Intervention Summary

Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT): Empowering Families Who Are at Risk for Physical Abuse

Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT): Empowering Families Who Are at Risk for Physical Abuse is a structured treatment program for children ages 3-17 and their parents (or caregivers) in families where parents engage in a continuum of coercive parenting strategies. The target population includes families in which child physical abuse by parents has been substantiated, families that have had multiple referrals to a child protection services agency, and parents who have reported significant stress and fear that they may lose control and hurt their child. The program aims to reduce children's posttraumatic stress disorder (PTSD) symptoms, other internalizing symptoms, and behavior problems while improving parenting skills and parent-child relationships and reducing the use of corporal punishment by parents.

CPC-CBT is grounded in cognitive behavioral theory and incorporates elements (e.g., trauma narrative and processing, positive reinforcement, timeout, behavioral contracting) from empirically supported CBT models for families who have experienced sexual abuse, physical abuse, and/or domestic violence, as well as elements from motivational, family systems, trauma, and developmental theories. CPC-CBT can be delivered in either an individual or a group modality. The individual therapy program consists of 90-minute sessions, and the group therapy program (which was used in the study evaluated by NREPP) consists of 2-hour sessions. Trained clinicians deliver the CPC-CBT components in 16-20 sessions. In the first segment of each session, clinicians conduct child- and parent-only sessions concurrently. The second segment of each session involves integrated joint parent-child therapy, where families receive coaching on child behavior management strategies and alternative methods of conflict resolution. In both individual and group therapy programs, more time is allotted for the joint parent-child segments as treatment progresses. The sessions are grouped into four phases:

Engagement, which focuses on engagement, motivational interviewing, rapport building, treatment initiation, goal setting, and violence psychoeducation. Violence psychoeducation includes education for both parents and children about different types of violence, the continuum of coercive behavior, and the impact of violent behavior on children, as well as education for parents about child development and realistic expectations for children's behavior.
Skill building, which involves effective coping skills training (e.g., cognitive coping, assertiveness, relaxation, anger management, problem solving) for parents and children. These skills assist parents to remain calm while interacting with their children, to develop nonviolent problem-solving skills related to child rearing, and to develop positive parenting skills.
Safety, which involves the development of a family safety plan and a continuation of effective skills development. Other safety components are introduced across the therapy.
Clarification, which involves the clinician encouraging the children to write about or share their abusive experiences while focusing on their thoughts and feelings associated with the abuse. While the child is developing this trauma narrative, the clinician also assists parents in processing their own thoughts and feelings while writing and revising a "clarification" letter to their children to enhance their empathy for their children and to demonstrate that they take full responsibility for their abusive behavior. The clarification letter also serves to alleviate the child of blame, respond to the child's questions and/or worries, and correct the child's cognitive distortions concerning the abuse. The parents and children share the clarification letter and trauma narrative in joint segments, unless this process is contraindicated. However, in most cases, this process enhances the parent's empathy for the child and is a powerful therapeutic tool for strengthening the parent-child relationship.

Parenting skills training is provided across all phases. Parents practice implementing communication, positive parenting, and behavior management skills independently with the therapist and then with their children. The therapists coach parents and offer positive reinforcement and corrective feedback to enhance the generalization of these skills.

Descriptive Information

Areas of Interest	Mental health treatment
Outcomes	1: Children's PTSD symptoms 2: Parenting skills
Outcome Categories	Family/relationships Mental health Social functioning
Ages	6-12 (Childhood) 13-17 (Adolescent) 18-25 (Young adult) 26-55 (Adult)
Genders	Male Female
Races/Ethnicities	Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Outpatient
Geographic Locations	Urban Suburban Rural and/or frontier
Implementation History	Staff at 11 mental health agencies in the United States (Louisiana, Mississippi, New Jersey, North Carolina, and Utah) and 5 in Sweden have received extensive training and ongoing consultation in CPC-CBT and have implemented the intervention with approximately 400 families who have experienced or are at risk for physical abuse by the parent. Through a learning collaborative with the developer, three agencies have implemented CPC-CBT in the Gulf Coast region, with data being collected for clinician fidelity and client outcomes. Two pilot studies have been completed, and pilot data have been collected in Sweden in preparation for a large-scale dissemination study.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	This program has been adapted for use with a Spanish-speaking population, and many of the client forms, handouts, and outcome measures have been translated into Spanish. Session-by-session guides, client handouts, and forms have been translated into Swedish.
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Runyon, M. K., Deblinger, E., & Steer, R. A. Group cognitive behavioral treatment for parents and children at-risk for physical abuse: An initial study. Child and Family Behavior Therapy, 32(3), 196-218.

Outcomes

Outcome 1: Children's PTSD symptoms
Description of Measures	Children's PTSD symptoms were assessed using the PTSD Section of the Schedule for Affective Disorders and Schizophrenia for School-Age Children--Present and Lifetime Version (K-SADS-PL), a semistructured interview that was administered independently to parents and children at pretest, posttest, and 3-month follow-up. The K-SADS-PL is designed to assess current and past episodes of psychopathology in children and adolescents according to DSM-III-R and DSM-IV criteria. Using a 3-point scale (0 = no information, 1 = no, and 2 = yes), parents and children respond separately to the same items regarding PTSD symptoms, and the interviewer uses the same scale in assigning a summary rating on the basis of these responses. If the parent and child responses differ on an item, the interviewer uses his or her best clinical judgment in assigning the summary rating. The summary ratings of items for symptoms representing reexperiencing, avoidance, and hypervigilance were added to yield a total PTSD symptoms score. Lower scores indicate a lower total number of PTSD symptoms.
Key Findings	Participants were randomly assigned to the intervention condition, in which both parents and their children received CPC-CBT, or to the comparison condition, in which parents received CBT and children took part in other activities (e.g., games, art). At posttest, children in the intervention group had a lower adjusted mean score for total PTSD symptoms relative to those in the comparison group (p < .05).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.2 (0.0-4.0 scale)

Outcome 2: Parenting skills
Description of Measures	Parenting skills were assessed using the Positive Parenting subscale of the parent and child versions of the 35-item Alabama Parenting Questionnaire (APQ-P and APQ-C, respectively). The APQ-P and APQ-C were administered to parents and children, respectively, by a master's-level clinician (the project coordinator) at pretest, posttest, and 3-month follow-up. Using a scale ranging from 1 (never) to 5 (always), participants rate each item as to how often it typically occurs. Higher scores on the Positive Parenting subscale indicate better parenting skills.
Key Findings	Participants were randomly assigned to the intervention condition, in which both parents and their children received CPC-CBT, or to the comparison condition, in which parents received CBT and children took part in other activities (e.g., games, art). At posttest, participants in the intervention group had a higher adjusted mean score on the Positive Parenting subscale of the APQ-P relative to those in the comparison group (p < .05); the adjusted mean scores for children on the Positive Parenting subscale of the APQ-C showed no significant group difference.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.2 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	6-12 (Childhood) 13-17 (Adolescent) 18-25 (Young adult) 26-55 (Adult)	63.5% Female 36.5% Male	46.5% Black or African American 21.1% White 16.7% Hispanic or Latino 15.8% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Children's PTSD symptoms	4.0	4.0	3.0	2.5	2.0	3.5	3.2
2: Parenting skills	4.0	4.0	3.0	2.5	2.0	3.5	3.2

Study Strengths

The study was well designed and employed widely used instruments with good psychometric properties. Participants were randomly assigned to treatment groups, and analyses included a comparison of program completers and noncompleters at follow-up. Appropriate statistical techniques were used in the analysis of data.

Study Weaknesses

Baseline equivalence of groups was not established despite random assignment; for example, 19% of intervention group participants and 50% of comparison group participants reported previous physical abuse. Although the analysis included all variables as covariates, the study had a small sample size and very high overall attrition (30% of participants did not complete the posttest), raising concerns about bias and other confounding variables.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

CPC-CBT implementation materials:

Clinician handouts
CPC-CBT Fidelity Checklist
CPC-CBT Readiness Guide
CPC-CBT Training Brochure
CPC-CBT Training Metrics
Runyon, M. K., & Deblinger, E.. Combined Parent-Child Cognitive Behavioral Therapy: A group session-by-session guide for co-facilitators (parent and child versions). Stratford, NJ: Child Abuse Research Education and Service Institute.
Runyon, M. K., & Deblinger, E.. Combined Parent-Child Cognitive Behavioral Therapy: A session-by-session guide for clinicians (parent and child versions). Stratford, NJ: Child Abuse Research Education and Service Institute.
Runyon, M. K., & Deblinger, E. How to implement Combined Parent-Child Cognitive Behavioral Therapy. Stratford, NJ: Child Abuse Research Education and Service Institute.
Skills and parenting information sheets

CPC-CBT Learning Collaborative materials:

CPC-CBT Learning Collaborative Application
CPC-CBT Learning Collaborative Change Package
CPC-CBT Learning Collaborative Pre-work
CPC-CBT Training Exercises for Learning Sessions I, II, and III
Sample materials for consultation calls following Learning Sessions I, II, and III
Sample materials from the National Center for Child Traumatic Stress Guidelines for Conducting a Learning Collaborative

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
4.0	4.0	4.0	4.0

Dissemination Strengths

Implementation materials are comprehensive and easy to follow and incorporate information on the well-researched program model. The implementation manual thoroughly addresses organizational readiness to implement CPC-CBT and provides guidance on when CPC-CBT should be used and when its use is contraindicated. Session-by-session guides detail each session for children and parents, including information on the delivery methods for individual and group programs. Three levels of training, with varying degrees of intensity, are available, and all provide opportunities for trainees to use case scenarios in practicing key skills. Training materials are extensive, particularly those for the CPC-CBT Learning Collaborative. The resource list of supplemental materials to support clinicians is nicely organized and highlights materials that are highly recommended. The recommended clinical outcome monitoring instruments include detailed questions, and information is provided on the interpretation of scores. Parent and child feedback forms are available to collect client satisfaction data.

Dissemination Weaknesses

No weaknesses were identified by reviewers.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
CPC-CBT implementation materials (including forms and handouts for clients and clinicians)	Included in training cost	Yes
CPC-CBT Readiness Guide	Included in training cost	Yes
CPC-CBT Training Brochure	Included in training cost	Yes
CPC-CBT Training Application	Included in training cost	Yes
Therapeutic Children's Book: Helping Families Heal	$25 each	No
Educational Card Game: What Do You Know?	$19.95 each	No
Combined Parent-Child Cognitive Behavioral Therapy: An Approach To Empower Families At-Risk for Child Physical Abuse (book)	$55 each	No
On-site training	$2,000-$3,000 per day per trainer, plus travel expenses	Yes
Phone or videoconference consultation	$260 per hour	No
CPC-CBT Fidelity Checklist	Free	Yes
Additional quality assurance metrics	Free	Yes
Client outcome measures	Varies depending on the measure, although some are available from the developer at no cost	No

Additional Information

The cost of training varies depending on the amount and intensity of the training requested by the site and the availability of grant funds to support CPC-CBT trainings.