Parenting in the Context of Trauma: Dyadic Interventions for Trauma-Exposed Parents and Their Young Children



Treatment description


Attachment and Biobehavioral Catch-Up (ABC)

For infants (ABC-I)

(Bernard et al. 2012, 2017, 2015a, b, c; Bick and Dozier 2013; Dozier et al. 2009; Lewis-Morrarty et al. 2012; Lind et al. 2014; Sprang 2009; Yarger et al. 2016)

For toddlers (ABC-T)

(Lind et al. 2017)

ABC-I: 6 months to 2 years old and experienced early adversity ABC-T: 2–4 years old and experienced early adversity

Parent-child dyad

Weekly for 1 h for ten sessions


• Help caregiver to provide nurturing care even when child behaves in ways that push the caregiver away

• Help caregivers provide a responsive, predictable environment that helps the child develop regulatory capacities

• Caregivers are coached to follow the child’s lead and show delight in the child

• Help caregivers to decrease behaviors that may be frightening or overwhelming to the child

• ABC-T: Teach caregivers ways to co-regulate their children when they are distressed

• Video feedback, homework, and in-the-moment feedback are used to reach these goals

ABC-I: RCTs with at-risk children (N = 24–120) and children in foster care (N = 46–173). ABC-I is associated with:

 • Lower rates of child disorganized attachment, higher rates of secure attachment, and less avoidant behavior

 • Lower child negative affect during a challenging task

 • Lower child internalizing and externalizing behavior

 • Higher child cognitive flexibility, theory of mind skills, and receptive vocabulary

 • More normative child diurnal pattern of cortisol production, with effects persisting into preschool age

 • Improvement in sensitive caregiving, decreases in intrusive caregiving

 • Enhanced maternal ERP responses for emotional faces relative to neutral faces

 • Lower scores on measures of child abuse potential and parenting stress

ABC-T: RCT with children in foster care (N = 173). ABC-T is associated with:

 • Lower rates of attention problems, higher cognitive flexibility

Child and Family Interagency Resource, Support, and Training (Child FIRST)

(Lowell et al. 2011)

0–5-year-old children at high risk of emotional, behavioral, or developmental problems or child maltreatment

Parent-child dyad

1 month 2×/week and then weekly for 1–1.5 h for 6–12 months

Home or early care and education setting

• Team consists of mental health/developmental clinician and a care coordinator

• Observation and collaboration with teachers in early care and education setting

• Trauma-informed child-parent psychotherapy and parent guidance

• Care coordination and connection to community services

RCT with multi-risk urban mothers and children (N = 157). Child FIRST is associated with:

 • Improved child language

 • Improved child externalizing symptoms

 • Less parenting stress

 • Lower maternal psychopathology symptoms

 • Less protective service involvement

 • Greater access to wanted services

Child-Parent Psychotherapy (CPP)

(Cicchetti et al. 2006, 1999; Lieberman et al. 2006, 2005, 1991; Toth et al. 2002)

0–5 years old, exposed to trauma

Parent-child dyad, with some parent-only sessions

1–1.5-h sessions, weekly for ~1 year (M = 32 sessions)

Home or clinic

• Based on attachment, psychodynamic, developmental, trauma, social learning, and cognitive behavioral theories

• Foundational phase focuses on developing trauma-informed formulation of dyad’s functioning

• Core intervention phase utilizes primarily play-based developmental-relational therapy

• Creates shared positive memories

• Dyad develops a play-based narrative of traumatic experience

• Sustainability and termination phase helps family process upcoming goodbye and review family’s story

• Focus on safety, affect regulation, reciprocity in relationships, continuity of daily living, and focus on the traumatic event

• Reflective supervision

RCTs with anxiously attached dyads (N = 93), children with depressed mothers (N = 108, 198), low-income families with a history of maltreatment (N = 122, 137), witnesses of domestic violence (N = 75, 50). CPP is associated with:

 • More positive mother-child relationship expectations

 • Higher parental empathic responsiveness and goal-corrected partnership, lower angry behavior

 • Lower likelihood of child anxious attachment

 • Increase in levels of child secure attachment

 • Decline in child traumatic stress disorder symptoms and behavior problems

 • Reductions in problematic maternal representations

 • Decline in mothers’ avoidant symptoms, general distress, and PTSD symptoms

Circle of Security (COS)

Home Visiting-4 (COS-HV4)

(Cassidy et al. 2011)

COS Group

(Hoffman et al. 2006; Huber et al. 2015)

COS-Parenting (COS-P)

(Cassidy et al. 2017)

0–5 years old, high-risk populations (e.g., enrolled in Early Head Start, teen moms, irritable babies)

COS-HV4: Parent-only; COS group, COS-P: Parent group

COS-HV4: 1 3-h assessment session and 4 1.5-h sessions over 3 months; COS group: 20 weekly 1.25-h sessions, COS-P: 10 weekly 1.5-h sessions

COS-HV4: Home; COS Group, COS-P: Clinic or community

• Teach caregivers about attachment theory using the “circle” graphic

• Help parents to provide a safe haven in times of distress or threat and a secure base in times of exploration

• Teach parents about ways children might “miscue” what they need

• Help caregivers to see how their own strong feelings influence their responses to their children

• COS-HV4, Group: Review of video of caregiver interacting with his or her own child

• COS-P: DVD-based

COS-HV4 RCT with low-income mothers with irritable infants (N = 220). COS-HV4 is associated with:

 • Reduced risk of child insecure attachment, for dismissing mothers with highly irritable infants

COS Group pre-post design with low-income children and their caregivers (N = 65), and clinically-referred children and their caregivers (N = 83). COS Group is associated with:

 • Shift from child disorganized to organized (mostly secure) attachment classifications

 • Improved caregiver reflective functioning and caregiving representations

COS-P RCT with low-income children and their caregivers (N = 141). COS-P is associated with:

 • Improved child inhibitory control

 • Fewer unsupportive maternal responses to child distress

Minding the Baby

(Sadler et al. 2013)

Prenatal to 2-year-old children; first-time parents at high risk for problems (e.g., young maternal age, poverty, history of trauma)

Parent-child dyad

Weekly for 1 h from prenatally until baby is 1 and then biweekly until baby is 2


• Team consists of pediatric nurse practitioner and clinical social worker; providers alternate who attends home visit

• Help parents to become more reflective and responsive in their interactions with their infant

• When applicable, social worker conducts mental health assessment and provides treatment to parent

• Home visitors maintain close contact with mother’s and child’s physicians and coach families with regard to health-care information and accessing social services

RCT with primiparous women receiving care at a community health center (N = 105). Minding the Baby is associated with:

 • Higher likelihood of being on-track with child immunization schedule

 • Lower rates of rapid subsequent childbearing

 • Lower likelihood of referral to Child Protective Services

 • Higher likelihood of child secure attachment relationship; lower likelihood of child disorganized attachment relationship

 • Improved maternal capacity to reflect on their own and their child’s experience for mothers who were high risk

 • Less likely to have disrupted mother-infant interactions when mothers were teenagers

Mom Power (MP)

(LePlatte et al. 2012; Muzik et al. Under Review, 2014, 2015, 2016, 2009; Rosenblum et al. 2017a, b; Swain et al. 2017, 2016)

Prenatal to 5-year-old children. High-risk populations often with maternal trauma and psychopathology

Separate mother and child groups run simultaneously, with guided parent-child interactions

3 h group, weekly for 10 weeks, plus one to three individual sessions

Clinic or community setting (e.g., church, community center)

• Two facilitators run mother group

• Teach an attachment-based parenting education curriculum using the “tree” metaphor of building roots (connecting) and branching out (exploring)

• Focus on maternal self-care, teaching skills such as diaphragmatic breathing and progressive muscle relaxation

• Enhances peer/social support with other group members and with parenting support in mothers’ lives

• Includes in vivo guided parent-child interactions (separations and reunions)

• Aims to enhance engagement and connects mothers to ongoing care when indicated

• Corresponding child curriculum focused on child-led play

Pre-post design with low-income mothers and their children (N = 99). MP is associated with:

 • Decreased maternal depression, PTSD, and caregiving helplessness

 • Improved maternal reflective capacity

 • Improved parenting confidence, social support, and connection to care

RCT with high-risk mothers and their children (N = 122). MP is associated with:

 • Improvements in mental health symptoms and parenting stress

 • Improved maternal reflective capacity

 • Increase in “balanced” maternal representations

 • Better outcomes for mothers with a history of interpersonal trauma

 • Improvement in mothers’ brain-based indices of social cognition and empathy

Multidimensional Treatment Foster Care-Preschool/Preventive (MTFC-P)

(Fisher et al. 2005, 2007, 2011; Fisher and Kim 2007; Fisher and Stoolmiller 2008)

3–6-year-old children at risk of out-of-home placement

Child resides with MTFC-P foster family and attends weekly playgroup; parent(s) meet with family therapist and then parents and child meet with family therapist

9–12 months

MTFC-P foster home, clinic

• Child resides in MTFC-P foster home

• Child attends weekly therapeutic play group

• Foster carers implement treatment plan (e.g., behavioral management strategies) and attend weekly meetings with other MTFC-P parents

• Family therapist meets weekly with biological/adoptive parents for parent training and problem-solving; child is included in later sessions; this continues about 3 months after child is reunified

RCT with children in need of a new foster placement (N = 90–177). MTFC-P is associated with:

 • Fewer failed foster placements

 • Increase in child secure attachment behavior

 • Decrease in child avoidant behavior

 • More normative child diurnal pattern of cortisol production

 • Protection from effects of placement changes on child’s diurnal HPA axis activity

 • Reduced foster parent stress

Parent-Child Interaction Therapy (PCIT)

(Bagner and Eyberg 2007; Kennedy et al. 2016; Leung et al. 2017; McCabe and Yeh 2009; Mersky et al. 2016; Solomon et al. 2008; Ward et al. 2016)

Children ages 2–7 years old with behavior and caregiver-child relationship problems

Parent-child dyad

1-h weekly sessions for approximately 14 weeks (not time limited)


• Focuses on decreasing externalizing child behavior problems, increasing child social skills and cooperation, and improving the parent-child attachment relationship

• Teaches parents play-therapy skills to use as social reinforcers of positive child behavior (child-directed interaction) and behavior management skills to decrease negative child behavior (parent-directed interaction)

• Parents are taught and practice these skills with their child while live coached by a therapist through an ear piece

RCTs with children with behavior problems (meta-analysis N = 372), premature birth (N = 28), cognitive impairments (N = 30), high-functioning autism spectrum disorder (N = 19), maltreating parents and their children (meta-analysis N = 571), foster families (N = 102), Chinese families (N = 64, 111), and Mexican-American families (N = 58). PCIT is associated with:

 • Increased positive parenting behaviors and decreased negative parenting behaviors

 • Increased child compliance and adaptability

 • Improved parent-reported child internalizing problems, externalizing problems, and attention problems

 • Improvement in children’s cardiac vagal regulation

 • More normative levels of parental stress

 • Significantly fewer re-reports of child maltreatment


(Wettig et al. 2011)

0–18 years old with behavior problems

Parent-child dyad

30–45-min sessions weekly for 18–24 weeks, then 4 follow-up sessions


• Play therapy for children and their caregiver; very few toys—play centers around social interaction

• Child-caregiver dyad participates in challenging, engaging, and nurturing activities

• Aim to recreate a “healthy mother-child relationship”

Pre-post control group study with children with language disorders, behavior problems, and shyness (N = 22,167). Theraplay is associated with:

 • Improved child assertiveness, self-confidence, and trust

 • Improved child expressive and receptive communication

 • Reduced child social withdrawal

Child-Parent Psychotherapy

Child-Parent Psychotherapy (CPP) is an intervention model for children aged 0–5 who have experienced traumatic events and have behavioral attachment, or psychiatric problems (Lieberman and Van Horn 2004, 2008). CPP specifically targets those who have experienced domestic violence, medical trauma, or separation from a caregiver, as in military families, foster care, or similar circumstances. Based on attachment theory, and borrowing from psychodynamic, developmental, trauma, social learning, and cognitive behavioral theories, CPP aims to use the caregiver-child relationship as the vehicle to restore a child’s well-being. One of the key features of CPP is its focus on trauma; both the child’s and caregiver’s history of trauma are explored, and the clinician works to help the caregiver(s) to identify ways that their history might impact the way they understand and respond to their child. Caregivers may or may not be referred for their own individual treatment, depending on their particular circumstances.

CPP begins with a foundational phase wherein information is gathered about the caregiver and child’s history and symptoms, and a trauma-informed formulation of the dyad’s functioning is developed. In the core intervention phase of treatment, the caregiver-child dyad engages in play-based developmental-relational therapy wherein the focus of the work is on developing a play-based narrative about the traumatic experience, acknowledging the impact of the trauma, as well as creating shared positive memories and engaging in pleasurable joint activities. In contrast to exposure-based treatments, in CPP, the clinician introduces the trauma narrative but allows play to be child-directed. Clinicians utilize “ports of entry” (i.e., potential targets of intervention throughout a session) to provide information, help the dyad to notice something in the relationship, or shift the dyad’s understanding of something with the ultimate goal of helping the dyad to heal from the trauma. The last phase of treatment, the sustainability and termination phase, involves processing the upcoming goodbye and reviewing the family’s story.

Throughout all phases of treatment, there is substantial emphasis on safety and how the caregiver can assure that the child remains physically and psychologically safe both in more material ways (e.g., safe housing, access to services) and psychological ways (e.g., acknowledgment of past risks to safety, consistency and predictability in relationships). CPP can be conducted with biological parents and/or foster or adoptive parents. Whether or not the perpetrator of the trauma is the caregiver participating in CPP, a crucial goal of treatment is ensuring that the child is currently safe, and when appropriate, clinicians often collaborate with child welfare workers. CPP clinicians help to support the caregiver-child relationship by providing developmental guidance as needed, reframing misattributions that may be shaped by the caregiver’s history, and regulating both the child’s and parent’s affect during emotionally charged play and discussions. CPP clinicians participate in reflective supervision or consultation, which allows clinicians to explore countertransference, become aware of cultural blind spots, and prioritize self-care. The time course of each phase of CPP is fluid and depends on each family’s needs. Generally, however, a course of treatment lasts about 1 year, with weekly 1-hour sessions, conducted either in a clinic or in a family’s home.

CPP has a well-established evidence base and has had several randomized controlled trials (RCT). In an RCT with a diverse sample of 3–5-year-old children (N = 75) and their mothers who had all experienced domestic violence, children who received CPP had significant reductions in both behavior problems and traumatic stress symptoms, and mothers who received CPP had significant reductions in avoidant symptoms (Lieberman et al. 2005). Six months later, CPP children continued to show fewer behavior problems, and CPP mothers had reductions in general distress (N = 50; Lieberman et al. 2006). Similar intervention effects are evident for a subsample of higher-risk children, with effects maintained at 6-month follow-up (Ghosh Ippen et al. 2011). In two RCTs, CPP was associated with increases in rates of secure attachment for maltreated infants, and children of depressed mothers, but no differences were found in rates of secure attachment between CPP and a psychoeducational parenting intervention (Cicchetti et al. 2006). An RCT with maltreated preschoolers (N = 122) found that children who received CPP (called Preschooler-Parent Psychotherapy in this study) had improved representations of themselves and of their caregivers, as well as improved relationship expectations (Toth et al. 2002). In an RCT of anxiously attached Latino infants (N = 93), CPP was associated with toddlers with lower avoidance, resistance, and anger and mothers with higher empathy and interactiveness with their children (Lieberman et al. 1991). Studies of potential effects of CPP on the biology of children and caregivers who have experienced trauma are currently in progress.

Circle of Security

Circle of Security (COS) is an intervention for parents of children from birth to 5, aimed at helping parents to become more attuned to their children’s attachment needs (Powell et al. 2014). COS utilizes a user-friendly graphic (“the circle”) to highlight the two primary modes of the attachment system; parents provide a safe haven to their child in times of distress or threat, and a secure base when the child is able to venture out and explore. COS teaches parents about the ways that young children might “miscue” what they need (e.g., push parents away when they are in need of a welcoming, safe haven), helps parents to improve their observational and inferential skills related to their child’s behavior, and also helps parents to identify the way that their own strong feelings can interfere with their ability to respond appropriately to their children’s needs. The COS program was initially designed as a 20-week multifamily group format that involved videotaped observations and feedback guided by clinician co-leaders. Numerous adaptations of the program have since been developed, including a four-session home-based program targeting high-risk, low-income parents of infants that also utilized video feedback of caregiver-child interactions. More recently, COS has been modified into a ten-session DVD-based parent group intervention, Circle of Security Parenting (COS-P), that utilizes psychoeducation and standardized video clips in lieu of personalized video feedback.

COS has become widely used in clinical settings and has an emerging evidence base to support its use. Using the original 20-week group treatment format, a pre-post design study with 65 toddler- or preschooler-caregiver dyads from Head Start and Early Head Start programs found that while 39 of 65 children were classified as having disorganized attachments at baseline, 27 of these children (70% of baseline disorganized) attained an organized attachment classification after the intervention (Hoffman et al. 2006). Results were in the same direction for attachment security; 52 of 65 children had insecure attachments at baseline, but 23 of these children (44% of baseline insecure) attained a secure attachment classification after the intervention (Hoffman et al. 2006). A similar pre-post design study of clinically referred children found the COS Group intervention to be associated with improved caregiver reflective function and caregiving representations and improved child attachment security and organization (Huber et al. 2015). An additional study utilized a COS intervention together with an intensive jail-diversion program for pregnant offenders with a history of substance abuse; after the intervention, participants had rates of attachment security, attachment disorganization, and maternal sensitivity that were comparable to low-risk samples (Cassidy et al. 2010). Thus far, COS has undergone two RCTs. In a study of 174 irritable infants randomized to the 4-week home-visiting (COS-HV4) model or a psychoeducational control intervention, there was no main effect of treatment, but an interaction revealed that there were significant intervention effects only for the most irritable infants (Cassidy et al. 2011). The COS-P DVD program has begun to show potential benefits to parents in measures of parent risk factors (Horton and Murray 2015) and child care providers in terms of self-efficacy and reduced depressive symptoms, but not reflective functioning (Gray 2015). Recently, an RCT of the COS-P DVD program found that relative to a waitlist control group, COS-P mothers provided fewer self-reported unsupportive responses to child distress, and 3–5-year-old children of COS-P mothers had better observed inhibitory control (Cassidy et al. 2017). Exploratory analyses suggest that mothers’ attachment style might moderate the effects of COS-P, but more research is needed (Cassidy et al. 2017).

Attachment and Biobehavioral Catch-Up

Attachment and Biobehavioral Catch-Up (ABC) is a manualized ten-session in-home caregiver-child intervention program that is designed for children who have experienced early adversity (Bernard et al. 2012). ABC for Infants (ABC-I) is designed for children 6 months to 2 years old, and ABC for Toddlers (ABC-T) is designed for children 2–4 years old. ABC is based on attachment theory and informed by stress neurobiology. The goals of ABC are to help caregivers to provide nurturing care when their child is distressed and to have more synchronous interactions with their child. To reach these goals, interventionists provide in-the-moment feedback and video feedback, use structured activities to help caregivers practice being synchronous, discuss research supporting the importance of nurturing and synchronous care, and explore how caregivers’ early experiences affect their ability to provide nurturing and synchronous care. Interventionists focus especially on helping caregivers to provide a responsive, predictable environment so that children are better able to regulate themselves, to follow the child’s lead and show delight in the child, and to decrease any behaviors that might be frightening or overwhelming to the child. In ABC-T, caregivers are also taught how to co-regulate their children when they are distressed.

ABC-I has been widely studied in at-risk caregiver-child dyads, with favorable results for both children and caregivers in behavioral and biological domains. In an RCT in high-risk mothers (N = 24), mothers in the ABC-I condition showed significant increases in sensitivity and decreases in intrusiveness relative to a psychoeducational control intervention, and rates of change were faster in the first half of treatment (Yarger et al. 2016). RCTs with foster families found that ABC-I foster mothers had improvements in sensitive parenting (N = 96; Bick and Dozier 2013) and reductions in child abuse potential and parenting stress (N = 53; Sprang 2009). Accompanying these behavioral changes, Child Protective Services-referred mothers who participated in ABC-I also demonstrated enhanced event-related potentials in response to emotional faces relative to a control group (N = 86; Bernard et al. 2015c).

Children who participated in the ABC-I intervention show lower rates of disorganized attachment and higher rates of secure attachment (N = 120; Bernard et al. 2012), less avoidance behavior (N = 46; Dozier et al. 2009), less negative affect in a challenging task (N = 117; Lind et al. 2014), lower levels of externalizing and internalizing behavior problems (N = 53; Sprang 2009), higher receptive vocabulary (N = 52; Bernard et al. 2017), and improvement in cognitive flexibility and theory of mind skills (N = 61; Lewis-Morrarty et al. 2012). Foster children who participated in the ABC-T intervention had better parent-reported attention and cognitive flexibility than children who participated in a control intervention (N = 173; Lind et al. 2017). There is mounting evidence that ABC-I is associated with lasting biological changes for children as well. Children with a history of neglect who participated in ABC-I showed normalized diurnal cortisol patterns 3 months post-intervention, when children were 5 months to 3 years old (N = 101; Bernard et al. 2015a), and these changes persisted until children were about 4–6 years old (N = 115; Bernard et al. 2015b).

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Apr 12, 2018 | Posted by in PSYCHIATRY | Comments Off on Parenting in the Context of Trauma: Dyadic Interventions for Trauma-Exposed Parents and Their Young Children
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