Help-Seeking Mothers and Their Children Kate L. Kogan, PhD University o f Washington School o f Medicine
Forty-three mothers sought help with management of childhood behaviors. Presenting complaints in half or more of the families included stubbornness, talking back to parents, disobedience and other traits indicative of parent-child interaction difficulties. Pretreatment behavioral observations revealed that mothers shared c o m m o n characteristics of being low in positive warmth and high in negative and oppositional responses. The children were observed to share c o m m o n traits of little independent play, frequent frustration, and either ignored their mothers or were verbally and physically oppositional. Behavioral counselling and monitored rehearsal served to reverse many of the behaviors. Almost all mothers reported reduction in problem behaviors. Mothers varied widely in attributing usefulness to different program components.
ABSTRACT:
The problems of assessing the effectiveness of psychotherapeutic intervention, or of defining and measuring the o u t c o m e of treatment are well recognized. The issues become even more controversial and less clearcut when the focus is on the o u t c o m e of behavioral approaches to treatment, when the subjects are children, and when interpersonal rather than intrapersonal factors are at stake. Perhaps the largest area of uncertainty is that of appropriate criteria of outcome. Garfield, Prager and Bergin [1] emphasized that eight different evaluations of outcome, derived from their data, were essentially unrelated. Fiske's [2] comments on that report put forth the opinion that it was more important to concentrate on adaptive strengths following therapy than on measures of disturbance. Luborsky's [3] comments on the same report suggested that specific gains and changes might indeed show up in different, n o t necessarily correlated, areas and that perhaps global ratings were the most appropriate criteria afReprint requests should be sent to Kate L. Kogan, PhD, Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 98195. This study was supported by Grant #19642 from the National Institute of Mental Health.
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ter all. Garfield and his colleagues however, preferred to emphasize the importance of utilizing a variety of outcome measures. Strupp and Hadley [4] recently suggested that there are three discrepant vantage points from which mental health and/or o u t c o m e of therapy may be judged. They distinguished between the point of view of society, the point of view of the individual and the point of view of the mental health professional. The present report is a summary of observational data accumulated over a two year period in the behavioral counselling program of The Parenting Clinic of the University of Washington. Earlier reports have presented detailed results derived from the specific parent instruction program which was developed in the initial research [5, 6, 7]. That project focused on the effectiveness of the interventions; it was open to some of the same shortcomings that other reports have had. Its findings corroborated those of Garfield, et al., that different measures of change were essentially unrelated. At the completion of that project the techniques for analyzing videotaped interaction records were revised in the interests of greater economy and more precise clinical utility [8]. The system now provides for retaining much more precise identification of specific behaviors. The earlier publications were focused on documenting the evidence that change had taken place in individual dyads, and noting the transience or persistence of such change. The primary focus of the current report is in identifying specific behaviors and subsequent behavioral changes which were characteristically shared by the subjects, despite their individual uniquenesses. Changes discussed in this framework may be conceived of as being more or less directly attributable to the kinds of intervention procedures utilized. The material which follows requires no particular theoretical model of outcome measurement. It provides a condensation of behavioral records and questionnaire responses before and after a series of monitored and guided interaction rehearsal sessions. It details the respects in which the behaviors of help-seeking mothers and their children differed from and/or conformed with the recorded behaviors of a comparison population.
Subjects Subjects were 43 mothers of 2-8 year old children who were referred to The Parenting Clinic of the University of Washington because they were concerned about, or were seeking guidance in, appropriate management of various child behaviors. There were 32 males and 11 females in the group of children. So-
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cial class, according to the Hollingshead Two-Factor Index of Social Position [9] was distributed as follows: Social class 1 2 3 4 5
7 8 8 16 4
Nine of the children were two-three years of age, 15 were four or five years old, and 19 were six, seven, or eight years old.
Procedures In their first two visits, usually a week apart, each mother and child were asked to play together with a selection of toys for thirty minutes. At this time each mother also completed a modified form of the Washington Symptom Checklist [10]. She was asked to indicate which of a list of 63 behaviors she viewed her child as exhibiting more than most children his age, which ones about the same as most children his age, and which ones less than most. The tabulated behavior frequencies from the recorded observations and the behavior symptoms checked by the mother together constituted the basis for formulating specific suggestions for the mother's altering her interactive style during succeeding monitored play sessions. At her next visit after the recorded baseline play sessions, selected excerpts from her videotapes were reviewed with the mother to illustrate specific behaviors which the observers encouraged her to use more frequently and in more varied situations. Examples were also shown and discussed illustrating behaviors which the observers recommended that she try to decrease and replace with suggested alternative responses. She was given a written summary o f three o r four concrete suggestions to practice during the play session which immediately followed the videotape review. The mother was given a small earphone device which permitted the observer to talk to her while she played with her child, without the child hearing the comments. Thus the observer was able to give recognition when the mother carried out recommendations successfully, to point out additional opportunities for her to use desired behaviors, or to suggest specific things she might say or do. Mothers were asked to arrange for daily play sessions of at least 15 minutes duration and t o use these for conscious rehearsal of the specific suggestions made to them. They were also asked to become alert to additional opportunities to apply the suggestions to a variety of daily situations. Monitored play sessions in the laboratory t o o k place once a week for eight weeks, and observers continued to prompt the mother over the earphone so as to provide her with immediate feedback while she was actively engaged in interaction with her child. At the beginning of each weekly session the mother was asked about the events of the preceding week, and the course of the daily play sessions. Special problems or events were discussed and ways of handling similar situations in the future were discussed. At the end of eight weekly guided play sessions, two more play sessions were recorded without providing the mother with any prompting or cuing. The mother also completed the Washington Symptom Checklist again.
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In her final clinic visit the mother reviewed selected videotape excerpts from each of the weekly observational or instructional sessions in which she had participated so that she was able to see the sequence of progress and behavioral changes that had taken place over the three month period. When the entire project was completed, a questionnaire was sent to each mother asking her to evaluate her clinic experience by indicating the extent to which the problems that first led her to seek help still occurred. She was also asked to rank six different defined aspects of the program from most to least helpful in terms of her experience. The timing of the questionnaire was such that some mothers had completed the program as much as 12 to 15 months earlier whereas others had finished their series of visits only three or four months before the questionnaire was sent out.
Data Analysis The videotapes were analyzed in forty-second units. The occurrence of interactive behaviors in each forty-second unit was recorded according to the Interpersonal Behavior Constructs system, which had been developed in earlier research in this laboratory. The system employs a checklist of behavior transactions which represent a range of important interactions that characterize the unique interpersonal styles of a wide variety of parent-child dyads. The content of the checklist items fall into several categories. The focus of the participants' attention is identified as being primarily on the other person, on his own activity, or on joint activity. Vocal behavior is classified as being absent or limited, one-sided, or reciprocal and responsive. Lead-taking is assessed in terms of recurrent attempts to impose structure on the other person's behavior whether he is engaged in individual or joint activity. Behaviors in these categories are checked if their duration characterizes the major portion of the forty-second time unit being reviewed. The remainder of the items are viewed as being important even if they occur only once during the time unit being assessed. One cluster of items covers specific instances of positive behaviors,--smiling, animated voice, stating personal pleasure, praising, or physical expression of affection. Another section of the list itemizes behaviors which imply negative feelings; pouting, frowning, and unfriendly tone of voice are checked here. Note is made of slaps, snatches, threat gestures or other aggressive acts toward the other person or the thing with which he is occupied. Note is also made of ambiguous affect such as is reflected in sarcasm or teasing. A group of items reflect various manifestations of efforts to dominate the other's behavior by contradicting, criticising, correcting, or refusing to comply; intruding physically into the other's ongoing activity, issuing commands or arbitrary rules, or expressing the intention to compete are recorded in the same section. A final group of items covers behaviors which reflect a variety of submissive roles, such as seeking permission, help, or approval or actively complying with the other person's directions, suggestions, or lead. With the exception of two items (working together and shared conversation) each item may be checked for mother and/or child. When the two recorded baseline play sessions had been analyzed, there were 90 separate sets of behavior ratings for each parent-child pair. Frequencies of occurrence of the 21 behavior items reviewed for each dyad were compared with preliminary normative data available from a series of 20 nonclinic comparison subjects [ 1 1 ] . A behavior frequency was identified as being excessive when a be-
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havior occurred either more or less frequently than it did in any comparison subject's behavior observation. It was labeled extreme when the frequency was in the range exhibited only by the highest or lowest 15% of the comparison subjects. Behavioral change was viewed from two vantage points--normative and clinical. When they entered the counselling program, how did the behaviors of this group of concerned and help-seeking parents and their children differ from those of nonclinic comparison families? And how did they compare at the end? The second assessment of change was made in terms of each individual dyad's changes over time, regardless of whether they conformed to or deviated from normative standards. In the latter case the absolute frequencies of occurrence of separate checklist items of behavior were examined before and after the series of instruction sessions for each individual dyad. Comparison of pretreatment and posttreatment frequencies was made by means of analysis of variance, testing whether before- and after-treatment differences were systematically greater than differences between days or between separate portions of a single day's session. While there is some room for criticism in this application of analysis of variance, on the basis that separate behaviors may not, in fact, be independent of each other, the decision was made that each dyad brought to the study its own individual repertoire of habitual responses, and that it could be argued that there was equal probability that one or another response from that repertoire might be elicited at any given moment. In the absence of any better means of looking at changes within single dyads, using each pair as its own control, the advantages of analysis of variance appeared to outweigh the disadvantages.
Results Behaviors R e p o r t e d as D e v i a n t b y Mothers. Three o f the 43 m o t h ers neglected to r e t u r n their s y m p t o m checklists at the end o f the study. In o r d e r t o clarify t h e t a b u l a t i o n o f b e f o r e and after characteristics and their differences, o n l y the 40 c o m p l e t e responses were analyzed. On this i n s t r u m e n t , behaviors are c o n s t r u e d t o be d e v i a n t in the eyes o f the p e r s o n c o m p l e t i n g the checklist w h e n either m o r e t h a n m o s t or less t h a n m o s t is in a d i r e c t i o n usually a c c e p t e d as constituting a p r o b l e m . Thus D I S O B E Y S M O T H E R m o r e t h a n m o s t is t a b u l a t e d as being deviant; IS S E L F - S U F F I C I E N T less t h a n m o s t is also t a b u l a t e d as being deviant. The m e a n n u m b e r o f deviant behaviors r e p o r t e d b y m o t h e r s at the beginning o f the s t u d y was 1 7 . 9 8 ( m e d i a n 16.93), with a range f r o m 3 t o 38. Deviant behaviors r e p o r t e d b y half or m o r e o f the m o t h e r s were as follows: T h i r t y (75%) o f the m o t h e r s described t h e i r children as S T U B B O R N m o r e t h a n m o s t ; 22 (55%) r e c o r d e d O V E R A C T I V E a n d / o r T A L K S B A C K T O P A R E N T S in the m o r e - t h a n - m o s t c o l u m n ; DEMANDS A G R E A T D E A L O F A T T E N T I O N , F E E L I N G S EASIL Y H U R T , a n d / o r R E S E N T F U L O F D I S C I P L I N E were m a r k e d b y
Kate L. Kogan
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21 (53%) of mothers; 20 (50%) marked DISOBEYS MOTHER and/ or REFUSES PARENTAL INSTRUCTIONS. Only one checklist response was related to social class,--HAS SERIOUS FIGHTS WITH OTHER CHILDREN. More boys t h a n birls were reported to be DESTRUCTIVE. Five items were reported with different frequencies for different aged children. DAYDREAMS, HAS DIFFICULTY MAKING GRADES IN SCHOOL, and LACKS SELF-CONFIDENCE were reported more for older children; BLAMES OTHERS FOR HIS TROUBLES and TEASES OTHERS were marked more often for younger children. Following the counselling sessions the mean number of deviant behaviors reported by the mothers was 9.45 (median 6.5), with a range from 2 to 35. Of the 40 mothers, 2 perceived a greater number of deviant behaviors than they had before, and one saw the same number. No checklist item was marked by as many as half of the mothers. Two items were marked by 16 (40%) of the mothers,--FEELINGS EASILY HURT and GETS ALONG WELL WITH ADULTS. The next most prominent complaint was STUBBORN, which was marked by 14 (35%) of the mothers; prior to treatment, that item had been marked by 75% of the group. In descending order IS BOSSY was marked by 13 (33%), PREFERS TO PLAY WITH CHILDREN NOT HIS OWN AGE by 11 (28%), and POUTS OR SULKS WHEN TOLD TO DO SOMETHING, and WETS BED by 10 (25%) of the mothers. The items which reflected the greatest number of changes from more than most to about the same as most were STUBBORN, RESENTFUL OF DISCIPLINE, and DISOBEYS MOTHER, each in 16 instances; TALKS BACK TO PARENTS, REFUSES PARENTAL INSTRUCTIONS, and OVERACTIVE each were reported to have changed in 14 cases. Behaviors Identified as Deviant in Behavior Observations. Each dyad member's interactive behaviors were tabulated under 21 behavior categories. Thus 903 mother behavior frequencies and 903 child behavior frequencies (43 dyads • 21 behavior categories) were matched against the frequency distributions of nonclinic comparison subjects. Ninety six of the mother behavior frequencies (10.6%) were bey o n d the frequency ranges of the comparison subjects, and were designated as excessive. One hundred ninety three additional behavior frequencies were identified as extreme, i.e., in the range exhibited only by the highest or lowest 15% of the comparison subjects. Thus
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there were among khese 43 help-seeking mothers, 289 deviant behavior frequencies, at or beyond the frequency levels of the top or bottom 15% of nonclinic mothers. These extreme and excessive occurrences a m o u n t e d to 32% of the total behavior tabulation for the group; 68% of their behavior frequencies fell in the same ranges as the middle 70% of comparison mothers. This distribution indicates that although certain kinds of extremes and excesses of behaviors could be identified in the behavioral records of the mothers, the remainder of their interactive characteristics fell within expected limits to an appropriate extent. When the separate Interpersonal Behavior Construct categories were examined, it was apparent that the deviant behaviors were clustered in a few categories and that five behaviors accounted for 116 (40%) of the deviant frequency tabulations. The upper half of Table 1 details the distribution of the mothers' frequency tabulations in these five categories. The greatest number of deviant behavior tabulations was noted in NEGATIVE CONTENT. This category covers contradictions, corrections, criticisms, refusals of requests or suggestions, and other responses which involve active nonacceptance of or opposition to the other person or something he has said or done. The second greatest number of deviant behavior frequencies was in the low occurrence of behaviors categorized under SMILES, ANIMATED VOICE, and POSITIVE COMMENTS. PRAISE was the next most deviant category; again the mothers displayed low occurrence. The help-seeking mothers were next most deviant in responses categorized as COMMENTS. This category covers verbal activity, during the majority of a forty-second unit, which is clearly not responsive to the other person's verbalization, or which occur while the other person is quiet. The next most deviant category for the help-seeking mothers was in low occurrence of PHYSICAL WARMTH, covering a variety of explicit nonverbal expressions of positive affection. Thus the deviant interaction style which the largest number of the help-seeking mothers shared in common was characterized by its low expression of warmth and acceptance, high incidence of opposition, and extremes (either too much or too little) of one-sided talking. At the end of the series of earphone monitored sessions, two more half hour play sessions were recorded and analyzed. These data were subjected to analyses parallel to the pretreatment ones. Following behavioral counselling and monitoring, the 43 help-seeking mothers exhibited 76 excessive behavior frequencies (beyond the range of any comparison subject) and 194 extreme frequencies (in the range ex-
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Table 1
Behavtor Frequencies of Help-Seeking Hothers Compared to Non-Clinic Subjects Behavior
Below renqe of
Lowest 155 of
Htddle 70~ o f
Htqhest 15Z of
Aboverange of
categories
comparison S's
comcartson S's
comoartson S's
comparison S's
comartson S'$
Before behavioral monitoring N
Z
N
~
N
Z
N
~
N
content
2
4.7
2
4.7
14
32.5
8
18.6
17
Smtles, etc.
Neqattve 39.5
19
44.2
8
18.6
15
34.9
0
0
1
2.3
Pratse
2
4.7
14
32.5
23
53.5
1
2.3
3
6.9
Comments
O
0
8
18.6
23
53.5
3
6.9
9
20.9
13
30.2
24
$5.8
6
13.9
0
0
Phystcal warmth
0
0
After behavioral monttortnq
Pratse
N
~
N
~
8
~
N
~
N
Z
0
0
0
0
17
39.5
9
20.9
17
39.S
0
0
18
4t .9
19
44.2
5
t l .5
1
2.3
3
6.9
21
48.8
6
13.9
1
2.3
Shared conversation Negattve content
12
27.9
10
23,3
2
4.7
2t
48.8
7
16.3
3
6.9
0
O
0
0
22
51.2
18
41.9
3
6.9
2
4.7
19
22
51.2
0
0
0
0
Acttvely follow gatch Controls and dtrects
44.2
hibited only by the highest or lowest 15% of the comparison subjects). These extreme and excessive occurrences a m o u n t e d to 29.9% of their total behavior tabulations, and the remainder of their interactive characteristics fell within expected limits to an appropriate extent. Thus in total quantity help-seeking mothers conformed to normative standards both before and after behavioral intervention. Following intervention their extremes and excesses of behavior also tended to be concentrated in a few specific Interpersonal Behavior Construct items. Six separate checklist items accounted for 45% of the posttreatment deviant behavior frequencies. These are listed in the lower half of Table 1.
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The greatest number of extreme and excessive frequencies, after behavioral monitoring, were reflected in the high occurrence of PRAISE, a shift in the opposite direction from the pretreatment skewed distribution. The second most deviant category was SHARED CONVERSATION, a category which has reference to both m o t h e r and child. Following counselling mothers deviated from the comparison standards next most frequently in NEGATIVE CONTENT; this too constituted a shift in the opposite direction from their original pretreatment skew. ACTIVELY FOLLOWS was the category with the next greatest frequency o f extreme or excessive frequencies. This was followed by WATCHING, which refers to the mother's functioning as an attentive audience to the child's play rather than as a participant. Low incidence of CONTROLS AND DIRECTS had the same number of deviant response frequencies as WATCHING. In summary, the behavioral program described in this program led to mothers' praising more than most, spending more time in watching and less in conversation than most, and being less directive and less negative than most. They also followed the child's lead either more or less than most,--probably dependent on the extent to which different children assumed leadership in the play relationship. These tabulations suggested that the normative approach was not the most direct way to summarize or d o c u m e n t the overall effectiveness of the behavioral counselling program being reviewed, since the counselling program resulted in some new extremes. A more concise summary was obtained from reviewing the individual clinical changes in single dyads, using each case as its own control by means of single analyses of variance. The six categories of m o t h e r behaviors in which most frequent significant individual changes at the .01 level of probability were noted were: Praise Control and Direct Negative Content Lead Taking Smiles, etc. Watch
22 17 16 15 13 11
increased decreased decreased decreased increased increased
frequencies frequencies frequencies frequencies frequencies frequencies
Sixty-nine of the child behavior frequencies (7.6% of them) were beyond the frequency ranges of the comparison subjects, and 198 additional behavior frequencies were in the range exhibited by the highest or lowest 15% of the comparison children. Thus 29.6% of the tabulated child behaviors were classified as being excessive or extreme
Kate L. Kogan
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and 70.4% fell within the expected limits of the ranges of the middle 70% of comparison children. The same kind of clustering of deviant child behavior frequencies in a few categories was noted as has been described for their mothers. Five Interpersonal Behavior Construct categories accounted for 109 (41%) of the children's deviant behavior frequencies. The upper half of Table 2 describes their distributions. IGNORE was the category with the greatest number of extreme or excessive behavior frequencies for the children before the behavioral monitoring sessions. The next most deviant frequency tabulations were found in the DOES OWN THING category, which refers to attention being concentrated on one's own activity rather than on the
Table Behavior Frequencies of Children of Help-seeking Mothers Compared to Non-clinic Subjects
Behavior
Below range of
Lowest15~ of
Mtddle 70% of
Highest 15% of
Aboverange of
categories
comparisonS's
com~arlson S's
comoarlsonS's
comoarlsonS's
comoarlsonS's
Before b~havlorel monitoring
Ignore
N
%
N
0
%
N
%
N
%
N
%
0
19
44.2
19
44.2
5
11,6
10
23.3
14
Does own thing Frustration
1
2.3
32.5
20
46.5
8
18.6
0
0
0
O
0
21
48.8
10
23.3
12
z7.g
0
0
O
2
4.7
22
51.2
15
34.9
4
9.3
0
O
3
6.9
24
55.8
12
27.9
4
9.3
N
%
N
%
N
%
N
~
N
0
0
8
18.6
15
34.9
18
41.9
2
4.7
2
4.7
22
51.2
Ig
44.2
0
0
0
0
2.3
Negative content Phystcal intrusion
After behavioral monitoring
Does own thing
Actively follow Shared 0
0
18
41.9
Ig
44.2
5
II .6
1
Ignore
conversation
0
0
18
41 .g
20
46.5
4
9.3
1
2.3
Frustration
0
O
0
0
22
51.2
11
25.6
10
23.3
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Child Psychiatry and Human Development
other person or on joint activity. Exhibiting FRUSTRATION was the next most frequent behavioral characteristic of the children of helpseeking mothers. The fourth highest category of deviant child behavior frequencies was NEGATIVE CONTENT. PHYSICAL INTRUSION was the next most numerous category for the occurrence of deviant behavior frequencies. This checklist item covers a variety of behaviors which share a c o m m o n element of interfering with the other person's ongoing activity, invading his body space, offering physical resistance, snatching or grabbing, etc. Thus at the beginning of the program the behavior of the problem children was characterized by low incidence of independent play, high frustration, being either verbally or physically oppositional, or ignoring their mothers. Following their participation in the monitored play sessions the children exhibited 286 (out of 903) excessive or extreme behavior frequencies, and 68.3% of their frequency tabulations fell in the ranges of the middle 70% of the comparison subjects. Thus, as was pointed out for their mothers, the children's behavior frequencies fell within expected limits to an appropriate extent, both before and after behavioral interventions, but when extreme and excessive frequencies occurred, they tended to be concentrated in a few areas. Five behavioral categories accounted for 41.9% of the children's post, treatment deviant frequencies. The lower half of Table 2 details the c o m m o n l y shared areas of deviance in child behaviors following treatment. DOES OWN THING had the highest incidence of extreme and excessive frequency tabulations, mostly in the opposite direction from the pretreatment skew. ACTIVELY FOLLOWS was the second largest area of deviance. SHARED CONVERSATION exhibited the third largest a m o u n t of deviance. This was followed by IGNORES,--again in the opposite direction from the pretreatment skew. FRUSTRATION exhibited the next most frequent occurrence of extreme and excessive scores; this entry is of interest in that there was little change from pretreatment entries. The tabulation does not necessarily imply that the same children were involved on the two occasions, but 11 children did exhibit extreme or excessive expressions of frustration both before and after treatment. In summary, following the monitored play sessions, many of the children shared the c o m m o n behavioral characteristics of being involved in independent play a large part of the time, and in conversation less than most, and doing little ignoring of their mothers. They also complied with mothers' lead less than most, but this was probably a direct result of their mothers' being trained in encourag-
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ing independence. They were high in overt expressions of frustration, the only high deviance area which was relatively unchanged by the treatment process. When significant changes in individual's behavior frequencies were examined, child behavior changes were n o t nearly so uniform from one subject to the next as was true for mother behaviors. The greatest number of significant analyses of variance (at or below the .01 level of confidence) were recorded for these child behaviors: Actively Follows Does Own Thing Ignore Physical Intrusion Quiet
14 9 5 5 2 5 1
decreased increased decreased decreased increased increased decreased
frequencies frequencies frequencies frequencies frequencies frequencies frequency
Parent Retrospective Evaluation of Program. Thirty-two of the 43 mothers returned the questionnaires. The nonresponses were a b o u t equally accounted for by letters returned by the post office as having no forwarding address and by those who failed to respond to two requests. The parent follow-up questionnaire asked the mothers to place a check somewhere on the continuous line running from yes to no to answer the question, " D o the problems that first led y o u to come in still occur?" The response line was divided into five equal segments. The responses were placed as follows: Closest to y e s Next closest Middle segment Closer to n o Closest to n o
11 7 11 2 1
Another question, using the same recording technique asked, "In the long run, did y o u r coming to the sessions here make any difference?" Twenty seven responses were in the segment closest to yes, four were in the segment next closest, and one was in the middle. The last question asked the parents to rank order six c o m p o n e n t s of the program in order of their helpfulness. When the rankings of each of these components were totalled, their order from most to least helpful was: (1) taking part in weekly play sessions; (2) weekly
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Child Psychiatry and Human Development
discussions with staff; (3) having staff talk to me over earphone; (4) seeing videotapes of the first sessions (baselines); (5) having card with written suggestions; (6) reviewing videotaped samples at the end. With one exception, each of the components had been ranked in every possible position; no one ranked the weekly play sessions as least helpful. When the responses were regrouped according to the social class memberships of the respondents, it appeared that there might be a meaningful trend toward group differences in evaluating the helpfulness of seeing the original videotaped excerpts. This component was ranked in first or second place by six members of social classes I and II, two group III members, and none of the group IV or group V members. Summary and Discussion The results reported here suggested that the mother-child interactions of mothers who were seeking help in the management of child behavior problems were like those of nonproblem comparison families to an appropriate extent. But when their behavior frequencies did become extreme or excessive they were likely to be more deviant from the normative range than the recorded behaviors of comparison subjects. Although individual mother-child dyads exhibited many individual and unique interaction styles, the group of help-seeking mothers and children shared some striking c o m m o n behavioral deviations. As a group, mothers who were seeking help in child behavior management displayed little positive acceptance and warmth; they exhibited unusually low amounts of friendly smiling and tone of voice, praise, or affectionate demonstrativeness. They did n o t behave as though they liked their children. They were most different from the normative population in their high numbers of non acceptance or oppositional responses. They talked to their children either unusually much or unusually little. Although they reported their children to have a variety of behavioral characteristics, half or more of the mothers described their children as exhibiting problem amounts of disobedience, stubbornness and talking back to parents; they were also perceived b y their mothers as demanding a great deal of attention, resenting discipline, being overactive, and having their feelings easily hurt. All b u t the last two specifically implied disturbances in the area of parent-child management and interaction. To the laboratory observers the children were seen to have the fol-
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lowing unusual characteristics. They had difficulty becoming engaged in independent play, and were easily and frequently frustrated. They often ignored their mothers, but when they responded they did so with high usage of the same kind of non accepting or oppositional behaviors their mothers used toward them. They were physically as well as verbally oppositional and interfering. They were, in short, happy and comfortable with neither themselves and their play, nor with their mothers. Behavioral counselling and monitored play sessions were directly geared toward eliminating the complaints and excesses described. It was to be expected that the targeted interactions would change. Following the series of guided play sessions, the children engaged in independent activity more than most children, b u t they did not ignore their mothers as they had. Mothers watched attentively, praised, and followed the child's lead. They supported the ongoing activity by imposing rules or by correcting or opposing what the child was doing very infrequently. Smiling and friendly tone and comments increased, b u t the activity was not interrupted by sustained conversations. One might criticise the facts reported above as demonstrating only the well known fact that it is possible to influence the kinds and amounts of behavior displayed by providing selectiye reinforcement. Longterm follow-up behavioral observations were n o t obtained. In an ongoing study with a different population sample, substantial behavior changes are being maintained after one year. The play behaviors which were the targets of intervention certainly changed. The only sources for inferring broader areas of change were in parent reports. Immediately after the instructional series, mothers reported only half as many devia~.t behaviors in their children. The greatest reductions were in aspects of parent-child conflict such as disobedience, stubbornness, discipline, etc. Parents concerns had now shifted to the child's extended relationships with other people,--getting along with adults and age-peers, feelings easily hurt and sulkiness, and the practical problem of bedwetting. In their final retrospective assessment almost all mothers reported that the presenting problems had been reduced to a measurable extent, and that the laboratory sessions had made a difference. Parent assessments of the relative utility of the separate program components had little unanimity. It is tempting to conjecture that the questionnaire task of assigning relative values required greater analytical judgment than many subjects had. On the other hand, one may take the responses at their face value, and assume that some facets of the program helped some people while others f o u n d different
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components more useful. One might design future research to test the efficacy of each such component singly. However, perhaps' the most effective program is one which makes multiple use of as many avenues of change as possible. And thus to return to the beginning theme of this report: perhaps this is one reason why multiple criteria of outcome rarely agree with each other. References 1. Garfield SL, Prager RA, Bergin AE: Evaluation of outcome in psychotherapy. J Consult Clin Psychol 37:307-313, 1971. 2. Fiske DW: The shaky evidence is slowly put together. J Consult Clin Psychol 37:314-315, 1971. 3. Luborsky L: Perennial mystery of poor agreement among criteria for psycho-therapy outcome. J Consult Clin Psychol 37:316-319, 1971. 4. Strupp HH, Hadley SW: A tripartite model of mental health and therapeutic outcomes. A m Psychol 32:187-196, 1977. 5. Kogan KL, Gordon BN: A mother-instruction program: Documenting change in mother-child interactions. Child Psychiatry Hum Dev 5:189-200, 1975. 6. Gordon BN, Kogan KL: A mother-instruction program: Behavior changes with and without therapeutic intervention. Child Psychiatry Hum Dev 6: 89-106, 1975. 7. Gordon BN, Kogan KL: A mother-instruction program: Analysis of intervention procedures. Family Process 14:205-221, 1975. 8. Kogan KL, Gordon BN: Interpersonal behavior constructs: A revised approach to defining dyadic interaction styles. Psychol Rep 36:835-846, 1975. 9. Hollingshead AB: Two factor index of social position. Mimeographed, 1957. 10. Wimberger HC, Gregory RJ: A behavior checklist for use in child psychiatry clinics. J A m Acad Child Psychiatry 1:677-688, 1968. 11. Vann D: A comparison of mother-child interactions between clinic and nonclinic mother-child dyads. Unpublished master's thesis, University of Washington, 1974.
Forty-three mothers sought help with management of childhood behaviors. Presenting complaints in half or more of the families included stubbornness, talking back to parents, disobedience and other traits indicative of parent-child interaction difficulties. Pretreatment behavioral observations revealed that mothers shared c o m m o n characteristics of being low in positive warmth and high in negative and oppositional responses. The children were observed to share c o m m o n traits of little independent play, frequent frustration, and either ignored their mothers or were verbally and physically oppositional. Behavioral counselling and monitored rehearsal served to reverse many of the behaviors. Almost all mothers reported reduction in problem behaviors. Mothers varied widely in attributing usefulness to different program components.
ABSTRACT:
The problems of assessing the effectiveness of psychotherapeutic intervention, or of defining and measuring the o u t c o m e of treatment are well recognized. The issues become even more controversial and less clearcut when the focus is on the o u t c o m e of behavioral approaches to treatment, when the subjects are children, and when interpersonal rather than intrapersonal factors are at stake. Perhaps the largest area of uncertainty is that of appropriate criteria of outcome. Garfield, Prager and Bergin [1] emphasized that eight different evaluations of outcome, derived from their data, were essentially unrelated. Fiske's [2] comments on that report put forth the opinion that it was more important to concentrate on adaptive strengths following therapy than on measures of disturbance. Luborsky's [3] comments on the same report suggested that specific gains and changes might indeed show up in different, n o t necessarily correlated, areas and that perhaps global ratings were the most appropriate criteria afReprint requests should be sent to Kate L. Kogan, PhD, Department of Psychiatry & Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 98195. This study was supported by Grant #19642 from the National Institute of Mental Health.
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ter all. Garfield and his colleagues however, preferred to emphasize the importance of utilizing a variety of outcome measures. Strupp and Hadley [4] recently suggested that there are three discrepant vantage points from which mental health and/or o u t c o m e of therapy may be judged. They distinguished between the point of view of society, the point of view of the individual and the point of view of the mental health professional. The present report is a summary of observational data accumulated over a two year period in the behavioral counselling program of The Parenting Clinic of the University of Washington. Earlier reports have presented detailed results derived from the specific parent instruction program which was developed in the initial research [5, 6, 7]. That project focused on the effectiveness of the interventions; it was open to some of the same shortcomings that other reports have had. Its findings corroborated those of Garfield, et al., that different measures of change were essentially unrelated. At the completion of that project the techniques for analyzing videotaped interaction records were revised in the interests of greater economy and more precise clinical utility [8]. The system now provides for retaining much more precise identification of specific behaviors. The earlier publications were focused on documenting the evidence that change had taken place in individual dyads, and noting the transience or persistence of such change. The primary focus of the current report is in identifying specific behaviors and subsequent behavioral changes which were characteristically shared by the subjects, despite their individual uniquenesses. Changes discussed in this framework may be conceived of as being more or less directly attributable to the kinds of intervention procedures utilized. The material which follows requires no particular theoretical model of outcome measurement. It provides a condensation of behavioral records and questionnaire responses before and after a series of monitored and guided interaction rehearsal sessions. It details the respects in which the behaviors of help-seeking mothers and their children differed from and/or conformed with the recorded behaviors of a comparison population.
Subjects Subjects were 43 mothers of 2-8 year old children who were referred to The Parenting Clinic of the University of Washington because they were concerned about, or were seeking guidance in, appropriate management of various child behaviors. There were 32 males and 11 females in the group of children. So-
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Child Psychiatry and Human Development
cial class, according to the Hollingshead Two-Factor Index of Social Position [9] was distributed as follows: Social class 1 2 3 4 5
7 8 8 16 4
Nine of the children were two-three years of age, 15 were four or five years old, and 19 were six, seven, or eight years old.
Procedures In their first two visits, usually a week apart, each mother and child were asked to play together with a selection of toys for thirty minutes. At this time each mother also completed a modified form of the Washington Symptom Checklist [10]. She was asked to indicate which of a list of 63 behaviors she viewed her child as exhibiting more than most children his age, which ones about the same as most children his age, and which ones less than most. The tabulated behavior frequencies from the recorded observations and the behavior symptoms checked by the mother together constituted the basis for formulating specific suggestions for the mother's altering her interactive style during succeeding monitored play sessions. At her next visit after the recorded baseline play sessions, selected excerpts from her videotapes were reviewed with the mother to illustrate specific behaviors which the observers encouraged her to use more frequently and in more varied situations. Examples were also shown and discussed illustrating behaviors which the observers recommended that she try to decrease and replace with suggested alternative responses. She was given a written summary o f three o r four concrete suggestions to practice during the play session which immediately followed the videotape review. The mother was given a small earphone device which permitted the observer to talk to her while she played with her child, without the child hearing the comments. Thus the observer was able to give recognition when the mother carried out recommendations successfully, to point out additional opportunities for her to use desired behaviors, or to suggest specific things she might say or do. Mothers were asked to arrange for daily play sessions of at least 15 minutes duration and t o use these for conscious rehearsal of the specific suggestions made to them. They were also asked to become alert to additional opportunities to apply the suggestions to a variety of daily situations. Monitored play sessions in the laboratory t o o k place once a week for eight weeks, and observers continued to prompt the mother over the earphone so as to provide her with immediate feedback while she was actively engaged in interaction with her child. At the beginning of each weekly session the mother was asked about the events of the preceding week, and the course of the daily play sessions. Special problems or events were discussed and ways of handling similar situations in the future were discussed. At the end of eight weekly guided play sessions, two more play sessions were recorded without providing the mother with any prompting or cuing. The mother also completed the Washington Symptom Checklist again.
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In her final clinic visit the mother reviewed selected videotape excerpts from each of the weekly observational or instructional sessions in which she had participated so that she was able to see the sequence of progress and behavioral changes that had taken place over the three month period. When the entire project was completed, a questionnaire was sent to each mother asking her to evaluate her clinic experience by indicating the extent to which the problems that first led her to seek help still occurred. She was also asked to rank six different defined aspects of the program from most to least helpful in terms of her experience. The timing of the questionnaire was such that some mothers had completed the program as much as 12 to 15 months earlier whereas others had finished their series of visits only three or four months before the questionnaire was sent out.
Data Analysis The videotapes were analyzed in forty-second units. The occurrence of interactive behaviors in each forty-second unit was recorded according to the Interpersonal Behavior Constructs system, which had been developed in earlier research in this laboratory. The system employs a checklist of behavior transactions which represent a range of important interactions that characterize the unique interpersonal styles of a wide variety of parent-child dyads. The content of the checklist items fall into several categories. The focus of the participants' attention is identified as being primarily on the other person, on his own activity, or on joint activity. Vocal behavior is classified as being absent or limited, one-sided, or reciprocal and responsive. Lead-taking is assessed in terms of recurrent attempts to impose structure on the other person's behavior whether he is engaged in individual or joint activity. Behaviors in these categories are checked if their duration characterizes the major portion of the forty-second time unit being reviewed. The remainder of the items are viewed as being important even if they occur only once during the time unit being assessed. One cluster of items covers specific instances of positive behaviors,--smiling, animated voice, stating personal pleasure, praising, or physical expression of affection. Another section of the list itemizes behaviors which imply negative feelings; pouting, frowning, and unfriendly tone of voice are checked here. Note is made of slaps, snatches, threat gestures or other aggressive acts toward the other person or the thing with which he is occupied. Note is also made of ambiguous affect such as is reflected in sarcasm or teasing. A group of items reflect various manifestations of efforts to dominate the other's behavior by contradicting, criticising, correcting, or refusing to comply; intruding physically into the other's ongoing activity, issuing commands or arbitrary rules, or expressing the intention to compete are recorded in the same section. A final group of items covers behaviors which reflect a variety of submissive roles, such as seeking permission, help, or approval or actively complying with the other person's directions, suggestions, or lead. With the exception of two items (working together and shared conversation) each item may be checked for mother and/or child. When the two recorded baseline play sessions had been analyzed, there were 90 separate sets of behavior ratings for each parent-child pair. Frequencies of occurrence of the 21 behavior items reviewed for each dyad were compared with preliminary normative data available from a series of 20 nonclinic comparison subjects [ 1 1 ] . A behavior frequency was identified as being excessive when a be-
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havior occurred either more or less frequently than it did in any comparison subject's behavior observation. It was labeled extreme when the frequency was in the range exhibited only by the highest or lowest 15% of the comparison subjects. Behavioral change was viewed from two vantage points--normative and clinical. When they entered the counselling program, how did the behaviors of this group of concerned and help-seeking parents and their children differ from those of nonclinic comparison families? And how did they compare at the end? The second assessment of change was made in terms of each individual dyad's changes over time, regardless of whether they conformed to or deviated from normative standards. In the latter case the absolute frequencies of occurrence of separate checklist items of behavior were examined before and after the series of instruction sessions for each individual dyad. Comparison of pretreatment and posttreatment frequencies was made by means of analysis of variance, testing whether before- and after-treatment differences were systematically greater than differences between days or between separate portions of a single day's session. While there is some room for criticism in this application of analysis of variance, on the basis that separate behaviors may not, in fact, be independent of each other, the decision was made that each dyad brought to the study its own individual repertoire of habitual responses, and that it could be argued that there was equal probability that one or another response from that repertoire might be elicited at any given moment. In the absence of any better means of looking at changes within single dyads, using each pair as its own control, the advantages of analysis of variance appeared to outweigh the disadvantages.
Results Behaviors R e p o r t e d as D e v i a n t b y Mothers. Three o f the 43 m o t h ers neglected to r e t u r n their s y m p t o m checklists at the end o f the study. In o r d e r t o clarify t h e t a b u l a t i o n o f b e f o r e and after characteristics and their differences, o n l y the 40 c o m p l e t e responses were analyzed. On this i n s t r u m e n t , behaviors are c o n s t r u e d t o be d e v i a n t in the eyes o f the p e r s o n c o m p l e t i n g the checklist w h e n either m o r e t h a n m o s t or less t h a n m o s t is in a d i r e c t i o n usually a c c e p t e d as constituting a p r o b l e m . Thus D I S O B E Y S M O T H E R m o r e t h a n m o s t is t a b u l a t e d as being deviant; IS S E L F - S U F F I C I E N T less t h a n m o s t is also t a b u l a t e d as being deviant. The m e a n n u m b e r o f deviant behaviors r e p o r t e d b y m o t h e r s at the beginning o f the s t u d y was 1 7 . 9 8 ( m e d i a n 16.93), with a range f r o m 3 t o 38. Deviant behaviors r e p o r t e d b y half or m o r e o f the m o t h e r s were as follows: T h i r t y (75%) o f the m o t h e r s described t h e i r children as S T U B B O R N m o r e t h a n m o s t ; 22 (55%) r e c o r d e d O V E R A C T I V E a n d / o r T A L K S B A C K T O P A R E N T S in the m o r e - t h a n - m o s t c o l u m n ; DEMANDS A G R E A T D E A L O F A T T E N T I O N , F E E L I N G S EASIL Y H U R T , a n d / o r R E S E N T F U L O F D I S C I P L I N E were m a r k e d b y
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21 (53%) of mothers; 20 (50%) marked DISOBEYS MOTHER and/ or REFUSES PARENTAL INSTRUCTIONS. Only one checklist response was related to social class,--HAS SERIOUS FIGHTS WITH OTHER CHILDREN. More boys t h a n birls were reported to be DESTRUCTIVE. Five items were reported with different frequencies for different aged children. DAYDREAMS, HAS DIFFICULTY MAKING GRADES IN SCHOOL, and LACKS SELF-CONFIDENCE were reported more for older children; BLAMES OTHERS FOR HIS TROUBLES and TEASES OTHERS were marked more often for younger children. Following the counselling sessions the mean number of deviant behaviors reported by the mothers was 9.45 (median 6.5), with a range from 2 to 35. Of the 40 mothers, 2 perceived a greater number of deviant behaviors than they had before, and one saw the same number. No checklist item was marked by as many as half of the mothers. Two items were marked by 16 (40%) of the mothers,--FEELINGS EASILY HURT and GETS ALONG WELL WITH ADULTS. The next most prominent complaint was STUBBORN, which was marked by 14 (35%) of the mothers; prior to treatment, that item had been marked by 75% of the group. In descending order IS BOSSY was marked by 13 (33%), PREFERS TO PLAY WITH CHILDREN NOT HIS OWN AGE by 11 (28%), and POUTS OR SULKS WHEN TOLD TO DO SOMETHING, and WETS BED by 10 (25%) of the mothers. The items which reflected the greatest number of changes from more than most to about the same as most were STUBBORN, RESENTFUL OF DISCIPLINE, and DISOBEYS MOTHER, each in 16 instances; TALKS BACK TO PARENTS, REFUSES PARENTAL INSTRUCTIONS, and OVERACTIVE each were reported to have changed in 14 cases. Behaviors Identified as Deviant in Behavior Observations. Each dyad member's interactive behaviors were tabulated under 21 behavior categories. Thus 903 mother behavior frequencies and 903 child behavior frequencies (43 dyads • 21 behavior categories) were matched against the frequency distributions of nonclinic comparison subjects. Ninety six of the mother behavior frequencies (10.6%) were bey o n d the frequency ranges of the comparison subjects, and were designated as excessive. One hundred ninety three additional behavior frequencies were identified as extreme, i.e., in the range exhibited only by the highest or lowest 15% of the comparison subjects. Thus
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there were among khese 43 help-seeking mothers, 289 deviant behavior frequencies, at or beyond the frequency levels of the top or bottom 15% of nonclinic mothers. These extreme and excessive occurrences a m o u n t e d to 32% of the total behavior tabulation for the group; 68% of their behavior frequencies fell in the same ranges as the middle 70% of comparison mothers. This distribution indicates that although certain kinds of extremes and excesses of behaviors could be identified in the behavioral records of the mothers, the remainder of their interactive characteristics fell within expected limits to an appropriate extent. When the separate Interpersonal Behavior Construct categories were examined, it was apparent that the deviant behaviors were clustered in a few categories and that five behaviors accounted for 116 (40%) of the deviant frequency tabulations. The upper half of Table 1 details the distribution of the mothers' frequency tabulations in these five categories. The greatest number of deviant behavior tabulations was noted in NEGATIVE CONTENT. This category covers contradictions, corrections, criticisms, refusals of requests or suggestions, and other responses which involve active nonacceptance of or opposition to the other person or something he has said or done. The second greatest number of deviant behavior frequencies was in the low occurrence of behaviors categorized under SMILES, ANIMATED VOICE, and POSITIVE COMMENTS. PRAISE was the next most deviant category; again the mothers displayed low occurrence. The help-seeking mothers were next most deviant in responses categorized as COMMENTS. This category covers verbal activity, during the majority of a forty-second unit, which is clearly not responsive to the other person's verbalization, or which occur while the other person is quiet. The next most deviant category for the help-seeking mothers was in low occurrence of PHYSICAL WARMTH, covering a variety of explicit nonverbal expressions of positive affection. Thus the deviant interaction style which the largest number of the help-seeking mothers shared in common was characterized by its low expression of warmth and acceptance, high incidence of opposition, and extremes (either too much or too little) of one-sided talking. At the end of the series of earphone monitored sessions, two more half hour play sessions were recorded and analyzed. These data were subjected to analyses parallel to the pretreatment ones. Following behavioral counselling and monitoring, the 43 help-seeking mothers exhibited 76 excessive behavior frequencies (beyond the range of any comparison subject) and 194 extreme frequencies (in the range ex-
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Table 1
Behavtor Frequencies of Help-Seeking Hothers Compared to Non-Clinic Subjects Behavior
Below renqe of
Lowest 155 of
Htddle 70~ o f
Htqhest 15Z of
Aboverange of
categories
comparison S's
comcartson S's
comoartson S's
comparison S's
comartson S'$
Before behavioral monitoring N
Z
N
~
N
Z
N
~
N
content
2
4.7
2
4.7
14
32.5
8
18.6
17
Smtles, etc.
Neqattve 39.5
19
44.2
8
18.6
15
34.9
0
0
1
2.3
Pratse
2
4.7
14
32.5
23
53.5
1
2.3
3
6.9
Comments
O
0
8
18.6
23
53.5
3
6.9
9
20.9
13
30.2
24
$5.8
6
13.9
0
0
Phystcal warmth
0
0
After behavioral monttortnq
Pratse
N
~
N
~
8
~
N
~
N
Z
0
0
0
0
17
39.5
9
20.9
17
39.S
0
0
18
4t .9
19
44.2
5
t l .5
1
2.3
3
6.9
21
48.8
6
13.9
1
2.3
Shared conversation Negattve content
12
27.9
10
23,3
2
4.7
2t
48.8
7
16.3
3
6.9
0
O
0
0
22
51.2
18
41.9
3
6.9
2
4.7
19
22
51.2
0
0
0
0
Acttvely follow gatch Controls and dtrects
44.2
hibited only by the highest or lowest 15% of the comparison subjects). These extreme and excessive occurrences a m o u n t e d to 29.9% of their total behavior tabulations, and the remainder of their interactive characteristics fell within expected limits to an appropriate extent. Thus in total quantity help-seeking mothers conformed to normative standards both before and after behavioral intervention. Following intervention their extremes and excesses of behavior also tended to be concentrated in a few specific Interpersonal Behavior Construct items. Six separate checklist items accounted for 45% of the posttreatment deviant behavior frequencies. These are listed in the lower half of Table 1.
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The greatest number of extreme and excessive frequencies, after behavioral monitoring, were reflected in the high occurrence of PRAISE, a shift in the opposite direction from the pretreatment skewed distribution. The second most deviant category was SHARED CONVERSATION, a category which has reference to both m o t h e r and child. Following counselling mothers deviated from the comparison standards next most frequently in NEGATIVE CONTENT; this too constituted a shift in the opposite direction from their original pretreatment skew. ACTIVELY FOLLOWS was the category with the next greatest frequency o f extreme or excessive frequencies. This was followed by WATCHING, which refers to the mother's functioning as an attentive audience to the child's play rather than as a participant. Low incidence of CONTROLS AND DIRECTS had the same number of deviant response frequencies as WATCHING. In summary, the behavioral program described in this program led to mothers' praising more than most, spending more time in watching and less in conversation than most, and being less directive and less negative than most. They also followed the child's lead either more or less than most,--probably dependent on the extent to which different children assumed leadership in the play relationship. These tabulations suggested that the normative approach was not the most direct way to summarize or d o c u m e n t the overall effectiveness of the behavioral counselling program being reviewed, since the counselling program resulted in some new extremes. A more concise summary was obtained from reviewing the individual clinical changes in single dyads, using each case as its own control by means of single analyses of variance. The six categories of m o t h e r behaviors in which most frequent significant individual changes at the .01 level of probability were noted were: Praise Control and Direct Negative Content Lead Taking Smiles, etc. Watch
22 17 16 15 13 11
increased decreased decreased decreased increased increased
frequencies frequencies frequencies frequencies frequencies frequencies
Sixty-nine of the child behavior frequencies (7.6% of them) were beyond the frequency ranges of the comparison subjects, and 198 additional behavior frequencies were in the range exhibited by the highest or lowest 15% of the comparison children. Thus 29.6% of the tabulated child behaviors were classified as being excessive or extreme
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and 70.4% fell within the expected limits of the ranges of the middle 70% of comparison children. The same kind of clustering of deviant child behavior frequencies in a few categories was noted as has been described for their mothers. Five Interpersonal Behavior Construct categories accounted for 109 (41%) of the children's deviant behavior frequencies. The upper half of Table 2 describes their distributions. IGNORE was the category with the greatest number of extreme or excessive behavior frequencies for the children before the behavioral monitoring sessions. The next most deviant frequency tabulations were found in the DOES OWN THING category, which refers to attention being concentrated on one's own activity rather than on the
Table Behavior Frequencies of Children of Help-seeking Mothers Compared to Non-clinic Subjects
Behavior
Below range of
Lowest15~ of
Mtddle 70% of
Highest 15% of
Aboverange of
categories
comparisonS's
com~arlson S's
comoarlsonS's
comoarlsonS's
comoarlsonS's
Before b~havlorel monitoring
Ignore
N
%
N
0
%
N
%
N
%
N
%
0
19
44.2
19
44.2
5
11,6
10
23.3
14
Does own thing Frustration
1
2.3
32.5
20
46.5
8
18.6
0
0
0
O
0
21
48.8
10
23.3
12
z7.g
0
0
O
2
4.7
22
51.2
15
34.9
4
9.3
0
O
3
6.9
24
55.8
12
27.9
4
9.3
N
%
N
%
N
%
N
~
N
0
0
8
18.6
15
34.9
18
41.9
2
4.7
2
4.7
22
51.2
Ig
44.2
0
0
0
0
2.3
Negative content Phystcal intrusion
After behavioral monitoring
Does own thing
Actively follow Shared 0
0
18
41.9
Ig
44.2
5
II .6
1
Ignore
conversation
0
0
18
41 .g
20
46.5
4
9.3
1
2.3
Frustration
0
O
0
0
22
51.2
11
25.6
10
23.3
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Child Psychiatry and Human Development
other person or on joint activity. Exhibiting FRUSTRATION was the next most frequent behavioral characteristic of the children of helpseeking mothers. The fourth highest category of deviant child behavior frequencies was NEGATIVE CONTENT. PHYSICAL INTRUSION was the next most numerous category for the occurrence of deviant behavior frequencies. This checklist item covers a variety of behaviors which share a c o m m o n element of interfering with the other person's ongoing activity, invading his body space, offering physical resistance, snatching or grabbing, etc. Thus at the beginning of the program the behavior of the problem children was characterized by low incidence of independent play, high frustration, being either verbally or physically oppositional, or ignoring their mothers. Following their participation in the monitored play sessions the children exhibited 286 (out of 903) excessive or extreme behavior frequencies, and 68.3% of their frequency tabulations fell in the ranges of the middle 70% of the comparison subjects. Thus, as was pointed out for their mothers, the children's behavior frequencies fell within expected limits to an appropriate extent, both before and after behavioral interventions, but when extreme and excessive frequencies occurred, they tended to be concentrated in a few areas. Five behavioral categories accounted for 41.9% of the children's post, treatment deviant frequencies. The lower half of Table 2 details the c o m m o n l y shared areas of deviance in child behaviors following treatment. DOES OWN THING had the highest incidence of extreme and excessive frequency tabulations, mostly in the opposite direction from the pretreatment skew. ACTIVELY FOLLOWS was the second largest area of deviance. SHARED CONVERSATION exhibited the third largest a m o u n t of deviance. This was followed by IGNORES,--again in the opposite direction from the pretreatment skew. FRUSTRATION exhibited the next most frequent occurrence of extreme and excessive scores; this entry is of interest in that there was little change from pretreatment entries. The tabulation does not necessarily imply that the same children were involved on the two occasions, but 11 children did exhibit extreme or excessive expressions of frustration both before and after treatment. In summary, following the monitored play sessions, many of the children shared the c o m m o n behavioral characteristics of being involved in independent play a large part of the time, and in conversation less than most, and doing little ignoring of their mothers. They also complied with mothers' lead less than most, but this was probably a direct result of their mothers' being trained in encourag-
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ing independence. They were high in overt expressions of frustration, the only high deviance area which was relatively unchanged by the treatment process. When significant changes in individual's behavior frequencies were examined, child behavior changes were n o t nearly so uniform from one subject to the next as was true for mother behaviors. The greatest number of significant analyses of variance (at or below the .01 level of confidence) were recorded for these child behaviors: Actively Follows Does Own Thing Ignore Physical Intrusion Quiet
14 9 5 5 2 5 1
decreased increased decreased decreased increased increased decreased
frequencies frequencies frequencies frequencies frequencies frequencies frequency
Parent Retrospective Evaluation of Program. Thirty-two of the 43 mothers returned the questionnaires. The nonresponses were a b o u t equally accounted for by letters returned by the post office as having no forwarding address and by those who failed to respond to two requests. The parent follow-up questionnaire asked the mothers to place a check somewhere on the continuous line running from yes to no to answer the question, " D o the problems that first led y o u to come in still occur?" The response line was divided into five equal segments. The responses were placed as follows: Closest to y e s Next closest Middle segment Closer to n o Closest to n o
11 7 11 2 1
Another question, using the same recording technique asked, "In the long run, did y o u r coming to the sessions here make any difference?" Twenty seven responses were in the segment closest to yes, four were in the segment next closest, and one was in the middle. The last question asked the parents to rank order six c o m p o n e n t s of the program in order of their helpfulness. When the rankings of each of these components were totalled, their order from most to least helpful was: (1) taking part in weekly play sessions; (2) weekly
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discussions with staff; (3) having staff talk to me over earphone; (4) seeing videotapes of the first sessions (baselines); (5) having card with written suggestions; (6) reviewing videotaped samples at the end. With one exception, each of the components had been ranked in every possible position; no one ranked the weekly play sessions as least helpful. When the responses were regrouped according to the social class memberships of the respondents, it appeared that there might be a meaningful trend toward group differences in evaluating the helpfulness of seeing the original videotaped excerpts. This component was ranked in first or second place by six members of social classes I and II, two group III members, and none of the group IV or group V members. Summary and Discussion The results reported here suggested that the mother-child interactions of mothers who were seeking help in the management of child behavior problems were like those of nonproblem comparison families to an appropriate extent. But when their behavior frequencies did become extreme or excessive they were likely to be more deviant from the normative range than the recorded behaviors of comparison subjects. Although individual mother-child dyads exhibited many individual and unique interaction styles, the group of help-seeking mothers and children shared some striking c o m m o n behavioral deviations. As a group, mothers who were seeking help in child behavior management displayed little positive acceptance and warmth; they exhibited unusually low amounts of friendly smiling and tone of voice, praise, or affectionate demonstrativeness. They did n o t behave as though they liked their children. They were most different from the normative population in their high numbers of non acceptance or oppositional responses. They talked to their children either unusually much or unusually little. Although they reported their children to have a variety of behavioral characteristics, half or more of the mothers described their children as exhibiting problem amounts of disobedience, stubbornness and talking back to parents; they were also perceived b y their mothers as demanding a great deal of attention, resenting discipline, being overactive, and having their feelings easily hurt. All b u t the last two specifically implied disturbances in the area of parent-child management and interaction. To the laboratory observers the children were seen to have the fol-
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lowing unusual characteristics. They had difficulty becoming engaged in independent play, and were easily and frequently frustrated. They often ignored their mothers, but when they responded they did so with high usage of the same kind of non accepting or oppositional behaviors their mothers used toward them. They were physically as well as verbally oppositional and interfering. They were, in short, happy and comfortable with neither themselves and their play, nor with their mothers. Behavioral counselling and monitored play sessions were directly geared toward eliminating the complaints and excesses described. It was to be expected that the targeted interactions would change. Following the series of guided play sessions, the children engaged in independent activity more than most children, b u t they did not ignore their mothers as they had. Mothers watched attentively, praised, and followed the child's lead. They supported the ongoing activity by imposing rules or by correcting or opposing what the child was doing very infrequently. Smiling and friendly tone and comments increased, b u t the activity was not interrupted by sustained conversations. One might criticise the facts reported above as demonstrating only the well known fact that it is possible to influence the kinds and amounts of behavior displayed by providing selectiye reinforcement. Longterm follow-up behavioral observations were n o t obtained. In an ongoing study with a different population sample, substantial behavior changes are being maintained after one year. The play behaviors which were the targets of intervention certainly changed. The only sources for inferring broader areas of change were in parent reports. Immediately after the instructional series, mothers reported only half as many devia~.t behaviors in their children. The greatest reductions were in aspects of parent-child conflict such as disobedience, stubbornness, discipline, etc. Parents concerns had now shifted to the child's extended relationships with other people,--getting along with adults and age-peers, feelings easily hurt and sulkiness, and the practical problem of bedwetting. In their final retrospective assessment almost all mothers reported that the presenting problems had been reduced to a measurable extent, and that the laboratory sessions had made a difference. Parent assessments of the relative utility of the separate program components had little unanimity. It is tempting to conjecture that the questionnaire task of assigning relative values required greater analytical judgment than many subjects had. On the other hand, one may take the responses at their face value, and assume that some facets of the program helped some people while others f o u n d different
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components more useful. One might design future research to test the efficacy of each such component singly. However, perhaps' the most effective program is one which makes multiple use of as many avenues of change as possible. And thus to return to the beginning theme of this report: perhaps this is one reason why multiple criteria of outcome rarely agree with each other. References 1. Garfield SL, Prager RA, Bergin AE: Evaluation of outcome in psychotherapy. J Consult Clin Psychol 37:307-313, 1971. 2. Fiske DW: The shaky evidence is slowly put together. J Consult Clin Psychol 37:314-315, 1971. 3. Luborsky L: Perennial mystery of poor agreement among criteria for psycho-therapy outcome. J Consult Clin Psychol 37:316-319, 1971. 4. Strupp HH, Hadley SW: A tripartite model of mental health and therapeutic outcomes. A m Psychol 32:187-196, 1977. 5. Kogan KL, Gordon BN: A mother-instruction program: Documenting change in mother-child interactions. Child Psychiatry Hum Dev 5:189-200, 1975. 6. Gordon BN, Kogan KL: A mother-instruction program: Behavior changes with and without therapeutic intervention. Child Psychiatry Hum Dev 6: 89-106, 1975. 7. Gordon BN, Kogan KL: A mother-instruction program: Analysis of intervention procedures. Family Process 14:205-221, 1975. 8. Kogan KL, Gordon BN: Interpersonal behavior constructs: A revised approach to defining dyadic interaction styles. Psychol Rep 36:835-846, 1975. 9. Hollingshead AB: Two factor index of social position. Mimeographed, 1957. 10. Wimberger HC, Gregory RJ: A behavior checklist for use in child psychiatry clinics. J A m Acad Child Psychiatry 1:677-688, 1968. 11. Vann D: A comparison of mother-child interactions between clinic and nonclinic mother-child dyads. Unpublished master's thesis, University of Washington, 1974.
