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The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
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Core Components
Child Parent Psychotherapy (CPP) as described by Liberman, is a trauma focussed intervention for children aged birth to 5 years and their parents. The programme is delivered by an individual practitioner meeting with the parent-child dyad, on a weekly basis for between 20 and 32 weeks or more. The programme is clearly operationalised through extensive training and programme manual. The intervention has three phases focusing on (a) assessment and engagement, (b) intervention, and (c) ending. Within each phase there are clearly defined strategies that tailored to the specific dyad. The foundation phase includes assessment of both the child’s and parent’s experiences of trauma and how this related to current concerns. CPP has six primary intervention strategies.
Promoting developmental progress thorough play, physical contact and language
Offering unstructured reflective developmental guidance
Modelling appropriate protective behaviours
Interpreting feelings and actions
Providing emotional support and empathic communication
Providing crisis intervention, case management and concrete assistance with problems of living, such as poor housing.
CPP is typically delivered by individual practitioners working in teams specialising in the intervention.
Fidelity
Child Parent Psychotherapy has extensive fidelity assessments for each phase of treatment. CPP measures six stands of fidelity which includes process and theoretical components as well as content and procedural components. The fidelity measures incorporate the reflections of the clinician and views of supervisor.
Modifiable Components
Child Parent Psychotherapy is a tailored intervention, responding to the needs and issues of the parent-child dyad, within the framework of the intervention. CPP can be delivered either in the clinic or as a home-visiting model. For each dyad, practitioners are directed to consider the cultural context and values of the family.
Child Parent Psychotherapy was developed by the Child Trauma Research Program, USCF-Zuckerberg San Francisco General Hospital and Trauma Centre, US. UCSF-Zuckerberg San Francisco General Hospital and Trauma Center UCSF-Zuckerberg San Francisco General Hospital and Trauma Center Training is offered in conjunction with National Child Traumatic Stress Network.
Support for Organisation / Practice
Implementation Support
Child Parent Psychotherapy have a comprehensive programme of support for systems and agencies considering undergoing training. The overall process from exploring readiness to having a sustainable site is intense, and training component takes 18 months. Prospective CPP sites are required to consider their ability to implement and sustain delivery of CPP. This process is supported by a number of tools including an agency readiness tool and budgetary tools. Once there is agreement to train a system or agency, a learning collaborative is established.
Licence Requirements
Child Parent Psychotherapy does not licence practitioners. However, on successful competition of training, appropriately qualified mental health professionals can apply to be on the CPP roster.
Start-up Costs
Child Parent Psychotherapy advises to establish a two-year budget to support the initial implementation of CPP. Training is delivered by approved trainers and day and hourly rates are not set centrally. A budgeting tool is provided, as costs are dependent on the size of the learning collaborative, number of trainers required, and any further training and support requested. Minimum costs include 7 days of face to face training, 36 hours of consult calls, training books/manuals at approx. £20 each and travel and subsistence for trainers.
Building Staff Competency
Qualifications Required
Clinical team members must be masters or doctoral-level psychotherapists with a degree in a mental health disciplinePractitioners need to be qualified and registered mental health professionals. Practitioners are typically psychotherapists, clinical psychologists and social workers.
Training Requirements
Availability of training is limited. Training is delivered through the establishment of a learning collaborative, where an agency team is established and trained together. The minimum team size is 3 clinicians plus a supervisor. The supervisor can undertake training along side their team. Larger teams are recommended to support sustainability. Individual training places are not generally available. CPP is based in San Francisco, US, however international training is available.
Training last 18 months , and is comprised of :
1. Didactics (18 hour minimum) 2. Read CPP manual 3. Conduct CPP
2 cases for Supervisor Participants; 4 cases for Clinician Participants
4. Reflective CPP supervision within the agency 5. Ongoing consultation calls 6. Case presentation 7. Intensive CPP competency building workshops 8. Fidelity monitoring
(a) 3 days of dida ctic teaching (b) self-directed study of manuals, (c) undertaking CPP training cases (d) participat ion in weekly reflective supervision provided by local agency , (e) participat ion in twic e-monthly consult call s with CPP trainer (f) case presentation (g) 4 day s of intensive CPP competency building workshops and (h) fidelity monitoring.
Supervision Requirements
Weekly supervision is a requirement of delivering CPP. As part of establishing a learning collaborative, agencies identify suitably qualified and experienced clinicians to undergo training to be a local supervisor. CPP offers supervisor calls to support new supervisors, at additional cost.
Theory of Change
Child Parent Psychotherapy has a clearly articulated logic model. CPP integrates psychoanalytic, attachment and developmental psychopathy perspectives. It uses a trauma framework to guide the intervention. This framework views frightening and traumatic events as causing strong emotions of fear and anger. In turn, the child and parents may express these emotions though aggression, dysregulation and withdrawal. The intervention delivered though a supportive therapeutic relationship helps the parent create a safe environment for the child, and supports the parent and child to tolerate and transform difficult emotions.
Infants and Toddlers: 0-36 months - Rating: 4+
Research Design & Number of Studies
Two randomised controlled trials investigating child parent psychotherapy with child 0-36 months, conducted by researcher external to the programme developers were identified.
Outcomes Achieved
Receiving child parent psychotherapy was associated with:
Child Outcomes
• For children of depressed mothers, significant improvements in attachment security compared with control group (Toth et al., 2006)
• For children from maltreating families, significant increase in rates of secure attachment in comparison with control (Cicchetti et al., 2006)
Key References
Cicchetti, D., Rogosch, F.A. & Toth, S.L. (2006). Fostering secure attachment in infants in maltreating families through preventive interventions. Development and Psychopathology, 18, 623-650.
Toth, S.L., Rogosch, F.A., Manly, J.T., & Cicchetti, D. (2006). The efficacy of toddler-parent psychotherapy to reorganise attachment in the young offspring of mothers with major depressive disorder: A randomized preventive trial. Journal of Consulting and Clinical Psychology, 74, 1006-1016.
Preschool: 3 to 5 years - Rating: 4
Research Design & Number of Studies
The best evidence for Child Parent Psychotherapy (CPP) as described above for children aged 3-5 years old comes from one randomised control trial conducted by the programme developers, reported in three papers (Lieberman et al, 2005; Lieberman et al, 2006; Ghosh Ippen 2011). Participants were children aged 3-5, where there was concern about the child’s behaviour or the mother’s parenting following the child witnessing or overhearing marital violence.
Outcomes Achieved
In comparison to participants receiving case management with individual treatment, Child Parent Psychotherapy was associated with:
Child Outcomes
Significant decrease in behaviour problems (Lieberman, 2005) maintained at six-month follow up (Lieberman, 2006)
Significant decrease in trauma symptoms, and significantly less likely to be diagnosed with Traumatic Stress Disorder (Lieberman, 2005).
A subgroup of children who had experienced multiple (>4) traumatic stressful events had significant decrease in behaviour problems and trauma symptoms; which was maintained at six-month follow up (Ghosh Ippen, 2011).
Parent Outcomes
Mothers showing significantly less distress at end of treatment (Lieberman, 2005) maintained at six-month follow-up (Lieberman, 2006).
Key References
Ghosh Ippen, C., Harris, WW., Van Horn, P. & Lieberman, A.F. (2011). Traumatic and stressful events in early childhood: Can treatment help those at highest risk? Child Abuse & Neglect, 35, 504– 513.
Lieberman, A. F., Van Horn, P. J., & 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, 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.
Need
Comparable Population
Child Parent Psychotherapy is targeted to young children and their parent where there has been an experience of trauma. Prospective participants need a willingness to acknowledge the impact of trauma, and an ability to commit to a potentially long-term weekly intervention. CPP has been shown to be effective with mothers with depression, and children from maltreating families.
Is this an identified population of particular concern to your organisation? Desired Outcome
CPP aims to improve reduce the impact of trauma and improve parent child relationships. Research has shown increases the rates of secure attachment for child parent dyads who have received CPP in comparison to controls.
Is this a current priority for your organisation? Do you have other existing initiatives that would be supportive of addressing this need and achieving these outcomes?
Need Score
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Fit
Values
Child Parent Psychotherapy views infants and young children as potential patients; who can be impacted both positively and negatively by their early experiences, especially the relationship with their primary caregiver. CPP requires the exploration of both the child and parent’s experience of trauma. Parents are helped to understand the impact of life events on the current difficulties, and how this links to CPP intervention.
Is this in keeping with the values and beliefs of your organisation? Priorities
Child Parent Psychotherapy focussed on infants and young children who have experienced trauma. In addition to direct therapeutic work, CPP practitioners take on the wider case management role with the families they are working with. This includes extensive liaison with other services working with the family, and may include attendance at multiagency meetings.
Is a trauma focussed intervention a current priority for your service? Is your service able to offer the case management role of CPP? Existing Initiatives
Child Parent Psychotherapy teams need to be connected to multi-agency services that support parents and very young children, including specialist adult mental health services, perinatal mental health services and child and adolescent mental health services; and primary care services such as GPs, midwives and health visitors. These services provide referrals for intervention, and onward, or concurrent input for parent and infants.
Does your service have links with this wide range of services? Are there already working relationships between adult and child services?
Fit Score
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Capacity
Workforce
Child Parent Psychotherapy is delivered by teams, established via a Learning Collaborative. CPP recommend the minimum team size is 3 clinicians with 1 supervisor. CPP practitioners require time for direct face to face contact, extensive liaison work in relation to the family, and supervision time. CPP practitioners may work with a family on a weekly basis for 20 to 32 weeks.
Does your service know the demand for the service, and have sufficient workforce to manage the intensity and duration of the intervention? Do you have professionals with prerequisite knowledge and skills to form a CPP learning collaborative? Technology Support
Child Parent Psychotherapy does not require specific technological support.
Administrative Support
Child Parent Psychotherapy teams require administrative support in supporting the CPP casework, and completion of fidelity measures.
Are you able to provide this? Financial Support
Establishing CPP will require significant investment in staff and training over at least a two-year period.
Do you have sufficient funding to establish a team?
Capacity Score
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