In our last issue, we shared that CPP providers in Arkansas are eligible for an increased reimbursement rate. In this issue, we will take a deeper dive to understand how Arkansas made these shifts in policy and practice.
Arkansas invests in its children’s mental health. Founded in 2009, the Arkansas Building Effective Services for Trauma (ARBEST) program receives over $1 million dollars from the state general assembly each year to improve outcomes for children affected by trauma. CPP is one of the models disseminated by ARBEST, with roughly 100 providers completing rostering requirements as of 2023. Working in close coordination with state health services, the organization has three main activities:
- 1Technical assistance for childhood mental health services offered at Childhood Advocacy Centers
- 2Community-wide education on trauma informed principles/practices (e.g. schools, daycares, medical offices)
- 3Dissemination of evidence-based child trauma treatments offered at no cost to clinicians across the state
Arkansas has undertaken policy reforms to harness this growing early childhood workforce. In 2017, a state work group of administrators and providers from community mental health, pediatric, and hospital clinics developed standards around infant mental health certification, to ensure that young children and their families had access to developmentally appropriate, evidence-based care. Reports suggest possible cost savings through reductions in downstream diagnosis and service utilization—provided the child had access to the right care. One work group member offered a metaphor to highlight the necessity of specialized, trauma-focused care: “You could go to the best ophthalmologist in Arkansas, and if your leg is broken, it will still be broken when you leave the ophthalmologist.”
Adopted by the state in 2018, the new certification standards include requirements before a mental health clinician can be reimbursed by Medicaid for mental health services provided to children under four years of age. In addition to educational and licensing requirements, clinicians must be trained in ZERO TO THREE’s Diagnostic Classification System (DC: 0-5) and at least one dyadic evidence-based treatment for young children (such as CPP). The certification standards allow clinicians to receive a 10% enhanced reimbursement rate for the services they provide. The certification criteria also specified changes to the types of services young children can receive. For example, the initial expanded benefits package for children under four includes 4 'mental health assessment' sessions and 4 'interpretation of diagnosis' sessions prior to creating a treatment plan. Finally, efforts were made to prioritize dyadic treatment by eliminating codes for individual therapy and family therapy without patient present.
While the certification standards expanded the breadth and depth of childhood trauma treatment in Arkansas, there is still work to be done. For example, current advocacy efforts focus on the provision of family therapy without patient present sessions, given the frequency for caregiver-only work in treatment for young children. Additionally, the work group recommended including psychological evaluations, but so far providers cannot bill these services without prior authorization. The work group is no longer active, but members continue to respond to questions from Arkansas policymakers. More importantly, the forum has cultivated relationships between Arkansas’s legislators and its mental health community, a crucial catalyst for funding infant and early childhood services.
The Arkansas CPP team built solid relationships with policy makers through regular engagement. This steady, authentic work has led to a consistent seat at the table when key decisions are made, such as how to best spend available funds to address the mental health needs of their community. In this process, they learned to get the message through to different people: when to share clinical stories, argue morals, or use facts and numbers. Lastly, they highlighted the value of local voices, “Arkansans would rather hear it from people who live here and are dedicated to our community and ensuring that they have access to their right to recovery.”
Voices from the Field
Our community is growing and thriving! CPP is now implemented in 7 countries and 48 U.S. states and territories. We are spotlighting the voices of our international community so that we can all celebrate the spread of CPP throughout the world. Please view past newsletters to learn about CPP implementation in Australia, Israel, Sweden, and Norway. In our next issue, we plan to highlight CPP implementation in Hong Kong.
Implementation of CPP in the United Kingdom began in 2016, through a partnership with the National Society for the Prevention of Cruelty to Children, the United Kingdom’s leading children’s charity specializing in child protection. Through this collaboration, Julie Larrieu provided CPP implementation training to two cohorts of infant mental health specialists: the Glasgow Infant and Family Team and the London Infant and Family Team. Today, these teams are replicating a model developed by the Infant Team at Tulane University, in which therapists work with the courts and the child welfare system to provide intensive intervention for both young children who have been maltreated and their caregivers.
Julie Larrieu with CPP trainees from the National Society for the Prevention of Cruelty to Children and National Health Service (2020)
Julie Larrieu with Tulane colleague Charley Zeanah and members of the University of Glasgow, National Society for the Prevention of Cruelty to Children, National Health Service, and Human Development Scotland from London and Glasgow
Following the training of these two cohorts, CPP training expanded to include the Bradford District Care National Health Service Foundation Trust. This expansion brought the model to clinicians and supervisors with the Specialist Early Attachment and Development Service and the Specialist Mother and Baby Mental Health Service.
Planning is underway for a fourth cohort in 2024-2025, to increase the number of CPP providers within the National Health Service.
Julie Larrieu sees CPP as “the gold standard for the treatment of trauma in young children and their caregivers.” Her journey with CPP began in 2001, when she helped establish Tulane University as an inaugural site of the Early Trauma Treatment Network. As a senior supervisor of the Tulane Comprehensive Assessment and Treatment Team, Julie appreciates the rigor of CPP. She sees it as an ideal model for families with longstanding trauma, as well as parents with serious trauma histories. In these complex cases, CPP is robust enough to hold the child-caregiver dyad, as well as the larger family unit, sociocultural dynamics, and historical trauma. “It is such a multifactorial treatment,” Julie says, “All those aspects position CPP well for child welfare-involved families. In 30 years, I don’t think I’ve ever worked with a family who’s had only one single trauma.”
An important result of this robustness, Julie notes, is the preventative, protective effect that CPP can have on others in the clients’ life. The model holds reflection for the parent’s inner child. Through treatment, parents learn to contextualize what happened
Dr. Julie Larrieu
to them, change negative attributions, and understand the emotional connection to their own behavior. Julie highlights the protective effects of this process, citing reductions in maltreatment for mothers with other children, even without reunification with the first child. She calls it “the magic of CPP.”
In addition to clinical work, Julie consults with a variety of child-serving systems, where she applies CPP principles to hold a relationship focus for the systems themselves. “There are trauma and disenfranchisement in [those] systems,” Julie says, “…and we need to be mindful of the interface between who we are and the privilege and power that we have.” She strives to educate stakeholders on the tension between timelines for decision making in the child-welfare system and the clinical timelines for repairing trauma and relationships. Julie believes that concepts such as benevolence, speaking the unspeakable, and looking for underlying meanings of behavior are vital to strengthening system-to-system relationships. This, in turn, will result in better care for the children and families they serve. “Indirectly, through systems work, I will be invited into those families’ relationships.”
Julie is currently working with other CPP leaders to develop certification standards for the model and a framework for holding issues around social justice and DEI. She and her team appreciate that parental practices are deeply rooted in culture. Whether working at home in the Deep South or training internationally, she strives to “understand, from their mouths, the family stories about child rearing and ancestry.”
Looking forward, Julie is excited to begin training a new Apprentice Trainer in Oregon and a cohort of clinicians and supervisors across the United Kingdom next year. She finds training to be immensely fulfilling, noting how trainees share new ideas and perspectives, which she then integrates into her own practice. Between her work as a trainer and as a senior supervisor to Tulane’s CPP internship program, she has sown the seeds of CPP far and wide. “I am delighted to have trained providers, supervisors, and systems who can help families heal for generations.”
Oh, The Places We've Gone...
This fall, the Child Trauma Research Program (the "CPP Mothership") wrapped up a five year SAMHSA grant in collaboration with Benioff Children's Hospital Oakland Early Intervention Services and the Infant Parent Program. The goal of this grant was to partner with rural communities in rural counties from northern California, Michigan, Minnesota, and New Mexico to enhance the provision of infant mental health services in communities that are often underserved.
Together we offered core infant mental health trainings to 2,900 providers across these rural communities. The CTRP team also conducted 4 CPP Learning Collaboratives and trained 23 CPP Clinicians to implementation-level standards so that now more families with young children are able to receive trauma-informed treatment. The CPP trainings took place during the pandemic, when many services pivoted to telehealth modalities. We continue to explore the effectiveness of telehealth to ensure that more communities have access to these critically important services.
Jill Gay LCSW LISW-S, TRCC
Chief Program Officer, Family Nurturing Center
As the Chief Program Officer for the Family Nurturing Center, Jill Gay describes her role as “guiding the ship of trauma-informed care.” The organization promotes well-being and healthy relationships, often for victims of childhood trauma that are involved with the child welfare system. In response to a growing number of clients aged zero to two, Jill and her team identified CPP as an evidence-based model that “fit who we are at the essence of our being as an organization.”
The team now has seven full-time staff trained in CPP, equipping the agency with “a technique and a skillset to serve the littlest of the littles.” In the clinical setting, Jill highlighted the impact that the model can have not only on the child’s life but also on that of the parent. One therapist recently described a breakthrough with one mother, who said in an aha-moment:
“I figured it out: when I’m calm and relaxed, she [the daughter] is calm and relaxed. So it really is a parent problem, not my child.”
In addition to empowering clinical work, the CPP model also serves as a lens through which the team engages with the child welfare system. Jill emphasized that the Family Nurturing Center has a longstanding relationship with the local child welfare office, which has allowed for honest, respectful conversations around trauma-informed practices. Much of this education involves a shift away from the medical model of mental health (which emphasizes a pathway from diagnosis to medication) to an understanding that true healing requires relationship building.
Looking ahead, Jill hopes to formalize a training program for child welfare prosecutors and judges. She is also looking to expand the team’s partnership with child welfare agencies to train on sharing space with families and help children and adults have hard conversations. “So many people in the child welfare system don’t get good support in knowing how to do that,” Jill says, “Part of the beauty of CPP is making the unspeakable speakable.”
The Road Ahead
A Visit to Webinars Past
We are excited to share that we have expanded the Events page on our website. In addition to upcoming training opportunities, the page also features recordings of CPP webinars and presentations by those at the forefront of model implementation, research, and advocacy. These resources are available free of charge—click here to explore!
In 1995, the Irving Harris Foundation (IHF) provided grant funding that made it possible for the Child Trauma Research Program to establish a training program and develop and pilot test the CPP treatment model. Irving Harris and the IHF are truly angels in our therapeutic nursery, making what we have done possible. Since that time, the IHF provided the funding for Patricia Van Horn to train Illinois-based CPP trainers and to conduct multiple CPP Learning Collaborative involving practitioners throughout Illinois. The IHF is much more than a funder. It is a true partner, one who has helped us to stretch and grow through thoughtful initiatives. They have pushed us to grow our capacity to serve fathers, deepen our commitment to diversity and equity-informed practice, consider the possibility of child welfare system reform or abolition, and integrate a reproductive justice framework. We are incredibly grateful for our enduring partnership and the multiple ways that IHF has enriched our lives and our practice.