Child–Parent Psychotherapy (CPP) is a dyadic, relationship-based treatment for parents and young children, which aims to help 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. The treatment is also known as Infant–Parent Psychotherapy (IPP), which is an adaption for infants, and Child–Parent Psychotherapy for Family Violence, which is available for families who experience multiple forms of familial violence.
Originally designed to use with parents and children who witness domestic violence, CPP and IPP are 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.
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 is to provide individual sessions 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.
Lieberman, Van Horn, and Ippen (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 included 39 girls, 36 boys, and their mothers who were referred to treatment because of clinical concerns after the child witnessed or overheard marital violence. Children and mothers were eligible for the study if the child was 3 to 5 years old, if marital violence was confirmed by the mother’s report on the Conflict Tactics Scale 2, and if the perpetrator was not living in the home. Mothers were ineligible if there was documented abuse of the target child, current substance abuse and homelessness, mental retardation, or 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 or a comparison group that received monthly case management plus referrals for individual treatment in the community for the mother and child.
Study participants who were randomly assigned to CPP treatment received weekly child–mother sessions that each lasted about 60 minutes and were held over the course of 50 weeks. Treatment fidelity was monitored through intensive weekly supervision that included a review of process notes and case conferences. Participants who were randomly assigned to the comparison group received case management and information about mental health clinics, and they were connected to the clinics of their choice. Case managers contacted the mothers through monthly phone calls, and mothers could contact their case managers whenever necessary. Case managers also helped secure needed services, inquired about the well-being of the mother and child, asked about any life changes, and intervened during crises. The calls generally lasted about 30 minutes. Face-to-face meetings were scheduled when indicated.
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 another ethnicity, while the sample of mothers was 37.3 percent Latina, 24 percent white, 14.7 percent African American, 10.7 percent Asian, and the rest mixed ethnicities. The treatment and comparison groups were not statistically significant on demographic variables, dependent variables, or trauma exposure at intake.
Mothers and children were assessed at intake, at 6 months into treatment, and at the conclusion of treatment. Measures of child symptomatology and functioning included
· 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 stress-related behavior not represented in the internalizing and externalizing scales (such as 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 mother symptomatology included
· Life Stressor Checklist—Revised, which inquired about the lifetime incidence of very distressing events of the mothers, including specific stressors that are found to be 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.
· Clinician-Administered PTSD Scale (CAPS) is a semistructured interview that provided a PTSD diagnosis and total intensity and frequency scores for re-experiencing, avoidance, and hyperarousal symptoms.
The study used a general linear model repeated-measures procedure for each dependent variable with group (CPP versus comparison) as the between-subject variable and time (intake versus posttreatment) as the within-subject variable. Cases that had any missing data were deleted listwise for each analysis. Significant group x time interactions indicated treatment effects and were followed with repeated-measures analyses within each group to determine whether significant change occurred in both groups. Analyses of the treatment outcome included the 66 child–mother dyads that completed the outcome assessment. The original 76 dyads were included in the intent-to-treat analyses.
Lieberman, Van Horn, and Ippen (2005) found significant differences on measures of child functioning and maternal symptoms between the treatment group that received Child–Parent Psychotherapy (CPP) and the comparison group.
Children in the CPP group had a significant reduction in the number of traumatic stress disorder (TSD) symptoms from intake to posttreatment, whereas the comparison group did not. The CPP group also showed significant reduction in behavior problems from intake to posttreatment as measured by the Child Behavioral Checklist Total scores.
The clinical significance of treatment effects was measured by comparing the percentage of children in each group who met the criteria for a diagnosis of TSD. At intake, there was no group difference (50 percent of children in the CPP group and 39 percent of the children in the comparison group met the criteria). At posttest, there was a statistically significant difference between the groups. Only 6 percent of the children in the CPP group met the criteria for TSD, whereas 36 percent of the children in the comparison group met the criteria.
Scores from the CAPS showed a significant reduction in avoidance symptoms for mothers in the CPP group only. However, there were no significant treatment effects found for re-experiencing and hyperarousal symptoms. The total CAPS scores showed a significant reduction from intake to posttreatment for mothers in both the CPP and comparison groups. Analysis of the Global Severity Index scores, which is considered the best single indicator of current distress, showed that mothers in the CPP group showed a significant reduction, whereas the comparison group showed a trend in this direction but it was not statistically significant.
The clinical significance of treatment was determined by comparing the percentage of mothers in each group who were diagnosed with PTSD. At intake, there was no difference between the groups (47 percent of mothers in the CPP group and 46 percent of mothers in the comparison group met the PTSD criteria). At posttest, there was a decline in PTSD diagnosis for mothers in both groups. Twelve percent of CPP mothers and 27 percent of comparison mothers met the PTSD criteria. The difference was not statistically significant.
Intent-to-treat analyses—in which scores from intake or 6-months were used in place of missing posttest scores—resulted in similar results as those described above for both children and mothers.