Parent Child Interaction Therapy with Domestic Violence Populations

Transcription

1 J Fam Viol (2008) 23: DOI /s ORIGINAL ARTICLE Parent Child Interaction Therapy with Domestic Violence Populations Joaquin Borrego Jr. & Mindy R. Gutow & Shira Reicher & Chikira H. Barker Published online: 19 March 2008 # Springer Science + Business Media, LLC 2008 Abstract Domestic violence continues to be a significant social problem impacting our society. Battered women and their children experience a myriad of negative consequences as a result of domestic violence. Of the possible negative sequelae that mothers and children experience, the disrupted parent child relationship has received relatively little attention in the literature. Though psychosocial interventions are available to treat women who experience violence and children who witness violence, few interventions focus on the parent child relationship. This article describes parent child interaction therapy (PCIT), a relationship-based intervention. Although not initially developed to treat domestic violence, PCIT has unique characteristics that make it a promising intervention with this population. A rationale for the use of PCIT with battered women and their children is presented. Keywords Parent child interaction therapy. Domestic violence. Parent child relationships It is estimated that one in four women will experience domestic violence and roughly 5.3 million incidents of such violence will be reported each year (Center for Disease Control and Prevention 2003). Not only are these situations detrimental for the victims, but often times children are witnesses or even victims of the violence themselves. A significant number of children witness domestic violence each year; and in 30 70% of domestic violence cases, child physical abuse and other forms of child maltreatment (e.g., verbal abuse and neglect) co-occur (Rumm et al. 2000; Tajima 2000). In addition, younger children are more likely than older children to witness domestic violence (Fantuzzo et al. 1997). As such, researchers have begun to examine the impact of domestic violence on the child and the family unit. Effects of Domestic Violence on Families As evidenced by recent statistics, domestic violence remains a significant social problem affecting not just the couple, but the family as well. Heightened parental conflict negatively impacts children s academic, behavioral, and social emotional functioning (Riggio 2004) and the parents well being (Holden et al. 1989). Additionally, abused women may have limited social support networks (Levendosky and Graham-Bermann 2001), and have poor relationships with their children (McNeal and Amato 1998). While some episodes of domestic violence remain concealed, statistics reveal that children may witness up to 75% of parental aggression (Kérouac et al. 1986), which may lead a child to imitate the aggression (DeVoe and Smith 2002) or replicate it in future intimate relationships (Maker et al. 1998). J. Borrego Jr. (*) : C. H. Barker Department of Psychology, Texas Tech University, Lubbock, TX , USA Joaquin.Borrego@ttu.edu M. R. Gutow : S. Reicher Towson University, Towson, MD, USA Effects of Domestic Violence on Children As previously mentioned, child physical abuse and maltreatment often co-occur with family violence. Thus, children exposed to domestic violence share similar characteristics to children who have been physically abused

2 496 J Fam Viol (2008) 23: (Kitzmann et al. 2003). Children exposed to domestic violence may have a wide range of externalizing and internalizing problems (McCloskey et al. 1995). More specifically, research has found child witnesses to have increased levels of aggression (Holden and Ritchie 1991; Lemmey et al. 2001), anger (Adamson and Thompson 1998), defiance toward parents (Lemmey et al. 2001), and social skill impairment (Fantuzzo et al. 1991). As a consequence of witnessing domestic violence, children often suffer symptoms of internalizing difficulties, such as elevated levels of depression and anxiety (Fantuzzo et al. 1991; Holden and Ritchie 1991). Among one of the most commonly cited effects on children is traumatization, which can be exhibited through distress symptoms such as excessive crying, sleep disturbance, fear, argumentativeness, and nightmares (Kemp et al. 1995; Lemmey et al. 2001; Levendosky et al. 2003). Effects of Domestic Violence on the Parent Child Relationship Domestic violence often has implications on parenting and the parent child relationship as the quality of the parent child relationship is impacted by family violence (Anderson and Cramer-Benjamin 1999; Ybarra et al. 2007). Several factors influence the quality of the parent child relationship including marital satisfaction (Graham-Bermann 2001), the mother s psychological functioning (Holden and Ritchie 1991; Levendosky and Graham-Bermann 2001), and the parent child attachment (Davies and Cummings 1994). Consistent with an ecological model of parenting (Belsky 1984), it is thought that a caregiver s stress level, available support, and psychological functioning are factors that predict parenting quality. Specifically, preoccupation with life-stress and emotions may be associated with battered mothers feeling less emotionally available (Holden et al. 1998), as well as having a tendency to overlook or underestimate the emotional impact of domestic violence on their children (Peled and Edleson 1992). In addition, being depressed, which frequently found in battered women, has been associated with negative parenting (Levendosky et al. 2003). Research suggests that battered mothers often practice inconsistent, unemotional, and ineffective parenting (Egeland and Susman-Stillman 1996; Holden et al. 1998), or parenting that could be determined to be reactive and punitive (Osofsky 1998; Rossman and Rea 2005). Further, some battered mothers reportedly display less warmth toward their children (Levendosky and Graham-Bermann 2000). The high rate of parent child conflict and reciprocal physical aggression between mother and child (Holden et al. 1998; Levendosky and Graham-Bermann 2000) can impact parenting strategies and the parent child relationship as well. While authoritative parenting has been linked to more positive child behavior outcomes (Rossman and Rea 2005), battered women and their children are at greater risk of disorganized and insecure mother child attachments (Quinlivan and Evans 2005; Zeanah et al. 1999). There is also an increased likelihood of diminished quality of the father daughter relationship and less closeness between children and their mothers (McNeal and Amato 1998). The effects of battering on parenting and the parent child relationship may also materialize in different ways. Evidence suggests that children tend to treat their mothers like the abusive parent (Levendosky and Graham-Bermann 2000). Thus, behaviors and emotions displayed by the abuser (e.g., hitting and yelling) are observed in the parent child relationship. In their study of mothers and their preschool children, Levendosky et al. (2003) reported that preschool-aged children of battered mothers were less focused on tasks, interacted less positively, had fewer verbal interactions, and children physically sat further away from their own mothers than children of non-battered mothers. Additionally, McCloskey et al. (1995) reported that children of battered women perceive less maternal support than children from non-violent families, which is concerning as some studies suggest that when mothers show less affection and are less supportive, young children display higher levels of aggressive behavior (Murray et al. 1999). Thus, recognition of the effects of domestic violence on the parent child relationship is of great importance when considering interventions. Domestic Violence Interventions The choice of treatment modality for children exposed to domestic violence is dependent on a variety of factors including, but not limited to, the family s safety, the child s symptomotology, and the practitioner s conceptualization of family violence. In general, children may participate in interventions at the individual, group, or family level, many of which tend to follow a structured curriculum with specific goals and objectives (Peled and Edleson 1995). Most commonly described in the literature are psychoeducational groups that are based on cognitive behavioral, learning, and feminist theory (Johnston 2003). As such, behavior problems are understood as learned social responses modeled by violent caretakers and peers. Research on the efficacy of intervention models is sparse in the domestic violence field (Graham-Bermann 2000), and little systematic evaluation of effectiveness has been conducted (Graham-Bermann and Hughes 2003). Of those studied, methodological concerns, such as small sample size, lack of control group, measures with little psychometric support, and little to no follow-up assessments, have been

3 J Fam Viol (2008) 23: noted (for a review, see Agar 2004; Graham-Bermann 2001; Graham-Bermann and Hughes 2003). The lack of empirically supported models has been attributed to the complexity of treating children who have been exposed to domestic violence (Ducharme et al. 2000; Lutzker et al. 1998). As previously mentioned, children who have been exposed to domestic violence may exhibit a constellation of behavioral and psychological sequelae. Often, treatments focus on specific presenting problems such as trauma symptoms (Lieberman et al. 2005a; Graham-Bermann 2001), oppositional behavior (Ducharme et al. 2000), and other conduct problems (Jouriles et al. 1998, 2001). Although focusing on targeted symptoms has demonstrated positive outcomes, some interventions may be too narrow in that they focus on just one factor such as child management skills (e.g., Jouriles et al. 2001). Given the myriad of presenting problems, interventions may need to have multiple components that focus on different child and parent domains. In addition, what seems to be paramount in interventions that address specific behavioral or psychological difficulties in children is the active involvement of the mother in treatment. Unfortunately, a substantial number of interventions focus on either the child or the parent. Given that domestic violence can have a detrimental impact on the parent child relationship, it is crucial that the parent child relationship be a primary focus of treatment. The focus on dyadic interventions that utilize the mother child relationship as a mechanism for change is in its infancy in the domestic violence literature. This type of intervention has already been demonstrated to be effective in studies of children with anxious attachment (Lieberman et al. 1991), maltreated children (Chaffin et al. 2004; Toth et al. 2002), children with oppositional behaviors (Brinkmeyer and Eyberg 2003), and children with co-morbid separation anxiety disorder and oppositional defiant disorder (Chase and Eyberg 2008). Recently, there has been an expansion of dyadic-focused therapy in the domain of domestic violence. One intervention gaining empirical support is Child Parent Psychotherapy for Family Violence (CPP-FV; Lieberman et al. 2005a). CPP-FV is an intervention based on psychodynamic, attachment, cognitive behavioral, and social learning theories (The National Child Traumatic Stress Network [NCTSN] 2007). The treatment is designed for families with infant, toddler, and preschool-aged children. Typical CPP-FV treatment consists of weekly 1-h sessions over the course of a 12-month period. Throughout sessions, the therapist works with the mother to effectively play with her child, modeling effective protective behaviors and play. CPP-FV is focused on understanding and normalizing the mother and child s affective states, providing emotional support, and fostering the development of the parent child relationship through play, communication and physical contact. Research supports that this treatment can potentially decrease the severity of both mothers and children s maladaptive symptoms (Lieberman et al. 2005b). While this treatment has gained support, another promising treatment that may be applicable to domestic violence populations is Parent Child Interaction Therapy (PCIT). Parent Child Interaction Therapy PCIT is an evidenced-based, parent-focused, behavioral intervention for disruptive behavior problems in young children between the ages of 2 to 7 years (Brestan and Eyberg 1998; Hembree-Kigin and McNeil 1995; Schoenfield and Eyberg 2005). Based on theoretical premises that dysfunctional parent child interactions lead to the development and maintenance of conduct problems (Patterson 1982), and that authoritative parenting leads to positive child outcomes (Baumrind 1967), PCIT focuses on the parent child relationship and the dyad is in treatment together. The goal of treatment is changing dyadic interactions by teaching the parent skills to improve the parent child relationship. This is accomplished by having the parent be attentive when the child is behaving appropriately and decreasing attention when the child misbehaves (Eyberg and Boggs 1998). In this same context, parents are also taught to decrease disruptive child behaviors through consistent discipline while in the context of developmentally appropriate play situations (Borrego and Urquiza 1998). PCIT is conducted in weekly 1-h sessions and though progression through PCIT is based on mastery of certain skills, the treatment is relatively short as the average number of coaching sessions is 13 (Schoenfield and Eyberg 2005). Treatment objectives (i.e., improvement in the parent child relationship and teaching the parent effective behavior management skills) are accomplished through a sequential two-phase process; with play being a mechanism to change dysfunctional parent child interactions (Harwood and Eyberg 2006). Before each treatment phase, parents are taught the skills through a didactic session. The first phase of treatment is Child-directed Interaction (CDI), also known as the Relationship Enhancement phase. Based on attachment theory, CDI focuses on building a positive relationship and attachment between the parent child dyad while the child leads the play activity. Through live coaching and hands-on exercises, parents are taught the PRIDE skills: Praising the child, Reflecting the child s verbalizations, Imitating the child s play, Describing what the child is doing during play, and using Enthusiasm while interacting. The PRIDE skills are used in the context of the child behaving appropriately and serve to reinforce appropriate and prosocial behavior whereas active ignoring is used for inappropriate behavior. Thus, parents are taught to be responsive to the child by attending to

4 498 J Fam Viol (2008) 23: appropriate behavior. As an example, the parent is taught to actively ignore minor behavior problems (e.g., whining for negative attention seeking) and provide positive attention when the child is behaving appropriately (e.g., praising the child when using an indoor voice; Bell et al. 2003; Harwood and Eyberg 2006). Through this process, the parent learns skills to elicit prosocial behaviors in the child. During this same phase, parents are encouraged to avoid making critical statements, asking questions, and giving commands. Through this process, negative parent child interactions are replaced with more positive and nurturing parent child exchanges. Parents learn this process through the therapist s verbal prompts that serve to shape their behavior. The therapist prompts the parent to notice and socially reinforce (i.e., verbally praise) the child s prosocial behaviors (Borrego and Urquiza 1998). When parents master and are comfortable with the CDI skills, they move on to the second phase of treatment. Parent-directed Interaction (PDI), also known as the Discipline phase, uses a social learning framework in which child behavior problems are further decreased through developmentally appropriate and effective child management skills. Parents continue to use the Relationship Enhancement skills learned in the first phase and therapists coach parents to give specific, effective commands followed with appropriate consequences. As an example, parents are taught to follow through with social reinforcement (i.e., verbal praise) when the child complies. When noncompliance occurs, parents are taught to follow through with a verbal warning and then a time-out from positive attention if the child does not comply within 5 s of the verbal warning. The parent s newly acquired or strengthened child behavior management skills are meant to address different behavior problems such as noncompliance, aggression, and other disruptive behaviors. Thus, an important component is for the parent to acquire or further develop problem solving skills in which they are able to apply to a variety of problems in different settings (e.g., acting out in public). Evidence for PCIT PCIT has been shown to effectively reduce disruptive behaviors in young children with behavior problems (Capage et al. 2001; Nixon et al. 2003; Schuhmann et al. 1998). Follow-up assessments have found these reductions maintained over time (Eyberg et al. 2001; Hood and Eyberg 2003; McNeil et al. 1999). Additionally, PCIT also seems to have a positive impact on untreated siblings (Brestan et al. 1997) and has been shown to decrease the parent s level of stress and abuse potential (Borrego et al. 1999). PCIT has shown to be effective with different diagnostic and clinical populations such as separation anxiety disorder (Choate et al. 2005), ADHD (Nixon 2001), children with developmental disabilities (McDiarmid and Bagner 2005), and families with chronic illness (Bagner et al. 2004). Additionally, PCIT has been demonstrated to be effective with diverse cultural groups and low-income populations (Borrego et al. 2006; Capage et al. 2001; Matos et al. 2006). PCIT has also been applied with other clinical populations that have a disruption in the parent child relationship such as physically abusive families (Borrego et al. 1999; Chaffin et al. 2004; Timmer et al. 2005). Although traditional PCIT is implemented with one family at a time, recent data suggest that PCIT can also be delivered in a group format (Niec et al. 2005). Finally, PCIT can be carried out with any caregiver who has substantial contact with the child on a consistent basis, such as foster parents (McNeil et al. 2005). As illustrated with the extensive research conducted, PCIT has been shown to be efficacious with many different populations and is flexible in the format, structure, and applied setting of the treatment. This is a potential strength that PCIT can provide over other interventions for domestic violence. PCIT with Domestic Violence Populations We propose that PCIT would be a suitable and beneficial psychotherapeutic intervention for mothers who have been victims of domestic violence and their children. Tables 1 and 2 provide a summary of the effects of domestic violence on children, women, the quality of the parent child relationship, and PCIT s potential to addresses these areas. As noted in the literature review, children exposed to domestic violence display many similar characteristics to children who have been physically abused. Given that PCIT has been used with maltreating families (e.g., Borrego et al. 1999; Chaffin et al. 2004; Timmer et al. 2005), is seems appropriate to use this intervention with domestic violence populations. Throughout PCIT, parents are directly coached by the therapist and given specific instructions and appropriate feedback contingent upon what the therapist observes. Depending on the specific mother child situation, PCIT coaches have the flexibility of focusing on specific skill building exercises during each session. As an example, a PCIT therapist might notice that the mother is hesitant in carrying out a specific discipline exercise or quick to criticize and yell at the child. In this instance, the PCIT therapist would walk the mother through the exercise in a very supportive manner. The therapist would provide immediate feedback on how she is doing and point out the positive aspects of the exercise. In essence, the PCIT therapist becomes a mediator of social reinforcement for the

5 J Fam Viol (2008) 23: Table 1 Effects of domestic violence on children Characteristics Disruptive behavior (Lemmey et al. 2001) Aggressive behavior (DeVoe and Smith 2002; Lemmey et al. 2001) Antisocial behavior (Fantuzzo et al. 1991) Impaired social skills (Fantuzzo et al. 1991) Trauma symptoms (Levendosky et al. 2003) Internalizing problems (Holden and Ritchie 1991) Difficulty focusing on tasks (Levendosky et al. 2003) Academic problems (Wildin et al. 1991) Insecure attachment (Quinlivan and Evans 2005; Zeanah et al. 1999) Imitating batterer (Levendosky and Graham- Bermann 2000) How PCIT can address these issues Parent use of social reinforcement (differential attention) and effective discipline techniques (e.g., time out) Parents model positive, non-aggressive behavior while in play. Time-out can also be used. Parents use PRIDE skills to help teach children to verbalize frustration and anger CDI helps to increase prosocial behaviors by using the PRIDE skills and reinforcement techniques Social skills are modeled and reinforced in session Supportive parenting is provided, but PCIT currently does not address these symptoms. Enhancing the parent child relationship is hypothesized to reduce trauma symptoms Change parent child interactions and certain parent behaviors that are thought to contribute to internalizing problems (Chase and Eyberg 2008) Parents can be encouraged to praise child and to provide other rewards when remaining on task An adaptation in PCIT can be made where parents can make use of a token economy method such as sticker charts so that children are rewarded for each good grade The PRIDE skills in play help to improve the parent child relationship and foster a secure attachment Parents are taught to model positive, non-aggressive behaviors in play and in discipline mother (Borrego and Urquiza 1998). This is crucial for this population as battered women may have low levels of confidence in their own parenting capabilities and may also have low self-esteem. Through being a mediator of social reinforcement, the therapist can provide words of encouragement and verbally reinforce appropriate maternal verbalizations and interactions with her child. These words of encouragement and positive interactions with the therapist can help increase a mother s level of confidence regarding her parenting. Since PCIT is relationship-based, the intervention improves the quality of the parent child relationship and assists in the development of a secure attachment. The underlying assumption is that improving the quality of the parent child relationship will in turn improve parent and child functioning. It is hypothesized that improving the quality of the parent child relationship will decrease the severity of the trauma symptoms that the child and parent are experiencing, as has been demonstrated in the previously mentioned dyadic intervention of CPP-FV (Lieberman et al. Table 2 Effects of domestic violence on abused mothers Characteristics Less warmth in interactions (Levendosky and Graham- Bermann 2000) Less nurturing behaviors (Egeland and Susman-Stillman 1996) Inconsistent with discipline (Egeland and Susman-Stillman 1996; Holden and Ritchie 1991; Holden et al. 1998) Unemotional parenting (Egeland and Susman-Stillman 1996; Holden et al. 1998) Reactive, harsh, and punitive parenting (Rossman and Rea 2005) Potentially abusive cases (Rumm et al. 2000) High levels of stress (Layzer et al. 1986) Low levels of social support (Levendosky and Graham- Bermann 2001) How PCIT can address these issues The PRIDE skills help mothers to learn to become more nurturing and attentive during play The PRIDE skills help the parent become more nurturing by teaching parents to give verbal reinforcement often The PDI phase teaches parents effective behavior management skills. These skills focus on giving consistent consequences for compliance (e.g., verbal praise) and noncompliance (e.g., time-out) The PRIDE skills encourage parents to be enthusiastic during play. Additionally praise helps to foster emotional connections between the parent and child The PDI phase teaches parents to use behavior management skills to discipline the child rather than physical and verbal aggression PDI skills help to reduce abuse risk by teaching parents to control anger and use effective behavior management strategies (e.g., time-out) as a punishment rather than physical discipline Decreases in child disruptive behavior and increases in the quality of the parent child relationship can reduce stress Therapists are very interactive with the parents and provide social reinforcement and support both for treatment-related and personal issues

6 500 J Fam Viol (2008) 23: a, b). CPP-FV emphasizes the parent child relationship with a greater affective component, whereas PCIT teaches parents behavior management techniques to target specific child behaviors while concurrently aiming to improve the parent child relationship. One potential benefit of PCIT is the direct assessment of the parent child relationship through behavioral observations. Behavioral observations can give clinicians valuable information regarding the nature and quality of the dyadic relationship (Querido and Eyberg 2003). Behavioral observations of parent child interactions provide valuable information with regard to behaviors that may be occurring in excess (e.g., child physical aggression, parent criticisms), occurring very little (e.g., child prosocial behaviors, parent praises), or clearly absent (e.g., positive physical contact between the parent and child). In addition, direct observation of the dyad can provide important temporal information such as under what circumstances the mother attends to her child, how the child responds to the mother s attention and commands, and how the mother responds to compliance or noncompliance. The observational data can lead to the identification of target behaviors used to formulate a specific treatment plan for the mother and child. As previously mentioned, one of the goals is for parents to develop an authoritative parenting style where nurturing is balanced with setting firm limits (Schoenfield and Eyberg 2005). Since battered mothers often demonstrate inconsistent, unemotional, harsh, or punitive parenting practices, PCIT focuses on building discipline skills that are consistent, nurturing, non-coercive, and non-violent. Having a parent who is supportive, psychologically available, and displaying consistent discipline practices over time can assist the child in effectively coping with the witnessed or experienced violence in the home (Fosco et al. 2007). In addition, parents are taught to focus on the positive aspects of the parent child relationship during the CDI phase. Parents are coached to use the PRIDE skills to attend to their child in the context of a non-threatening play setting. These attending skills improve the quality and strengthen the parent child relationship by helping the parent convey warmth, affection, and excitement to the child during play. By observing how the parent interacts and responds to the child, the therapist can provide immediate feedback. The PCIT therapist gradually does this by teaching the parent to recognize appropriate instances of when the child should be given verbal praises for appropriate behaviors. Having the therapist provide verbal praises and encouragement reinforces successive approximations by the parent. As previously noted, lower levels of positive interactions are characteristic of battered mother child interactions (e.g., Levendosky et al. 2003). PCIT can address this issue by teaching the mother to attend to and reinforce her child s prosocial behaviors. Based on the mother s needs, the therapist can model appropriate verbalizations or isolate specific deficits (e.g., mother will not praise the child), and practice intense, but short, skill building drills. In the latter example, the PCIT therapist can introduce different ways of praising the child or conduct a 2-min skills-building drill with the mother in which the only instruction the mother has is to provide a verbal praise when the child is behaving appropriately. These exercises serve to expand the mother s repertoire. When the mother emits a desired behavior in session (e.g., praises her child while providing a hug), the PCIT therapist would immediately provide words of encouragement and positive feedback to the mother to build confidence in her parenting. If the mother emits a behavior that is not desired in therapy (e.g., criticizes the child), the PCIT therapist would simply redirect the mother to provide a more appropriate response. Previous PCIT treatment outcome literature has shown that positive maternal interactions and verbalizations increase as treatment progresses (e.g., Borrego et al. 1999). Child externalizing problems such as defiance, disruptive behaviors and aggression are targeted during the two PCIT phases. In CDI, parents use differential attention to decrease the occurrence of these behaviors. For negative behaviors such as negative attention seeking, parents are instructed to actively ignore the child. In contrast to ignoring, the PRIDE skills serve to reinforce positive behavior by providing attention when the child is engaging in desirable behavior. Parents are taught to give praises specific to child behaviors that are socially appropriate. In addition, reflecting the child s statements, imitating appropriate behaviors, describing what the child is doing, and displaying enthusiasm are indicators that the parent is involved in the child s activities. Child aggression requires special consideration since the behavior may be a result of imitating the batterer or difficulty in communicating frustration (a 3-year old child may hit the parent if they are upset with them). In PCIT, the parent is taught to model appropriate verbal and nonverbal behaviors for the child and teach the child to appropriately manage expressions of anger and frustration. In PDI, parents are guided to follow the time-out procedure calmly without yelling. The purpose of these practice sessions is to model that aggression is not the correct way to remedy conflict and more specifically to help the child realize that physical punishments (hitting, slapping) will not be used. As yelling and hitting may serve as reminders of the abuse, teaching parents to speak calmly and use non-physical forms of discipline may decrease the children s trauma symptoms.by acquiring and improving their child management skills, mothers may experience a decrease in parenting stress. Additional literature also notes that battered women use inconsistent and punitive discipline strategies when inter-

7 J Fam Viol (2008) 23: acting with their children (Holden et al. 1998; Osofsky 1998). Inconsistent and harsh discipline practices are targeted during PDI by teaching parents to use non-violent discipline strategies consistently. First, parents are taught to give clear, specific developmentally appropriate commands that are stated in a positive form (e.g., Please put the toys in the box). The purpose is to show the child specifically what he or she is expected to do, which reduces ambiguity in interpreting the command. Positively stated commands tell the child the appropriate behavior that the parent wants completed. For example, a parent would tell the child Please walk when in the house versus telling the child to Stop running. In addition, parents are also taught to follow through with appropriate consequences for both compliance and non-compliance. If compliance occurs, parents are taught to follow through with positive consequences such as social reinforcement in the form of praises, hugs, and excitement. In contrast, if noncompliance occurs, parents are taught to follow through with a warning and then a time out procedure if the child is non-responsive to the warning. If a time-out is necessary, parents are taught to complete time-out without yelling or engaging in aggressive behavior. During the time-out procedure, parents are coached through the process step by step. This approach helps build confidence in the parent s ability to manage her child s behavior. Other disruptive behaviors and social skills impairments are addressed throughout the course of PCIT. Appropriate social skills are taught through parent modeling while using the PRIDE skills and praising the child s prosocial behaviors (e.g., sharing, listening). Other forms of antisocial behaviors (e.g., physical aggression) have been shown to decrease as the quality of the parent child relationship improves and the mother acquires consistent discipline practices. Following treatment completion, social competencies in children have been found to be similar to normative samples (Funderburk et al. 1998). In addition, since child witnesses of domestic violence often have trouble focusing on tasks, parents are coached to provide the child with praise for staying on-task during therapy. Aside from parenting practices, PCIT has been shown to improve internalized problems. Specifically, mothers have been shown to have significant reductions in stress and increased control following PCIT treatment (Eyberg et al. 2001; Hood and Eyberg 2003). This is important as domestic violence victims may feel significant stress and not feel they are in control of their child s behavior or feel competent as a parent (Graham-Bermann and Levendosky 1998; Levendosky and Graham-Bermann 2001). Related to this, it is well documented that lower psychological functioning is related to poorer parenting such that depression and psychological distress contributes to mothers feeling less effective as parents (Levendosky and Graham-Bermann 2001). Research also suggests that mothers depressive symptomotology is related to having negative perceptions and behaviors toward their child (Harwood and Eyberg 2006). Additionally, PCIT significantly reduces the reoccurrence of child abuse in families involved with child protective services (Chaffin et al. 2004). Evaluation of the CPP-FV intervention has focused on cases of domestic violence without concurrent child abuse. This is particularly important considering that many children are witnesses to domestic violence and are victims of child abuse (Apple and Holden 1998). As noted in previous research, PCIT has the potential to enhance the relationship quality between the child and the offending parent through positive parenting skills and teaching the parent appropriate non-violent, behavior management practices. There may also be cases where child neglect is occurring due to the domestic violence. From this, the abused parent may not be as responsive to the child due to the domestic violence. PCIT can also be of benefit in child neglect cases by using live coaching and hands on exercises. Parents may not notice that they are not being responsive to their child s needs and prosocial behaviors. The PCIT therapist can work with the parent, through coaching, on noticing when the child is being appropriate. At first, the PCIT therapist can point out the child s appropriate behavior and have the parent follow the therapist s lead. The therapist can instruct the parent to repeat a praise that is directed toward the child. When the parent repeats the verbal praise, the parent is provided social reinforcement from the therapist (Borrego and Urquiza 1998). In subsequent practice drills, the therapist would point out the behavior and the parent would follow with her own verbal praise. As with before, the therapist would reinforce any successful approximations from the parent. The eventual goal would be for parents to attend to their child on their own and provide their own verbal reinforcement with minimal or without therapist prompts. A concern for mothers who have been victims of domestic violence is the low level of social support they obtain from close friends and family when living with an abusive partner. As suggested in the literature, lack of social support also plays a role in the mother s psychological functioning (Levendosky and Graham-Bermann 2001). PCIT has a unique design in that parents work very closely with therapists so that parenting skills can be mastered and a wide array of services may be obtained if needed. PCIT therapists work with parents to problem solve potential issues in their personal lives (e.g., employment, child care) and behavior issues with the child that may need to be addressed. In fact, recent data suggest that parents reporting greater support from family and friends experience greater improvements in mother child functioning (Harwood and Eyberg 2006). Coaching sessions can also focus on teaching stress

8 502 J Fam Viol (2008) 23: management and anger management skills as the mother interacts with her child (Schoenfield and Eyberg 2005). Since social support may be limited for women who have recently experienced interpersonal violence, consideration of a PCIT group format may be warranted. Through a group PCIT format, other women may serve as social support. As suggested earlier, group PCIT shows preliminary positive results (McNeil et al. 2005). As discussed, standard PCIT is able to address clinical problems pertaining to parenting skills, stress related to parenting, and the child s disruptive behaviors. Internalizing behavior problems and trauma symptoms associated with domestic violence may require adaptations to treatment. With domestic violence populations, a question arises as to how PCIT can address some of the more severe forms of child distress, trauma, and anxiety such as PTSD-related symptoms. There is recent data to suggest that PCIT might be effective in reducing some forms of childhood anxiety (e.g., separation anxiety disorder; Choate et al. 2005) and co-morbid internalizing and externalizing behaviors (Chase and Eyberg 2008). A working hypothesis is that improvement in the quality of the mother child relationship will ameliorate some of the severity of these symptoms. One possible adaptation to PCIT may include adding a didactic session whereby the PCIT therapist conducts some psychoeducation with the mother regarding the negative consequences of domestic violence on women and children. Another adaptation to PCIT might be the content of the mother s verbalizations during play to emphasize issues related to safety and protection. The parent may also be taught to focus on the child s expression of emotions and model appropriate conflict resolution and affect during different play situations. A third possible adaptation might be an extended focus on affect identification and regulation with the mother and the child especially. In standard PCIT, the therapist coaches the mother through stressful situations such as the command compliance sequence in PDI. Early in the PDI phase, before the mother is able to master the behavior management skills, such exercises may elicit negative affect such as frustration or anger. The therapist can walk the mother through the process, provide words of encouragement and positive feedback, model appropriate affect, and instruct the mother on how to appropriately respond to the child. As an adaptation, this exercise can also be extended to the child. The young child may have difficulty in labeling and regulating his or her emotions. The PCIT therapist can coach the mother on how to appropriately respond to the child. This can be accomplished by having the mother model appropriate affect (e.g., remaining calm in a frustrating situation), model appropriate responses when the child is experiencing certain emotions, and redirect the child to respond in a more prosocial manner. In addition, although PCIT has been shown to reduce stress related to parenting, it is not known what kind of impact PCIT would have on overall distress. A clinical focus could be spending time and reflecting the concerns of parents who are experiencing other personal stressors in their lives (Harwood and Eyberg 2006). Clinicians should also be prepared to make therapeutic decisions on whether PCIT is the best option for the parent and child at that point in time. It could be that individual therapy is warranted at first or that PCIT can be implemented in conjunction with the mother receiving individual services. Finally, concurrent problem areas can be addressed through different techniques. Child academic problems are one example. Academic problems can be addressed through the addition of a token economy system. As an adaptation, parents would be encouraged to initially develop a system in which the child can earn tokens that can be traded for some larger reinforcer. Parents could be provided with sticker charts and stickers that can be used to give a small reward for accomplishing a goal. Parents can give stickers for homework completion, studying, and good grades. Conclusions As evidenced by the literature, domestic violence continues to be a social epidemic that has numerous negative consequences. An area that has received relatively little attention is the impact that domestic violence has on battered women and their children in the context of the parent child relationship. Due to diminished parental capacities (e.g., decreased feelings of self-worth and perceived parenting competencies) and child characteristics (e.g., socially disruptive behavior problems), there is a natural disruption of the mother child relationship. Although psychosocial interventions are available for battered women and their children, few treatments focus on working with the mother and child together. PCIT, a relationshipbased intervention, is introduced as a possible treatment to be used with battered women and their children. PCIT can address many of the problems that battered women (e.g., stress, ineffective parenting strategies) and their children (e.g., behavior problems) present for in treatment. In addition, through careful monitoring, some of the distress, anxiety, and affect problems can be addressed through an improvement in the quality of the parent child relationship. Some possible modifications are also highlighted that may need to be made if working families in significant distress. Though the focus of this paper has been on mother child dyads, PCIT can also be carried out with fathers who have experienced domestic violence at home. The authors acknowledge that bi-directional violence occurs at times

9 J Fam Viol (2008) 23: between fathers and mothers. The reason the focus here is on the mother child dyad is because more females present at domestic violence shelters for services. In turn, mothers are more likely to be referred for mental health treatment. Finally, it is important to address ethical and legal responsibilities that therapists have when working with these families. Ethically, PCIT may not be the treatment of choice if the main presenting problem for the parent or child is severe traumatization or other related symptoms. In this case, other treatments may be more appropriate and PCIT can be used as an adjunct treatment. As an example, the mother or child can be seen individually or in group to address severe PTSD while also being in PCIT. In addition, PCIT would not be an appropriate treatment if family violence were ongoing. If violence in the home is persistent, safety issues for the battered parent and the child(ren) need to be addressed prior to commencing treatment. The emotional, psychological, and physical well being of the child and the parent should be assessed at the onset of therapy. The therapist should work with the battered parent in developing a safety plan and obtaining appropriate referrals and potential resources. Additionally, appropriate agencies, such as child protection services (CPS), are to be contacted to report any suspected cases of child maltreatment. PCIT would not be as beneficial with families where there is ongoing trauma and violence as it would be difficult to successfully implement PCIT with a family that is constantly worried about ongoing and pending violence in the home. Acknowledgements We would like to thank Katrina Cook, Kelly Davis, and Leslie; Romero for helpful feedback and editorial suggestions. References Adamson, J. L., & Thompson, R. A. (1998). Coping with interparental verbal conflict by children exposed to spouse abuse and children from nonviolent homes. Journal of Family Violence, 13, Agar, S. (2004). Interventions for children who witness intimate partner violence: A literature review. Institute Against Family Violence. Retrieved May 10, 2006 from pubs/archives/2004_11.shtml. Anderson, S. A., & Cramer-Benjamin, D. B. (1999). The impact of couple violence on parenting and children: An overview and clinical implications. The American Journal of Family Therapy, 27, Apple, A. E., & Holden, G. W. (1998). The co-occurrence of spouse and physical child abuse: A review and appraisal. Journal of Family Psychology, 12, Bagner, D. M., Fernandez, M. A., & Eyberg, S. M. (2004). Parent child interaction therapy and chronic illness: A case study. Journal of Clinical Psychology in Medical Settings, 11, 1 6. Baumrind, D. (1967). Child care practices anteceding three patterns of preschool behavior. Genetic Psychology Monographs, 75, Bell, S., Boggs, S. R., & Eyberg, S. M. (2003). Positive attention. In W. O Donohue, J. D. Fisher, & S. C. Hayes (Eds.) Empirically supported techniques of cognitive behavior therapy: A step-bystep guide for clinicians. New York: Wiley. Belsky, J. (1984). The determinants of parenting: A process model. Child Development, 55, Borrego J., Jr., Anhalt, K., Terao, S. Y., Vargas, E., & Urquiza, A. J. (2006). Parent child interaction therapy with a Spanish-speaking family. Cognitive & Behavioral Practice, 13, Borrego J., Jr., & Urquiza, A. J. (1998). Importance of therapist use of social reinforcement with parents as a model for parent child relationships: An example with parent child interaction therapy. Child and Family Behavior Therapy, 20, Borrego J., Jr., Urquiza, A. J., Rasmussen, R. A., & Zebell, N. (1999). Parent child interaction therapy with a family at high risk for physical abuse. Child Maltreatment, 4, Brestan, E., & Eyberg, S. M. (1998). Effective psychosocial treatments of conduct-disordered children and adolescents: 29 years, 82 studies, and 5,272 kids. Journal of Clinical Child Psychology, 27, Brestan, E. V., Eyberg, S. M., Boggs, S. R., & Algina, J. (1997). Parent child interaction therapy: Parent perceptions of untreated siblings. Child & Family Behavior Therapy, 19, Brinkmeyer, M. Y., & Eyberg, S. M. (2003). Parent child interaction therapy for oppositional children. In A. Kazdin, & J. Weisz (Eds.) Evidence-based psychotherapies for children and adolescents (pp ). New York: Guilford. Capage, L. C., Bennett, G. M., & McNeil, C. B. (2001). A comparison between African-American and Caucasian children referred for treatment of disruptive behavior disorders. Child and Family Behavior Therapy, 23, Center for Disease Control and Prevention. (2003). Costs of intimate partner violence against women in the United States. Retrieved March 18, 2006, from htm. Chaffin, M., Silvosky, J. F., Funderburk, B., Valle, L. A., Brestan, E. V., Balachova, T., et al. (2004). Parent child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72, Chase, R. M., & Eyberg, S. M. (2008). Clinical presentation and treatment outcome for Children with Comorbid Externalizing and Internalizing Symptoms. Journal of Anxiety Disorders, 22, Choate, M. L., Pincus, D. B., Eyberg, S. M., & Barlow, D. H. (2005). Parent child interaction therapy for treatment of Separation Anxiety Disorder in young children: A pilot study. Cognitive and Behavioral Practice, 12, Davies, P. T., & Cummings, E. M. (1994). Marital conflict and child adjustment: An emotional security hypothesis. Psychological Bulletin, 116, DeVoe, E. R., & Smith, E. L. (2002). The impact of domestic violence on urban preschool children. Journal of Interpersonal Violence, 17, Ducharme, J. M., Atkinson, L., & Poulton, L. (2000). Success-based, noncoercive treatment of oppositional behavior in children from violent homes. Journal of the American Academy of Child & Adolescent Psychiatry, 39, Egeland, B., & Susman-Stillman, A. (1996). Dissociation as a mediator of abuse across generations. Child Abuse & Neglect, 20, Eyberg, S., & Boggs, S. R. (1998). Parent child interaction therapy: A psychosocial intervention for the treatment of young conductdisordered children. In J. M. Breismeister, & C. E. Schafer (Eds.) Handbook of parent training: Parents as co-therapists for children s behavior problems (pp ). New York: Wiley. Eyberg, S. M., Funderburk, B. W., Hembree-Kigin, T. L., McNeil, C. B., Querido, J. G., & Hood, K. (2001). Parent child interaction therapy with behavior problem children: One and two

10 504 J Fam Viol (2008) 23: year maintenance of treatment effects in the family. Child & Family Behavior Therapy, 23, Fantuzzo, J., Boruch, R., Beriama, A., Atkins, M., & Marcus, S. (1997). Domestic violence and children: Prevalence and risk in five major cities. Journal of the American Academy of Child and Adolescent Psychiatry, 36, Fantuzzo, J. W., DePaola, L. M., Lambert, L., Martino, T., Anderson, G., & Sutton, S. (1991). Effects of interparental violence on the psychological adjustment and competencies of young children. Journal of Consulting and Clinical Psychology, 59, Fosco, G. M., DeBoard, R. L., & Grych, J. H. (2007). Making sense of family violence Implications of children s appraisal of interparental aggression for their short- and long-term functioning. European Psychologist, 12, Funderburk, B. W., Eyberg, S. M., Newcomb, K., McNeil, C., Hebree-Kigin, T., & Capage, L. (1998). Parent child interaction therapy with behavior problem children: Maintenance of treatment effects in the school setting. Child & Family Behavior Therapy, 20, Graham-Bermann, S. A. (2000). Evaluating interventions for children exposed to family violence. In S. K. Ward, & D. Finkelhor (Eds.) Program evaluation and family violence research (pp ). Binghamton, NY: Haworth. Graham-Bermann, S. A. (2001). Designing intervention evaluations for children exposed to domestic violence: Applications of research and theory. In S. A. Graham-Bermann, & J. L. Edleson (Eds.) Domestic violence in the lives of children & the future of research, intervention & social policy (pp ). Washington, DC: American Psychological Association. Graham-Bermann, S. A., & Hughes, H. M. (2003). Intervention for children exposed to interparental violence (IPV): Assessment of needs and research priorities. Clinical Child and Family Psychology Review, 6, Graham-Bermann, S. A., & Levendosky, A. A. (1998). The social functioning of preschool-age children whose mothers are emotionally and physically abused. Journal of Emotional Abuse, 1, Harwood, M. D., & Eyberg, S. M. (2006). Child-directed interaction: Prediction of change in impaired mother child functioning. Journal of Abnormal Child Psychology, 34, Hembree-Kigin, T., & McNeil, C. B. (1995). Parent child interaction therapy. New York: Plenum. Holden, E. W., Willis, D. J., & Foltz, L. (1989). Child abuse potential and parenting stress: Relationships in maltreating parents. Psychological Assessment, 1, Holden, G. W., & Ritchie, K. L. (1991). Linking extreme marital discord, child rearing, and child behavior problems: Evidence from battered women. Child Development, 62, Holden, G. W., Stein, J. D., Ritchie, K. L., Harris, S. D., & Jouriles, E. N. (1998). Parenting behaviors and beliefs of battered women. In G. M. Holden, R. Geffner, & E. N. Jouriles (Eds.) Children exposed to marital violence (pp ). Washington, DC: American Psychological Association. Hood, K., & Eyberg, S. M. (2003). Outcomes of parent child interaction therapy: Mother s reports on maintenance three to six years after treatment. Journal of Clinical Child and Adolescent Psychology, 32, Johnston, J. (2003). Group interventions for children at risk from family abuse and exposure to domestic violence: A report of a study. In R. Geffner, R. Igelman, & J. Zelner (Eds.) The effects of intimate partner violence on children (pp ). Binghamton: Haworth. Jouriles, E., McDonald, R., Stephens, N., Norwood, W., Collazos Spiller, L., & Shinn Ware, H. (1998). Breaking the cycle of violence: Helping families departing from battered women s shelters. In G. W. Holden, R. Geffner, & E. N. Jouriles (Eds.) Children exposed to marital violence: Theory, research & applied issues (pp ). Washington, DC: American Psychological Association. Jouriles, E. N., McDonald, R., Spiller, L., Norwood, W. D., Swank, P. R., Stephens, N., et al. (2001). Reducing conduct problems among children of battered women. Journal of Consulting and Clinical Psychology, 69, Kemp, A., Green, B. L., Hovanitz, C., & Rawlings, E. I. (1995). Incidence and correlates of posttraumatic stress disorder in battered women. Journal of Interpersonal Violence, 10, Kérouac, S., Taggart, M. E., Lescop, J., & Fortin, M. F. (1986). Dimensions of health in violent families. Health Care for Women International, 7, Kitzmann, K. M., Gaylord, N. K., Holt, A. R., & Kenny, E. D. (2003). Child witness to domestic violence: A meta-analytic review. Journal of Consulting and Clinical Psychology, 71, Layzer, J. I., Goodson, B. D., & delange, C. (1986). Children in shelters. Response, 9, 2 5. Lemmey, D., McFarlane, J., Wilson, P., & Malecha, A. (2001). Intimate partner violence: Mothers perspectives of effects on their children. The American Journal of Maternal/Child Nursing, 26, Levendosky, A. A., & Graham-Bermann, S. A. (2000). Behavioral observations of parenting in battered women. Journal of Family Psychology, 14, Levendosky, A. A., & Graham-Bermann, S. A. (2001). Parenting in battered women: The effects of domestic violence on women and their children. Journal of Family Violence, 16, Levendosky, A. A., Huth-Bocks, A. C., Shapiro, D. L., & Semel, M. A. (2003). The impact of domestic violence on the maternal child relationship and preschool-age children s functioning. Journal of Family Psychology, 17, Lieberman, A. F., Van Horn, P., & Ghosh Ippen, C. (2005a). Toward evidence-based treatment: Child parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child and Adolescent Psychiatry, 44, Lieberman, A. F., Van Horn, P., & Ozer, E. J. (2005b). Preschooler witnesses of marital violence: Predictors and mediators of child behavior problems. Developmental Psychopathology, 17, Lieberman, A. F., Weston, D. R., & Pawl, J. H. (1991). Preventive intervention and outcome with anxiously attached dyads. Child Development, 62, Lutzker, J. R., Van Hasselt, V. B., Bigelow, K. M., Greene, B. F., & Kessler, M. L. (1998). Child abuse and neglect: Behavioral research, treatment, and theory. Aggression and Violent Behavior, 3, Maker, A. H., Kemmelmeier, M., & Peterson, C. (1998). Long-term psychological consequences in women of witnessing parental physical conflict and experiencing abuse in childhood. Journal of Interpersonal Violence, 13, Matos, M., Torres, R., Santiago, R., Jurado, M., & Rodriguez, I. (2006). Adaptation of parent child interaction therapy for Puerto Rican families: A preliminary study. Family Process, 45, McCloskey, L. A., Figueredo, A. J., & Koss, M. P. (1995). The effects of systemic family violence on children s mental health. Child Development, 66, McDiarmid, M. D., & Bagner, D. M. (2005). Parent child interaction therapy for children with disruptive behavior and developmental disabilities. Education and Treatment, 28, McNeal, C., & Amato, P. R. (1998). Parents marital violence: Longterm consequences for children. Journal of Family Issues, 19, McNeil, C. B., Capage, L. C., Bahl, A., & Blanc, H. (1999). Importance of early intervention for disruptive behavior prob-

11 J Fam Viol (2008) 23: lems: Comparison of treatment and waitlist-control groups. Early Education & Development, 10, McNeil, C. B., Herschell, A. D., Gurwitch, R. H., & Clemens- Mowrer, L. (2005). Training foster parent child interaction therapy. Education and Treatment of Children, 28, Murray, L., Sinclair, D., Cooper, P., Ducournau, P., & Turner, P. (1999). The socioemotional development of 5-year-old children of postnatally depressed mothers. Journal of Psychology and Psychiatry and Allied Disciplines, 40, Niec, L. N., Hemme, J. M., Yopp, J., & Brestan, E. V. (2005). Parent- Child Interaction Therapy: The rewards and challenges of a group format. Cognitive and Behavioral Practice, 12, Nixon, R. D. V. (2001). Changes in hyperactivity and temperament in behaviourally disturbed preschoolers after parent child interaction therapy (PCIT). Behaviour Change, 18, Nixon, R. D., Sweeney, L., Erickson, D. B., & Touyz, S. W. (2003). Parent child interaction therapy: A comparison of standard and abbreviated treatments for oppositional defiant preschoolers. Journal of Consulting and Clinical Psychology, 71, Osofsky, J. D. (1998). Children as invisible victims of domestic and community violence. In G. W. Holden, R. Geffner, & E. N. Jouriles (Eds.) Children exposed to marital violence: Theory, research and applied issues (pp ). Washington, DC: American Psychological Association. Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castalia. Peled, E., & Edleson, J. L. (1992). Multiple perspectives on groupwork with children of battered women. Violence and Victims, 7, Peled, E., & Edleson, J. L. (1995). Process and outcome in small groups for children of battered women. In E. J. Peled, & J. L. Edleson (Eds.) Ending the cycle of violence: Community responses to children of battered women (pp ). Thousand Oaks, CA: Sage. Querido, J. G., & Eyberg, S. M. (2003). Parent child interaction assessment. In T. H. Ollendick, & C. S. Schroeder (Eds.) Encyclopedia of clinical child and pediatric psyschology. New York: Plenum. Quinlivan, J. A., & Evans, S. F. (2005). Impact of domestic violence and drug abuse in pregnancy on maternal attachment and infant temperament in teenage mothers in the setting of best clinical practice. Archives of Women s Mental Health, 8, Riggio, H. R. (2004). Parental marital conflict and divorce, parent child relationships, social support, and relationship anxiety in young adulthood. Personal Relationships, 11, Rossman, B. B., & Rea, J. G. (2005). The relation of parenting styles and inconsistencies to adaptive functioning for children in conflictual and violent families. Journal of Family Violence, 20, Rumm, P. D., Cummings, P., Krauss, M. R., Bell, M. A., & Rivara, F. P. (2000). Identified spouse abuse as a risk factor for child abuse. Child Abuse & Neglect, 24, Schoenfield, L., & Eyberg, S. M. (2005). Parent management training. In G. P. Koocher, J. C. Norcross, & S. S. Hill (Eds.) Psychologist s desk reference(2nd ed.). New York: Oxford University Press. Schuhmann, E. M., Foote, R., Eyberg, S. M., Boggs, S., & Algina, J. (1998). Parent child therapy: Interim report of a randomized trial with short-term maintenance. Journal of Clinical Child Psychology, 27, Tajima, E. A. (2000). The relative importance of wife abuse as a risk factor for violence against children. Child Abuse & Neglect, 24, The National Child Traumatic Stress Network, (2007). Child parent psychotherapy for family violence (CPP-FV). Retrieved March 6, 2007, from practices/cppsychptherapyforfv_21105.pdf. Timmer, S. G., Urquiza, A. J., Zebell, N. M., & McGrath, J. M. (2005). Parent child interaction therapy: Application to maltreatment parent child dyads. Child Abuse & Neglect, 29, Toth, S. L., Maughan, A., Manly, J. T., Spagnola, M., & Cicchetti, D. (2002). The relative efficacy of two interventions in altering maltreated preschool children s representational models: Implications for attachment theory. Development and Psychopathology, 14, Wildin, S. R., Williamson, W. D., & Wilson, G. S. (1991). Children of battered women: Developmental and learning profiles. Clinical Pediatrics, 30, Ybarra, G., Wilkens, S. L., & Lieberman, A. (2007). The influence of domestic violence on preschooler behavior and functioning. Journal of Family Violence, 22, Zeanah, C. H., Danis, B., Hirshberg, L., Benoit, D., Miller, D., & Heller, S. S. (1999). Disorganized attachment associated with partner violence: A research note. Infant Mental Health Journal, 20,