Program Profile: Child–Parent Psychotherapy

This is a dyadic, relationship-based treatment for parents and young children designed to help restore normal developmental functioning in the wake of violence and trauma. The program is rated Promising. The treatment group had statistically significant reductions in the number of child traumatic stress disorder symptoms, child co-occurring diagnoses, child problem behaviors, maternal symptoms, and maternal depression, compared with the comparison group, at the posttest and 6-month follow ups.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

A Promising rating implies that implementing the program may result in the intended outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals

Child–Parent Psychotherapy (CPP) is a dyadic, relationship-based treatment for parents and young children, which helps restore normal developmental functioning in the wake of domestic violence and trauma. CPP concentrates on restoring the attachment relationships that are negatively affected by violence, establishing a sense of safety and trust within the parent–child relationship, and addressing the co-constructed meaning of the event or trauma shared by parent and child.

Program Theory

Originally designed to use with parents and children who witness domestic violence, CPP is based on psychoanalysis and attachment theory, but they combine and integrate principles from multiple theories (developmental, trauma, social learning, psychodynamic, and cognitive–behavioral theories) to help parents and their children recover from exposure to violence and other traumatic stressors (Lieberman and et al. 2005).

Services Provided

CPP sessions concentrate on parent–child interactions to support and foster healthy coping, affect regulation, and increase appropriate reciprocity between parent and child. The initial assessment session of CPP includes a meeting with the mother to discuss the emerging assessment findings, agree on the course of treatment, and plan how to explain the treatment to the child. Weekly joint child–parent sessions are conducted while the mother continues individual sessions. The sessions concentrate on changing maladaptive behaviors, supporting developmentally appropriate interactions, and guiding the child and mother to create a joint narrative of the traumatic events while working toward their resolution.

Although the goals of CPP may be pursued through various therapeutic modalities, the emphasis of the therapy sessions is always on the parent–child interaction. When the family structure is threatened with disruption (such as possible removal of the children from the home), crisis intervention, case management, assistance with problems of living, and advocacy with the social system and agencies that can provide assistance to maintain the family’s well-being are also provided.

Study

Lieberman and colleagues (2005) employed a randomized clinical trial to examine the efficacy of Child–Parent Psychotherapy (CPP) to alleviate traumatic stress symptoms and behavior problems of children exposed to marital violence. The sample of 39 girls, 36 boys, and their mothers (75 child-parent dyads) were referred for treatment because of clinical concerns after the child witnessed or overheard marital violence. Children and mothers were eligible for the study if 1) the child was 3 to 5 years old, 2) marital violence was confirmed by the mother’s report on the Conflict Tactics Scale 2, and 3) the person perpetrating the abuse (who was usually the father figure) was not living in the home. Exclusionary criteria for participating mothers included documented abuse of the target child; current substance abuse and homelessness; mental retardation; and psychosis. Children with mental retardation and autistic spectrum disorder were also ineligible. After mothers provided informed consent, the mother–child dyads were randomly assigned to either the CPP treatment group (n = 36) or a comparison group (n = 29) that received monthly case management plus referrals for individual treatment in the community for both mother and child.

The sample of children was 37.7 percent mixed ethnicity (mostly Latino/white), 28.0 percent Latino, 14.7 percent African American, 9.3 percent white, 6.7 percent Asian, and 3.6 percent of another ethnicity. The sample of mothers was 37.3 percent Latina, 24 percent white, 14.7 percent African American, 10.7 percent Asian, and the rest were of mixed ethnicity. There were no statistically significant differences between treatment and comparison groups on demographic variables (i.e. ethnicity, income) , dependent variables (i.e. child functioning, maternal symptoms), or trauma exposure at intake.

Mothers and children were assessed at intake, 6 months into treatment, and at the conclusion of treatment (posttreatment). Measures of child symptomatology and functioning included the following:

• Children’s Exposure to Community Violence: Parent Report Version, which assesses children’s exposure to 16 forms of community violence and violence-related activities (completed by the mother).
• Child Behavior Checklist (CBCL 2/3 and 4/18), which includes the Total Behavior Problems score that measures parent reported stress-related behavior not represented in the internalizing and externalizing scales (e.g., staring into space, refusing to eat, destroying his or her own things).
• Semistructured Interview for Diagnostic Classification DC: 0–3 for Clinicians, which was administered to the mothers and used a standardized format to systematize the traumatic stress disorder (TSD) diagnostic criteria of the Diagnostic Classification Manual for Mental Health and Developmental Disorders of Infancy and Early Childhood.

Measures of maternal symptomatology included the following:

• Life Stressor Checklist—Revised, which inquired about the mothers’ lifetime incidences of very distressing events, including specific stressors more prevalent among women.
• Symptoms Checklist–90—Revised (SCL–90–R), which measured current psychiatric symptoms using a 90-item checklist. The Global Severity Index was also used to assess maternal functioning and current levels of maternal distress.
• Clinician-Administered PTSD Scale (CAPS), which is a semistructured interview that provided a PTSD diagnosis and total intensity and frequency scores for re-experiencing, avoidance, and hyperarousal symptoms.

The study authors used a general linear model repeated-measures procedure for each dependent variable, comparing the CPP group with the comparison group as the between-subject variable, and using time (intake versus posttreatment as the within-subject variable. Cases that had any missing data were deleted listwise for each analysis. The original sample of 75 dyads was included in the intent-to-treat (ITT) analysis. The study authors did not conduct subgroup analyses.

Study

Lieberman and colleagues (2006) conducted a randomized controlled trial using children and their mothers from the original CPP evaluation in Study 1 (Lieberman et al. 2005). In this study, participating mother-child dyads were followed 6 months after the end of treatment (i.e., the dyads were followed for 6 months longer than in Study 1). This study included 22 girls and 28 boys ages 3 to 6 years. Mothers and children at the 6-month follow up were demographically the same as described in Study 1 (Lieberman et al. 2005). Dyads lost to attrition at the 6-month follow up did not differ from those who completed the 6-month posttreatment assessment on the outcome variables of child gender, ethnicity, income, or maternal education. The one exception was that the mothers who did not complete the posttreatment assessment typically had younger children. However, at the 6-month follow up, there was a statistically significant difference between treatment and comparison groups in child gender, with the treatment group comprising fewer boys than the comparison group (30 percent versus 61 percent, respectively).

ITT analyses were conducted using a last observation carried forward (LOCF) method, in which the score at the most recent time period (intake, 6-month, or posttreatment) was substituted for later incomplete data points. The original 75 dyads are included in the ITT analyses.

Outcomes of interest were child functioning and maternal symptoms at the 6-month posttreatment follow up. Child functioning was measured using the Child Behavior Checklist (CBCL 2/3 and 4/18), which included the Total Behavior Problems score that measured stress-related behavior that was not represented in the Internalizing and Externalizing Scales. The maternal symptoms outcome was measured through the Symptoms Checklist, Revised (SCL-90–R), as described in Study 1. The Global Severity Index was also used to assess maternal functioning because it is considered a reliable indicator of current maternal distress. The study authors used a general linear model (GLM) repeated-measures procedure for each dependent variable, comparing the CPP group with the comparison group as the between-subject variable, and using time (intake versus 6-month follow up) as the within-subject variable. The study authors did not conduct subgroup analyses.

Study

Ippen and colleagues (2011) conducted a randomized controlled trial, using the same mother-child dyads as in the CPP evaluations in the previous studies (Lieberman et al. 2006; 2005). This study examined whether CPP was efficacious for children in early childhood who have experienced multiple traumatic and stressful events (TSEs).

The sample of intent-to-treat participants included the 39 girls and 36 boys, ages 3 to 5 years, and their mothers from the original evaluation, 6 months after the end of treatment (i.e., the same follow-up period as in Study 2). Mothers and children in this study were demographically the same as those described in Study 1 (Lieberman et al. 2005). Of the children, 12 percent had experienced two TSEs, 41.3 percent had experienced three TSEs, and 46.7 percent had experienced four or more TSEs. TSEs were calculated by summing across the following eight categories that correspond with Adverse Child Experiences (ACEs): 1) physical abuse, 2) sexual abuse, 3) witnessing domestic violence, 4) neglect, 5) separation from a caregiver, 6) caregiver criminal history, 7) caregiver substance abuse, and 8) caregiver mental illness. There were no statistically significant differences between treatment and comparison groups in posttest completion or follow up for any of the outcome variables; however, children who dropped out of the study were generally older.

Treatment and comparison group dyads were assessed at intake, posttest (12 months after intake), and at a 6-month follow up after posttest. Outcomes of interest were child depression, child co-occurring diagnoses, and maternal PTSD and depression, which were examined at the 6-month follow up between the treatment and comparison groups. Child symptomatology, including PTSD, depression, and the number of co-occurring diagnoses (i.e., anxiety, sleep disorders), was measured using the Semistructured Interview for Diagnostic Classification DC: 0-3. Maternal symptomatology was measured using the Clinician-Administered PTSD Scale (CAPS).

Data were retrieved from family history interviews; Department of Human Services (DHS) report; diagnostic interviews with mothers; and the 51-item questionnaire, Screening Survey of Children’s Exposure to Community Violence: Parent Report Version. Due to the study inclusion criteria that specified that the father figure perpetrating marital violence no longer reside in the home, all children had experienced a major separation from their biological fathers. Thus, this TSE was coded only if reports indicated that the child had witnessed at least one domestic violence event. The study authors used general linear model (GLM) repeated-measures analyses to investigate differences between the treatment and comparison groups for the outcomes of interest, except for maternal and child PTSD symptoms data that were examined through a chi-square analysis. Subgroup analyses were conducted to determine treatment effects by the level of child TSE exposure (< 4 versus 4+) and child TSE status (low- versus high-risk).

A treatment manual is available at Alicia F. Lieberman and Patricia Van Horn. 2005. “Don’t Hit My Mommy!”: A Manual for Child–Parent Psychotherapy With Young Witnesses of Family Violence. Washington, D.C.: Zero to Three Press. Materials are also available in Spanish.

Child–Parent Psychotherapy (CPP) is primarily provided by master’s degree professionals in psychology or social work who have parent and child mental health experience and training, or by trainees in psychiatry or mental health services, such as predoctoral interns.

The treatment has been adapted for use with infants who experience maltreatment known as Infant Parent Psychotherapy, which can also be found on CrimeSolutions: https://www.crimesolutions.ojp.gov/ratedprograms/106. Child–Parent Psychotherapy for Family Violence is available for families who experience multiple forms of familial violence.

Additional information on CPP treatment is available at https://childparentpsychotherapy.com/.

Subgroup Analysis

With regard to subgroup analyses, Ippen and colleagues (2011) divided CPP dyads into high-risk (4 +) and low-risk (< 4) groups based on child traumatic and stressful event (TSE) exposure. At the 6-month follow up, high-risk children in the CPP group showed statistically significant reductions in problem behaviors, compared with high-risk children in the comparison group. However, there was no statistically significant difference in problem behaviors between children in the CPP low-risk group and children in the comparison low-risk group. In addition, at the 6-month follow up, high-risk mothers in the CPP group showed a statistically significant reduction in maternal depression, compared with mothers in the high-risk comparison group. Similarly, CPP low-risk mothers showed a statistically significant reduction in maternal depression, compared with mothers in the low-risk comparison group.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Cicchetti, Dante, Fred A. Rogosch, and Sheree L. Toth. 2006. “Fostering Secure Attachment in Infants in Maltreating Families Through Preventive Interventions.” Development and Psychopathology 18:623–49.

Lieberman, Alicia F., Allison Briscoe–Smith, Chandra Ghosh Ippen, and Patricia Van Horn. 2006. “Violence in Infancy and Early Childhood: Relationship-Based Treatment and Evaluation.” In Alicia F. Lieberman and Robert DeMartino (eds.). Intervention for Children Exposed to Violence, a publication of the Johnson & Johnson Pediatric Round Table Series.

Lieberman, Alicia F., and Patricia Van Horn. 2005. “Don’t Hit My Mommy!”: A Manual for Child–Parent Psychotherapy With Young Witnesses of Family Violence. Washington, D.C.: Zero to Three Press.

Lieberman, Alicia F. and Patricia Van Horn, 2008. Psychotherapy With Infants and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment. New York, N.Y.: The Guilford Press.