Effectively intervening in traumatized parents and children after structural domestic violence

While the adverse effects of domestic violence on victimized parents and
children have been extensively documented, there is still little knowledge on
effective intervention approaches for these families. Even more scarce are
intervention studies that target young children including infants and toddlers,
even though these children are particularly vulnerable for the long-term
effects of domestic violence. Their risk to develop trauma-related
psychopathology is exacerbated because victimized parents are likely to show
disrupted parenting due to their own traumatization (resulting from domestic
violence and often also from their own traumatic childhood). This increases the
risk on a disturbed attachment relationship. It is therefore crucial that the
parent-child relationship is targeted in an intervention for these families. In
addition, treatment should focus on reducing individual post-traumatic stress
symptoms (PTSD symptoms) of the parent.

The goal of this study is first to test the effectiveness of a short-term,
attachment-based parenting intervention (NIKA) for victimized mothers and their
children after domestic violence (phase 1). Next, we will evaluate the
additional effectiveness of an intervention focused on individual trauma
therapy for the mother (EMDR) (phase 2). The goals of this study are:
1. To test whether mothers who receive NIKA will show less disrupted parenting
than mothers in the waitlist usual care group.
2. To test whether mothers who receive NIKA will show more sensitive parenting
than mothers in the waitlist usual care group.
3. For mothers who report clinically significant PTSD symptoms in phase 2: To
test whether mothers who receive EMDR will show fewer PTSD symptoms than
mothers in the waitlist usual care group.
Furthermore, we will explore the additive effects of NIKA and EMDR for mothers
with clinical PTSD symptoms on their parenting behavior.

The hypotheses will be tested using a randomized controlled trial (RCT).
Families who are residing in or receive care from one of the included women
shelters will be randomly assigned to either NIKA or a waitlist usual care
group (phase 1). A pre-test will be conducted prior to the treatment period and
a post-test will be conducted directly afterwards (six weeks later). During the
post-test of phase 1, all mothers will be screened for clinical PTSD symptoms.
Those mothers who do not report clinical PTSD symptoms will not participate in
the randomization for EMDR, whereas those mothers who do report clinical PTSD
symptoms will be randomly assigned to either EMDR or a waitlist usual care
group. Six weeks later, directly after the treatment period, a post-test of
phase 2 will be conducted for all families.

NB: Even though we refer to *clinical PTSD symptoms* in our study protocol, the
mothers who will be included in this study will not be classified with
posttraumatic stress disorder by a psychiatrist. Selection of mothers for EMDR
will occur based on a validated self-report questionnaire that measures PTSD
symptoms consistent with the DSM-V. Only those mothers with self-reported
clinical PTSD symptoms will receive EMDR.

NIKA consists of 5 sessions during which mother and child are videotaped by a
trained therapist. The therapist will provide personalized feedback to the
mother, which is focused on reducing disrupted parenting behavior and
increasing sensitive parenting behavior. EMDR is a short trauma therapy (in
this trial a maximum of 6 90-min sessions) aimed at reducing the negative load
of the memories of traumatic events. The parent is asked to bring the traumatic
event to mind while the therapist provides a distracting task. Mother-child
dyads in the waitlist usual care group will only receive care as usual at the
women shelter during the study.

The families will be asked to fill out questionnaires and to participate in
observational tasks that are not intrusive or dangerous. The researchers and
therapists will make sure participants can ask questions and everything will be
explained carefully. The pre- and post-tests will take 1 hr and will take place
at the women shelter where the families are staying. The 5 NIKA sessions will
take approximately 1 hr each in a time span of 5 weeks. The 6 EMDR sessions
will take approximately 1.5 hr each. If the mothers encounter difficult themes
or feelings, they will be supported by the therapist or social worker if
needed. Therapists who encounter difficulties are able to share these issues in
supervision meetings which will be organized frequently by highly experienced
therapists. Other studies that investigated similar interventions show no
negative consequences of the intervention (Bernard et al., 2012; Moss et al.,
2011; De Jongh et al., 2019). There is still a big gap in the current knowledge
regarding effective treatment approaches for young children who are traumatized
after domestic violence. In these families, there is a high risk of
co-occurring child maltreatment and often both mother and child suffer from
PTSD symptoms. How these families can be best supported is still unknown. If
NIKA and EMDR are effective in improving the quality of parent-child
interactions and decreasing both parents* and children*s PTSD symptoms, the
wellbeing of these children will improve.