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Article history: Background: Child-to-parent violence is an often hidden serious problem for parental
Received 13 May 2015 caregivers of mentally ill adult children who experience violence toward them. To date, the
Received in revised form 29 February 2016 comprehensive dyadic parent-adult child intervention to manage child-to-parent violence
Accepted 4 March 2016 is scarce.
Objective: To evaluate the effect of Child- and Parent-focused Violence Program, an
Keywords: adjunctive intervention involved with both violent adult children with mental illness and
Child-to-parent violence their victimized biological parent (parentadult child dyads) on violence management.
Repetitive violence
Design: Open-label randomized controlled trial.
Victimized parents
Setting: A psychiatric ward in a teaching hospital and two mental hospitals in Southern
Nurse-led violence intervention
Mental illness
Taiwan.
Randomized controlled trial Participants: Sixty-nine patients aged 20 years, with thought or mood disorders, having
Nursing violent behavior in the past 6 months toward their biological parent of either gender were
recruited. The violent patients victimized biological parents who had a major and ongoing
role in provision of care to these patients, living together with and being assaulted by their
violent children were also recruited. The parentadult child dyads were selected.
Methods: The intervention was carried out from 2011 to 2013. The parentadult child
dyads were randomly assigned to either the experimental group (36 dyads), which
received Child- and Parent-focused Violence Intervention Program, or to the control group
(33 dyads), which received only routine psychiatric care. The intervention included two
individualized sessions for each patient and parent, separately, and 2 conjoint sessions for
each parental-child dyad for a total of 6 sessions. Each session lasted for at least 60-min.
Data collection was conducted at 3 different time frames: pre-treatment, post-treatment,
and treatment follow-up (one month after the completion of the intervention).
Results: Occurrence of violence prior to intervention was comparable between two
groups: 88.9% (n = 32) parents in the experimental group versus 93.9% (n = 31) in the
control group experienced verbal attack, and 50% (n = 18) versus 48.5% (n = 16) received
* Corresponding author at: Department of Nursing, I-Shou University, No. 8, Yida Road, Jiaosu Village Yanchao District, Kaohsiung City 82445, Taiwan,
ROC. Tel.: +886 7 6151100x7720; fax: +886 7 6155150.
E-mail addresses: gcsun39@yahoo.com.tw (G.-C. Sun), hsu88@isu.edu.tw (M.-C. Hsu).
1
Address: National Cheng Kung University, No. 1, University Road, Tainan City 701, Taiwan, ROC; Kaohsiung Medical University Hospital, No. 100, Tzyou
1st Road, Kaohsiung 807, Taiwan, ROC; Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan; Kaohsiung Veterans
General Hospital, No. 386, Dazhong 1st Road, Zuoying Dist., Kaohsiung City 81362, Taiwan, ROC.
http://dx.doi.org/10.1016/j.ijnurstu.2016.03.002
0020-7489/ 2016 Elsevier Ltd. All rights reserved.
80 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990
body attack and were injured. The intervention signicantly reduced violence, improved
impulsivity, changed patients and parents violence attributions, and fostering active
coping processes in the experimental group as compared to the control group (p < 0.05).
No signicant reductions were found in verbal aggression, cognitive and social reactions in
the parents reactions to assault, attentional subscale of impulsivity and wishful thinking
(p > 0.05).
Conclusions: Child- and Parent-focused Violence Intervention Program is effective on
child-to-parent violence management in parentadult child dyads. Thus, the intervention
can be helpful for patients who have just been diagnosed with mental illness and had an
episode of violence toward their parents within a narrow time frame.
2016 Elsevier Ltd. All rights reserved.
What is already known about the topic? bipolar disorder (Flynn et al., 2014; Tiihonen et al., 1997).
For example, schizophrenia occurring during periods of
Parents are among one of the most frequent victims of active psychosis increased the risk of violent offenses
repetitive violence by their children diagnosed with (Buckley et al., 2003) by as much as 7-fold (Tiihonen et al.,
mental illnesses, particularly if the violence is long-term, 1997) or 2 to 8-fold for both men and women compared
and the occurrence of violence is often unpredictable. with general population (Fazel and Grann, 2006). Fazel and
Several empirically driven treatment have been devel- Grann (2006) have also found that patients with severe
oped to decrease child-to-parent violence or violence, mental illness commit one in 20 violent crimes. Violent
such as parent-child interaction therapy for disruptive patients with mental illness are at risk for relapses of
behavior in preschool-aged youth, non-violent resis- violence even when undergoing pharmacotherapy. Repet-
tance program, individual family support programs itive violent acts are generally associated with coexisting
(family consultation), individual- or group-family groups cognitive impairment, patients history of violence or
and psychoeducation interventions. disorganization with impaired reality testing (Chen et al.,
There is also a lack of data examining the complex dyadic 2014; Volavka, 2013).
effects in family therapy. Family members are among the most frequent victims
of violence by patients diagnosed with mental disorders
What this paper adds (Volavka, 2013). In comparison with other family mem-
bers, parents, as the major caregiver of their children, are
This is the rst known randomized controlled trial of more likely to be violently victimized (Hsu et al., 2014;
dyadic parent-adult child intervention to manage child- Ibabe et al., 2014; Ibabe and Jaureguizar, 2010). Child-to-
to-parent violence in patients with mental illnesses. parent violence is an often hidden serious social problem.
This randomized clinical trial demonstrated the benet It describes violence or aggressive behavior committed
of a nurse-led child- and parent-focused violence by a child (either under 18 or an adult child) who
intervention on violent adult patients with mental intentionally uses physical force/power or aggressive/
illnesses and victimized parents in addition to usual inappropriate language to threaten or actually cause
care, on the primary prevention of repetitive violence. physical or psychological harm, damage or pain or nancial
This study demonstrated that Child- and Parent-focused deprivation to a parent (Calvete et al., 2013; Coogan and
Violence Intervention Program, which targets child-to- Lauster, 2014). An earlier study has found that 18% of two-
parent violence concurrently for both patients and their parent and 29% of single-parent families experience child-
parents, was an empirically effective adjunctive inter- to-parent violence (Pelletier and Coutu, 1992). Walsh and
vention for improving violence management, alleviating Krienert (2009) found that biological parents were the
intensity of a parent assault victims emotional and most predominant victim relation to the aggressor, and
biophysiological reactions, managing impulsivity and 79% of parricides and 92% of child-to-parent violence
violence attributions, and fostering active coping pro- incidents involved a biological parent. When the victims
cesses. gender was examined, 8188% of the victims was
biological mothers (Kethineni, 2004; Nock and Kazdin,
1. Introduction 2002). Thus, parent-child relations are dynamic interac-
tions, which are prone to conict and turmoil (Walsh and
Violence is becoming a major concern in mental health Krienert, 2009).
practice. Most studies appear to support a clear association This becomes an increasing concern for parental
between violence and mental illness (e.g., Fazel and Grann, caregivers who experience violence from their mentally
2006; Tiihonen et al., 1997). Flynn et al. (2014) have shown ill adult children (Hsu and Tu, 2014; Ibabe et al., 2014). As
that 5% of the serious violent offenders had been in recent traumas of child-to-parent violence pose a serious threat,
contact with mental health services, with 61% having they can also cause various effects on parents emotional,
previous convictions for violence. The most common psychological, and physical well-being, particularly if the
psychotic disorders are schizophrenia, depression, and violence from their mentally ill children is long-term and
G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990 81
often unpredictable. Unfortunately, the repetitive nature and uncontrolled behavior (Coogan and Lauster, 2014;
of child-to-parent violence, typically in the form of verbal Lauster et al., 2014). The program helps parents learn to
or physical violence committed by the mentally ill manage the violent and destructive behavior of their
aggressor, is the most traumatic and often hidden issue children, reduce their feelings of helplessness, and improve
of family violence, and often ignored in clinical manage- their mental health. Despite the types of interventions,
ment of violence (Coogan and Lauster, 2014; Ibabe and targeted behaviors, age of children, and contextual factors
Jaureguizar, 2010). varied, most of these studies have shown improvements in
To date, various and interrelated determinants, risks, child-to-parent violence after interventions. Nevertheless,
contributory factors and prevalence across various cultural these studies were short-term in nature and limited focus
settings in relation to child-to-parent violence in the home on only one or two issues of concerns. Since child-to-
have been identied. These have prompted several studies parent violence has serious and long lasting detrimental
to determine the nature and scope of this specic issue consequences for both parents and children, it would be
with respect to child-to-parent violence. They include: (1) important to examine if concurrently involvement of both
child and/or parental mental health (Kennair and Mellor, mentally ill violent patients and their victimized biological
2007; Pagani et al., 2004), (2) childrens higher levels of parent in an intervention could improve the effectiveness
personal maladjustment, with a notable incidence of of the intervention.
depressive symptoms (Ibabe et al., 2014), (3) psychological
stress and behavior disorders (Howard and Rottem, 2008), 1.1. Aim and hypotheses of the study
(4) emotional disorders, thought disorder, learning dis-
orders, personal psychological dysfunction and dysfunc- In this study, a randomized controlled trial was carried
tional family relations (Calvete et al., 2013; Howard and out to evaluate the effect of Child- and Parent-focused
Rottem, 2008), and (5) parenting style and family conict Violence Intervention Program (CP-VIP), an adjunctive
(Gallagher, 2004). intervention, which involved both violent adult children
However, very few studies have focused on the form of with mental illness and their victimized biological parent
emotional and/or physical violence carried out by adult (parentadult child dyads), on violence management. The
children against their parents (Chien et al., 2005, 2006). research hypothesis was that Child- and Parent-focused
Even fewer studies have comprehensively examined the Violence Intervention Program, when used in addition to
child-to-parent violence in a dyadic context (e.g., Chien psychiatric standard care, could be more effective than
and Chan, 2013), and explicitly investigated the non- psychiatric standard care alone in reducing the severity of
reciprocal violence initiated by the violent adult child with the patients violent behaviors and improvements in coping
mental illness. This may be due in part to the difculty of of the patients and their parents.
including both victimized parental caregivers and their
mentally ill and violent adult children in a study. As a
2. Methods
result, there has been a lack of intervention strategies
dealing with the child-to-parent violence. There is also a 2.1. Study design
lack of data examining how the violence management
program might have affected childrens violent behavior This study was an open-label randomized, clinical trial
and the reactions (as the assaulted victim, coping process) from 2011 to 2013. Data were collected at 3 different time
of parents and how children and parents think of each frames: pre-treatment (T1), post-treatment (T2), and
other. Several studies have discussed child-to-parent treatment follow-up (one month after the completion of
violence toward parents and its challenges on family the intervention) (T3).
violence, and evaluated different intervention programs
designed to assist family caregivers of persons with mental 2.2. Settings, participants and recruitment
illness. For example, individual family support programs
(family consultation) (Citron et al., 1999), and individual- The study was conducted at three hospitals located in
or group-family groups and psycho-education interven- Southern Taiwan. The rst mental hospital with 700 beds is
tions (Solomon, 2000) have been examined, and all seemed under auspices of the Ministry of Health and Welfare. The
to be promising. second one is a general hospital with 50 psychiatric beds
Chien et al. (2005, 2006) have reported that mutual and the third is an 80-bed mental hospital, both are
support in comparison with psycho-educational and privately owned and operated. All three hospitals are
routine family support services, could improve functioning similar in respect to philosophy of care and stafng.
for both caring Chinese families and the relative with The inclusion criteria for patients were: age 20 years,
schizophrenia. Lyon and Budd (2010) have investigated the a conrmed diagnosis of thought or mood disorders, and
effect of ParentChild Interaction Therapy on both psychiatrically hospitalized, having violent behavior in the
preschool-aged youth with disruptive behavior and fami- past 6 months toward their biological parent of either
lies, and demonstrated improvements of parent behavior gender, and able to give informed consent. This study
and stress, and child functioning. Unfortunately, the high targeted adult patients because their violence often caused
premature dropout rate had limited the effectiveness of injury or harm to their parent. The inclusion criteria for
the study. In another study, a non-violent resistance those being physically or psychologically assaulted parents
program, a form of family therapy, has been designed to (victimized parents) were: having a major and ongoing
target directly parents living with children with violent role in providing care to their violent children, living
82 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990
together with and being assaulted by their children in the behavioral problems by gaining more adaptive and accurate
past 6 months, and being able to provide clear and perspectives and developing coping techniques for negative
conscious consent. From them the parentadult child thoughts and violence. The components included: learning
dyads were selected. the skills involved in identifying cognitive distortions that
To ensure the quality of the study, the research team cause negative feelings (i.e. personalization and blame),
included psychiatrists, nurses, allied health professionals modifying dysfunctional beliefs that contribute to violence,
(social worker and clinical psychologists), and nursing and disrupting the dangerous acts of violence as a repeated
educators with specialized skills and expertise. Patients pattern and changing behaviors.
were recruited based on inclusion and exclusion criteria by In addition, the core contents of the intervention for the
psychiatrists and social workers of the domestic violence victimized parent included: conict resolution strategies,
prevention center in hospitals. The patients parents were communication skills, coping process, and recognition and
then contacted by social workers, and asked for agreement management of childrens violence. The core contents for
to give their telephone number to the research team. The the violent children included: homework assignments that
research team members then approached both patients promote generalization of skills into regular life, discussion
and parents for the study, and conducted baseline and of how their characteristics may interact with parents
post-intervention assessments. to produce a violent event, discussion of how mental
symptoms impact their propensities for violence, skills
2.3. Sample size and estimated study power training to manage violence such as mad/bad/sad feelings,
communication and impulse control. The core contents of
The sample size was calculated based on a previous conjoint sessions included: de-escalation skills for both
clinical trial of professionally lead support group for parties to de-escalate and avoid unnecessary confronta-
Taiwanese people with schizophrenia in three waves of tions, re-focusing interactions away from persistent
data collection (before intervention, after intervention and conict, commitment to avoid violence and provocation
one-month follow-up) (Chou et al., 2002), and two clinical elements that could cause altercations, and acts of
trials of supportive and psychoeducational group treat- reconciliation and offering of encouragement to each
ments for Chinese people with schizophrenia (Chien et al., other.
2005, 2006). Based on these calculations, 32 child-parent In the experimental group, each patient and parent
dyads in each group would be needed for three waves of received separately, 2 individualized sessions of the Child-
data collection in order to provide 80% power (two-sided and Parent-focused Violence Intervention Program, and
p < 0.05) to detect statistically signicant differences each parentalchild dyad received 2 conjoint sessions, for a
(p-value of 0.05) between 2 groups, at moderate effect total of 6 sessions. In each session, each participant had at
sizes of 0.68 and 0.70, respectively, and power of 0.8 to least a 30-min preparation before the session started. Each
account for a 15% attrition rate (Cohen, 1992, 1998). In this session lasted approximately one and one-half hours. The
study, sixty-nine dyads (patient and parent) were selected time period of the intervention was approximately two
and randomly allocated to 2 study groups. months. The intervention program was carried out by
primary researcher, nurse and psychologists.
2.4. Randomization In the control group, patients received psychiatric
standard care, which consists of routine psychiatric and
After a written informed consent was obtained, patients functional evaluations, regular ward group psychothera-
were randomly assigned to either the experimental or the peutic efforts, occupational therapies, supportive listening,
control group. The randomization schedule was generated medication management, social skill trainings, practice
by computer and sealed in serially numbered opaque with activities of daily living and individualized program
envelopes by a trained nurse. The researcher opened the for rehabilitation, etc.
allocation envelope selected by the patient.
2.6. Outcome measures
2.5. Intervention
The study design incorporates a number of outcome
The theoretical foundation which guided the develop- measures to reect the effect of intervention on psycho-
ment of the intervention was cognitive and behavior theory logical, behavioral and cognitive domains and violence.
(Beck, 1970) and ndings from earlier studies of child-to- The theoretical foundation for designing the intervention
parent violence. The cognitive and behavior theory is known also guided the selection of outcomes to be measured. In
to be effective on patients with agitated or aggressive this study, the primary outcome of the trial involved the
behavior (Hofmann et al., 2012; Saini, 2009). In this study, evaluation of ways of coping; and the secondary outcome
cognitive and behavioral individual risk factors for violence included general cognitive functioning of patients, and
and intertwined factors which interacted at multiple levels the intensity of a parent reaction as an assaulted victim,
and placed parent at risk of child-to-parent violence, were violence attributions and impulsivity.
examined and therapeutic concerns on the conjoint sessions
evaluated. The most essential components of the interven- 2.6.1. Patient only
tion were: developing trusting relationships; describing and
dening multidimensional conceptualization differences in 1. Aggression/violence: The aggression questionnaire
patients and their parents; and assisting them to address developed by Buss and Perry (1992) was used. It
G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990 83
Table 1
Characteristics of patients and their parents at recruitment.
Gender Male 24 66.7 13 36.1 27 81.8 10 30.3 2.050 0.261 0.152 0.609
Female 12 33.3 23 63.9 6 18.2 23 69.7
Age (years) 3140 29 80.5 1 2.8 24 72.8 1.211 1.417 0.750 0.841
4160 7 19.5 18 50.0 9 27.3 19 57.6
61 17 47.2 14 42.4
Education Primary 5 13.9 25 69.4 2 6.1 24 72.8 1.844 2.010 0.764 0.848
school/below
Secondary/ 28 77.7 8 22.2 28 84.9 8 24.2
high school
Junior 3 8.4 3 8.4 3 9.1 1 3.0
college/college
Occupation Unemployed 25 69.4 17 47.2 23 69.7 13 39.4 2.207 7.945 0.531 0.159
Employed 11 30.6 19 52.8 10 30.3 20 60.6
Religion None 4 11.1 4 11.1 1 3.0 4 12.1 2.766 2.025 0.598 0.731
Buddhism/Taoism 27 75.0 30 83.4 24 72.7 27 81.8
Christian/others 5 13.9 2 5.6 8 24.3 2 6.1
Frequency- Rarely 18 50.0 6 16.7 11 33.3 4 12.1 3.416 7.481 0.491 0.113
religious 13/month 11 30.5 20 55.5 13 39.4 23 69.7
practice 15/week 7 19.5 10 27.8 9 27.3 6 18.2
Family month < 25,000 25 69.4 24 66.7 24 72.7 24 72.7 1.894 1.926 0.595 0.382
income (NT$) >25,00150,000 11 30.6 12 33.3 9 27.3 9 27.3
Have chronic No 29 80.6 18 50.0 23 69.7 19 57.6 1.093 0.397 0.296 0.528
disease Yes 7 19.4 18 50.0 10 30.3 14 42.4
Smoking Yes 21 58.4 3 8.3 19 57.6 1 3.0 1.690 2.930 0.639 0.231
No 15 41.6 33 91.7 14 42.4 32 97.0
CP-VIP, Child- and Parent-focused Violence Intervention Program; Verbal V, verbal violence; Physical V, physical violence; AAP, aggression against property.
two groups. All other demographic variables of patients in the (n = 18) versus 48.5% (n = 16) received physical violence
control were similar to those in the experimental group and were injured.
(p > 0.05). Similarly, the demographics of parents in the
control group were compatible to those in the experimental 3.2. Effects on patients
group (p > 0.05).
The occurrence of violence prior to intervention was Scores on aggression in patients were signicantly
also comparable between two groups: 88.9% (n = 32) reduced in the experimental group as compared to those in
parents in the experimental group versus 93.9% (n = 31) the control group at T2 and T3 time points (p < 0.05)
in the control group experienced verbal violence and 50% (Table 2). However, no signicant reduction in verbal
G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990 85
to 1.97
to 2.92
to 8.08
to 1.02
to 0.92
to 0.59
to 0.33
to 1.42
0.93 to 1.31
to 0.22
intervention has also signicantly improved impulsivity in
the experimental group as compared to the control group
95% CIs
15.24
3.17
2.27
5.96
5.57
6.33
3.65
3.18
0.91
(p < 0.01), whereas it reduced the scores of the motor and
non-planning subscales at T2 and T3 (p < 0.05), respec-
tively.
0.665
0.03, 0.737
0.106
0.016
0.009
0.007
0.000
0.000
0.000
0.000
2.68,
2.78,
2.46,
0.44,
6.50,
3.90,
69.85
17.27
25.48
27.09
27.06
77.92*
66.22*
27.25*
19.36
14.94
23.28
17.53
23.36
25.33
20.67
CPb x
to 3.28
to 1.24
to 1.90
to 0.08
to 0.06
0.96 to 1.83
to 0.12
to 0.15
to 0.20
17.68
2.59
7.79
4.97
6.85
1.95
3.36
3.06
3.04
0.082
0.085
0.005
0.042
0.000
0.000
0.000
4.45,
2.89,
1.77,
1.75,
4.90,
2.07,
t, pa
25.21
26.79
17.00
28.00
RC x
20.64
79.33
14.33
23.22
21.78
66.17
26.58
27.22
16.08
23.50
2.73
1.25
1.24
1.15
2.83
1.61
1.93
1.53 to 1.47
0.82
0.59
to
to
to
to
to
95% CIs
4.26
3.49
1.56
3.10
0.255
0.178
0.473
0.222
0.829
0.530
0.765
0.689
0.04, 0.968
1.15,
1.36,
1.23,
0.63,
0.72,
0.22,
0.30,
0.40,
t, pa
increased.
Results in Table 5 also show there were time and group
91.33
22.61
28.67
24.76
16.55
25.97
27.73
26.36
70.24
15.30
RC x
87.72
27.11
69.53
16.97
24.64
27.92
26.33
22.03
15.08
23.50
CP x
Physical aggression
Suspicion, hostility
Verbal aggression
Cognitive function
4. Discussion
Nonplanning
Attentional
Impulsivity
Aggression
Motor
Table 2
to 3.13
to 2.16
to 5.07
to 2.19
to 0.76
counseling format would be difcult to obtain adequate
efforts and feedback from each parent-adult child dyad in
95% CIs
18.31
9.89
1.15
6.82
3.17
each session. On the other hand, the Child- and Parent-
focused Violence Intervention Program, which is an
individualized approach to each of parent-adult child
dyads, is more suitable to manage child-to-parent
0.538
0.224
0.001
0.000
0.000
violence. Indeed, as shown in this study, individualized
intervention is effective on managing the parentadult
3.53,
3.84,
3.85,
1.23,
0.62,
t, pa
91.58*
x
37.28
16.64
14.61
23.06
b
1.79
0.72
1.06
10.82
7.19
2.87
2.55
0.76
0.422
0.237
0.413
0.045
1.19,
0.81,
0.82,
2.04,
t, pa
24.55
13.61
RC x
16
41.94
16.51
23.47
12.86
95
1.33
3.80
3.50
to
to
to
to
95% CIs
0.87
1.70
2.05
0.60
1.41,
1.26,
0.91,
0.42,
105.47
46.64
17.69
27.19
13.94
CP x
Cognitive
ARQ
Table 4
Clinical measure scores at pre-test and two post-tests and t-test results for both patients (PT) and parents (PR).
Violence attributions PT 1.59 1.77, 0.082 1.64 2.04, 0.045 1.99 3.28, 0.002
PR 1.42 1.41, 0.164 3.73 4.65, 0.000 2.67 3.59, 0.001
Ways of coping
Problem-focused coping PT 0.09 0.90, 0.371 0.34 3.57, 0.001 0.59 6.96, 0.000
PR 0.14 1.53, 0.130 0.27 4.29, 0.000 0.42 6.83, 0.000
Wishful thinking PT 0.40 0.38, 0.708 0.22 1.84, 0.70 0.06 0.41, 0.683
PR 0.14 1.02, 0.310 0.16 1.36, 0.179 0.08 0.78, 0.439
Detachment PT 0.06 0.71, 0.479 0.27 3.36, 0.001 0.83 7.44, 0.000
PR 0.02 0.24, 0.810 0.30 3.66, 0.000 0.96 8.90, 0.000
Seeking social support PT 0.11 1.13, 0.265 0.73 10.07, 0.001 1.06 15.06, 0.002
PR 0.11 1.22, 0.229 0.48 6.79, 0.000 0.69 7.91, 0.000
Focusing on the positive PT 0.22 1.63, 0.109 0.60 5.32, 0.001 0.71 7.45, 0.003
PR 0.26 1.81, 0.075 0.42 4.63, 0.000 0.51 6.34, 0.000
Self blame PT 0.33 2.31, 0.024 0.68 5.70, 0.001 0.69 7.59, 0.001
PR 0.19 1.60, 0.114 0.68 6.36, 0.002 0.70 7.18, 0.000
Tension reduction PT 0.10 0.78, 0.44 0.82 6.35, 0.001 0.98 8.50, 0.001
PR 0.31 2.88, 0.005 0.79 8.67, 0.000 0.81 7.16, 0.000
Keep to self PT 0.08 0.67, 0.50 0.59 4.83, 0.000 0.94 8.18, 0.001
PR 0.09 0.80, 0.427 0.56 4.97, 0.002 0.85 7.56, 0.002
a
Examined by independent t-test between groups. D, mean difference.
complaints such as sleep disturbance which may be due to with the stressful encounters of everyday living. Prior to
psychological effects of childrens violence or the percep- intervention, parents often have difculties coping with
tion that child-to-parent violence is part of the caregiving the problem by way of escaping or avoiding the problem.
or life (Coogan and Lauster, 2014). After intervention, the availability of social support and
In studies conducted by Coogan and Lauster (2014) and resources from relatives, friends, and health professionals
Lauster et al. (2014), the authors have indicated that and psychological resource such as their gradual improve-
coping with child-to-parent violence is important when ments of assault reaction, were important contributing
dealing with a violent incident. Coping is highly affected by factors to their development of coping ability to overcome
violence itself (Calvete et al., 2008). Parents needed an those difculties and related stress resulted from their
intervention that gave practical strategies to cope with the childrens violence. Indeed, improvement of both parents
complexities and dynamics of the child-to-parent violence. and childrens coping processes became their strengths
In this study, we emphasized the ways of coping by and attributes which helped their development of coping
measuring the coping processes that one would use to cope ability in the stressful violent situation.
Table 5
Repeated-measures effects of the Child- and Parent-focused Violence Intervention Program on violence.
In other psychiatric research studies, the frequency of for violence problems. Patients reduced their victim-
aggression event has also been used as an outcome (e.g., blaming attributions more than parents did on self-
Amore et al., 2013; Monahan et al., 2001). Their ndings blaming. Admitting being responsible for violence and
showed that approximately 1828% of discharged patients reducing the victim-blaming attributions were important
had violent act/physical aggressiveness only once and that components of the effectiveness of intervention as reported
12% were involved in two or more violent acts in by others (Brisebois et al., 2010; Coogan and Lauster, 2014;
subsequent follow-up contacts. These ndings indicated Lila et al., 2014).
that the frequency or the number of violent can help to
identify those repeatedly violent patients after discharge 4.5. Child-to-parent violence intervention in a cross cultural
from psychiatric wards, and reect the clinically important context
treatment outcome. In the present study, the frequency or
the actual number of violent acts was not evaluated as an Cultural contexts are critical and highly inuential in
outcome measure. It is suggested that evaluations of analyzing violence (World Health Organization, 2009).
frequency, severity, and type of violent episode are Indeed, areas where child-to-parent violence may be
included in our future studies. unique to the particular cultural contexts. Intervention in
managing violent patients with mental illness and their
4.3. Impulsivity victimized parents may be more applicable if cultural
elements are implemented and integrated. An insightful
Poor impulse control is also an important factor of exploration and understanding of violence and the
violent behavior (Hsu and Tu, 2014). Results in this study interplay of factors within Chinese or other cultural
show that violence-prone patients had weak impulse contexts including the highly involved parental roles,
control which rendered them difcult in dealing with beliefs and ideas in child-to-parent violence, is unavoid-
stressful circumstances with parents at home. These able (Hsu and Tu, 2014; World Health Organization,
patients might easily trust their own perception of reality 2009). Both patients and parents have to correct the
without conscious interpretation. Thus, patients with misperceptions, raise awareness of child-to-parent vio-
poor impulse control are likely to have violence toward lence and reinforce the shared responsibilities and be
parents whether or not they are angry. Anger manage- supportive of non-violent behavior. They have to ac-
ment alone may not be sufcient in managing this type of knowledge a more realistic sense of actual behavioral
violence. norms, and actively manage the child-to-parent violence,
thereby reducing the violent behavior in a cross-cultural
4.4. Violence attributions context.
Addressing the violent behaviors of an individual,
Individual differences in violent behavior may also versus parents might overlook the causal family conditions
relate to different attributional styles (Dodge, 2006). in treatment. Through trusting relationships, the research-
Attributions (attribution styles and errors) of those who ers developed a better understanding of the victims
commit violent acts are considered important in assessing characteristics, and subsequently developed strategies to
risk of recurrence of many forms of violence (Lila et al., manage the conicts in its cultural context, and solve the
2013, 2014). In addition, patients individual and clinical problems during the conjoint sessions.
characteristics such as increased irritability and poor
impulse control, dyadic factors are also closely related to 4.6. Limitations and recommendations for future research
child-to-parent violence (Hsu et al., 2014). Causes of
violence can be bidirectional or mutual. How to change the One of the limitations of this study was the lack of
victim-blaming attributions is a challenge for violence evaluation of frequency or the actual number of violent
intervention programs (Lila et al., 2013). acts/behaviors as an outcome of the study, which has been
In this study prior to intervention, patients used the described in the discussion section. Another limitation was
victim-blaming attributions to explain their parent-in- smaller sample size and relatively short follow-up period
duced violent behavior, whereas the parents reports of which renders the generalization difcult. Future investi-
self-blaming were inconsistent with patients point of gation is suggested to include lager samples of both
view. The difference of attributional styles between patients and their parents with a longer follow-up period
patients and parents in response to child-to-parent (>6 months), so that more conclusive claims of treatment
violence may be due in part to the conventional social mechanism, cognitive and behavioral changes and effec-
and cultural norms in relation to children and violence tiveness may be claimed. A 3-arm design with an active
within families (Coogan, 2011). Fung et al. (2007) have control group and a usual care control group is recom-
demonstrated that Chinese persons with mental illness mended which would help to control the nonspecic
may be more susceptible to self-stigma, due to personal features of an intervention. In addition, positive sibling
beliefs. On the other hand, Chinese parents often believe interactions are important in supporting or serving as
the cause of childrens mental illness (e.g., mind-body supporters or resources for their aging parents who are
imbalance) was a form of punishment for the sufferers who caring for their siblings with mental illness. It is suggested
may have sinned in their previous life. that the future study includes siblings in the trial if the
Results in this study show that the intervention was siblings are identied as the future primary caregivers of
effective in changing both parents and patients attributions their mentally ill siblings.
G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990 89
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was an empirically effective adjunctive intervention for ment, attributional style, and violence in male batterers. World Acad.
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