Rewind and Fast Forward: Effectiveness of a high intensive
trauma-focused, family based therapy for children exposed to family violence.

Family violence is a common problem and affects children and their families.
Family violence refers to any violence between other family members, e.g.
interparental violence - with or without child (sexual, physical) maltreatment.
5,5% of the Dutch population aged 18 and older have experienced some incident
of family violence over the 5 years prior to the study (Van Eijkern et al.,
2018). Based on self-report research, interparental partner violence
co-occurred with child maltreatment in 2,5% of the Dutch youth population aged
12-17 (Schellingerhout & Ramakers, 2017). Also, 48% of maltreated children
witnessed violence between parents concurrently (Alink et al., 2018). Family
violence shows strong adverse impact, both immediately and in the long term,
across somatic and psychological domains (Alink et al., 2012). The effects of
family violence are direct, in the form of posttraumatic stress symptoms,
anxiety and depressive symptoms (Janssen et al., 2019; Tierolf et al., 2014)
and indirect, through the association of family violence with parenting and the
parent-child interaction (Visser et al, 2015; Visser et al., 2016). When
treating childhood trauma effect sizes of *golden standard*- trauma treatments
are generally lower than for children who have suffered other forms of trauma
(Ehring et al., 2014). Also, in 85% of the families referred to mental health
care after family violence, violence was found to have continued 7 years later
(Lünnemann et al., 2020).

Direct effects of family violence
One out of every three children exposed to family violence develops
trauma-related symptoms, such as posttraumatic stress symptoms, anxiety, and
depressive symptoms (Janssen et al., 2019; Tierolf et al., 2014). The Cognitive
Context Theory states the violence is a stressor and children try to understand
and cope with this stressor. Contextual, cognitive and developmental factors
determine the child*s understanding and therefor response to family violence
(Grych & Fincham, 1990). According to Emotional Security Theory (Davies &
Martin, 2013), witnessing family violence directly triggers affective,
behavioral, and cognitive responses to the perceived threat to the integrity of
the family system. Sustained exposure to destructive family conflict may lead
to cascading developmental adaptations that underlie mental health risks.
Children may become hypervigilant and easily distressed (affective response)
(Katz el. al, 2007), take a distancing or domineering approach to the family
conflict (behavioral response) (Deborad-Lucas et al., 2011; Koss et al., 2011),
or devalue their family relationships (cognitive response) (Fosco et al, 2007).
In the aftermath of family violence children*s responses may no longer be
adaptive, increasing vulnerability for psychological problems.

Indirect effects of family violence
In addition to direct effects, family violence may also indirectly cause
symptoms in children because of the association of family violence with
diminished parental availability (Visser et al., 2015) and disturbed
parent-child interaction (Visser, 2016). Parents may experience a broad range
of mental health problems, such as depression (Renner, 2009) and post-traumatic
stress disorder (Dutton et al., 2006) after exposure to family violence. These
mental health problems can be assumed to affect their parenting and quality of
parent-child relationships. For example, the spillover hypothesis predicts that
distressing experiences in interparental relationships, like violence, carry
over to parenting behavior (Krishnakumar & Buehler, 2000) and to the
parent-child interaction (Floyd et al, 1998). Consequently, family violence has
been linked to more negative and less positive parenting compared to
non-violent families, to harsh discipline towards their children (Osofsky,
2003), less supportive and less effective parenting (Levendosky &
Graham-Bermann, 2001), and more emotional unavailability and psychological
control (Fauber et al., 1990; Gonzales et al, 2000).

Trauma treatment
The current Dutch guidelines for treatment of PTSD in adults (Trimbos, 2013),
as well as international guidelines for children (AACAP, 2010; NICE, 2018),
recommend individual trauma-focused cognitive behavioral therapy (TF-CBT) and
Eye Movement Desensitization and Reprocessing (EMDR). Also, Dutch studies just
recently showed that an intensive trauma-focused treatment with three to five
treatment days per week can be effective for adults (Woudenberg et al., 2018)
and adolescents (Hendriks et al, 2017) with PTSD. However, as TF-CBT and EMDR
on average are effective in addressing PTSD symptoms of children (Mavranezouli
et al., 2019), treatment effect sizes were generally lower for different forms
of childhood maltreatment like family violence, than for other forms of trauma
(Ehring et al., 2014). Moreover, little is known about the reciprocal effects
of TF-CBT and EMDR on family relationships and emotional family safety.
Individual trauma treatments may be enhanced by adding a parental and systemic
component. Evidence that adding a parental component to individual trauma
treatment increases treatment success is promising, yet inconclusive
(Mavranezouli et al., 2019). Minor studies have systematically reviewed and/or
meta-analytically examined effectiveness trials towards an intervention
focusing on parenting factors in situations of family violence. Our systematic
literature search only found four publications (Johnsen et al., 2018; Hacket
et al., 2016; Rizo et al., 2011, and Austin et al.,2019), which included the
following parenting factors 1) knowledge of trauma and family violence, 2)
trauma sensitive parenting, 3) resilience of the parent, 4) social
support/resources, 5) the parent-child relationship, 6) safety within the
family and 7) parental stress and competence. The review of Johnson et al.
(2018) showed that a parent-child or parent intervention positively affects
positive parenting behavior (effect size Cohen*s d=0.72, C.I. 0.43-1.00) and
child*s functioning (effect size internalizing problems d=0.59, C.I. 0.43-0.74;
externalizing problems d=0.48, C.I. 0.34-0.62; trauma symptoms d=0.56, C.I.
0.36-0.76). Interventions focusing on family violence produce greater
improvements in parenting behavior in comparison to interventions focusing on
child maltreatment, while interventions for child maltreatment produce greater
improvements in PTSD-symptoms. From this review there is limited evidence for
the value of combining parent and child interventions, except for a few
studies. One study suggests this combination leads to a decrease in PTSD
symptoms for the child and this decrease is mediated by improved parent mental
health (not by parenting or decreased parental stress). The review of Johnson
et al. (2018) also indicated that the type of intervention, that is parent
intervention versus parent-child intervention, did not account for a
significant variability in effect sizes. In the other three reviews no
distinction was made between child intervention, parent-child intervention or
parent intervention when discussing the effects of these interventions.
Evidence for these different approaches is combined. For example, the review of
Hacket et al. (2016) states that interventions focused on the parent, child
and/or the parent-child interaction in general are effective (effect size,
d=0.76, C.I. 0.58-0.93). Effects differed depending on the informant. Mothers
as informants delivered a medium effect; for children as informants there was a
medium to large effect, measured to external stress, psychological adjustment,
self-concept, social adjustment and family relationships. Mothers also reported
a decrease in maltreatment effects within the family (large effect). The review
of Rizo et al. (2011) discussed the effects of interventions on parent, child
and parent-child or a combination of these interventions in a narrative manner.
Rizo et al. (2011) concluded that adolescents showed least improvements, that
children with outside support fared better on behavior problems and that there
is more improvement when offering more





than five contacts to the family. Furthermore, they stated that changes in
parenting behavior and psychiatric symptoms are largely responsible for the
treatment effects on children*s conduct problems. Unfortunately, because of the
great variation in interventions studied in these reviews, it is not possible
to draw unambiguous conclusions about the effects of parent and family-focused
interventions on parent functioning, child functioning, and the parent-child
relationship because of different limitations of the reviewed studies. It is
not possible to draw conclusions about the association between specific
interventions and improvement in child and family functioning. There is a need
towards greater sample sizes, controlled study designs, protocolized
treatments, and assessment of treatment fidelity, to understand which parent
factors are most important in the treatment of children with PTSD symptoms
after family violence (Austin et al., 2019). Engagement of maltreated children
in the research process can further enhance study quality (Head, 2011), such as
more honest findings (Racine et al., 2023) and increased insight in outcomes of
interventions that are important to children themselves (Cuijpers, 2019). At
the same time this engagement can empower children (Racine et al., 2023; Head,
2011). Besides these positive outcomes, children have the right to be involved
in research that concerns themselves and their voices need to be heard (Head,
2011).

Primary Objective:
1. Is FITT more effective than ITT in terms of trauma reduction in children and
improvement of structural emotional safety in families?

Secondary Objective(s):
1. Is FITT more effective than TAU in terms of trauma reduction in children and
improvement structural emotional safety in families, based on the intermediate
measurement?
2. To what extent do we find differences between FITT and ITT in trauma
informed parenting at the end-of-treatment measurement?
3. Is trauma reduction in children and improvement of structural emotional
safety in families equivalent between FITT and TAU, based on the
end-of-treatment measurement?
4. What do participants identify as improved outcomes as a result of (F)ITT?
What key elements of (F)ITT do the participants perceive as important for
treatment success and what do they perceive as barriers?

This multi-center study examines the addition of a parenting training and
family-sessions to an intensive trauma-focused therapy for children exposed to
family violence, which results in a randomized controlled trial. Participating
families are divided over three trauma treatment arms, intensive trauma
treatment, family-based intensive treatment, and treatment as usual. The
effectiveness trial comprises a pre-treatment, during treatment, end of
treatment, and follow-up design.

FITT is a four-week family-based intensive trauma treatment program, containing
a preparation phase in week 1, an intensive phase in week 2 and 3 and an
integration phase in week 4. Research indicates intensive trauma therapy for
adults (Van Woudenberg al., 2018) and adolescents (Hendriks et al. 2017)
results in lower levels of PTSD symptoms. In different studies no adverse
events occurred and the dropout rate is low (Van Woudenberg et al., 2018).

Preparation phase
The preparation phase consists of two treatment days. On the first treatment
day the adolescent, parents and the support system will receive a 90-minute
session of psycho-education about trauma, the impact of trauma and the
treatment program. They receive psycho-education about trauma, sensitive
parenting and how they can support the adolescent during and after treatment.
On the second treatment day the adolescent is offered a 90-minute session in
which the different traumatic memories are clustered. The adolescent and the
therapist choose the six most traumatic memories, ordered by their level of
disturbance (SUD, subjective units of disturbance) and these memories will be
reprocessed in the exposure and EMDR sessions.

Intensive phase
In the intensive phase the adolescent and parents have 6 treatment days. The
first six treatment days the adolescent has a fixed program each day,
consisting of a:
• 90-minute session Exposure
• 60-minute session Physical Activity
• 90- minute session EMDR
On the correspondent days the parents have a:
• 60-minute session Parent training

Exposure and EMDR
The exposure and EMDR in the program will be given by different therapists.
Hypotheses are that this therapist rotation can decrease fear and avoidance
behavior of the therapist (Van Minnen et al., 2018). The exposure and EMDR
sessions will be given by therapists with at least two years of experience in
treating adolescents with trauma and advanced training in exposure and EMDR
therapy. One traumatic memory each day will be treated with exposure and EMDR.
The exposure therapy is based on the protocol from Minnen and Arntz (2007).
Prolonged exposure therapy is a form of cognitive behavioral therapy in which
the adolescent repeatedly describes the traumatic event in detail and in
present tense, focusing on the anxiety-provoking parts of the traumatic event.
Every 5 to 10 minutes the therapist checks the level of disturbance experienced
by the adolescent. The adolescent learns fearful expectations stay away when
being exposed to the trauma and there is no need for avoidance behavior. For
the EMDR session we will use the Dutch EMDR protocol for children and youth
(2019). During EMDR therapy the adolescent is asked to focus on the most
disturbing image of the traumatic memory and the therapist asks questions about
the thought and feelings associated with the traumatic image and the level of
disturbance. The therapist will ask the adolescent to focus on the image and
the associated thoughts and feelings and at the same time focus on a
distracting stimulus. This will bring a stream of associations in the form of
thoughts, feelings, images and bodily sensations and helps to reprocess the
traumatic memory. The therapist will then ask what the adolescent notices and
repeat the distracting stimulus. After a while the adolescent will notice the
level of disturbance will lower until the traumatic memory is desensitized. If
necessary, the therapist
can add cognitive interweaves during the desensitization phase to elicit new
associations.

Physical activity
Physical activity is a standard component of intensive trauma treatment,
because trauma
therapy combined with physical activity results in lower PTSD symptoms
(Rosenbaum et
al.,2015). The sessions psychical activity consists of exercises focusing on
activation,
relaxation, and recognizing and controlling bodily sensations.

Parent training
The aim of the parent training and parent-child interaction session is to
increase parental skills, parental availability and insightfulness in
children*s needs and strengthen the parent-child relationship and therefor the
emotional safety in the family. The parent training is given by a family
therapist or family worker with at least two years of experience in counseling
parents of children with complex trauma. In the parent training parents learn:
1. The difference between their own trauma history and children*s trauma
history,
2. The difference between their own trauma-related symptoms and children*s
symptoms,
3. About the consequences of exposure to family violence on the individual and
relational level for children and their families,
4. How to practice parenting skills in a trauma-sensitive way.
5. Recognizing destructive family patterns.

Integration phase
The integration phase consists of three family sessions in the final week.
These sessions focus on sharing thoughts and feelings about the traumatic
events, recognizing and breaking destructive patterns, and finding solutions
for recurring problems.

Family violence has a devastating effects on children and families. Current
trauma treatments show lower effect on trauma reduction in children exposed to
family violence, they do not (intent to) restore family functioning. In 85% of
the families referred to youth mental health care after family violence,
violence was found to have continued 7 years later (Lünnemann et al., 2019).
Family based intervening added upon trauma treatment may impede recovery from
trauma, and the expected benefits await empirical testing. It is in the best
interest of the children to make sure that there comes a family based intensive
trauma treatment available, that is able to reduce trauma in children and
increases structural emotional and physical safety in families. If FITT
performs according to the expectations than the mental health professional has
a tool to help children structurally recover from family violence, which
improves their wellbeing.

Questionnaires and interviews will always be administered by research
psychologists, and research assistants (assisted by graduate students, with at
least a bachelor*s degree in psychology, education or a related discipline).
The majority of the instruments is already part of the routine outcome
monitoring of (some of the) participating trauma centers or are used in
previous research. Based on previous experiences we estimate that completion of
the questionnaire at T0, T12-T14 takes about one hour for child and caregivers.
Questionnaires at T1-T11 take about 10 minutes to complete by child and
caregivers. The interview at T0 and T13 takes about 1 hour. The observational
task at T12 takes about half an hour. The adolescents who participated in ITT
or FITT will be asked to participate in an interview about their experience
with intensive trauma treatment.

Considering the expected benefits of this study, we find the emotional burden
acceptable. Especially because there is no scientific prove that symptoms
increase when children are asked about traumatic experiences, nor is there
scientific prove that trauma-related research has a more negative impact than
not-trauma related research (Van der Velden, Bosmans, Scherpenzeel, 2013).
However, traumatic incidences inflicts feelings of shame, quilt and
embarrassment, which has severe and long-lasting consequences when left
untreated (Felliti et al., 1998).

The risk for participating in this project is considered moderate. Therefor an
monitoring board will be installed, and researcher will receive supervision
from clinical trauma experts (e.g. Margreet Visser & Valerie Fictorie). When a
child seems adversely affected by the questionnaires, interview, or
observational tasks it may be decided to (temporarily) discontinue
participation in the project.