue between the parent and the child. Aris enjoyed playing with his mother; however, at CDI 4, he had difficulty engaging in play with his mother, indicating that the child's disruptive behavior had negative impact on the use of parenting skills by the caregiver.
The mothers' CDI skills were documented during the first five minutes of each session using the DPICS and her progress was supported via coaching until the caregiver had mastered these skills (see Figure 1 for the mothers' CDI progress). At CDI 7, the mother reached mastery criteria-defined as 10 labeled praises, 10 behavioral descriptions, and 10 reflections-within the 5-minute observation period, which required the move to the next phase, PDI.
During PDI, the parent learned to implement effective discipline strategies.
Specifically, throughout the PDI didactic session, the mother was coached on how to give developmentally appropriate direct commands and how to respect the time-out sequence, while the therapist encouraged the parent to practice this knowledge and receive the relevant feedback. In the next sessions, Aris was introduced to the time-out protocol through role-playing using a teddy bear, as recommended in the PCIT manual. In the first stages, the parent only used PDI during special play; however, as she gradually corrected and implemented the PDI skills, the parent broadened the range of these commands to various settings in the natural environment. PDI skills mastery was met when 75% of the caregiver commands were directly followed by labeled praises, dependent on the child's appropriate behavior to her demand.
Aris quickly learned to comply with the parent's effective commands and a structured time-out procedure was followed only on one occasion (PDI session 7; hitting mother and screaming). PDI was implemented at home during special playtime; then, the mother expanded PDI to cleanup following a special play, and eventually to Aris' regular routines (e.g., brushing teeth). The PCIT House Rules protocol was applied to reduce the child's disruptive actions. The parent selected a behavior to treat, and then taught the child the House Rules.
In Aris' case, the rule was "no hitting" and any violation led to immediate timeout, which yielded significant results in reducing his aggressive behavior.

Baseline Data
The parent and teacher completed baseline measures of Aris' behavior functioning; clinically significant behavioral problems in various situations were recorded on both the Intensity and Problem scales on the ECBI and SESBBI-R (in each case, T-score > 60; Table 1). In addition, for the CBCL 1 1 2 -5/C-TRF 1 1 2 -5, both parent and teacher rated the child's behavior within the clinical range on the following DSM-oriented scales: Pervasive Developmental Disorder, Attention Deficit/Hyperactivity, and Oppositional Defiant Problems (in each case, T-score > 70; Table 1). Regarding maternal mental health, a total raw-score of 98 on the PSI-SF was reported by the mother, indicating clinically significant stress (Table 1). Additionally, maternal behaviors were coded during baseline DPICS situations; the parent's use of Do skills was limited, reflecting weakness in the parent-child interactions.

Intervention Outcomes
In terms of caregiver behavior, maternal use of 'Do' skills continued to improve at post-treatment DPICS observation, indicating gains in parent-child interaction ( Figure 3). This resulted in improvements in parent and teacher-rated behavioral problems. As expected, the ECBI Intensity and Problem scales showed that scores were within the normal limits, indicating a marked decline on both the Intensity scale (T = 50) and Problem scale (T = 48; Table 1). Similar trends were observed across the SESBI-R scales (Table 1), where the teacher rating declined to within the normal range (T = 52 for Intensity and T = 50 for Problem). -5/C-TRF1 1 2 -5, which indicate a decrease in emotional and behavioral difficulties across most areas, compared with the baseline score. As shown in Table 1, at post-treatment, the CBCL1 1 2 -5 parent ratings were within the average range for Affective Problems (T = 56), Anxiety Problems (T = 57) and Oppositional Defiant Problems (T = 58); teacher ratings on the C-TRF1 1 2 -5 were reduced for Affective (T = 57) and Anxiety Problems (T = 54). A significant reduction was observed in the parent total stress score on the PSI-SF (raw score = 70; Figure  4), indicating significant improvement in maternal emotional state.

Follow-Up Outcomes
A 12-week follow-up was conducted with Aris' mother and his new teacher (see Table 1 for summary). The ECBI scores were still within the nonclinical range for both the Intensity (T = 48) and Problem scales (T = 46). The teacher report on the SESBI-R was within the normal range (Intensity: T = 50, and Problem: T = 48), which reflected the current perspective of the elementary school teacher, rather than his teacher during PCIT treatment. CBCL1

Discussion
This study is the first of its kind from Greece that is written in English, describing the PCIT treatment for a child with ASD and a co-occurring behavioral problem, while bridging an evidence-based therapy to Eastern Europe. Furthermore, the participating clinic was the first to implement the intervention in Greece. To the best of the author's knowledge, there have been very few studies in Europe to examine the effects of PCIT; additionally, existing studies include mainly children without ASD (Bjørseth & Wichstrøm, 2016). This case study provides evidence that PCIT is effective in prompting several improvements in a child's behavioral functioning as well as in parent's skills. It is also indicates that PCIT reduces parental stress, as measured from baseline to post-treatment and maintained for a 3-month period. The case was a unique opportunity to test PCIT's developmental and behavioral-related benefits.
First, substantial changes in parenting skills were demonstrated during treatment by both observation measures and the self-reporting tool. As expected, a notable increase was observed during CDI; moreover, the skills of the caregiver continued to improve during PDI, and these skills remained proficient at the follow-up. Specifically, when the mother engaged with the child in a child-led play activity, she was able to learn and incorporate greater use of "Do skills," including labeled praise, behavioral description and reflection, and less use of commands and negative verbalizations. These findings are consistent with previous PCIT studies indicating that parent training interventions are effective in strengthening the parent-child relationship in families with ASD (Timmer, Ho, Urquiza, Zebell, Garcia, & Boys, 2011;Scattone, Sarver, & Cox, 2018).
From a developmental perspective, research has shown that children with ASD tend to show insecure and disorganized attachments and fewer contact seeking and maintaining behaviors with caregivers (McKenzie & Dallos, 2017;Teague, Gray, Tonge, & Newman, 2017); this negatively impacts parent-child communication and emotional connectedness (Thomas & Zimmer-Gembeck, 2007). Building warm and positive parent-child relationships-which is the focus in the CDI phase of PCIT-is critical for establishing attachments with caregivers (Bowlby, 1969) that allow children to build trust. In turn parents' responsiveness to the children's emotions and behaviors increases (Thomas & Zimmer-Gembeck, 2011). In this case, parental stress-as reported on the PSI-SFwas significantly reduced between pre-and post-treatment, demonstrating that the caregiver was less frustrated with the child. This finding is consistent with studies demonstrating PCIT's ability to reduce parental stress caused by dysfunctional parent-child relationships (Hosogane, Kodaira, Kihara, Saito, & Kamo, 2018;Timmer, Zebell, Culver, & Urquiza, 2010). Parent-training programs improve parental factors considering children with behavioral and emotional problems (Eyberg, Nelson, & Boggs, 2008), and hence, this study adds to the literature by showing that essential parenting mechanisms can be modified within ASD treatment.
Second, as it was expected, PCIT led to significant reductions in the child's disruptive behavior. This reflected improvement in his emotional regulation and behavioral functioning, as measured by the ECBI/SESBI-R and CBCL1 1 2 -5/C-TRF1 1 2 -5 at post-treatment and at follow-up. From a behavioral perspective, the outcomes of this study are consistent with PCIT research, showing its effectiveness in reducing behavioral problems in children with developmental disorders when complying with the core elements of treatment (Leasack et al., 2014;Solomon, Ozonoff, Carter, & Caplan, 2008;Bagner, & Eyeberg, 2007 and Agazzi et al. (2013). These case studies also employed PCIT for families with children with ASD, and indicated behavioral improvements close to those of children without ASD who received PCIT (Ware, McNeil, Masse, & Stevens, 2008).

Limitation and Future Research
This case study contributes to the relevant literature by presenting evidence supporting the effectiveness of PCIT in a different cultural group from which the original intervention was tested; however, some limitations must be addressed.

Clinical Implications
This case study's results have several clinical implications. The evidence from the current study suggests that visualizing and sharing weekly graphic reports of ECBI and DPICS data were useful in helping the caregiver improve her CDI skills and encouraging her efforts. In clinical practice, this method is strongly recommended in order to enhance parents' awareness of ways to foster their relationship with their child, resulting in an increased level of positive affect in their interaction. Additionally, practitioners may find it useful to engage school staff in the treatment strategies by introducing consultations with the teachers; this would ensure that the child receives consistent messages across settings regarding appropriate and inappropriate behaviors.
Furthermore, formal training in Teacher-Child Interaction Therapy (McIntosh, Rizza, & Bliss, 2000) using PCIT techniques may help reduce aggressive behaviors and increase student compliance. In the present study, the preschool teacher contributed to this effort by creating a reinforcement system that allowed Aris to earn privileges at the end of the week based on his daily behavior in school. Further, therapists utilizing this approach will find that using additional assessment methods-such as functional assessments-prior to treatment could help in identifying individuals' social reinforcers. This may be useful for gauging the child's social behaviors in different settings (Armstrong & Kimonis, 2013). Although research has documented clinical PCIT progress within the autism spectrum, it is worth noting that it may not be helpful for children with ASD and intellectual disabilities, including children who do not understand basic instructions. Indeed, clinicians must include an initial formal assessment of children's cognitive abilities, as a child's individual developmental level is an important element influencing PCIT success. In such cases, PCIT may require additional adaptations to meet children's needs. Although parents from Greece who raise children on the autism spectrum are not familiar with the use of strict behavior-based methods such as "time-out"; this study helped the caregiver to realize that the implementation of these techniques had a positive impact on the child's behavior. Lastly, the transferability of PCIT in real-world therapy settings might be critical for both research and clinical practice (Abrahamse, Junger, van Wouwe, Boer, & Lindauer, 2016) and policymakers should consider how to make PCIT training more accessible to community mental health providers to implement empirical-based treatments for children with ASD and their families.

Conclusion
From the development and behavioral points of view, this case study provides useful preliminary evidence supporting the effectiveness of PCIT in treating a child's disruptive behavior, improving the parent-child relationship, and reducing parental stress by using positive parenting skills. In turn, the child's socio-emotional areas of development-including emotional self-regulation and socialization-were improved. These changes in the child's behavior and parental mental health increased opportunities to improve their wellbeing and to cope with the frustrations of daily life.