Mediators and Treatment Factors in Intervention for Children Exposed to Interparental Violence.

Changes in children's emotion differentiation, coping skills, parenting stress, parental psychopathology, and parent-child interaction were explored as mediators of treatment factors in two selective preventive group interventions for children exposed to interparental violence (IPV) and their parents. One hundred thirty-four IPV-exposed children (ages 6-12 years, 52% boys) and their parents were randomized to an IPV-focused or common factors community-based group intervention and completed baseline, posttest, and follow-up assessments for posttraumatic stress (PTS). A multilevel model tested mediators that included children's ability to differentiate emotions and coping skills, parenting stress, parental psychopathology, and parent-child interactions. In both conditions, exposure to nonspecific factors, specific factors unrelated to IPV and trauma-specific intervention factors was coded from videotaped child and parent sessions. Improved parental mental health mediated the link between greater exposure to nonspecific treatment factors and decreases in PTS symptoms. In addition, an increase in emotion differentiation and a decrease in parenting stress were associated with a decrease in PTS symptoms. Greater exposure to trauma-specific factors in child sessions was associated with a small decrease in emotion differentiation, an increase in coping skills, and a decrease in PTS symptoms over time. Greater exposure to nonspecific treatment factors in child and parent sessions was associated with more positive parent-child interaction. Parental mental health appears to be an important mechanism of change that can be promoted through exposure to nonspecific factors in parent intervention. For children, the effect of greater exposure to trauma-specific factors in intervention is less clear and may not have clear benefits.

The effects of parental components in a trauma-focused cognitive behavioral based therapy for children exposed to interparental violence: study protocol for a randomized controlled trial.

BACKGROUND: Interparental violence is both common and harmful and impacts children's lives directly and indirectly. Direct effects refer to affective, behavioral, and cognitive responses to interparental violence and psychosocial adjustment. Indirect effects refer to deteriorated parental availability and parent-child interaction. Standard Trauma Focused Cognitive Behavioral Therapy may be insufficient for children traumatized by exposure to interparental violence, given the pervasive impact of interparental violence on the family system. HORIZON is a trauma focused cognitive behavioral therapy based group program with the added component of a preparatory parenting program aimed at improving parental availability; and the added component of parent-child sessions to improve parent-child interaction. METHODS/DESIGN: This is a multicenter, multi-informant and multi-method randomized clinical trial study with a 2 by 2 factorial experimental design. Participants (N = 100) are children (4-12 years), and their parents, who have been exposed to interparental violence. The main aim of the study is to test the effects of two parental components as an addition to a trauma focused cognitive behavioral based group therapy for reducing children's symptoms. Primary outcome measures are posttraumatic stress symptoms, and internalizing and externalizing problems in children. The secondary aim of the study is to test the effect of the two added components on adjustment problems in children and to test whether enhanced effects can be explained by changes in children's responses towards experienced violence, in parental availability, and in quality of parent-child interaction. To address this secondary aim, the main parameters are observational and questionnaire measures of parental availability, parent-child relationship variables, children's adjustment problems and children's responses to interparental violence. Data are collected three times: before and after the program and six months later. Both intention-to-treat and completer analyses will be done. DISCUSSION: The current study will enhance our understanding of the efficacy interparental violence-related parental components added to trauma focused cognitive behavioral group program for children who have been exposed to IPV. It will illuminate mechanisms underlying change by considering multiple dimensions of child responses, parenting variables and identify selection criteria for participation in treatment. TRIAL REGISTRATION: Netherlands Trial Register NTR4015 . Registered 4th of June, 2013.

Temperament, disordered attachment, and parental sensitivity in foster care: differential findings on attachment security for shy children.

In a foster care sample, the moderating effect of temperamental shyness on the association between parental sensitivity and attachment quality was tested. The foster parents of 59 foster children (age M = 57 months, SD = 16.4) filled out the Child Behavior Questionnaire. To control for confounds, symptoms of inhibited and disinhibited disordered attachment were derived from the Disturbances of Attachment Interview. The Strange Situation Procedure as well as a 15 minute parent-child interaction task were administered. Analyses indicated an interaction effect between parental perceptions of shyness and parental sensitivity for attachment quality. Shy children who had more sensitive foster parents were more often securely attached. For less shy children, no differences in attachment security were found in relation to the foster parents' sensitivity. These results are partially consistent with the differential susceptibility hypothesis. Shy children may benefit more from more sensitive foster parents when entering foster care.

Quality of Mother-child Dialogue About Emotional Events, Coping and Posttraumatic Stress Symptoms Among Children Exposed to Interpersonal Trauma.

Children exposed to traumatic events are at increased risk for developing symptoms of a Post-Traumatic Stress Disorder. Children often discuss emotional, and therefore also traumatic, events in their lives with their parents, and the quality of these discussions can facilitate coping and further development. The study aim was 1) to explore whether the association between the quality of dialogue between mothers and children about emotional events and children's posttraumatic stress symptoms (PTSS) might be indirectly linked through children's adaptive coping skills, and 2) whether this association differed when discussing different negative emotions. 169 mother-child dyads with interpersonal trauma-exposure (86% domestic violence, 14% mother and/or child sexually abused) participated in the Autobiographical Emotional Events Dialogue (AEED). Quality of mother-child emotion dialogue, captured in maternal sensitive guidance and child cooperation, and approach-oriented coping were coded from transcripts. PTSS was measured with the Child Behavior Checklist. Lower quality of mother-child emotion dialogue was associated with less approach-oriented coping and more symptoms of posttraumatic stress. There was an indirect effect of approach-oriented coping with angry feelings linking quality of mother-child emotion dialogue and child PTSS. Children's symptoms of posttraumatic stress were reflected in the quality of mother-child dialogues about traumatic and other emotional events. Findings support that dialogues about emotional events may be a promising target for intervention with children exposed to trauma.

Talking About Feelings: Mother-Child Emotion Dialogues Among Sexually Abused Children.

Mother-child dialogues about children's emotional experiences are associated with children's adaptive coping with stressful situations and mental health. Despite these findings, dialogues have not been examined yet in the context of child sexual abuse. This gap is surprising given that mother-child dialogues may particularly promote children's recovery from traumatic events. The current exploratory study examined the quality of mother-child emotion dialogues, as well as the quality of child and maternal contributions to dialogues, among dyads with sexually abused children (n = 30; 60% female; M age = 8.03), as compared with dyads with nonabused children (n = 30; 60% female; M age = 8.20). Quality of dialogues was assessed using the Autobiographical Emotional Events Dialogue. Mothers reported on their own childhood maltreatment history and psychopathological symptoms. Results showed that dyads with abused children were more likely to engage in overwhelming/excessive dialogues and dialogues lacking content, as compared with dyads with nonabused children. After controlling for differences in background characteristics, mothers of abused children showed lower sensitive guidance. Although mothers of abused children had more experiences of childhood maltreatment and higher levels of psychopathology, they did not add to explain group differences in maternal sensitive guidance. Our findings suggest that the ability to discuss emotional experiences may be impaired among mother-child dyads with sexually abused children. This may be an important target in the treatment of sexually abused children and their families.

Autonomic reactivity in relation to attachment and early adversity among foster children.

This study examined whether the quality of relationships with foster caregivers was associated with autonomic nervous system reactivity of children during separation and reunion with their foster caregiver. Moreover, effects of early adversity were examined in relation to attachment and autonomic nervous system reactivity. The sample included 60 children between 26 and 88 months of age, who participated with their primary foster caregivers in the Strange Situation. Respiratory sinus arrhythmia and preejection period were measured as indicators of parasympathetic and sympathetic nervous system reactivity, respectively. Attachment quality (ordered/disordered and secure/insecure attachment), was coded on the basis of children's behavior in the Strange Situation using the Cassidy and Marvin coding system. Children with a background of neglect and those with disordered (disorganized-controlling or insecure-other) attachment showed most sympathetic reactivity during the procedure. Moreover, children with disordered attachment showed less vagal regulation (respiratory sinus arrhythmia decreases on separation and increases on reunion) than children with ordered attachment. The findings show that the quality of relationships with current caregivers, and to a lesser extent specific experiences of neglect, may have an impact on children's abilities to regulate emotions in the context of environmental stress and challenges.

Attachment behaviour towards support staff in young people with intellectual disabilities: associations with challenging behaviour.

BACKGROUND: Attachment research has shown the importance of attachment behaviour for the prevention of dysregulated behaviour due to emotional distress. The support of an attachment figure may be especially important for people with intellectual disability (ID), because they are less adept in dealing with stressful situations on their own. Our purpose was to examine the role of support staff as targets of attachment behaviour for young people with ID by testing the hypothesis that young people who more often engage in attachment interactions with group care staff are less at risk for challenging behaviours. The study design included professional caregivers' report of young persons' attachment behaviour across different relationships to address the relationship-specific nature of attachment behaviour in a group care context. METHODS: Support staff rated attachment behaviour of 156 young participants with moderate to severe ID who were attending a group care setting. For each participant, we asked two members of the classroom support staff to fill out the Secure Base Safe Haven Observation list. One of them also rated challenging behaviour (Abberant Behavior Checklist). RESULTS: Young people who showed more secure attachment behaviour towards professional caregivers were less irritable, less lethargic and less stereotypic in their behaviour, even if we controlled for developmental age and Autism Spectrum Disorders. Two results point in the direction of relationship-specific attachment behaviour: the absence of high consistency in a person's attachment behaviour towards two different caregivers and the independent contribution of each of these relationships to explaining differences in lethargy and stereotypies. A certain preference in attachment behaviour towards specific caregivers was not associated with challenging behaviour. CONCLUSIONS: Findings suggest that attachment behaviour may be part of young persons' adaptation to the stresses and challenges of group care. Furthermore, adaptation may be determined by the integration of relationships with support staff, because each relationship with a care staff member bears uniquely on challenging behaviour.

Trauma Exposure in Relation to the Content of Mother-Child Emotional Conversations and Quality of Interaction.

Parent-child conversations contribute to understanding and regulating children's emotions. Similarities and differences in discussed topics, quality of interaction and coherence/elaboration in mother-child conversations about emotional experiences of the child were studied in dyads who had been exposed to interpersonal trauma (N = 213) and non-trauma-exposed dyads (N = 86). Results showed that in conversations about negative emotions, trauma-exposed children more often discussed trauma topics and focused less on relationship topics than non-trauma-exposed children. Trauma-exposed dyads found it more difficult to come up with a story. The most common topics chosen by dyads to discuss for each emotion were mostly similar between trauma-exposed dyads and non-trauma-exposed dyads. Dyads exposed to interpersonal traumatic events showed lower quality of interaction and less coherence/elaboration than dyads who had not experienced traumatic events. Discussion of traumatic topics was associated with lower quality of mother-child interaction and less coherent dialogues. In conclusion, the effect of the trauma is seen at several levels in mother-child interaction: topics, behavior and coherence. A focus on support in developing a secure relationship after trauma may be important for intervention.

I'll Never Forgive You: High Conflict Divorce, Social Network, and Co-Parenting Conflicts.

The relation between divorce, co-parenting conflicts, and children's adjustment problems has been well established. An unresolved question for research and clinical interventions, however, is how conflicts between parents are maintained and/or escalate. This cross-sectional research tested the hypothesis that co-parenting conflicts in divorced couples are associated with perceived social network disapproval and that this relation is mediated by parents' tendency to forgive each other. In Study 1, a convenience sample of 136 divorced parents recruited via online forums, we showed that perceived social network disapproval was indeed positively related to co-parenting conflicts and that parents' tendency to forgive the other parent-albeit partly-explained this relationship. Strength of our research is that in Study 2, 110 parents referred to children's mental health care because the wellbeing of the children was severely compromised by the severity of the conflicts between parents, we replicated these results. In both studies perceived social network disapproval and co-parenting conflicts were positively related and this link was mediated by forgiveness: perceived social network disapproval was negatively related to forgiveness, which in turn was negatively related to more parental conflicts.

Professional caretakers as attachment figures in day care centers for children with intellectual disability and behavior problems.

Do children with intellectual disabilities (ID) show attachment behavior towards their professional caretaker? Five children, varying in chronological age, developmental age and DSM-diagnosis, were observed in a day care setting. Their attachment behavior was described by means of the Attachment Q-sort. Attachment behavior varied within and between children, irrespective of their diagnosis. This data indicates that professional caretakers are potential attachment figures for children with ID. Attachment introduces certain considerations for day care for children with ID, as well as opportunities for prevention and intervention. Implications for research and practice are discussed.

Family Functioning and Children's Post-Traumatic Stress Symptoms in a Referred Sample Exposed to Interparental Violence.

This study examined the association between interparental violence (IPV), child abuse and neglect, other traumatic experiences, and children's post-traumatic stress (PTS) symptoms and explored the moderating role of family functioning in the aftermath of IPV. One hundred and twenty IPV-exposed children (53.3 % male, M age = 9.85) and parents who were referred to community mental health centers participated in the study. Combined, IPV, child abuse and neglect, and other traumatic experiences were associated with PTS symptoms. For family functioning, higher levels of parenting stress were associated with higher levels of PTS symptoms. No moderating effects were found. To understand the variability in PTS symptoms among children exposed to IPV, other traumatic and stressful experiences need to be taken into account.

Risk factors as moderators of recovery during and after interventions for children exposed to interparental violence.

High family risk was tested as an impediment to recovery in children exposed to interparental violence (IPV) participating in community-based intervention. Characteristics of IPV were also explored as moderators for the effect of an IPV-focused intervention over a common factors intervention. Baseline, posttest and follow-up measurements of 155 parents and children (aged 6 to 12 years; 55.5% boys) were fitted in a multilevel model. Outcomes were clinical classifications of internalizing and externalizing problems, and posttraumatic stress symptoms. Tested moderators were child maltreatment, symptoms of disordered attachment, parental psychopathology, parenting stress, poverty, and IPV characteristics. Children without symptoms of disinhibited social engagement disorder, children of parents with high levels of psychopathology, and children of parents with high levels of parenting stress showed strongest recovery. Participation in an IPV-focused intervention was not more effective than in a common factors intervention, irrespective of the nature of the IPV. Based on rate of recovery, participation in community-based group interventions does not need to be contraindicated for children facing high family risk after being exposed to IPV, except for children with symptoms of disinhibited social engagement disorder.

Screening symptoms of reactive attachment disorder: evidence for measurement invariance and convergent validity.

The Relationship Problems Questionnaire (RPQ) was developed to screen symptoms of the inhibited and disinhibited subtype of reactive attachment disorder (RAD). This study further examines the psychometric properties of the RPQ in children with severe emotional and behavioural problems by testing its measurement invariance across informants and its convergent validity. Parents and teachers of 152 children [mean age (Mage) = 7.92] from 20 schools for special education filled out the RPQ and the Strengths and Difficulties Questionnaire (SDQ). During a home visit in a subsample of 77 children the Disturbances of Attachment Interview (DAI) was administered to the caregiver and the child was observed using an observational schedule for RAD. Exploratory and confirmatory factor analyses revealed the expected two-factor structure for both parent and teacher RPQ. Configural and metric invariance, but no scalar invariance, were obtained across informants. Both RPQ-subscales had acceptable to good internal consistencies and correlated as expected with similar DAI-subscales. Furthermore, the disinhibited RPQ-scale related with observations of the child's approach to a stranger. Finally, significant associations were found between the RPQ and the SDQ. Overall, the RPQ has good psychometric qualities as a multi-informant instrument for RAD-symptoms in children with severe emotional and behavioural problems.

Effectiveness of specific factors in community-based intervention for child-witnesses of interparental violence: a randomized trial.

A community-based intervention with specific factors for children and parents exposed to interparental violence (IPV) was compared with a control intervention based on non-specific factors. We hypothesized that participation in an intervention with specific factors, focused on IPV, parenting and coping, would be associated with better recovery. IPV exposed children and parents were group randomized over a specific factors- and control intervention. Baseline, posttest and follow-up measurements of 155 parents and children (aged 6-12 years, 55.5% boys) were fitted in a multilevel model. Outcomes were parent and teacher reported children's internalizing and externalizing problems (CBCL, TRF), child self-reported depressive symptoms (CDI) and parent and child reported children's post-traumatic stress symptoms (TSCYC, TSCC). Based on intention-to-treat and completer analyses, children in the specific factors intervention did not show better recovery than children in the control intervention. Children in both interventions decreased significantly in parent-reported children's internalizing and externalizing problems and post-traumatic stress symptoms. Children reported a decrease in their mean level of depressive and post-traumatic stress symptoms. Teachers reported a decrease in internalizing problems, but not in externalizing problems. No association between time since exposure and level and course of symptoms was found. Treatment differentiation was assessed and both programs were significantly different on hypothesized effective factors. Higher treatment adherence in both programs did not result in a larger difference in recovery. IPV exposed children improve over the course and after participating in a community-based child- and parent program, but specific factors in intervention may not carry additional benefits when implemented in community settings.

Children's physical health complaints after exposure to intimate partner violence.

OBJECTIVES: A clear association between exposure to intimate partner violence (IPV) and children's physical health is still not well determined, because adverse effects might be explained by the confounding detrimental effects of other traumatic experiences. This study investigated whether children exposed to IPV have higher risks for physical health complaints compared to children in a general population sample. Second, health complaint differences were explored between IPV witnesses and those who in addition experienced other forms of abuse or neglect. DESIGN: Risk estimates for 21 everyday physical health complaints were made for children exposed to IPV compared to a general population sample using odds ratios. METHODS: Primary caregivers of 275 child witnesses of IPV (6-12 years of age) referred to several specialized mental health or child welfare institutes throughout the Netherlands (2004-2009) reported on children's somatic complaints using 21 items of the Child Behaviour Checklist (CBCL; Achenbach & Rescorla, 2001) reflecting sleeping, eating, pain complaints, and self-harm. RESULTS: Compared to a population sample (n= 903), child witnesses more often experienced health complaints, in particular, more eating, sleeping, and pain problems and more self-harm. Few differences in health complaints were found between child witnesses with and without additional adverse experiences of maltreatment. CONCLUSIONS: The degree of physical health complaints in children exposed to IPV is considerable, whether or not they were also victims of other forms of abuse. Early attention to everyday health complaints in children exposed to IPV might prevent more serious health problems in adolescence and adulthood.

The effectiveness of a trauma-focused psycho-educational secondary prevention program for children exposed to interparental violence: study protocol for a randomized controlled trial.

BACKGROUND: Children who witness interparental violence are at a heightened risk for developing psychosocial, behavioral and cognitive problems, as well as posttraumatic stress symptoms. For these children the psycho-educational secondary prevention program 'En nu ik...!' ('It's my turn now!') has been developed. This program includes specific therapeutic factors focused on emotion awareness and expression, increasing feelings of emotional security, teaching specific coping strategies, developing a trauma narrative, improving parent-child interaction and psycho-education. The main study aim is to evaluate the effectiveness of the specific therapeutic factors in the program. A secondary objective is to study mediating and moderating factors. METHODS/DESIGN: This study is a prospective multicenter randomized controlled trial across cities in the Netherlands. Participants (N = 140) are referred to the secondary preventive intervention program by police, social work, women shelters and youth (mental health) care. Children, aged 6-12 years, and their parents, who experienced interparental violence are randomly assigned to either the intervention program or the control program. The control program is comparable on nonspecific factors by offering positive attention, positive expectations, recreation, distraction, warmth and empathy of the therapist, and social support among group participants, in ways that are similar to the intervention program. Primary outcome measures are posttraumatic stress symptoms and emotional and behavioral problems of the child. Mediators tested are the ability to differentiate and express emotions, emotional security, coping strategies, feelings of guilt and parent-child interaction. Mental health of the parent, parenting stress, disturbances in parent-child attachment, duration and severity of the domestic violence and demographics are examined for their moderating effect. Data are collected one week before the program starts (T1), and one week (T2) and six months (T3) after finishing the program. Both intention-to-treat and completer analyses will be done. DISCUSSION: Adverse outcomes after witnessing interparental violence are highly diverse and may be explained by multiple risk factors. An important question for prevention programs is therefore to what extent a specific focus on potential psychotrauma is useful. This trial may point to several directions for optimizing public health response to children's exposure to interparental violence.