Children With Special Needs and Circumstances: Conceptualization Through a Complex Trauma Lens

Edward Franc Hudspeth

When conceptualizing this special issue, we had a basic idea of what might be included; however, as submissions arrived, it was evident that our basic definition of special needs was limited and could include much more when broadened. Therefore, the issue was reconceptualized as “Children with Special Needs and Circumstances.” It is my hope that when practitioners, researchers and faculty read this issue, each begins to see that the term special needs encompasses more than we think, because anything that hinders the optimal growth and development of a child constitutes a special need. In this issue, readers will find articles concerning fears, trauma, sensory processing disorder, foreign adoption, cystic fibrosis, spina bifida, homelessness, special education and parent–child interaction therapy.

Keywords: counseling, children, special needs, complex trauma

To set the stage for this special issue, to provide a foundation for understanding and to link the various articles, I encourage readers to conceptualize the impact of a special need through a complex trauma or developmental lens. Over the past 15 years, countless articles have reported and described the impact of chronic stress and adverse childhood experiences (Anda et al., 2006; Edwards et al., 2005) and the subsequent development of complex trauma. Complex and Developmental TraumaThe National Child Traumatic Stress Network (n.d.-a) has defined complex trauma as a series of traumatic experiences that are usually interpersonal in nature and lead to numerous long-term adverse effects on health and well-being. Similarly, van der Kolk, Roth, Pelcovitz, Sunday and Spinazzola (2005) described experiencing repeated traumatic events during childhood as developmental trauma. The duration and intensity of the traumatic experiences, as well as the age of onset of these experiences, can determine the outcome of both complex trauma and developmental trauma. Neuroscience research provides ample evidence of neurochemical and brain structural changes caused by complex trauma that result in affective and behavioral dysregulation (Lanius, Bluhm, & Frewen, 2011). Though the terms developmental trauma and complex trauma were originally used to represent repeated abuse or an accumulation of traumatic experiences, recent neuroscience research has extended these terms to other conditions and experiences. Copeland, Keeler, Angold, and Costello (2007) noted that a long-term physical illness may lead to complex trauma, while D’Andrea, Ford, Stolbach, Spinazzola, and van der Kolk (2012) and Finkelhor, Ormrod, and Turner (2007) reported that bullying also may lead to similar outcomes. Courtois (n.d.), as well as Ford and Courtois (2009), Vogt, King, and King (2007), and the National Child Traumatic Stress Network (n.d.-b), offered a more descriptive explanation and extensive list when they stated the following: Cumulative adversities faced by many persons, communities, ethno-cultural, religious, political, and sexual minority groups, and societies around the globe can also constitute forms of complex trauma. Some occur over the life course beginning in childhood and have some of the same developmental impacts described above. Others, occurring later in life, are often traumatic or potentially traumatic and can worsen the impact of early life complex trauma and cause the development of complex traumatic stress reactions. These adversities can include but are not limited to:

  • Poverty and ongoing economic challenge and lack of essentials or other resources
  • Community violence and the inability to escape/relocate
  • Homelessness
  • Disenfranchised ethno-racial, religious, and/or sexual minority status and repercussions
  • Incarceration and residential placement and ongoing threat and assault
  • Ongoing sexual and physical re-victimization and re-traumatization in the family or other contexts, including prostitution and sexual slavery
  • Human rights violations including political repression, genocide/“ethnic cleansing,” and torture
  • Displacement, refugee status, and relocation
  • War and combat involvement or exposure
  • Developmental, intellectual, physical health, mental health/psychiatric, and age-related limitations, impairments, and challenges
  • Exposure to death, dying, and the grotesque in emergency response work (para. 7)

Cook et al. (2005) stated that as a result of complex trauma, individuals experience impairments in (a) attachment, (b) affect regulation, (c) behavioral control, (d) cognition, (e) self-concept, and (f) sensory and motor development. Treatment recommendations include (a) being developmentally sensitive, (b) building on the safety and security of caregivers and community (e.g., teachers), and (c) addressing affective and behavioral dysregulation. Special Issue: Children with Special Needs and Circumstances The articles in this special issue provide implications for counselors and ways that specific special needs and circumstances may be addressed with individuals, families, schools and communities. In order to support the educational and emotional development of children and youth experiencing homelessness, Havlik and Bryan indicate that school counselors must first identify which students are experiencing homelessness in their school and then determine their specific needs. Some of these needs, to name a few, include violence, abuse, neglect, mental and physical health issues, and mobility issues. The authors note that once homeless children and their individual needs are identified, school counselors should engage the students within their schools and assist with collaborative efforts between school and community resources. Havlik and Bryan challenge schools counselors to seek out and participate in professional development regarding the policies related to individual needs of homeless students. Geddes Hall states that less than half of school counselor preparation programs include content related to special education in their training. Geddes Hall encourages school counselors to have a comprehensive knowledge of the specific needs of those receiving special education services, and she offers precise recommendations for how counselor educators can infuse special education content throughout a school counseling curriculum. She reflects that it is in the best interest of future school counselors, as well as the special students they will serve, to receive support and supervision during such experiences as they complete their programs. Buss, Warren, and Horton provide in-depth coverage of the short- and long-term impact of trauma on the physical, mental, emotional and social development of traumatized children that includes associated trajectories to adult mental and physical health conditions. The authors indicate that early intervention and treatment can minimize the social and emotional impact of a child’s exposure to a traumatic event. The authors also discuss the advantages of numerous evidence-based treatment strategies as well as the realistic limitations of these strategies. Across treatment methods, factors such as safety and attachment are paramount. Liu and Hazler delineate differences noted among adoptees from various countries. These differences include behavioral, social and emotional characteristics, as well as the adoptees’ proclivity to form an attachment with a primary caregiver. The authors demonstrate that pre-adoption characteristics are associated with smooth transitions during the adoption process as well as post-adoption integration. Liu and Hazler discuss ways that counselors may emphasize adoptee–parent relationships in which trust is a fundamental element. They provide specific recommendations for counselors and adoptive parents that ease the transition and support successful attachme Sheperis and colleagues acknowledge that counselors, whether working with children who have disruptive behavior or providing parenting training to families, should be knowledgeable of the application of various behavioral techniques in order to utilize them effectively and to teach them to parents. In their article, the authors review a wealth of research information related to one evidence-based method and demonstrate how this method may be useful when working with children with special needs. Sheperis and colleagues describe a session-by-session application of this model as well as report contemporary research about the model’s application to working with children with special needs. Leppma, Szente, and Brosch provide an overview of the current landscape of children’s fears to help delineate a contemporary, adaptive and holistic approach to treatment. The authors convey an image of fear and anxiety development that can be physically and mentally paralyzing for individuals who experience these states. In their treatment section, the authors outline an approach that addresses affect regulation and development of positive emotions, as well as inoculating the client against stress and supporting the development of resilience. They report on several studies that demonstrate the value of play in the development of self-efficacy, optimism and positive affect. Despite the fact that few within the world of counseling have written about the subject, Goodman-Scott and Lambert pull together many resources to conceptualize the special needs of children with sensory processing disorder (SPD). The authors provide a detailed description of the disorder and its subtypes and describe in detail appropriate assessment of the disorder. Goodman-Scott and Lambert recommend that counselors collaborate with occupational therapists in order to address the unique needs of children with SPD. They report that counselors can provide individual, group and family counseling modalities using solution-focused and cognitive-behavioral techniques to address children’s mental health needs and co-occurring disorders. Storlie and Baltrinic’s article illuminates the impact of a chronic disease on the individual, the caregivers and the counselors working with the family. They indicate that counselors working with children and families affected by cystic fibrosis (CF) should consider the physical and psychosocial challenges facing this special-needs population. The authors encourage counselors to be knowledgeable about CF so that they will be sensitive to the traumatic impact of this life-shortening disease on the child or adolescent with CF and caregivers. Storlie and Baltrinic offer suggestions for compassionate counseling as well as for avoiding compassion fatigue.  In a personal account of rearing a child with spina bifida, Richmond-Frank expresses both the successes and shortcomings that she has experienced over nearly 3 decades. The author provides a thorough account of her experience as a parent of a child with special needs, as well as what she has to teach others who may be working with a child with special needs. As a professional counselor, as well as a parent of a special-needs child, Richmond-Frank provides readers with specific and realistic suggestions. She shares that a systemic, strengths-based counseling model respects the inherent worth of the child with a disability by not presuming that he or she is the identified patient. Conclusion From the special issue editor’s point of view, issues that are prolonged, intense and cumulative, and vary over developmental periods should be conceptualized through lenses that address the complexity of intermingled systems. By failing to see this complexity and all of its aspects, we fail to fully address the complexity of children with special needs and circumstances. Conflict of Interest and Funding Disclosure The author reported no conflict of interest or funding contributions for the development of this manuscript.   References Anda, R. F., Felitti, V. J., Walker, J., Whitfield, C. L., Bremner, J. D., Perry, B. D., . . . Giles, W. H. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neurosciences, 256, 174–186. doi:10.1007/s00406-005-06244 Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., . . . van der Kolk, B. (2005). Complex trauma in children and adolescents. Psychiatric Annals, 35, 390–398. Copeland, W., Keeler, G., Angold, A., & Costello, J. (2007). Traumatic events and posttraumatic stress in childhood. Archives of General Psychiatry, 64, 577–584. Courtois, C. A. (n.d.). Understanding complex trauma, complex reactions, and treatment approaches. Retrieved from D’Andrea, W. D., Ford, J., Stolbach, B., Spinazzola, J., & van der Kolk, B. A. (2012). Understanding interpersonal trauma in children: Why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry, 82, 187–200.  doi:10.1111/j.1939-0025.2012.01154.x Edwards, V. J., Anda, R. F., Dube, S. R., Dong, M., Chapman, D. F., & Felitti, V. J. (2005). The wide-ranging health consequences of adverse childhood experiences. In K. A. Kendall-Tackett & S. M. Giacomoni (Eds.), Child victimization: Maltreatment, bullying, and dating violence prevention and intervention (pp. 8-1–8-12). Kingston, NJ: Civic Research Institute. Finkelhor, D., Ormrod, R. K., & Turner, H. A. (2007). Poly-victimization: A neglect component in child victimization. Child Abuse and Neglect, 31, 7–26. doi:10.1016/j.chiabu.2006.06.008 Ford, J. D., & Courtois, C. A. (2009). Defining and understanding complex trauma and complex traumatic stress disorders. In C. A. Courtois & J. D. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp.13–30). New York, NY: Guilford Press. Lanius, R. A., Bluhm, R. L., & Frewen, P. A. (2011). How understanding the neurobiology of complex post-traumatic stress disorder can inform clinical practice. A social cognitive and affective neuroscience approach. Acta Psychiatrica Scandinavica, 124, 331–348. doi:10.1111/j.1600-0447.2011.01755.x The National Child Traumatic Stress Network. (n.d.-a). Complex trauma. Retrieved from The National Child Traumatic Stress Network. (n.d.-b). Types of traumatic stress. Retrieved from van der Kolk, B. A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of a complex adaptation to trauma. Journal of Traumatic Stress, 18, 389–399. Vogt, D. S., King, D. W., & King, L. A. (2007). Risk pathways for PTSD: Making sense of the literature. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD: Science and practice (pp. 99–115). New York, NY: Guilford Press. Edward Franc Hudspeth, NCC, is an Assistant Professor of Counselor Education at Henderson State University and served as the guest editor for the special issue of The Professional Counselor on children with special needs and circumstances. Correspondence can be addressed to Edward Franc Hudspeth, Department of Counselor Education, Henderson State University, 1100 Henderson Street, Arkadelphia, AR 71999,

Addressing the Needs of Students Experiencing Homelessness: School Counselor Preparation

This study of 207 school counselors revealed significant relationships between types of counselors’ training, number of students in counselors’ schools experiencing homelessness, and counselors’ perceived knowledge and provision of services regarding students experiencing homelessness. In-service training and professional development, but not graduate training, were related to counselors’ knowledge of the McKinney-Vento Homeless Assistance Act and their advocacy for and provision of services to students experiencing homelessness. Differences also existed by school level and school setting. Implications of these findings are discussed.

Keywords: school counselors, homelessness, McKinney-Vento Homeless Assistance Act, advocacy, professional development

Homeless, although a difficult term to clearly define, refers to those who “lack a fixed, regular, and adequate nighttime residence” (U.S. Department of Education, 2004, p. 2). Families with children are the fastest growing homeless population in the United States, comprising one third of the homeless population (National Coalition for the Homeless, 2009). Twenty-two percent of all sheltered persons experiencing homelessness are under the age of 18, with over half of this group under the age of 6 (U.S. Department of Housing and Urban Development, 2010). Some live doubled-up with other families, in transitional housing such as shelters or in inhumane conditions (U.S. Department of Education, 2004). In 2012, the National Center for Homeless Education (NCHE) reported that 1,065,794 children in schools experienced homelessness, an increase of over 50% since 2007. The rapidly increasing figures, due in part to the economic recession in the United States, are cause for grave concern because homelessness is detrimental to the emotional, social and cognitive development and well-being of children (Coker et al., 2009; Grothaus, Lorelle, Anderson, & Knight, 2011).

Families who experience homelessness are more likely to experience separation from each other, violence and serious health conditions (National Center on Family Homelessness, 2011). Children experiencing homelessness may face high rates of abuse, neglect and mental health issues, as well as barriers that make it nearly impossible for them to succeed academically and emotionally without additional systemic supports (Buckner, Bassuk, Weinreb, & Brooks, 1999; Gewirtz, Hart-Shegos, & Medhanie, 2008; Swick, 2008; U.S. Department of Education, 2004). Due to the challenges of homelessness, students can be worse off academically and socially than their middle-class peers (Obradović et al., 2009; Shinn et al., 2008). Unlike most of their peers, they may lack supports such as before- and after-school services, mentors, transportation to and from school, and attendance support (Hicks-Coolick, Burnside-Eaton, & Peters, 2003; Miller, 2009; U.S. Department of Education, 2004). Higher levels of mobility and absenteeism make it difficult for homeless students to acquire a consistent education (Hicks-Coolick et al., 2003; Miller, 2009; Rafferty, Shinn, & Weitzman, 2004; U.S. Department of Education, 2004). Students experiencing homelessness, and those who are highly mobile, have lower reading and math scores from second through seventh grade than students living in poverty (Obradović et al., 2009). Further, relative to their peers, students experiencing homelessness are less likely to aspire to postsecondary education (Rafferty et al., 2004).

In response to the growing crisis among children experiencing homelessness, policymakers designed the McKinney-Vento Homeless Assistance Act (U.S. Department of Education, 2004) to provide access to education and remove barriers in order to ensure that schools address the unique needs of students experiencing homelessness. The provisions of the act require that school districts provide transportation to and from the school of origin for students experiencing homelessness, even when the students relocate to an area outside of their home school. Further, the act allows students to enroll in school immediately without the required paperwork (e.g., immunization records, educational records, lease or deed), assigns a homeless liaison to schools to ensure that provisions under McKinney-Vento are being met, and assigns a State Coordinator to coordinate services for students experiencing homelessness.

School counselors, teachers and administrators can help support students experiencing homelessness at the school level and ensure that the provisions of the McKinney-Vento Act are met. In their roles, they provide supportive services that address the academic, personal, social and career planning needs of all students (American School Counselor Association [ASCA], 2012). Interventions and services provided by school counselors include individual and group counseling, classroom guidance, academic advisement and planning, consultation with teachers and staff, collaboration with outside services, and parental support (ASCA, 2012). According to ASCA (2010), an important role of school counselors is to promote awareness and understanding of the McKinney-Vento Act and the rights of students experiencing homelessness. School counselors collaborate with other service providers in children’s education to address the academic, career planning and personal/social needs of students experiencing homelessness (ASCA, 2010; Baggerly & Borkowski, 2004; Daniels, 1992, 1995; Grothaus et al., 2011). They should be knowledgeable about the issues faced by children and youth experiencing homelessness and be equipped to provide appropriate services to these students (Grothaus et al., 2011; Walsh & Buckley, 1994). In particular, school counselors must be aware of the McKinney-Vento program requirements (Baggerly & Borkowski, 2004) and understand how to advocate for their effective implementation. However, without knowledge of the policies that impact students experiencing homelessness and the interventions necessary to help them, school counselors may find it difficult to serve this population. In order to develop comprehensive school counseling programs that systemically address the needs of children and youth experiencing homelessness, school counselors need awareness of the policies that pertain to these students, and the emotional and educational issues they face.


To date, limited research exists concerning school counselors’ knowledge of the McKinney-Vento Act, knowledge about the educational and emotional issues that homeless students face, and service provision for these students (Gaenzle, 2012). Also, limited research exists on whether school counselors receive training regarding homelessness and the source of that training, whether graduate training, in-service training or professional development. Further, little is known about the size of school counselors’ caseloads of students experiencing homelessness and whether these caseloads differ in some locations (e.g., urban schools, high schools). Given that 77% of the homeless population is found in urban areas (Henry & Sermons, 2010), perhaps school counselors in urban schools face larger caseloads and greater demands for services from students experiencing homelessness. Exploring school counselors’ knowledge, service provision and experiences regarding students experiencing homelessness would help to better focus service delivery at the school level to this student population. To this end, this exploratory study attempts to investigate school counselors’ knowledge and service provision regarding students experiencing homelessness and to examine related variables (e.g., school level, school setting, years of experience, training received). The results of this study may help to guide future research and improve counselor preparation and interventions regarding homelessness. The following questions guided this research:


  1. What is school counselors’ knowledge about
  • the McKinney-Vento Homeless Assistance Act?
  • the emotional and educational needs of students experiencing homelessness?
  1. What services and interventions are school counselors providing for students experiencing homelessness?
  2. What are the relationships of demographic and other variables (e.g., school type, school setting, school level, number of students in the school who are homeless, years of experience as a school counselor, type of training received and knowledge of location of homeless shelters) to school counselors’ knowledge and provision of services related to students experiencing homelessness?





Participants included 207 respondents from a random sample of 1,000 school counselors who were listed in the ASCA member directory. Of the participants, 72 (36.4%) worked in elementary schools, 35 (17.6%) in middle schools, 86 (43.4%) in high schools and 5 (2.5%) in both middle and high schools. Fifty-nine (29.6%) of the participants worked in urban settings, 55 (27.6%) in rural settings and 85 (42.7%) in suburban school settings. Most respondents (185 or 93%) worked in public schools while 7 (3.5%) worked in private schools and 7 (3.5%) worked in parochial schools.



The survey (see Appendix) was developed by the first author to assess school counselors’ perceived knowledge of the McKinney-Vento Act and the needs of students experiencing homelessness as well as counselors’ provision of services to these students (Baggerly & Borkowski, 2004; Strawser, Markos, Yamaguchi, & Higgins, 2000; Walsh & Buckley, 1994). The survey was piloted on 12 second-year master’s-level school counseling students at a large East Coast university who were completing their internships at the time. After students completed a paper version of the survey, they provided feedback on the clarity and comprehensibility of the survey items. Minor adjustments were made to improve clarity on several items.


Demographic items. Three items assessed school setting (urban, rural, suburban), school level (elementary, middle, high) and years of experience as a school counselor. Years of experience was reported as a continuous variable with a mean of 9.35 years (SD = 7.25) and a range from 1–31.


Training. Two items assessed training. The first item assessed the extent of training in work with students experiencing homelessness and was rated on a scale from 1 (no training) to 3 (extensive training). The second item assessed type of training (i.e., in graduate school, in-service training at their school, required professional development outside of school, voluntary professional development outside of school, two or more sources of training, and no training).


Number of students experiencing homelessness. One item measured the number of students experiencing homelessness that counselors reported as enrolled at their schools. Participants were asked to select a category that best fit the amount. The categories were 0, 1–5, 6–10, 11–15, 16–25, 26–35, 36–45, 46–55 or over 55 students.


Perceived knowledge of McKinney-Vento and emotional and educational issues. Seven Likert scale items were written specifically to assess school counselors’ perceived knowledge of the McKinney-Vento Act and the emotional and educational issues of students experiencing homelessness. Participants were instructed to rate their knowledge on a scale from 1 (no knowledge) to 5 (extensive knowledge). Items were designed to measure school counselors’ perceptions of their knowledge on specific requirements under the McKinney-Vento Act, as well as their knowledge on general emotional and educational issues affecting students experiencing homelessness.


Provision of services. Two items focused on the services and interventions that participants reported implementing with students experiencing homelessness. One item prompted participants to report the frequency of their engagement in these interventions on a scale from 1 (not at all) to 5 (always), where interventions signified nine specific services to students experiencing homelessness. The second item required school counselors to indicate any of 25 interventions provided to students experiencing homelessness, including the option I have not provided any services or interventions. The services and interventions were selected based on the McKinney-Vento requirements and the literature on education and homelessness.



Using Survey Monkey (, the survey was e-mailed to 1,000 randomly selected ASCA members selected via the ASCA member directory ( Of the 1,000 surveys sent, 80 e-mails bounced back or were invalid, while 713 recipients did not reply and 207 responded. The total response rate was 22.5%, with 19.8% (N = 182) completing all sections of the survey. Completing the survey in its entirety included filling out one qualitative section (for results see Havlik, Brady, & Gavin, 2014). Several participants did not complete this section.


Data Analysis

Descriptive analyses. To answer research questions one and two, we examined frequencies and means of school counselors’ responses to survey items.


Analyses of variance (ANOVAs). To answer question 3, we conducted four one-way ANOVAS: (1) one to examine whether elementary, middle and high school counselors differed in the extent of training they received for working with students experiencing homelessness; (2) a second to examine whether urban, rural and suburban school counselors differed in the extent of training they received for working with students experiencing homelessness; (3) a third to examine whether elementary, middle and high school counselors differed in the number of students experiencing homelessness at their school; and (4) a fourth to examine whether urban, rural and suburban school counselors differed in the number of students experiencing homelessness at their school.


Regression analyses. To answer the fourth research question, we conducted simultaneous multiple regression analyses to examine the relationships among the demographic variables (e.g., school setting, school level, number of students experiencing homelessness at school, years of experience as a school counselor, type of training received) and school counselors’ knowledge and provision of services related to students experiencing homelessness.


Factor analysis. Prior to conducting the multiple regression analyses, we conducted a principal component analysis (PCA) of the seven items assessing counselors’ perceived knowledge of McKinney-Vento and students’ emotional and educational needs, and the nine items assessing the extent to which counselors provided nine specific services for students experiencing homelessness (see Tables 1 and 2). The PCA with varimax rotation was conducted as a data reduction method (Costello & Osborne, 2005) to determine how participants’ responses were structured. The components or factors derived from the PCA comprised the dependent variables in the study. Decisions to retain the factors were based on (a) the scree test, (b) eigenvalues greater than one (Kaiser criterion) and (c) the conceptual meaning of each item.


Post hoc analyses. One-way ANOVAs and Crosstabs analyses were used to take a closer look at any interesting findings from the multiple regression analyses.




Descriptive Analyses

In Table 1, we present the means and standard deviations for the 16 items used to assess school counselors’ knowledge and provision of services regarding students experiencing homelessness.


Question 1a: Perceived knowledge of McKinney-Vento. The average response to the five items that assessed school counselors’ knowledge of McKinney-Vento was 2.90 (SD = 1.38), slightly below the midpoint of 3 on the 5-point scale (1 = no knowledge to 5 = extensive knowledge). More specifically, school counselors reported about average knowledge of the McKinney-Vento Act (M = 2.86, SD = 1.47). They also reported lower levels of knowledge of the role of the State Coordinator (M = 2.04, SD = 1.19), but slightly above average knowledge of the role of the homeless liaison (M = 3.19, SD = 1.45). Counselors reported above average knowledge of registration policies for students experiencing homelessness (M = 3.45, SD = 1.25), and about average levels of knowledge of transportation requirements (M = 2.97, SD = 1.53).


Table 1


Means, Standard Deviations and Factor Loadings of Knowledge and Provision of Services

Factor loadings








Knowledge of McKinney-Ventoa 2.86





I review the McKinney-Vento Act policies to ensure homeless students’ needs arebeing metb 2.77





Knowledge of transportation requirements under McKinney-Ventoa 2.97





Knowledge of role of the State Coordinatora 2.04





I have contact with my school’s homeless liaisonb 3.48





Knowledge of the role of the homeless liaisona 3.19





Knowledge of registration policies for homeless studentsa 3.45





I assess the emotional needs of homeless studentsb 3.86





I make contact with homeless familiesb 3.42





I ensure that homeless students with whom I work have equal opportunitiescompared to their non-homeless peersb 4.31





I assist with the registration of homeless studentsb 3.45





I ensure that homeless students have transportation to attend before- or after-schoolprogramsb 3.01





I provide mentorship programs for homeless students at my schoolb 2.43





I visit shelters where homeless students at my school liveb 1.44





Knowledge of emotional/social issuesa 3.85





Knowledge of educational issuesa 3.87





a On these items the scale ranged from 1 = no knowledge at all to 5 = extensive knowledge.

b On these items the scale ranged from 1 = not at all to 5 = always.



Question 1b: Perceived knowledge of emotional and educational issues. The average response to the two items written to assess school counselors’ knowledge of emotional and educational issues faced by homeless students was 3.86 (SD = 0.97), above the midpoint of 3 on the 5-point scale used (1 = no knowledge to 5 = extensive knowledge). School counselors reported above average knowledge of emotional issues (M = 3.85, SD =. 97) and knowledge of educational issues (M = 3.87, SD = .955), suggesting that counselors may perceive themselves as fairly knowledgeable about the emotional and educational issues faced by students experiencing homelessness.


Question 2: Provision of services and advocacy. The average response to the nine items written to assess school counselors’ provision of services was 3.10 (SD = 1.35), slightly above the midpoint of 3 on the 5-point scale used (1 = not at all to 5 = always). School counselors provided responses close to average regarding their frequency of assisting with registration (M = 3.20, SD = 1.58). Their responses were above average for their frequency of assessing the emotional needs of students experiencing homelessness (M = 3.86, SD = 1.21). However, most school counselors reported infrequently conducting shelter visits (M = 1.44, SD = .88) or providing mentorship programs (M = 2.43, SD = 1.34). The highest average was of school counselors’ reports on the extent to which they ensured equal opportunities for students experiencing homelessness (M = 4.31, SD = 1.04).


Types of interventions. In response to the item that requested for participants to report on their engagement in 25 types of interventions provided to students experiencing homelessness, nearly 70% of all participants reported making referrals to community resources (69.5%) and providing individual counseling (68.0%). Other frequent interventions reported included providing academic support (57.9%), teacher consultation (52.8%), parent consultation (50.3%) and advocating for homeless students (43.7%). Interventions infrequently reported included parent education workshops (6.6%), workshops/training for teachers (7.1%), behavioral skills training (13.7%), mentor programs (16.2%), communicating with shelter staff (17.8%), after-school programs (20.3%), college planning (21.8%), small group counseling (22.8%) and IEP (Individualized Education Program) planning (23.9%). Only 3% of counselors reported conducting shelter visits, while 13.2% of school counselors reported not providing any services at all to students experiencing homelessness.



Question 3a: Training received for working with students experiencing homelessness. No significant differences existed among school counselors by school level or school setting in the extent of training received for working with students experiencing homelessness.


Question 3b: Number of students experiencing homelessness at their school. No significant differences existed among elementary, middle and high school counselors in the number of students experiencing homelessness at their schools. However, significant differences existed among urban, rural and suburban school counselors in the number of students at their schools experiencing homelessness, F(2, 196) = 7.14, p = .001, with a very small effect size, η2 = .07. Urban school counselors had significantly higher numbers of students experiencing homelessness (M = 3.09, SD = 2.34) than rural (M = 1.98, SD = 1.82) and suburban (M = 1.89, SD = 1.72) school counselors. A rating of 3 is equivalent to 11–15 students, a rating of 2 is equivalent to 6–10 students, and a rating of 1 is equivalent to 1–5 students experiencing homelessness.


Principal Component Analysis

A PCA of the 16 items resulted in three components or factors, which were the dependent variables in subsequent regression analyses. A four-factor model was initially considered; however, the three-factor model was selected based on the scree test and eigenvalues greater than one. The Kaiser-Meyer-Olkin measure of sampling adequacy was .88, indicating that factor analysis of these variables was appropriate. Barlett’s Test of Sphericity was significant, indicating that the items were excellent candidates for PCA. The factor loadings of each factor are presented in Table 1. Factor 1, perceived knowledge of McKinney-Vento, comprised seven items with factor loadings ranging from .83–.51 with 24.2% of the variance explained and a Cronbach’s alpha of .91. Items loading on this factor measured school counselors’ perceived knowledge of McKinney-Vento and the policies that schools must implement under McKinney-Vento. Factor 2, advocacy and provision of services, comprised seven items with factor loadings from .45–.81 with 21.19% of the variance explained and a Cronbach’s alpha of .81. Items on this factor described services and forms of advocacy that school counselors provided for students experiencing homelessness. Factor 3, perceived emotional and educational issues, comprised two items with loadings of .87 and .83 with 17.78% of variance explained and a Cronbach’s alpha of .96. Factor scores were created for each factor using the regression method approach so that participants had a score on each factor. The factor score is a linear combination of the items that load on that factor and is a standardized score. Therefore, the three factors used in the following regression analyses were standardized variables, each with a mean of zero and a standard deviation of one.


Multiple Regression Analyses

Following the PCA, we conducted three simultaneous multiple regression analyses with each factor serving as a dependent variable in each regression. The B coefficients and standard errors for each regression analysis appear in Table 2.


Table 2


Regression Analyses of Variables Related to School Counselors’ Knowledge and Service Provision Regarding Students Experiencing Homelessness


Perceived knowledge of McKinney-Vento

Knowledge of emotional and educational needs

Advocacy and provision of services




























High (reference category)







Private/parochial (reference category)














Suburban (reference category)
Years of experience







1–25 homeless students







26–55 homeless students







55+ homeless students







No homeless (ref)
Graduate training







In-service training







Professional development







Two or more sources







No training (ref)
R2 (adj. R2)








***p < .001. **p <. 01. *p < .05.



Perceived knowledge of McKinney-Vento. The independent variables explained 47% of the variability in school counselors’ perceived knowledge of McKinney-Vento, R2 = .45, Adjusted R2 = .43, F(23, 146) = 10.87, p = .000. Participant grade levels, β = .15, t = 2.18, p = .003, numbers of students experiencing homelessness and training predicted knowledge of McKinney-Vento. Relative to school counselors who had received no training, responses of having received in-service training, β = .54, t = 7.32, p = .000, professional development outside of school, β = .39, t = 5.65, p = .000, and two or more sources of training, β = .43, t = 6.03, p = .000, predicted perceived knowledge of McKinney-Vento. However, no relationship with perceived knowledge of McKinney-Vento existed among those who received their training in their graduate program and those who had no training.


Perceived knowledge of emotional and educational issues. The independent variables explained 30% of the variability in school counselors’ perceived knowledge of emotional and educational issues, R2 = .28, Adjusted R2 = .23, F(12, 175) = 6.24, p = .000. Number of students experiencing homelessness predicted participants’ perceived knowledge of emotional and educational issues in schools with 1–25 students, β = .32, t = 3.50, p = .001, in schools with 26–55 students, β = .22, t = 2.62, p = .010, and in schools with more than 55 students, β = .32, t = 4.00, p = .000. Type of training received also predicted perceived knowledge of emotional and educational issues in participants who received their training in their graduate program, β = .14, t = 2.11, p = .000, as well as those who received in-service training, β = .39, t = 5.13, p = .000, professional development outside of school, β = .27, t = 3.74, p = .000, and two or more sources of training, β = .36, t = 4.92, p = .000.


Advocacy and provision of services. The independent variables explained 30% of the variability in school counselors’ reported advocacy and provision of services, R2 = .28, Adjusted R2 = .23, F(12, 151) = 5.31, p = .000. Number of students experiencing homelessness in the school and type of training received both predicted school counselors’ reported advocacy and provision of services. As expected, when compared to participants who reported having no students experiencing homelessness, the number of homeless students at each school predicted advocacy and provision of services from participants who reported having 1–25 students experiencing homelessness, β = .39, t = 3.72, p = .000, 26–55 students, β = .24, t = 2.47, p = .014, and 55 or more students, β = .36, t = 4.02, p = .000. Type of training received also predicted advocacy and provision of services. Compared to participants who had received no training on homelessness, training responses that included in-service training, β = .31, t = 3.69, p = .000, professional development outside of school, β = .29, t = 3.61, p = .000, and two or more sources of training, β = .43, t = 4.06, p = .000, predicted advocacy and provision of services. However, no relationship was reported in advocacy and provision of services among those who received their training in their graduate program and those who had no training on homelessness.


Post Hoc Analyses

To take a closer look at the significant differences between elementary, middle and high school counselors on perceived knowledge of McKinney-Vento, we conducted a one-way ANOVA, F(2, 157) = 6.44, p = .002, η2 = .07. Elementary school counselors fell significantly above the mean on perceived knowledge of McKinney-Vento (M = .33, SD = .91), while high school counselors fell significantly below the mean (M = -.27, SD = .97). Middle school counselors (M = -.10, SD = 1.06) also fell below the mean, although the difference was not significant. To shed further light on this relationship, we conducted a crosstabs analysis with school level and source of training. Although the previous ANOVA (see research question 3a) revealed no significant differences in extent of training by school level or setting, a post hoc examination of the frequencies regarding source of training revealed that elementary school counselors (59.3%) were more likely than high school counselors (29.6%) or middle school counselors (11.1%) to receive training from two or more sources (i.e., from some combination of graduate school, professional development outside of school and in-service training). High school counselors (52.9%) were more likely to report that they had received no training from any source than were elementary school counselors (28.6%).


Discussion and Implications


This national study explored school counselors’ perceived knowledge of the McKinney-Vento Act, perceived knowledge of the emotional and educational needs of students experiencing homelessness, and perceived involvement in advocacy and provision of counseling services. In general, school counselors in the current study appear to view themselves as less knowledgeable about the McKinney-Vento Act and its requirements, but more knowledgeable about the general emotional and educational issues of students experiencing homelessness. However, due to the general nature of the questions, reporting greater knowledge of emotional and educational issues may be a result of self-report bias, since specific knowledge was not solicited. A lower level of knowledge about McKinney-Vento is not surprising given that about 40% of school counselors in the study reported never having received training related to working with students experiencing homelessness. In addition, whether they had no or some training, school counselors reported working in various ways with students experiencing homelessness, including enrolling them in school and assessing their needs. However, regarding more collaborative services such as visiting shelters and involving students in mentoring programs, school counselors reported less involvement. As recommended in the school counseling literature on homelessness (Baggerly & Borkowski, 2004; Strawser et al., 2000; Walsh & Buckley, 1994), these school counselors appear to provide more services such as referrals, individual counseling and teacher consultation to students experiencing homelessness. Yet, Miller (2009, 2011) emphasized the importance of school personnel’s collaboration with families and community stakeholders and building bridges to connect homeless students to after-school programs and community services to improve their academic and emotional outcomes. Previous research suggests that training specifically related to building partnerships is a prerequisite of school–community collaboration and that 40% of school counselors lack this type of training (Bryan & Griffin, 2010).


Overall, while 90% of school counselors in the current study appear to work with students experiencing homelessness, school counselors in urban settings appear to face larger caseloads of homeless students than counselors in rural and suburban schools. Yet, no differences exist between the surveyed urban, rural and suburban school counselors’ levels of knowledge about McKinney-Vento and about emotional and educational issues or advocacy and provision of services. Given the increasingly large number of families experiencing homelessness in urban areas (Henry & Sermons, 2010), though a variable not investigated in this study, one might expect that with larger caseloads, urban school counselors would report higher levels of advocacy and provision of services. Provision of services and levels of advocacy are related to training. Without adequate training, counselors in urban schools may find themselves ill-equipped to perform the boundary-spanning role that is integral to providing these students with adequate support—that is, linking them to information, resources and programs (Miller, 2009, 2011). Note that the numbers related to participants’ school location should be interpreted with caution due to the lack of specific percentages of students experiencing homelessness on their caseloads available for this study.


In general, elementary, middle and secondary school counselors appear to face similar situations regarding the numbers of students experiencing homelessness and their perceived training for working with this population. However, elementary school counselors reported above average knowledge of the McKinney-Vento provisions, significantly higher than high school counselors, although these groups do not differ in the perceived extent of training received. The findings suggest that their knowledge of McKinney-Vento may be attributed to the source or type of training they are receiving. Also, this difference may reflect the fact that most school counseling publications on students experiencing homelessness, although few, have focused on elementary school counselors (e.g., Baggerly & Borkowski, 2004; Daniels, 1992, 1995; Strawser et al., 2000).


According to the results of this study, training on homelessness is positively related to school counselors’ knowledge of McKinney-Vento, knowledge of emotional and educational issues, and advocacy and provision of services. Overall, school counselors with no training regarding students experiencing homelessness reported less knowledge of McKinney-Vento and of their emotional and educational issues, and less advocacy and provision of services compared to counselors who with some training (with the exception of those who received their training in graduate programs). For the participants in this study, graduate program training regarding homelessness is only indicative of higher knowledge of emotional and educational issues of students experiencing homelessness when compared to counselors with no training. These findings suggest the need for an intentional focus in counseling graduate programs on the McKinney-Vento Act and its provisions as well as on specific practices for advocating and implementing service delivery to students experiencing homelessness. Graduate students in school counseling programs and related degree programs in education would benefit from specific training that helps them develop skills as effective boundary spanners and information brokers who function within and across the contexts of families and children experiencing homelessness (Miller, 2009, 2011).


Taken together, the relationships between the number of students experiencing homelessness, school counselor training, and advocacy and provision of services are particularly interesting. These findings suggest that school counselors’ exposure to issues related to homelessness, through both training and direct contact with students experiencing homelessness, may compel them to learn about homelessness and to advocate for and provide recommended services to these students. Indeed, as their caseloads of students experiencing homelessness increase, school counselors may feel compelled to find resources and supports for these students. More importantly, for counselors who have caseloads with only a few students experiencing homelessness, these findings highlight the value of training and its implications for services. Perhaps these findings hint at the need to couple school counselor training on homelessness with direct exposure to students experiencing homelessness—that is, with immersion experiences. Intentional and coherent integration of service learning experiences with families and children experiencing homelessness into counselor education programs can provide school counseling trainees with appropriate and invaluable real-world learning experiences for developing the requisite skills for working with students experiencing homelessness (Baggerly, 2006; Constantine, Hage, Kindaichi, & Bryant, 2007).


Implications for School Counselor Practice

The findings of this study have several implications for the practice of school counselors. We recommend that school counselors (a) seek professional development to enhance their knowledge of the policies and needs related to students experiencing homelessness, (b) build relationships with the students experiencing homelessness in their schools, and (c) build partnerships with families experiencing homelessness, homeless liaisons, homeless shelters, and community organizations in order to better advocate for and provide services to students experiencing homelessness.


Professional development on homelessness. School counselors are required to promote awareness and understanding of McKinney-Vento and the rights of students experiencing homelessness and provide services aligned to meet their needs (ASCA, 2010). Based on the results of this study, school counselors who do not receive training regarding students experiencing homelessness may lack knowledge of McKinney-Vento. Without knowledge of policies that impact students experiencing homelessness and the interventions necessary to work with them, counselors may provide students with ineffective support.


School counselors must take the initiative to seek training on the McKinney-Vento Act and the specific needs and challenges faced by students experiencing homelessness. They may seek this knowledge by attending state, regional or national conferences on homelessness, and should advocate for the topic to be included at state, regional and national conferences of counseling associations. In the absence of these opportunities, school counselors may arrange to meet with the local homeless liaison to discuss the provisions of the McKinney-Vento Act and the needs of students experiencing homelessness and to explore available services in the school district.


Build relationships with students experiencing homelessness. In order to support the educational and emotional development of children and youth experiencing homelessness, school counselors must first identify which students are experiencing homelessness in their school and then determine their specific needs (Daniels, 1992). Identifying students experiencing homelessness requires that all stakeholders, including teachers, know the variety of definitions that qualify students as experiencing homelessness (U.S. Department of Education, 2004; Zerger, Strehlow, & Gundlapalli, 2008). Educating all teachers and staff on the definitions of homelessness will allow them to quickly and confidentially report if they suspect a student is experiencing homelessness and recognize issues that may arise due to their housing status. When students and families are identified as experiencing homelessness, school counselors may then plan interventions accordingly to support their educational and developmental needs.


Build partnerships with stakeholders. One critical way in which school counselors can support the needs of students experiencing homelessness is by building collaborative relationships with partners in the community (ASCA, 2010; Grothaus et al., 2011). Determining student needs may require visiting shelters to find ways to connect with families and children. Given that shelters offer families a variety of resources that may or may not adequately meet their needs (Shillington, Bousman, & Clapp, 2011), it is important for school counselors to know what services local shelters provide in order to understand what additional supports are needed. For instance, determining what educational support is available at the shelter (e.g., whether there is allotted space for students to study) may help counselors determine what academic enrichment and support programs (e.g., tutoring, computer access, homework help) are needed at the school level.


As previously mentioned, McKinney-Vento requires that every local educational agency has a designated local homeless liaison. This person ensures that students experiencing homelessness are identified and have equal opportunities to be successful. Therefore, when coordinating services and planning interventions for students, counselors should collaborate with the assigned homeless liaison at their school (Grothaus et al., 2011; Strawser et al., 2000). Counselors and homeless liaisons can collaborate to plan appropriate interventions for meeting the identified needs of students experiencing homelessness. They also may partner to educate staff members about the emotional and educational challenges that homeless students face. In some cases, school counselors may be assigned as the local homeless liaison, which requires them to better understand the requirements of McKinney-Vento and initiate partnerships between all stakeholders.


School counselors also might partner with teachers and community stakeholders to provide supportive services for students experiencing homelessness. They may collaborate to coordinate tutoring or mentoring programs and to develop safe classroom and school environments for students (Bryan, 2005). They also can plan culturally sensitive classroom guidance units that relate to the personal and social issues faced by students experiencing homelessness. For example, a classroom lesson on the topic of developing social skills might be particularly beneficial for all students, including those experiencing homelessness (Baggerly & Borkowski, 2004).


Limitations and Future Research

The limitations of this study include self-report bias, sample bias, low response rate, and the validity and reliability of the survey itself. The survey measures participants’ perceptions of their knowledge rather than their actual knowledge, which may have led to self-report bias in reporting levels of knowledge. Further, the low response rate might render these findings ungeneralizable to all school counselors. The response rate may be due to the e-mail-only method of sending out the survey, which has been shown to generate lower response rates than mailing surveys (Dillman et al., 2009; Kaplowitz, Hadlock, & Levine, 2004; Kongsved, Basnov, Holm-Christensen, & Hjollund, 2007; Shih & Fan, 2009). For instance, one study suggested that e-mail surveys have a response rate approximately 20% lower than that of mail surveys (Shih & Fan, 2009). However, the response rate also may suggest that the counselors who chose not to participate in the survey did so because they did not have or were not aware of any students experiencing homelessness on their caseloads. Another limitation concerns the selection of respondents exclusively among ASCA members. Thus, this sample may not be representative of all counselors in the United States. As a caveat, the results of this study should not be interpreted in causal terms because the findings suggest relationships between variables, not specific causality. Finally, since the survey is newly developed, its reliability and validity should be considered with caution. Though there are several limitations, due to the exploratory nature of this study, the results provide insight into school counselors’ work with students experiencing homelessness and guide future research on this important subject.


This exploratory study is one of only two studies (e.g., Gaenzle, 2012) to examine the relationship between counselor demographics and their knowledge, advocacy and provision of services for students experiencing homelessness. This initial information lays the foundation for further research on the topic. It is possible that other variables, such as actual (rather than perceived) knowledge, may predict school counselor advocacy and provision of services. The omission of certain variables may explain the low R squares (e.g., R2 < .30) in some of the regression models. Future research should use a larger sample to explore school counselors’ knowledge about and advocacy for students experiencing homelessness as well as examine additional variables that may influence school counselors’ and other service providers’ advocacy and service provision for students experiencing homelessness. Further, this study suggests a need for future research that examines the efficacy of current school counseling programs with students experiencing homelessness.


Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.



American School Counselor Association. (2010). The professional school counselor and children experiencing homelessness. Retrieved from

American School Counselor Association. (2012). The American School Counselor Association national model: A framework for school counseling programs (3rd ed.). Alexandria, VA: Author.

Baggerly, J. (2006). Service learning with children affected by poverty: Facilitating multicultural competence in counseling education students. Journal of Multicultural Counseling and Development, 34, 244–255. doi:10.1002/j.2161-1912.2006.tb00043.x

Baggerly, J., & Borkowski, T. (2004). Applying the ASCA national model to elementary school students who are homeless: A case study. Professional School Counseling, 8, 116–123.

Bryan, J. (2005). Fostering educational resilience and achievement in urban schools through school-family-community partnerships. Professional School Counseling, 8, 219–227.

Bryan, J. A., & Griffin, D. (2010). A multidimensional study of school-family-community partnership involvement: School, school counselor, and training factors. Professional School Counseling, 14, 75–86.

Buckner, J. C., Bassuk, E. L., Weinreb, L. F., & Brooks, M. G. (1999). Homelessness and its relation to the mental health and behavior of low-income school-age children. Developmental Psychology, 35, 246–257.


Coker, T. R., Elliott, M. N., Kanouse, D. E., Grunbaum, J. A., Gilliland, M. J., Tortolero, S. R., . . . Schuster, M. A. (2009). Prevalence, characteristics, and associated health and health care of family homelessness among fifth-grade students. American Journal of Public Health, 99, 1446–1452.

Constantine, M. G., Hage, S. M., Kindaichi, M. M., & Bryant, R. M. (2007). Social justice and multicultural issues: Implications for the practice and training of counselors and counseling psychologists. Journal of Counseling and Development, 85, 24–29. doi:10.1002/j.1556-6678.2007.tb00440.x

Costello, A. B., & Osborne, J. W. (2005). Best practices in exploratory factor analysis: Four recommendations for getting the most from your analysis. Practical Assessment, Research & Evaluation, 10. Retrieved from

Daniels, J. (1992). Empowering homeless children through school counseling. Elementary School Guidance & Counseling, 27, 104–112.

Daniels, J. (1995). Homeless students: Recommendations to school counselors based on semistructured interviews. School Counselor, 42, 346–352.

Dillman, D. A., Phelps, G., Tortora, R., Swift, K., Kohrell, J., Berck, J., & Messer, B. L. (2009). Response rate and measurement differences in mixed-mode surveys using mail, telephone, interactive voice response (IVR) and the Internet. Social Science Research, 38, 1–18. doi:10.1016/j.ssresearch.2008.03.007

Gaenzle, S. A. (2012). An investigation of school counselors’ efforts to serve students who are homeless: The role of perceived knowledge, preparation, advocacy role, and self-efficacy to their involvement in recommended interventions and partnership practices (Doctoral dissertation). Available from ProQuest Dissertations and Theses database. (UMI No. 3543452)

Gewirtz, A., Hart-Shegos, E., & Medhanie, A. (2008). Psychosocial status of homeless children and youth in family supportive housing. American Behavioral Scientist, 51, 810–823. doi:10.1177/0002764207311989

Grothaus, T., Lorelle, S., Anderson, K., & Knight, J. (2011). Answering the call: Facilitating responsive services for students experiencing homelessness. Professional School Counseling, 14, 191–201.

Havlik, S. A., Brady, J., & Gavin, K. (2014). Exploring the needs of students experiencing homelessness from school counselors’ perspectives. Journal of School Counseling, 12(20). Retrieved from

Henry, M., & Sermons, M. W. (2010). Geography of homelessness. Washington, DC: The Homeless Research Institute at the National Alliance to End Homelessness. Retrieved from

Hicks-Coolick, A., Burnside-Eaton, P., & Peters, A. (2003). Homeless children: Needs and services. Child & Youth Care Forum, 32, 197–210.

Kaplowitz, M. D., Hadlock, T. D., & Levine, R. (2004). A comparison of web and mail survey response rates. Public Opinion Quarterly, 68, 94–101. doi:10.1093/poq/nfh006

Kongsved, S. M., Basnov, M., Holm-Christensen, K., & Hjollund, N. H. (2007). Response rate and completeness of questionnaires: A randomized study of Internet versus paper-and-pencil versions. Journal of Medical Internet Research, 9, e:25.

Miller, P. M. (2009). Boundary spanning in homeless children’s education: Notes from an emergent faculty role in Pittsburgh. Educational Administration Quarterly, 45, 616–630. doi:10.1177/0013161X09333622

Miller, P. M. (2011). Homeless families’ education networks: An examination of access and mobilization. Educational Administration Quarterly, 47, 543–581. doi:10.1177/0013161X11401615

National Center for Homeless Education. (2012, June). Education for homeless children and youths program: Data collection summary. Retrieved from

National Center on Family Homelessness. (2011). The characteristics and needs of families experiencing homelessness. Retrieved from

National Coalition for the Homeless. (2009, July). Homeless families with children. Retrieved from

Obradović, J., Long, J. D., Cutuli, J. J., Chan, C.-K., Hinz, E., Heistad, D., & Masten, A. S. (2009). Academic achievement of homeless and highly mobile children in an urban school district: Longitudinal evidence on risk, growth, and resilience. Development and Psychopathology, 21, 493–518. doi:10.1017/S0954579409000273

Rafferty, Y., Shinn, M., & Weitzman, B. C. (2004). Academic achievement among formerly homeless adolescents and their continuously housed peers. Journal of School Psychology, 42, 179–199. doi:10.1016/j.jsp.2004.02.002

Shih, T.-H. & Fan, X. (2009). Comparing response rates in e-mail and paper surveys: A meta-analysis. Educational Research Review, 4, 26–40. doi:10.1016/j.edurev.2008.01.003

Shillington, A. M., Bousman, C. A., & Clapp, J. D. (2011). Characteristics of homeless youth attending two different youth drop-in centers. Youth & Society, 43, 28–43. doi:10.1177/0044118X09351277

Shinn, M., Schteingart, J. S., Williams, N. C., Carlin-Mathis, J., Bialo-Karagis, N., Becker-Klein, R., & Weitzman, B. C. (2008). Long-term associations of homelessness with children’s well-being. American Behavioral Scientist, 51, 789–809. doi:10.1177/0002764207311988

Strawser, S., Markos, P. A., Yamaguchi, B. J., & Higgins, K. (2000). A new challenge for school counselors: Children who are homeless. Professional School Counseling, 3, 162–172.

Swick, K. J. (2008). The dynamics of violence and homelessness among young families. Early Childhood Education Journal, 36, 81–85. doi:10.1007/s10643-007-0220-5

U.S. Department of Education. (2004, July). Education for homeless children and youth program: Title VII-B of the McKinney-Vento homeless assistance act. Washington, DC: Author. Retrieved from

U.S. Department of Housing and Urban Development, Office of Community Planning and Development. (2010, June). The 2009 annual homeless assessment report to congress. Retrieved from

Walsh, M. E., & Buckley, M. A. (1994). Children’s experiences of homelessness: Implications for school counselors. Elementary School Guidance and Counseling, 29, 4–15.

Zerger, S., Strehlow, A. J., & Gundlapalli, A. V. (2008). Homeless young adults and behavioral health: An overview. American Behavioral Scientist, 51, 824–841. doi:10.1177/0002764207311990





Knowledge and Skills with Homeless Students Survey

Self-Administered Questionnaire


The following survey will be on the topic of homeless students. Please take some time to answer each item. The survey should take you 3–5 minutes to complete. You will not be asked for any identifying information. Therefore, all responses to this survey are anonymous.


This survey is about your work with homeless students. For your information, the following is the definition for homeless students:


The McKinney-Vento Homeless Assistance Act (U.S Department of Education, 2004) defines homeless children and youth as those who are sharing housing of other persons due to loss of housing, economic hardship or a similar reason (sometimes referred to as doubled-up); living in motels, hotels, trailer parks or camping grounds due to lack of alternative adequate accommodations; living in emergency or transitional shelters; abandoned in hospitals; or awaiting foster care placement (p. 2). This additionally includes children or youth who reside in locations that are not suitable for humans and those who live in places such as in cars, substandard housing, or places like bus or train stations, and migratory children who fall into any of the above descriptions (U.S. Department of Education, 2004).


Please read carefully and respond to the following items:


  1. For the following items, please check the category that best applies to you:


Your current school setting (select one):  ___ Urban                  ___ Rural                     ___ Suburban

Your current school type (select one):      ___ Private                 ___ Public                   ___ Parochial

Your current school level (select one):     ___ Elementary          ___ Middle                  ___High


  1. Please fill in the blank: How many years have you been a school counselor? _____


  1. Estimate the number of homeless students in your school. Please check the range that best fits (if you are not sure, take your best guess!):


___ 0

___ 1–5

___ 6–10

___ 11–15

___ 16–25

___ 26–35

___ 36–45

___ 46–55

___ 55+



  1. Have you received training to work with homeless students (no training, some training, or extensive training)? Rate this item on a scale from 1–5, 1 being no training, 5 being extensive training:


No training     1————–2————–3————–4————–5     Extensive training

  1. If you marked a 2, 3, 4 or 5, please answer the following question (if not, move onto the next section): Where did you receive training? Check all that apply.


___ Graduate school

___ In-service training while at my school

___ Required professional development outside of school

___ Voluntary professional development outside of school

___ Other: _____________________________________



  1. For the following items, please rate your knowledge on a scale from 1–5, 1 meaning that you have no knowledge and 5 meaning that you have extensive knowledge


No knowledge      1————–2————–3————–4————–5      Extensive knowledge


___ The McKinney-Vento Act

___ The registration policies for homeless students entering your school

___ The role(s) of the local homeless liaison for your school

___ The role of the State Coordinator for homeless services

___ The transportation requirements for homeless students under the McKinney-Vento Act

___ The emotional and personal/social issues (e.g., feelings of isolation, difficulty making friends,

embarrassment) faced by homeless students in schools

___ The educational issues that homeless students face in school (i.e., the academic issues)


  1. Do you know the location of homeless shelters near the school where you work? Please check the category that best applies to you.


___ I know none of them.

___ I know some of them.

___ I know all of them.

___ There are no shelters near my school.


  1. Can you identify the students who are homeless on your caseload? Please check the category that best applies to you.


___ I can identify none of them.

___ I can identify some of them.

___ I can identify all of them.

___ There are no homeless students on my caseload.

  1. Do you know where homeless students in your school reside? Please check the category that best applies to you.


___ I know where none of them reside.

___ I know where some of them reside.

___ I know where all of them reside.

___ There are no homeless students in my school.



  1. What types of programs/interventions do you provide to homeless students and parents? Check all that apply.

___ I have not provided any services or interventions.

___ Parent consultation

___ Parent education workshops

___ Teacher consultation

___ Community partnerships

___ Mentoring program

___ Academic support

___ Small group counseling

___ Individual counseling

___ Communication with shelter staff

___ Shelter visits

___ Home visits

___ After-school programs

___ Tutoring

___ Referrals to community resources

___ Provided workshops/training for teachers

___ Classroom guidance

___ Career exploration

___ Behavioral skills training

___ IEP planning

___ 504 planning

___ Advocating for homeless students

___ Postsecondary planning

___ College planning

___ Other (please specify): ____________________



  1. Is there anything else you would like to add about your interventions with homeless students? Please write below.



Knowledge and Experience

  1. List the FIVE most important academic/educational, personal/social and career/college planning needs of homeless students. If you are unable to list 5, list as many as you can.


a. ____________________________________

b. ____________________________________

c. ____________________________________

d. ____________________________________

e. ____________________________________



Please answer the following items on a scale from 1–5, 1 meaning not at all and 5 meaning always.


Not at all   1————–2————–3————–4————–5   Always


___ I ensure that homeless students with whom I work have equal opportunities compared to their non-homeless


___ I assist with registration of homeless students.

___ I assess the emotional needs of homeless students.

___ I visit the shelter(s) where homeless students in my school live.

___ I ensure that homeless students have transportation to attend before- or after-school programs.

___ I have contact with my school’s homeless liaison.

___ I make contact with homeless families.

___ I provide mentorship programs for homeless students at my school.

___ I review the McKinney-Vento Act policies to ensure homeless students’ needs are being met.



Stacey Havlik is an Assistant Professor at Villanova University. Julia Bryan is an Assistant Professor at Pennsylvania State University. Correspondence can be addressed to Stacey Havlik, 800 East Lancaster Avenue SAC 356, Villanova, PA 19085,                           


The School Counselor and Special Education: Aligning Training With Practice

Jennifer Geddes Hall

The intent of this article is to discuss the importance of training school counselors in providing adequate services to students with special needs, as mandated by special education law and supported by school counseling standards created by the American School Counselor Association (ASCA). In addition, the lack of adequate and unified training for school counselors in this area will be explored. This article suggests implementing a more consistent school counselor education program across institutions that would include coursework and experiences in special education that are in alignment with the standards of ASCA, legal obligations, and daily counselor roles. Examples of ways to incorporate such experiences and assignments into courses across counselor training programs are provided. 

Keywords: counselor education, school counselor, special education, counselor training, American School Counselor Association


The enactment of special education laws and mandates such as the Education for All Handicapped Children Act of 1975 (PL 94–142) and the Individuals with Disabilities Education Act (IDEA), which require schools to provide free appropriate public education to all students within the regular education setting, have immensely impacted the school counseling profession (Bowen & Glenn, 1998; Dunn & Baker, 2002; Milsom, 2002; Owens, Thomas, & Strong, 2011). The number of students identified as appropriate to receive special education services is growing (Dunn & Baker, 2002; McEachern, 2003; Owens et al., 2011). Therefore, school counselors  are now required to provide equal services to more students with special needs within the regular education setting. Similarly, school counselors are required to take a more active role in the Individual Education Program (IEP) process, from identification to implementation, than what was previously expected in the past (Dunn & Baker, 2002; Milsom, Goodnough, & Akos, 2007; Owens et al., 2011). School counselors’ involvement in special education is not only required by specific legislation, but also poses ethical considerations regarding to direct and indirect services for students with special needs. In response to legislation, the American School Counselor Association (ASCA) has advocated for school counselor involvement in special education and published guidelines for servicing students with special needs (Isaacs, Greene & Valesky, 1998; Myers, 2005; Studer & Quigney, 2005).


Despite a study conducted by Studer and Quigney (2003) which showed that school counselors are becoming more involved with special education by serving on teams that assist with disability identification and implementation of services, counselor education programs are not adequately training future school counselors to deal with changing roles and responsibilities included in servicing students with special needs (McEachern, 2003; Milsom & Akos, 2003; Romano, Paradise, & Green, 2009; Studer & Quigney, 2005). Additionally, there is a dearth of recent research in the literature addressing concerns that special education is not being adequately addressed in school counselor preparation programs. Although there is an increasing trend in school counselor training programs to include some instruction about special education (Studer & Quigney, 2005), no specific suggestions for implementing such content into the curriculum have been published to date. In response, this article provides ideas and recommendations for infusing special education content throughout the school counseling curriculum required by the Council for Accreditation of Counseling and Related Educational Programs (CACREP). Counselor education programs must recognize the importance of the school counselor in the lives of students with disabilities, and adequate training should become a priority.


Students with Special Needs, the School Counselor and the Law


Since the enactment of special education laws and mandates such as the Education for All Handicapped Children Act of 1975 (PL 94-142) and IDEA, the role of the school counselor has continued to evolve (Bowen & Glenn, 1998; Dunn & Baker, 2002; Milsom, 2002; Owens et al., 2011). The aforementioned laws require school counselors to provide services to students with disabilities and their parents, thus increasing the need for school counselor involvement with students who have been labeled as having special needs (Dunn & Baker, 2002; Owens et al., 2011). Findings by Studer and Quigney (2003) indicated that legal and ethical issues, participation in multidisciplinary pre-referral teams, and IEP development and review were among the top 10 activities involving school counselors. With the passage of IDEA, schools are now required to include students with disabilities within the school in the least restrictive environment through mainstreaming and inclusion. A greater population of students with disabilities within the regular education setting increases the likelihood of school counselor contact. An additional aspect of IDEA is that it requires transition planning for students in secondary schools. Therefore, it is logical for special educators to collaborate with school counselors when making such plans, as school counselors are trained in career and lifespan development (Milsom et al., 2007).


Students identified as needing special education services are estimated to account for 10–18% of the school population and are expected to increase (Dunn & Baker, 2002; McEachern, 2003). Schools are required to write IEPs for these students and implement appropriate supports and accommodations outlined in IEPs. School counselors are increasingly taking a greater role in the process of identifying students and developing IEPs, as well as implementing aspects of IEPs (Milsom et al., 2007; Owens et al., 2011). School counselors bring invaluable skills and knowledge such as understanding of group dynamics, facilitation of communication, awareness of community resources, and collaboration to IEP and pre-referral multidisciplinary teams (Milsom et al., 2007). School personnel roles and responsibilities within the team should be shared, in that the special educator should be viewed as the expert in content, while the school counselor should be viewed as the expert in process and transition services. School counselors also are equipped to make connections between student personal and social factors in relation to academic performance, which may come up in IEP meetings. Additionally, school counselors are viewed as leaders in the school and act as advocates for students, both directly and indirectly, and are therefore a notable asset to students and multidisciplinary teams (Owens et al., 2011).


In addition to legal responsibilities, school counselors also have a professional and ethical obligation to provide adequate direct and indirect services to students with special needs. Dunn and Baker (2002) stated that as members of multidisciplinary teams, school counselors are called upon to “engage in advocacy, consultation, diagnosis, assessment, development of delivery system, and provision of support services for students, parents and teachers” (p. 227). Therefore, it is clear that advocating and supporting students of all abilities in personal, social, academic and career domains are requirements for professional school counselors. Similarly, ASCA also supports professional and ethical guidelines concerning students with special needs.


ASCA Guidelines for Servicing Students with Special Needs


ASCA has delineated specific roles and responsibilities of school counselors regarding involvement with students identified as having special needs (Isaacs et al., 1998; Myers, 2005; Studer & Quigney, 2005). Roles may include many tasks, from serving on multidisciplinary teams to providing direct counseling services to students. School counselors are required to participate in the identification of students with disabilities by serving on screening teams and assisting in evaluation where appropriate. By serving as a member of the multidisciplinary team, the school counselor is able to provide input on planning and placement for identified students. For example, school counselors may assist with the preparation of IEPs by discussing student levels of functioning in academic, personal or social domains. The school counselor also may provide services such as consulting with outside agencies to coordinate supportive services for families and students. Additionally, for students identified within the school, school counselors may provide direct services such as individual and group counseling. These services must be consistent with services provided for all students, regardless of ability. Indirect services include consulting with personnel about identified students’ educational and affective needs as well as developing and implementing professional trainings for staff working with exceptional students. Moreover, ASCA encourages school counselors to advocate for students with special needs in the school and community.


Changing school counselor roles and responsibilities are evident in the literature. Studer and Quigney (2003) examined professional school counselors’ time regarding students with special needs. Among the top five activities performed were the following: (a) providing individual counseling, (b) meeting with administrators or supervisors about students with special needs, (c) utilizing problem-solving and conflict resolution techniques regarding students with special needs, (d) scheduling classes, programs and services, and (e) providing career counseling and education. The role of advocate is infused into many of these activities, which is viewed by both professionals in the field and ASCA as an essential function of school counselors (Milsom, 2006; Myers, 2005; Owens et al., 2011).


School counselors are in a position to advocate for students with special needs in a variety of ways, both directly and indirectly. Through active involvement in the appropriateness of educational planning during the IEP process, school counselors give these students a voice and work to facilitate an understanding of students with special needs among school personnel. Raising awareness and understanding about disabilities among professionals in the school as well as among parents and students is another imperative role, since students with special needs are often stigmatized, which can create negative experiences and barriers for them (Milsom, 2006; Scarborough & Deck, 1998). Through activities such as assessment of systems, programs, policies and attitudes, school counselors can better support students with special needs academically, personally and socially by working to shift negative school climates and perceptions (Bowen & Glenn, 1998; Milsom, 2006; Quigney & Studer, 1998; Scarborough & Deck, 1998). Implementation of programs for both school personnel and students aimed at examining self-awareness of bias, increasing sensitivity towards differences, accepting others, and positively supporting students with special needs can assist in adjusting attitudes as well as school climates (Milsom, 2006; Quigney & Studer, 1998; Scarborough & Deck, 1998).


Additionally, school counselors can directly support and advocate for students with special needs through providing individual and group counseling, as well as classroom-based lessons and interventions. Such initiatives should focus on the areas of development in tolerance and respect, empathy, self-esteem, anger management, diversity, cooperation, as well as other anti-bullying and character education themes such as citizenship, fairness and caring (Milsom, 2006; Milsom et al., 2007; Myers, 2005). School counselors also should begin to help students with special needs develop skills that encourage them to eventually become self-advocates (Owens et al., 2011). Progress monitoring, as outlined in the ASCA Model’s management and accountability sections, should entail collecting and measuring data for the interventions previously mentioned in order to assess areas of effectiveness, need and improvement (Myers, 2005). Along with these emerging roles and shifts in school counselor responsibilities, there is added responsibility for counselor educators and counselor education programs to adjust accordingly.


School Counselor Education Programs and Students with Special Needs


Although involvement of school counselors in the special education process and interactions with students who have special needs is increasing, there are findings suggesting that counselor education programs are not adequately training future school counselors to deal with these changes (McEachern, 2003; Milsom & Akos, 2003; Nichter & Edmonson, 2005; Romano et al., 2009; Studer & Quigney, 2005). McEachern (2003) found that less than 40% of school counselor preparation programs required students to take coursework that included special education topics and subjects related to students with special needs. In other studies, results indicated that school counseling programs are inconsistent regarding coursework pertaining to special education and that more programs are infusing such content into already required classes instead of creating additional required special education classes (Milsom, 2002; Milsom & Akos, 2003; Studer & Quigney, 2005). However, the types of content, how it is infused, and to what extent have not been revealed or regulated. Despite the increase in coursework pertaining to special education from 28% to 40% and the infusion of special education content into coursework, training programs for school counselors continue to fail to address the needs of today’s students (Korinek & Prillaman, 1992; Nichter & Edmonson, 2005; Studer & Quigney, 2005).


Coursework and experiences related to working with students with disabilities have been shown to correlate with school counselors’ perceptions of their readiness to work with this population (Isaacs et al., 1998; Milsom, 2002; Milsom & Akos, 2003; Nichter & Edmonson, 2005). Several studies have indicated that school counseling programs are not thorough enough in providing training regarding special education issues and students with special needs (Dunn & Baker, 2002; Milsom, 2002; Nichter & Edmonson, 2005; Studer & Quigney, 2005). School counselors have indicated a desire for more training in supporting students with disabilities from programs before graduation. A study conducted by Studer and Quigney (2005) revealed that only 5.9% of ASCA members surveyed had completed one or more courses about special education in their graduate programs and that 59% had never completed a course or taken a workshop about special education. Participants indicated that they did not feel prepared to support students with special needs. Areas that were viewed as receiving little attention in training included the following: (a) participation in development and review of IEPs, (b) collaboration with special education and general education teachers, and (c) consultation with outside agencies or professionals. These areas are all are integral in educational programming and the success of students with special needs, and therefore should be addressed in school counselor preparation programs. A study conducted by Nichter and Edmonson (2005) produced similar results, indicating that 89% of counselors surveyed in Texas felt that more training in special education would help them feel more competent and prepared to work with this population. Topics reported as potentially helpful in additional training included the following: (a) special education law and legal issues, (b) disability characteristics, (c) techniques for working with students in special education, and (d) information about medication and side effects. Additionally, 82% of participants indicated that counselor education programs should require special education instruction. Counselor preparation programs appear to have similar concerns. Over 60% of counselor education programs, when surveyed by Korinek and Prillaman (1992), indicated needing adjustment in school counselor training requirements for their programs in order to increase student capability in working with special education requirements. Similarly, McEachern (2003) surveyed counselor educators at various universities and colleges across the country and 55% stated that their coursework needed improvements regarding providing special education curricula.


Several recommendations have been made to address the lack of special education coursework for school counselors. Studer and Quigney (2005) suggested that it may be advantageous for school counselors to enroll in a class designed for special education teachers in which essential information is taught about this population and the areas discussed above. Additionally, enrollment in a course with pre-service special education teachers would provide school counselors the opportunity to practice collaborating with teachers. Recommendations also have been made for school counseling programs to increase coursework covering the ASCA Model and strategies related to students with special needs (Isaacs et al., 1998; Milsom & Akos, 2003; Studer & Quigney, 2005). Similarly, it is recommended that school counselor preparation programs require experiences with exceptional students to increase competency and positive attitudes (Milsom & Akos, 2003; Studer & Quigney, 2005).


Recommendations: Infusing Special Education into the School Counseling Curriculum


Students being trained in counseling programs to become school counselors can build their knowledge and experience related to special education throughout their counselor education coursework. An integrative approach may be provided in which material about special education is infused into required studies (Studer & Quigney, 2005). However, coursework must be organized and comprehensive across all courses in the program, including core courses and those specifically designed for school counseling students. Courses that lend themselves to infusion of special education activities and assignments include the following: learning and development, career, group, ethics, theories, multiculturalism, techniques, assessment, practicum and internship, as well as courses specifically designed for school counselors like introduction to school counseling or a leadership and advocacy course. Infusing activities will be discussed in depth below, and requires creativity and flexibility on the part of counselor educators in the field. Assignments and teaching styles may need to be adjusted to incorporate special education material into the standard counseling curriculum. It should be noted that when training school counselors in special education concerns, a combination of requiring specific disability coursework in conjunction with infusing such information into existing coursework is more effective (Milsom & Akos, 2003). Designing such a course is beyond the scope of this article; therefore, suggestions for infusing special education material into existing courses required by CACREP will be discussed.


Course Assignments Related to Special Education

Counselor educators can adjust class requirements for assignments to include aspects of special education. For example, students could compare and contrast typical child development and its implications regarding specific disability categories for children. School counseling students also could locate a specific student with special needs and formulate a case study about that child in which various aspects of developmental and learning theory would be identified. Assignments for a career course could require students to identify considerations for children with special needs when applying career theories and engaging in career planning (e.g., closely analyzing strengths and needs to align with viable career options when applying Holland’s approach). Students would then design a career exploration activity with these considerations for a student with special needs in mind. When completing an assignment such as group counseling planning, students could design a group for children with special needs. The group would address specific issues that these children face and for which they may need support (e.g., self-esteem), and include appropriate activities that would be accessible for the children involved (e.g., for activities that require reading or writing, replace the language with pictures, or create activities based on reading ability). Additionally, school counseling students could design a group and discuss how they would make accommodations for students with special needs in a group consisting of regular and special education students (e.g., pairing students for activities or reading content aloud to the group). Likewise, when completing an assignment for a school counselor course, such as developing a classroom guidance lesson, school counseling students could learn about accommodations similar to those discussed above that would ensure that all students could fully participate to their ability level.


Laws and ethical issues surrounding special education can be addressed in a professional issues class, ethics course or course specific to school counselors through the discussion of case studies and scenarios. The cases used should depict various school counseling ethical and legal dilemmas involving students with special needs (e.g., teacher is not following accommodations outlined in the IEP). Students would then apply ASCA special education guidelines and special education laws to issues presented, in order to illustrate how those involved are or are not acting in accordance with established professional mandates and what action should be taken. Additionally, students would then describe what the person in the scenario could have done differently and how the school counselor should intervene. In a theories class, school counseling students could critique the effectiveness of various theories for students who are identified as having special needs, through applying theoretical concepts, reviewing research, and considering qualities associated with different disability diagnoses that could impact treatment. A case study could also be developed, to which school counseling students would apply various theories to address issues faced by students with special needs (e.g., anxiety, depression). Similarly, in a techniques class, school counseling students could identify techniques that they found to be the most effective with special-needs students and practice applying them in class role-plays. Linking strategies to specific theories and disabilities may help school counselors feel more prepared and confident (Myers, 2005). Moreover, to increase competence and confidence, school counseling students should be exposed to assessments routinely used in the school setting with students identified as having special needs. During an assessment course students could practice utilizing and interpreting tools such as the Child Behavior Checklist (CBC), Behavior Assessment System for Children (BASC) and Connors Rating Scale through role-plays in pairs or small groups. School counseling students enrolled in the assessment course also could be required to look at mock IEPs and evaluation reports and discuss how accommodations and findings outlined in the documents would impact their services with the students.


The assignments described in this section can be used as in-class activities or outside assignments and also may utilize technology (e.g., slide shows, discussion boards). Requiring assignments such as those discussed above provides a foundation for infusing more experiential activities into other courses as well.


Exposure Activities to Enhance Student Learning About Special Education

Direct experiences with students who have special needs have been recommended in past research and is thought to increase school counselor competence, understanding and positive attitudes in working with this population (Bowen & Glenn, 1998; Isaacs et al., 1998; Milsom & Akos, 2003). Various interactive experiences with students with disabilities could be a required part of many courses throughout the school counseling program. Students could participate in interactive experiences both in schools and in community settings.


For example, students could be assigned to participate in an immersion experience for a multicultural class that would require students to spend an established amount of time with children who have been identified as having special needs (in schools or advocacy group settings). Students would then be required to reflect upon their experience, examine their own biases and stereotypes, and consider how their interactions had impacted their multicultural development. This assignment could be done through journaling (written or video), arts projects (e.g., collages, drawings, poems) or through a research paper tied to counselor professional development. Additionally, students could interview parents of these children or older children with special needs to gain insight into the barriers and discrimination that these individuals face because of their disabilities. School counseling students could volunteer at a local community agency such as a center for individuals who are deaf, blind, or developmentally disabled that offers services for teens with disabilities. Students would then use the information from their visit to outline and develop a specific program they could implement in the school to better support special-needs students and their families (e.g. partner with the special education teacher and provide a parent support night in which parents are able to discuss issues they are facing or provide representatives from various community agencies that support different needs for people with disabilities). Students also could visit a college campus center for student disability services and support. During the visit they could interview a staff member as well as a student seeking services in order to help develop a perspective on how to better serve individuals with special needs during high school and transition planning.


The experiences outlined above might help school counseling students become more sensitive to the needs and issues faced by individuals with special needs and might reinforce the need for advocacy in school counseling. Advocacy for students with special needs could be explored by requiring counseling students to take part in activities run by community groups for special populations, or to design a workshop presentation for school staff that raises awareness about disabilities, discrimination and attitudes. School counseling students also could work with a school counselor to develop a disability awareness week for the school that included activities such as a pep rally, guest speakers and classroom guidance lessons. Additionally, students could observe a school counselor during the transition planning process, attend a transition meeting and develop a transition plan as part of career course requirements. During this process they would be required to reflect upon how the school counselor acted as an advocate for the student.


Specific school counseling coursework and practicum and internship experiences also provide many opportunities for infusing the activities described above as well as others that will be discussed. Students involved in courses specific to school counseling could be required to observe a school counselor for a day and interview him or her about daily requirements involving special education, experiences with special education and suggestions for working with this population. Students should be required to attend a multidisciplinary team meeting and discuss the IEP process with a special educator or job shadow various special educators who serve students with different disability levels and categories. Requiring school counseling students to gain experiences during their practicum and internship with special-needs students should be a priority in school counselor training. These experiences provide an opportunity for school counseling students to interact with children in special education, while supervision is provided to effectively address issues that may be faced by this population (Milsom & Akos, 2003). Students should be required to log an established number of direct and indirect hours in which they are involved in the special education services that have been discussed throughout this article. Completion of a log, along with journal entries in which students reflect upon their experiences, could be used as a portfolio assessment upon graduation. Similarly, this documentation might be used for gatekeeping purposes or to measure student development in competency with special education and as a future school counselor.


Conclusion and Recommendations


Lack of coursework and experiences in special education can result in school counselors’ limited self-efficacy, feelings of frustration and anxiety, erosion in morale, and interference with other counseling duties (Romano et al., 2009). Therefore, in an effort to unify the field and produce more confident and competent school counselors, it is imperative that school counselor education programs collaboratively reexamine, regulate, and redefine program requirements. Today, school counselors not only need a solid knowledge base, but also need to be given opportunities to develop skills involved in collaboration, referral, advocacy, problem-solving, team-building, leadership and working directly with students who have been identified as having special needs (Bowen & Glenn, 1998; Dunn & Baker, 2002).


As suggested by Milsom and Akos (2003), providing a combination of practical experience with coursework related to special education appears to be the most effective way to prepare future school counselors. It is in the best interest of future school counselors, as well as the students they will serve, to offer support and supervision during such experiences as they complete their programs (Korinek & Prillaman, 1992). If the professionals in school counseling would like to grow and develop in a way that is consistent with the state of the educational system today and beyond, then it is clear that changes in training at the counselor education level must be made. Additionally, more research must be done to assess present trends in school counselor education programs and preparedness of practicing school counselors regarding special education. Research in this area would be useful in examining what improvements have been made, if any, and where adjustments need to be made in school counseling coursework. This article sought to provide specific recommendations to support change by outlining ways that counselor educators can incorporate special education training throughout their curricula. Including special education in counselor education programs must become a priority that is consistent across training institutions. This shift in counseling program requirements not only works to ensure adequate training for future school counselors, but also to provide exceptional services and support that special-needs children need and deserve.


Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.



Bowen, M. L., & Glenn, E. E. (1998). Counseling interventions for students who have mild disabilities. Professional School Counseling, 2, 16–25.

Dunn, N. A. W., & Baker, S. B. (2002). Readiness to serve students with disabilities: A survey of elementary school counselors. Professional School Counseling, 5, 277–284.

Isaacs, M. L., Greene, M., & Valesky, T. (1998). Elementary school counselors and inclusion: A statewide attitudinal survey. Professional School Counseling, 2, 68–76.

Korinek, L., & Prillaman, D. (1992). Counselors and exceptional students: Preparation versus practice. Counselor Education and Supervision, 32, 3–11.

McEachern, A. G. (2003). School counselor preparation to meet the guidance needs of exceptional students: A national study. Counselor Education and Supervision, 42, 314–325. doi:10.1002/j.1556-6978.2003.tb01822.x

Milsom, A. (2006). Creating positive school experiences for students with disabilities. Professional School Counseling, 10, 66–72.

Milsom, A., & Akos, P. (2003). Preparing school counselors to work with students with disabilities. Counselor Education and Supervision, 43, 86–95. doi:10.1002/j.1556-6978.2003.tb01833.x

Milsom, A., Goodnough, G., & Akos, P. (2007). School counselor contributions to the individualized education program (IEP) process. Preventing School Failure: Alternative Education for Children and Youth, 52, 19–24. doi:10.3200/PSFL.52.1.19-24

Milsom, A. S. (2002). Students with disabilities: School counselor involvement and preparation. Professional School Counseling, 5, 331–338.

Myers, H. N. F. (2005). How elementary school counselors can meet the needs of students with disabilities. Professional School Counseling, 8, 442–450.

Nichter, M., & Edmonson, S. L. (2005). Counseling services for special education students. Journal of Professional Counseling: Practice, Theory, and Research, 33(2), 50–62.

Owens, D., Thomas, D., & Strong, L. A. (2011). School counselors assisting students with disabilities. Education, 132, 235–240.

Quigney, T. A., & Studer, R. (1998). Touching strands of the educational web: The professional school counselor’s role in inclusion. Professional School Counseling, 2, 77–81.

Romano, D. M., Paradise, L. V., & Green, E. J. (2009). School counselors’ attitudes towards providing services to students receiving section 504 classroom accommodations: Implications for school counselor educators. Journal of School Counseling, 7(37), 1–36.

Scarborough, J. L., & Deck, M. D. (1998). The challenges of working for students with disabilities: A view from the front lines. Professional School Counseling, 2, 10–15.

Studer, J. R., & Quigney, T. A. (2003). An analysis of the time spent with students with special needs by professional school counselors. American Secondary Education, 31(2), 71–83.

Studer, J. R., & Quigney, T. A. (2005). The need to integrate more special education content into pre-service preparation programs for school counsellors. Guidance and Counseling, 20, 56–63.


Jennifer Geddes Hall, NCC, is a doctoral candidate at the University of North Carolina-Charlotte. Correspondence may be addressed to Jennifer Geddes Hall, College of Education Suite 241, 920 University City Boulevard, Charlotte, NC 28223,


Trauma and Treatment in Early Childhood: A Review of the Historical and Emerging Literature for Counselors

Kristen E. Buss, Jeffrey M. Warren, Evette Horton

Young children are especially susceptible to exposure to trauma. Rates of abuse and neglect among this population are staggering. This article presents a review of relevant literature, including research findings specific to early childhood vulnerability to trauma, symptoms associated with traumatic events, diagnostic validity of early childhood trauma, and treatments for young children. In the past, misconceptions about the mental health of young children have hindered accurate diagnosis and treatment of trauma-related mental illness. Due to the prevalence of trauma exposure in early childhood, counselors are encouraged to become familiar with ways that clients and families are impacted and methods for treatment. Implications for future research also are presented.


Keywords: early childhood, trauma, treatment, mental health, mental illness


Children from birth to age 5 are at a particularly high risk for exposure to potentially traumatic events due to their dependence on parents and caregivers (Lieberman & Van Horn, 2009; National Child Traumatic Stress Network, 2010). Traumatic events are incidents that involve the threat of bodily injury, death or harm to the physical integrity of self or others and often lead to feelings of terror or helplessness (National Library of Medicine, 2013). The American Psychological Association (APA) Presidential Task Force on Posttraumatic Stress Disorder (PTSD) and Trauma in Children and Adolescents (2008) indicated that traumatic events include suicides and other deaths or losses, domestic or sexual violence, community violence, medical trauma, vehicle accidents, war experiences, and natural and manmade disasters. With more than half of young children experiencing a severe stressor, they are especially susceptible to accidents, physical trauma, abuse and neglect, as well as exposure to domestic or community violence (National Child Traumatic Stress Network, 2010).


Over 20 years ago, Straus & Gelles (1990) estimated that three million couples per year engage in severe in-home violence toward each other in the presence of young children. The Administration on Children, Youth, and Families (2003) reported that in 2001, 85% of abuse fatalities occurred among children younger than 6 years of age, and half of all child victims of maltreatment are younger than 7. More recently, the Child Welfare Information Gateway (2014) indicated that 88% of child abuse and neglect fatalities occurred among children 7 years of age and younger. Often, there is an overlap between domestic violence and child physical and sexual abuse (Osofsky, 2003). In addition to domestic violence, young children also are vulnerable to community violence.


A study conducted by Shahinfar, Fox, and Leavitt (2000) suggested that the majority of young children enrolled in Head Start experienced violence in their communities. Young children also are exposed to traumatic stressors such as accidental burns or falls resulting in hospitalization or death (Grossman, 2000). It is common for children to experience more than one traumatic event (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008).


Young children birth to age 5 are especially vulnerable to adverse effects of trauma due to rapid developmental growth, dependence on caregivers and limited coping skills. However, despite decades of statistical data, counselors generally have limited knowledge of the impact of traumatic events on younger children in comparison to older children and adolescents (De Young, Kenardy, & Cobham, 2011). Reasons for this disparity in knowledge include a historical resistance to the notion that early childhood mental health is important and concerns about diagnosing young children with mental disorders.


Research in early childhood mental health has developed rapidly over the past 20 years. Practitioners and researchers who work with this population continue to contribute to the understanding of trauma and early childhood mental health. However, the broader counselor population seems less informed which hinders referrals for this vulnerable population of young children. For example, a counselor may work with a victim of domestic violence who has young children. However, due to the counselor’s limited knowledge of early childhood trauma and the impact of domestic violence, the counselor may not consider support services for the children. The present article examines the history and diagnostic validity of trauma-related mental illnesses in young children, the symptoms of trauma in early childhood, the longitudinal impact of early childhood trauma, the protective and risk factors associated with trauma in early childhood, and current and emerging treatments for this vulnerable population.


Mental Health, Trauma and Young Children: A Historical Perspective


Historically, researchers have spent little time and energy researching the effects of trauma exposure in early childhood. A widely held misconception has been that infants and young children lack the perception, cognition and social maturity to remember or understand traumatic events (Zeanah & Zeanah, 2009). Additionally, mental health counselors have been hesitant to diagnose trauma-related mental illness as a result of the associated stigmas that plague young children. In some cases when a child is diagnosed with mental illness, society focuses on the diagnosis and not the child.


Today it is widely accepted that children have the capacity to perceive and remember traumatic events. From birth, the tactile and auditory senses of a child are similar to those of an adult, which suggests that a child can experience stressful events (De Young et al., 2011). At 3 months of age, a child’s visual sensory development increases exponentially. A study by Gaensbauer (2002) suggested that infants as young as 7 months of age can remember and reenact traumatic events for up to 7 years. By 18 months of age, children begin to develop autobiographical memory; however, it is unlikely that memories from before that age can be recalled verbally (Howe, Toth, & Cicchetti, 2006). Researchers have demonstrated that infants and young children have the perceptual ability and memory to be impacted by traumatic events (De Young et al., 2011; Howe et al., 2006).


While research findings have confirmed that traumatic events can impact children, clinicians without proper training in early childhood mental health may have difficulty diagnosing trauma-related mental illness in childhood. Children younger than 5 years of age typically experience rapid developmental changes that often are misinterpreted or not fully accounted for which hinders proper diagnosis and intervention (Zero to Three, 2005). Given time and insurance reimbursement constraints, there can be difficulties observing children’s behaviors across settings (Carter, Briggs-Gowan, & Davis, 2004). Although verbal skills develop rapidly in early childhood, children may lack the communication skills necessary to accurately express their thoughts, emotions and experiences (Cohen, 2010). When conducting assessments, mental health professionals rely on parental feedback, inventories and reports from multiple sources, thus increasing the accuracy of the assessment (Carter, Briggs-Gowan, Jones, & Little, 2003).


There is a lack of psychometrically sound diagnostic tools for directly assessing trauma symptoms in children (Strand, Pasquale, & Sarmiento, 2011). Those tools currently available do not appropriately consider the developmental levels of young children (Carter et al., 2004; Egger & Angold, 2006; Strand et al., 2011). However, there are well-designed instruments for early childhood that utilize indirect assessments such as clinician observations and parent/teacher reports (Yates et al., 2008).


Diagnostic tools and assessments developed for children over age 5 are not suitable for assessing young children. For example, young children may not fully understand the directions or the vocabulary used in certain assessment tools. Furthermore, the diagnostic criteria for specific mental health issues (e.g., PTSD) are not developmentally appropriate for children younger than 5 (Scheeringa & Haslett, 2010). The APA Presidential Task Force on PTSD and Trauma in Children and Adolescents (2008) argues that children are not being appropriately identified or diagnosed as having trauma histories and do not receive adequate help.


From a historical perspective, mental health counselors as well as society as a whole have hesitated to acknowledge the plight that young children face in terms of trauma exposure. Several historical factors have contributed to counselors’ general lack of knowledge and expertise regarding this population. However, recent advances in research and in the counseling profession, such as the new American Counseling Association division, the Association for Child and Adolescent Counseling, have begun to broaden counselor knowledge in this area.


Symptoms of Trauma in Early Childhood


Trauma reactions can manifest in many different ways in young children with variance from child to child. Furthermore, children often reexperience traumas. Triggers may remind children of the traumatic event and a preoccupation may develop (Lieberman & Knorr, 2007). For example, a child may continuously reenact themes from a traumatic event through play. Nightmares, flashbacks and dissociative episodes also are symptoms of trauma in young children (De Young et al., 2011; Scheeringa, Zeanah, Myers, & Putnam, 2003).


Furthermore, young children exposed to traumatic events may avoid conversations, people, objects, places or situations that remind them of the trauma (Coates & Gaensbauer, 2009). They frequently have diminished interest in play or other activities, essentially withdrawing from relationships. Other common symptoms include hyperarousal (e.g., temper tantrums), increased irritability, disturbed sleep, a constant state of alertness, difficulty concentrating, exaggerated startle responses, increased physical aggression and increased activity levels (De Young et al., 2011).


Traumatized young children may exhibit changes in eating and sleeping patterns, become easily frustrated, experience increased separation anxiety, or develop enuresis or encopresis, thus losing acquired developmental skills (Zindler, Hogan, & Graham, 2010). There is evidence that traumas can prevent children from reaching developmental milestones and lead to poor academic performance (Lieberman & Knorr, 2007). If sexual trauma is experienced, a child may exhibit sexualized behaviors inappropriate for his or her age (Goodman, Miller, & West-Olatunji, 2012; Pynoos et al., 2009; Scheeringa et al., 2003; Zero to Three, 2005).


The symptoms that young children experience as a result of exposure to a traumatic event are common to many other childhood issues. Many symptoms of trauma exposure can be attributed to depression, separation anxiety, attention-deficit/hyperactivity disorder, oppositional defiant disorder or other developmental crises (see American Psychiatric Association, 2013). It is important for counselors to consider trauma as a potential cause of symptomology among young children.


Long-Term Consequences of Early Childhood Trauma


Recently, researchers have focused on how trauma during early childhood impacts mental and physical health later in life. Symptoms of mental illness can manifest immediately after a trauma, but in some cases symptoms do not emerge until years later. PTSD, anxiety disorders, behavior disorders and substance abuse have all been linked to traumatic events experienced during early childhood (Kanel, 2015). The types and frequencies of traumatic events and whether they were directly or indirectly experienced also can have various effects on physical and mental health later in adulthood. In a review of literature, Read, Fosse, Moskowitz and Perry (2014) described support for the traumagenic neurodevelopmental model. This model proposes that brain functioning changes following exposure to trauma during childhood. These biological factors often lead to psychological issues and physical and mental health concerns in adulthood.


Mental health professionals are often challenged to accurately diagnose PTSD in early childhood, leading to inconclusive reports of the actual prevalence of post-traumatic stress (De Young et al., 2011). Still, there is a clear relationship between PTSD diagnoses and trauma experienced in childhood. For example, higher rates of PTSD are reported among children residing in urban populations where neighborhood violence is prevalent (Crusto et al., 2010; Goodman et al., 2012). Briggs-Gowan et al. (2010) found an association between family and neighborhood violence exposure and oppositional defiant disorder, attention-deficit/hyperactivity disorder, conduct disorder and substance abuse. Additionally, noninterpersonal traumatic events (e.g., car accidents, burns, animal attacks) are associated with PTSD as well as anxiety, phobias, seasonal affective disorder and major depressive disorder (Briggs-Gowan et al., 2010).


Violence exposure is associated with externalizing problems while nonpersonal traumatic events are associated with internalizing problems (Briggs-Gowan et al., 2010). In a more recent study, Briggs-Gowan, Carter, & Ford (2011) found that exposure to neighborhood and family violence in early childhood is associated with poor emotional health and poor performance in school. Low socioeconomic status and traumatic events in early childhood also are correlated with low academic achievement in school (Goodman et al., 2012). Similarly, De Bellis, Woolley, and Hooper (2013) found maltreated children demonstrated poorer neuropsychological functioning and aggregate trauma was negatively related to academic achievement.


According to Schore (2001a), children and adults who experienced relational trauma during infancy are often faced with the struggles of mental disorder due to right brain impairment (p. 239). More recently, Teicher, Anderson, and Polcari (2012) found exposure to maltreatment and other types of stress as a child impacts hippocampal neurons leading to alterations in the brain and potential developmental delays. Additionally, there is evidence of relationships between mistreatment, bullying and accidents in early childhood and the development of delusional symptoms in later childhood (Arseneault et al., 2011). Young children who experience trauma and later use cannabis in adolescence are also at a higher risk for experiencing psychotic symptoms (Harley et al., 2010). Other studies have shown a correlation between early childhood trauma and development of schizophrenia later in life (Bendall, Jackson, Hulbert, & McGorry, 2008; Morgan & Fisher, 2007; Read, van Os, Morrison, & Ross, 2005). Changes in the brain may mediate these relationships between trauma exposure and mental health, as suggested by Schore (2001a, 2001b) and others.


Infants exposed to trauma are often inhibited by emotional and behavioral dysregulation in childhood and as an adult (Ford et al., 2013; Schore, 2001a, 2001b). Dysregulation resulting from trauma is predictive and related to substance use and functionality (Holtmann et al., 2011). For example, findings from a study by Strine et al. (2012) suggested that early childhood trauma and substance abuse are directly correlated. Children who had experienced more than one traumatic event were found to be 1.4 times more likely to become alcohol dependent. Strine et al. (2012) noted that females who experience trauma are more likely than males to abuse or become dependent on alcohol. The relationship between trauma and alcohol use and dependence often stems from untreated psychological distress (Strine et al., 2012).


In addition, there is ample evidence that early childhood trauma impacts later physical health. Some of the most well-known data on this topic come from the adverse childhood experiences study (Edwards et al., 2005). Multiple studies have found that early childhood trauma is associated with autoimmune disorders (Dube et al., 2009), headaches (Anda, Tietjen, Schulman, Felitti, & Croft, 2010), heart disease (Dong et al., 2004), lung cancer (Brown et al., 2010) and other illnesses. In fact, these studies often have found that the more frequent the exposure to early childhood trauma, the higher the risk of poor health outcomes in adulthood (Felitti et al., 1998).


Researchers have found clear evidence that children who experience traumatic events in early childhood are impacted well beyond their youth. Mental health disorders as well as alcohol and substance abuse emerge intermittently with age. Changes in brain functioning and physical health issues are also associated with early childhood trauma.


Risk and Protective Factors


Researchers have begun to explore factors that interact with trauma and the effects they may produce in young children. Environmental and demographic factors as well as parent–child relationships significantly impact outcomes for young children exposed to traumatic events (Briggs-Gowan et al., 2010). These factors may either insulate a child from adverse effects of trauma or increase the child’s risk for developing psychological distress.


Briggs-Gowan et al. (2010) found that symptoms of psychopathology and trauma were related to factors such as economic disadvantage and parent depressive and anxious symptoms. While ethnicity of the minor, parental education level and number of parents were associated with violence exposure, those factors were not associated with symptoms of mental illness. A more recent study found that young children exposed to a traumatic event along with a combination of socio-demographic factors (e.g., poverty, minority status, single parent, parental education less than high school, teenage parenting) are at greater risk for mental illness (Briggs-Gowan et al., 2011). Additionally, Crusto et al. (2010) found that high levels of parental stress are associated with adverse trauma reactions in young children. Parental dysfunction, family adversity, residential instability and problematic parenting can increase the impact of traumatic events as well (Turner et al., 2012). Young children exposed to chronic and pervasive trauma in addition to these risk factors are especially vulnerable to adverse effects (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008).


There are factors that may help protect young children from the negative impact of exposure to trauma. Turner et al. (2012) found that nurturing familial relationships can insulate children from psychological distress associated with traumatic events. Other factors such as safety and stability also might serve as protective factors. Safety implies that the child is free from harm or fear of harm, both physically and socially. Stability indicates consistency in the family environment, while nurturing suggests availability, sensitivity and warmth of caregivers or parents. Well-established, secure parent–child relationships are likely to provide protection from negative effects of trauma experienced by young children. A secure parental attachment has been shown to help children effectively regulate emotional arousal (Aspelmeier, Elliot, & Smith, 2007). Emotional regulation may be a mechanism that protects young children from extreme trauma reactions (De Young et al., 2011). Similarly, Crusto et al. (2010) found that caregiver support and healthy family functioning reduce the risk of psychological distress in young children after a traumatic event.




Early intervention and treatment can minimize the social and emotional impact of a child’s exposure to a traumatic event. Professional counselors should consider making referrals to counselors trained in providing early childhood mental health support. If the professional counselor has difficulties finding a referral source, the counselor’s basic counseling skills can provide the foundation for a safe, secure and trusting relationship between the counselor, family and child. Demonstrating empathy, genuine care and acceptance also fosters rapport among stakeholders (Corey, 2009). Mental health counselors can emphasize strengths and resources for the child and family.


Incorporating existing coping strategies can serve to minimize family stress and foster rapport with the child. Providing information about community support groups or other mental health agencies and resources also can help support and encourage the family. Informing parents and caregivers about symptoms common to young children exposed to traumatic events can foster awareness and allow for adequate support during the treatment process. Counselors can help the family establish or reestablish routines that begin to restore stability for the child, minimizing the adverse effects of the trauma (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008; Clay, 2010).


There are several evidence-based methods available to counselors treating trauma symptoms in young children. Evidence-based approaches are rooted in theory, evaluated for scientific rigor and tend to yield positive results (National Registry of Evidence-Based Programs and Practices, 2012). Trauma-focused cognitive behavioral therapy (TF-CBT) is a popular evidence-based treatment used with children aged 3–18. Based on cognitive behavioral therapy, humanism and family systems theory, TF-CBT includes many therapeutic elements for children and caretakers (Child Welfare Information Gateway, 2012). This form of therapy helps children develop different perceptions and a more adaptive understanding of the traumatic event (APA Presidential Task Force on PTSD and Trauma in Children and Adolescents, 2008). Caretakers learn parenting and communication skills as they play active roles throughout the TF-CBT process. Multiple studies demonstrate the effectiveness of TF-CBT in reducing symptoms of trauma in early childhood (see Cohen & Mannarino, 1996, 1997; Deblinger, Stauffer, & Steer, 2001).


While TF-CBT is an established treatment for children and adolescents, there are evidence-based treatments developed specifically for treating trauma in children between birth and 6 years of age. Child–parent psychotherapy (CPP), one of the most widely used interventions for young children, was created to address exposure to domestic violence, although it can treat a variety of traumatic experiences (Lieberman & Van Horn, 2008). In this form of dyadic therapy, the child and the caregiver reestablish safety and security in the parent–child relationship (Lieberman & Van Horn, 2008). CPP is one of the few early childhood treatments validated for use with ethnic minorities (Lieberman & Van Horn, 2008). The primary goal of CPP is to equip parents to meet the psychological needs of their child and maintain a secure relationship after treatment has ended.


Attachment and biobehavioral catch-up (ABC) is another treatment option that is designed primarily for use with young children who have experienced neglect (Dozier, 2003). This approach was developed specifically for low-income families and later adapted for use with foster families. ABC is based on the neurobiology of stress and attachment theory. The goal of ABC is to foster the development of the child’s optimal regulatory strategies by equipping parents with tools for effective response (Dozier, 2003; Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008).


Counselors also can utilize parent–child interaction therapy (PCIT) when working with traumatized youth. PCIT is a structured technique for children ages 2–8 years in which the counselor teaches the parent or caregiver how to interact with the child and set effective limits (Chaffin et al., 2004). In this form of therapy, the counselor often assumes the role of coach, instructing the client on specific skills. Counselors frequently use PCIT when working with children abused by a caregiver. PCIT has been implemented successfully with various populations including Hispanic and Latino clients (Chaffin et al., 2004). The focus of PCIT is on improving the quality of the parent–child relationship as well as child behavior management (Chaffin et al., 2004; McCabe, Yeh, Garland, Lau, & Chavez, 2005).


The treatment interventions previously mentioned are geared toward very young children, all incorporating play as a treatment modality. Since young children do not have extensive vocabularies, they often communicate information about themselves, their trauma and relationships with their caregivers through play (Landreth, 2012). Play therapy intervention research using samples with children between birth and 5 years of age is scant; however, several case studies indicate that play therapy is effective with trauma in early childhood. For example Dugan, Snow, and Crowe (2010) utilized play with a 4 year old exhibiting PTSD symptomology after experiencing Hurricane Katrina in 2005. Anderson and Gedo (2013) provided a case study in which play was used to treat a 3 year old with aggressive behaviors who was separated from his primary caregiver. There also are intervention examples of using play therapy with young children exposed to domestic violence (Frick-Helms, 1997; Kot, Landreth, & Giordano, 1998).


Finally, there are emerging approaches specifically for treating young children exposed to trauma. Tortora (2010) developed Ways of Seeing, a program combining movement and dance therapy with Laban movement analysis to create a sense of regulation and homeostasis for the child exposed to a traumatic event. The Ways of Seeing program does not yet have empirical evidence of its effectiveness. However, it is rooted in attachment theory, multisensory processing, play and sensorimotor psychotherapy. Counselors can use this program to determine how a parent and child experience each other, implement creative interventions for healthy bonding, and renew a sense of efficacy for the parent and child. While much more research is needed, this program appears to be a promising approach to treating trauma in early childhood (see waysofseeing.html).


Another emerging treatment, known as Honoring Children, Mending the Circle (HC-MC), is based on TF-CBT. The HC-MC approach was developed to address the spiritual needs of young Native American and Alaska Native children exposed to trauma. This method emphasizes preestablished relationships, wellness and healing during the treatment process. Spirituality is a critical component of healing and is integrated throughout the HC-MC approach. The goal of HC-MC is to help the traumatized child attain and reestablish balance (BigFoot & Schmidt, 2007, 2010). Additional research is needed on the efficacy of the HC-MC approach in working with Native American and Alaska Native youth.


A third emerging treatment, Trauma Assessment Pathway, is an assessment-based treatment that focuses on providing triage to young children exposed to traumatic events (Conradi, Kletzka, & Oliver, 2010). In this approach, the counselor uses assessment domains to determine the focus of treatment, provides triage to identify an appropriate pathway for intervention and establishes referrals to community resources if needed (Chadwick Center for Children and Families, 2009). The trauma assessment pathway method, which includes the trauma wheel, is a versatile mode of treatment available for the child and family. However, in many instances counselors may determine that an evidence-based practice, such as CPP, is the most appropriate mode of treatment (see Chadwick Center for Children and Families, 2009).


Each method of treatment offers specific strategies for working with traumatized young children and their families. However, findings from most studies investigating the effectiveness of these treatments are inconclusive (Forman-Hoffman et al., 2013). The strength of evidence for these and many other interventions are relatively low while the magnitudes of treatment effects are small (see Fraser et al., 2013). Common to the treatment models presented is the emphasis on system support, the importance of relationships in the recovery process and developmentally appropriate intervention modalities. These factors likely will serve as integral components of future methods focused on the treatment of traumatized young children.


Discussion and Implications


Young children are at high risk for exposure to traumatic events and are particularly vulnerable for several reasons. They are dependent upon caregivers and lack adequate coping skills. Children also experience rapid development and growth, leaving them particularly impressionable when faced with a traumatic event. Young children benefit from preventive psychoeducation aimed at teaching parents and caregivers about child development and parenting skills (McNeil, Herschell, Gurwitch, & Clemens-Mowrer, 2005; Valentino, Comas, Nuttall, & Thomas, 2013). Counselors who work with this population endeavor to increase protective factors and decrease risk factors while exploring preventive methods, which may reduce young children’s exposure to traumatic events. Similarly, legislators can influence public policy related to enhancing childhood mental health. For example, legislation can address prevention and offer incentives to parents participating in psychoeducation focused on enhancing protective factors and reducing childhood trauma exposure.


In recent years research has emerged that provides an understanding of how trauma impacts young children. Researchers and clinicians know that infants, toddlers and preschoolers have the capacity to perceive trauma and are capable of experiencing psychopathology following a traumatic event. Although these children can experience mental illnesses often associated with older children, adolescents and adults, the symptomology can manifest in various ways. Additionally, professional counselors working with children in a variety of settings should consider the residual impact of traumatic events experienced in early childhood. School-aged children may experience behavioral problems and have difficulty learning and forming relationships as a result of early childhood trauma (Cole, Eisner, Gregory, & Ristuccia, 2013; Cole et al., 2005). A number of studies indicate that trauma is a strong predictor of academic failure (Blodgett, 2012). Therefore, school counselors serving as mediators between academics and wellness should explore ways to advocate for and support students with known or suspected exposure to traumatic events in early childhood. For example, the trauma-sensitive schools initiative provides school counselors with a framework for fostering schoolwide awareness and creating a safe and supportive environment (Cole et al., 2013). School counselors can easily embed these types of preventive measures as part of a comprehensive school counseling program. These efforts will presumably result in increases in student success, wellness and awareness, three outcomes that will benefit all children exposed to traumatic events.


While great strides have been taken recently in understanding and treating early childhood trauma, there are clear gaps in the dissemination of information to counselors. Professional counselors should receive training in specifically designed interventions and attempt to raise public awareness of early childhood trauma in hopes that young children will receive necessary treatment. The findings of this literature review suggest that various methods of treatment might effectively reduce symptoms experienced by traumatized children. Parent–child relationships and other environmental factors also can have significant influence on children’s reaction to trauma.


A major purpose of this article is to educate counselors about the impact of trauma in early childhood and advocate for appropriate assessment and treatment of these traumatic exposures. While not all counselors choose to work with this vulnerable population, they often work with clients who have extended families with young children. Counselors who work with adult clients can provide psychoeducation about this important issue and initiate referrals to counselors trained to work with early childhood trauma. There is a body of information about trauma in early childhood available for further review. Sources include the National Child Traumatic Stress Network (, the California Evidence-Based Clearinghouse for Child Welfare (, and the Association for Child and Adolescent Counseling ( Counselors interested in learning more about this issue can review these online resources.



Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.



Administration on Children, Youth, & Families. (2003). Child maltreatment 2001. Washington, DC: Government Printing Office. Retrieved from

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

American Psychological Association Presidential Task Force on Posttraumatic Stress Disorder and Trauma in Children and Adolescents. (2008). Children and trauma: Update for mental health professionals. American Psychological Association. Retrieved from

Anda, R., Tietjen, G., Schulman, E., Felitti, V., & Croft, J. (2010). Adverse childhood experiences and frequent headaches in adults. Headache, 5, 1473–81. doi:10.1111/j.1526-4610.2010.01756.x

Anderson, S. M., & Gedo, P. M. (2013). Relational trauma: Using play therapy to treat a disrupted attachment. Bulletin of the Menninger Clinic, 77, 250–268. doi:10.1521/bumc.2013.77.3.250

Arseneault, L., Cannon, M., Fisher, H. L., Polanczyk, G., Moffitt, T. E., & Caspi, A. (2011). Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study. The American Journal of Psychiatry, 168, 65–72. doi:10.1176/appi.ajp.2010.10040567

Aspelmeier, J. E., Elliot, A. N., & Smith, C. H. (2007). Childhood sexual abuse, attachment, and trauma symptoms in college females: The moderating role of attachment. Child Abuse & Neglect, 31, 549–566.

Bendall, S., Jackson, H. J., Hulbert, C. A., & McGorry, P. D. (2008). Childhood trauma and psychotic disorders: A systematic, critical review of the evidence. Schizophrenia Bulletin, 34, 568–579. doi:10.1093/schbul/sbm121

BigFoot, D. S., & Schmidt, S. R. (2007). Honoring children, mending the circle. Retrieved from

BigFoot, D. S., & Schmidt, S. R. (2010). Honoring children, mending the circle: Cultural adaptation of trauma-focused cognitive-behavioral therapy for American Indian and Alaska native children. Journal of Clinical Psychology, 68, 847–856. doi:10.1002/jclp.20707

Blodgett, C. (2012). Adopting ACEs screening and assessment in child serving systems. Retrieved from

Briggs-Gowan, M. J., Carter, A. S., Clark, R., Augustyn, M., McCarthy, K. J., & Ford, J. D. (2010). Exposure to potentially traumatic events in early childhood: Differential links to emergent psychopathology. Journal of Child Psychology and Psychiatry, 51, 1132–1140. doi:10.1111/j.1469-7610.2010.02256.x

Briggs-Gowan, M. J., Carter, A. S., & Ford, J. D. (2011). Parsing the effects violence exposure in early childhood: Modeling developmental pathways. Journal of Pediatric Psychology, 37, 11–22. doi:10.1093/jpepsy/jsr063

Brown, D. W., Anda, R. F., Felitti, V. J., Edwards, V. J., Malarcher, A. M., Croft, J. B., & Giles, W. H. (2010). Adverse childhood experiences are associated with the risk of lung cancer: A prospective cohort study. BMC Public Health, 10, 10–20. doi:10.1186/1471-2458-10-20

Carter, A. S., Briggs-Gowan, M. J., & Davis, N. O. (2004). Assessment of young children’s social-emotional development and psychopathology: Recent advances and recommendations for practice. Journal of Child Psychology and Psychiatry, 45, 109–134.

Carter, A. S., Briggs-Gowan, M. J., Jones, S. M., & Little, T. D. (2003). The infant–toddler social emotional assessment (ITSEA): Factor structure, reliability, and validity. Journal of Abnormal Child Psychology, 31, 495–514.

Chadwick Center for Children and Families. (2009). Assessment-based treatment for traumatized children: A trauma assessment pathway (TAP). San Diego, CA: Author.

Chaffin, M., Silovsky, J. F., Funderburk, B., Valle, L. A., Brestan, E. V., Balachova, T., . . . Bonner, B. L. (2004). Parent–child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72, 500–510.

Child Welfare Information Gateway. (2012, August). Trauma-focused cognitive behavioral therapy for children affected by sexual abuse or trauma. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. Retrieved from

Child Welfare Information Gateway. (2014). Child abuse and neglect fatalities 2012: Statistics and interventions. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. Retrieved from

Clay, R. A. (2010, July/August). Treating traumatized children: Five years after Katrina, new data are illuminating the best ways to help children after natural disasters. Monitor on Psychology, 41, 36–39.

Coates, S., & Gaensbauer, T. J. (2009). Event trauma in early childhood: Symptoms, assessment, intervention. Child and Adolescent Psychiatric Clinics of North America, 18, 611–626. doi:10.1016/j.chc.2009.03.005

Cohen J. A., & Mannarino, A. P. (1996). A treatment outcome study for sexually abused preschool children: Initial findings. Journal of the American Academy of Child & Adolescent Psychiatry, 35, 42–50.

Cohen J. A., & Mannarino, A. P. (1997). A treatment study for sexually abused preschool children: Outcome during a one-year follow-up. Journal of the American Academy of Child & Adolescent Psychiatry, 36, 1228–1235.

Cohen, N. J. (2010). The impact of language development on the psychosocial and emotional development of young children. In R. E. Tremblay, M. Boivin, & R. D. Peters (Eds.), Encyclopedia on early childhood development. Retrieved from

Cole, S. F., Eisner, A., Gregory, M., & Ristuccia, J. (2013). Helping traumatized children learn: Safe, supportive learning environments that benefit all children. Creating and advocating for trauma-sensitive schools. Boston, MA: Massachusetts Advocates for Children.

Cole, S. F., O’Brien, J. G., Gadd, M. G., Ristuccia, J., Wallace, D. L., & Gregory, M. (2005). Helping traumatized children learn: Supportive school environments for children traumatized by family violence. A report and policy agenda. Boston, MA: Massachusetts Advocates for Children.

Conradi, L., Kletzka, N. T., & Oliver, T. (2010). A clinician’s perspective on the trauma assessment pathway (TAP) model: A case study of one clinician’s use of the (TAP) model. Journal of Child and Adolescent Trauma, 3, 40–57. doi:10.1080/19361520903520450

Corey, G. (2009). Theory and practice of counseling and psychotherapy (8th ed.). Belmont, CA: Brooks/Cole.

Crusto, C. A., Whitson, M. L., Walling, S. M., Feinn, R., Friedman, S. R., Reynolds, J., . . . Kaufman., J. S. (2010). Posttraumatic stress among young urban children exposed to family violence and other potentially traumatic events. Journal of Traumatic Stress, 23, 716–724. doi:10.1002/jts.20590

De Bellis, M. D., Woolley, D. P., & Hooper, S. R. (2013). Neuropsychological findings in pediatric maltreatment: Relationship of PTSD, dissociative symptoms, and abuse/neglect indices to neurocognitive outcomes. Child Maltreatment, 18, 171–183. doi:1077559513497420.

Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their non-offending mothers. Child Maltreatment, 6, 332–343. doi:10.1177/1077559501006004006

De Young, A. C., Kenardy, J. A., & Cobham, V. E. (2011). Trauma in early childhood: A neglected population. Clinical Child & Family Psychology Review, 14, 231–250. doi:10.1007/s10567-011-0094-3

Dong, M., Giles, W. H., Felitti, V. J., Dube, S. R., Williams, J. E., Chapman, D. P., & Anda, R. F. (2004). Insights into causal pathways for ischemic heart disease: Adverse childhood experiences study. Circulation, 110, 1761–1766.

Dozier, M. (2003). Attachment-based treatment for vulnerable children. Attachment and Human Development, 5, 253–257.

Dozier, M., Peloso, E., Lewis, E., Laurenceau, J. P., & Levine, S. (2008). Effects of an attachment-based intervention on the cortisol production of infants and toddlers in foster care. Development and Psychopathology, 20, 845–859. doi:10.1017/S0954579408000400

Dube, S. R., Fairweather, D., Pearson, W. S., Felitti, V. J., Anda, R. F., & Croft, J. B. (2009). Cumulative childhood stress and autoimmune diseases in adults. Psychosomatic Medicine, 71, 243–250. doi:10.1097/PSY.0b013e3181907888

Dugan, E. M., Snow, M. S., & Crowe, S. R. (2010). Working with children affected by hurricane Katrina: Two case studies in play therapy. Child and Adolescent Mental Health, 15, 52–55. doi:10.1111/j.1475-3588.2008.00523.x

Edwards, V. J., Anda, R. F., Dube, S. R., Dong, M., Chapman, D. F., & Felitti, V. J. (2005). The wide-ranging health consequences of adverse childhood experiences. In K. A. Kendall-Tackett & S. M. Giacomoni (Eds.), Child victimization: Maltreatment, bullying, and dating violence prevention and intervention (pp. 8-1–8-12). Kingston, NJ: Civic Research Institute.

Egger, H. L., & Angold, A. (2006). Common emotional and behavioral disorders in preschool children: Presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry, 47, 313–337.

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, 245–258.

Ford, J. D., Grasso, D., Greene, C., Levine, J., Spinazzola, J., & van der Kolk, B. (2013). Clinical significance of a proposed developmental trauma disorder diagnosis: Results of an international survey of clinicians.  Journal of Clinical Psychiatry74, 841–849.

Forman-Hoffman, V., Knauer, S., McKeeman, J., Zolotor, A., Blanco, R., Lloyd,…Viswanathan, M. (2013). Child and adolescent exposure to trauma: Comparative effectiveness of interventions addressing trauma other than maltreatment or family violence (Review No. 107). Retrieved from Agency for Healthcare Research and Quality, Effective Health Care Program website: /reports/final.cfm

Fraser, J. G., Lloyd, S. W., Murphy, R. A., Crowson, M. M., Casanueva, C.,Zolotor, A.,…Viswanathan, M. (2013). Child exposure to trauma: Comparative effectiveness of interventions addressing maltreatment (Review No. 89). Retrieved from Agency for Healthcare Research and Quality, Effective Health Care Program website: /reports/final.cfm

Frick-Helms, S. B. (1997). “Boys cry better than girls:” Play therapy behaviors of children residing in a shelter for battered women. International Journal of Play Therapy, 61, 73–91.

Gaensbauer, T. J. (2002). Representations of trauma in infancy: Clinical and theoretical implications for the understanding of early memory. Infant Mental Health Journal, 23, 259–277. doi:10.1002/imhj.10020

Goodman, R. D., Miller, M. D., & West-Olatunji, C. A. (2012). Traumatic stress, socioeconomic status, and academic achievement among primary school students. Psychological Trauma: Theory, Research, Practice, and Policy, 4, 252–259. doi:10.1037/a0024912

Grossman, D. C. (2000). The history of injury control and the epidemiology of child and adolescent injuries. The Future of Children, 10, 23–52.

Harley, M., Kelleher, I., Clark, M., Lynch, F., Arseneault, L., Connor, D., . . . Cannon, M. (2010). Cannabis use and childhood trauma interact additively to increase the risk of psychotic symptoms in adolescence. Psychological Medicine, 40, 1627–1634. doi:10.1017/S0033291709991966

Holtmann, M., Buchmann, A. F., Esser, G., Schmidt, M. H., Banaschewski, T., & Laucht, M. (2011). The Child Behavior Checklist-Dysregulation Profile predicts substance use, suicidality, and functional impairment: A longitudinal analysis. Journal of Child Psychology and Psychiatry52(2), 139–147. doi:10.1111/j.1469-7610.2010.02309.x.

Howe, M. L., Toth, S. L., & Cicchetti, D. (2006). Memory and developmental psychopathology. In D. Cicchetti & D. J. Cohen (Eds.), Developmental psychopathology, Vol. 2: Developmental neuroscience (pp. 629–655). Hoboken, NJ: Wiley.

Kanel, K. (2015). A guide to crisis intervention (5th ed.). Belmont, CA: Brooks/Cole.

Kot, S., Landreth, G. L., & Giordano, M. (1998). Intensive child-centered play therapy with child witnesses of domestic violence. International Journal of Play Therapy, 7(2), 17–36.

Landreth, G. L. (2012). Play therapy: The art of the relationship (3rd ed.). New York, NY: Taylor & Francis.

Lieberman, A. F., & Knorr, K. (2007). The impact of trauma: A developmental framework for infancy and early childhood. Psychiatric Annals, 37, 416–422.

Lieberman, A. F., & Van Horn, P. (2008). Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment. New York, NY: Guilford.

Lieberman, A. F., & Van Horn, P. (2009). Giving voice to the unsayable: Repairing the effects of trauma in infancy and early childhood. Child and Adolescent Psychiatric Clinics of North America, 18, 707–720. doi:10.1016/j.chc.2009.02.007.

McCabe, K. M., Yeh, M., Garland, A. F., Lau, A. S., & Chavez, G. (2005). The GANA program: A tailoring approach to adapting parent child interaction therapy for Mexican Americans. Education and Treatment of Children, 28, 111–129.

McNeil, C. B., Herschell, A. D., Gurwitch, R. H., & Clemens-Mowrer, L. (2005). Training foster parents in parent-child interaction therapy. Education and Treatment of Children, 28, 182–196.

Morgan, C., & Fisher, H. (2007). Environmental factors in schizophrenia: Childhood trauma—a critical review. Schizophrenia Bulletin, 33, 3–10. doi:10.1093/schbul/sbl053

National Child Traumatic Stress Network. (2010). Early childhood trauma. Retrieved from

National Library of Medicine. (2013). Traumatic events. Retrieved from

National Registry of Evidence-Based Programs and Practices. (2012). A roadmap to implementing evidence-based programs. Substance Abuse and Mental Health Services Administration. Retrieved from

Osofsky, J. D. (2003). Prevalence of children’s exposure to domestic violence and child maltreatment: Implications for prevention and intervention. Clinical Child and Family Psychology Review, 6, 161–170. doi:10.1023/A:1024958332093

Pynoos, R. S., Steinberg, A. M., Layne, C. M., Briggs, E. C., Ostrowski, S. A., & Fairbank, J. A. (2009). DSM-V PTSD diagnostic criteria for children and adolescents: A developmental perspective and recommendations. Journal of Traumatic Stress, 22, 391–398. doi:10.1002/jts.20450

Read, J., Fosse, R., Moskowitz, A., & Perry, B. (2014). The traumagenic neurodevelopmental model of  psychosis revisited. Neuropsychiatry4(1), 65-79.

Read, J., van Os, J., Morrison, A. P., & Ross, C. A. (2005). Childhood trauma, psychosis and schizophrenia: A literature review with theoretical and clinical implications. Acta Psychiatrica Scandinavica, 112, 330–350. doi:10.1111/j.1600-0447.2005.00634.x

Scheeringa, M. S., Zeanah, C. H., Myers, L., & Putnam, F. W. (2003). New findings on alternative criteria for PTSD in preschool children. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 561–570.

Scheeringa, M. S., & Haslett, N. (2010). The reliability and criterion validity of the diagnostic infant and preschool assessment: A new diagnostic instrument for young children. Child Psychiatry & Human Development, 41, 299–312. doi:10.1007/s10578-009-0169-2

Schore, A. N. (2001a). The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal22(1–2), 201–269. doi:10.1002/1097-0355(200101/04)22:1<201::AID-IMHJ8>3.0.CO;2-9

Schore, A. N. (2001b). Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal22(1–2), 7–66. doi:10.1002/1097-0355(200101/04)22:1<7::AID-IMHJ2>3.0.CO;2-N

Shahinfar, A., Fox, N. A., & Leavitt, L. A. (2000). Preschool children’s exposure to violence: Relation of behavior problems to parent and child reports. American Journal of Orthopsychiatry, 70, 115–125.

Strand, V. C., Pasquale, L. E., & Sarmiento, T. L. (2011). Child and adolescent trauma measures: A review. Retrieved from

Straus, M. A., & Gelles R. J. (1990). How violent are American families? Estimates from the national family violence resurvey and other studies. In M. A. Straus & R. J. Gelles (Eds.), Physical violence in American families: Risk factors and adaptations to violence in 8,145 families (pp. 95–112). New Brunswick, NJ: Transaction.

Strine, T. W., Dube, S. R., Edwards, V. J., Prehn, A. W., Rasmussen, S., Wagenfeld, M., . . . Croft, J. B. (2012). Associations between adverse childhood experiences, psychological distress, and adult alcohol problems. American Journal of Health Behavior, 36, 408–423. doi:10.5993/AJHB.36.3.11

Teicher, M. H., Anderson, C. M., & Polcari, A. (2012). Childhood maltreatment is associated with reduced volume in the hippocampal subfields CA3, dentate gyrus, and subiculum. Proceedings of the National Academy of Sciences, 109(9), E563–E572. doi:10.1073/pnas.1115396109

Tortora, S. (2010). Ways of seeing: An early childhood integrated therapeutic approach for parents and babies. Clinical Social Work Journal, 38, 37–50. doi:10.1007/s10615-009-0254-9

Turner, H. A., Finkelhor, D., Ormrod, R., Hamby, S., Leeb, R. T., Mercy, J. A., & Holt, M. (2012). Family context, victimization, and child trauma symptoms: Variations in safe, stable, and nurturing relationships during early and middle childhood. American Journal of Orthopsychiatry, 82, 209–219. doi:10.1111/j.1939-0025.2012.01147x

Valentino, K., Comas, M., Nuttall, A. K., & Thomas, T. (2013). Training maltreating parents in elaborative and emotion-rich reminiscing with their preschool-aged children. Child Abuse & Neglect, 37, 585–595. doi:10.1016/j.chiabu.2013.02.010

Yates, T., Ostrosky, M. M., Cheatham, G. A., Fettig, A., Shaffer, L., & Santos, R. M. (2008). Research synthesis on screening and assessing social-emotional competence. Center on the Social Emotional Foundations for Early Learning. Retrieved from

Zeanah, C. H., Jr., & Zeanah, P. D. (2009). The scope of infant mental health. In C. H. Zeanah, Jr. (Ed.), Handbook of infant mental health (3rd ed., pp. 5–21). New York, NY: Guilford Press.

Zero to Three. (2005). Diagnostic classification of mental health and developmental disorders of infancy and early childhood (DC: 0-3R; revised edition). Washington, DC: Author.

Zindler, P., Hogan, A., & Graham, M. (2010). Addressing the unique and trauma-related needs of young children. Tallahassee, FL: Florida State University Center for Prevention & Early Intervention Policy.


Kristen E. Buss, NCC, is a counselor at Hope-Thru-Horses, Inc. in Lumber Bridge, NC. Jeffrey M. Warren, NCC, is an Assistant Professor at the University of North Carolina-Pembroke. Evette Horton is a clinical instructor at the UNC OBGYN Horizons Program at the University of North Carolina-Chapel Hill. Correspondence can be addressed to Jeffrey Warren, The University of North Carolina-Pembroke, P.O. Box 1510, School of Education, Pembroke, NC 28372,



All Foreign-Born Adoptees Are Not the Same: What Counselors and Parents Need to Know

Yanhong Liu, Richard J. Hazler

International adoption provides U.S. families with parenting opportunities as well as with challenges accompanying adoptees’ post-adoption adjustment. The literature indicates differences in adjustment outcomes between Chinese and other international adoptees. Differences are found in behavioral adjustment, attachment formation and social-emotional development. Pre-adoption circumstances, including the political and cultural reasons for adoption, institutionalization experiences, and family stress, are relevant factors for adoptees’ post-adoption adjustment. A closer look at Chinese adoptees offers insights on components that may prohibit or contribute to post-adoption adjustment outcomes. Each component provides implications for professional counselors and the adoptive families they serve for nurturing the growth of international adoptees.

Keywords: international adoption, international adoptees, Chinese adoptees, post-adoption adjustment, professional counselors, adoptive families

International adoption, involving transferring children from a country of origin to a host country, creates a unique set of circumstances where adoptive parents and adopted children meet across lines of differences in biology, race, cultural heritage, nationality, socioeconomic status and more (Bartholet, 2006). World circumstances of war, poverty and lack of social welfare have created multiple scenarios in which countries now provide U.S. couples with additional parenting opportunities, while increasing infertility rates and other difficulties have reduced U.S. domestic adoption opportunities. These increases in international adoptions have both global significance and local importance for related countries, societies and communities (Hoshman, Gere, & Wong, 2006). Many advantages and challenges accompany the adoption process that counselors increasingly need to face in their schools, communities and private practices.


     International adoption provides many opportunities for the countries involved, for the individuals wanting to adopt and for the children needing adoption; however, the post-adoption process is accompanied by multiple challenges for adoptive parents, professional counselors and human service agencies. A meta-analysis by Juffer and van IJzendoorn (2005) showed that internationally adopted children exhibit more behavioral problems and receive more mental health services than non-adopted children. Higher rates of attachment and social-emotional problems also were found among internationally adopted children when compared to non-adopted and domestically adopted peers. As such, this group needs to be considered an at-risk population deserving of specific attention (Barcons et al., 2011; van den Dries, Juffer, IJzendoorn, & Bakermans-Kranenburg, 2010).


     Professional counseling journals currently provide little help to their readers about international adoptees and the resources needed to work effectively with them. Journal articles from psychology, social work, children and youth services, adoption, and sociology (e.g., Bruder, Dunst, Mogro-Wilson, & Tan, 2010; Cohen & Farnia, 2011; Pugliese, Cohen, Farnia, & Lojkasek, 2010) provide more information on these issues, and their findings can be utilized to meet the needs of professional counselors. This article will utilize the findings from related disciplines to demonstrate how professional counselors can more effectively support children and parents among this population.


     International adoptees from China have been shown to have better adjustment outcomes in comparison with international adoptees as a whole, making them an important subgroup to examine (Cohen & Farnia, 2011; Tan, Camras, Deng, Zhang, & Lu, 2012; Tan & Marfo, 2006). China also is the largest country of origin of children for international adoption, accounting for over one fourth of the 242,602 U.S. international adoptions between 1999 and 2012 (U.S. Department of State, 2012). The post-adoption adjustment of international adoptees from China and the wealth of literature regarding them provide important sources of information on what influences an international adoption. Consequently, this article gives significant focus to Chinese adoptees and, where possible, compares that information to studies of adoptees from other countries. This article transforms the information into practical implications for counselors and parents with international adoptees and those who are considering an international adoption.


A Closer Look at Chinese Adoptees


     Chinese adoptees deserve particular research attention because they show more positive post-adoption outcomes in areas such as personal-social development, problem-solving skills, behavioral adjustment, child–parent attachment patterns and academic achievement (Cohen & Farnia, 2010; Tan, Marfo, & Dedrick, 2010; Welsh & Viana, 2012). Cohen and Farnia (2010, 2011) found a common trend in that Chinese adoptees display rapid growth in overall development within the first 6 months after adoption and increased attachment 2 years later. Their preschool years contain fewer behavioral problems compared even to U.S. preschool-age non-adopted girls from the normative sample (Tan et al., 2012). Behaviors exhibited by Chinese adoptees are comparable to those of U.S. non-adopted peers, which means Chinese adoptees demonstrate no more internalizing (directed toward oneself), externalizing (directed toward the environment) or total problem behaviors than all children in a similar age range (Tan et al., 2012). Internalizing problems, externalizing problems and overall behavior problems are the three subscales of the Child Behavior Checklist that Tan et al. (2012) used to measure preschool-age Chinese girls’ behaviors.


     A study from another Western culture compared the academic achievement of 77 Chinese adoptees with those of 77 Norwegian-born children of similar age and found no significant difference between the two samples (Dalen & Rygvold, 2006). These results differ from results of studies on international adoptees from other countries, in which these adoptees have been shown to exhibit lower academic performance than non-adoptees (e.g., Miller, Chan, Tirella, & Perrin, 2009; van IJzendoorn, Juffer, & Poelhuis, 2005). The combined results consistently indicated better post-adoption results for Chinese children. These results raise the following question: What is it about Chinese children and the process of their adoptions that might account for such differences?


Politics and Culture

     More than 90% of Chinese adoptees are female infants, a fact influenced by China’s political and cultural characteristics. Adoption from China to the United States was greatly affected by China’s one-child policy, first implemented in 1979. The policy was designed to control population growth by only allowing one child per couple. This policy, along with China’s cultural emphasis on sons over daughters, has caused the abandonment of many infant girls (Johnson, 2004). This abandonment practice is one way for a family to have a second child but still be a one-child family. Most of the abandonments happen in rural areas of China where households without a son are likely to experience discrimination for potentially losing their family name in following generations (Chen & Li, 2009). Family name has great cultural importance throughout China, but rural populations are the most concerned about these issues, making female children most vulnerable and more likely to be put up for international adoption.


     The one-child policy impacts more than the number and gender of adoptees. It is believed that this policy is an indirect factor in Chinese adoptees’ better physical and experiential conditions when adopted (Kreider & Cohen, 2009). The one-child policy, along with the cultural preference for male infants, indicates that healthy parents abandon the majority of Chinese children put up for adoption for poverty-related, political or cultural reasons, and not for health or disability reasons, as is often the case in other countries. Adoptees from Eastern Europe and Russia, for example, consistently experience pre-adoption adversities such as poverty and birth mothers’ alcohol and substance use during pregnancy (Kreider & Cohen, 2009; Welsh &Viana, 2012). The physical and emotional pre-adoption environments for non-Chinese children understandably make a significant difference for their potential to successfully develop as they meet the multiple demands of the adoption process.


Pre-Adoption Institutionalization Experience

     Approximately 85% of international adoptees have some level of institutionalization experience in their birth countries (Gunnar, van Dulmen, & the International Adoption Project Team, 2007). Along with pre-adoption parental quality and biological factors, the institutionalization experiences were found to be a significant factor in predicting post-adoption behavioral problems (Hawk & McCall, 2010; van den Dries et al., 2010). The quality of institutional care received by adoptees varies from country to country. The psychological aspect of institutional care is better in China because of the family-like atmosphere within institutions (Neimetz, 2010; Shang, 2002). A case study by Neimetz (2010) found that the director, codirector and other caregivers were called father, mother and siblings, respectively. This family-style psychological emphasis demonstrates recognition of a quasi-family environment aimed at counterbalancing the effects of the large number of children in an institution, which does not seem to appear in many other countries.


Risk Factors for Adoptee Adjustment


Cognitive Development

     The status of adoptees’ cognitive development at the time of adoption has been noted as predictive of attachment outcome and social-emotional reactivity. Recent literature has indicated a positive relationship between international adoptees’ post-adoption adjustment and their cognitive level when they arrived in the host country (Cohen & Farnia, 2010). Cohen and Farnia (2011) found that mental development index scores are significant predictors of Chinese adoptees’ later social-emotional activities and attachment outcomes, which in turn affect cognitive development. After 6 months, adoptees with higher mental development index scores were associated with better social-emotional adjustment and faster rates of forming attachment relationships with their adoptive mothers. Cohen and Farnia (2010) speculated that a lack of cognitive resources is associated with adoptees’ difficulty in post-adoption adjustment.


Behaviors at Time of Adoption

Positive relationships have been found between rejection behaviors at the time of adoption and both internalizing and externalizing behavioral problems of preschool-age and school-age Chinese adoptees (Tan & Marfo, 2006). Rejection behaviors are adoptees’ resistant behaviors toward adoptive parents during the initial period after adoption (Tan & Marfo, 2006). Tan and Marfo (2006) found that the behaviors present at the time of adoption were better predictors of later adjustment outcomes than adoptees’ age on arrival. Therefore, initial behaviors are more influential for adoption outcomes than the maturity that comes with age (Tan et al., 2010).


Family Stress

     Tan et al. (2012) studied the post-adoption adjustment of 133 preschool-age Chinese adoptees and found that the level of stress in the adoptive family positively correlated with the child’s presenting behavioral problems. The higher the level of stress that a family encounters, the more behavioral problems are identified in the child. Maternal depression prior to adoption, as well as high parental expectations of problems (i.e., expecting a high rate of occurrence of the child’s behavioral problems), were significant predictors for post-adoption family stress (Viana & Welsh, 2010). Familial stress is a significant factor in child–parent relationships and a risk factor for overall child psychopathology (Deater-Deckard, 1998).


Parental Sensitivity and Authoritative Parenting

Parental sensitivity refers to parents’ ability to sense various cues that an infant exhibits and to respond to those cues consistently (Karl, 1995). Sensitive parenting provided by adoptive parents is related to better developmental growth following adoption (Palacios & Brodzinsky, 2010). Parents who are consistently sensitive in caregiving develop more secure attachment with adoptees, and changing from insensitive to sensitive caregiving results in a transition from insecure to secure attachment (Beijersbergen, Juffer, Bakermans-Kranenburg, & van IJzendoorn, 2012).


Parental sensitivity in the literature refers generally to parents’ responsiveness to infants, but the concept of parenting styles takes on greater significance when it concerns young children. Baumrind (1978) proposed three primary parenting approaches: authoritative parenting, authoritarian parenting and permissive parenting. Authoritative parenting was highlighted positively for its emphasis on parents’ setting up reasonably high expectations while showing support for children’s interests. Tan et al. (2012) studied the role of authoritative parenting in adoptive families with Chinese children and found that authoritative parenting was associated with fewer behavioral problems in Chinese adoptees in the study.


     A closer look at Chinese adoptees’ pre-adoption circumstances and post-adoption protective factors offers insights about the critical components that may prohibit or contribute to positive adjustment outcomes. Political and cultural influences, institutionalization experiences prior to adoption, adoptees’ cognitive development level, and parents’ sensitive care and authoritative parenting in post-adoption all appear to be important factors in post-adoption adjustment. Each component provides implications for professional counselors and the adoptive families they serve in facilitating adoptees’ development.


Implications for Parents and Counselors


     Post-adoption protective factors such as parental sensitivity and appropriate parenting approaches can mitigate adoptees’ adverse experiences and promote resilience (Barcons et al., 2011; Scroggs & Heitfield, 2001; van den Dries et al., 2010). The impact of pre-adoption conditions diminishes as the influence of the adoptive family becomes more salient (Gagnon-Oosterwaal et al., 2012). Studies showing significantly better results for Chinese adoptees’ adjustment provide insights related to key issues deserving attention from professional counselors and their parent clients. Examining pre-adoption conditions and experiences of international adoptees can be a challenging issue due to the distance from countries of origin and confidential nature of the information.


Awareness of Gender Differences and Health Status

The availability of more female than male infants for adoption, created by China’s one-child policy and cultural emphasis on males over females, is related to a healthier status of most adopted Chinese children (Kreider & Cohen, 2009). These gender and health differences provide insights into caregiving by adoptive parents and the counseling services offered to adoptive families. Designing and implementing preventative and intervening approaches should be carefully examined and adapted based on considerations of male versus female adoptees, and of healthy children versus children with special needs.


     Implications for parents. Parents need to understand the context of countries from which they wish to adopt a child. Families differ in their reasons for adoption, the countries they choose from which to adopt and characteristics of the child whom they wish to adopt. These differences make it important for parents to conduct a self-analysis and rationalize the adoption choice by specifying characteristics of an adopted child such as gender, age, race and health conditions prior to the international adoption process (Gunnar, Bruce, & Grotevant, 2000). Becoming familiar with the context of countries of origin facilitates the family’s matching process with a potential child. For example, parents may choose to adopt from a country with more female infants on the waiting list, such as China, if they prefer adopting a female child and have no specific restrictions on other characteristics.


     Parents also need to be aware of potential relationships between abandonment and the gender or health of the child so as to provide appropriate post-adoption care. Obtaining pre-adoption information about the child and the country of origin is an important step (Gunnar et al., 2000). Additionally, adoptive parents should understand that health and medical information, including family and prenatal history, is probably more comprehensive for a child from some countries than others. Families may follow up with the adoption agency by making specific requests for information that is more detailed than the standard information provided (Bledsoe & Johnston, 2004).


     Implications for counselors. When considering the gender and health of the adoptee, two main types of services are suggested for professional counselors working with internationally adoptive parents and adopted children—information interpretation (Gunnar et al., 2000) and pre- and post-adoption counseling services (Welsh, Viana, Petrill, & Mathias, 2007). The connection between the adoption process and the individual characteristics of the child to each country’s policy and culture make it necessary for counselors to take into consideration the context of the country of origin and to help families interpret adoption-related information (Gunnar et al., 2000). Quality interpretation increases the likelihood of the child’s positive post-adoption development. At the same time, the interpretation of information also has the potential to prevent a child from being adopted due to possible physical and mental health concerns of the child, expenses involved, and additional requirements about parents’ age, income or sexual orientation regulated by specific countries of origin (Gunnar et al., 2000).


     Counselors may utilize pre-adoption information (e.g., health and behavioral information, diagnosis) in designing interventions for adopted children. Most counselors do not receive professional training in adoption or working with adoptive families and children, so establishing a professional network with adoption agencies, social workers and psychologists becomes essential. This network will provide more accurate information and ensure necessary referrals, access to available medical and health data, appropriate consultation, and professional collaboration that will best serve adoptees and families.


 Recognizing Adoption-Point Behaviors

     Tan et al. (2010) reported in a longitudinal study of preschool-age Chinese adoptees that behaviors exhibited at the time of adoption predict adjustment outcomes regardless of the age at adoption. Risk indicators were identified as refusal/avoidance and crying/clinging behaviors, and more internalizing and externalizing behavioral problems were found in children exhibiting more physical risk indicators at the time of adoption (Tan et al., 2012).


     Implications for parents. International adoptive parents should be aware of the behaviors exhibited at the time of adoption by adoptees, which can be particularly helpful for recognizing potential adjustment issues. To deal with noncompliance and clinging related to problem behaviors and social-emotional learning, it is suggested that parents provide timely comfort and be attuned to the child’s needs (Brennan, 2013). Parents also are encouraged to recognize changes from the environment of the adoptee’s origin to a U.S. environment and consider preparing resources to help with children’s transitions. These can include music or stories in languages of birth countries along with toys and other sources of origin environment comfort.


     Implications for counselors. Professional consultation with adoption agencies can provide the basis for understanding specific behaviors that the child presents and how the behaviors can affect development. Some behaviors displayed by an adoptee may be related to his or her developmental stage, and frequently avoidance and clinging behaviors are identified as major symptoms of separation anxiety disorder in children (Ehrenreich, Santucci, & Weiner, 2009). Counselors may work with parents to track the frequency of the behaviors during the initial period after adoption. Appropriate interventions can then be designed and implemented according to the presentation of behaviors and/or specific diagnosis made by qualified professionals.


Facilitating Secure Attachment Development

Understanding the mutually influential factors of social-emotional reactivity and attachment security of adopted children are of practical significance (Cohen & Farnia, 2010). According to attachment theory, children with secure attachment are more likely to develop strong internal working models with salient self-efficacy, enabling them to be empathic and more capable of maintaining relationships, whereas children with insecure attachment may develop weak internal working models that lack social competency in relationships (Bowlby, 1969). Internationally adopted children experience a variety of transitions in culture, language and living environment, which present as separation and loss, adding difficulty to the development of attachment to new caregivers (Bowlby, 1969).


     Implications for parents. Parental sensitivity, or providing appropriate, timely and consistent responses, is a major contributor to secure child–parent attachment. It is a protective factor for international adoptees and can counteract otherwise problematic pre-adoption risk factors. Parents can increase their sensitivity by utilizing a form of mind-mindedness as an effective strategy for helping infants form secure attachments (Meins, Fernyhough, Fradley, & Tuckey, 2001). The technique involves naming children’s feelings, wishes, intentions and thoughts in situationally appropriate ways. The act of naming encourages active recognition of the need to respond to the child and the time to do so, thereby building a pattern of productive, sensitive, parental behaviors.


     Implications for counselors. Counselors may emphasize adoptee–parent relationships in which trust is a fundamental element (Barcons et al., 2011; Tan & Camras, 2011). Parent training and psychoeducation based on individual family needs can help establish the necessary parental desire and skills required. Trust-Based Relational Intervention is one sample of a program developed for adoptive families of children with social-emotional needs (Purvis, Cross, & Pennings, 2009). This program emphasizes the following two main principles in developing a family-based program: (a) awareness (i.e., understanding adoptees’ responses and feelings) and (b) engagement (i.e., interacting with adoptees in a way that makes them feel safe). Modeling eye contact and imitating the child’s body position are recommended for working with internationally adopted children for whom extreme changes in culture, environment and other factors can make developing trust more difficult. Counselors should be cautious when using these strategies before getting to know the child and parents in-depth. Active eye contact and body gestures may intimidate children due to cultural reasons or previous traumatic experiences (Becker-Weidman, 2006).


Coping With Family Stress

     Numerous studies have demonstrated a positive correlation between family stress and child psychopathology (Grant, Compas, Thurm, McMahon, & Gipson, 2004; Tan et al., 2012), and have shown that a significant sign of parental stress is maternal depression prior to adoption (Viana & Welsh, 2010). Parents must consider the parenting role differences in balancing family stress because parenting is not just the responsibility of a single parent.


     Implications for parents. Parents must evaluate the impact of family stress that can inhibit family function, thereby increasing children’s behavioral problems, and the family’s ability to deal with those problems. In two-parent households, parents are encouraged to participate in a parenting process in which one parent provides more emotional support to children by encouraging them to be independent and to explore unknown things (i.e., proactive approach), while the other provides emotional support through sensitive caring and responding to the child’s distress (i.e., reactive approach; Grossmann, Grossmann, Winter, & Zimmermann, 2002). Adoptive parents must consider a self-check on overall mental health as individuals, as a couple and as a family. Seeking support from a pre-adoptive preparation program focusing on evaluating self-wellness and promoting family resilience is an extremely valuable step (Viana & Welsh, 2010).


     Implications for counselors. Meeting the needs of adoptive families often requires implementing techniques to help recognize and deal with the sources of family stress. Parents must have an understanding of the family stress issues before they can effectively move on to developing and implementing interventions for adoptees’ behavioral problems, which can be exacerbated or even created by the stress. Counseling services for parental depression, anxiety, and other relevant feelings and symptoms are critical (Viana & Welsh, 2010).


     Conflict within a couple’s relationship is a key factor that predicts family stress because low-conflict couples are positively associated with satisfying parent–child interactions (Krishnakumar & Buehler, 2000). A variety of psychoeducational programs focus specifically on improving couple relationships for new parents (Halford & Petch, 2010). Counselors must consider the importance of parents’ focusing on conflict management and pre-parental anxieties of internationally adopting prior to the child’s arrival.


Cultivating Authoritative Parenting

     Parenting and attachment are two parallel behavioral systems that facilitate effective caregiving and attachment relationships in adopted children (Roberson, 2006). Results of hierarchical multiple regression analyses by Kriebel and Wentzel (2011) indicated that adoptees’ cumulative risk from pre-adoption circumstances is a negative predictor for later adaptive behaviors, whereas authoritative parenting is a positive predictor of children’s adaptability. Authoritative parenting also was found to be associated with fewer behavioral problems in Chinese adoptees, whereas authoritarian and permissive parenting styles were correlated with more behavioral problems exhibited by the children (Tan et al., 2012).


     Implications for parents. Cultivating authoritative parenting refers to promoting parents’ supportive role accompanied by consistent rather than harsh discipline. Parents with an authoritative parenting style tend to show warmth, affection and responsiveness and support children’s interests, but they also set up reasonably high demands and expectations for children (Baumrind, 1978). Inconsistent, overly harsh or emotionally vacant parenting has deleterious effects on children’s development. A lack of parental control or consistency in discipline is associated with greater behavioral problems at all child developmental stages.


     The concept of parenting styles is the same in all cultures, but its application may vary by race, culture or socioeconomic status. For example, Kisilevsky et al. (1998) maintained that parenting methods of Chinese parents differ substantially from those of U.S. parents, so adopted children from China experience different parenting before and after they are adopted. Parents with internationally adopted children are encouraged to take all social and cultural variables of parenting into consideration (Kotchick & Forehand, 2002), while using an authoritative parenting style as the principal guideline.


     Implications for counselors. Psychoeducational programs can be intervention strategies for counselors to better serve adoptive families’ parenting needs. Programs may include a miniature of Baumrind’s (1978) work with emphasis on how current parent themes align with the parenting typologies (i.e., authoritative, authoritarian and permissive). Counselors also may consider providing parenting examples; specifically, as suggested by Morris, Cui, and Steinberg (2013), they may provide examples related to intercultural parenting. Group counseling is another option that counselors can consider for families. Parental networks of families with children adopted from the same country of origin were found to be an effective intervention for post-adoption adjustment of families (Welsh et al., 2007), as international adoptive parents tend to listen to and seek help from informal networks whose participants have experienced similar challenges. Focus can be on feedback or experiences that families can gain from each other, while lessening the facilitating role of the counselor.




     A close review of the unique international circumstances related to adoption from China draws attention to risk and protective factors of post-adoption adjustment. Parents of all international adoptees and counselors working with adopted children and adoptive families may want to take the multicultural characteristics of each child into consideration. There are vast differences within international adoptees as a group. Children’s health, attachment and adjustment patterns vary based on their countries of birth, and each individual differs from others in the post-adoption adjustment process due to personal reasons other than cultural factors.



Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.



Barcons, N., Abrines, N., Brun, C., Sartini, C., Fumadó, V., & Marre, D. (2011). Social relationships in children from intercountry adoption. Children and Youth Services Review, 34, 955–961. doi:10.1016/j.childyouth.2012.01.028.

Bartholet, E. (2006). International adoption. In L. Askeland (Ed.), Children and youth in adoption, orphanages, and foster care: A historical handbook and guide (pp. 63–78). Westport, CT: Greenwood Press.

Baumrind, D. (1978). Parental disciplinary patterns and social competence in children. Youth & Society, 9, 239–276. doi:10.1177/0044118X7800900302

Becker-Weidman, A. (2006). Treatment for children with trauma-attachment disorders: Dyadic developmental psychotherapy. Child and Adolescent Social Work Journal, 23, 147–171. doi:10.1007/s10560-005-0039-0

Beijersbergen, M. D., Juffer, F., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2012). Remaining or becoming secure: Parental sensitive support predicts attachment continuity from infancy to adolescence in a longitudinal adoption study. Developmental Psychology, 48, 1277–1282. doi:10.1037/a0027442

Bledsoe, J. M., & Johnston, B. D. (2004). Preparing families for international adoption. Pediatrics in Review, 25, 242–249.

Bowlby, J. (1969). Attachment and loss, Volume. I: Attachment. New York, NY: Basic Books.

Brennan, C. (2013). Challenging behaviors in infant and toddler non-parental care: An exploration of caregiver beliefs and response strategies (Doctoral dissertation, University of Washington). Retrieved from

Bruder, M. B., Dunst, C. J., Mogro-Wilson, C., & Tan, T. X. (2010). Continuity of parental behavioral ratings of children adopted from China and parenting competence, confidence and enjoyment. Adoption and Fostering, 34(4), 3–16. doi:10.1177/030857591003400402

Chen, Y., & Li, H. (2009). Mother’s education and child health: Is there a nurturing effect? Journal of Health Economics, 28, 413–426. doi:10.1016/j.jhealeco.2008.10.005

Cohen, N. J., & Farnia, F. (2010). Social-emotional adjustment and attachment in children adopted from China: Processes and predictors of change. International Journal of Behavioral Development, 35, 66–67. doi:10.1177/0165025410371602

Cohen, N. J., & Farnia, F. (2011). Children adopted from China: Attachment security two years later. Children and Youth Services Review, 33, 2342–2346. doi:10.1016/j.childyouth.2011.08.006

Dalen, M., & Rygvold, A. L. (2006). Educational achievement in adopted children from China. Adoption Quarterly, 9(4), 45–58. doi:10.1300/J145v09n04_03

Deater-Deckard, K. (1998). Parenting stress and child adjustment: Some old hypotheses and new questions. Clinical Psychological Science and Practice, 5, 314–332. doi:10.1111/j.1468-2850.1998.tb00152.x

Ehrenreich, J. T., Santucci, L. C., & Weiner, C. L. (2009). Trastorno de ansiedad por separación en jóvenes: fenomenología, evaluación y tratamiento [Separation anxiety disorder in youth: Phenomenology, assessment, and treatment]. Psicol Conductual, 16, 389–412.

Gagnon-Oosterwaal, N., Cossette, L., Smolla, N., Pomerleau, A. Malcuit, G., Chicoine, J. F., . . . Séguin, R. (2012). Pre-adoption adversity, maternal stress, and behavior problems at school-age in international adoptees. Journal of Applied Developmental Psychology, 33, 236–242. doi:10.1016/j.appdev.2012.04.002.

Grant, K. E., Compas, B. E., Thurm, A. E., McMahon, S. D., & Gipson, P. Y. (2004). Stressors and child and adolescent psychopathology: Measurement issues and prospective effects. Journal of Clinical Child and Adolescent Psychology, 33, 412–425. doi:10.1207/s15374424jccp3302_23

Grossmann, K. E., Grossmann, K., Winter, M., & Zimmermann, P. (2002). Attachment relationships and appraisal of partnership: From early experience of sensitive support to later relationship representation. In L. Pulkkinen & A. Caspi (Eds.), Paths to successful development (pp. 73–105). Cambridge, United Kingdom: Cambridge University Press.

Gunnar, M. R., Bruce, J., & Grotevant, H. D. (2000). International adoption of institutionally reared children: Research and policy. Development and Psychopathology, 12, 677–693.

Gunnar, M. R., van Dulmen, M. H. M., & the International Adoption Project Team. (2007). Behavior problems in postinstitutionalized internationally adopted children. Development and Psychopathology, 1, 129–148. doi:10.1017/S0954579407070071

Halford, W. K., & Petch, J. (2010). Couple psychoeducation for new parents: Observed and potential effects on parenting. Clinical Child and Family Psychology Review, 13, 164–180. doi:10.1007/s10567-010-0066-z

Hawk, B., & McCall, R. B. (2010). CBCL behavior problems of post-institutionalized international adoptees. Clinical Child and Family Psychology Review, 13, 199–211. doi:10.1007/s10567-010-0068-x

Hoshmand, L. T., Gere, S., & Wong, Y.-S. (2006). International adoption and the case of China: Implications of policy, theory, and research for psychoeducation and counseling. Asian Journal of Counselling, 13, 5–50.

Johnson, K. A. (2004). Wanting a daughter, needing a son: Abandonment, adoption, and orphanage care in China. St. Paul, MN: Yeong & Yeong Book.

Juffer, F., & van IJzendoorn, H. M. (2005). Behavior problems and mental health referrals of international adoptees: A meta-analysis. The Journal of the American Medical Association, 20, 2501–2515. doi:10.1001/jama.293.20.2501

Karl, D. (1995). Maternal responsiveness of socially high-risk mothers to the elicitation cues of their 7-month-old infants. Journal of Pediatric Nursing, 10, 254–263. doi:10.1016/S0882-5963(05)80022-3

Kisilevsky, B. S., Hains, S. M. J., Lee, K., Muir, D. W., Xu, F., Fu, G., …Yang, R. L. (1998). The still-face effect in Chinese and Canadian 3- to 6-month-old infants. Developmental Psychology, 34, 629–639.


Kotchick, B. A., & Forehand, R. (2002). Putting parenting in perspective: A discussion of the contextual factors that shape parenting practices. Journal of Child and Family Studies, 11, 255–269.

Kreider, R. M., & Cohen, P. N. (2009). Disability among internationally adopted children in the United States. Pediatrics, 124, 1311–1318. doi:10.1542/peds.2008-3206

Kriebel, D. K., & Wentzel, K. (2011). Parenting as a moderator of cumulative risk for behavioral competence in adopted children. Adoption Quarterly, 14, 37–60. doi:10.1080/10926755.2011.557945

Krishnakumar, A., & Buehler, C. (2000). Interparental conflict and parenting behaviors: A meta-analytic review. Family Relations, 49, 25–44.

Meins, E., Fernyhough, C., Fradley, E., & Tuckey, M. (2001). Rethinking maternal sensitivity: Mothers’ comments on infants’ mental processes predict security of attachment at 12 months. Journal of Child Psychology and Psychiatry, 42, 637–648.

Miller, L., Chan, W., Tirella, L., & Perrin, E. (2009). Outcomes of children adopted from Eastern Europe.International Journal of Behavioral Development, 33, 289–298. doi:10.1177/0165025408098026

Morris, A. S., Cui, L., & Steinberg, L. (2013). Parenting research and themes: What we have learned and where to go next. In R. E. Larzelere, A. S. Morris, & A. W. Harrist (Eds.), Authoritative parenting: Synthesizing nurturance and discipline for optimal child development (pp. 35–58). Washington, DC: American Psychological Association.

Neimetz, C. (2011). Navigating family roles within an institutional framework: An exploratory study in one private Chinese orphanage. Journal of Child and Family Studies, 20, 585–595. doi:10.1007/s10826-010-9431-2

Palacios, J., & Brodzinsky, D. (2010). Review: Adoption research: Trends, topics, outcomes. International Journal of Behavioral Development, 34, 270–284. doi:10.1177/0165025410362837

Pugliese, M., Cohen, N. J., Farnia, F., & Lojkasek, M. (2010). The emerging attachment relationship between adopted Chinese infants and their mothers. Children and Youth Services Review, 32, 1719–1728.


Purvis, K. B., Cross, D. R., & Pennings, J. S. (2009). Trust-Based relational intervention™: Interactive principles for adopted children with special social-emotional needs. Journal of Humanistic Counseling, Education and Development, 48, 3–22. doi:10.1002/j.2161-1939.2009.tb00064.x

Roberson, K. C. (2006). Attachment and caregiving behavioral systems in intercountry adoption: A literature review. Children and Youth Services Review, 28, 727–740. doi:10.1016/j.childyouth.2005.07.008

Scroggs, P. H., & Heitfield, H. (2001). International adopters and their children: Birth culture ties. Gender Issues, 19, 3–30.

Shang, X. (2002). Looking for a better way to care for children: Cooperation between the state and civil society in China. Social Service Review, 76, 203–228. doi:10.1086/339671

Tan, T. X., & Camras, L. A. (2011). Social skills of adopted Chinese girls at home and in school: Parent and teacher ratings. Children and Youth Services Review, 33, 1813–1821. doi:10.1016/j.childyouth.2011.05.006

Tan, T. X., Camras, L. A., Deng, H., Zhang, M., & Lu, Z. (2012). Family stress, parenting styles, and behavioral adjustment in preschool-age adopted Chinese girls. Early Children Research Quarterly, 27, 128–136. doi:10.1016/j.ecresq.2011.04.002

Tan, T. X., & Marfo, K. (2006). Parental ratings of behavioral adjustment in two samples of adopted Chinese girls: Age-related versus socio-emotional correlates and predictors. Applied Developmental Psychology, 27, 14–30. doi:10.1016/j.appdev.2005.12.004

Tan, T. X., Marfo, K., & Dedrick, R. F. (2010). Early developmental and psychosocial risks and longitudinal behavioral adjustment outcomes for preschool-age girls adopted from China. Journal of Applied Developmental Psychology, 31, 306–314. doi:10.1016/j.appdev.2010.04.002

U.S. Department of State, Bureau of Consular Affairs. (2012). Intercountry adoption statistics. Retrieved from

van den Dries, L., Juffer, F., van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (2010). Infants’ physical and cognitive development after international adoption from foster care or institutions in China. Journal of Developmental and Behavioral Pediatrics, 31, 144–150. doi:10.1097/DBP.0b013e3181cdaa3a

van IJzendoorn, M. H., Juffer, F., & Poelhuis, C. W. K. (2005). Adoption and cognitive development: A meta-analytic comparison of adopted and nonadopted children’s IQ and school performance. Psychological Bulletin, 131, 301–316. doi:10.1037/0033-2909.131.2.301

Viana, A. G., & Welsh, J. A. (2010). Correlates and predictors of parenting stress among internationally adopting mothers: A longitudinal investigation. International Journal of Behavioral Development, 34, 363–373. doi:10.1177/0165025409339403

Welsh, J. A., & Viana, A. G. (2012). Developmental outcomes of internationally adopted children. Adoption Quarterly, 15, 241–264. doi:10.1080/10926755.2012.731029

Welsh, J. A., Viana, A. G., Petrill, S. A., & Mathias, M. D. (2007). Interventions for internationally adopted children and families: A review of the literature. Child and Adolescent Social Work Journal, 24, 285–311.



Yahnong Liu, NCC, is a doctoral student at the Pennsylvania State University. Richard J. Hazler, NCC, is a Professor and the Program Coordinator of Counselor Education at the Pennsylvania State University. Correspondence may be addressed to Yahnong Liu, 317 Cedar Building, The Pennsylvania State University, University Park, PA 16802,


Parent–Child Interaction Therapy for Children With Special Needs

Carl Sheperis, Donna Sheperis, Alex Monceaux, R. J. Davis, Belinda Lopez

ParentChild Interaction Therapy (PCIT) is an evidence-based method for reducing disruptive behavior in children and improving parent management of behavior. PCIT is a form of behavioral intervention that can be used in clinical, home and school settings. Although initially designed for intervention related to oppositional defiant disorder and conduct disorder, PCIT has been found to be a promising intervention for addressing behavioral issues among children with special needs. We present methods, research-based instructions and a case example of PCIT with a child diagnosed with autism. This article is intended to assist professional counselors in designing appropriate interventions for both children and parents.

Keywords: autism, parent–child interaction therapy, special needs, behavioral intervention, case example

Counseling techniques for children stem from a myriad of theoretical perspectives, and professional counselors are often in the unique position to provide systems intervention and training to families when a child has disruptive behavior. Despite the seniority of behaviorism in the field of psychology, behavioral family approaches have only recently been acknowledged as an effective practice in professional counseling. According to Gladding (2011), the following three premises underlie behavioral family counseling: (a) all behaviors are learned, (b) maladaptive behaviors are the target for change and (c) not everyone in the family has to be treated for change to occur. With these assumptions, it is easily deduced that the following also are true: (a) behavior can be unlearned and that new behaviors can be taught, (b) underlying, unresolved issues are not the key components of treatment, and (c) positive changes for one family member will impact the entire family system and surrounding ecology.

When working with children of preschool or early elementary age, it is important to directly involve the child’s caregivers. Parents’ influence on their children is significant and some parenting practices may exacerbate some children’s problems (McNeil & Hembree-Kigin, 2010). Behavioral family counseling models recognize the relationship between the child’s behavior and the family system. One behavioral family counseling technique, Parent-Child Interaction Therapy (PCIT), helps families work together with their children in reaching therapeutic goals. PCIT involves teaching parents some fundamental relationship-building strategies, including therapeutic play techniques for parents to use in the home environment (Johnson, Franklin, Hall, & Prieto, 2000). The clinician typically teaches and models PCIT techniques for the parents over the course of 8–10 weeks.

The purpose of this article is to demonstrate the practicality of PCIT as a component of behavioral family counseling, to facilitate the professional counselor’s understanding of the model through a review of PCIT and to illustrate the utility of this model for children with special needs through a case study.


An Overview of PCIT

PCIT (Neary & Eyberg, 2002) is an assessment-driven form of behavioral parent training designed for families with preschool-aged children. We present a brief overview of PCIT, define the key components integral to the process, provide the framework for implementation and discuss the application of PCIT to special populations. The core of PCIT is twofold—to create nurturing parent–child relationships and to model prosocial behaviors while increasing a child’s appropriate, compliant behaviors (Eyberg & Boggs, 1989). Play therapy skills are introduced to parents within the PCIT model to enhance the relationship between the parent and child. Additionally, PCIT cultivates problem-solving skills with parents who can then generalize gains made in the therapeutic milieu into the family environment. Similar to other models of family counseling, PCIT begins with the assessment process. Counselors using PCIT collect psychosocial information from the family through either structured or semistructured clinical interviews. Because PCIT is a behavioral model, family dynamics also are assessed through direct observation of clients. Once clinical interview and observational data are collected and evaluated, the counselor can explore family relationship dynamics.

PCIT counselors attempt to identify family roles, interactions and maladaptive disciplinary techniques (e.g., yelling, lack of follow-through, unrelated consequences) inherent in the system. The ultimate goal of these observations is to derive methods for replacing current ineffective parenting strategies with more adaptive ones, thus creating greater stability in the family system. Similar to other parenting approaches, family counselors using PCIT offer support and assistance in improving parent–child relationships without placing blame on the child or the parents (Webster-Stratton & Herbert, 1993).


The Benefits of PCIT

There are many benefits to PCIT; it is a brief, short-term family counseling procedure that teaches effective parenting skills and helps parents interact better with their children on a daily basis. Fundamentally, PCIT’s two-tailed approach benefits both parents and children (Asawa, Hansen, & Flood, 2008) by reducing the internalization of problems and parent–child stress. Additionally, PCIT empowers parents through teaching positive interactive techniques that build parent–child rapport. PCIT fosters creativity and increases child self-esteem, decreases noncompliance or disruptive behavior, and increases the quality of parent-provided positive regard through developmentally appropriate play (Eyberg et al., 2001). These positive interactions effectively decrease problem behavior, resulting in a reduction or elimination of emergency counseling visits. One PCIT study reported that only 19% of participants in a randomized controlled trial with physically abusive parents re-reported physical abuse more than 2 years after the implementation of the PCIT model (Chaffin et al., 2004).

While PCIT sessions may focus on home and play, the behavioral skills that the parent learns can be generalized to other children and additional settings, building stronger interactions across a spectrum of familial and social settings. According to Urquiza and Timmer (2012), PCIT focuses on the following three essential non-fixed elements: (a) increased positive parent–child interaction and emotional communication skills, (b) appropriate and consistent discipline methods, and (c) direct scaffolding for parent training in the interventions. Thus, once the parent has mastered these skills in the session with the child and therapist, the parent is able to transfer the skills to any location or setting to maintain positive interactions, emotional communication and disciplinary consistency with the child.


The Effectiveness of PCIT

Eyberg and her colleagues have researched and published extensively on the efficacy of PCIT and have empirically supported the effectiveness of PCIT with children exhibiting a range of behavioral and emotional problems (Neary & Eyberg, 2002). Specifically, PCIT has proven effective with problems including attention-deficit/hyperactivity disorder (ADHD), conduct disorders, separation anxiety, depression, postdivorce adjustment, self-injurious behavior and abuse (Eyberg et al., 2001; McNeil & Hembree-Kigin, 2010). For example, Nieter, Thornberry, and Brestan-Knight (2013) conducted a pilot study with 17 families completing PCIT treatment and found a significant decrease in disruptive child behaviors as well as a decrease in inappropriate parent behaviors over the 12-week group program. This study was the first to deliver PCIT via group sessions. The researchers found that treatment effects remained in place for more than 6 months after the group’s completion.

Eyberg et al. (2001) investigated long-term treatment outcomes of PCIT for families of preschoolers with conduct disorders over a period of 1–2 years, and found that treatment effects were sustained over time. According to the researchers, the study was the first of its kind to include long-term follow-up with families receiving PCIT treatment (Eyberg et al., 2001). Hood and Eyberg (2003) established further evidence in another follow-up study on PCIT treatment effects over a period of 3–6 years. In the study of treatment effects on families with young children diagnosed with oppositional defiant disorder, the researchers found that treatment effects and behavioral change were again sustained over time. Thomas and Zimmer-Gembeck (2007) conducted a review of behavior outcomes in 24 studies on PCIT and another parenting intervention, Triple P—Positive Parenting Programs. All of the studies involved children aged 3–12 and their caregivers. Meta-analyses revealed positive effects for PCIT as well as the other intervention, adding support within the literature on the efficacy of PCIT.

To demonstrate the effectiveness of PCIT for treating ADHD, Guttmann-Steinmetz, Crowell, Doron, and Mikulincer (2011) examined the interactions of children with ADHD and their mothers. Their findings suggest that while Behavior Parent Training is useful in managing ADHD, PCIT may be highly effective in impacting the attachment-related processes during the child’s later developmental stages. These researchers suggested that parents’ successful adaptation of PCIT’s verbal and behavioral skills during interaction with their child might increase the child’s sense of security.

The effectiveness of PCIT has been expanded to other disorders such as separation anxiety. For example, Choate, Pincus, Eyberg, and Barlow (2005) conducted a pilot study involving three families with children 4–8 years of age diagnosed with separation anxiety disorder. The researchers found that the child-directed activities fostered children’s sense of control and reduced separation anxiety symptomology to normative levels by the conclusion of treatment. Again, the treatment effects were shown to persist long after treatment ceased. This study was replicated by Anticich, Barrett, Gillies, and Silverman (2012), providing further support of PCIT’s effectiveness in alleviation of separation anxiety disorder symptomology.

Individuals or populations with special needs also appear to respond positively to PCIT. Bagner and Eyberg (2007) found that mothers of young children diagnosed with mental retardation and oppositional defiant disorder reported a reduction in disruptive behaviors, increased compliance and less parenting stress after participating in a randomized, controlled trial study utilizing PCIT. PCIT also has been cited as a promising evidence-based intervention for autism (Agazzi, Tan, & Tan, 2013). Solomon, Ono, Timmer, and Goodlin-Jones (2008) conducted a randomized trial of PCIT for treating autism and found the same results as researchers studying other disorders have. PCIT was shown to reduce behavioral disruptions, increase adaptability and increase positive parental perceptions of child behavior. While PCIT was originally developed to address behavioral disorders, it clearly serves as an intervention for various other disorders that impact parent–child interactions.


The impact of PCIT on parents. PCIT has been shown to have equally effective outcomes for parent-related issues as it does for child behavioral disruptions. For example, Luby, Lenze, and Tillman (2012) reported highly favorable results for using PCIT to reduce behavioral disruptions and improve executive function among preschoolers. However, PCIT also showed significant effects for parents. Specifically, PCIT interventions helped to reduce depression severity and parenting stress while increasing emotion recognition. Furthermore, Urquiza and Timmer (2012) found that parental depression decreases the likelihood that the child will complete the treatment course. However, if the parents are persuaded to continue until completion, their own psychological symptoms may be relieved.

PCIT has been shown to have positive effects on parents in a variety of circumstances. For example, Baker and Andre (2008) suggested that PCIT might offer a unique and promising advantage in the treatment of postdivorce adjustment issues in children. PCIT also has been found to be effective in working with abusive parents, many of whose histories included depression, substance abuse and violent behavior (Chaffin et al., 2004). Although still effective in reducing parenting stress and child behavior problems, Timmer et al. (2011) found that PCIT was less effective in foster parent homes than in non-foster parent homes. While PCIT is clearly an effective intervention for both children and parents, in cases with complex systems like foster care placement and abuse, PCIT could be used in conjunction with other interventions. The same is true for clients with special needs.

Diverse population efficacy. Although we recognize that one size does not fit all, PCIT has shown significant results with ethnic minorities and underserved populations. Different cultural and ethnic group parenting styles (strict vs. relaxed styles) vary across the United States. In addition to effectively increasing positive parenting behaviors and deceasing behavioral problems in children, treatment outcomes and efficacy studies support the notion that PCIT is culturally effective and produces robust modifications among diverse groups (see Bagner & Eyberg, 2007; Borrego, Anhalt, Terao, Vargas, & Urquiza, 2006; Matos, Torres, Santiago, Jurado, & Rodríguez, 2006; McCabe & Yeh, 2009). Additional literature and empirical research is available for review regarding work with specific populations such as African Americans and Asians. There also is promising evidence pointing to PCIT’s efficacy in populations exhibiting neurological and behavioral disorders such as autism (Tarbox et al., 2009).

Efficacy through translation. Matos et al. (2006) conducted research in Puerto Rico with parents of children aged 4–6 with ADHD. The manual and handouts were translated into Spanish with a few modifications. Results showed significant decreases in behavior problems and hyperactivity. A recent follow-up study using the culturally adapted version further revealed that significant and robust outcome measures resulted from large treatment effect sizes. Mothers reported reductions in “hyperactivity-impulsivity, inattention, and oppositional defiant and aggressive behavior problems, as well as a reduced level of parent-child related stress and improved parenting practices” (Matos, Bauermeister, & Bernal, 2009, p. 246). Additionally, in a single-case study with a Spanish-speaking foster mother and a 3-year-old Mexican-Chilean-Filipina child, PCIT proved to be effective; reports from other family members noted substantive behavior improvement (Borrego et al., 2006). Thus, we can deduce that PCIT can be used effectively across cultural groups.


Key Components

There are three main components of PCIT: child-directed interaction (CDI), parent-directed interaction (PDI) and cleanup. Depending on the session being held, the components are presented in 5-minute segments with varying degrees of parent control required. CDI is characteristically the first stage in PCIT. Similar in approach to filial play therapy, this first stage creates an opportunity to strengthen the parent–child relationship. Because PCIT is utilized in the context of dyadic play, it is conducted in a room conducive to play (McNeil & Hembree-Kigin, 2010). Thus, a room designated for CDI should contain a variety of toys, crayons, paper, modeling compounds and other developmentally appropriate activities for a child. As with other play techniques, in order to give children the opportunity to determine the rules by which they will play, games with rules are generally excluded from a CDI playroom. Children engaged in CDI should be allowed to play with any or all of the items in the room. Encouraging free play indicates to the child that he or she is the creator of the play, not the caregiver. This approach allows the time to truly be child-directed.

Within CDI, the establishment of a positive therapeutic relationship is a crucial step in building a foundation for the introduction of compliance training. Compliance training is simply teaching a child to mind or comply over a period of time, through small compliance goals set by the parents. To lay the groundwork for this process during CDI, the parents are instructed to praise, reflect, imitate and describe their child’s play, while not asking questions, placing demands or criticizing the activities that transpire unless harmful to the child (McNeil, Eyberg, Eisentadt, Newcomb, & Funderburk, 1991).

Another essential concept introduced during CDI, includes fostering the enthusiasm and willingness of the parent. Although responding positively to a child’s free play during CDI may appear simple, parents often need considerable practice to master this response set. For example, one of the toys in our clinic is a Mr. Potato Head. Young children can be very creative in their placement of the various accessories that come with the toy. Often they will place an arm on top of the head, lips on the ear hole or eyes over the mouth hole. In PCIT, we view this action as an expression of creativity. However, when we observe parents in free play with their children, we often witness the parents limiting their children’s creativity by redirecting the placement of the appendages on Mr. Potato Head. Parents often say, “No, honey, the lips go here,” or “That’s not where the arms go.” Instructing parents to refrain from making such comments is generally all that a PCIT counselor needs to do. PCIT counselors understand that this is a difficult skill for most parents to master, and they teach parents the acronym PRIDE for use during CDI as well as other elements of PCIT. PRIDE simply stands for praise, reflection, imitation, description and enthusiasm (Eyberg, 1999). Table 1 provides some practical examples of desired responses from parents during CDI using the PRIDE approach.

Table 1

Responses Using PRIDE model



Praise Parent: “Thank you for putting away the toys.”
Reflection Child: “I’m drawing a dinosaur.”Parent: “I see. You are drawing a dinosaur.”
Imitation Child is playing with a car. Parent gets a similar car and begins playing in the same manner.
Description Child is playing with a toy airplane. Parent says, “You are making the airplane fly.”
Enthusiasm Parent: “Wow. Your drawing is very creative.”


In the second stage of PCIT, PDI usually is initiated once parents master CDI. Mastery is evidenced during the child’s play by the parents exhibiting proper implementation of the PRIDE responses. PDI also is conducted in the playroom or room selected for CDI. PDI consists of teaching parents how to manage their child’s behavior and promoting compliance with parental requests (Bahl, Spaulding, & McNeil, 1999). Parents should understand that PDI is more difficult for children than CDI and will likely be challenging for both the child and parent. When beginning PDI, parents must understand the importance of appropriate discipline techniques and receive training in giving clear directions to their children. Because children require a great deal of structure, professional counselors emphasize the importance of consistency, predictability and follow-through in this training (McNeil & Hembree-Kigin, & 2010). In order to initiate compliance training, parents practice giving effective instructions to their child. McNeil and Hembree-Kigin (2010) offered several rules for giving good instructions as part of the parent training element of PDI that can be conceptualized in the following ways: Command Formation, Command Delivery and Command Modeling:

Command Formation

  1. Give direct commands for things you are sure the child can do. This increases the child’s opportunity for success and praise.
  2. Use choice commands with older preschoolers. This fosters development of autonomy and decision making. (e.g., “You can put on this dress or this dress” rather than “What do you want to wear?” or “Wear this”).
  3. Make direct commands. Tell the child what to do instead of asking whether they would like to comply (e.g., “Put on your coat”).
  4. State commands positively by telling child what to do instead of what not to do. Avoid using words such as “stop” and “don’t.”
  5. Make commands specific rather than vague. In doing so, the child knows exactly what is expected and it is easier to determine whether or not the child has been compliant.

Command Delivery

  1. Limit the number of commands given.
  • Some children are unable to remember multiple commands. The child’s opportunity for success and praise increases with fewer, more direct instructions given at a time.
  • When giving too many commands, parents have difficulty following through with consequences for each command. Additionally, the parent’s ignoring some minor behaviors may be best.
  1. Always provide a consequence for obedience and disobedience. Consequences are the quickest ways to teach children compliance. Consistency when providing consequences is the key to encouraging compliance.
  2. Use explanations sparingly. Some children would rather stall than know the answer. Avoiding the explanation trap prevents children from thinking they have an opportunity to talk their way out of it.

Command Modeling

  1. Use a neutral tone of voice instead of pleading or yelling. Interactions are more pleasant in this manner and the child learns to comply with commands that are given in a normal conversational voice.
  2. Be polite and respectful while still being direct. This models appropriate social skills and thus interactions are more pleasant.

After teaching parents to deliver effective instructions and allowing time for in vivo practice, professional counselors introduce appropriate discipline strategies to be used in PDI. The in vivo coaching model utilizes an observation room with a two-way mirror and the ability to for the counselor to communicate with the parent via microphone. The focus on training includes communication and behavior management skills with additional homework sessions (Urquiza & Timmer, 2012). In a study by Shanley and Niec (2010), parents who were coached via a bug-in-ear receiver with in vivo feedback during parent–child interactive play demonstrated rapid increases in positive parenting skills and interactions. Of these strategies, timeout is the most common as it is “a brief, effective, aversive treatment that does not hurt a child either physically or emotionally” (Eaves, Sheperis, Blanchard, Baylot, & Doggett, 2005, p. 252). Furthermore, Eaves et al. (2005) wrote that timeout benefits both children with problematic behaviors and those who view the technique being used on other children, in addition to those children and adolescents demonstrating developmental delays, psychiatric issues and defiance. However, for the parent to experience timeout’s full benefit, the technique must be appropriately and consistently administered. Eaves et al.’s (2005) article, “Teaching Time-Out and Job Card Grounding Procedures to Parents: A Primer for Family Counselors” is an excellent article on timeout and why it is an effective intervention.

All aspects of timeout are reviewed with the parents, such as the rationale for timeout, where timeout should take place in the home, what to do when the child escapes timeout, what to do if the child does not comply with timeout, the length of timeout, what should happen right before timeout and what should happen right after timeout. Parents receive written instructions illustrating each step of timeout and offering guidance on how to implement the procedure. These discipline strategies may not be necessary if a child is motivated to be compliant. Determining compliance is often a very hard decision for parents to make. According to McNeil and Hembree-Kigin (2010) there are several rules used to help parents determine compliance or noncompliance.

  1. Parents must be sure that the instructions are developmentally appropriate for the child. If the child is asked to bring the orange cup to the parent, one must know that the child can determine which cup is actually orange.
  2. Parents should know that the request is completely understood by the child. If there are any questions about this the parents should point or direct the child to help him or her fully understand the request.
  3. Parents should allow the child approximately 3 seconds to begin to attempt the task. If the child has not begun to attempt the task by this time it should be considered noncompliance.
  4. Parents should state the request only once. If the child pretends not to hear the request, this should be considered noncompliance.
  5. Parents should not allow the child to partially comply with instructions. If parents accept half-compliance then children will often repeat the negative behavior because they know they can get away with it.
  6. Parents should not respond to a child’s bad attitude in completing a request. As long as he or she completes the instruction, it is compliance.
  7. Parents should consider it compliance if a child does what is asked and then undoes what is asked. Compliance is compliance no matter how long it lasts.

When a parent determines that a child is compliant, verbal praise should be provided. This praise should be given immediately and focus on the child’s compliance. Parents are encouraged to practice the skills of giving good directions by delivering multiple commands to the child. These commands are given during the playtime and may include requests to hand things to the parent (e.g., “Give me the red block”) or play with certain toys (e.g., “Place the blue car in the box”). This activity allows the child to practice following directions, while also affording the parent the opportunity to practice praise (McNeil & Hembree-Kigin, 2010). The child begins to learn that when he or she follows directions, his or her parents are very appreciative and excited. After the small tasks are accomplished, parents begin to place demands on the child that are less desirable, such as cleaning up the toys or moving on to another task (McNeil & Hembree-Kigin, 2010). By assigning less desirable tasks, parents find themselves in a position to practice a timeout procedure with the child. The professional counselor is there to model timeout and coach the parents when practicing timeout.

The third and final component to consider is called cleanup, which occurs as part of PDI. This time during the PCIT process is exactly what one might think; it is intended to teach the child to clean up the toys at the end of the parent–child interaction in both the counseling and home milieus. Cleanup should be done without the parents’ help but with the parents’ direction. Although this component may seem simple, it tends to be a challenging situation, as significant behavior problems often are displayed during this phase. The expectation is that this phase lasts 5 minutes, but time varies depending upon the behavior of the child (McNeil & Hembree-Kigin, 2010). Cleanup occurs only at the end of parent-directed play, not at the end of child-directed play, to avoid confusing the child about the role of parental help during cleanup. All three components—CDI, PDI and cleanup—are opportunities for behavioral observation and data collection.

Implementing PCIT

According to McNeil and Hembree-Kigin (2010), there are six steps in conducting PCIT with a family. These authors have briefly described the contents of each step as well as provided guidelines for the number of sessions typically devoted to completing the tasks within each step. Step 1 requires one to two sessions for the intake process, Step 2 requires one session to introduce and teach parents CDI skills, and Step 3 requires two to four sessions in which the parents are coached on these skills. Steps 4 and 5 introduce and coach the PDI and may take up to six sessions. The final session is the follow-up session. These six steps complete a 10- to 15-session triadic training program.

Step 1 is the initial intake and can be accomplished in one to two counseling sessions, unless classroom or other observations are warranted. These sessions consist of assessing family dynamics, obtaining the family’s perception of the presenting problems, probing for insights into the current disciplinary beliefs and methods held by the parents, and observing the natural interactions between parents and child. In addition to the information-gathering component, the clinician defines the parameters of the sessions as well as the rules and expectations. Certain parameters involve an understanding by the parents that this CDI time is designated for the child to lead and for the parent to follow—a time often described to the parents as time-in for the child. Thus, time-in is defined as a time when the child facilitates play by selecting the type of play and initiating all play interactions.

The initial informal observation usually takes place in a sitting area while the family is waiting to visit with the counselor. In this informal observation, the counselor looks for “the child’s ability to play independently, strategies the child uses to engage the parent’s attention, parental responsiveness to child overtures, parental limit-setting, warmth of parent-child interactions, and evidence of clinging and separation anxiety” (McNeil & Hembree-Kigin, 2010, p. 20). After this stage of observation, a more formal observation is completed using the Dyadic Parent–Child Interaction Coding System (DPICS; Eyberg & Robinson, 1983). This observation is typically accomplished in three 5-minute increments in which behaviors and verbalizations are marked on the DPICS sheet. The formal observation occurs over the three PCIT stages previously described—CDI, PDI and cleanup. Following the initial observations, a third observation may be executed as a classroom observation. This type of observation is done with students who attend day care, preschool or elementary school, and allows one to see the child interact within his or her daily environment. Observation occurring in an alternate setting increases the chances of obtaining normative behavior (McNeil & Hembree-Kigin, 2010).

In Steps 2 and 3, the counselor presents and provides coaching on the CDI skills. Step 2 typically requires one counseling session. During this time the parents are taught the behavioral play therapy skills of CDI. The third step, coaching the CDI skills, may take two to four sessions depending on how the family adopts these principles into their daily interactions with their child. Coaching is described as modeling the behavior for the family, allowing the family to practice in session with feedback and prompts as needed, assigning the family homework to practice, and then repeating these steps until the parents are comfortable and fluent in the process.

In Steps 4 and 5, respectively, the counselor teaches and coaches the parents about discipline skills. These skills include both PDI and compliance training. Step 4 is typically accomplished in one session. Coaching may last from four to six sessions. Again, coaching is described as modeling, in-session practice with feedback and prompts, assigning homework, and evaluating success.

Step 6 consists of having a follow-up counseling session. This session is an opportunity to assess the family’s progress with proper implementation of each component of the PCIT model, gauge the strides made in compliance and assess the overall family satisfaction gained throughout the journey. Finally, one should use boosters to help parents maintain learned skills as they face new challenges with their children. Table 2 delineates the steps to implementing PCIT over a typical 10–15-session treatment plan.

Table 2

Implementing PCIT


Number of sessions




Informal and formal observation




Coaching CDI skills


Teaching discipline skills via PDI and compliance training






Case Study

PCIT was selected for use in the treatment of Manny, a 6-year-old Hispanic male diagnosed with autism and noncompliant to his mother. Like many children with autism, Manny had difficulty with unpredicted changes and verbalization of concerns. As Manny’s frustration with communication increased, he demonstrated stereotypies such as hand flapping and eventually progressed to tantrum behavior. The two goals of treatment were to increase the frequency of appropriate verbalizations and to decrease the frequency of inappropriate behavior including physical aggression, noncompliance and making noises. Manny was experiencing other issues related to autism, but his mother indicated that the behavioral problems were preventing him from making progress in other area.

As a result, we decided to conduct a functional behavior analysis prior to beginning treatment. This assessment of Manny’s behavior indicated that some of the behavior disruptions were a means of seeking attention, and therefore it was determined that PCIT would teach the mother to provide more consistent attention for appropriate behavior and to encourage appropriate communication more effectively. If needed, the addition of the timeout component was available after the mother began adequately attending to Manny’s appropriate behavior and ignoring inappropriate behavior.

Session 1

The counselor explained the procedure and rationale for PCIT to the mother, including CDI, PDI and timeout. CDI was modeled and demonstrated with Manny. The mother was uncomfortable about being judged on her parenting skills, so it was decided that she would practice the skills at home using the Child’s Game nightly with Manny. The Child’s Game is simply defined as any free play activity the child chooses. The family would return to the clinic in 1 week.

Session 2

The counselor reviewed CDI and had the mother conduct the Child’s Game for 5 minutes. During CDI, the counselor observed and noted the mother’s responses. The mother included 13 questions, one criticism and one demand in the 5-minute session. The mother praised Manny frequently, but did not use the other desired skills often. Manny was compliant with the demand that the mother gave and did not exhibit any of the disruptive behaviors. Following the CDI, feedback was given to the mother about increasing descriptions, reflections, imitations and praises, and reducing questions. The mother also was encouraged to recognize and praise communication attempts. Overall, the mother was directed to allow Manny to lead the play. When queried about CDI practice at home, the mother reported that the activity the family had used for the Child’s Game was watching television. Because there is no inherent interaction in television viewing, the mother was directed to provide a choice to play with action figures or art materials, both indicated as reinforcing by Manny, in place of video games or television. The Child’s Game was again given as homework.

Session 3

The professional counselor reviewed CDI and viewed the family during the Child’s Game. The mother showed improvement using descriptions (16), reflections (3), imitations (1) and praises (15). She also limited her use of questions (6), criticisms (0) and demands (0). However, Manny exhibited disruptive behavior in 23% of the observed intervals. The mother also reported that Manny continued to be noncompliant and make noises at home. The professional counselor introduced PDI and timeout. Each was modeled with Manny, and his mother was allowed to practice and receive feedback. Homework was to continue the Child’s Game, issue 10 demands throughout the day and follow through with the brief timeout procedure. Also, the mother was asked to develop five house rules to bring the following week. To keep a record of the number of instructions with which Manny complied before going to timeout, and the number of timeouts per day, the mother received a homework compliance worksheet to keep for 1 week. This log allows the parent to record the homework—in this case, using the Child’s Game daily, issuing 10 demands throughout each day and recording the Manny’s compliance to each, and using timeout as indicated.

Session 4

The counselor reviewed PDI, giving effective instructions and timeout to begin the session. The counselor then observed the family during CDI/PDI. The mother gave clear, concise instructions six out of nine times, only failing to wait before reissuing instructions when Manny did not immediately comply. Manny complied with all issued demands except when the mother reissued the demands too quickly. The mother followed Manny’s compliant behavior with praise statements four out of nine times. Manny was put in timeout for disruptive behavior and the mother used the procedure correctly. Manny demonstrated disruptive behavior during 33% of the observed intervals. A review of the homework compliance worksheet from the previous week indicated that Manny complied with 10 out of 10 instructions on 5 out of 9 days, and nine out of 10 instructions the remaining 2 days. The mother was encouraged to continue generalizing the skills she had learned throughout the day. The house rules developed by the family over the previous week were discussed and worded in positive statements and then introduced to Manny. The rules were explained and both examples and non-examples were modeled. Homework was given to continue incorporating the Child’s Game, issuing 10 demands in a brief period of time, using timeout as needed and recording compliance rates for 1 week.

Session 5

The counselor reviewed PDI, EID, timeout and the homework compliance worksheet. The mother indicated that Manny had been compliant before timeout 10 out of 10 times for 6 days and nine out of 10 times for 1 day. The mother also noted that Manny had been placed in timeout for breaking house rules. The mother reported that Manny’s behavior had improved and he had had fewer tantrums related to schedule changes. She was encouraged to continue using the PCIT skills and adapting them to more situations. Because compliance was increasing, it was not necessary to continue CDI and PDI in this session. The family was given homework to continue the Child’s Game, PDI, using timeout as needed and recording compliance rates. This time, the family was to work at home for 2 weeks before the next session.

Session 6

The counselor reviewed the family’s progress and addressed further generalization and concerns about daycare. The mother indicated that the child had been compliant before timeout on 10 out of 14 days. Two of the other days Manny had been placed in timeout 10 times and six times for violating house rules. The zero out of 10 compliance rating occurred during his birthday party, and the six out of 10 compliance rating was primarily the result of an unexpected trip to the grocery store. The family was again given homework to continue practicing generalizing CDI, PDI, using timeout as needed and recording compliance rates for 2 weeks.

Session 7

The counselor addressed concerns including the beginning of school in a few weeks and provided suggestions to ease the transition. While the mother indicated that Manny had been compliant before timeout on only 4 of the previous 14 days, a review of the compliance rates revealed that on the other 10 days, Manny was compliant no less than 80% of the time. These compliance rates from various family settings were indicative of behaviors being generalized across settings. The mother also showed evidence of her generalization of skills by adapting the house rules to address new problematic behaviors. The family was encouraged to begin reviewing material learned in the previous session and work on behavioral skills such as sitting for appropriate lengths of time. The mother was instructed to continue both the use of her attending skills in order to reinforce appropriate behavior, as well as the use of the timeout procedure to diminish inappropriate behaviors.

Session 8

For the final follow-up session, the counselor reviewed the family’s progress and determined that treatment goals were met. Concerns about how to get other family, friends and teachers to use PCIT skills with Manny were addressed in this final session. The family noted the improvements made as a result of PCIT and felt equipped to maintain the behavioral changes gained as a result of this counseling approach. Termination of the PCIT intervention was appropriate at this time; the case provided clear evidence of the application and utility of the PCIT model. Manny’s mother was offered the opportunity to continue interventions related to the other autism-specific issues that Manny was experiencing.



Professional counselors, whether working with children who have disruptive behavior or providing parenting training to families, should be knowledgeable of the application of various behavioral techniques in order to utilize them effectively and to teach them to parents. Researchers have proven that when implemented appropriately, PCIT procedures are effective in reducing undesirable and problematic behaviors in children and adolescents. Furthermore, it is clear that PCIT can be effectively applied to behavioral issues faced by children with special needs. We suggest that counselors who are interested in PCIT seek additional training to develop mastery of the techniques.

PCIT is a complex process that is often mistakenly viewed as simplistic. Thus, counselors who use PCIT without appropriate training will likely provide ineffective parental coaching. This point is especially poignant when working with children who have special needs. These children often present with numerous significant issues and deserve appropriate application of evidence-based intervention. We strongly suggest that counselors complete the web-based training provided by the University of California at Davis Children’s Hospital. The training is free and can be accessed at Given that PCIT is an effective approach and that the effectiveness of the model increases with appropriate education, professional counselors who further educate themselves on PCIT’s uses and applications can benefit their practices and the families they serve through the correct use of this empirically validated method of behavioral family counseling.

Counselors who are interested in PCIT also should consider advancing research related to counseling applications. While PCIT has been shown to be an effective intervention for autism and other disorders, more research is needed. We encourage counselors to consider implementation of studies that determine outcomes of PCIT for various child disorders and to conduct program evaluation for PCIT-based clinics.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of  interest or funding contributions for  the development of this manuscript.



Agazzi, H., Tan, R., & Tan, S. Y. (2013). A case study of parent–child interaction therapy for the treatment of autism spectrum disorder. Clinical Case Studies, 12, 428–442. doi:10.1177/1534650113500067

Anticich, S. A. J., Barrett, P. M., Gillies, R., & Silverman, W. (2012). Recent advances in intervention for early childhood anxiety. Australian Journal of Guidance and Counselling, 22, 157–172. doi:10.1017/jgc.2012.24

Asawa, L. E., Hansen, D. J., & Flood, M. F. (2008). Early childhood intervention programs: Opportunities and challenges for preventing child maltreatment. Education and Treatment of Children, 31, 73–110.

Bagner, D. M., & Eyberg, S. M. (2007). Parent–child interaction therapy for disruptive behavior in children with mental retardation: A randomized controlled trial. Journal of Clinical Child and Adolescent Psychology, 36, 418–429. doi:10.1080/15374410701448448

Bahl, A. B., Spaulding, S. A., & McNeil, C. B. (1999). Treatment of noncompliance using parent child interaction therapy: A data-driven approach. Education and Treatment of Children, 22, 146–156.

Baker, A. J. L., & Andre, K. (2008). Working with alienated children & their targeted parents. Annals of the American Psychotherapy Association, 11(2), 10–17.

Borrego, J., Jr., Anhalt, K., Terao, S. Y., Vargas, E. C., & Urquiza, A. J. (2006). Parent-Child interaction therapy with a Spanish-speaking family. Cognitive and Behavioral Practice, 13, 121–133.

Chaffin, M., Silovsky, J. F., Funderburk, B., Valle, L. A., Brestan, E. V., Balachova, T., . . . Bonner, B. L. (2004). Parent–Child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72, 500–510. doi:10.1037/0022-006X.72.3.500

Choate, M. L., Pincus, D. B., Eyberg, S. M., & Barlow, D. H. (2005). Parent–Child interaction therapy for treatment of separation anxiety disorder in young children: A pilot study. Cognitive and Behavioral Practice, 12, 126–135. doi:10.1016/j.cbpra.2005.09.001

Eaves, S. H., Sheperis, C. J., Blanchard, T., Baylot, L., & Doggett, R. A. (2005). Teaching time-out and job card grounding procedures to parents: A primer for family counselors. The Family Journal: Counseling and Therapy for Couples and Families, 13, 252–258. doi:10.1177/1066480704273638

Eyberg, S., & Boggs, S. (1989). Parent training for oppositional-defiant preschoolers. In C. E. Schaefer & J. M. Briesmeister (Eds.), Handbook of parent training: Parents as co-therapists for children’s behavior problems (pp. 105–132). New York, NY: Wiley & Sons.

Eyberg, S. M. (1999). Parent-Child interaction therapy: Integrity checklists and session materials. Retrieved from

Eyberg, S. M., Funderburk, B. W., Hembree-Kigin, T. L., McNeil, C. B., Querido, J. G., & Hood, K. K. (2001). Parent-Child interaction therapy with behavior problem children: One and two year maintenance of treatment effects in the family. Child & Family Behavior Therapy, 23(4), 1–20. doi:10.1300/J019v23n04_01

Eyberg, S. M., & Robinson, E. A. (1983). Conduct problem behavior: Standardization of a behavioral rating scale with adolescents. Journal of Clinical Child Psychology, 12, 347–354. doi:10.1080/15374418309533155

Gladding, S. T. (2011). Family therapy: History, theory, and practice (5th ed.). Upper Saddle River, NJ: Prentice Hall.

Guttmann-Steinmetz, S., Crowell, J., Doron, G., & Mikulincer, M. (2011). Associations between mothers’ and children’s secure base scripts in ADHD and community cohorts. Attachment & Human Development, 13, 597–610. doi:10.1080/14616734.2011.609010

Hood, K. K., & Eyberg, S. M. (2003). Outcomes of parent–child interaction therapy: Mothers’ reports of maintenance three to six years after treatment. Journal of Clinical Child and Adolescent Psychology, 32, 419–429. doi:10.1207/S15374424JCCP3203_10

Johnson, B. D., Franklin, L. C., Hall, K., & Prieto, L. R. (2000). Parent training through play: Parent-Child interaction therapy with a hyperactive child. The Family Journal: Counseling and Therapy for Couples and Families, 8, 180–186. doi:10.1177/1066480700082013

Luby, J., Lenze, S., & Tillman, R. (2012). A novel early intervention for preschool depression: Findings from a pilot randomized controlled trial. Journal of Child Psychology and Psychiatry, 53, 313–322. doi:10.1111/j.1469-7610.2011.02483.x

Matos, M., Bauermeister, J. J., & Bernal, G. (2009). Parent-Child interaction therapy for Puerto Rican preschool children with ADHD and behavior problems: A pilot efficacy study. Family Process, 48, 232–252. doi:10.1111/j.1545-5300.2009.01279

Matos, M., Torres, R., Santiago, R., Jurado, M., & Rodríguez, I. (2006). Adaptation of parent–child interaction therapy for Puerto Rican families: A preliminary study. Family Process, 45, 205–222. doi:10.1111/j.1545-5300.2006.00091.x

McCabe, K. & Yeh, M. (2009). Parent–Child interaction therapy for Mexican Americans: A randomized clinical trial. Journal of Clinical Child and Adolescent Psychology, 38, 753–759. doi:10.1080/15374410903103544

McNeil, C. B., Eyberg, S., Eisentadt, T. H., Newcomb, K., & Funderburk, B. (1991). Parent–Child interaction therapy with behavior problem children: Generalization of treatment effects to the school setting. Journal of Clinical Child Psychology, 20, 140–151. doi:10.1207/s15374424jccp2002_5

McNeil, C. B., & Hembree-Kigin, T. L. (2010). Parent-Child interaction therapy. New York, NY: Springer.

Neary, E. M., & Eyberg, S. M. (2002). Management of disruptive behavior in young children. Infants and Young Children, 14(4), 53–67.

Nieter, L., Thornberry, T., Jr., & Brestan-Knight, E. (2013). The effectiveness of group parent–child interaction therapy with community families. Journal of Child and Family Studies, 22, 490–501.

Shanley, J., & Niec, L. N. (2010). Coaching parents to change: The impact of in vivo feedback on parents’ acquisition of skills. Journal of Clinical Child and Adolescent Psychology, 39, 282–287. doi:10.1080/15374410903532627

Solomon, M., Ono, M., Timmer, S., & Goodlin-Jones, B. (2008). The effectiveness of parent–child interaction therapy for families of children on the autism spectrum. Journal of Autism and Developmental Disorders, 38, 1767–1776. doi:10.1007/s10803-008-0567-5

Tarbox, J., Wilke, A. E., Najdowski, A. C., Findel-Pyles, R. S., Balasanyan, S., Caveney, A. C., . . . Tia, B. (2009). Comparing indirect, descriptive, and experimental functional assessments of challenging behavior in children with autism. Journal of Developmental and Physical Disabilities, 21, 493–514. doi:10.1007/s10882-009-9154-8

Thomas, R., & Zimmer-Gembeck, M. J. (2007). Behavioral outcomes of parent-child interaction therapy and triple p—positive parenting program: A review and meta-analysis. Journal of Abnormal Child Psychology, 35, 475–495.

Timmer, S. G., Ho, L. K. L., Urquiza, A. J., Zebell, N. M., Fernandez y Garcia, E., & Boys, D. (2011). The effectiveness of parent–child interaction therapy with depressive mothers: The changing relationship as the agent of individual change. Child Psychiatry & Human Development, 42, 406–423. doi:10.1007/s10578-011-0226-5

Urquiza, A. J., & Timmer, S. (2012). Parent-Child interaction therapy: Enhancing parent-child relationships. Psychosocial Intervention, 21, 145–156. doi:10.5093/in2012a16

Webster-Stratton, C., & Herbert, M. (1993). “What really happens in parent training?” Behavior Modification, 17, 407–456. doi:10.1177/01454455930174002


Carl Sheperis, NCC, is the Chair of the Department of Counseling and Special Populations at Lamar University. Donna Sheperis, NCC, is an Associate Professor at Lamar University. Alex Monceaux is an instructor at Lamar University. R. J. Davis and Belinda Lopez are Assistant Professors at Lamar University. Correspondence may be addressed to Carl Sheperis, Box 10034, Beaumont, TX 77710,