International Journal of Nursing Studies 60 (2016) 7990

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International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

Effects of nurse-led child- and parent-focused violence

intervention on mentally ill adult patients and victimized
parents: A randomized controlled trial
Gwo-Ching Sun a,b,c,1, Mei-Chi Hsu d,*
a
Institute of Clinical Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
b
Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
c
Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
d
Department of Nursing, I-Shou University, Taiwan, ROC

A R T I C L E I N F O A B S T R A C T

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?
 Parents are among one of the most frequent victims of
repetitive violence by their children diagnosed with
mental illnesses, particularly if the violence is long-term,
and the occurrence of violence is often unpredictable.
 Several empirically driven treatment have been devel-
oped to decrease child-to-parent violence or violence,
such as parent-child interaction therapy for disruptive
behavior in preschool-aged youth, non-violent resis-
tance program, individual family support programs
(family consultation), individual- or group-family groups
and psychoeducation interventions.
 There is also a lack of data examining the complex dyadic
effects in family therapy.
What this paper adds
 This is the rst known randomized controlled trial of
dyadic parent-adult child intervention to manage child-
to-parent violence in patients with mental illnesses.
 This randomized clinical trial demonstrated the benet
of a nurse-led child- and parent-focused violence
intervention on violent adult patients with mental
illnesses and victimized parents in addition to usual
care, on the primary prevention of repetitive violence.
 This study demonstrated that Child- and Parent-focused
Violence Intervention Program, which targets child-to-
parent violence concurrently for both patients and their
parents, was an empirically effective adjunctive inter-
vention for improving violence management, alleviating
intensity of a parent assault victims emotional and
biophysiological reactions, managing impulsivity and
violence attributions, and fostering active coping pro-
cesses.
1. Introduction
Violence is becoming a major concern in mental health
practice. Most studies appear to support a clear association
between violence and mental illness (e.g., Fazel and Grann,
2006; Tiihonen et al., 1997). Flynn et al. (2014) have shown
that 5% of the serious violent offenders had been in recent
contact with mental health services, with 61% having
previous convictions for violence. The most common
psychotic disorders are schizophrenia, depression, and
bipolar disorder (Flynn et al., 2014; Tiihonen et al., 1997).
For example, schizophrenia occurring during periods of
active psychosis increased the risk of violent offenses
(Buckley et al., 2003) by as much as 7-fold (Tiihonen et al.,
1997) or 2 to 8-fold for both men and women compared
with general population (Fazel and Grann, 2006). Fazel and
Grann (2006) have also found that patients with severe
mental illness commit one in 20 violent crimes. Violent
patients with mental illness are at risk for relapses of
violence even when undergoing pharmacotherapy. Repet-
itive violent acts are generally associated with coexisting
cognitive impairment, patients history of violence or
disorganization with impaired reality testing (Chen et al.,
2014; Volavka, 2013).
Family members are among the most frequent victims
of violence by patients diagnosed with mental disorders
(Volavka, 2013). In comparison with other family mem-
bers, parents, as the major caregiver of their children, are
more likely to be violently victimized (Hsu et al., 2014;
Ibabe et al., 2014; Ibabe and Jaureguizar, 2010). Child-to-
parent violence is an often hidden serious social problem.
It describes violence or aggressive behavior committed
by a child (either under 18 or an adult child) who
intentionally uses physical force/power or aggressive/
inappropriate language to threaten or actually cause
physical or psychological harm, damage or pain or nancial
deprivation to a parent (Calvete et al., 2013; Coogan and
Lauster, 2014). An earlier study has found that 18% of two-
parent and 29% of single-parent families experience child-
to-parent violence (Pelletier and Coutu, 1992). Walsh and
Krienert (2009) found that biological parents were the
most predominant victim relation to the aggressor, and
79% of parricides and 92% of child-to-parent violence
incidents involved a biological parent. When the victims
gender was examined, 8188% of the victims was
biological mothers (Kethineni, 2004; Nock and Kazdin,
2002). Thus, parent-child relations are dynamic interac-
tions, which are prone to conict and turmoil (Walsh and
Krienert, 2009).
This becomes an increasing concern for parental
caregivers who experience violence from their mentally
ill adult children (Hsu and Tu, 2014; Ibabe et al., 2014). As
traumas of child-to-parent violence pose a serious threat,
they can also cause various effects on parents emotional,
psychological, and physical well-being, particularly if the
violence from their mentally ill children is long-term and
 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990
often unpredictable. Unfortunately, the repetitive nature
of child-to-parent violence, typically in the form of verbal
or physical violence committed by the mentally ill
aggressor, is the most traumatic and often hidden issue
of family violence, and often ignored in clinical manage-
ment of violence (Coogan and Lauster, 2014; Ibabe and
Jaureguizar, 2010).
To date, various and interrelated determinants, risks,
contributory factors and prevalence across various cultural
settings in relation to child-to-parent violence in the home
have been identied. These have prompted several studies
to determine the nature and scope of this specic issue
with respect to child-to-parent violence. They include: (1)
child and/or parental mental health (Kennair and Mellor,
2007; Pagani et al., 2004), (2) childrens higher levels of
personal maladjustment, with a notable incidence of
depressive symptoms (Ibabe et al., 2014), (3) psychological
stress and behavior disorders (Howard and Rottem, 2008),
(4) emotional disorders, thought disorder, learning dis-
orders, personal psychological dysfunction and dysfunc-
tional family relations (Calvete et al., 2013; Howard and
Rottem, 2008), and (5) parenting style and family conict
(Gallagher, 2004).
However, very few studies have focused on the form of
emotional and/or physical violence carried out by adult
children against their parents (Chien et al., 2005, 2006).
Even fewer studies have comprehensively examined the
child-to-parent violence in a dyadic context (e.g., Chien
and Chan, 2013), and explicitly investigated the non-
reciprocal violence initiated by the violent adult child with
mental illness. This may be due in part to the difculty of
including both victimized parental caregivers and their
mentally ill and violent adult children in a study. As a
result, there has been a lack of intervention strategies
dealing with the child-to-parent violence. There is also a
lack of data examining how the violence management
program might have affected childrens violent behavior
and the reactions (as the assaulted victim, coping process)
of parents and how children and parents think of each
other. Several studies have discussed child-to-parent
violence toward parents and its challenges on family
violence, and evaluated different intervention programs
designed to assist family caregivers of persons with mental
illness. For example, individual family support programs
(family consultation) (Citron et al., 1999), and individual-
or group-family groups and psycho-education interven-
tions (Solomon, 2000) have been examined, and all seemed
to be promising.
Chien et al. (2005, 2006) have reported that mutual
support in comparison with psycho-educational and
routine family support services, could improve functioning
for both caring Chinese families and the relative with
schizophrenia. Lyon and Budd (2010) have investigated the
effect of ParentChild Interaction Therapy on both
preschool-aged youth with disruptive behavior and fami-
lies, and demonstrated improvements of parent behavior
and stress, and child functioning. Unfortunately, the high
premature dropout rate had limited the effectiveness of
the study. In another study, a non-violent resistance
program, a form of family therapy, has been designed to
target directly parents living with children with violent
81
and uncontrolled behavior (Coogan and Lauster, 2014;
Lauster et al., 2014). The program helps parents learn to
manage the violent and destructive behavior of their
children, reduce their feelings of helplessness, and improve
their mental health. Despite the types of interventions,
targeted behaviors, age of children, and contextual factors
varied, most of these studies have shown improvements in
child-to-parent violence after interventions. Nevertheless,
these studies were short-term in nature and limited focus
on only one or two issues of concerns. Since child-to-
parent violence has serious and long lasting detrimental
consequences for both parents and children, it would be
important to examine if concurrently involvement of both
mentally ill violent patients and their victimized biological
parent in an intervention could improve the effectiveness
of the intervention.
1.1. Aim and hypotheses of the study
In this study, a randomized controlled trial was carried
out to evaluate the effect of Child- and Parent-focused
Violence Intervention Program (CP-VIP), an adjunctive
intervention, which involved both violent adult children
with mental illness and their victimized biological parent
(parentadult child dyads), on violence management. The
research hypothesis was that Child- and Parent-focused
Violence Intervention Program, when used in addition to
psychiatric standard care, could be more effective than
psychiatric standard care alone in reducing the severity of
the patients violent behaviors and improvements in coping
of the patients and their parents.
2. Methods
2.1. Study design
This study was an open-label randomized, clinical trial
from 2011 to 2013. Data were collected at 3 different time
frames: pre-treatment (T1), post-treatment (T2), and
treatment follow-up (one month after the completion of
the intervention) (T3).
2.2. Settings, participants and recruitment
The study was conducted at three hospitals located in
Southern Taiwan. The rst mental hospital with 700 beds is
under auspices of the Ministry of Health and Welfare. The
second one is a general hospital with 50 psychiatric beds
and the third is an 80-bed mental hospital, both are
privately owned and operated. All three hospitals are
similar in respect to philosophy of care and stafng.
The inclusion criteria for patients were: age  20 years,
a conrmed diagnosis of thought or mood disorders, and
psychiatrically hospitalized, having violent behavior in the
past 6 months toward their biological parent of either
gender, and able to give informed consent. This study
targeted adult patients because their violence often caused
injury or harm to their parent. The inclusion criteria for
those being physically or psychologically assaulted parents
(victimized parents) were: having a major and ongoing
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
past 6 months, and being able to provide clear and
conscious consent. From them the parentadult child
dyads were selected.
To ensure the quality of the study, the research team
included psychiatrists, nurses, allied health professionals
(social worker and clinical psychologists), and nursing
educators with specialized skills and expertise. Patients
were recruited based on inclusion and exclusion criteria by
psychiatrists and social workers of the domestic violence
prevention center in hospitals. The patients parents were
then contacted by social workers, and asked for agreement
to give their telephone number to the research team. The
research team members then approached both patients
and parents for the study, and conducted baseline and
post-intervention assessments.
2.3. Sample size and estimated study power
The sample size was calculated based on a previous
clinical trial of professionally lead support group for
Taiwanese people with schizophrenia in three waves of
data collection (before intervention, after intervention and
one-month follow-up) (Chou et al., 2002), and two clinical
trials of supportive and psychoeducational group treat-
ments for Chinese people with schizophrenia (Chien et al.,
2005, 2006). Based on these calculations, 32 child-parent
dyads in each group would be needed for three waves of
data collection in order to provide 80% power (two-sided
p < 0.05) to detect statistically signicant differences
(p-value of 0.05) between 2 groups, at moderate effect
sizes of 0.68 and 0.70, respectively, and power of 0.8 to
account for a 15% attrition rate (Cohen, 1992, 1998). In this
study, sixty-nine dyads (patient and parent) were selected
and randomly allocated to 2 study groups.
2.4. Randomization
After a written informed consent was obtained, patients
were randomly assigned to either the experimental or the
control group. The randomization schedule was generated
by computer and sealed in serially numbered opaque
envelopes by a trained nurse. The researcher opened the
allocation envelope selected by the patient.
2.5. Intervention
The theoretical foundation which guided the develop-
ment of the intervention was cognitive and behavior theory
(Beck, 1970) and ndings from earlier studies of child-to-
parent violence. The cognitive and behavior theory is known
to be effective on patients with agitated or aggressive
behavior (Hofmann et al., 2012; Saini, 2009). In this study,
cognitive and behavioral individual risk factors for violence
and intertwined factors which interacted at multiple levels
and placed parent at risk of child-to-parent violence, were
examined and therapeutic concerns on the conjoint sessions
evaluated. The most essential components of the interven-
tion were: developing trusting relationships; describing and
dening multidimensional conceptualization differences in
patients and their parents; and assisting them to address
behavioral problems by gaining more adaptive and accurate
perspectives and developing coping techniques for negative
thoughts and violence. The components included: learning
the skills involved in identifying cognitive distortions that
cause negative feelings (i.e. personalization and blame),
modifying dysfunctional beliefs that contribute to violence,
and disrupting the dangerous acts of violence as a repeated
pattern and changing behaviors.
In addition, the core contents of the intervention for the
victimized parent included: conict resolution strategies,
communication skills, coping process, and recognition and
management of childrens violence. The core contents for
the violent children included: homework assignments that
promote generalization of skills into regular life, discussion
of how their characteristics may interact with parents
to produce a violent event, discussion of how mental
symptoms impact their propensities for violence, skills
training to manage violence such as mad/bad/sad feelings,
communication and impulse control. The core contents of
conjoint sessions included: de-escalation skills for both
parties to de-escalate and avoid unnecessary confronta-
tions, re-focusing interactions away from persistent
conict, commitment to avoid violence and provocation
elements that could cause altercations, and acts of
reconciliation and offering of encouragement to each
other.
In the experimental group, each patient and parent
received separately, 2 individualized sessions of the Child-
and Parent-focused Violence Intervention Program, and
each parentalchild dyad received 2 conjoint sessions, for a
total of 6 sessions. In each session, each participant had at
least a 30-min preparation before the session started. Each
session lasted approximately one and one-half hours. The
time period of the intervention was approximately two
months. The intervention program was carried out by
primary researcher, nurse and psychologists.
In the control group, patients received psychiatric
standard care, which consists of routine psychiatric and
functional evaluations, regular ward group psychothera-
peutic efforts, occupational therapies, supportive listening,
medication management, social skill trainings, practice
with activities of daily living and individualized program
for rehabilitation, etc.
2.6. Outcome measures
The study design incorporates a number of outcome
measures to reect the effect of intervention on psycho-
logical, behavioral and cognitive domains and violence.
The theoretical foundation for designing the intervention
also guided the selection of outcomes to be measured. In
this study, the primary outcome of the trial involved the
evaluation of ways of coping; and the secondary outcome
included general cognitive functioning of patients, and
the intensity of a parent reaction as an assaulted victim,
violence attributions and impulsivity.
2.6.1. Patient only
1. Aggression/violence: The aggression questionnaire
developed by Buss and Perry (1992) was used. It
 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990
included 29 items which were grouped into 4 subscales
(physical aggression, verbal aggression, anger, hostility).
The options for each item were scaled from 1 (extremely
uncharacteristic of me) to 5 (extremely characteristic of
me) with a summed score ranged between 29 and 145.
Higher scores indicate more aggression.
2. Impulsivity (Barratt Impulsiveness Scale, BIS-11 Patton
et al., 1995): Barratt Impulsiveness Scale included 30
items, which were grouped into six rst-order factors
(attention, motor, self-control, cognitive complexity,
perseverance, and cognitive instability impulsiveness)
and three second-order factors (attentional, motor, and
non-planning impulsiveness). The score for each scale
ranged from 1 (rarely/never) to 4 (almost always/
always). Higher scores indicate higher levels of impul-
siveness.
3. General cognitive functioning (Mini-Mental State
Examination, MMSE, Chinese version Guo et al.,
1988): The examination included 30 items with
variable ranges of scores, for example: orientation
time, orientation place, attention/concentration (range
of scores: 0-5); registration, recall, command (0-3);
naming (0-2); repetition, read and obey, write, copy and
design (0-1). The higher score indicates the better
cognitive function.
4. Patients violent behavior in the past 6 months toward
their victimized parent was rated by number of patients,
in four distinct forms of violence.
2.6.2. Parent only
The intensity of a parent reaction as an assaulted victim
was measured using Assault Response Questionnaire
(ARQ) developed by Ryan and Poster (1989). The ques-
tionnaire included 61 items which were grouped into 4
subscales (emotional, biophysiological, cognitive and
social reactions). Scores were on a 5-point scale ranging
from 1 (none) to 5 (severe). The higher the score, the more
intense the response to assault.
2.6.3. Patient and parent
1. Attributions (Attribution Questionnaire Dutton,
1992):The Questionnaire included 6 items measuring
dimension of violence attributions in terms of internal/
external attributions regarding the responsibility/
blame for the violence and the attribution of the
cause of violence in patient/parent relationship. They
were scored on a continuum of 1 (e.g., totally due to
child/parent; not at all likely; not at all able, etc.)
through 7 (e.g., totally due to me; totally likely; totally
able, etc.).
2. Ways of coping (Ways of Coping Questionnaire, WCQ
Folkman and Lazarus, 1985): The questionnaire includ-
ed 66 items measuring coping processes in a particular
stressful encounter. They were grouped into 8 subscales
(problem-focused coping, wishful thinking, detach-
ment, seeking social support, focusing on the positive,
self-blame, tension reduction and keep to self) and
scored on a 4-point Likert scale ranged from 0 (does not
apply and/or not used) to 3 (used a great deal). A higher
score indicated that the person used those coping
behaviors more.
83
2.7. Intervention delity, validity and reliability
The delity, reliability and validity of the intervention
were assessed as described by Borrelli (2011). The
components of delity focused primarily on three dimen-
sions: researcher training, methods of intervention deliv-
ery, and how participants received and applied the
intervention. Before intervention was delivered, a training
plan for researchers was prepared. Written intervention
manuals which ensure the content of and adherence to the
protocol and features, were also utilized. Further, the
intervention was tested in a pilot study of 2 parent-child
dyads.
2.8. Ethical considerations
The study protocol was approved by the Institutional
Review Board in the participating hospital. Throughout the
study, the researchers ensured patients rights according to
the ethical principles for medical research on human
beings set out in the Declaration of Helsinki (World
Medical Association, 2013). Written informed consent was
obtained from patients. As patients and parents were
relatively vulnerable, a thorough evaluation of the poten-
tial participants was conducted by the research team and
the domestic violence prevention center of the hospitals
before study began.
2.9. Data analysis
Data analyses were performed using software, SPSS for
Windows (version 22.0, IBM). Descriptive statistics with
mean and standard deviation (SD) for continuous demo-
graphic variable, and frequency for categorical demographic
variables were used. To verify the homogeneity between
groups, the chi-square test (x2 test) was used for categorical
demographic data. Between-group differences in all 6
outcome measures were examined using independent
t-tests. The paired t-tests were conducted to compare the
changes of aggression, impulsivity and cognitive function-
ing in patients and assault victims reaction in parents
between consecutive time points. A repeated-measures
ANOVA was performed for the outcome measures to
determine whether the interventions produced the with-
in-between group and group-by-time interaction effects.
The level of statistical signicance was set at p < 0.05.
3. Results
3.1. Basal characteristics of the participants
A total of 71 parentchild dyads were screened and
recruited initially. Two dyads refused to participate in the
study. The reasons were not interested and too busy/no
time. A total of 69 dyads (97.1%) completed the study. The
mean ages (SD) of patients and parents in the experimental
group (36 dyads) were 36.19 (6.82) and 62.58 (9.96) years,
respectively, whereas those in the control group (33 dyads)
were 35.64 (7.78) and 61.85 (9.41) years, respectively
(Table 1). The distributions of age were compatible between
84 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990

Table 1
Characteristics of patients and their parents at recruitment.

Characteristics CP-VIP (36 dyads) Routine care group x2 P

(33 dyads)

Patients Parents Patients Parents

n % n % n % n % Patients Parents Patients Parents

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

Marriage status Single 24 66.7 17 51.5 3.463 3.001 0.326 0.391

Married 1 2.8 23 63.9 24 72.7
Separated/ 11 30.6 13 36.1 16 48.5 9 27.3
divorced

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

Age of disease <20 11 30.6 16 48.2 4.728 0.193

onset (yr) 2130 19 52.8 16 48.5
31 6 16.7 1 3.0

Diagnosis Mood disorders 13 36.1 14 42.4 0.288 0.591

Schizophrenia 23 63.9 19 57.6

Admission to 1 13 36.1 15 45.5 4.720 0.451

hospital in 2 15 41.7 16 48.5
recent 1 year 3 8 22.2 2 6.1

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

Alcohol No 23 63.9 29 80.6 20 60.3 25 75.8 3.085 2.170 0.687 0.852

consumption Yes 13 36.1 7 19.4 13 39.7 8 24.2

Verbal V Yes/no 32/4 88.9 31/2 93.9 0.553 0.457

Physical V Yes/no 18/18 50.0 16/17 48.5 0.016 0.900
AAP Yes/no 18/18 50.0 16/17 48.5 0.016 0.900
Injured Yes/no 18/18 50.0 16/17 48.5 0.930 0.628

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
control were similar to those in the experimental group
(p > 0.05). Similarly, the demographics of parents in the
control group were compatible to those in the experimental
group (p > 0.05).
The occurrence of violence prior to intervention was
also comparable between two groups: 88.9% (n = 32)
parents in the experimental group versus 93.9% (n = 31)
in the control group experienced verbal violence and 50%
(n = 18) versus 48.5% (n = 16) received physical violence
and were injured.
3.2. Effects on patients
Scores on aggression in patients were signicantly
reduced in the experimental group as compared to those in
the control group at T2 and T3 time points (p < 0.05)
(Table 2). However, no signicant reduction in verbal
 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990 85

aggression was observed (p > 0.05) at any time point. The

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

3.3. Effects on parents

1.64,
3.97,
6.39,

2.68,

2.78,
2.46,
0.44,
6.50,
3.90,

At baseline, scores on parents reaction to assault in the

t, pa

experimental group were slightly higher than those in the

control group (Table 3). The scores in the experimental
89.58
21.45
15.97
27.24
24.91

69.85
17.27
25.48
27.09

27.06

group were progressively decreased whereas those in the

RC x

control group were increased at T3. As a result, the

difference between two groups became very signicant at
Time 3

77.92*

66.22*

27.25*

T3 (p = 0.001). In terms of the emotional and bio-physiolog-

19.36
14.94
23.28

17.53
23.36
25.33
20.67
CPb x

ical subscales, the scores in the experimental group as

compared to those in the control group were signicantly
lowered (p < 0.05).
to 7.11

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

3.4. Effects on both patients and parents

95% CIs

17.68
2.59

7.79
4.97

6.85
1.95
3.36
3.06

3.04

Patients and parents violence attributions were signi-

cantly changed in the experimental group (p < 0.05)
(Table 4). Before intervention (T1), no signicant differences
0.62, 0.537
0.038
0.076

0.082

0.085
0.005

0.042
0.000

0.000
0.000

on coping process in patients and parents in both groups

were found (p > 0.05). After intervention, no change was
4.68,
2.12,
1.81,

4.45,

2.89,
1.77,

1.75,
4.90,

2.07,
t, pa

found on wishful thinking (p > 0.05), but signicant

differences on coping process were found from T2 and
thereafter (p < 0.05). The self-blame scores in parents in the
70.21
91.73
21.97
15.79
28.76
25.21

25.21

26.79
17.00

28.00

RC x

control group were increased and signicantly higher than

those in the experimental group at T2 and T3 (p < 0.05)
(Table 4).
Time 2

20.64
79.33

14.33
23.22
21.78

66.17

26.58

27.22
16.08
23.50

A two-way repeated measure ANOVA was used to

CP x

determine whether any change in aggression, impulsivity,

cognitive functioning, assault victims reaction and ways of
Clinical measure scores at pre-test and two post-tests and t-test results for patients.

2.73
1.25
1.24
1.15

2.83
1.61

1.93

1.53 to 1.47
0.82
0.59

coping resulted of interaction between intervention and

time (Table 5). Results show that time signicantly affected
to
to
to
to

to
to
to
to
to
95% CIs

the intervention outcomes. At all three test times, patients

0.75
9.95
2.41
1.68
4.26

4.26

3.49
1.56
3.10

aggression (F = 18.05, p = 0.000), impulsivity (F = 6.09,

p = 0.003), cognitive functioning (F = 5.28, p = 0.006), assault
victims reaction (F = 13.50, p = 0.000) and ways of coping for
CP-VIP: Child- and Parent-focused Violence Intervention Program.
0.259

0.255
0.178

0.473
0.222
0.829
0.530
0.765

0.689

0.04, 0.968

patient (F = 22.69, p = 0.000) and parent (F = 16.13, p = 0.000)

were signicantly different between the experimental and
1.14,

1.15,
1.36,

1.23,
0.63,

0.72,

0.22,
0.30,

0.40,
t, pa

the control groups. Differences became greater as time

Examined by paired t-test within groups. x: mean.
Examined by independent t-test between groups.

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

interactions. In the experimental group as compared to the

control group, there was a signicant improvement over time
in aggression (F = 12.46, p = 0.001), impulsivity (F = 4.88,
Time 1

87.72

27.11

69.53
16.97
24.64
27.92

26.33
22.03
15.08

23.50

CP x

p = 0.031), assault victims reaction (F = 26.66, p = 0.000) and

ways of coping for patient (F = 87.52, p = 0.000) and parents
(F = 12.24, p = 0.000). There was an increase but not
Anger with resentment

statistically signicant (p > 0.05) in cognitive functioning.

CP-VIP (CP) vs. Routine

Physical aggression
Suspicion, hostility
Verbal aggression

Cognitive function

4. Discussion
Nonplanning
Attentional
Impulsivity
Aggression

4.1. Main ndings

care (RC)

Motor
Table 2

It is known that when mentally ill patients with

b
a

violence and their victimized parents are involved at the

86 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990

same time, the intervention becomes complex. A group

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

child dyads exposed to child-to-parent violence.

There are three possible explanations of why the Child-
and Parent-focused Violence Intervention Program was
103.27
43.79
16.12
27.55
15.82

RC x

effective on child-to-parent violence. First, the interven-

tion program focused on both mentally ill patients with
violence and the victimized parents. As mentioned earlier
Time 3

91.58*

x

37.28
16.64

14.61
23.06
b

in the Introduction section, many interventions carried out

CP

in either hospitals or community have focused mainly on

providing harm-reduction treatment, family support,
0.08
2.13

1.79
0.72
1.06

psycho-education and support groups for management

of mental health problems to either parents or their
to
to
to
to
to
95% CIs

10.82
7.19

2.87
2.55
0.76

children but not both (e.g., Timmer et al., 2010). Second,

the design of this study was novel; it employed individu-
alized sessions for each patient and parent separately
which neatly side-stepped a dilemma of presenting violent
0.185

0.422
0.237
0.413
0.045

children too early to their parents before the conjoint

sessions. Third, the study design has also taken the
1.34,

1.19,
0.81,

0.82,
2.04,
t, pa

concerns of the victimized parents toward their violent

Clinical measure scores at pre-test and two post-tests and t-test results for parent assault victims reaction (n = 69).

children into account. Thus, the intervention in this study

emphasized empirically supported strategies of manage-
99.34
45.58

24.55
13.61

RC x

16

ment of violence, conict resolution, and ways of coping in

child-to-parent violence. It helped both parties to be more
Time 2

41.94
16.51
23.47
12.86

competent to manage the violent situations.

CP x

95

4.2. Coping with violence

10.80
4.56

1.33
3.80
3.50

The overall impact of violence depends on individuals

to

to
to
to

to
95% CIs

reactions to stress, ways of coping with violence and

2.83

0.87
1.70

2.05
0.60

potential actions to reduce violence by juxtaposing those

coping processes with individual willingness. Coping with
a mentally ill adult child with violence, particularly if the
0.247
0.366
0.163
0.213
0.673

child is living at home, is a great challenge to parents.

1.17,

1.41,
1.26,
0.91,

0.42,

Folkman and Lazarus (1985) have identied and catego-

t, pa

rized various approaches used in coping process such as

confrontational coping, self-controlling, accepting respon-
sibility, planful problem solving, and positive reappraisal.
101.48
45.21
16.24
25.73
14.30

Examined by paired t-test within groups. x: mean.

RC x

Examined by independent t-test between groups.

The appraisal of adverse event and coping options, the use

of coping strategies and intention to change the situation

are key steps in the coping process (Pincus and Friedman,

Time 1

105.47
46.64
17.69
27.19
13.94

CP x

2004). As parents encountered more violence, they

developed more emotional reactions related to a sense
of impotence in controlling child-to-parent violence,
CP-VIP (CP) vs. Routine care (RC)

violence-related external reminders such as places, con-

versations, activities, or situation, and negative trauma-
related emotions such as fear, guilt, or shame. They have
difculty of self-regulating their negative cognitive
Biophysiological
Social reactions

thoughts such as doubting and decreased self-worth,

and forming close parent-child relationship with their
Emotional

Cognitive

children (Coogan, 2011; Hsu and Tu, 2014). Negative

emotions appear to have a cyclical pattern which has a
Table 3

ARQ

negative inuence on parents coping process to alleviate

b
a

distress. Parents have also experienced some typical

 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990 87

Table 4
Clinical measure scores at pre-test and two post-tests and t-test results for both patients (PT) and parents (PR).

CP-VIP vs. Routine care Time 1 Time 2 Time 3

a a
D t, p D t, p D t, pa

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
psychological effects of childrens violence or the percep-
tion that child-to-parent violence is part of the caregiving
or life (Coogan and Lauster, 2014).
In studies conducted by Coogan and Lauster (2014) and
Lauster et al. (2014), the authors have indicated that
coping with child-to-parent violence is important when
dealing with a violent incident. Coping is highly affected by
violence itself (Calvete et al., 2008). Parents needed an
intervention that gave practical strategies to cope with the
complexities and dynamics of the child-to-parent violence.
In this study, we emphasized the ways of coping by
measuring the coping processes that one would use to cope
with the stressful encounters of everyday living. Prior to
intervention, parents often have difculties coping with
the problem by way of escaping or avoiding the problem.
After intervention, the availability of social support and
resources from relatives, friends, and health professionals
and psychological resource such as their gradual improve-
ments of assault reaction, were important contributing
factors to their development of coping ability to overcome
those difculties and related stress resulted from their
childrens violence. Indeed, improvement of both parents
and childrens coping processes became their strengths
and attributes which helped their development of coping
ability in the stressful violent situation.

Table 5
Repeated-measures effects of the Child- and Parent-focused Violence Intervention Program on violence.

Sum of squares Degree of Mean square F p

freedom

Group (inter-group) effect

Patients Aggression 18,298.203 67 282.51 15.55 0.000
Impulsivity 6445.24 67 96.19 4.19 0.044
Cognitive functioning 1260.38 67 18.81 0.11 0.744
Parents Assault victims reaction 28,203.95 65 433.91 1.52 0.222
Patient/Parent WOC 22,257.92/10,373.68 66/67 337.24/154.83 8.81/1.68 0.004/0.200

Time (within) effect

Patients Aggression 1207.26 2 603.63 18.05 0.000
Impulsivity 145.10 2 7 2.55 6.09 0.003
Cognitive functioning 25.36 2 12.68 5.28 0.006
Parents Assault victims reaction 1828.87 2 914.44 13.50 0.000
Patient/Parent WOC 1342.04/846.49 2/2 671.02/423.25 22.69/16.13 0.000/0.000

Group and time interaction

Patients Aggression 557.58 1 557.58 12.46 0.001
Impulsivity 72.98 1 72.98 4.88 0.031
Cognitive functioning 0.42 1 0.42 0.12 0.728
Parents Assault victims reaction 1929.27 1 1929.27 26.66 0.000
Patient/Parent WOC 2818.33/399.01 1/1 2818.33/399.01 87.52/12.24 0.000/0.000

WOC, ways of coping.

88 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990
In other psychiatric research studies, the frequency of
aggression event has also been used as an outcome (e.g.,
Amore et al., 2013; Monahan et al., 2001). Their ndings
showed that approximately 1828% of discharged patients
had violent act/physical aggressiveness only once and that
12% were involved in two or more violent acts in
subsequent follow-up contacts. These ndings indicated
that the frequency or the number of violent can help to
identify those repeatedly violent patients after discharge
from psychiatric wards, and reect the clinically important
treatment outcome. In the present study, the frequency or
the actual number of violent acts was not evaluated as an
outcome measure. It is suggested that evaluations of
frequency, severity, and type of violent episode are
included in our future studies.
4.3. Impulsivity
Poor impulse control is also an important factor of
violent behavior (Hsu and Tu, 2014). Results in this study
show that violence-prone patients had weak impulse
control which rendered them difcult in dealing with
stressful circumstances with parents at home. These
patients might easily trust their own perception of reality
without conscious interpretation. Thus, patients with
poor impulse control are likely to have violence toward
parents whether or not they are angry. Anger manage-
ment alone may not be sufcient in managing this type of
violence.
4.4. Violence attributions
Individual differences in violent behavior may also
relate to different attributional styles (Dodge, 2006).
Attributions (attribution styles and errors) of those who
commit violent acts are considered important in assessing
risk of recurrence of many forms of violence (Lila et al.,
2013, 2014). In addition, patients individual and clinical
characteristics such as increased irritability and poor
impulse control, dyadic factors are also closely related to
child-to-parent violence (Hsu et al., 2014). Causes of
violence can be bidirectional or mutual. How to change the
victim-blaming attributions is a challenge for violence
intervention programs (Lila et al., 2013).
In this study prior to intervention, patients used the
victim-blaming attributions to explain their parent-in-
duced violent behavior, whereas the parents reports of
self-blaming were inconsistent with patients point of
view. The difference of attributional styles between
patients and parents in response to child-to-parent
violence may be due in part to the conventional social
and cultural norms in relation to children and violence
within families (Coogan, 2011). Fung et al. (2007) have
demonstrated that Chinese persons with mental illness
may be more susceptible to self-stigma, due to personal
beliefs. On the other hand, Chinese parents often believe
the cause of childrens mental illness (e.g., mind-body
imbalance) was a form of punishment for the sufferers who
may have sinned in their previous life.
Results in this study show that the intervention was
effective in changing both parents and patients attributions
for violence problems. Patients reduced their victim-
blaming attributions more than parents did on self-
blaming. Admitting being responsible for violence and
reducing the victim-blaming attributions were important
components of the effectiveness of intervention as reported
by others (Brisebois et al., 2010; Coogan and Lauster, 2014;
Lila et al., 2014).
4.5. Child-to-parent violence intervention in a cross cultural
context
Cultural contexts are critical and highly inuential in
analyzing violence (World Health Organization, 2009).
Indeed, areas where child-to-parent violence may be
unique to the particular cultural contexts. Intervention in
managing violent patients with mental illness and their
victimized parents may be more applicable if cultural
elements are implemented and integrated. An insightful
exploration and understanding of violence and the
interplay of factors within Chinese or other cultural
contexts including the highly involved parental roles,
beliefs and ideas in child-to-parent violence, is unavoid-
able (Hsu and Tu, 2014; World Health Organization,
2009). Both patients and parents have to correct the
misperceptions, raise awareness of child-to-parent vio-
lence and reinforce the shared responsibilities and be
supportive of non-violent behavior. They have to ac-
knowledge a more realistic sense of actual behavioral
norms, and actively manage the child-to-parent violence,
thereby reducing the violent behavior in a cross-cultural
context.
Addressing the violent behaviors of an individual,
versus parents might overlook the causal family conditions
in treatment. Through trusting relationships, the research-
ers developed a better understanding of the victims
characteristics, and subsequently developed strategies to
manage the conicts in its cultural context, and solve the
problems during the conjoint sessions.
4.6. Limitations and recommendations for future research
One of the limitations of this study was the lack of
evaluation of frequency or the actual number of violent
acts/behaviors as an outcome of the study, which has been
described in the discussion section. Another limitation was
smaller sample size and relatively short follow-up period
which renders the generalization difcult. Future investi-
gation is suggested to include lager samples of both
patients and their parents with a longer follow-up period
(>6 months), so that more conclusive claims of treatment
mechanism, cognitive and behavioral changes and effec-
tiveness may be claimed. A 3-arm design with an active
control group and a usual care control group is recom-
mended which would help to control the nonspecic
features of an intervention. In addition, positive sibling
interactions are important in supporting or serving as
supporters or resources for their aging parents who are
caring for their siblings with mental illness. It is suggested
that the future study includes siblings in the trial if the
siblings are identied as the future primary caregivers of
their mentally ill siblings.
 G.-C. Sun, M.-C. Hsu / International Journal of Nursing Studies 60 (2016) 7990
5. Conclusions
This study examined the effects of Child- and Parent-
focused Violence Intervention Program concurrently on both
patients and their parents. Results show that intervention
was an empirically effective adjunctive intervention for
improving violence management, alleviating intensity of a
parent assault victims emotional and bio-physiological
reactions, managing impulsivity and violence attributions,
and fostering active coping processes. Parents in the
experimental group reported fewer violent behaviors at
home than those in the control group.
6. Implications for nursing and clinical practice
The ndings provide evidence about the promising
effects of a form of family therapy. The intervention
utilized both children and parents strengths to nd ways
to manage child-to-parent violence. This approach is
particularly practical in a clinical setting for patients
who have just been diagnosed with mental illness and had
an episode of violence within a narrow time frame. The
distinction between the Child- and Parent-focused Vio-
lence Intervention Program in our study and the family-
involved therapy is that parent in our intervention is
deemed to be one of the primary therapeutic group. Nurses
would need to undergo training on both concepts and skills
of child-to-parent violence management. Management of
violent victimization should become a part of routine
clinical health care that complements their already
existing skills, values and knowledge for both patients
with mental illness and their victimized parents as the
primary caregiver. In particular, documenting how the
intervention can be modied for the particular clinical
context or patients and parents outcomes can make a
signicant contribution to management of child-to-parent
violence.
Acknowledgements
This study was supported by Ministry of Science and
Technology (NSC-99-2314-B-214-003-MY3).
Conict of interests: The authors declare that they have no
conict of interests.
Funding: This study was supported by National Science Coun-
cil NSC-99-2314-B-214-003-MY3.
Ethical approval: Institutional Review Board of I-Shou Uni-
versity, Taiwan: ISU-IRB-98-005; Institutional Review Board
of E-DA Hospital, Taiwan: EMRP-099-050; Institutional Re-
view Board of Jianan Mental Hospital, Department of Health,
Execution Yuan, ROC.: 11-001.
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