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

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.