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Child-Parent Psychotherapy

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Evidence rating: 3+
Cost rating: NA

Child-Parent Psychotherapy (CPP) is a psychoanalytic intervention targeting mothers and preschool children (aged three to five) who may have experienced trauma or abuse (eg domestic violence), or are otherwise at risk of an insecure attachment and/or other behavioural and emotional problems.

Specifically, CPP aims to improve children’s representations of their relationship with their parent and reduce maternal and child symptoms of psychopathology.

Mothers and their child attend weekly sessions for a period of 12 months or longer. The sessions are delivered by practitioners with a Masters (or higher) qualification in psychology or social work. During each session, the practitioner uses empathic, non-didactic support to help the mother reflect on her childhood experiences and differentiate them from her current relationship with her child. 

Parent sessions are interspersed with sessions involving the child where the mother, therapist and child jointly engage in structured play aimed at eliciting trauma-related feelings and behaviours. This allows the therapist to help the mother and child develop a joint narrative around the traumatic events and bring them to their resolution. Mothers also receive support in appropriate discipline and an increased awareness of their child’s moods and emotional states.

Please note that this Guidebook page describes the evidence for a specific programme that makes use of psychotherapy.  It does not describe the evidence for psychotherapy with children as a broader practice.

EIF Programme Assessment

Evidence rating: 3+
Level 3 indicates evidence of efficacy. This means the programme can be described as evidence-based: it has evidence from at least one rigorously conducted RCT or QED demonstrating a statistically significant positive impact on at least one child outcome. This programme does not receive a rating of 4 as it has not yet replicated its results in another rigorously conducted study, where at least one study indicates long-term impacts, and at least one uses measures independent of study participants.
Cost rating: NA

Not available

What does the plus mean?

The plus rating indicates that this programme has evidence from at least one level 3 study, along with evidence from other studies rated 2 or better.

Child outcomes

This programme can affect outcomes for children in Active and healthy, physical and mental wellbeing.

According to the best available evidence for this programme's impact, it can achieve the following positive outcomes for children:

Supporting children's mental health and wellbeing

Improved representations of the mother-child relationship

based on study 1

Improved expectations of the mother-child relationship

based on study 1

Reduced traumatic stress disorder symptoms

based on study 2

  • Statement: 2.29-point improvement on the semistructured interview for diagnostic classification
  • Score: 24
  • Timeframe: Immediately after the intervention

Preventing crime, violence and antisocial behaviour

Improved child behaviour

based on study 2

  • Statement: 2.38-point improvement on the Child Behaviour Checklist
  • Score: 9
  • Timeframe: Immediately after the intervention
  • Statement: 4-point improvement on the Child Behaviour Checklist
  • Score: 16
  • Timeframe: 6 months later

This programme also has evidence of supporting positive outcomes for couples, parents or families that may be relevant to a commissioning decision. Please see About the evidence for more detail.

Who is it for?

The best available evidence for this programme relates to the following age-groups:

Preschool

How is it delivered?

The best available evidence for this programme relates to implementation through these delivery models:

  • Individual

Where is it delivered?

The best available evidence for this programme relates to its implementation in these settings:

  • Home
  • Children's centre or early-years setting
  • Primary school
  • Secondary school
  • Sixth-form or FE college
  • Community centre
  • In-patient health setting
  • Out-patient health setting

How is it targeted?

The best available evidence for this programme relates to its implementation as:

  • Targeted indicated

Where has it been implemented?

  • United Kingdom
  • United States

Ireland provision

This programme has not been implemented in Ireland.

Ireland evaluation

This programme’s best evidence does not include evaluation conducted in Ireland.

About the programme

What happens during the delivery?

How is it delivered?

  • CPP is delivered in 32 sessions of approximately 1 to 1.5 hours’ duration each by one clinical practitioner with QCF-7/8 qualifications (and 92 hours of programme training).

What happens during the intervention?

  • CPP is delivered by a practitioner with a Masters (or higher) qualification in psychology or social work.  Mothers and their child attend weekly sessions for a period of 12 months or longer.
  • During each session, the practitioner uses empathic, non-didactic support to help the mother reflect on her childhood experiences and differentiate them from her current relationship with her child.
  • Parent sessions are interspersed with sessions involving the child, where the mother, therapist and child jointly engage in structured play aimed at eliciting trauma related feelings and behaviours. This allows the therapist to help the mother and child develop a joint narrative around the traumatic events and bring them to their resolution.
  • Mothers also receive support in appropriate discipline and an increased awareness of their child’s moods and emotional states.

What are the implementation requirements?

Who can deliver it?

  • The practitioner who delivers this programme is a Masters level clinical practitioner with NFQ-9/10 qualification.


What are the training requirements?

  • The practitioners have 92 hours of programme training (seven days' face-to-face training with 36 hours of phone consultation). Booster training of practitioners is recommended.

How are the practitioners supervised?

  • Practitioners are supervised by one host-agency supervisor with NFQ-level 9/10, who provides clinical, skills and case-management supervision.


What are the systems for maintaining fidelity?


Is there a licensing requirement?

There is no licence required to run this programme.


How does it work? (Theory of Change)

How does it work?

  • Positive and sensitive parent/child interactions increase the likelihood of a secure parent/child attachment relationship.
  • Parents experiencing multiple hardships and/or an insecure attachment relationship in their own childhood are less likely to develop positive representations of their child, reducing their ability to respond sensitively and appropriately to their child’s behaviour.
  • Parents receive therapeutic support to improve their ability to form positive representations of their child and provide an appropriately nurturing and sensitive caregiving environment.
  • In the short term, parents develop positive representations of their child, their sensitivity increases and the child experiences greater attachment security.
  • In the longer term, children will develop positive expectations of themselves and others, demonstrate improved mental health and be at a reduced risk of child maltreatment.

Intended outcomes


Contact details

Chandra Ghosh
University of California San Francisco
chandra.ghosh@ucsf.edu
www.ucsf.edu/

NSPCC
infantmentalhealth@nspcc.org.uk
https://learning.nspcc.org.uk/services-children-families/infant-and-family-teams/


About the evidence

CPP’s most rigorous evidence comes from two RCTs, both of which were conducted in the USA.

These studies identified statistically significant positive impact on a number of child and parent outcomes.

This programme has evidence from at least one rigorously conducted RCT along with evidence from an additional comparison group study.  Consequently, the programme receives a 3+ rating overall.

Study 1

Citation:Toth et al (2002)
Design:RCT
Country:United States
Sample:155 mother-child (aged four) pairs, 112 where there was a known incident of child maltreatment
Timing:Approximately 1 and 3 years after baseline evaluation
Child outcomes:
  • Improved representations of the mother-child relationship
  • Improved expectations of the mother-child relationship
Other outcomes:
    Study rating:2+

    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.

    Available at
    http://europepmc.org/abstract/med/12549708

    Study design and sample

    The first study is an RCT.  

    This study involved random assignment of families to CPP treatment, psychoeducational home visiting intervention (PHV), and community standard (CS) control condition. 

    This study was conducted in the US, with a sample of 155 mothers and their preschoolers. During baseline, the children were approximately 4 years of age (M = 48.18 months, SD = 6.88). The majority of children in all groups were from minority ethnicities while the majority of the mothers in all groups were not married. 

    Measures

    Children’s maternal and self-representations and expectations of the mother-child relationship were measured using narrative story-stems selected from the MacArthur Story Stem Battery (MSSB) and the Attachment Story Completion Task (ASCT) ( diagnostic interview).

    Intelligence was measured using the abbreviated version of the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-R) (achievement test)

    Findings

    This study identified statistically significant positive impact on a number of child outcomes.

    This includes:

    • Improved representations of the mother-child relationship
    • Improved expectations of the mother-child relationship

    The conclusions that can be drawn from this study are limited by methodological issues pertaining to a lack of intention-to-treat analysis, hence why a higher rating is not achieved.

    Study 2

    Citation:Lieberman et al (2005); Lieberman et al (2006); Ghosh et al (2011)
    Design:RCT
    Country:United States
    Sample:75 mother-child (aged three to five) pairs who have witnessed trauma or domestic violence
    Timing:Post-test; 6 month follow-up
    Child outcomes:
    • Reduced traumatic stress disorder symptoms
    • Improved child behaviour
    Other outcomes:
    • Reduced symptoms of PTSD
    • Reduced symptoms of PTSD (maintained for high-risk group at six-month follow-up)
    • Reduced depressive symptoms (maintained for high-risk group at six-month follow-up)
    Study rating:3

    Lieberman, A.F., van Horn, P., & Ghosh Ippen, C. (2005).  Toward evidence-based treatment:  Child-parent psychotherapy with pre-schoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1241-1248.

    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, 913- 918.

    Ghosh Ippen, C., Harris, W.W., Van Horn, P. l., & Lieberman, A.F. (2011). Traumatic and stressful events in early childhood:  Can treatment help those at highest risk? Child Abuse and Neglect, 35, 504 -513.

    Available at
    http://www.jaacap.com/article/S0890-8567(09)62235-8/fulltext?refuid=S0890-8567(10)00082-1&refissn=0890-8567&mobileUi=0
    http://www.jaacap.com/article/S0890-8567(09)61891-8/abstract
    http://www.sciencedirect.com/science/article/pii/S0145213411001499

    Study design and sample

    The second study is a rigorously conducted RCT.  

    This study involved random assignment of families to a CPP treatment group and families to a case management plus individual therapy group, respectively.

    This study was conducted in the US, with a sample of 65 children and their mothers. The children were between 3 to 5 years of age. More than a third (38.7%) of the children had mixed ethnicity (predominantly Latino/White). Further, 41% of the families had incomes below the federal poverty level. 

    Measures

    Child trauma symptomatology was measured using the Semistructured Interview for Diagnostic Classification DC: 0-3 for trauma stress disorder (DSC 0-3 TSD) (diagnostic interview). Child behaviour was measured using the total Child Behaviour Checklist (CBCL) score (parent report). 

    Maternal reexperiencing, avoidance, and hyperarousal symptoms were measured using the Clinician-Administered PTSD Scale (CAPS) (diagnostic interview). Maternal current psychiatric symptoms were measured using the Symptoms Checklist-90 Revised (SCL-R-90) (parent report)

    Findings

    This study identified statistically significant positive impact on a number of child and parent outcomes.

    Child outcomes include:

    • Reduced PTSD symptoms
    • Improved behaviour
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