Domestic Violence Clinical Trial
Official title:
Cluster Randomized Trial of Embedded Dyadic Mother-child and Father-focused Intervention for Preventing Recurrence of Maltreatment and Reducing Impairment in Young Children Exposed to Domestic Violence
The current cluster randomized trial examines the efficacy of embedding two different
parenting interventions within child protection services for young children (0 to 4) who
have been exposed to domestic violence and who are at moderate to high risk for recurrent
experiences of maltreatment. Interventions are "embedded" in recognition of the significant
role played by child protection case workers in identifying families in need of
intervention, referring/engaging families in intervention, and being able to use information
resulting from intervention (e.g., reports from the intervention program, observations of
parenting behaviour changes made as a result of intervention) to improve decision-making in
their child protection practice. Thus in this trial, ongoing child protection case workers
for families are randomly assigned to receive professional development training, supervision
support, and priority client access to parenting interventions in the following four
conditions: a) embedded mother-child dyadic intervention (Mothers in Mind); b) embedded
fathering intervention (Caring Dads); c) both mother-child dyadic and fathering
intervention; d) service as usual.
Mothers in Mind (MIM) is a dyadic mother-child intervention aimed at preventing child
impairment resulting from exposure to domestic violence. Intervention focuses on increasing
mothers' awareness of the impact that exposure to family violence/trauma may have had on
their infants and themselves as mothers, helping identify and promote positive parenting
skills such as sensitivity and responsiveness to infant needs, promoting parental competence
and emotional closeness and decreasing mothers' social isolation. Mothers in Mind uses an
attachment and trauma-informed psycho-educational process approach in 12 weekly sessions (10
group and 2 individual).
Caring Dads (CD) aims to prevent recurrence of child exposure to domestic violence by
intervening with fathers. Caring Dads includes 15 group sessions, an individual intake, and
two individual sessions to set and monitor specific behaviour change goals. Major aspects of
innovation in the Caring Dads program include the use of a motivational approach to engage
and retain men in intervention, consistent emphasis on the need to end violence against
children's mothers alongside of improving fathering; program content addressing
accountability for past abuse; focus on promoting child-centered fathering over developing
child management skills; and a model of collaborative practice with child protection.
Hypotheses are posed for differential outcomes among child protection workers (level of
randomization) and for children who are the subject of the child protection referral (nested
within workers). At the level of the individual child (primary outcome) it is hypothesized
that there will be lower rates of re-referral for children of families on the caseloads of
child protection workers assigned to the embedded CD, MIM and combined intervention than for
those on the caseloads of workers in the service as usual condition. At the worker level
(secondary outcomes), outcomes are hypothesized in two areas: 1) worker skill in
conceptualizing risk and need in cases of child exposure to domestic violence and 2)
increased self-efficacy for referring to and collaborating with embedded interventions.
Specifically, we hypothesized that following training and at 12-month follow-up, workers in
the CD/MIM intervention and combined CD and MIM condition will have greater case
conceptualization skills in responding to hypothetical cases as compared to workers in the
treatment as usual condition. We further hypothesize that assignment to an intervention
condition will lead workers to report greater self-efficacy for collaborating with embedded
parenting interventions than workers in the treatment as usual condition post-training and
at 12-months follow-up.
Study focus is the promotion of healthy outcomes in young children (0 to 4) whose exposure
to domestic violence (DV) has been substantiated by child protective services. Young
children are particularly vulnerable to damage resulting from exposure to DV. Research in
developmental neuroscience has shown that infancy and toddlerhood is a time of greater
plasticity of the brain and of sensitive periods for the development of a number of core
cognitive, emotional, social, and self-regulatory capacities. The public institution with
the greatest opportunity to promote better outcomes among very young children at high risk
for compromised mental and physical health development as a result of exposure to domestic
violence is child protective services. Exposure to domestic violence is one of the most
frequently substantiated forms of child maltreatment experienced by Canadian children. As
with other forms of maltreatment, very young children experience disproportionately high
levels of victimization. Moreover, because infants and toddlers are more often in the
presence of their mothers than older children, their exposure experiences are more likely to
be direct (i.e., witnessing violence) as opposed to indirect (i.e., hearing or knowing about
violence).
Unfortunately, there is ongoing concern about child protection response to domestic violence
and about the availability of interventions to address this issue. Interventions are needed
in two areas. The first is interventions that will reduce impairment (i.e., cognitive,
social, emotional development) of young child victims of exposure. This issue has been the
focus of many academic and policy critiques and the source of considerable tension within
and between the child protection and Violence Against Women (VAW) service communities. One
tension is that mothers, on whom children rely for sensitive contingent responding to
traumatic events and traumatic reminders, are also victims of DV. There is a robust
relationship between DV victimization and symptoms of trauma and depression, and between
maternal symptoms of depression and trauma and elevated levels of maternal intrusiveness,
hostility, and non-responsiveness to young children. Domestic violence victimization is also
a strong risk factor for mother-perpetrated maltreatment and many of the more complex child
protection cases present with a combination of risk due to ongoing concerns about fathers'
perpetration of domestic violence and about mothers' DV- or mental health-related neglect.
There have been numerous calls for better training and greater collaboration between child
protection and VAW services at this complex area of practice to avoid retraumatization of
women and to promote better outcomes for children in the context of exposure to domestic
violence.
Second, a strong child protection response to DV needs interventions to prevent the
recurrence of child exposure to violence. Historically, child protection practice in DV has
focused almost exclusively on mothers' capacity to take actions to "appropriately protect"
their children from violence exposure. There are many problems with this mother-focused
strategy of child protection. The more appropriate alternative response is to offer
effective services to parents (most often fathers) who have perpetrated DV in their
families. Child protective services have been relatively slow to include fathers in their
work, though this is changing. There have been numerous calls to continue to change practice
in this area in order to make work with fathers a greater part of child protection responses
to child exposure to domestic violence.
The current study is designed to test the efficacy of providing families' child protection
ongoing service workers with professional development training, supervision support, and
priority client access to embedding two parenting interventions - one for mothers focused on
preventing impairment and one for fathers focused on preventing recurrence - into child
protection practice. These interventions are "embedded" in recognition of the unique context
of child protection practice. Within child protection, families are assigned primary workers
(in this case, ongoing service workers) whose job it is to work with a family to improve
child safety to the point that the child is safe enough to close the file. Surprisingly,
referral to parenting intervention is seldom part of child protection practice - most often,
workers rely on their own work with families to prompt change. However, when parenting
interventions are suggested, this referral is often linked to child protection plans; i.e.,
families are not really choosing to access these interventions on their own accord. [There
is nuance to this, as families are not legally mandated to attend. Yet given the power
difference between the child protection worker and the family, a strong suggestion from a
worker that a family access an intervention program carries substantial weight. Families
retain the ultimate choice about whether or not to participate, but this choice cannot be
understood as fully independent and voluntary]. Moreover, parents' success (or failure) in
attending these programs and in making changes to their parenting can have implications for
the length, intensity, and nature of ongoing involvement of the family with child protective
services. In this context, it is not feasible to have workers "suggest" that a family access
an experimental intervention program and then be randomly assigned to receive, or not
receive, this program. Moreover, given this context, improving outcomes by providing
parenting intervention requires that change occur first at the child protection worker
level. Specifically, workers need to be able to identify families in need of intervention,
be successful at referring/engaging families in intervention, and be able to use information
resulting from intervention (e.g., reports from the intervention program, observations of
parenting behaviour changes made as a result of intervention) to improve decision making in
their child protection practice. Improved child outcomes also hinge on having interventions
that are themselves efficacious. Because of the embedded, systems context of parenting
intervention for child protection client, and because the first point of change is worker
referral, the appropriate level of experimental manipulation is the child protection worker,
not the individual families. Accordingly, this study makes use of a cluster-randomized
design, where child protection workers are assigned to additional training, consultation,
and support in making referrals to mothering, fathering, or both interventions as compared
to practice as usual. Also relevant to considering design is the fact that child protection
workers who will be the subjects of this CRT are nested in teams of 5 or 6 under a
supervisor. Supervisors are responsible (generally speaking) for providing clinical
supervision, administrative management, and leadership to their team of workers. As such,
supervisors should be understood as potential "gatekeepers" (i.e., someone who may be called
up to protect group-based interests that are affects by enrollment in a CRT). Given this
organizational structure, the most practical and realistic design is to nest randomization
by teams. Thus, workers in any one team will all be assigned to the same condition.
Parenting Interventions, Child Protection and Clinical Equipoise In conducting a clinical
trial, it is also necessary that genuine uncertainty exists in the relevant expert community
about what therapy(ies) are most effective. Here, the relevant question is whether referral
to a formal mothering/fathering intervention program is more efficacious than providing
regular ongoing child protection service, which consists of in-home visits and
individualized problem-solving with families. There is genuine uncertainty about this
question in the area of both interventions for mothers and intervention for fathers.
In terms of intervention for mothers, a major question is whether a "therapeutic" parenting
program is efficacious when offered as part of child protection service where the typical
provisions around client-therapist confidentiality are replaced by an agreement for
collaborative information sharing between the intervention program and the child protection
worker. This issue has been written about frequently and is one of the sources of tension
between the CAS and VAW sectors. Also of concern is whether this difficult to engage group
of mothers can be engaged in services when they are embedded in child protection practice.
The specific program to be offered in this trial is Mothers in Mind. The Mothers in Mind
program was developed in response to a recognized service gap for mothers who had
experienced abuse/trauma, were showing abuse-related deficits in parenting, and had children
under the age of four. This program is built on the foundation of research showing that
dyadic parent-child responsivity based approaches are efficacious for improving outcomes for
children in at-risk circumstances, including infants born prematurely, parented by depressed
mothers, dyads who have been trauma exposed, and who are in anxiously attached. There is
preliminary evidence in support of the value of MIM. A 2013 intervention study found that
both facilitators and management identify that they are satisfied with the support provided
by CDI in the areas of consultation and training. Pre- to post-program self-report
evaluation data suggest that the MIM program is specifically helpful to mothers initially
presenting with challenges in parenting. Specifically, in the subgroup of mothers presenting
with high levels of challenge, completion of the MIM program was associated with significant
positive changes in mothers' isolation, attachment, and sense of parenting competency (no
other dimensions of outcome were assessed).
In terms of fathering intervention, there is a great deal of concern in the literature about
the efficacy of any group intervention aimed at reducing abuse recurrence, especially
domestic violence. A recent meta-analysis concluded that the research evidence on programs
aiming to change men's perpetration of domestic violence is insufficient to draw conclusions
about effectiveness. Specifically, Smedslund et al. noted in 2011: "This does not mean that
there is evidence for no effect. We simply do not know whether the interventions help,
whether they have no effect, or whether they are harmful" (p. 8). Given the state of
evidence, experts would certainly be divided on their opinion about whether a trial of this
nature will show any advantage over service as usual.
The specific program to be examined in this trial is Caring Dads. Caring Dads aim to reduce
recurrence of domestic violence by working with fathers to increase their healthy,
supportive, and non-abusive engagement with their partners and children.
Caring Dads is currently considered a "promising practice" for addressing child
maltreatment. Preliminary research on Caring Dads, using a comprehensive evaluation
framework, established that Caring Dads addresses a need in communities, can be implemented
in a way that is acceptable to clients and stakeholders, and matched, in its underlying
theory, the characteristics and needs of most referred. Subsequent examination of Caring
Dads using a pre- to post-research design showed that intervention is associated with
changes in fathers' over-reactivity to children's misbehaviour and respect for their
partner's commitment and judgment, with results being statistically significant, medium in
size, moving mean scores into the normative range. Interim findings from independent
research on Caring Dads being carried out in the UK are also promising. Based on data from
204 fathers, 72 partners, and 22 children, McConnell reports that completion of Caring Dads
is associated with pre- to post-group reductions in parenting stress and in level of
hostility, indifference, and rejection as reported by fathers and reductions in domestic
violence victimization (emotional abuse, isolation, violence, injury, use of children),
depression, and anxiety as reported by mothers. Changes in identified domains persist over
six-months and are well in excess of changes made by comparison group fathers over a similar
time period. Finally, a small ongoing study by the Child Welfare Institute and K. Scott in
Toronto finds that, consistent with Caring Dads' model of collaboration between group
co-facilitators and child protection workers, enrolment in Caring Dads is associated with
substantially higher levels of contact between men and their families' child protection
workers and lower rates of re-referral for men enrolled in the program as compared to those
referred but on a wait-list for service.
Both the MIM and CD interventions will be embedded as a collaborative intervention across
child protection and community service. Child protection workers will be directly trained by
staff of the MIM and Caring Dads program on the nature of the programming provided. Cases
potentially eligible for this program on the basis of referral and ongoing concerns will be
flagged. Moreover, child protection staff will have ongoing consultation around the
complexity of how to interpret and effectively respond to women's joint status as survivors
of DV and mothers ensuring the safety and well-being of their children and on how to best
intervene with fathers. Other aspects of embeddedness include ongoing communication through
intervention and collaborative planning (child protection and community agency) and
agency-CAST co-facilitation of intervention groups.
Duty of Care Considerations. The child protection workers and supervisors being recruited
into this study have a duty of care to the clients on their caseload. As part of their job,
they need to make decision as to the best services and interventions to provide to their
clients. Workers and supervisors will be fully aware that they are participating in a study
where we are examining the effect of embedded parenting interventions. They will also be
made aware that there is genuine uncertainty about the value of these interventions and will
be cautioned about the possibility of therapeutic misconception. Depending on the trial arm,
workers will be trained to better assess and recognize issues in the parenting of mothers
and fathers of young children and they will be given information about intervention programs
that have promising evidence of success. In addition, cases potentially eligible for
referral to these programs will also be "flagged" for workers. However, it is important to
note that there will be no (explicit or implicit) mandate that flagged clients will be
referred to these intervention programs. Workers and supervisors will need to continue to
use their judgment about the ultimate appropriateness of referral for individual clients. In
addition, workers not assigned to a particular intervention arm (e.g., those assigned to
service as usual) will not be prevented from making referrals to CD or MIM. Although workers
will again be aware of the uncertainty of outcomes of these interventions (and the
possibility of therapeutic misconception) and of their assignment in the trial, we will
respond to their professional judgment about referral. If space is available for clients of
these workers, they will be offered intervention regardless of the fact that this will
weaken the intervention design. However, we anticipate that this will occur in a low number
of cases because survey of practice reveals that few workers make referrals to parenting
interventions and because within the context of this trial, we do not expect to have many
"empty" spaces in intervention.
Conditions and Hypotheses
As explained earlier, because the focus of this study is on changing the ways in which child
protection workers embed intervention into ongoing child protection family service, the
appropriate level of experimental manipulation is the child protection worker, not the
individual families. Outcomes will be examined at two levels - the level of the child
protection worker and the level of the young child identified as being in need of the
service of the Children's Aid Society (CAST). This trial will have four condition arms: a)
embedded mother-child dyadic intervention (Mothers in Mind); b) embedded fathering
intervention (Caring Dads); c) both mother-child dyadic and fathering intervention; d)
service as usual. Hypotheses are outlined in detail as follows:
Worker level Case Conceptualization H1: Professional training on embedded interventions
(i.e., training, ongoing consultation and supported referral) will increase the workers'
capacity to conceptualize risk and needs in hypothetical cases typical of those open to
child protection services as a result of child exposure to domestic violence. Specifically,
workers will demonstrate greater capacity to identify intervention needs relevant to
fathers'/mothers' attitudes and behaviors; will be more likely to recommend interventions
relevant to addressing fathers'/mothers' attitudes and behaviors; will be more likely to
identify specific, concrete behavior changes in fathers/mothers as part of the rationale for
case closure; and will increase the extent to which workers take intervention progress, or
lack of progress, into account when making decisions about case closure in responding to
hypothetical case descriptions. Effects will be evident following training and at a 12-month
follow-up point in case conceptualization around mothers (for the MIM and combined
intervention groups) and fathers (for the CD and combined intervention groups) as compared
to workers in the treatment as usual condition.
H2: Workers randomly assigned to an embedded intervention condition will have greater
self-efficacy for referring to and collaborating with intervention programs. Effects will be
evident following training and at a 12-month follow-up point. Specifically, workers in the
CD and combined condition (i.e., conditions 3 and 4) will report greater self-efficacy for
referring fathers and collaborating with fathering interventions than workers in the
treatment as usual condition and workers in the MIM intervention and combined condition
(i.e., conditions 2 and 4) will report greater self-efficacy for referring mothers and
collaborating with mothering interventions than workers in the treatment as usual condition.
Child Level Rates of re-referral for child protection concerns H3: There will be lower rates
of re-referral for children of families on the caseloads of child protection workers
assigned to the embedded CD, MIM and combined intervention than for those on the caseloads
of workers in the service as usual condition.
H4: Young children on the caseloads of child protection workers assigned to the embedded CD,
MIM, and combined intervention will have fewer emotional and behavioural symptoms at one
year follow-up than children of workers in the service as usual condition.
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