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CONTEXT: Parent-child interaction therapy (PCIT) is effective at reducing children's externalizing behavior. However, modifications are often made to PCIT, and it is not known whether these impact effectiveness. OBJECTIVE: To systematically review and meta-analyze the effects of PCIT on child externalizing behaviors, considering modifications, study design, and bias. DATA SOURCES: We searched PubMed, PsycINFO, Education Resources Information Center, Sociological Abstracts, and A+ Education. STUDY SELECTION: We selected randomized controlled or quasi-experimental trials. DATA EXTRACTION: We analyzed child externalizing and internalizing behaviors, parent stress, parent-child interactions, PCIT format, and study design and/or characteristics. RESULTS: We included 23 studies (1144 participants). PCIT was superior to control for reducing child externalizing (standardized mean difference [SMD]: -0.87, 95% confidence interval [CI]:-1.17 to -0.58). PCIT studies that required skill mastery had significantly greater reductions in externalizing behavior than those that did not (Mastery: SMD: -1.09, 95% CI: -1.44 to -0.73; Nonmastery: SMD: -0.51,95% CI: -0.85 to -0.17, P = .02). Compared with controls, PCIT significantly reduced parent-related stress (mean difference [MD]: -6.98, 95% CI: -11.69 to -2.27) and child-related stress (MD: -9.87, 95% CI: -13.64 to -6.09). Children in PCIT were observed to be more compliant to parent requests (SMD: 0.89, 95% CI: 0.50 to 1.28) compared with controls. PCIT effectiveness did not differ depending on session length, location (academic versus community settings), or child problems (disruptive behaviors only compared with disruptive behavior and other problems). LIMITATIONS: Results for parent-child observations were inconsistently reported, reducing the ability to pool important data. CONCLUSIONS: PCIT has robust positive outcomes across multiple parent-reported and observed parent-child interaction measures, and modifications may not be required even when implemented in diverse populations. [ABSTRACT FROM AUTHOR]