cpp brief research overview -...

Research Overview

Chandra Ghosh Ippen, Ph.D.Sheree Toth, Ph.D.Jody Manly, Ph.D.

Alicia. F. Lieberman, Ph.D.

Child-Parent Psychotherapy

CPP Research Overview

2

Five Randomized Controlled Trials

With trauma-exposed children

1. Preschoolers exposed to domestic violence

2. Maltreated preschoolers

3. Infants from families with a history of maltreatment

With other populations of children

4. Anxiously attached infants of Latina immigrant mothers

5. Toddlers with depressed mothers

3

Effectiveness and Dissemination Studies

Effectiveness Studies• CPP with Culturally Diverse Children in Foster Care • Dissemination of CPP in Israel

• Dissemination of CPP in Sweden

Adaptations• Perinatal CPP

4

Ethnically Diverse Families

Mixed

39%

Latino

28%

Black

15%

White

9%

Asian

7%

Other

2%

5

Latino

12%

Black

54%

White

25%

Other

9%

• Maltreated Preschoolers: 76.2% ethnic minority (predominantly Black)

• Anxiously attached infants: 100% immigrant Latina mothers

• Toddlers of Depressed Moms: 94.5% White

Biracial 14%

Latino 18%

Black 43%

White 25%

Preschoolers Exposed to DVInfants in Families with Maltreatment

Effectiveness StudyRandomized Controlled Trials

Illinois wrap-around foster care program

Presenting Concerns

6

Child Maltreatment

DomesticViolence

MaternalDepression

Anxiously Attached Latino Dyads

Lieberman, Weston, & Pawl, 1991

7

Improved Mother-Child Play Interactions(Observational Data)

CPP mothers vs. Comparison group mothers⬆ Empathic responsiveness⬆ Initiation

CPP infants vs. Comparison group infants⬆ Goal corrected partnership⬇ Anger⬇ Avoidance⬇ Resistance

8Lieberman, Weston & Pawl, 1991

Preschoolers Exposed to Domestic Violence

9

Findings: Reduced Child Trauma Symptoms

0

2

4

6

8

10

PRE POST

Child Traumatic Stress Symptoms

CPP

CT-CM

Lieberman, Van Horn, & Ghosh Ippen, 2005 10

50

39

6

36

CPP CT-CM

Traumatic Stress Disorder Diagnosis

PostPre PostPre

Group x Time: F1,59= 10.98, p < .001, d = .57 Χ21,(n = 61) = 8.43, p < .01, Φ = .37

t(32)=5.46***

Findings: Reduced Children’s Behavior Problems

54

56

58

60

62

PRE POST

Child Behavior Problems (CBCL) Pre to Post

CPP

CT-CM

11

45

50

55

60

65

PRE 6-MONTH F-UP

Child Behavior Problems (CBCL) Pre to Follow-Up

Lieberman, Van Horn, & Ghosh Ippen, 2005; Lieberman, Ghosh Ippen, & Van Horn, 2006

Group x Time: F1,61= 5.77, p < .05, d = .24 Group x Time: F1,48= 5.39, p < .05, d = .41

t(34)=2.86**t(26)=3.92***

Findings: Reduced Maternal Symptoms

12

0

5

10

15

20

25

PRE POST

Maternal PTSD Avoidance

CPP

CT-CM

Group x Time: F1,47= 5.12, p < .05, d = .38Group x Time: F1,57= 5.08, p < .05, d = .50

00.20.40.60.8

11.2

PRE 6-MONTH F-UP

Maternal Global Symptoms

Lieberman, Van Horn, & Ghosh Ippen, 2005; Lieberman, Ghosh Ippen, & Van Horn, 2006

t(33)=5.16*** t(26)=5.11***

Can Treatment Help Those at Highest Risk

13

Can Treatment Help Those at Highest Risk?

• Same participants as Preschoolers Exposed to Domestic Violence study

• Coded for Adverse Childhood Experiences (ACEs)

14

<4 ACEsCT-CM

n=18

<4 ACEsCPPn=22

4+ ACEsCT-CM

n=15

4+ ACEsCPPn=20

Ghosh Ippen, Harris, Van Horn & Lieberman, 2011

Findings: Child Trauma Symptoms

0

2

4

6

8

10

PRE POST

Child Traumatic Stress Symptoms

CPP <4

CPP 4+

CT-CM <4

CT-CM 4+

3036.4

60.9

41.2

13.3

23.5

0

55

0

10

20

30

40

50

60

70

CPP <4 CT-CM <4 CPP 4+ CT-CM 4+

Ghosh Ippen, Harris, Van Horn & Lieberman, 2011

Pre

CPP 4+ > CT-CM 4+**

Pre Pre PrePost Post

15

t(14)=2.46*, d =.66

t(17)=5.79***, d =1.79

Traumatic Stress Disorder Diagnosis

PostPost

Findings: Child Symptoms

16

Time x Txt: F1,57= 4.40, p < .05, h2=.07

Ghosh Ippen, Harris, Van Horn, & Lieberman, 2011

0

0.5

1

1.5

2

2.5

PRE POST

Child Depression

CPP <4

CPP 4+

CT-CM <4

CT-CM 4+

t(17)=3.36**, d=1.03

0

0.5

1

1.5

2

PRE POST

# Co-Occurring Diagnoses

t(17)=3.32**, d=1.12

Findings: Child Behavior Problems

45

50

55

60

65

70

PRE POST F-UP

CPP <4

CPP 4+

CT-CM <4

CT-CM 4+

17

Post: Time x Txt x TSE: F1,59= 7.41, p < .01, h2=.11Follow-Up: Time x Txt x TSE: F1,48= 8.72, p < .01, h2=.15


Pre to Post: t(18)=3.71**, d=.74

Pre to F-Up: t(14)=5.11***, d=1.69

Findings: Maternal Symptoms

18

Time x Txt: F1,55= 4.32, p < .05, h2=.07


20

30

40

50

60

PRE POST

Maternal PTSD

CPP <4

CPP 4+

CT-CM <4

CT-CM 4+

t(17)=3.26**, d=1.02

40

45

50

55

60

65

70

PRE POST F-UP

Maternal Depression

t(17)=4.39***, d=.95

t(17)=2.60*, d=.82

Post: Time x Txt: F1,57= 5.89, p < .01, h2=.09

Follow-Up: Time x Txt: F1,47= 2.92, p < .1, h2=.06

t(16)=3.13***, d=.97

t(15)=3.13**, d=.93

t(14)=3.88***, d=1.06 t(11)=5.19***, d=1.13

t(15)=2.78*, d=.86

Pre to F-UpPre to Post

Infants from Maltreating Families

19

Strengthened Attachment

20

3.10 0

32.7

60.754.5

1.9

38.6

55.6

22.7

12.2

38.3

0

10

20

30

40

50

60

70

CPP PPI CS NC

Pre Post

F-Up Pre Post F-Up

Pre

Post F-Up

Pre

Post F-Up

Pre to Post: Χ21,(3, n = 148) = 39.35***; CPP vs CS h=1.51; PPI vs CS h = 1.41; NC vs CS; h = 1.17

Cicchetti, Rogosch, & Toth, 2006; Stronach, Toth, Rogosch, & Cicchetti, 2013

Pre to F-Up: Χ21,(9, n = 145) = 33.49***; CPP more secure than CS*** and PPI*

Positive Effect on Infant Cortisol Regulation

21

• No group differences at intake• By 19 months

– MI group indistinguishable from NC

– CS group evidenced progressively lower morning cortisol

• Intervention children had cortisol levels comparable to non-maltreated children

CS

NC

MI=CPP+PPI

13 moIntake

19 moMid

26 moPost

38 moF-Up

Cicchetti, Rogosch, Toth, & Sturge-Apple, 2011

Findings: Maternal Psychological & Physiological Stress

22Toth, Sturge-Apple, Rogosch, & Cicchetti, 2015

CPP

Reduced Child Related Stress

Improvement inMaternal Cortisol

Regulation

Maltreated Preschoolers

Toth, Maughan, Manly, Spagnola, & Cicchetti, 2002

23

1

2

3

4

5

PRE POST

Maladaptive Maternal Representations

CPP

PHV

CS

NC

24

2

2.5

3

3.5

4

4.5

PRE POST

Negative Self Representations

Toth et al., 2002

CPP > NC*; CPP > CS+ CPP > PHV**; CPP>CS**, CPP>NC*

Reduced Negative Views of Self and Others

Time x Txt: F3,118= 3.13* Time x Txt: F3,118= 4.93**

t (22)=4.05*** t (22)=3.86***

2

2.5

3

3.5

4

PRE POST

Mother-Child Relationship Expectations

CPP

PHV

CS

NC

25Toth et al., 2002

CPP > NC*; CPP > PHV+

Improved Child Expectations of Relationships

Time x Txt: F3,118= 2.72*

t (22)=6.46*** t (22)=2.96** t (22)=3.20***

Toddlers of Depressed Mothers

26

Toddlers of Depressed Mothers (additional studies)

27

Improved Attachment: Change from Insecure to Secure

54.3

11.8

29.4

58.8

7.4

56

36

814.3

38.530.8 30.8

Insecure to Secure

Stable Dis Dis to Insecure

Dis to Secure

CPP DC NC

28

Insecure to Secure• CPP>DC: Χ2,(1, n = 100) = 26.58***,

h = 1.11• CPP>NC: Χ2,(1, n = 109) = 19.88***• DC and NC did not differ

Disorganized Pattern• Stability of disorganized pattern:

– DC>CPP Χ2,(1, n = 100) = 15.69*** – DC>NC Χ2,(1, n = 117) = 19.06***

• Disorganized to secure: CPP>DC– Χ2,(4, n = 55) = 14.34**

Toth, Rogosch, Manly, & Cicchetti, 2006

Findings: Maternal Depression & Cognitive Functioning

107.09

104.21

108.67

100.78

97.5

103.75

107.41

103.7

109.49

Full Scale IQ Verbal IQ Performance IQ

CPP DC NC

29

• At intake (age 20 months) no significant group differences in cognitive functioning

• At post (age 3)– No difference between CPP &

NC for Full Scale & Verbal IQ– DC Full Scale IQ < CPP & NC– DC Verbal IQ < CPP & NC


Findings: Maternal Depression & Cognitive Functioning

106103102.56

99.8

109.92107.33

97.2292.76

Full Scale IQ Verbal IQ

CPP NO MDD DC NO MDD

CPP MDD DC MDD

30

• Subsequent depressive episodes (MDD)– CPP: 27.9%– DC: 33.3%

• Children in DC group whose mothers had a subsequent depressive episode (MDD) had the lowest cognitive scores

• CPP may safeguard children’s cognitive functioning in the presence of maternal depression


Full Scale IQ Effect: F1,92= 6.50*Verbal IQ Group X MDD Effect: F1,90= 3.92*

Findings: Peer Relationships at Age 9

31Guild, Toth, Handle, Rogosch, & Cicchetti, 2017

Findings: Marital Satisfaction

95100105110115120

Mothers’ Relationship Satisfaction

CPP

DC

NC

32Peltz , Rogge, Rogosch, Cicchetti, & Toth, 2015

β=.299***

• Overall husband’s and wives relationship satisfaction declined over the 3 years.

• Higher satisfaction predicted slower rate of decline

• CPP mothers reported slight increase in relationship satisfaction

• Benefits of CPP extend beyond mother-child dyad

CPP with Culturally Diverse Children in

Foster CareWeiner, Schneider, Lyons,

2009

33

Intervention Effects

34

4

5

6

7

8

9

10

Pre Post

Black

Biracial

Latino

White

Traumatic Stress Symptoms

**

** 10

12141618202224

Pre Post

Child Strengths (lower is better)

***

Weiner, Schneider, & Lyons, 2009


35

23456789

Pre Post

Black

Biracial

Latino

White

Life Domain Functioning

***

**

*23456789

Pre Post

Behavioral/Emotional Needs

****


*

* p<.05 **p<.01 ***p<.001


012345678

Pre Post

Black

Biracial

Latino

White

36

Summary• CPP universally effective across

racial/ethnic subgroups• Significant improvement

– Black children: All domains– Biracial children: 4 of 5 domains– Latino children: 3 of 5 domains– White children: Life domain

functioning• Number of CPP sessions attended

predicted outcome (traumatic stress symptoms)

Risk Behaviors

****


* p<.05 **p<.01 ***p<.001

Placement Effects

Lyons, 2008: Similar sample• Compared to all Foster Care youth, dramatic reductions in

placement interruptions for participants.• Among comparable youth in SOC (a program which improves

stability) CPP significantly reduced all placement interruptions

37Lyons, 2008

ReferencesPreschoolers Exposed to Domestic Violence

• 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.J. (2006). Child-Parent Psychotherapy: Six month follow-up of a randomized control trial. Journal of the American Academy of Child and Adolescent Psychiatry, 45(8), 913-918.

• Ghosh Ippen, C., Harris, W.W., Van Horn, P., & 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.

38

ReferencesMaltreated Preschoolers • 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. Developmental Psychopathology, 14, 877-908.

39

ReferencesInfants from Families with a History of Maltreatment• 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.

• Stronach, Toth, Rogosch, & Cicchetti (2013). Preventive interventions and sustained attachment security in maltreated children. Development and Psychopathology, 25, 919-930.

• Cicchetti, D., Rogosch, F.A., Toth, S.L., & Sturge-Apple, M.L. (2011). Normalizing the development of cortisol regulation in maltreated infants through preventive interventions, 23, 789-800.

• Toth, S.L., Sturge-Apple, M.L., Rogosch, F.A., & Cicchetti, D. (2015). Mechanisms of change: Testing how preventative interventions impact psychological and physiological stress functioning in mothers in neglectful families, 27, 1661-1674.

40

References

Anxiously attached infants of Latina immigrant mothers• Lieberman, Weston, & Pawl (1991). Preventive intervention

and outcome with anxiously attached dyads. Child Development, 62, 199-209.

41

ReferencesToddlers with depressed mothers• Cicchetti D., Toth S.L., Rogosch F.A. (1999). The efficacy of toddler-parent

psychotherapy to increase attachment security in offspring of depressed mothers. Attachment and Human Development 1, 34-66.

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

• Toth, S. L., Rogosch, F. A., & 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.

• Peltz, J. S., Rogge, R. D., Rogosch, F. A., Cicchetti, D., & Toth, S. L. (2015, July 20). The benefits of Child-Parent Psychotherapy to marital satisfaction. Families, Systems, & Health, 33(4), 372-382.

42

References: Effectiveness and Dissemination Studies

CPP with Culturally Diverse Children in Foster care• Weiner, Schneider, & Lyons (2009). Evidence-based

treatment for trauma among culturally diverse foster care youth: Treatment retention and outcomes. Children and Youth Services Review, 31, 1199-1205.

• Lyons, J. (2008). Evidence-based trauma interventions for foster children in Illinois. Presentation to funders and stakeholders, Chicago, IL.

43

References: Effectiveness and Dissemination Studies

Dissemination of CPP in Israel• David, P., & Schiff, M. (2015). Learning from bottom-up

dissemination: Importing an evidence-based trauma intervention for infants and young children to Israel. Evaluation and Program Planning, 53, 18-24.

44

References: Adaptations

Perinatal CPP• Diaz, M., Van Horn, P.J., & Lieberman, A.F. (2008). Perinatal Child-

Parent Psychotherapy Manual. Unpublished Manual. San Francisco: University of California, San Francisco.

• Lavi, I., Gard, A.M., Hagan, M., Van Horn, P.J., & Lieberman, A.F. (2015). Child-Parent Psychotherapy examined in a perinatal sample: Depression, Posttraumatic stress symptoms and child rearing attitudes. Journal of Social and Clinical Psychology, 34(1), 64-82.

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