Outcomes of psychotherapeutic and psychoeducative group interventions for children exposed to intimate partner violence

Child Abuse & Neglect 79 (2018) 213–223

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Research article

Outcomes of psychotherapeutic and psychoeducative group interventions for children exposed to intimate partner violence

T

⁎

Karin Perneboa,b, , Mats Fridellc, Kjerstin Almqvistd a

Department of Psychology, Linnaeus University, Växjö, Sweden Department of Research and Development, Region Kronoberg, Växjö, Sweden Department of Psychology, Lund University, Lund, S-221 00, Sweden d Department of Social and Psychological Sciences, Karlstad University, Karlstad, S-651 88, Sweden b c

AR TI CLE I NF O

AB S T R A CT

Keywords: Children Domestic violence Child witness of intimate partner violence IPV Post traumatic stress Treatment Outcome research

Witnessing violence toward a caregiver during childhood is associated with negative impact on children’s health and development, and there is a need for effective interventions for children exposed to intimate partner violence in clinical as well as in community settings. The current effectiveness study investigated symptom reduction after participation in two established group interventions (one community-based psychoeducative intervention; one psychotherapeutic treatment intervention) for children exposed to intimate partner violence and for their non-offending parent. The study included 50 children—24 girls and 26 boys—aged 4–13 years and their mothers. Child and maternal mental health problems and trauma symptoms were assessed preand post-treatment. The results indicate that although children showed benefits from both interventions, symptom reduction was larger in the psychotherapeutic intervention, and children with initially high levels of trauma symptoms benefited the most. Despite these improvements, a majority of the children’s mothers still reported child trauma symptoms at clinical levels posttreatment. Both interventions substantially reduced maternal post-traumatic stress. The results indicate a need for routine follow-up of children’s symptoms after interventions.

1. Introduction Children’s exposure to intimate partner violence (IPV) is associated with more emotional, behavioral, social, and cognitive problems and more trauma symptoms than children who grow up in nonviolent homes (Chan & Yeung, 2009; Evans, Davies, & DiLillo, 2008; Kitzmann, Gaylord, Holt, & Kenny, 2003; Wolfe, Crooks, Lee, McIntyre-Smith, & Jaffe, 2003). The long-term effects of exposure to IPV have also been shown to include risks of behavioral, mental, and physical health problems in adolescence and adulthood (Cater, Miller, Howell, & Graham-Bermann, 2015; Herrera & McCloskey, 2001; Miller-Graff, Cater, Howell, & GrahamBermann, 2015; Moylan et al., 2010). This accords with results from the broader field of trauma research. Research has repeatedly shown that witnessing interpersonal trauma as a child carries a high risk of negative impacts on children’s health and development through the neurobiological, psychological, and relational effects of trauma and chronic stress (D’Andrea, Ford, Stolbach, Spinazzola, & van der Kolk, 2012; Felitti et al., 1998; Teicher & Samson, 2016). A substantial proportion, 40%–60%, of children who have witnessed violence toward a caregiver have been estimated to need treatment interventions (Grych, Jouriles, Swank, McDonald, & Norwood, 2000). The accumulated body of knowledge on the negative impact of parental IPV on children’s health and development has led to an increased demand for effective interventions within society. ⁎

Corresponding author at: Department of Research and Development, Region Kronoberg, Box 1223, S-351 12, Växjö, Sweden. E-mail addresses: [email protected], [email protected] (K. Pernebo).

https://doi.org/10.1016/j.chiabu.2018.02.014 Received 20 April 2017; Received in revised form 8 February 2018; Accepted 15 February 2018 Available online 20 March 2018 0145-2134/ © 2018 Elsevier Ltd. All rights reserved.

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1.1. Effects of interventions for children exposed to IPV To prevent or limit the adverse consequences of exposure to IPV, there is a need for accessible interventions for children with clinical-level as well as subclinical-level problems (Graham-Bermann, Miller-Graff, Howell, & Grogan-Kaylor, 2015; Weisz, Sandler, Durlak, & Anton, 2005). Children should ideally be referred for treatment within the healthcare sector—for example, in child and adolescent mental health service units—when their symptoms exceed a threshold that indicates a need for clinical treatment. Alternatively, they could be offered an intervention, typically community-based with a psychoeducative approach, motivated by their exposure to parental IPV even if their problems are not in the clinical range. Unfortunately, few of the interventions designed for children exposed to IPV have been studied or evaluated (Rizo, Macy, Ermentrout, & Johns, 2011). Among treatment interventions for children exposed to IPV with clinical-level problems, Trauma-Focused Cognitive Behavioral Therapy (TFCBT) and Child–Parent Psychotherapy (CPP) have repeatedly been found to be effective in randomized controlled efficacy trials (Cohen, Mannarino, & Iyengar, 2011; Lieberman, Van Horn, & Ippen, 2005, Lieberman, Ghosh Ippen, & Van Horn, 2006). To varying degrees, these interventions show small to medium sized reductions in children’s symptoms of general psychological distress and trauma reactions, and decreases in parental symptoms of depression and traumatic stress. The Kids Club group program has been found to be an effective intervention targeting at-risk children before their problems reach clinical levels (Graham-Bermann, Lynch, Banyard, DeVoe, & Halabu, 2007, Graham-Bermann et al., 2015). Community-based interventions, including group interventions for children, combined interventions for children and their parents, individual interventions for children, and psychoeducative interventions for parents do not typically target post-traumatic stress in children and therefore often do not assess children’s symptoms of trauma in their evaluations. However, other outcomes have been assessed, and promising results have been shown in changing attitudes toward violence and reducing symptoms of distress. The level of improvement might be affected by the recruitment process, since intervention programs in community settings often involve children from more heterogeneous populations and draw upon fewer resources than programs carried out in the context of efficacy trials (Marchand, Stice, Rohde, & Becker, 2011). The objectives of psychoeducative and psychotherapeutic interventions overlap in some ways and differ in others. Preventive psychoeducative interventions aim to strengthen people’s capacity to handle negative experiences and thereby reduce their risk of future negative effects of trauma, while psychotherapeutic interventions aim primarily to reduce current symptoms and suffering. Both kinds of interventions share the goals of decreasing shame, preventing alienation, and strengthening the capacity to understand and express feelings, thoughts, and experiences. Current empirically supported treatments for trauma-related psychological problems have much in common and are typically focused on (1) psychoeducation on reactions to trauma and strategies for managing distress; (2) emotion regulation and coping skills; (3) imaginal exposure; (4) cognitive processing, restructuring, and/or meaning making; (5) emotions; and (6) memory processes (Schnyder et al., 2015). Including parents in interventions for children exposed to IPV has also been associated with positive outcomes (Graham-Bermann et al., 2007), although external or confounding variables may also influence outcomes of interventions and should not be overlooked.

1.2. Predictive, mediating, and moderating factors in the outcomes of interventions for children exposed to IPV The impact of predictive, mediating, and moderating factors on the outcomes of treatment for children exposed to IPV is unclear. Only a few studies have reported associations between child outcomes, such as reductions in emotional, behavioral, and trauma symptoms, and possible confounding variables outside treatment. Young age, initial high levels of child symptoms, high maternal trauma symptoms pretreatment, decreased maternal exposure to violence, and high child attendance at sessions have been associated with greater reductions in psychological symptoms in children after treatment (Broberg et al., 2011; Grip, Almqvist, & Broberg, 2012). The results of studies investigating predictors, mediators, and moderators of treatment outcomes for children exposed to a broad range of traumatic events suggest that the type of trauma, type of treatment, parental involvement in treatment, dosage (number of treatment sessions), and age may be moderating influences on effect sizes (Silverman et al., 2008).

1.3. Aim and research questions The aim of the present study was to investigate and compare symptom reduction in children exposed to IPV after their participation in a community-based psychoeducative intervention or a psychotherapeutic treatment. We had five main research questions: (1) What are the outcomes of the two interventions in terms of the children’s emotional, behavioral, and trauma symptoms? (2) What are the outcomes in maternal psychological health and trauma symptoms? (3) Are there associations between the age of the child, the frequency of exposure to IPV, exposure to IPV only versus exposure to IPV and additional physical child maltreatment, and the outcomes of interventions? (4) Do current conditions such as the level of child symptoms of post-traumatic stress pre-intervention, ongoing child visitations with the violent parent, and ongoing parental mental health problems influence outcomes? (5) Does the pretreatment to post-assessment change in child symptomatology differ between the two types of intervention?

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2. Method 2.1. Study design The current effectiveness study investigated the outcomes of two well-established interventions provided by regular staff in their natural settings, offered to children exposed to IPV and their non-offending parents. The study used a quasi-experimental design with assessment before (T1) and after termination of (T2) the intervention. Sociodemographic data were collected and outcomes defined as psychological symptoms, including symptoms of post-traumatic stress were assessed in both children and their mothers. By using the same research method to explore the two forms of intervention, we aimed to increase knowledge of the effectiveness of interventions for children exposed to IPV. 2.2. Participants The study included 50 children (24 girls and 26 boys aged 4–13 years; M = 7.4 years, SD = 2.5 years) and their mothers. One part of the study was in a community sample of children (n = 31) and their mothers attending a community-based intervention (CBI). The second group was in a clinical sample of children (n = 19) and their mothers attending psychotherapeutic treatment within a child and adolescent mental health service intervention (CAMHSI). Both interventions offered treatment for children accompanied by mothers or fathers, however, only mothers attended the interventions during the time of the study. At the pre-intervention assessment, all children had been exposed to IPV and 62% of them had also experienced child physical abuse according to the mothers’ reports. One mother reported ongoing physical abuse from the perpetrator toward the child, and eight mothers reported ongoing verbal abuse toward the child. The children who received the CBI were significantly older [t (48) = 5.45, p ≤ .001] and had more ongoing contact with their father [χ² (1) = 13.94, p ≤ .001] than the children who received the CAMHSI. Mothers in the CAMHSI reported higher rates of symptom in their children pre-treatment than mothers of children in the CBI. Significant differences were reported on the Strength and Difficulties Questionnaire (SDQ-P) impact score [t (45) = 2.20, p = .033]; the Emotion Questionnaire (EQ-P) emotionality scale [t (43) = 2.78, p = .008]; and the Trauma Symptom Checklist for Young Children (TSCYC) on anxiety [t (45) = 2.50, p ≤ .016], total posttraumatic stress [t (45) = 2.97, p = .005], intrusion [t (45) = 2.95, p = .005], avoidance [t (45) = 3.06, p = .004], dissociation [t (45) = 2.53, p = .015], and sexual concerns [t (45) = 2.16, p = .036]. There were no other significant differences in background characteristics or reported symptoms between children in the two intervention groups (see Table 1). The mothers were 23–51 years old (M = 36.9 years, SD = 6.3 years) and the perpetrators were 24–54 years old (M = 40.1 years, SD = 7.3 years). All mothers reported exposure to physical and psychological aggression from a former partner, while 87% also reported experiences of sexual coercion and 85% reported partner-inflicted physical injuries. There were no significant differences in maternal background characteristics or in self-reported symptoms between mothers of children in the two intervention groups. 2.3. Procedure The study was carried out in two major urban areas in Sweden at two agencies specializing in interventions for children suffering from the consequences of domestic violence: one community-based agency offering psychoeducative interventions, and one specialized child and adolescent mental health outpatient unit offering psychotherapeutic treatment interventions. Both agencies offered group interventions as a part of their regular services. During 2013–2015, all children invited to take part in group interventions for Table 1 Background characteristics of children in the community-based intervention (CBI) and the child and adolescent mental health service intervention (CAMHSI), n = 50.

Demographic description

CBI (n = 31) Freq. (%)

CAMHSI (n = 19) Freq. (%)

Girl Boy Child born in Sweden Mother born in Sweden Mother single Mother married or co-habiting with other than the perpetrator Mother with university education Mother employed or student Mother custodian Ongoing judicial and custody disputes Perpetrator biological father Perpetrator step-parent Multiple perpetrators Perpetrator born in Sweden Perpetrator with university education Perpetrator employed or student

17 (55) 14 (45) 28 (90) 19 (61) 24 (77) 6 (19) 14 (45) 17 (55) 15 (48) 15 (48) 27 (87) 3 (10) 1 (3) 17 (55) 4 (13) 21 (68)

7 (37) 12 (63) 19 (100) 14 (74) 16 (84) 3 (16) 10 (53) 16 (84) 14 (74) 15 (79) 18 (95) 1 (5) 0 (0) 9 (47) 3 (16) 14 (74)

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Fig. 1. Flow chart of children included in the study from the community-based intervention (CBI) and from the child and adolescent mental health service intervention (CAMHSI).

children exposed to IPV at the two agencies were eligible for inclusion in the study. To be included the child had to be older than 4 years but under 16, and the mothers needed to have sufficient Swedish language skills to understand and answer the questionnaires. During the period of inclusion, 54 children were invited to participate in the interventions. Two families were excluded because of poor language skills, and two families declined to participate (see Fig. 1). When invited to take part in the interventions, the mothers received written and verbal information about the study from the staff members. At their next appointment, the mothers were asked for written consent to participate. Once before the group intervention (T1) and once after completing the intervention (T2), mothers who agreed to participate provided background information on themselves and their child in a structured interview and responded to self-report inventories about themselves and their child. Identical instruments for assessment were used at T1 and T2. The pre- and post-assessments were conducted at the treatment units by the regular staff. No payment or other compensation for participation was provided. 2.4. The intervention programs The intervention programs at the two agencies were both well-established. The community unit offered an intervention with a psychoeducative concept and the child and adolescent mental health unit offered an intervention with a psychotherapeutic approach. Both programs were manualized and consisted of 12–15 weekly 90-min sessions, with parallel group sessions for children and for abused parents. Taking part in the intervention programs implied that the child and the abused parent had acknowledged the IPV. The intimate relationship between the mother and the abusive partner should have been terminated before start of the intervention. In all cases, the parents and the staff considered IPV to be the main reason for the intervention; however, there was no formal routine for performing in-depth trauma screening. Participation was voluntary and free of charge. 2.4.1. The psychoeducative intervention The psychoeducative intervention was provided at a unit offering community services for children exposed to IPV and their nonoffending parent. The intervention was directed at children exposed to IPV whether or not they presented symptoms or difficulties. The group program was based on the Children Are People Too (CAP) program (Hawthorne, 1990). CAP was originally developed for children of parents who abuse alcohol or drugs, and it has been revised, adjusted, and evaluated for use with children exposed to IPV (Georgsson, Almqvist, & Broberg, 2007; Grip, Almqvist, & Broberg, 2011, Grip et al., 2012). The groups were led by two experienced social workers and were composed of four to eight children aged 4–13 years, with an age range of 18 months within each group. Each session had a unique theme and combined a short lesson with additional exercises, discussions, play, and a snack. Themes included education on violence, safety planning, reactions to IPV, feelings, family relationships, and communication. The goals were to 216

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strengthen the children’s capacity to cope with their experiences and to reduce the risk of them being negatively affected by those experiences in the future. Other goals were to help children express and understand their feelings, thoughts, and experiences and to decrease their feelings of alienation and shame. The parents’ program used themes parallel to those in the children’s group, with the aim of increasing parental knowledge and skills and reducing parental feelings of shame and alienation. 2.4.2. The psychotherapeutic treatment intervention The psychotherapeutic treatment intervention was provided at an outpatient child and adolescent mental health unit specializing in assessment and interventions for traumatized children. The intervention was trauma-focused time-limited psychotherapy in a group setting for children exposed to IPV who showed psychiatric symptoms and complex reactions. The treatment was based on trauma theory, attachment theory, and psychodynamic theory (Brager & Lichtenstein, 2015). The groups were composed of four to six children with an age range of 18 months. Each group was led by two experienced group leaders who were psychologists or social workers. The sessions followed a fixed structure and targeted themes such as violence within the family, separation, visitations, fears, grief, and conflicts in daily life. The different themes were approached using dialogue, exercises, trauma-focused play, and free play. The treatment goals were to decrease the children’s psychiatric symptoms; to help the children express and understand their feelings, thoughts, and experiences; and to reduce their feelings of alienation and shame. Themes in the parent group paralleled those in the children’s group and were aimed at increasing parents’ knowledge and skills, reducing their feelings of shame and alienation, and strengthening the parent–child relationship. 2.5. Attrition and missing data Two mothers provided incomplete data on child and maternal measures for the pre-treatment assessment. In all other cases, missing data due to non-responses were few and were considered randomly distributed. The dropout rate from pre-treatment to postassessment was 14%. Seven mother–child dyads (6 in the CBI and 1 in the CAMHSI) discontinued the interventions. All dropouts took place before half of the sessions were completed and provided no post-treatment data (see Fig. 1). In all cases the reason for dropout was maternal health problems. There were no significant differences in background variables or initial child and maternal symptoms between the completer group and the non-completer group. All dyads that completed the interventions participated in the postassessment. Group leaders estimated high attendance from all participants, but no formal measure of attendance was applied. 2.6. Measures 2.6.1. Exposure to violence The revised Conflict Tactics Scale (CTS2) was used to assess the degree and type of IPV (Straus, Hamby, Boney-McCoy, & Sugarman, 1996). The revised version includes parental reports on the child’s exposure to the violence experienced by the parent (Broberg et al., 2011). The instrument assesses the prevalence and frequency of psychological aggression, physical assault, sexual coercion, injury, and negotiation. Internal consistency in this study varied, ranging from α = 0.59 to α = 0.90, with poor consistency on the injury subscale and acceptable or good consistency on the remaining subscales. 2.6.2. Child mental health The mothers completed the Swedish parental version of the Strength and Difficulties Questionnaire (SDQ-P; Goodman, Ford, Simmons, Gatward, & Meltzer, 2000). The questionnaire is designed to assess prosocial behavior and psychopathology in 3- to 16year-olds and consists of five subscales, plus a supplemental inquiry into the impact of problems. The subscales are emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems, and prosocial behavior; a total difficulties score is generated by summing all scores except on the prosocial behavior subscale (Goodman, 2001). The suggested Swedish cutoff score for problems in the clinical range is ≥14 points on the total difficulties scale and ≥1 on the impact scale (Smedje, Broman, Hetta, & von Knorring, 1999). Internal consistency in this study was generally satisfactory (mean α = 0.74); it was particularly good on the total difficulties and hyperactivity/inattention subscales (α = 0.83 and 0.84, respectively), but lower (α = 0.58) on the peer relationship problems subscale. 2.6.3. Child post-traumatic stress symptoms To assess the children’s post-traumatic stress symptoms, the mothers filled out the Trauma Symptom Checklist for Young Children (TSCYC; Briere et al., 2001; Nilsson, Gustafsson, & Svedin, 2012). The TSCYC is a broad-spectrum caretaker report instrument designed for the assessment of trauma symptoms in children aged 3–12 years. Its purpose is to identify symptoms that a young child can show in the aftermath of potentially traumatic experiences and it contains nine clinical scales. One scale for total post-traumatic stress consists of three subscales of intrusion, avoidance, and arousal; the other scales are anxiety, depression, anger/aggression, dissociation, and sexual concerns. The questionnaire has been shown to be reliable and valid for children exposed to potentially traumatic events (Briere et al., 2001; Nilsson et al., 2012). The suggested clinical cutoff is a T-score of 70, with T-scores of 65–69 indicating potential problems. In this study, raw scores were used as primary outcomes, and a T-score of 70 was used as the clinical cutoff. Internal consistency was satisfactory on all nine scales (mean α = 0.84, range 0.74–0.91). 2.6.4. Child emotionality and emotional regulation Emotional reactivity and capacity for emotional regulation were assessed using the Emotion Questionnaire for parents (EQ-P), a 217

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parental report on a child’s reactivity to emotional stimuli and capacity to regulate emotions (Rydell, Berlin, & Bohlin, 2003). In the present study, internal consistency was good on both the emotionality and the emotion regulation subscales (α = 0.85 for both scales). 2.6.5. Maternal mental health The Brief Symptom Inventory (BSI) was used to measure current parental psychological distress and symptoms. It is a screening instrument based on the Symptom Checklist-90 (SCL-90) rating scale (Derogatis & Melisaratos, 1983). The Global Severity Index (GSI) was used, with higher scores indicating more problems. In the Swedish validation, the norm group had a mean of 0.45 (SD = 0.4; Fridell, Cesarec, Johansson, & Malling Thorsen, 2002). In the present study, internal consistency was satisfactory (α = 0.93). 2.6.6. Maternal post-traumatic stress symptoms The Impact of Event Scale–Revised (IES-R), a self-report trauma symptoms inventory with the three subscales of intrusion, avoidance, and hyperarousal, was used to measure maternal symptoms of post-traumatic stress (Weiss, 2004). Although the IES-R is not intended as a diagnostic instrument, a mean of ≥1.89 on any subscale indicates problems and a mean of ≥1.8 on the total score indicates post-traumatic stress disorder. Internal consistency in the current study was good: α = 0.83 on the intrusion subscale, 0.79 on the avoidance subscale, 0.82 on the hyperarousal subscale, and 0.90 on the total score. 2.7. Statistical analyses Two-tailed paired t-tests were used to calculate within-group differences between pre- and post-assessment and independent ttests and Pearson’s chi-squared test were used to compare differences between the CBI and the CAMHSI. The interaction between the type of intervention received and the change in symptoms from pre- to post-assessment was explored using a general linear model (GLM) repeated measures procedure for each dependent variable, with group (CBI versus CAMHSI) as the between-subject variable and time (pre- versus post-intervention assessment) as the within-subject variable. To calculate effect sizes, Cohen’s d was applied, with ≥0.80 indicating a large effect, ≥0.50 indicating a moderate effect, and ≥0.20 indicating a small effect (Cohen, 1988). For dropouts, dependent t-tests using the last observation carried forward (LOCF) method were conducted. Univariate regression analyses were used to analyze the possible co-variation of outcomes, measured as a child’s change in symptoms between the pre- and postintervention assessment, with child’s age and gender or frequency of IPV. Multiple regression analyses were applied to control for possible associations between a child’s change in symptoms from pre- to post-intervention and possible influential variables such as child’s experience of physical abuse, child’s ongoing contact with the father, maternal ongoing symptoms of traumatic stress, and child trauma symptoms at the onset of the intervention. Clinical cutoff scores on the SDQ-P and the TSCYC were used to investigate whether the reported symptoms were clinically significant. The statistical software SPSS, version 23.0, was used for all calculations. 2.8. Ethical approval The study was approved by the Regional Ethics Committee in Uppsala (Dnr 2012/246). 3. Results All analyses were carried out both on completers and on the intention-to-treat group using LOCF. No significant differences were found between the two levels of analysis, and only analyses of data from the completers are presented in this section. 3.1. Outcomes of the interventions 3.1.1. Children’s symptoms The mothers in the CBI reported a significant reduction in their child’s emotional symptoms (SDQ-P; d = 0.34), in total posttraumatic stress (TSCYC; d = 0.35), and in intrusive symptoms (TSCYC; d = 0.40). Mothers in the CBI additionally reported a significant decrease in impact scores (SDQ-P; d = 0.62). The mothers in the CAMHSI reported significant reductions in their child’s symptoms in several areas: overall mental health symptoms (SDQ-P; d = 0.67), emotional symptoms (SDQ-P; d = 0.73), hyperactive symptoms (SDQ-P; d = 0.46), impact score (SDQ-P; d = 0.68), emotionality (EQ-P; d = 0.57), and (TSCYC) symptoms of anger (d = 0.65), arousal (d = 0.66), and dissociation (d = 0.76). Large effects were reported by the mothers in the CAMHSI for a decrease in depressive symptoms (TSCYC; d = 0.99) and an increased capacity for emotion regulation (EQ-P; d = 0.85) (see Table 2). 3.1.2. Maternal symptoms Mothers in both interventions reported significant improvements (medium to large effect size) in post-traumatic stress symptoms (IES-R), and mothers in the CBI reported significant (medium effect size) improvements in maternal general mental health (BSI; see Table 3). 218

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Table 2 Outcomes on the Strength and Difficulties Questionnaire (SDQ-P), the Emotion Questionnaire for parents (EQ-P), and the Trauma Symptom Checklist for Young Children (TSCYC) in the community-based intervention (CBI), n = 23, and in the child and adolescent mental health service intervention (CAMHSI), n = 18, pre- and post-assessment. CBI

CAMHSI

Measure

Pre M (SD)

Post M (SD)

Sig.

d

Pre M (SD)

Post M (SD)

Sig.

d

SDQ-P Total difficulties score Impact score Emotional symptoms Conduct problems Hyperactivity/inattention Peer problems Prosocial behavior

12.65 (6.12) 2.00 (2.43) 4.26 (2.77) 2.39 (2.39) 4.26 (2.73) 1.74 (1.60) 8.43 (1.56)

10.65 (6.57) 0.83 (1.34) 3.30 (2.91) 1.96 (1.69) 3.70 (3.05) 1.70 (1.46) 8.17 (1.77)

0.056 0.044* 0.031* 0.162 0.188 0.901 0.354

0.31 0.62 0.34 0.21 0.19 0.03 0.16

15.72 (6.80) 3.83 (2.83) 5.00 (2.33) 3.56 (1.85) 5.28 (3.29) 1.89 (1.88) 7.44 (2.64)

11.67 (5.33) 2.17 (2.04) 3.50 (1.79) 2.67 (1.78) 3.89 (2.76) 1.61 (1.91) 8.22 (1.90)

0.002** 0.020* 0.003** 0.053 0.032* 0.550 0.090

0.67 0.68 0.73 0.49 0.46 0.15 0.34

EQ-P Emotionality Emotion regulation

2.71 (0.80) 3.31 (0.66)

2.57 (1.06) 3.41 (0.75)

0.449 0.341

0.14 0.14

3.51 (.88) 2.95 (.70)

2.99 (.94) 3.52 (.66)

0.027* 0.009**

0.57 0.85

TSCYC Anxiety Depression Anger/aggression Total post-traumatic stress Intrusion Avoidance Arousal Dissociation Sexual concerns

16.70 (3.81) 14.96 (4.48) 15.91 (5.43) 48.35 (10.23) 15.17 (3.37) 15.61 (4.52) 17.57 (4.73) 13.78 (5.10) 9.17 (0.49)

15.65 (5.62) 14.17 (5.16) 14.83 (5.45) 44.35 (12.41) 13.70 (4.05) 14.48 (4.18) 16.17 (5.55) 13.87 (5.29) 9.22 (0.52)

0.202 0.297 0.206 0.035* 0.041* 0.164 0.126 0.939 0.714

0.22 0.16 0.20 0.35 0.40 0.26 0.27 0.02 0.10

20.44 17.44 21.00 60.06 19.50 19.89 20.67 18.67 10.28

17.94 13.00 16.61 53.11 18.33 18.17 16.61 14.50 11.33

0.081 0.004** 0.001** 0.089 0.393 0.225 0.027* 0.007** 0.342

0.42 0.99 0.65 0.47 0.20 0.36 0.66 0.76 0.25

(6.18) (6.46) (6.84) (16.51) (6.41) (5.13) (6.33) (6.94) (2.40)

(5.79) (2.52) (6.56) (13.34) (5.52) (4.55) (5.92) (4.02) (6.00)

* p < .05. ** p < .01. Table 3 Outcomes on the Brief Symptom Inventory (BSI) and the Impact of Event Scale – Revised (IES-R) for mothers in the community-based intervention (CBI), n = 23, and in the child and adolescent mental health service intervention (CAMHSI), n = 18, pre- and post-assessment. CBI

CAMHSI

Measure

Pre M (SD)

Post M (SD)

Sig.

d

Pre M (SD)

Post M (SD)

Sig.

d

BSI global IES-R total IES-R intrusion IES-R avoidance IES-R hyperarousal

1.26 2.17 2.33 1.86 2.37

0.91 1.38 1.37 1.21 1.61

0.001** < 0.001*** < 0.001*** 0.012* 0.001**

0.60 1.03 1.19 0.75 0.76

1.43 2.42 2.58 2.22 2.50

1.13 1.76 1.83 1.60 1.86

0.080 0.004** 0.002** 0.015* 0.016**

0.46 0.93 0.86 0.74 0.68

(0.63) (0.77) (0.75) (0.93) (0.96)

(0.57) (0.76) (0.84) (0.80) (1.05)

(0.57) (0.60) (0.82) (0.72) (0.89)

(0.71) (0.84) (0.92) (0.94) (1.02)

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

3.2. Comparison of outcomes from the two interventions Significant group × time interactions indicated a difference in treatment effects between the two interventions. Mothers of children in the CAMHSI reported larger improvement on prosocial behavior (SDQ-P) [F (1, 39) = 4.45; p = .041; d = 0.66], emotional regulation (EQ-P) [F (1, 38) = 5.39; p = .026; d = 0.74], depression (TSCYC) [F (1, 39) = 6.45; p = .015; d = 0.80], anger (TSCYC) [F (1, 39) = 5.79; p = .021; d = 0.75], and dissociation (TSCYC) [F (1, 39) = 5.94; p = .020; d = 0.73] than mothers of children in the CBI. No significant differences in maternal outcomes were found between the two interventions.

3.3. Children’s outcome and possible predictors, moderators, and mediating factors High levels of post-traumatic stress (TSCYC) in children pre-treatment were associated with larger improvements from pre- to post-assessment on several measures: the emotional symptoms [B = 0.047 (SE = 0.02); β = 0.349; p = .025, adjusted R² = 0.099] and prosocial behavior [B = 1.056 (SE = 0.517); β = 0.311; p = .048, adjusted R² = 0.048] subscales of the Strength and Difficulties Questionnaire, the subscale of emotional regulation in the EQ-P [B = 0.026 (SE = 0.007); β = −0.493; p = .001, adjusted R² = 0.223], and four subscales of the Trauma Symptom Checklist for Children: anxiety [B = 0.104 (SE = 0.050); β = 0.317; p = .043, adjusted R² = 0.078], depression [B = 0.174 (SE = 0.046); β = 0.515; p = .001, adjusted R² = 0.246]; total post-traumatic 219

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Table 4 Percentage of children in the community-based intervention (CBI), n = 23, and the child and adolescent mental health service intervention (CAMHSI), n = 18, with psychiatric symptoms within clinical range pre- and post-intervention on the Strength and Difficulties Questionnaire (SDQ-P) and the Trauma Symptom Checklist for Young Children (TSCYC). CBI

CAMHSI

Measure

Pre

Post

Pre

Post

SDQ-P Total difficulties score SDQ-P Impact score TSCYC Anxiety TSCYC Depression TSCYC Anger/aggression TSCYC Total post-traumatic stress Intrusion Avoidance Arousal TSCYC Dissociation TSCYC Sexual concerns

43 % 60 % 54 % 43 % 50 % 71 % 61 % 64 % 54 % 36 % 7%

36 % 36 % 28 % 28 % 28 % 56 % 44 % 64 % 44 % 32 % 0%

58 % 79 % 74 % 74 % 74 % 95 % 90 % 100 % 79 % 68 % 42 %

39 67 56 50 33 89 72 94 44 39 28

% % % % % % % % % % %

Note. Cutoff score on SDQ-P total difficulties scale ≥ 14 and on SDQ-P impact scale ≥ 1, and cutoff score on all TSCYC subscales T ≥ 70.

symptoms [B = 0.583 (SE = 0.114); β = 0.674; p = < .0001, adjusted R² = 0.242]; and dissociation [B = 0.147 (SE = 0.061); β = 0.361; p = .020, adjusted R² = 0.108]. A high level of ongoing maternal post-traumatic symptoms (IES-R total) post-treatment was associated with a small decrease in symptoms measured on the TSCYC total post-traumatic stress subscale [B = − 0.313 (SE = 0.092); β = − 0.445; p = .002]. A model including children’s post-traumatic stress pre-treatment and maternal post-traumatic stress post-treatment explained 40% of the variance in the changes in the children’s symptoms of post-traumatic stress during the interventions (adjusted R² = 0.403). No interactions were found between subgroups based on background characteristics and outcome. No significant association was found between the children’s outcomes on any measure and the children’s gender, age, or frequency of IPV reported by mothers, nor was any association found between the children’s experience of physical maltreatment, their visitations with the violent parent, and reported changes in the children’s symptoms after participating in the interventions. 3.4. Clinical significance Despite the decreases in several reported symptoms from pre- to post-intervention, several mothers still reported their children’s symptoms post-treatment as above the cutoff score for clinical problems (see Table 4). 4. Discussion The present study aimed at expanding knowledge on the effectiveness of interventions for children exposed to IPV by exploring two forms of group intervention, one psychoeducative and one psychotherapeutic, using the same research method for both interventions. The findings indicate that children and their mothers both benefited from the psychoeducative and the psychotherapeutic intervention. The children in the psychotherapeutic treatment showed higher pre-treatment symptom rates than those in the psychoeducative intervention, and their mothers reported greater post-treatment reductions in child symptoms in more areas and with greater effect size. The two interventions did not differ in effectiveness in most areas, although the psychotherapeutic intervention seemed to have been more effective than the psychoeducative approach in reducing children’s symptoms of depression, anger, and dissociation and promoting their prosocial behavior. The present study indicates similarities as well as differences in the outcomes of these interventions with results from previous research on established interventions for children exposed to IPV. The reduction in children’s symptoms of general psychological distress accorded with effect sizes reported elsewhere for CBI (Graham-Bermann et al., 2007, Graham-Bermann et al., 2015). The reported reduction of depressive symptoms in children in the CAMHSI in this study was higher, with larger effect sizes, than the reduction of symptoms of general psychological distress presented in earlier studies. The effect sizes of decreases in trauma symptoms in children in both interventions were lower in this study than in previously reported individual and dyadic treatments (Cohen et al., 2011; Lieberman et al., 2005, Lieberman et al., 2006). Regardless of which of the two interventions was provided, children with high levels of post-traumatic stress before treatment improved the most in several areas, which is in accord with previous studies (Grip et al., 2012). Children’s post-traumatic stress pretreatment may serve as a predictor of outcomes in some areas, indicating that the children with the highest levels of post-traumatic stress may be the ones who benefit most from treatment. The results showing that high levels of ongoing maternal post-traumatic stress symptoms post-treatment were associated with less reduction of children’s post-traumatic stress symptoms imply that maternal post-traumatic stress may mediate the reduction of children’s symptoms of post-traumatic stress. Children with a mother severely affected by continuous trauma symptoms may benefit less than other children from the interventions. No association was found between the outcome of intervention for a child and the child’s age, type and degree of abuse, or contact with the violent parent and. This implies that differences in background variables did not influence the outcomes of the interventions. It should be noted that the violence experienced by the mothers in this study was severe in all cases, a factor that may have limited the variations necessary for 220

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detecting significant differences on this aspect. The results of the study indicate that the psychotherapeutic intervention was somewhat more effective than the psychoeducative intervention in reducing child symptoms in the aftermath of IPV. This result could be expected, considering the different goals and contexts of the interventions, with the CAMHSI addressing and explicitly targeting symptom reduction in children with psychiatric symptoms and complex reactions. The CBI aimed to strengthen the children’s capacity to cope with their experiences rather than to reduce their symptoms. Nevertheless, many mothers in the CBI reported a reduction in their children’s emotional and post-traumatic symptoms and a decrease in the everyday impact of these symptoms post-treatment. In both interventions, however, many mothers reported their children’s continuing high levels of symptoms, often within the clinical range, after treatment. Trauma symptoms in particular were unsatisfyingly affected by the interventions. It is relevant to consider to what extent the two interventions included the elements typical of empirically supported treatments: psychoeducation on reactions to trauma and strategies to manage distress; emotion regulation and coping skills; imaginal exposure; cognitive processing, restructuring, and/or meaning making; emotions; and memory processes (Schnyder et al., 2015). Most of these components were present in both interventions in this study and may be related to the positive outcomes. It is evident, though, that imaginal exposure (such as engaging in narratives and play focused on the individual trauma) and stimulating memory processes were minor components in both interventions. Neither of the group interventions focused clearly on the children’s individual experiences of trauma. The lack of these components may be related to the unsatisfying results for symptoms of posttraumatic stress. This may support the notion that severe symptoms of trauma, specifically avoidance and intrusion, are not well treated without the components of concrete or imaginal exposure and a focus on memory processes. These components may be particularly difficult to include in group interventions with traumatized children, especially young children. It is striking that mothers in both interventions reported significant improvements in their own mental health as well as substantial reductions in symptoms of post-traumatic stress. Whether the reported large effects on maternal health are associated with the mothers’ experience of improved health in their children, are linked to the specific content in the parental intervention such as sharing traumatic experiences, or are due to other factors remains to be understood through further research. This finding indicates that the interventions were more effective in reducing trauma symptoms in mothers than in children. 4.1. Clinical implications The results of this study are encouraging and suggest the possibility of providing effective group interventions in both community and clinical settings to children and mothers exposed to IPV. However, some points of concern remain. First, children’s symptoms of traumatic stress seem to be insufficiently treated in both of the studied interventions, indicating the importance of recognizing in clinical practice that some children need more extensive, additional, or different interventions. Children with severe symptoms of traumatic stress may need individualized components targeting their emotional and cognitive processes, including concrete or imaginal exposure. Second, the high proportion of children with a possible lasting need for treatment or other support after participating in the interventions calls attention to the need to develop routines for thorough post-treatment assessment and follow-up including continuing support or referral when required. Finally, continuing post-treatment symptoms of traumatic stress in their mothers might reduce the benefit of these programs for the children. This strongly suggests the importance of providing appropriate support and treatment opportunities for the mothers of children attending such interventions. 4.2. Strengths and limitations The study was carried out in a naturalistic setting, using well-established interventions led by regular staff members, among children and parents who would still have attended the interventions had the research project not been conducted. This amplifies the studies external validity: the findings can be regarded as representative of these two interventions and thus generalizable to similar community-based and clinical interventions. High compliance from the participants in both attendance and response to the research measures lend strong support to the findings. The low rate of attrition was fostered by the stability and continuity of the agencies and the parents’ trust in the staff. The structure of the research protocol, including the highly structured implementation of the study on all organizational levels and the concrete and accessible support offered by the first author to the staff, further strengthened the continuous participation of the mothers. A strength of the study is that it was completed with very low attrition and a very complete dataset. This might not have been possible had study contained a larger sample. The lack of a control group limits the conclusions that can be drawn from the results, but there was no practical or ethical way to construct a control group for this the study. Ethically, the immediate need for treatment and support of the included children and their mothers demanded the provision of a fast and safe intervention without the delay involved in recruiting and selecting a control group. Another limitation is that the study did not include data on attendance other than estimates from the group leaders, who all reported high attendance by all participants completing the interventions. An issue of interest that calls for follow-up studies is the sustainability of post-treatment results, including questions about possible continuing improvement or deterioration after treatment. The study was carried out at two different units in Stockholm and Gothenburg. These two units were the only ones in Sweden with long systematic experience of providing group interventions for children exposed to IPV. The period of inclusion was set to three years because longer would have increased the risk of influence of external contextual factors such as staff turnover and organizational changes. It was thus not possible to control which or how many children to include. The small sample size in the study limits our ability to analyze the heterogeneity of the populations and associations between subgroups (different ages, ethnicities, experiences, and living conditions) and outcome, although it did contribute to the studies high attendance and complete datasets. 221

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The limitations of the study further include no measure of treatment integrity/fidelity and reliance on maternal reports for both child and maternal variables. It has been argued that parental reports can be insufficient and/or invalid (Biering, 2010). This study relied solely on maternal reports owing to a lack of resources and valid measures for self-reports from the youngest children. Another crucial reason for relying on maternal reports was that active participation of the child in the research study would have required consent from the other parent (when the custodian), a procedure that may well have led to a substantial number of mothers not consenting to participate because of their fear of contact with the (formerly) abusive father. There were no significant differences in maternal demographics or in self-reported symptoms between mothers in the two intervention groups. Nevertheless, the results show between-group differences in maternal reports on child symptoms, which in fact strengthens the validity of the maternal reports. 4.3. Future research and development Future research and the development of interventions for children exposed to IPV would benefit from studies on identification and differentiation between children sufficiently supported by community or group interventions and those in need of different or extended support and interventions. More knowledge is also needed on specific components, such as imaginal or in-vivo exposure and the reduction of maternal symptoms, as well as the development of ways to add such individualized components to interventions as necessary. 5. Conclusion The results of this study indicate that children benefit from both psychoeducative and psychotherapeutic group interventions. Symptom reduction was substantially larger in the psychotherapy intervention, and children with initially high levels of trauma symptoms benefited the most. Both interventions were also successful in reducing mothers’ post-traumatic stress, but children whose mothers remained severely affected by symptoms of trauma benefited less from the interventions. The fact that most mothers still reported their children as having clinical-levels symptoms of traumatic stress post-treatment implies the necessity of developing clinical routines to identify children in need of different or extended support. Children who witness violence toward a caregiver seemed to benefit from both group interventions offered. We recommend including a focus on maternal psychological functioning as well as routine follow-ups of children’s symptoms and needs during and after interventions. Disclosure Statement No potential conflict of interest is reported by the authors. Funding The study was funded by Region Kronoberg and the County Council of Värmland, Sweden. Acknowledgements We would like to thank the Bojen foundation in Gothenburg and the Trauma Unit at the Child and Adolescent Psychiatry in Stockholm for their collaboration on this study. We would also like to thank all participating caregivers for their contributions. Senior lecturer, PhD, Anna Lindgren, Centre for mathematical Sciences, Lund University, Lund, Sweden, supported data analyzing and interpretation. References Biering, P. (2010). Child and adolescent experience of and satisfaction with psychiatric care: A critical review of the research literature. Journal of Psychiatric & Mental Health Nursing, 17(1), 65–72. http://dx.doi.org/10.1111/j.1365-2850.2009.01505.x. Brager, S., & Lichtenstein, A. (2015). Traumafokuserad psykoterapigrupp för barn som upplevt våld i familjen. [Trauma focused group psychotherapy for children with experience of family violence. Stockholm: BUP Traumaenhet. 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