Trauma-informed evidence-based treatments for the youngest children are insufficiently and unevenly implemented, and access to effective interventions for young children and their families is scarce in Sweden and internationally. Child-parent psychotherapy (CPP) is one of only a few treatment models for trauma-exposed children under the age of 6 years. The aim of this study was to explore the extent to which clinicians trained in CPP continued to work with the model after training and how they experienced its implementation and sustainability over time. We distributed a survey to all 66 clinicians in Sweden trained in CPP and conducted qualitative interviews with a sample of 12 from various organizations.

About two of three clinicians continued to work with the model post training, but few had treated enough cases to have acquired extended experience or expertise. Using a mixed methods model including thematic analysis, we identified four main themes (three with two subthemes): Work with trauma-exposed young children (sub-themes “Clinicians’ access to young trauma-exposed children” and “Complexity in providing services to trauma-exposed children”); Organizational and systems level aspects (sub-themes “Sociopolitical decisions, unclear responsibilities, and other external conditions” and “Like running my own little business—the clinician within the organization”); Support to deliver child-parent psychotherapy” (sub-themes “Collegial support—it makes all the difference” and “Continued learning and fidelity—the importance of methodological support to deliver the CPP model”); and The clinician and Child-Parent Psychotherapy” (no subthemes). Implementation and sustainability of the CPP model seemed to be both facilitated and hindered by interplay among systems-level, within-organization, and individual factors. The simultaneous need of treatment for young children affected by trauma and the lack of access to such treatment is particularly worrying.

Aim: To investigate the experience of Child Health Care Nurses (CHCNs) using language screening for 2.5-year-old children.Design: An exploratory qualitative design with an inductive approach.Method: Data were collected through semi-structured, interviews with Swedish CHCNs who regularly performed language screening for children. The interviews were analysed by thematic analysis.Results: Four themes were identified: 'The difficult visit', 'Explanations for language delay', 'Language screening across cultures' and 'Language screening with children exposed to adverse life events'.Patient or Public Contribution: Our findings suggest that in routine care a modified procedure is used for the language screening of children aged 2.5 to secure the child's cooperation and to preserve an alliance with the parents. Consequently, the validity of the screening is called into question, particularly when it comes to children from families with origins outside the dominant culture and children exposed to adverse life events.

This study investigated whether interventions for children exposed to intimate partner violence combining parallel groups for children and mothers contribute to positive outcomes for partaking mothers. The study included 39 mothers in a long-term within-subject design without a control group in a Swedish naturalistic setting. Maternal psychological health was assessed pre- and posttreatment and at 6-month and 12-month follow-up. Mothers reported medium- to large-sized decrease in psychological symptoms, including symptoms of posttraumatic stress, postintervention (p = < .001 d = 0.45-0.96). During the follow-up period, sustained and further decrease of symptoms was reported (p = < .001 d = 0.58-1.60). Mothers also reported decreased exposure to violence. Results indicate that these child-focused programs have major and sustainable positive effects on mothers' psychological health.

Introduction: It has been shown that negative impact of intimate partner violence (IPV) on the child begins early in the realm of the relationship between child and caregiver. Understanding how children experience and relate to an abused parent is essential for theory and to optimize interventions. The aim of this study was to elucidate how children describe their abused parent in the aftermath of IPV. Method: Face-to face interviews were conducted with 17 children with experience of IPV, aged 4 to 12 years. The interviews were analyzed using thematic analysis. Results: Three main themes were identified: Coherent telling about parent; Deficient telling about parent, and Parent as trauma trigger. The results indicate that children may carry integrated as well as deficient or blocked inner representations of the abused parent. Discussion: The finding that for some of the children talking about the abused parent seemed to serve as a trigger for trauma reactions carry theoretical as well as clinical implications. One challenge in clinical work is to help turn a relationship that at times is associated with danger into a calm and secure source of new experiences of trust, nurturance and protection. In this work it will be necessary to pay attention to and recognize signs of trauma reactions within the relationship and to address this in treatment.

Introduction: Effective and evidenced based treatments targeting young children exposed to domestic violence are scarce in Sweden and Norway. Child-Parent Psychotherapy (CPP) is a treatment model validated for work with young children and their caregiver(s) suffering from the consequences of domestic violence. CPP was introduced in Sweden as part of a research project concerning treatment methods for children exposed to violence, financed by the Swedish Board of Health and Welfare. CPP was not previously practiced in Sweden. 

Method: The implementation process of CPP in Sweden and Norway has included training of therapists, training of trainers and research. During 2013 – 2015 the first training of therapists in was realized in cooperation with the Child Trauma Research Program, University of California, San Francisco. A feasibility study, conducted in conjunction with the training, indicated that the dissemination of CPP was appropriate without particular adjustments to the Swedish cultural context, and that the method was appreciated by clinicians and families. The observed effects from the feasibility study indicated that the positive results from international (US) studies may be replicated in a Swedish context. The results from this study contributed to the decision in 2016 from the Swedish National Board of Health and Welfare to support the implementation of CPP in Sweden.

Results: To date three cohorts of clinicians have been trained in Sweden and training of Swedish trainers has been completed. The second cohort included participants from Norway, and subsequently a first training of clinicians has been completed in Norway. An effectiveness study is ongoing. Additionally a Nordic network has been established to scaffold training, implementation and sustainability of CPP in the Nordic countries.

Discussion: It was evident that CPP fills a gap in child and adolescent psychiatry in Sweden and Norway. Challenges and facilitators in the process of implementation will be discussed.

Background: Long-term follow-up studies of interventions for children exposed to intimatepartner violence are few, and the sustainability of their outcomes often remains unexplored anduncertain. Current research including follow-up assessment suggests that treatment gains may bemaintained or continue post termination. In addition some children may show increased levels ofsymptoms.

Objective: The present effectiveness study investigated the long-term outcomes of two establishedgroup interventions for children exposed to intimate partner violence and their non-offendingparent.

Participants and Setting: The study included 50 children, 24 girls and 26 boys, aged 4 to 13 yearsattending a psychotherapeutic child and adolescent mental health service intervention and apsychoeducative community-based intervention.

Methods: Background information, child and parental mental health problems, trauma symptoms,and exposure to violence were assessed pre- and post treatment and at 6 and 12 months’follow-up.

Results: Sustained treatment gains and late improvements in children’s internalizing and externalizingsymptoms and in symptoms of traumatic stress were recorded from post treatment tothe follow-up assessments (p = .004– .044; d = 0.29–0.67). No significant increase in symptomswas reported. Additionally, very little continued or renewed child exposure to violence was reported.

Conclusions: The results of the study indicate that the children did benefit from the two interventionsstudied and that the outcomes of reduced child symptoms and protection from exposureto violence were sustainable. Children with severe trauma symptoms benefited the most, thoughmaternal psychological problems may for some have hindered recovery. Clinical implications arediscussed.

Introduction: Children exposed to intimate partner violence are at risk of long-term consequences on their health and development as well as of continued or renewed exposure to witnessing violence and of being subjected to physical child abuse.

There is a need for effective interventions for children exposed to intimate partner violence. Existing interventions in Sweden have shown positive but insufficient outcomes. Long term health effects and children’s protection from violence are often not investigated. Extended knowledge on lasting outcomes, aiming at improving established interventions is needed.

Method: The current study is an effectiveness study investigating the outcomes of two established group interventions for children exposed to intimate partner violence and their non-offending parent. The study included 50 children, 24 girls and 26 boys, aged 4-13 years. Background information, child and parental mental health problems and trauma symptoms were assessed pre- and post-treatment, as well as 6 and 12 months post treatment. Additionally children’s exposure to physical and psychological child maltreatment and to intimate partner violence was tracked.

Results: The results indicate that children benefit from the group interventions. Late improvements were registered at the follow-up assessments. The findings indicate that children’s exposure to violence decreased, with physical maltreatment decreasing prior to exposure to psychological maltreatment.

Discussion: Currently data from the 6- and 12-months follow-up assessments are being analyzed. Preliminary results include paths of continuous symptoms reduction for children and children’s long-term exposure to violence. Possible associations between child and maternal levels of symptoms, as well as methodological and clinical implications will be discussed.

This thesis consists of three empirical studies, all part of the same research project, with a general aim to explore interventions for children exposed to intimate partner violence (IPV). Because witnessing violence toward a caregiver is associated with negative impact on children’s health and development, effective interventions for children exposed to IPV are necessary.

The aim of Study I was to elucidate young children’s experiences of participating in group interventions for children exposed to IPV. Nine children, aged 4 to 6 years, were interviewed after participating in group programs designed for children exposed to IPV. The interviews were analyzed using interpretative phenomenological analysis. Five master themes embracing the children’s experiences were identified: joy; security; relatedness; talking; and competence.

The aim of Study II was to investigate young children’s accounts of their abused parent. Interviews were conducted with 17 children between 4 and 13 years old who had witnessed IPV. Thematic analysis identified three main themes: coherent accounts of the parent; deficient accounts of the parent; and parent as a trauma trigger.

Study III was an effectiveness study investigating the outcomes of two group interventions for children exposed to IPV and their non-offending parent: one psycho-educative community-based intervention (CBI) and one psychotherapeutic treatment intervention. The study included 50 children between 4 and 13 years old and their mothers. Child and maternal mental health problems and trauma symptoms were assessed before and after treatment. The results indicate that although children benefited from both interventions, symptom reduction was larger in the psychotherapeutic intervention. Despite these improvements, most of the children’s mothers still reported child trauma symptoms at clinical levels post treatment. Both interventions, however, significantly reduced maternal post-traumatic stress.

The results showed that children generally appreciated and benefited from both interventions studied, but most still showed symptoms at clinical levels post treatment and a possible need for additional and/or different support and interventions. These results indicate not only the need for continuous and post-treatment assessment of children’s symptoms in routine clinical practice, but also the value of including children as informants in research.

Att som barn bevittna våld mot en förälder är förknippat med negativ påverkan på barns hälsa och utveckling, vilket medför att det finns ett behov av verksamma interventioner för barn som exponerats för våld mot en förälder. Denna avhandling innehåller tre empiriska studier som alla är del av ett sammanhållet forskningsprojekt. Det övergripande syftet är att undersöka interventioner för barn som exponerats för våld mot en förälder.

Studie I syftade till att belysa små barns upplevelser och erfarenheter av att delta i gruppinterventioner riktade till barn som bevittnat våld mot en förälder. Nio barn, 4 till 6 år gamla, intervjuades efter att de deltagit i gruppverksamhet för barn som bevittnat våld i sina familjer. Intervjuerna analyserades med interpretativ fenomenologisk analys, och fem huvudteman identifierades: glädje, trygghet, att vara i relation, att prata och kompetens.

Syftet med studie II var att undersöka hur barn berättar om en våldsutsatt förälder. Intervjuer genomfördes med 17 barn mellan 4 och 13 år som bevittnat våld mot en förälder. Tematisk analys identifierade tre huvudteman: sammanhängande berättande om föräldern, bristfälligt berättande om föräldern och föräldern som trigger för traumareaktioner.

Studie III var en utfallsstudie som undersökte utfallet av två olika gruppinterventioner för barn som bevittnat våld mot en förälder, en psykoedukativ och en psykoterapeutisk. Studien inkluderade 50 barn mellan 4 och 13 år och deras mammor. Symtom på psykisk ohälsa och posttraumatisk stress skattades före och efter interventionerna. Resultaten tyder på att barnen drog nytta av båda interventionerna, men förbättring av symtom var störst för de barn som deltagit i den psykoterapeutiska gruppinterventionen. Trots symtomförbättringarna rapporterade en majoritet av barnens mammor kvarstående symtom på klinisk nivå efter interventionerna. Mammorna visade signifikant lägre nivåer av egna symtom på posttraumatisk stress efter båda interventionerna.

Resultaten tyder på att barnen uppskattade och drog nytta av båda de studerade interventionerna, men en majoritet uppvisade symtom på klinisk nivå även efter behandling och ett möjligt behov av kompletterande och/eller alternativt stöd och behandling. Dessa resultat tydliggör såväl behovet av rutiner för att bedöma barns symtom under och efter behandling som värdet av att inkludera barn som informanter i forskning.