Experiences of Treatment-Seeking Children and Young People Following Parental Intimate Partner Homicide

Background

While the incidence of intimate partner violence (IPV) has declined worldwide over the past 25 years (Catalano, 2013), its occurrence is still widespread and remains a major concern. Between April 2012 and March 2018, 2998 homicides took place within England and Wales (Home Office, 2020). Of these, 575 (19.2%) were labeled as intimate partner homicide (IPH). In existing literature, some common characteristics and risk factors for IPH are described. In the large majority of cases (80.7%), the victim is a female and the perpetrator their male partner or ex-partner (Home Office, 2020). IPH accounted for almost half (42.8%) of all homicides with female victims, whereas for males, this constituted only 3.3% (Home Office, 2020). Despite men being the perpetrator in the vast majority of all homicides including IPH, in the case of IPH, females account for a relatively greater proportion of offenders compared to other types of homicides (Overstreet et al., 2021).

In most cases of IPH (67%–80%), IPV took place prior to the homicide (Campbell et al., 2007). Furthermore, evidence suggests that marginalized communities such as ethnic minorities are disproportionately affected by IPV (Breiding et al., 2014). Having access to a weapon that is readily available at the crime scene further increases the risk for IPH. Therefore, in IPH, as compared to other homicides, firearms are less likely to be used, while strangulation, suffocation and the use of knives are more common (Overstreet et al., 2021). The crime scene is most often a private location, such as in or around the victim’s residence (Corsaro et al., 2017). Further known risk factors include substance abuse and lower education level of both perpetrator and victim, a history of mental health problems and unemployment of the (male) perpetrator, and the (female) victim being separated from the perpetrator and having children from a previous relationship, especially when the children are living in the home (Spencer & Stith, 2020).

A report on domestic homicides covering the period from 2010 to 2015 stated that in just under half of cases of IPH, dependent children were present in the family structure (Home Office, 2016). This implies that with an average of 1.92 children per family (Office for National Statistics, 2015), approximately 50 children a year faced the death of a parent at the hands of the other parent in England and Wales in the period that the current study focused on, between 2012 and 2017. The current literature on IPH is largely focused on prevention, interweaved with investigating the IPV that often precedes IPH, or on characteristics of the offender. Few studies have systematically examined the wellbeing of children involved in the aftermath of IPH (Alisic et al., 2015), despite several attempts made by researchers and policy makers to make these “forgotten,” “silent,” “invisible”, or “secondary” victims of crime more visible.

In England and Wales, multi-agency reviews are written about the circumstances of death following a homicide. Since April 2011, these so-called Domestic Homicide Reports (DHRs) have been a statutory requirement for local areas in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom they were related or with whom they were, or had been, in an intimate personal relationship or within the same household (Home Office, 2016). A recent study by Stanley et al. (2019) examined children’s experiences following domestic homicides in 2011 through 2016 by analyzing these reports. They concluded that their study “has revealed much about the continuing invisibility of children living with domestic violence and abuse” (p. 74) as their experiences were often overlooked in research and reports.

Experiences of Children and Young People Following PIPH

Children and young people who are faced with PIPH may lose two parents at once: one to death, and one to jail, fleeing or suicide (Steeves & Parker, 2007). In most cases, the mother is the victim and the father or the ex- or new partner of mother, the offender (Alisic, Groot, Snetselaar, Stroeken, & van de Putte, 2017; Velopulos et al., 2019). In addition to processing the death of their parent at the hands of the other, and the traumatic circumstances under which this occurred and that some of them witnessed, PIPH bereaved children and young people face many additional challenges. As the family home has often become a crime scene, they might be denied access to their home, toys, photos, clothes (Steeves & Parker, 2007). Oftentimes, the new living situation and care arrangement with the family of the deceased or the perpetrator’s side results in separation of siblings, friends and change of school. Working out the care arrangement can create stress and conflict within the family (Alisic, Groot, Snetselaar, Stroeken, Hehenkamp, & van de Putte, 2017). Living with family of the killed or the offender parent may determine whether the child or young person has contact with the offender parent, which can greatly affect their experience.

Furthermore, PIPH bereaved children and young people may experience stigmatization resulting from trial procedures and media attention. “Disenfranchised grief” can occur when “there is no social recognition that the person has a right to grieve or a claim for social sympathy or support” (Doka, 2002, p. 5), specifically when the child or young person grieves a parent who was also a perpetrator. Amidst all this, the people who would usually help them cope with the loss of a loved one are no longer there. They have to form attachment bonds with new caregivers, who may experience symptoms of PTSD, depression and/or PGD themselves, carry hatred toward the offender parent, or, in the case of being related to the offender, condone the violence (Alisic et al., 2012).

Mental Health of Children and Young People Following PIPH

Although children and young people confronted with PIPH have an increased risk for developing PTSD, depression, and PGD, a systematic review on the mental health and well-being of children aged 0 to 18 after PIPH (Alisic et al., 2015) underlined the importance of looking beyond purely psychological symptoms. Responses to parental homicide vary greatly between individuals and may impact physical, social, and academic domains of child development. During childhood and adolescence, the developing brain is more sensitive to adversity and stress (Lupien et al., 2009). The loss of a parent, with whom the attachment bond is especially strong during childhood and adolescence, can result in loss of security and stability (Alvis et al., 2022). This may lead to various emotional, social and behavioral problems which may impact mental health throughout adulthood (Melhem & Brent, 2016).

Considering the potential broad and long-lasting effects on their wellbeing, it has been suggested that all children and adolescents can benefit from bereavement counseling or psychotherapy following PIPH (Kapardis et al., 2017), and that short-term care may likely be insufficient to meet their needs (Alisic, Groot, Snetselaar, Stroeken, Hehenkamp, et al., 2017). However, only few receive such intervention (Stanley et al., 2019). Furthermore, few empirical studies have evaluated such interventions. One goal of the current study was to address this issue by using routine outcome monitoring data of children and young people following PIPH and who received treatment. A recent study found that PGD can be successfully reduced in bereaved children and adolescents using CBT (Boelen et al., 2021). The study demonstrated statistically significant reductions in symptomatology overall as well as reliable individual changes in symptoms; these findings converge with prior findings (Layne et al., 2008; Spuij et al., 2013). Furthermore, a recent systematic review indicates that overall, symptoms of PGD, PTSD, and depression decreased significantly in adults who lost a loved one to homicide following psychological interventions (Alves-Costa et al., 2021). Accordingly, we hypothesized that the children and young people described in the current study would display (a) a statistically significant and (b) clinically significant decrease in posttraumatic stress (PTS) symptom severity following the TGF-CBT they received.

Study Design

The present study is a retrospective, naturalistic pre-test post-test study: treatment methods were not experimentally controlled but were measured retrospectively by therapist report. Data were collected in the context of routine outcome monitoring for diagnostic and evaluation purposes of the treatment participants received, consisting of pre-treatment and post-treatment symptom scores. Pre-treatment/post-treatment comparisons were used to indicate change in symptom severity.

Participants and Procedure

This study is part of a larger study (Soydas et al., 2020) investigating mental health outcomes and response to treatment in homicide survivors in the United Kingdom (UK), using ROM data of both children and adults seeking treatment through the National Homicide Service as provided by ASSIST Trauma Care across England and Wales. For the current study, we used a subsample of these data, specifically, of PIPH bereaved children and young people who underwent TGF-CBT.

Data for the current study were collected between January 2011 and December 2017.

A self-report questionnaire on PTS (described below) was administered at intake (T0) and at the end of treatment (T1). For the current study, data of 60 PIPH bereaved children and young people who engaged in TGF-CBT were available and included for the first aim of our study. Information about demographics, events leading up to and following the homicide, as well as the homicide itself, and judicial procedures, was documented in the client’s treatment files. Furthermore, it was indicated whether the client was related to other clients who sought treatment at the same specialized facility.

For the second aim, to compare pre- and post-treatment scores, we omitted the scores on questionnaires of 12 children aged between 0 and 7 as the questionnaires have not been validated for that age group. For three of the remaining 48 children and young people, no pre- and post-treatment scores were available. Finally, for five, no post-treatment scores were available. This left a total of 40 children and young people for whom questionnaires at both T0 and T1 were available and who were thus included in our analyses. The flowchart in Figure 1 gives an overview of the children and young people included in the final sample.

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Figure 1.

Flowchart of patients included in the study.

When available (due to their own referral to the same facility), and when given written consent to do so, ROM data of referred caregivers were also included in the current study. In total, 24 PIPH bereaved children and young people in our sample had a caregiver who was also referred. Of 22 of these caregivers, pre-treatment scores were available, and of 19 of these, also post-treatment scores.

Mean therapy duration (n = 40) was 15.31 (SD = 8.70) hr.

Ethical Standards

The Ethics Committee of the Faculty of Social and Behavioral Sciences of Utrecht University evaluated this study and deemed it exempted from formal review by the Dutch Act on Medical Research Involving Human Subjects (filed under number 20-0228). The study was conducted in accordance with ethical guidelines from the UK for service evaluation (cf. Soydas et al., 2020). Children and young people were given oral information about the course of treatment and study procedures, after which they, or their caregiver, gave written informed consent. All information from the clients’ files was anonymized and entered into a dataset that was made accessible only to the researchers and stored on a secured server.

Treatment

In accord with the clinical guidelines of the National Institute for Health and Care Excellence (NICE) for mental health care (National Collaborating Centre for Mental Health, 2005; World Health Organization, 2018), ASSIST Trauma Care offers TGF-CBT adjusted to the developmental level of the child. TGF-CBT originates from trauma focused CBT (TF-CBT), which is a form of psychological treatment encompassing psycho-education about traumatic reactions and the treatment; exposure to feared stimuli to learn that safe (but feared) stimuli need not to be avoided; and cognitive restructuring to become aware of, and change unhelpful thoughts (Zayfert & Becker, 2019). In TGF-CBT, grief-focused components are added to the trauma-focused opponents. These include both trauma and grief education in which the characteristics of the traumatic loss are discussed and basic information on cognitive processing and attachment reactions is given; grieving the loss and reducing traumatic reactions associated with the traumatic death by imaginal exposure with the use of mementos, such as objects linked to the deceased, and drawing or writing assignments to express intense emotions; and finally, cognitive restructuring by resolving ambivalent feelings about the loved one who died, preserving positive memories, and redefining the relationship with the person who died to one of memory (Boelen et al., 2021; Mannarino & Cohen, 2011; Smid et al., 2015; Smid, van der Meer, et al., 2018). TGF-CBT consists of approximately 15 sessions.

Key elements of the model of care as provided by ASSIST Trauma underlying this treatment are: timely and specialized assessment, application of time limited sessions, attention for legal and court proceedings, implementation of evidence-based traumatic grief focused CBT interventions (Boelen et al., 2006; National Collaborating Centre for Mental Health, 2005; Smid et al., 2015), provision of an outreach model of care with the possibility to engage in sessions at the homes of the clients, individual treatment with the possibility to engage other family members, deployment of qualified and experienced therapists supervised by the Oxford Cognitive Therapy Centre and close collaboration with caseworkers of Victim Support to provide practical and judicial support throughout the process. Consequently, the broad range of emotional, practical and judicial consequences that those bereaved by homicide are confronted with (Soydas et al., 2020), are addressed.

Consistency of therapy was fostered as all therapists were trained in TGF-CBT, through regular supervision and annual continuing education by the Oxford Therapy Center and through monitoring of therapy by a case manager and periodic team meetings.

Measures

Statistical Analyses

For our first aim, we adopted the categorization as used by Alisic, Groot, Snetselaar, Stroeken, & van de Putte (2017) to describe the experiences of the children and young people. We generated the descriptive statistics from SPSS (version 26.0; IBM). For our second aim, we checked assumptions and conducted the analyses using SPSS. To investigate hypothesis A, we used a paired samples t-test to compare the average total score on the CRIES-8 at pre-treatment and post-treatment. We then calculated the effect size (Cohen’s d) for within group effects. To interpret this result, we calculated the common language effect size for correlated samples (McGraw & Wong, 1992), and used the percentage associated with the upper tail probability of this value (Lakens, 2013).

Since most of the 40 children and young people that we included in our analyses were not nested within families (n = 28), we did not use a multilevel framework. To check whether it was necessary to control for a possible dependency of data between the 12 siblings belonging to six families within this dataset, we calculated the paired samples t-test and effect size twice: once for the 28 unrelated children and young people and six siblings who were randomly selected from their nine families (n = 34), and once for the full sample containing all children and young people including all siblings (n = 40). As the two t-tests and effect sizes were virtually similar we continued with the total sample including all siblings.

For hypothesis B, we calculated the Reliable Change Index (RCI) to evaluate individual changes in PTS from pre-treatment to post-treatment using the formula by Jacobson and Truax (1991): RCI = (X2−X1)/Sdiff, with X2 representing a participant’s score at post-treatment, X1 representing scores at pre-treatment, and Sdiff is calculated using the test-retest reliability and the standard deviation of the pre-treatment scores. Based on Jacobson and Truax’ recommendations, an RCI > |1.96| was considered as representing clinically significant change and was used to categorize participants into “improved,” “unchanged,” and “worsened.” Finally, we compared the frequencies of the descriptive statistics between these categories to describe any emerging similarities and differences.

Objective 1: Description of the Total Sample (N = 60)

An overview of patient/family, deceased parent, perpetrator, and homicide characteristics is given in Table 1. An overview of the characteristics of the homicide aftermath and the therapy are given in Tables 2 and 3, respectively. Characteristics with insufficient data for meaningful interpretation were not included in the tables.

Objective 2: PTS-Symptom Change Following Treatment

For the second objective of this study, we tested for differences on pre-treatment PTS-symptom severity, age, and gender between children and young people (aged 8 years and older) for whom both pre- and post-treatment scores were available and for those for whom only pre-treatment PTS-scores were available. Children and young people for whom both pre- and post-treatment scores were available (n = 40) did not differ from those for who no end scores were available (n = 5).

Observations From the RCI Categories

When considering the categories resulting from the RCIs, some differences were observed between the “changed” and “unchanged” group. The largest differences were observed for age (younger ages in the “unimproved” group), gender (more girls in the “unimproved” group), whether the perpetrator and deceased were separated (this was more likely in the “unimproved” group), whether the child or young person was a witness to the homicide (this was less likely for the “unimproved” group), baseline symptom severity (this was lower for the “unimproved” group) and response to treatment of the caregiver (this was lower for the “unimproved” group). However, we did not test whether these differences were statistically meaningful as we did not have sufficient information on all these variables and a large enough sample to do so. Although it would be interesting for future research to systematically collect information on these variables and to test whether they influence treatment outcome, one important observation was that the improved group was rather heterogenous in terms of gender (slightly more females), age (ranging from 8.0 to 24.0 years with a mean of 15.4 years), type of homicide (a knife was used in 61% of cases), being a witness (50%), the perpetrator being the biological parent (in 46% of cases) and timing of the verdict (52% of verdicts were spoken during therapy). This suggests that these individual characteristics and experiences may not have large impacts on therapy outcome.

Finally, it is important to note that six children and/or young people scored below cut-off score for clinically relevant PTS at the start of treatment. Recent latent class analyses in violently and homicidally bereaved adults showed that a class with no disturbance often emerges (Lenferink et al., 2019; Murphy et al., 2016). Although these six children and/or young people did display some PTS-symptoms (four scored in the “subclinical” range), and it is unclear whether they would also score low on measures assessing, for example, symptoms of PGD or depression, it would be of interest to include a broader range of symptom measures in future research to explore whether groups similar to those emerging in LCAs can be identified.

Limitations and Strengths

Several limitations should be taken into account. First, the absence of a control group prevents us from drawing any conclusions on the effects of the intervention in comparison to the passing of time, regression to the mean or other factors, on PTS-symptoms. Second, the sample comprised a treatment-seeking population and the degree to which the descriptive findings generalize to non-assessed groups not seeking treatment is unclear. As a result of the limited ethnic diversity in our dataset, we cannot infer whether our findings are generalizable across different cultures. Further, the inter-item correlation of the CRIES-8 fell below the optimal range whereas in other studies, internal consistency was acceptable to good (e.g., Verlinden et al., 2014). This may indicate that the internal consistency of the CRIES-8 in the current study was low. Alternatively, our finding that the inter-item correlation fell in the optimal range for both of the subscales may indicate that PIPH bereaved children and young people may present with incongruous intrusion and avoidance symptoms, possibly because the judicial proceedings and interest in the media prevent them from avoidance. Additionally, due to many missing values, we could not include predictors in our statistical analyses. Therefore, the impact of the experiences and characteristics of the sample on the reduction of PTS-symptoms remains unclear. It is conceivable that some of these factors affected symptoms reduction. For example, prior domestic violence likely exerted great influence on the high PTS-symptom severity found in this study; and the changes in living environment following the homicide may be associated with the decrease in symptom severity. Moreover, the reliance on self-report measures precludes any statements about the presence of a disorder. Finally, we did not measure grief symptoms and cannot make any statement about the presence of symptoms purely related to grief.

Strengths of the current study lie in its relatively large sample size, an almost equal gender distribution, and the use of quantitative data to measure symptomatology, next to the descriptive data. Since most prior studies have relied on smaller sample sizes or single cases, the combined descriptive and quantitative information of the current study contributes to the existing knowledge of this hard to reach and often overlooked target group.

Recommendations for Practice and Research

The consequences for children and young people following PIPH are severe, both in terms of mental health and wellbeing and disruptions in their caregiving, housing, and social environment. It is important for policy makers and those offering interventions to be aware of this, and to keep in mind the many different and complex factors that may contribute to this disruption. Information on the experiences and broader wellbeing of these children regarding physical, social, and academic domains of their development (Alisic et al., 2015) should be systematically collected and monitored over time, so that the impact of such factors both prior to and following the homicide can be better understood and targeted in interventions. Since none of the children and young people in our study worsened following treatment, clinicians should not be hesitant regarding the use of preventive or curative interventions.

PTS-symptoms and grief symptoms are likely to be intertwined in children and young people following PIPH. Prior research has shown that in patients confronted with traumatic loss, separation distress (yearning for the deceased, preoccupation with the death) may even overshadow traumatic distress (including intrusive symptoms and alterations in arousal and reactivity) (Boelen et al., 2020). Our study demonstrated that psychological interventions can effectively reduce PTS-symptoms in children and young people following PIPH. However, since the treatment that the children and young people in our study received included both trauma and grief focused components, it would be of great interest to also investigate their grief response, by measuring grief related symptoms such as PGD. Additionally, it would be valuable to evaluate the effect of TGF-CBT on such grief related symptoms following PIPH. Notably, recent evidence shows that PGD can be successfully reduced in bereaved children and adolescents, using cognitive behavioral therapy (Boelen et al., 2021). In the case of TGF-CBT, it would be of interest to unravel which specific components of the therapy are associated with, for example, change in PTS- and grief related symptoms. Furthermore, in addition to PGD, we would recommend including measures tapping into several additional disorders such as depression and generalized anxiety (Soydas et al., 2021).

It is important for all actors involved in the aftermath of a homicide, to be aware that ethnicity and culture influence the ways children and young people confronted with PIPH define their experiences and, especially in the case of marginalized groups, how they consequently seek out social or mental health services (Agoff et al., 2007; Bauer et al., 2000). Marginalized groups often experience high barriers in finding their way to (mental) health services. Future studies focusing specifically on marginalized groups are a major priority, and it would be interesting to examine whether the findings of the current study will be replicated in a more ethnically diverse sample.

Moreover, future studies could use systematically collected data to quantify the preliminary findings of the current study, investigate whether subgroups of children and young people can be distinguished who follow a similar course of complaints, and to broaden such research to children and young people bereaved by PIPH who did not undergo treatment. Studies including a non-treatment control condition are needed to enhance knowledge about which interventions yield the strongest symptom reductions. It would be useful for this research to consider the impact of potential risk and protective factors, including the ones mentioned above, on the impact of such interventions. Finally, qualitative studies such as those using participatory methods are needed, to include the perspectives of the children and young people and other actors involved.

Despite the aforementioned limitations, the current study suggests that children and young people faced with PIPH may benefit from treatment, and the working mechanisms of such interventions merit more research attention.