Parenting / interaction assessment tools
By Robin Balbernie

This page is an edited extract from a paper written by Robin Balbernie on assessment and evaluation measures / tools that can be used in early intervention services. See the full paper here. Robin divides the tools he describes into nine areas of which Parenting and parent-child interaction is the first, each of the nine areas has a separate page on this wiki, links to all nine areas are available on an overview page.)

1. The CARE index (created by Patricia Crittenden) was developed for use with high-risk populations. This covers 0 to age 2 or 3 and
assesses mother-infant interaction by using about 5 minutes of videoed play. It codes sensitivity in a free play situation. See
http://www.patcrittenden.com/include/care_index.htm The coding system is comprised of seven scales: three parent descriptors
(sensitive, controlling, unresponsive) and four infant descriptors (cooperative, difficult, compulsive and passive), each one having two
points allocated, giving a total scale score of 14 for the parent and child each. Seven aspects of maternal interactive behaviour are evaluated,
including facial and vocal expression, position and body contact, expressions of affection, pacing of turns, control and choice of activity.
The training is expensive and lasts about 13 days. Apparently reliability is difficult (and more expensive still) to achieve. But this does give a
good, fine-grained, assessment of parental sensitivity and baby’s responses, and also can pick up frightening / frightened behaviour. What
is called “false positive affect” in the baby is a form of dissociative behaviour, indicating a high-risk situation. Other measures may not
detect this.

2. The Keys to Interactive Parenting Scale (generally known as KIPS). See: http://www.comfortconsults.com/ This is video based and gives a
way of evaluating 12 different aspects of parenting behaviour from analysing about 15 minutes of interaction. Can be used from age 2
months on. (I can send a description and a recent study.) The scores on 12 scales may be recorded and provide a quick profile for
evaluating changes. On-line training ($150) and back up, and so good value. Re-accreditation necessary on a yearly basis and the cost of
annual recertification is $60. KIPS produces clinically useful information that can be fed back to caregiver, and can pinpoint clearly defined
strengths and thus be used as a basis for video feedback. In America this tool is recommended by The National Child Traumatic Stress
Network http://www.nctsn.org/content/keys-interactive-parenting-scale and the Californian Evidence-Based Clearing house for Child Welfare
http://www.cebc4cw.org/assessment-tool/keys-to-interactive-parentingscale/ This measure concentrates rather more on actual parenting
behavior and does not specifically look for markers for psychological problems in the parent or disorganized attachment in the child. One
scale is for sensitivity, and here the use of slow motion helps identify moments of mutual interactive regulation – ‘serve and return’
dialogues; this is separated from the capacity to appreciate and respond to the child’s emotions. The scores can be used to show
changes during treatment; and the mean score (not all dimensions may be observed) can track changes during and following intervention.

3. The Parent-Infant Relational Assessment Tool (known as PIRAT) has recently been developed by the Parent Infant Project at the Anna Freud
Centre and further revised by Carol Broughton. This is an excellent observational measure designed to assess the dyadic quality of parent infant
interactions in a variety of settings. PIRAT provides global ratings of parent-infant and infant-parent interactions (affects and behaviour),
including ratings of optimal parenting behavior and risks. Assessment of the level of concern focuses on three major themes: degree of
observed dyadic attunement; frequency of behaviours indicating relational disturbance; and severity of observed relational disturbance.
It is adapted for infants and toddlers up to age two, and is applied to live’ or videotaped observations of ten minutes of free play. Training is
at the Anna Freud Centre. This takes four days. Information on the measure and the training at: http://www.annafreud.org/courses.php/47/parent-infant-relationalassessment-
tool-pirat-training-for-health-professionals This is based on clinical practice and has been revised and piloted in the field.

4. The Brigance Parent-Child Interactions Scale. This is seen as a measurement of both resilience and psychosocial risk, and identifies
both positive and problematic parent child interactions as well as being an indicator of possible delays in development. It is recommended that
this is used at age 6 months and again at 15 months (or when parents’ concerns indicate a lack of awareness as to what is age-appropriate
behavior). There is a separate pro-forma for parents’ use, which taps perceptions and feelings, or for someone observing the interactions.
The parent version can be downloaded from http://www.pedstest.com/Portals/0/TheBook/BPCISinEnglish.pdf and the publisher’s website is
http://www.curriculumassociates.com/products/detail.aspx?title=BrigEC -Screens3

5. Structured observation is perhaps as good a way as any for noting and comparing significant aspects of caregiver-infant interactions; and this
can be used to give ‘snapshots’ at different points of time. I have an example of a useful format that has been adapted from the IMH service
at the Merrill Palmer Institute at Detroit University, which is good for picking up positive interactions. (Could back up PIR-GAS, see below.)

6. The Parent-Infant Interaction Observation Scale (PIIOS) developed by Jane Barlow and P. O. Svanberg, that again uses video to analyse
parent-infant interaction. Description available. This is designed specifically for health visitors and other front line staff to quickly pick up
at-risk families. It is not a tool for outcome evaluation as it is focused on early identification of at-risk interactions only. The training takes 3 days.
Well thought out and useful for practitioners.

7. The Emotional Availability Scales provide a method of assessing interaction inn order to gauge the emotional availability of the parent to
child and child to the parent. This makes it clinically useful for a psychodynamic approach as it may pick up the ‘ghosts in the nursery’.
It is a global measure of overall interactional style in each partner and requires clinical judgement and an awareness of contextual factors.
This is video based again. There is extensive research to show that caregiver’s emotional availability is highly associated with the infant’s
later attachment behaviour. Distance training is available http://www.emotionalavailability.com/ea-distance-training-andcertification/
Training is expensive, but cheaper than CARE Index.

8. There is the new ‘Parenting Interactions with Children: Checklist of Observations Linked to Outcomes’ measure, (or PICCOLO) – an
observational measure of developmental parenting which looks very useful both for assessment and intervention. Unfortunately training is
not available in the UK yet, although a training DVD and users guide are available from Brookes Publishing (www.brookespublishing.com) that
suggests that a team could self-train. This uses a short period of video to rate parenting behaviour on four scales: affection, responsiveness,
encouragement and teaching. (See: https://www.youtube.com/watch?v=0mDlMAMLLAc) Unfortunately it begins at age one year, although some aspects could still be applied earlier and in a way it could also triangulate with KIPS as the same activities are being graded through slightly different lenses. It does not
take long to train in and produces clinically salient information. This has been tested for validity (see IMHJ, 34 (4) 2013) and is psychometrically
sound. It has been identified as best practice in Michigan and I have some papers describing its use if anyone is interested. See:
http://www.cpdusu.org/projects/piccolo/ and http://products.brookespublishing.com/Parenting-Interactions-with-Children-Checklist-of-Observations-Linked-to-Outcomes-PICCOLOTool-P677.aspx

The advantage of all the measures listed above that use video is that they are, in theory, replicable and so minimize both observer bias and the risk of being
seen as purely subjective (or even faked for effect). They all provide a framework for relatively realistic observation of the interactions between
caregiver and child; although none provide an outcome within the standard attachment categories. To be valid such a tool should have an inherent
discipline or structure that can reduce inferences and value judgments. They need to be strength-based, and the results able to be shared with the family in
a comprehensible manner so that meanings can be co-constructed, reducing the potential for a power inequality in the therapeutic relationship. They
provide a sound basis for Interaction Guidance; and plenty of opportunity to ask “If baby could speak what do you think she might tell us about what she is
feeling or thinking right now?” All video-based systems for evaluating interactions should avoid using a clinical narrative to organize observation as
far as possible, it is best to stick to the parent’s preferred dialogue, as this may not be culturally sensitive and may also hide a prejudice towards seeing
the caregiver(s) as the source of the difficulty in the relationship that led to the referral in the first place.