Effectively intervening in traumatized parents and children after structural domestic violence: A multiple baseline analysis

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. Both parents and children
are at risk to develop trauma-related psychopathology after domestic violence.
In addition, 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 for developing a
disturbed attachment relationship for the child. Treatment should thus focus at
improvement on three levels (parenting behavior and post-traumatic stress
(PTSD) symptoms of the parent and the child), and can consist of trauma therapy
for parent and child and attachment-based therapy. Since the symptoms in
different families may exhibit in different ways, and can interact with each
other in a different way, an individualized treatment trajectory that takes
these interactions in account may be necessary to allow for maximum symptom
reduction.

The goal of this study is to evaluate the effectiveness of an individualized
treatment trajectory in which the order of trauma therapy for the parent,
trauma therapy for the child and attachment-based therapy is tailored towards
the complex needs of victimized parents and their young children after domestic
violence. The treatment trajectory is based on a guidance document that
supports therapists to determine the optimal order of interventions based on a
standardized set of factors. The primary goals of this study are:
1. To examine how PTSD symptoms of parent and child and parental sensitive and
disruptive parenting behavior develop and interact over time, while they follow
the individualized treatment trajectory.
2. To test whether the start of the treatment trajectory (e.g. the phase in
which parents can receive NIKA and EMDR therapy and their child can receive
EMDR therapy) leads to a decrease in disruptive parenting behavior, an increase
in sensitive parenting behavior, and a decrease in PTSD symptoms of the parent
in comparison to the baseline phase.
3. To test whether the start of the treatment trajectory (e.g. the phase in
which children can receive EMDR therapy and their parent can receive NIKA and
EMDR therapy) leads to a decrease in PTSD symptoms and behavioral and emotional
problems in comparison to the baseline phase.

The hypotheses will be tested using a single case experimental design (SCED)
study, with a non-concurrent, randomized multiple baseline design. Families who
receive treatment after experiencing severe domestic violence will be randomly
assigned 5 to a baseline length of 3, 4, 5, 6, 7 or 8 weeks (phase 1), and
randomization will occur for two sets of five participants. After the end of
the baseline phase the dyad will follow the individualized treatment
trajectory, that consists of different interventions (phase 2), including EMDR
therapy for parent and child to reduce their PTSD symptoms and NIKA to reduce
disrupted parenting behavior and increase sensitive parenting behavior. The
dyads will participate in weekly appointments throughout the whole duration of
the study (both baseline and treatment phase).

During the treatment phase, the dyad will follow a treatment trajectory that is
based on a draft-guidance document, and consists of different interventions.
This draft guidance document will guide the therapist in tailoring the
treatment trajectory towards the needs of the dyad. The treatment trajectories
can include a combination of NIKA, EMDR therapy for the parent and EMDR therapy
for the child. NIKA consists of 5 sessions during which parent 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 brief trauma
therapy (in this trial a maximum of six 90-min sessions) aimed at reducing the
negative load of the memories of traumatic events. Both parent and child can
receive this therapy. During the sessions, the subject is asked to bring the
traumatic event to mind while the therapist provides a distracting task.

The parent will be asked to fill out questionnaires, and the child will be
asked a few questions. Additionally, the dyad is asked 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 weekly research appointments will take 20-25 minutes
(except for the pre-test, 35 min. and post-test, 75 min.) and take place at the
community shelter where the families are staying. The 5 NIKA sessions will take
approximately 1 hour each in a time span of 5 weeks. The 6 EMDR sessions will
take approximately 1.5 hour each in a time span of 6 weeks for the parents. For
the children, the EMDR sessions will take 60 minutes each, also in a time span
of 6 weeks. If the parents encounter difficult themes or feelings, they will be
supported by the therapist or social worker if needed. 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 families with young children who are traumatized after domestic
violence. The treatment approach that is examined in the current study targets
problems on different levels, and is individualized toward the needs and
challenges of a specific dyad. Since such an approach has not been studied
earlier this study will give valuable insights in the effects of individualized
treatment for these vulnerable families.