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Child-Parent Psychotherapy (CPP)

Scientific Rating:
2
Supported by Research Evidence
See scale of 1-5
Child Welfare Relevance Level:
High

See descriptions of 3 levels

Brief Description

The information in this program outline is provided by the program representative and edited by the CEBC staff. The Child-Parent Psychotherapy (CPP) program has been rated by the CEBC in the areas of: Domestic/Intimate Partner Violence: Services for Women and their Children, Infant and Toddler Mental Health (0-3) and Trauma Treatment (Child & Adolescent).

CPP is a treatment for trauma-exposed children aged 0-5. Typically, the child is seen with his or her primary caregiver, and the dyad is the unit of treatment. CPP examines how the trauma and the caregivers’ relational history affect the caregiver-child relationship and the child’s developmental trajectory. A central goal is to support and strengthen the caregiver-child relationship as a vehicle for restoring and protecting the child’s mental health. Treatment also focuses on contextual factors that may affect the caregiver-child relationship (e.g., culture and socioeconomic and immigration related stressors). Targets of the intervention include caregivers’ and children’s maladaptive representations of themselves and each other and interactions and behaviors that interfere with the child’s mental health. Over the course of treatment, caregiver and child are guided to create a joint narrative of the psychological traumatic event and identify and address traumatic triggers that generate dysregulated behaviors and affect.

Essential Components

  • Focus on the parent-child relationship as the primary target of intervention.
  • Focus on safety: a) Focus on safety issues in the environment as needed; b) Promote safe behavior; c) Legitimize feelings while highlighting the need for safe/appropriate behavior; d) Foster appropriate limit setting; e) Help establish appropriate parent-child roles.
  • Affect regulation: a) Provide developmental guidance regarding how children regulate affect and emotional reactions; b) Support and label affective experiences; c) Foster parent's ability to respond in helpful, soothing ways when child is upset; d) Foster child's ability to use parent as a secure base; e) Develop/foster strategies for regulating affect.
  • Reciprocity in Relationships: a) Highlight parent's and child's love and understanding for each other; b) Support expression of positive and negative feelings for important people; c) Foster ability to understand the other's perspective; d) Talk about ways that parent and child are different and autonomous; e) Develop interventions to change maladaptive patterns of interactions.
  • Focus on the traumatic event: a) Help parent acknowledge what child has witnessed and remembered; b) Help parent and child understand each other's reality with regards to the trauma; c) Provide developmental guidance acknowledging response to trauma; d) Make linkages between past experiences and current thoughts, feelings, and behaviors; e) Help parent understand link between her own experiences and current feelings and parenting practices; f) Highlight the difference between past and present circumstances; g) Support parent and child in creating a joint narrative; h) Reinforce behaviors that help parent and child master the trauma and gain a new perspective.
  • Continuity of Daily Living: a) Foster prosocial, adaptive behavior; b) Foster efforts to engage in appropriate activities; c) Foster development of a daily predictable routine.
  • Reflective supervision

Child Component

Child-Parent Psychotherapy (CPP) was designed with a child component that addresses the following presenting problems and symptoms:

  • Exposure to trauma, internalizing and externalizing symptoms, and/or symptoms of posttraumatic stress disorder (PTSD).

Age range: 0 – 5

Developmental Delays:

This program was not developed for children with developmental delays, and has not been tested for children with developmental delays.

Parent / Caregiver Component

Child-Parent Psychotherapy (CPP) was designed with a parent/caregiver component that addresses the following presenting problems and symptoms:

  • Negative attributions about the child, problems in the parent-child relationship, and maladaptive parenting strategies. In addition, when appropriate, the program targets parental symptoms including PTSD symptoms (avoidance, intrusion, and hyperarousal), depression, and anxiety.

Group Format

Child-Parent Psychotherapy (CPP) was not designed to be conducted in a group setting, and has not been tested for use in a group setting.

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Community Agency
  • Foster Home
  • Outpatient Clinic
  • School

Homework

This program does not include a homework component.

Languages

Child-Parent Psychotherapy (CPP) does not have materials available in a language other than English.

Resources Needed to Run Program

The typical resources for implementing the program are:

No specific room requirements are needed as the program is often implemented through a home-visiting model.

Minimum Provider Qualifications

  • Practitioners: Master's level training.
  • Supervisors: Master's degree plus minimum of 1 year training in the model.

Education and Training Resources

There is a manual that describes how to implement this program, and there is training available for this program.

Training Contact:
Training is obtained:

There are a number of different training models. Training occurs can be arranged through the Child Trauma Research Program by contacting the individual above. Training also occurs through the Learning Collaborative model of the National Child Traumatic Stress Network. In general, training is tailored to the needs of the organization.

Number of days/hours:

Typically training involves an initial 3-day workshop and then quarterly (3 more times in a year) 2-day additional workshops. In addition, training involves bi-monthly telephone-based case consultation of ongoing treatment cases involving children aged 0-5 who have experienced a trauma.

Implementation Information

Since Child-Parent Psychotherapy (CPP) is highly rated on the Scientific Rating Scale, information was requested from the program representative on available pre-implementation assessments, implementation tools, and/or fidelity measures.

Show implementation information...

Pre-Implementation Assessments

To be given to organizations or providers in order to measure organizational or individual readiness:

The Organizational Readiness and Capacity Assessment is a 29-item questionnaire designed to help agencies evaluate their readiness to implement evidence-based practices like CPP.

Implementation Tools — for the program (e.g., implementation guides or manuals)

There is a manual for child-parent psychotherapy. It is published by Zero to Three Press under the title Don't hit my mommy!: A manual for child-parent psychotherapy with young witnesses of family violence (Lieberman, A. F., & Van Horn, P.). There is another book that describes the modality in more depth that was published in 2008 by Guilford Press. Lieberman, A. F., & Van Horn, P: Psychotherapy with infants and young children: Repairing the effects of stress and trauma on early attachment.

Fidelity Measures

Relevant Published, Peer-Reviewed Research

This program is rated a "2 - Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least one rigorous randomized controlled trial with a sustained effect of at least 6 months. Please see the Scientific Rating Scale for more information.

Child Welfare Outcomes: Safety and Child/Family Well-Being

Show relevant research...

Lieberman, A. F., Weston, D. R., & Pawl, J. H. (1991). Preventive interaction and outcome with anxiously attached dyads. Child Development, 62, 199-209.

Type of Study: Randomized controlled trial
Number of Participants: Intervention: 34; Anxious control: 25; Secure control: 34

Population:

  • Age range — 11 to 14 months at baseline
  • Race/Ethnicity — Recent immigrants from Mexico and Central America
  • Gender — Not Specified
  • Status — Low SES mothers recruited from pediatric clinics.

Location / Institution: California

Summary: (To include comparison groups, outcomes, measures, notable limitations)
After initial assessment using the Strange Situation, the Maternal Attitude Scale and the Life Event Inventory, which measures levels of potentially stressful events. Mother-infant pairs who were anxiously attached were assigned to an intervention group and a non-intervention control group. A second control group was also formed, consisting of pairs who were found at baseline to be securely attached. At 24 months, the measures used at baseline were re-administered. The observational measure at this phase was a longer version of the Strange Situation. Intervention group pairs had higher scores in empathic responsiveness and goal-corrected partnership and lower scores on angry behavior by the child than anxious control pairs. However, the intervention group did not differ from the anxious group on attachment security, although intervention children were less likely to show proximity avoidance and contact resistance. Both groups improved in maternal child-rearing attitudes over time. Although the secure control group still had higher secure attachment scores at the follow-up, the intervention and secure control groups did not differ significantly on other outcomes at 24 months.

Length of post-intervention follow-up: None.

Cicchetti, D., Toth, S. L., & Rogosch, F. A. (1999). The efficacy of toddler-parent psychotherapy to increase attachment security in off-spring of depressed mothers. Attachment & Human Development, 1(1), 34-66.

Type of Study: Randomized controlled trial
Number of Participants: 63 depressed mothers and 45 non-depressed control mothers

Population:

  • Age range — Average of 20.4 months at baseline
  • Race/Ethnicity — Not Specified
  • Gender — Not Specified
  • Status — Depressed mothers recruited through media and referrals from mental health professionals.

Location / Institution: Unknown

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Depressed mothers of young children were randomly assigned to receive the intervention or to a no-intervention control group. There was also a second control group of mothers from the same community who did not have any prior diagnosis of a mental disorder. At baseline the Diagnostic Interview Schedule (DIS-III-R) and the Beck Depression Inventory (BDI) were administered. Mothers were also asked to observe their child for two weeks and then complete the Attachment Q-set (AQS), which was used to assess the child's attachment behavior. At the end of the intervention, when the children were at 36 months, attachment was assessed again. Both the intervention and depressed control groups had had a higher proportion of insecurely attached children than the non-depressed control at baseline. At follow-up, the intervention group's proportion of insecurely attached children had decreased to the point that it was no longer significantly different from that of the non-depressed group, while the depressed control group experienced and increase in insecure attachment. This study is somewhat limited by the decision to omit mothers from low socioeconomic groups and the use of a more subjective method of classifying children's attachment.

Length of post-intervention follow-up: None.

Cicchetti, D., Rogosch, F. A., & Toth, S. L. (2000). The efficacy Toddler-Parent Psychotherapy for fostering cognitive development in offspring of depressed mothers. Journal of Abnormal Child Psychology, 28(2), 135-148.

Type of Study: Randomized controlled trial
Number of Participants: 158 mothers and toddlers

Population:

  • Age range — 20.47 months, on average
  • Race/Ethnicity — 92.4% Caucasian
  • Gender — Not Specified
  • Status — Mothers of non-low socioeconomic status recruited through mental health professionals, and the media.

Location / Institution: Not Specified

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study includes participants from the sample described in Cicchetti at al., 1999. Mothers with a history of depressive disorder were recruited and randomly assigned to either the intervention (DI group) or a non-intervention group (DC group). In addition, a control group of mothers with no history of psychiatric disorder was created by directly contacting families living in the same vicinity (NC group). Mothers were assessed using the Diagnostic Interview Schedule (DIS-III-R) and the Beck Depression Inventory (BDI). Children were assessed with the Bayley Mental Development Index (MDI) and the Wechsler Preschool and Primary Scales of Intelligence (WPPSI-R). Mothers and children in the intervention group received Toddler Parent Psychotherapy. Although there were no differences in child intelligence across groups at baseline, children in the DC group showed a decline, particularly if their mothers had a subsequent depressive episode.

Length of post-intervention follow-up: None.

Toth, S. L., Maughan, A., Manly, J. T., Spagnola, M., & Cicchetti, D. (2002). The relative efficacy of two interventions in altering maltreated preschool children's representational models: Implications for attachment theory. Development and Psychopathology, 14, 877-908.

Type of Study: Randomized controlled trial
Number of Participants: 122 mothers and their preschool children

Population:

  • Age range — 4-5 years
  • Race/Ethnicity — Unknown
  • Gender — Not Specified
  • Status — Families with a documented history of maltreatment recruited from the Department of Social Services.

Location / Institution: Unknown

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Mothers of families with history of maltreatment and their children were randomly assigned the Parent Preschooler Psychotherapy (PPP), psychoeducational home visitation (PHV), or community standard (CS) groups. A comparison group of low-income mothers and children with no history of maltreatment was also included. At baseline and follow-up children were administered narrative story-stems to complete, which measured perceptions of parent-child relationships, parenting behavior, socio-emotional development, and behavioral adaptation. Intelligence was also assessed, using the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-R). Results showed that the PPP children showed reductions in problematic maternal representations compared to PHV group children and greater reductions in negative self-representations compared to all other groups. Mother child-relationship expectations also became more positive than for non-maltreatment control and PHV groups.

Length of post-intervention follow-up: None.

Lieberman, A. F., Van Horn, P., & Ghosh Ippen, C. (2005). Toward evidence-based treatment: Child-Parent Psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44(12), 1241-1448

Type of Study: Randomized controlled trial
Number of Participants: 75 mother child pairs

Population:

  • Age range — 3-5
  • Race/Ethnicity — Mothers: 37.3% Latina, 24% White, 14.7% African American, 10.7% Asian, 13.3% mixed or other.
  • Gender — Not Specified
  • Status — Referred by court, CPS or other community services after child witnessed marital violence.

Location / Institution: California

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Participants were randomly assigned to either the Child Parent Psychotherapy (CPP) treatment group or to a comparison group receiving case management and referral to individual treatment in the community for mother and child. For the children the Child's Exposure to Community Violence: Parent Report Version, the Child Behavior Checklist (CBCL) were completed by parents. Clinicians also interviewed parents using the Semistructured Interview for Diagnostic Classification DC: 0-3 for Clinicians, which assesses traumatic stress disorder (TSD). Mothers completed the Life Stressor Checklist, the Clinician Administered PTSD Scale, and the Symptoms Checklist-90, which is a measure of psychiatric symptoms. Treatment was conducted over 50 weeks. CPP group children showed a significant decline in TSD symptoms and behavior problems at the conclusion of the study, while comparison group children did not. Mothers in the CPP group showed significant reductions in avoidant symptoms and there was a moderate effect on general distress and PTSD symptoms. Limitations include a small sample and reliance on maternal report.

Length of post-intervention follow-up: 6 months.

Cicchetti, D., Rogosh, F. A., & Toth, S. L. (2006). Fostering secure attachment in infants in maltreating families through preventive interventions. Development and Psychopathology, 18, 623-649.

Type of Study: Randomized controlled trial
Number of Participants: 137 mother-child pairs from maltreating families, 52 pairs from non-maltreating families.

Population:

  • Age range — 13.3 months on average at baseline
  • Race/Ethnicity — 74.1% minority on average
  • Gender — Not Specified
  • Status — Infants and their mothers in maltreating families recruited through Department of Human Services (DHS) liaison. A comparable control group was recruited through the Temporary Assistance to Needy Families (TANF) rolls.

Location / Institution: Not Specified

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Participants from maltreating families were randomly assigned to receive infant parent psychotherapy (IPP), a psychoeducational parenting intervention (PPI), or to a community standards control group (CS). An additional comparison group from low-income non-maltreating families was also included (NC). Assessments of mothers’ past experiences included the Childhood Trauma Questionnaire (CTQ) and the Perceptions of Adult Attachment Scale (PAAS). Observers also completed the Maternal Behavior Q-Set (MBQ) for mother-child interactions at baseline and follow-up and interviewed mothers using the Adult-Adolescent Parenting Inventory (AAPI), the Social Support Behaviors Scale (SSBS), and the Parenting Stress Inventory (PSI). Finally, the Strange Situation was conducted to assess attachment at baseline and follow-up. At baseline, infants in the maltreatment groups showed higher levels of disorganized attachment. At post-intervention, children in the IPP and PPI groups showed significant increases in levels of secure attachment, relative to the CS and NC groups.

Length of post-intervention follow-up: None.

Lieberman, A. F., Ghosh Ippen, C., & Van Horn, P. (2006). Child-Parent Psychotherapy: 6-month follow-up of a randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 45(8), 913-918.

Type of Study: Randomized controlled trial
Number of Participants: 59 mother-child pairs

Population:

  • Age range — 3-5 years
  • Race/Ethnicity — Mothers: 37.3% Latina, 24% White, 14.7% African American, 10.7% Asian, 13.3% mixed or other.
  • Gender — Not Specified
  • Status — Referred by court, CPS or other community services after child witnessed marital violence.

Location / Institution: California

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study uses the same sample as Lieberman, et al. (2005). Participants were randomly assigned to either the Child Parent Psychotherapy (CPP) treatment group or to a comparison group receiving case management and referral to individual treatment in the community for mother and child. Children's functioning was assessed using the Child Behavior Checklist (CBCL) and maternal symptoms of emotional distress were assessed using the Global Severity Index (GSI). In a comparison of baseline and 6-month follow-up scores, the CPP treatment children showed significant reductions in problems behaviors while the control group did not. Similarly, only the CPP group mothers showed a significant improvement in distress levels at 6 months. Limitations include small sample size and reliance on maternal report.

Length of post-intervention follow-up: These data are six-month follow-up data. There was no further follow-up.

Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D. (2006). The efficacy of toddler-parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder: A randomized preventive trial. Journal of Consulting and Clinical Psychology, 74(6), 1006-1016.

Type of Study: Randomized controlled trial
Number of Participants: 130 depressed mothers, 68 non-depressed mothers

Population:

  • Age range — 20.34 months on average
  • Race/Ethnicity — Not Specified
  • Gender — Not Specified
  • Status — Mothers of non-low socioeconomic status recruited through mental health professionals, and the media.

Location / Institution: Not Specified

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study includes participants from the sample described in Cicchetti at al., 1999. Mothers meeting the diagnostic criteria for depression were randomly assigned to the intervention (DI) or the non-intervention (DC) groups. A control group of non-depressed mothers (NC) was also created by directly contacting families. Mothers were assessed with the Diagnostic Interview Schedule (DIS-III-R) and the Beck Depression Inventory (BDI). Mother infant pairs also participated in the Strange Situation at baseline and follow-up to measure attachment. Both groups with depressed mothers showed insecure attachment at baseline. Post-intervention, rates of secure attachment in the DI group was higher than both the NC and DC groups.

Length of post-intervention follow-up: None.

References

Lieberman, A. F., Compton, N. C., Van Horn, P., & Ghosh Ippen, C. (2003). Losing a parent to death in the early years: Guidelines for the treatment of traumatic bereavement in infancy. Washington D.C.: Zero to Three Press.

Lieberman, A. F., & Van Horn, P. (2004). Don't hit my mommy: A manual for child parent psychotherapy with young witnesses of family violence. Zero to Three Press: Washington, D.C.

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: The Guilford Press.

Contact Information

Name: Chandra Ghosh Ippen, PhD
Agency/Affiliation: University of California, San Francisco
Department: Child Trauma Research Program
Email:
Phone: (415) 206-5312
Fax: (415) 206-5328

Date Reviewed: December 2009 (originally reviewed in May 2006)