We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids. I'm Dr. Jane Gilmour, honorary consultant, clinical psychologist, and Child Development Programme Director at UCL. And I'm Umar Toseeb, a professor at the University of York, focusing on children and young people's mental health and special educational needs. In each episode, we select a topic from the research literature, and in conversation with invited authors, sift through the data, dilemmas, and debates to leave you with our takeaways for academics and practitioners. Today, we'll be exploring parent-child interaction therapy. This episode is called Parenting Intervention-- Finding the Goldilocks Zone. Yes, I'm really excited about having this discussion today, because I've been trying to do much more intervention-based research. A lot of my previous work is secondary data analysis. And I'm trying to move into intervention, because I want to try and make more of an impact on children and young people more directly. So it's always nice to read papers where there's been a trial or an intervention to try and understand what works and what doesn't work. And what's particularly interesting is sometimes it's not just what the intervention is, but how it's delivered, who it's delivered with, the context, and all those kinds of things. So I'm really looking forward to getting into some of those conversations today. Yeah, it's a really powerful paper and a powerful message that it delivers. And I'm looking forward to it for a variety of reasons. But in the past, I have had various experiences in clinic working with different models of parenting intervention. And I'm thinking about a period where I worked with families who had a child who was at the edge of care, so in other words, removal from home was being considered unless the circumstances changed. And in that particular clinic, we used a method that had a lot of parallels with the methodology we're looking at today. So parent-child intervention therapy coaches the parent and child in the moment. And I really saw some powerful effects with that sort of technique. So I'm looking forward to asking our guests a little bit more about that approach. And also just to reiterate what you were saying, it's really wonderful to find an intervention that has such high clinical validity and an impressive evidence base. So there's a lot of aspects to this intervention that are particularly attractive for an academic or clinician. The thing that I want to touch upon also is in previous episodes, I've talked about my discomfort/unhappiness with the way in which we support people in general when they're experiencing mental health difficulties or whatever it might be, the intervention that we deliver, whether that's CBT or something else, which relies on the individual on their own. So you need to do something differently about the way you conceptualise these experiences, think about these experiences, the narratives that you create, et cetera. But we know that lots of young people's development happens in the context of the wider world, and that starts within the family. So what I really like about this particular intervention is it's about child-parent interactions. So it's acknowledging that the young person is embedded within a wider family system, and the interactions with the people in that family system will likely impact upon a young person's development. So I really like that about the paper that we're going to talk about. I think it goes even further as well, because it thinks about the societal experience of those families as well, and the families who are experiencing disadvantage. And I want to hear more about the delivery, which increases the engagement of disadvantaged families, because this is something that we are often dealing with clinically. And I think it's true to say, and maybe our guests will want to correct me on this, but I think more recently the literature has shifted in tone. It used to be-- why hasn't this family engaged? And now it's more often-- how can we shape the situation to increase the chances of engagement? It's a much more systemic approach, if you like. And I think we're going to talk a bit more about that, which I'm really looking forward to. And the final thing that I want to say before we bring the guests in is about the timing of this intervention in terms of developmental stage. So there, I think for a while, there's been an emphasis on early intervention and prevention when it comes to children and young people's difficulties. And some of that has now shifted in recent years, in the UK anyway, in terms of government policy or the policies that the government is trying to introduce towards much earlier in development and the early years, pre-primary school, before young people are going to primary school. So I like that the focus here is also on the early years, because it probably is the best time for prevention. So I was thinking about this, too. The programme we're going to discuss today has its origins in Diana Baumrind's work. And she established the idea of an optimum parenting style where there is one of warmth and attunement and clear expectations and boundaries, so-called authoritative parenting, as distinct from authoritarian, permissive, or neglectful. And there's a lot of evidence that this particular type of parenting is associated with an improved outcome in mental health or educational outcomes. And it really made me think and pause to reflect about that classic paper. Steinberg and Darling's paper, looking at the review of parenting styles and how it evolved into thinking about emotional climate. And the more recent evolution of the parenting support that we've been discussing really thinks about shaping the therapeutic climate as well, to increase the chances of success. So there's a lot of systemic and meta-analysis, if you like, of what the best circumstances are, as well as the best therapy. So we've got a lot to ask our guests. I think we should get on and ask some of our questions. Today, we're joined by Julia Ruggiero, advanced PhD student in clinical psychology from the University of Oregon. Also Dr. Xiaolan Liao from the University of Oklahoma, and Professor Elizabeth Skowron from Penn State University. Welcome to you all. Thank you. Thank you so much. Thank you for having us. Xiaolan, Elizabeth, and Julia are authors of the paper "Effects of Parent-Child Interaction Therapy on Child and Parent Outcomes-- Differentiating Child-Directed Interaction and Parent-Directed Interaction Session Impacts in Child Welfare-Informed Families," published in the JCPP. So we are delighted to have a trio of experts here. So we have three co-authors who were involved in this paper. And that really allows us to get into the heart of this paper. And there's a lot to discuss. So I wanted just to find out a little bit about what led you to this particular area of research. Thank you for having us. We're excited to be here and talk with you about the work that we've been doing, talk about the results and the broader programme of work that we're involved with. Myself, I came to this work from some basic research, which involved studying in very careful ways, the moment-by-moment interactions that unfold between parents, young mothers who are involved with child welfare services and their preschool-aged children. And while we're studying their parenting interactions with their children, also monitoring their physiological responses. And the long and the short of it is we discovered some patterns of parenting and stress reactions that led us to this intervention, parent-child interaction therapy. Basically, this notion of having a therapist right in your ear while you're trying to practise new skills with your child led us to this intervention and studying it to understand it better. And I think that's a wonderful pathway, if you like. Because thinking about those moment-to-moment experiences and being able to monitor the physiological response relative to an intervention, where we're assuming there is a calm voice in one's ear, that's a really interesting narrative. I always think about this idea of the therapist's voice in the parent's ear as a little bit like a spare pair of frontal lobes-- somebody else who's thinking and strategizing in the moment so that it calms the discussion down somewhat and allows one to think using best practise and so on. Maybe that's an unfair summary, but I think it's a really interesting and absolutely fascinating intervention. Let's talk about the intervention itself. So the intervention is parent-child interaction therapy. I wonder if we can just talk a bit about what the key ingredients are of the intervention. And so what does it look like, how long does it last, and what's the evidence base that already exists that you're trying to build upon? Great question. So this is an intervention that was developed several decades ago, and it was originally developed to help families who were trying to manage young children, who were showing a lot of externalising, aggressive outbursts kind of behaviour. And it's got a couple phases to it. And I'm going to hand it off to Julia, who's going to describe to you what the model looks like and what therapists actually do with parents and kids. So I think parent-child interaction therapy is really amazing. So essentially it has two separate phases. And the first phase is what we call child-directed interaction. So we have parents come in. We have a session where we teach them the skills that they're going to be learning in that particular phase. And then the next session, they'll come in again with their kid. And yeah, we'll have parents put a headphone in their ear so the therapist can speak with them and give them instructions while they're playing with their child in a separate room. And so this first phase is really focused on encouraging parents to increase warmth in whatever way that comes about for parents, because warmth can look really differently across different families, and really to increase their responsivity as parents, so responding in the moment to their kid, letting their kid lead the play, and really granting some independence in play with their child. And what we find in this phase of treatment is really a couple of things. Not only do we find that this is really just really great bonding for a parent and their kid, but we also find that really through these positive parenting techniques in and of themselves, we can see a lot of behaviour change in kids. So a lot of improvement in some of the externalising behaviours. So once parents have gone through the first phase, we transition into the second phase, which is known as parent-directed interaction. And this is a different set of skills. Again, we'll have parents come in. We'll teach them what it looks like, and then we'll have them bring their kid in the next session. We're still in their ear talking to them the whole way, but here we are really focused on more behaviour management and helping parents learn safe, effective, discipline skills and limit setting. Because we know for parents, one of the most stressful parts can be these limit-setting interactions. And so it can help to have a therapist in the ear really just talking them through these limit-setting interactions. And we see really great behaviour changes for kids and I think really more confidence in parenting through the second stage. Can we just go into a bit more detail there? So can you give us an example of what kind of behaviour parents might have difficulties limit setting and then what they might hear in their ear during a session that might help them with that? That's a really, really great question, and I think it can really depend. I've seen parents come in with different challenges and different growth edges and really different, unique strengths as well. And so for some parents, what the second phase might look like is really helping them get more comfortable actually setting limits. Some parents really have a bit of a harder time setting firmer boundaries with kids. We do know that kind of safe, effective boundaries for kids make kids feel really safe, protected in the world. And so for some parents who struggle to implement boundaries, this can be really helpful. And we can see some really great behaviour change for kids in that way. And then for other parents, what they need help with is really staying calm in these interactions. Some of these limit-setting interactions can be really stressful. And so some parents really benefit from just lots of practise staying calm in these interactions, helping themselves regulate in the moment. And really parent-child interaction therapy, this phase of it provides parents with really almost like a set of skills to implement in these limit-setting interactions so that, OK, when this interaction has to happen with kids, I know exactly what to do because I've practised it a bunch of times. And so it can feel a lot less stressful because I know exactly what to do. There's no room for spontaneity. And I think that can really help parents feel a lot more relaxed in those interactions. Yeah, Umar, for example, after a family goes through the first phase where therapists are coaching parents to use those positive skills to catch their children behaving well to show that they're tracking and paying attention to them, and they shift into the parent-directed interaction phase of the treatment, we teach them in that first parent-only session how to give a good direct command that's very clear, that's developmentally sort of matching the child's age, right? So it's a command that the child can cooperate with. We teach parents to give one command at a time, not a lot in a row. And then we teach the follow through. And when your child cooperates with you, really important follow through is recognising that with a big labelled praise-- thank you for putting your toy away in the toy box. Or follow through, if the child doesn't cooperate, is a graduated series of limit setting, as Julia talked about. And so we don't even wait for children to somehow start misbehaving in big ways in that PDI phase. What we do, in that first session when the parent comes back with their child, we introduce it to the child. We let them know that Mommy or Daddy and you are coming in and you're going to practise minding and listening. And Mommy or Daddy is going to tell you to do some things. And when they tell you, you have to listen and do what they say. And if you do, you'll have more time to play together. And if you don't, basically-- so the child knows that therapy's changed in this phase and that they have to practise cooperating, that that's part of the job of therapy. The way that PCIT is structured and taught to therapists is to start teaching parents to give little, easy commands to their children to cooperate with and then build up to the big commands and to not start practicing this new way of doing things at home until you've really mastered it in session with us, where we can support you, through the ear. And so the little itty-bitty commands are things like-- you're playing together, drawing with colouring pages. It might be, "Johnny, please hand me a red crayon from the bin." Very easy command. This is not going to improve conduct disorder. But the idea is start simple. Johnny doesn't have to interrupt what he's doing. He only needs to get you something over here-- really easy to cooperate with. And you gradually build up to those real-world commands that are the challenging ones that parents and children get into problematic interactions around-- "It's time to leave the session in a few minutes. Please put your shoes on." Right? Those big commands that require a child to transition, and maybe do something that they don't want to do. And you save those for after the parents have built up those skills in getting the child to cooperate with the really easy commands. And what is so striking about the intervention is that it is in the room. A lot of the principals will be familiar to those who have used other parenting intervention models, but the idea is that you're in the moment and you can allow the parent to self-correct. There's micro-shifts rather than understanding the theory, taking it home. And you can't, as a therapist, know exactly what went on and what the tone was when we're talking theoretically and doing that practise. Whereas in parent-child interaction therapy, you are in the room. You can see, you can observe, and you can shift in a much more immediate way, which is presumably part of its evidence base. So what is the evidence base for parent-child interaction therapy? Yeah, well, it is substantial. But just a brief recognition of Jane's thoughts there, I think it's important to note that there are many principles that are practised in parent-child interaction therapy, or PCIT, as we also call it, that are present in other intervention programmes for families with young children. There are a handful of very effective programmes that exist. PCIT is not the only game in town. I think one of the unique things about PCIT is that, as you mentioned, you have the therapist in real time scaffolding or supporting the parent while they're practicing those new skills. So right then and there, in the moment when a parent might be struggling, can't figure out what to say in the moment, maybe is going to gravitate towards something harsh or a little aversive or a little controlling, that the therapist is there, and they can really immediately support the parent in taking another, more positive direction. And I think that's a part of the power of that real-time component of the intervention. But that said, PCIT is a pretty intensive treatment, and not all families need that much intensity. So it's really important to acknowledge that there are some families who you can teach some skills to and you can send them home and they're going to be able to practise those skills and come back and report how things went. And so if those lighter-touch interventions work, from a cost effectiveness perspective, we should be using those if we're thinking about policy kinds of things. But when families can't make the changes they need with that level of support, PCIT, along with a small number of other kinds of intensive therapies, I think, are very effective. And also the cost effectiveness of these interventions is substantial. So there have been a number of randomised clinical trials of PCIT, both for families that are dealing with children with externalising disorders, but also, I think even more significantly, for families who are struggling, who are involved in the child welfare system. And the data suggests that there are medium-to-large effects on improving things like warm, responsive parenting skills, lowering the rates of harsh, aversive, negative critical parenting behaviours. The work that we did in my lab, one of the most recent clinical trials of PCIT with child welfare families shows PCIT even significantly improves or strengthens parent's self-regulatory skills, so their ability to regulate their emotions and to regulate their behaviour. The first clinical trial of PCIT with child welfare families was published back in 2004 by colleagues at the University of Oklahoma, where Xiaolan is. And they took a sample of a couple of hundred families involved with child welfare. These families had, on average, four substantiated reports of physical abuse before they entered treatment. So these were not families at risk for maltreatment. These were families who had chronic, entrenched instances of harming their children. And the authors of this paper randomly assigned families to the PCIT intervention versus services being provided, as usual, by child welfare. The effects were substantial on parenting skills, on children's behaviour outcomes. But I think one of the most significant things about that study that actually led us to begin to study PCIT as well, is that they did something called a survival analysis. So they right at the end of the study at post-treatment, they started to count the number of days until families might have a new report to child welfare, a new substantiated instance of child physical abuse. And they counted out for three years, how many families in the PCIT treatment group versus the services-as-usual control group stayed in the-- we haven't yet re-abused our child condition. And three years out, following treatment, only 19% of families who received the PCIT programme were found to re-abuse their children, whereas in the control condition, services as usual, 50%, half of the families had re-abused their child within that three-year time period. There have been cost effectiveness studies to show that for every dollar you invest in PCIT, you return $5 to $8 or $9 in savings on things that you're not having to spend in the juvenile justice system, the child welfare system, special education services for children, having more children go on and complete more education, become taxpaying citizens. So the investment on the front end really pays off for PCIT, but many other programmes like PCIT as well. So at the beginning, you mentioned that there were two phases of parent-child interaction therapy. And my reading of your paper is that you've investigated them separately. So why is it important to investigate each stage separately with reference to child and parent outcomes? I think my first answer to that really, is that we really believe that the two phases, we have really different things that we're teaching parents in the different phases. So the first phase, yeah, we're really focused on this encouraging, warm, responsive parenting. And in the second phase, we're really focused on encouraging safe, effective limit setting. And so these are two really pretty different skills that we're teaching parents. We focus a lot on the first phase, the tangible skills-- helping parents come up with really effective kind of praises for pro-social behaviours and other behaviours to help boost kids' confidence and increase the likelihood that they'll engage in behaviours that we want to see more of. We teach them to follow their kid's lead, and grant some independence in play, and basically make their kid feel really loved, really important. Because it's so meaningful to have that one-on-one time with parents, the undivided attention. In that second phase we're more focused on, like Elizabeth shared earlier, helping parents come up with really effective instructions that are going to be clear to their kids so their kids know what's expected, which is really important when it comes to times when kids' safety could be at risk. It's important for us kids to be able to follow instructions in times when they need to. And so that's one piece. And so we really think the two different phases are teaching parents different skills. And so we really wanted to see what the impacts on parenting behaviour, positive parenting and kids' outcomes are, child behaviour outcomes are, from these two distinct phases. You paint a really, very detailed picture about what we're expecting. We have heard that there's very strong evidence base and that these two phases are important to that evidence base. But I just want to just go back for a second and pick up on something that Elizabeth said, which I think is really important to this picture. Because we're talking about child welfare involved families. So we know that this is an effective strategy, but we've got to find a way of engaging our families in this intervention. And we know in the UK, we've got quite a lot of initiatives to support families living in deprivation. There's a really wonderful study just recently published by Walton and colleagues. And I wondered, did you use any of these initiatives or are there initiatives like this in the US? Now, I'm interested in this because we're thinking culturally, although on paper, the UK, and the US have a lot of similarities. There might be significant differences in terms of welfare and so on, that mean the interventions may be culturally specific. Can you talk a little bit about maintaining engagement with these families who are living in deprivation? There's so much we can talk about around this. I think that there are a couple of avenues to consider. When you are delivering a programme and you are really trying to evaluate its effectiveness, oftentimes you have additional resources at your disposal, so you can identify those barriers to engagement and treatment that we know from a lot of research. We've got resource barriers, transportation barriers. If the treatment programme doesn't involve the entire family-- oftentimes parents have other children, that they need childcare for-- you're often seeing families after school in the evenings or on the weekends. So where does the meal come in? If they're coming straight from after school, kids are hungry. Maybe parents haven't had a chance to eat. So we've got lots of barriers that are known and other barriers that might be unique to individual families. And I think that what we're able to do when we're doing funded clinical trials research is we're able to divert some of those resources to try to remove those barriers-- to assist with transportation, to assist with providing child care for children in the family who might not be in the treatment, to provide some healthy, nutritious food, snacks before or after the treatment. And I think that there's research that tells us that these are dollars that are really well spent, pounds that are really well spent, to ensure that you're lowering barriers so that you can deliver enough of the intervention so families can reap the benefits. And then again, society reaps the benefits of the treatments that have been well delivered. But I think one of the other avenues, which I think is a really exciting avenue, is we learned a lot in the COVID pandemic with the shutdown, in terms of loosening up restrictions to be able to deliver services online. And then, of course, we have really exciting efforts that are moving clinical service delivery into places in the community where families naturally go anyway, whether that's schools in the communities that families live that are not typically used after school is finished, or community centres and other places, these are important avenues that need to be explored. Because we cannot expect families to be coming into the clinic for services when they really struggle with having enough resources, time, and other kinds of resources to be able to do that. And they're trying to decide between-- do I get my child to the doctor for their annual checkup, or do I get to the grocery store, or do I do these other errands? How do I fit in the family treatment. So my background is in quantitative psychology and developmental science. And I have long been interested in how early caregiving relationships shape later childhood development and behavioural health over time. And I was fortunate to become involved in this work through meaningful cross-institutional collaboration. My faculty mentor, Dr. David Bard, who I think Elizabeth just mentioned, that he is the one has been leading important work in child welfare and a parent-child interaction therapy here at OUHSC. And it's through these collaborations with Dr. Elizabeth Skowron and this broader research team, I became increasingly interested not only in whether all these interventions work, but how they work and what actually drives the change, and also, what's the best way to deliver this service. So historically, in this intervention work, not just this parent-child interaction therapy intervention, but in this entire behavioural treatment research, we have done a very good job asking questions like, does it work? Does the treatment work? Does it improve outcomes? Does it work better than other approaches? But one of the questions that particularly interested me as a data scientist was-- what's the treatment dosage and dose-response relationships? This really inspired me from this medicine and drug trials. Not simply like whether a treatment works-- we want to know how and why it works, when it works, and for whom it works. And we want to know what is the most effective and efficient way to deliver it. And also we want to know how much treatment does each family really need. Which part of the treatment are most important for change? And does every family need the same amount of treatment? So all those kinds of questions, just like from a background with quantitative statistician perspective, I want to know why that worked. Excellent. Thank you. And so I suppose my follow-up question there is, what did you find in your study? So we've talked a lot about the intervention, the background, the evidence, and then your motivations for doing the work. But what did you find? One of the biggest findings from our study was-- both parts of the treatment matter. We have two phases-- relationship-building phase and limit-setting phase. We found that families who spend more time in the relationship-building phase part of this treatment, where parents learn to slow down, follow their children's lead, and build a more positive connection. And then more time in the discipline and limit-setting part of treatment tended to show stronger improvement in both parenting and child behaviour. We see that families who received more treatment sessions across both phases showed more positive parenting skills, fewer negative parenting behaviours, and fewer disruptive child behaviour problems. Another important finding was that the two phases of treatment did not seem to affect every outcome in the same way. For example, the relationship-building phase appeared to be especially important for helping parents become more warmer, more positive, and more supportive in their interaction with their child. On the other hand, the discipline and limit-setting phase appeared to play a stronger role in reducing disruptive child behaviours and helping parents manage behaviours more consistently. We also found that the two phases sometimes work together. For example, families who completed only a small number of relationship-building sessions, such as four sessions, appeared to benefit when they later received more discipline and limit-setting sessions. In those families, adding more the discipline-focused sessions was linked to stronger positive parenting skills. But for families who had already completed many relationship-building sessions, for example, those who received eight or more sessions, adding even more discipline-focused sessions did not contribute to improve positive parenting in the same way. I think this is important because it suggests that treatment may work more like a step-by-step process, where different parts of treatment help families in different ways, rather than one single treatment package where every part works the same way. Those are some of the things that stood out to me from these findings. But I love also to hear what the rest of the team thinks. Yeah, that's really summarises it beautifully. And Xiaolan was a brilliant methodologist on the effort, in terms of running those complex statistical analyses. I think a little bit of context I'll just add to the reason that we focused this paper on-- does dosage matter and does dosage in one phase or the other phase matter together more or less-- is that most of the research that's been published so far on PCIT has really focused on trying to understand the effects of that first phase of PCIT, that relationship-enhancement, positive-parenting skills-enhancement phase. Most of the work has focused only there, and there's been virtually no research that's really focused on-- does that positive discipline limit-setting phase matter? And we've even seen a handful of efforts by folks to package only the first part of PCIT and deliver only that first part to families. And we felt we really don't know enough yet about what the discipline, the positive discipline phase, the PDI phase of the treatment is doing. And before we decide to pull that out for all families, let's understand better how it's helping or whether or not it's needed. And as Xiaolan mentioned, it does seem to be pretty important for these child welfare involved families. I think it's absolutely fascinating. I think the idea that the relationship building is necessary, but perhaps it primes the families for that limit-setting phase, and that synergy is where the best outcomes might be. It's such an important question to ask to go back to first principles. And it was one of the reasons I was so fascinated about the paper, too. Hold on a minute, we have looked at the extensive literature on one phase, but let's think about the other. And that face validity may make some of us, as practitioners, or academics, get carried away with assuming that the process is one thing, and the data shows quite clearly that it's not. So it's such a valuable paper to allow us to stop and think. I wanted to come back to the limit setting and ask a question about the developmental stage of these young children, because they're young, up to age seven, I think that's correct. Do you think that there would be a different-- and of course, there's a different delivery depending on the age of the young person-- but do you think that the interaction effect or the dosage effect might be different for, let's say, older children or even post-pubertal children? Yeah, that's such a great question and super interesting to think about. I think the first thing that I will say is that parent-child interaction therapy, as you mentioned, Jane, was really designed for kids in this two to seven-year range. And so it's really been built and tailored for working with families of young kids and really kind of structured to be maximally beneficial for this particular developmental period. And really the reason why is because at this particular period, we know kids really benefit from autonomy and these play sessions, and then also limit setting to help them feel safe in this very big world. And so I think you're absolutely right there that intervention would probably look pretty different for older kids. We know that adolescents really need quite a bit more autonomy, quite a bit more independence. And so limit setting does look really different as you get older into your teenage years. And responsive parenting looks different, too. The warm, effusive praise that we have parents practise in parent-child interaction therapy for their little ones, like "you're doing such a great job building that tower," probably is not going to fly for a 16-year-old. You might want to use some more matter of fact praise. Like, "thanks for taking the garbage out." And so I think it's a really great question. I'd love to hear Xiaolan and Elizabeth's thoughts about dosage. But I think don't want to speculate there, because I do think it's just different skills that you bring to the table for an older kid. Because we are talking about dose-response relationship. And this data we have is an RCT, randomised clinical trials. But I do want to mention that the dosage here in this RCT experiment, they themselves are not randomised. They are natural variations we observed in this data. So I just want us to be cautious about making overly strong causal claims regarding this dose effects. Fantastic point there, and a nice one to end on there, because it's-- this is what we're finding, this is what it means, but let's be cautious about this one thing that we don't want to overclaim on. So let's take this opportunity to say thank you so much. It's been a really interesting conversation. It's been really nice to speak with you all. You're delightful. [LAUGHS] Oh, Elizabeth. You're really delightful. Stop it. We like it. Well, I'll tell you what I found fascinating about this paper-- the idea of both a dose effect, so for some families, at least, a smaller or at least a moderate amount of child-directed sessions and a higher number of parent-directed sessions was the sweet spot for some. And that interaction between those two types of sessions, which I think, as Elizabeth mentioned, I think, has been really neglected in the literature. The other thing that I enjoyed was the discussion about reducing the barriers to engagement. It was absolutely fascinating, because we were really zooming in and saying, look, parents need to establish trust with their children before offering boundaries and so on. And then zoom out and think about as agencies, we need to establish trust before offering intervention. Because the idea that families might be cautious about linking to external agencies who are in vulnerable circumstances, we need to be building that relationship in order to maximise the chances of these families engaging with that evidence-based intervention. So we're thinking about maybe getting a critical mass of families to increase peer support and destigmatize the process. And for me, I think Xiaolan put it nicely, I think she said what works, for whom, and when. And that was nice, because it's that one-size-fits-all approach will not work for lots of people. So it's about-- how can we take this concept and principle that we know about and what parts of it work, for whom, and when? And why does it work? And that's about that personalising the intervention to the people in front of you that you're trying to support. So that's what I really liked about this paper. I thought, Umar, if I was going to guess what you enjoyed most, I would also say that maybe the idea of looking at the system, as Elizabeth was talking about, thinking about tailoring it around timing, thinking about childcare, thinking about nutrition, the idea that nonadherence to an evidence-based treatment is likely to do with the system rather than the individual. And you are, I won't say banging on about it, but you often mention this. So I wondered if that would be something that you picked up on. Because I was certainly really interested to hear some of the strategies that Elizabeth talked about there. Yeah, absolutely. I think that's wider-focused, outside of the child was really interesting for me as well. I just want to pick up on something that happened in the conversation. Xiaolan, towards the end, said, oh, but we should be careful about inferring, because the dosage wasn't random within the intervention. And I actually was saying that, I was thinking, yes, this is a quantitative statistician, quantitative analyst type person speaking, because that's exactly my thought process. I was like, yeah, this is great, but we shouldn't infer this little bit about causation because that bit wasn't randomised. So that was really nice because I was like, oh yeah, our thinking is aligned on this because she thought the same thing that I thought. But it was a really lovely combination of an ecologically valid study with a randomization to a certain degree, and also an awareness of the degree to which we can use these data. And that is exactly-- that's a dream team right there-- the idea of taking a cautious approach with the data, but also using a group and a delivery that has a lot of immediate, as I say, ecological validity in terms of the sorts of families that will be offered these interventions. I think I've got two takeaways. The first is that dosage idea. So from these data, with the caution that we have just discussed, it's likely that it may be neither cost effective nor clinically effective to offer an excessive amount of child-directive sessions. But the other thing that I thought was very interesting was the order. So this paper strengthens that evidence underpinning a saying that's used in neuroscience and attachment as well as parenting fields, and that is "connection before correction." And my takeaway for academics is, what we were talking about today was partly-- which aspects of a given intervention might work for different people. And it got me thinking about some of the work that I'm doing, where we're looking at RCTs that didn't work for the group as a whole, and we're looking to see whether-- it still works for some people, just not the group as a whole. And I suppose this is looking at it in a different way. So I think if there's people out there who have an intervention that didn't work on an overall group or it didn't work as a collective, then there might be parts of that intervention that can still be taken and tested separately, because it's not to say that the entire intervention doesn't work. It might just be one part that is working, and you can take that and run with it. Yeah, lovely. OK, let's call it a day there. Next week, we welcome Una Coleman as we discuss psychological and social factors linked to childhood maltreatment. [MUSIC PLAYING]